The developmental origins of conversion disorders

Qualitative systematic review on the lived experience of functional neurological disorder

Objectives

Functional neurological disorder (FND) is a complex disorder, recently attracting much research into aetiology and treatment. However, there is limited research on the patient's lived experience. This paper addresses this gap to ask: 'What is the subjective life experience of adult patients living with FND?'

Methods

From 1980 to 2020, Medline, PsycInfo, Scopus, Science Direct, PubMed, CINAHL and Embase were searched for English language qualitative adult research. The disciplines used general medicine, psychiatry, physiotherapy, nursing, neurology, psychosomatic medicine and occupational therapy. The qualitative literature search included book chapters, theses, fellowship reports and conference articles as well as peer-reviewed scientific journals.The Critical Appraisal Skills Programme tool was used to assess 33 papers, with eight papers included in the final synthesis. Nine additional papers, suggested during review, were evaluated but excluded from synthesis, though incorporated elsewhere in the paper. Two authors used an integrative immersion approach to identify the literature's main themes using line-by-line and top-down methods.

Results

Eight main themes were identified: lost, body-mind dualism, preceding stressful events, relatedness, stigma, the battle or fight, the burden and losses of the illness and trust versus mistrust. From these emerged a central overarching theme of relationally regulated selves, which posits the essence of the lived experience of FND as responding to stressful experiences within a relational, regulatory context.

Conclusions

The prevalent themes give valuable insight into the lived experience of FND and the impact of stressors, past and present, and the relational environment in the development of and recovery from the disorder. Further research is needed to support the formulation of the patient experience and cocreated recovery pathways.

Molecular pathways underlying sympathetic autonomic overshooting leading to fear and traumatic memories: looking for alternative therapeutic options for post-traumatic stress disorder

The sympathoadrenal medullary system and the hypothalamic-pituitary-adrenal axis are both activated upon stressful events. The release of catecholamines, such as dopamine, norepinephrine (NE), and epinephrine (EPI), from sympathetic autonomic nerves participate in the adaptive responses to acute stress. Most theories suggest that activation of peripheral β-adrenoceptors (β-ARs) mediates catecholamines-induced memory enhancement. These include direct activation of β-ARs in the vagus nerve, as well as indirect responses to catecholamine-induced glucose changes in the brain. Excessive sympathetic activity is deeply associated with memories experienced during strong emotional stressful conditions, with catecholamines playing relevant roles in fear and traumatic memories consolidation. Recent findings suggest that EPI is implicated in fear and traumatic contextual memories associated with post-traumatic stress disorder (PTSD) by increasing hippocampal gene transcription (e.g., Nr4a) downstream to cAMP response-element protein activation (CREB). Herein, we reviewed the literature focusing on the molecular mechanisms underlying the pathophysiology of memories associated with fear and traumatic experiences to pave new avenues for the treatment of stress and anxiety conditions, such as PTSD.

Sense of control, selective attention and cognitive inhibition in pediatric functional seizures: A prospective case-control study

PURPOSE

To date, laboratory-based experimental behavioral methods have not been used to identify factors associated with pediatric functional seizures (FS), leaving a critical gap for effective treatment development.

METHODS

Children ages 13-18 with video-EEG-confirmed FS were matched to controls (MCs) based on income, sex, race, and age. A modified Stroop task which included a condition requiring participants to report the ink colors in which seizure symptom words were written (e.g., "shaking" in blue) measured selective attention and cognitive inhibition through response time. The magic and turbulence task assessed sense of control in three conditions (magic, lag, turbulence). Children with FS were asked to report premonitory symptoms predicting FS.

RESULTS

Participants included 26 children with FS and 26 MCs (Meanage=15.2, 74% female, 59% white). On Stroop, children with FS had a slower reaction time (Mean=1193.83) than MCs (Mean=949.26, p = 0.022) for seizure symptom words. Children with FS had significantly poorer sense of control in the turbulence condition of the magic and turbulence task (Mean=-3.99, SD=8.83) than MCs (Mean=-11.51, SD=7.87; t(20)=-2.61, p =0.017). Children with FS (Mean=-1.80, SD=6.54) also had significantly poorer sense of control in the magic condition than MCs (Mean=-5.57, SD=6.01; p =0.028). Ninety-eight percent of patients endorsed premonitory symptoms.

CONCLUSION

Compared with MCs, children with FS have (1) poorer selective attention and cognitive inhibition when presented with seizure-related information and (2) lower sense of control (i.e. poorer awareness that their control was manipulated). Premonitory symptoms were common. Sense of control, selective attention, and inhibition may be novel treatment targets for FS intervention.

Pediatric Somatic Symptom and Related Disorders: Parent Acceptance Influences Recovery

OBJECTIVES

To assess how clinicians discuss the diagnosis of somatic symptom and related disorders (SSRDs) in patients admitted to a children's hospital and explore the effect of parent and patient acceptance of the diagnosis on recovery.

STUDY DESIGN

In this cross-sectional study, we reviewed the electronic medical records of pediatric admissions diagnosed with SSRD over 18 months. All diagnostic discussions with patients and families were analysed to identify concepts used by clinicians within these discussions and the extent of parent and patient acceptance of the diagnosis. Recovery status up to 12 months after diagnosis was also identified. Acceptance and recovery were categorized as "full," "partial," or "none."

RESULTS

Ninety-five of 123 (77.2%) patients (median age 14.3 years, range 7.3-18.3) had at least 1 diagnostic discussion recorded. Clinical explanations within the diagnostic discussion spanned a variety of concepts, with the most common being a description of somatization (62%). Full parent acceptance of the diagnosis of SSRD was more likely when discussions involved two parents (P = .002). Full acceptance of the diagnosis by at least 1 parent was associated with complete functional recovery in their children (OR 8.94, 95% CI 2.24, 35.9, P = .002). In contrast, there was no significant association between full acceptance by patients and their recovery.

CONCLUSION

The influence of parent acceptance of the diagnosis of SSRD reinforces the importance of therapeutic engagement with families, as well as with children and adolescents.

Arousability, Personality, and Decision-Making Ability in Dissociative Disorder

BACKGROUND

There is a gap in understanding the pathogenesis of dissociative conversion disorder (DCD), despite the disorder having a strong historical root. The role of personality and neurocognitive factors are now highlighted; however, inconsistencies are reported. This study explores the personality disposition, arousability, and decision-making ability of patients with DCD, in reference to a healthy control group (HCG).

METHODS

In this cross-sectional study, the sample comprised ten adult psychiatric patients with DCD. Ten participants of the HCG were matched according to age, gender, education, economic status, domicile, religious background, and handedness. The study assessed personality disposition with Temperament and Character Inventory, arousability with reaction time task, and decision-making ability with the Iowa Gambling Task (IGT PEBL version).

RESULTS

The DCD group differed significantly on personality disposition related to both temperament and character. There was also evidence of easy arousability and frustration along with deficit in executive function related to decision-making ability.

CONCLUSION

This study highlights the presence of both temperamental and characterological factors associated with DCD. Moreover, this study identifies the role of cognitive arousability and decision-making or feedback utilization ability in the psychopathology of DCD.

Attachment styles, identification of feelings and psychiatric symptoms in functional neurological disorders

OBJECTIVE

The contribution of psychological and psychiatric symptoms in the development of Functional Neurological Disorders (FND) is unclear. We therefore aimed to investigate the role of different attachment styles (AS) and their relationship with psychiatric symptoms in FND patients as compared with both subjects with neurological disorders (ND) and healthy controls (HC); and the possible differences between patients with functional movement disorders (FMD) and with functional seizures.

METHODS

In this case-control study, forty-six patients with FND were compared to 34 with ND and 30 HC, by means of an extensive battery to investigate the presence of alexithymia, depression, anxiety, dissociation and to explore their AS using the Revised Experiences in Close Relationships instrument (ECR-R).

RESULTS

Patients with FND had higher depression and alexithymia as well as an avoidant pattern on the ECR-R than patients with ND. In the FND group, ECR-R avoidance was an independent predictor of psychiatric symptoms and, altogether, ECR-R avoidance, the somatic-affective component of depression and difficulty identifying feelings were independent predictors of FND. Gender, anxiety and difficulty identifying feelings predicted the presence of functional seizures.

CONCLUSION

The avoidant AS may be an important psychological factor influencing the presence of mood disorders and alexithymia. Their co-occurence might drive maladaptive responses underlying the presence of FND. Although we demonstrated a large overlap between FND phenotypes, patients with functional seizures might have higher alexithymia, which in turn could explain a defensive response less anchored to body reactions and physical symptoms.

Dissociation vs Repression: A New Neuropsychoanalytic Model for Psychopathology

Recent research on trauma, attachment and neuroscience point at a clear divide in psychopathology between disorders based on repression, (as in Freud's repression model) and psychopathologies structured on dissociative mechanisms, a response to severe interpersonal trauma. Pathologies based on repression are typical of a neurotic structure, (with better developmental outcome), while pathologies based on dissociation are of more severe, often borderline nature, as in Otto Kernberg's borderline organization (1975). Neurobiology of attachment and affect regulation theory (Allan Schore), developmental psychopathology (Giovanni Liotti) and contemporary relational psychoanalysis (Philip Bromberg), all provide clinical evidence that the most severe psychopathology is of dissociative structure. This paper clarifies the after-effects of first level of traumatization of human agency (i.e., lack of attunement) and of the second level as in cases with actual abuse, maltreatment or incest (Mucci, 2013), with the internalization of a dyad victim/persecutor within the self of the survivor, as seen in borderline psychopathology (Mucci, 2018).

What Does Neuroscience Tell Us About the Conversion Model of Functional Neurological Disorders?

A dualistic mind-body understanding of functional neurological disorders (FNDs), also known as conversion disorders, has led to the view that the cause of the symptom should be either psychological (psychogenic) or physical (neurogenic-"organic"). One of the most influential psychological approaches is the Freudian model of conversion, which suggests that FNDs arise from a defense process in which emotional stress is converted into physical symptoms. This conversion theory has been challenged in recent years, accompanied by a shift in emphasis toward neuropathophysiological models of FND and away from historical psychological concepts. In this review, the authors consider the contemporary relevance of the conversion model from the neuroscientific perspective to reconcile the role of both psychological and biological factors in FND. A narrative review of recent neuroscientific findings pertaining to the conversion model of FND, encompassing neuroimaging, cognitive psychology, biological markers, and epigenetic studies, was performed. Research on the role of psychological stressors is discussed. Neurobiological mechanisms of repression of traumatic memories and their translation into physical symptoms are then explored. Finally, the role of physical symptoms as a potential protective defense mechanism against social stressors is considered. The authors argue that the conversion concept is consistent with recent neuroscientific research findings, and the model allows psychological and neurobiological concepts to be reconciled within a single account of FND that begins to resolve the dualistic mind-body dichotomy.

Retraining and control therapy for pediatric psychogenic non-epileptic seizures

Objective

Our aim was to conduct a pilot randomized controlled trial of a novel cognitive behaviorally based intervention for pediatric PNES called Retraining and Control Therapy (ReACT).

Methods

Participants were randomized to receive either eight sessions of ReACT or supportive therapy, and participants completed follow‐up visits at 7‐ and 60‐days posttreatment. The primary outcome measure was PNES frequency at 7‐days posttreatment. Eligibility criteria included children with video‐EEG confirmed PNES and participant/parent or guardian willingness to participate in treatment. Exclusion criteria included substance use, psychosis, and severe intellectual disability. Forty‐two patients were assessed for eligibility and 32 were randomized. ReACT aimed to retrain classically conditioned, involuntary PNES by targeting catastrophic symptom expectations and a low sense of control over symptoms using principles of habit reversal. Supportive therapy was based on the assumption that relief from stress or problems can be achieved by discussion with a therapist.

Results

Twenty‐nine participants (M_age = 15.1 years, SD_age = 2.5; 72.2% female; 57.1% Caucasian, 28.6% African American) completed 7‐days postprocedures. For PNES frequency, the Wilcoxon Rank Sum test statistic was 273.5 yielding a normal approximation of Z = 4.725 (P < 0.0001), indicating a significant improvement in PNES frequency for ReACT at 7‐days posttreatment compared to supportive therapy. Participants with PNES in the 7‐days posttreatment were removed from the study for additional treatment, resulting in no 60‐day follow‐up data for supportive therapy.

Interpretation

ReACT resulted in significantly greater PNES reduction than supportive therapy, with 100% of patients experiencing no PNES in 7 days after ReACT. Additionally, 82% remained PNES‐free for 60 days after ReACT.

Stress and functional neurological disorders: mechanistic insights

At the interface between mind and body, psychiatry and neurology, functional neurological disorder (FND) remains poorly understood. Formerly dominant stress-related aetiological models have been increasingly challenged, in part due to cases without any history of past or recent trauma. In this perspective article, we review current evidence for such models, and how research into the role of traumatic stress in other disorders and the neurobiology of the stress response can inform our mechanistic understanding of FND. First, we discuss the association between stress and the onset or exacerbation of a variety of physical and mental health problems. Second, we review the role of hypothalamic-pituitary-adrenal axis dysfunction in the neurobiology of ill-health, alongside evidence for similar mechanisms in FND. Third, we advocate a stress-diathesis model, in which biological susceptibility interacts with early life adversity, where FND can be precipitated by traumatic events later in life and maintained by psychological responses. We hypothesise that greater biological susceptibility to FND is associated with less severe remote and recent stress, and that FND precipitated by more severe stress is associated with lower biological vulnerability. This would explain clinical experience of variable exposure to historical and recent traumatic stress among people with FND and requires empirical investigation. A testable, evidence-based stress-diathesis model can inform nuanced understanding of how biological and psychological factors interact at the individual level, with potential to inform personalised treatment pathways. Much-needed research to establish the aetiology of FND will enhance clinical care and communication, facilitate effective treatment and inform prevention strategies.

Abnormal postural behavior in patients with functional movement disorders during exposure to stress

BACKGROUND

Patients affected by functional (psychogenic) movement disorders (FMD) have abnormal processing of stress responses. However, little is known about the influence of this abnormal stress processing on automatic motor defense behavior, such as freeze response. Our aim was thus to investigate stress-induced postural motor responses in FMD.

METHODS

Nine FMD patients and thirteen healthy controls were engaged in the Trier Social Stress Test, while we measured the movement of their body by means of accelerometers and gyroscopes attached to the thorax. Standard deviation of thorax acceleration, reflecting the variability of movement amplitude (body sway), was compared across groups over time in a 2 × 2 ANOVA design. Higuchi's fractal dimension (HFD), reflecting the complexity of movement pattern over time, was also analyzed. Salivary cortisol and α-amylase samples were collected before and after the experiment, as stress biomarkers. Pearson's correlation coefficients were calculated between these biomarkers and movement parameters.

RESULTS

A significant interaction effect was found, showing that healthy controls reduced their thorax sway over time during exposure to stress (from 0.027 ± 0.010 m/s² to 0.023 ± 0.008 m/s², effect size of Cohen's d = 0.95), whereas patients with FMD did not. This change in body sway in controls over time negatively correlated with salivary cortisol values (ρ = -0.67, p = 0.012). A significant group effect revealed that FMD patients had an overall larger body sway (0.038 ± 0.013 m/s²) compared to controls (0.025 ± 0.009 m/s² - effect size of Cohen's d = 1.29) and a lower HFD (1.602 ± 0.071) than controls (1.710 ± 0.078 - Cohen's d = 1.43).

CONCLUSIONS

Patients with FMD failed to show a reduction of body sway over time, i.e., freeze response observed in the controls, thus suggesting an impairment in the automatic defense behavior. Moreover, our analysis found a lower complexity of movement (HFD) in FMD, which deserves future research in order to verify whether this could represent a characteristic trait of the disorder.

Different Strokes for Different Folks: The BodyMind Approach as a Learning Tool for Patients With Medically Unexplained Symptoms to Self-Manage

Medically unexplained symptoms (MUS) are common and costly in both primary and secondary health care. It is gradually being acknowledged that there needs to be a variety of interventions for patients with MUS to meet the needs of different groups of patients with such chronic long-term symptoms. The proposed intervention described herewith is called The BodyMind Approach (TBMA) and promotes learning for self-management through establishing a dynamic and continuous process of emotional self-regulation. The problem is the mismatch between the patient's mind-set and profile and current interventions. This theoretical article, based on practice-based evidence, takes forward the idea that different approaches (other than cognitive behavioural therapy) are required for people with MUS. The mind-set and characteristics of patients with MUS are reflected upon to shape the rationale and design of this novel approach. Improving services for this population in primary care is crucial to prevent the iterative spiraling downward of frequent general practitioner (GP) visits, hospital appointments, and accident and emergency attendance (A&E), all of which are common for these patients. The approach derives from embodied psychotherapy (authentic movement in dance movement psychotherapy) and adult models of learning for self-management. It has been developed from research and practice-based evidence. In this article the problem of MUS in primary care is introduced and the importance of the reluctance of patients to accept a psychological/mental health referral in the first instance is drawn out. A description of the theoretical underpinnings and philosophy of the proposed alternative to current interventions is then presented related to the design, delivery, facilitation, and educational content of the program. The unique intervention is also described to give the reader a flavor.

Processing of Emotion in Functional Neurological Disorder

Emotions have traditionally been considered crucial in the development of functional neurological disorder, but the evidence underpinning this association is not clear. We aimed to summarize evidence for association between functional neurological disorder and emotions as formulated by Breuer and Freud in their conception of hysterical conversion. Based on a systematic literature search, we identified 34 controlled studies and categorized them into four groups: (i) autonomic arousal, (ii) emotion-motion interactions, (iii) social modulation of symptoms, and (iv) bodily awareness in FND. We found evidence for autonomic dysregulation in FND; convergent neuroimaging findings implicate abnormal limbic-motor interactions in response to emotional stimuli in FND. Our results do not provide enough empirical evidence for social modulation of the symptoms, but there is a clinical support for the role of suggestion and placebo in FND. Our results provide evidence for abnormal bodily awareness in FND. Based on these findings, we propose that functional neurological symptoms are forms of emotional reactions shaped into symptoms by previous experience with illness and possibly reinforced by actual social contexts. Additional research should investigate the effect of social context on the intensity of functional neurological symptoms and associated brain regions.

A psychotic experience during adolescence: reasoning about differential diagnosis. case report

CONTEXT

The aim of the present clinical review was to illustrate the diagnostic difficulty associated with psychotic experiences during adolescence, in the light of the multiplicity of circumstances interplaying during this period. It was also intended to illustrate the observation that not all hallucinations occur in the context of a declared psychotic disorder.

CASE REPORT

The patient was a 16-year-old adolescent girl who came to the Emergency Department of Coimbra Pediatric Hospital. On admission, she displayed mood and sensory perception disorders, with a bizarre gait abnormality. A diagnosis of conversion disorder was finally suggested, in accordance with the International Classification of Diseases, 10th edition.

CONCLUSIONS

Conversive hallucinations are rare in the psychiatric literature. This diagnostic hypothesis only gained consistency over a long period of follow-up within a child and adolescent psychiatry outpatient service, which was fundamental for appropriate diagnostic clarification. The authors discuss psychotic experiences that can arise from a neurotic setting and share the reasoning that was constructed in relation to the differential diagnosis. The psychogenesis and phenomenology of this young patient's conversive hallucinations and the therapeutic strategies adopted over the course of the follow-up are also discussed.

Integrating neurobiology of emotion regulation and trauma therapy: reflections on EMDR therapy

Emotion dysregulation is a frequent feature in trauma-related disorders. Different kinds of emotion dysregulation seem to be linked to particular psychiatric conditions, and there is growing evidence of the association between neurobiological correlates and those dysregulation patterns. Nevertheless, many of the recent findings from the field of the neurobiology have not been translated into clinical practice and are insufficiently contemplated in trauma-oriented therapies. The aim of this article is to review recent developments in the field of emotion regulation connecting these issue with the practical implementation of psychotherapeutic procedures. The evaluation of emotion dysregulation patterns can guide decision making during the therapy independently to the approach, but there are some findings that can be especially useful for some concrete modalities of therapy. In this article we will focus our discussion on how emotion dysregulation may influence eye movement desensitization and reprocessing (EMDR) treatment in trauma-related disorders. EMDR is a well-defined and protocol-based intervention, with a strong empirical support for post-traumatic stress disorder (PTSD). We describe how different patterns of emotion dysregulation may influence EMDR treatment and procedures, and also how the application of EMDR beyond non-dissociative PTSD should take into account the predominant emotion-regulation strategies in specific posttraumatic disorders.

Emotion regulation strategies in trauma-related disorders: pathways linking neurobiology and clinical manifestations

Emotion regulation impairments with traumatic origins have mainly been studied from posttraumatic stress disorder (PTSD) models by studying cases of adult onset and single-incident trauma exposure. The effects of adverse traumatic experiences, however, go beyond the PTSD. Different authors have proposed that PTSD, borderline personality, dissociative, conversive and somatoform disorders constitute a full spectrum of trauma-related conditions. Therefore, a comprehensive review of the neurobiological findings covering this posttraumatic spectrum is needed in order to develop an all-encompassing model for trauma-related disorders with emotion regulation at its center. The present review has sought to link neurobiology findings concerning cortico-limbic function to the field of emotion regulation. In so doing, trauma-related disorders have been placed in a continuum between under- and over-regulation of affect strategies. Under-regulation of affect was predominant in borderline personality disorder, PTSD with re-experiencing symptoms and positive psychoform and somatoform dissociative symptoms. Over-regulation of affect was more prevalent in somatoform disorders and pathologies characterized by negative psychoform and somatoform symptoms. Throughout this continuum, different combinations between under- and over-regulation of affect strategies were also found.

Role of the Attachment Style in Determining the Association Between Headache Features and Psychological Symptoms in Migraine Children and Adolescents. An Analytical Observational Case-Control Study

OBJECTIVE

We aimed to study the role of attachment style on headache severity and psychological symptoms in migraineurs children/adolescents. Moreover, we investigated the association between attachment style, migraine severity, and psychological symptoms.

BACKGROUND

Attachment theory suggests that early interpersonal relationships may be important determinants of psychopathology and pain management. In particular, individuals with insecure attachment styles have been shown to experience more pain than people with secure attachment style. Few studies focused on headache and data on attachment style in pediatric headache are scarce.

METHODS

We studied 90 migraineurs (mean age 12.2 ± 2.6 years; female: 54, male: 36). Patients were divided in two groups according to headache attack frequency: (1) high frequency (HF) patients, having from weekly to daily episodes and (2) low frequency (LF) patients, showing ≤3 episodes per month. According to headache attack intensity, patients were classified in two groups: (1) mild pain (MP), allowing the patient to continue his/her daily activities and (2) severe pain (SP), leading to interruption of patient activities or forcing the child to go to bed. The psychological screening was assessed by SAFA Anxiety, Depression, and Somatization questionnaires. Attachment style was measured by the semi-projective test Separation Anxiety Test. Patients were divided into "secure," "avoidant," "ambivalent," and "disorganized/confused" attachment patterns.

RESULTS

We found a significant relationship between the attachment style and migraine features. The ambivalent attachment was the most common style among patients reporting high attack frequency (51%) and severe pain intensity (50%). Anxiety (SAFA-A Tot: F = 23.3, P < .001), depression (SAFA-D Tot: F = 11.8, P < .001), and somatization (SAFA-S Tot: F = 10.1, P < .001) were higher in patients with ambivalent attachment style. Moreover, our results showed an association between high attack frequency and high anxiety levels, in children with ambivalent attachment style (F = 6.7, P < .002).

CONCLUSIONS

Ambivalent attachment style may be a common vulnerability factor that impacts on pain severity, anxiety, depression, and somatization symptoms in young migraineurs. In particular, the present study provides the first evidence of the role of insecure attachment on the relationship between pain severity and psychological symptoms in migraine children.

Emotion-motion interactions in conversion disorder: an FMRI study

Objectives

To evaluate the neural correlates of implicit processing of negative emotions in motor conversion disorder (CD) patients.

Methods

An event related fMRI task was completed by 12 motor CD patients and 14 matched healthy controls using standardised stimuli of faces with fearful and sad emotional expressions in comparison to faces with neutral expressions. Temporal changes in the sensitivity to stimuli were also modelled and tested in the two groups.

Results

We found increased amygdala activation to negative emotions in CD compared to healthy controls in region of interest analyses, which persisted over time consistent with previous findings using emotional paradigms. Furthermore during whole brain analyses we found significantly increased activation in CD patients in areas involved in the ‘freeze response’ to fear (periaqueductal grey matter), and areas involved in self-awareness and motor control (cingulate gyrus and supplementary motor area).

Conclusions

In contrast to healthy controls, CD patients exhibited increased response amplitude to fearful stimuli over time, suggesting abnormal emotional regulation (failure of habituation / sensitization). Patients with CD also activated midbrain and frontal structures that could reflect an abnormal behavioral-motor response to negative including threatening stimuli. This suggests a mechanism linking emotions to motor dysfunction in CD.

Conversive disorders among children and adolescents: towards new "complementarist" paradigms?

This paper aims to describe current questions concerning conversive disorders among children and adolescents. We first describe prevalence and clinical characteristics of these. Many unresolved questions remain. Why do patients show excess, or loss of function? Attachment theory offers a relevant framework to answer this question. Does neurobiology of conversion disorders shed light on conversive processes? Current neurobiological research paradigms focus on the symptom, trying to infer processes, instead of proposing paradigms that test theoretical hypotheses. The most convincing theoretical framework that has already proposed a coherent theory of conversion is a psychodynamic one, which has not yet been tested with neurobiological paradigms. The interest of studying child and adolescent conversive disorders is to provide a means to more deeply investigate the two challenges we face: theoretical, and clinical ones. It provides the opportunity to access a pathopsychological process at its roots, not yet hidden by many defensive, rationalizing attitudes, and to better explore environmental features. We propose a "complementarist" model, which allows the combination of different approaches (neural, cognitive, environmental, attachment, intra-psychic) and permits proposal of different levels of therapeutic targets and means.

Factitious disorders and malingering: challenges for clinical assessment and management

Compared with other psychiatric disorders, diagnosis of factitious disorders is rare, with identification largely dependent on the systematic collection of relevant information, including a detailed chronology and scrutiny of the patient's medical record. Management of such disorders ideally requires a team-based approach and close involvement of the primary care doctor. As deception is a key defining component of factitious disorders, diagnosis has important implications for young children, particularly when identified in women and health-care workers. Malingering is considered to be rare in clinical practice, whereas simulation of symptoms, motivated by financial rewards, is regarded as more common in medicolegal settings. Although psychometric investigations (eg, symptom validity testing) can inform the detection of illness deception, such tests need support from converging evidence sources, including detailed interview assessments, medical notes, and relevant non-medical investigations. A key challenge in any discussion of abnormal health-care-seeking behaviour is the extent to which a person's reported symptoms are considered to be a product of choice, or psychopathology beyond volitional control, or perhaps both. Clinical skills alone are not typically sufficient for diagnosis or to detect malingering. Medical education needs to provide doctors with the conceptual, developmental, and management frameworks to understand and deal with patients whose symptoms appear to be simulated. Central to the understanding of factitious disorders and malingering are the explanatory models and beliefs used to provide meaning for both patients and doctors. Future progress in management will benefit from an increased appreciation of the contribution of non-medical factors and a greater awareness of the conceptual and clinical findings from social neuroscience, occupational health, and clinical psychology.

Connecting body and mind: the first interview with somatising patients and their families

In this article we outline the framework our consultation-liaison team has developed for interviewing families whose children present with medically unexplained symptoms. The framework was developed over many years in the context of our work with a large number of families, who collectively taught us to be more sensitive with regard to the experience of such families in the medical system, and who reacted strongly when we moved prematurely to the use of psychological language or to questions about family relationships or emotional functioning. Throughout the interview we maintain a focus on the body: the family history of illness and, in particular, the story of the child's symptoms. We take a detailed, temporally ordered history of the symptom and ask for collateral information - family illness, family life events, events at school, family emotional responses - all in relation to the story of the symptoms. In the assessment interview and in our work in general, we focus on the body. We move very carefully and very slowly from the physical to the psychological, from talking about the body to talking about relationships and about the mind.

Specific biases for identifying facial expression of emotion in children and adolescents with conversion disorders

OBJECTIVE

This study aimed to assess how children and adolescents with conversion disorders identify universal facial expressions of emotion and to determine whether identification of emotion in faces relates to subjective emotional distress.

METHODS

Fifty-seven participants (41 girls and 16 boys) aged 8.5 to 18 years with conversion disorders and 57 age- and sex-matched healthy controls completed a computerized task in which their accuracy and reaction times for identifying facial expressions were recorded. To isolate the effect of individual emotional expressions, participants' reaction times for each emotion (fear, anger, sadness, disgust, and happiness) were subtracted from their reaction times for the neutral control face. Participants also completed self-report measures of subjective emotional distress.

RESULTS

Children/Adolescents with conversion disorders showed faster reaction times for identifying expressions of sadness (t(112) = -2.2, p = .03; 444 [609] versus 713 [695], p = .03) and slower reactions times for happy expressions (t(99.3) = 2.28, p ≤ .024; -33 [35] versus 174 [51], p = .024), compared with controls (F(33.75, 419.81) = 3.76, p < .001). There were no significant correlations (at the corrected p value of .01) between reaction times and subjective reports of perceived distress (r values ranged from 092 to 0.221; p > .018). There were also no differences in identification accuracy for any emotion (p > .82).

CONCLUSIONS

The observation of faster reaction times to sad faces in children and adolescents with conversion disorders suggests increased vigilance and motor readiness to emotional signals that are potential threats to self or to close others. These effects may occur before conscious processing.

Fabricated illness: working within the family system to find a pathway to health

The term medically unexplained symptoms refers to a clinical presentation where the child's symptoms and impairment cannot be explained by any known organic pathology, and may include conversion disorders, somatoform pain disorders, factitious disorder, and factitious disorder by proxy. In this case study, we present our treatment of a 9-year-old girl with a 2-year history of medically unexplained abdominal cramping and vaginal discharge. During the 9 months that we worked with this family, we were never able to clarify in our own minds the source of the child's symptoms--that is, who was responsible for their induction or who was the instigator or maintainer of the exaggerated symptoms. Nor did we come to fully understand the function of the symptoms in the family system. Our case report does not answer either of these questions. Instead, we describe how we worked with the family despite the ongoing ambiguities as to why the symptoms were occurring and who was inducing them. The functional outcome was disappearance of symptoms, return to full school attendance, and improved parenting behavior.

Ascertainment of early onset eating disorders: a pilot for developing a national child psychiatric surveillance system

BACKGROUND

  A Child & Adolescent Psychiatric Surveillance System was established as part of a British Paediatric Surveillance Unit study of early onset eating disorders (EOED).

METHOD

  A study of EOED presenting to paediatricians was undertaken through the BPSU over 15 months in 2005-06.

RESULTS

  Monthly report cards compliance was 83%, identifying 208 EOED cases. On evaluation, 99% of psychiatrists responding supported the need for surveillance and 95% would continue to contribute.

CONCLUSIONS

  The findings of this pilot study suggest that a monthly surveillance of rare conditions in child and adolescent psychiatry is feasible and enhances ascertainment.

Patterns of emotional-cognitive functioning in pediatric conversion patients: implications for the conceptualization of conversion disorders

OBJECTIVES

To examine patterns of emotion processing in children and adolescents with conversion disorders and to determine whether those patterns are associated with particular clusters of conversion symptoms. Autobiographical narratives were used to investigate the organization of information about distressing feelings and memories.

METHODS

Structured interviews about attachment relationships and autobiographical events were administered to 76 controls and 76 matched subjects aged 6 to 18 years. Age-appropriate assessments of attachment were used: the School-aged Assessment of Attachment for children and the Transition to Adulthood Attachment Interview for adolescents. Patterns of emotion processing were identified using dynamic-maturational model discourse analysis and categorized into four clusters: inhibitory, normative/balanced, coercive-preoccupied, and mixed inhibitory and coercive-preoccupied. These clusters were then cross-tabulated with the sensorimotor characteristics of children with conversion disorders.

RESULTS

Emotion processing in children with conversion disorders was categorized as psychological inhibition (57%), psychological coercion-preoccupation (34%), and mixed (9%). Psychological inhibition was associated with negative conversion symptoms (discrete sensorimotor deficits, p = .003) and positive conversion symptoms (tremors and tics, p = .04). Psychological coercion-preoccupation was associated with all other disturbances of motor function: bizarre gaits and postures, whole-body floppiness, and refusals to move (p < .0001). Nonepileptic seizures occurred across both groups (56% versus 42%, p = .8).

CONCLUSIONS

Contrary to the classic understanding of conversion disorder as a unified diagnostic entity with diverse symptoms, this study identified two distinct subtypes of conversion patients-those using psychological inhibition and those using psychological coercion-preoccupation-whose symptoms fell into discrete clusters. Further research is needed to determine the neural mechanisms underlying these processes.

A developmental, body-oriented intervention for children and adolescents with medically unexplained chronic pain

The regulation of pain and other emotions is a developmental process that takes place in the context of attachment relationships. Children with chronic, medically unexplained pain struggle to accurately identify, communicate and regulate negative body states, and to connect these body states to their day-to-day experience. This article describes an individual intervention - one component of a multimodal treatment programme - whose aim is to help children find skills to manage their pain. The intervention incorporates ideas and practices from several theoretical models - the dynamic-maturational model of attachment, cognitive-behavioural theories, narrative therapy, art therapy, sensorimotor approaches -pragmatically selected and adapted to help children presenting to our Chronic Pain Service achieve good clinical outcomes. At the outset we assess the child's capacity to identify, regulate and communicate positive and negative body states, and tailor our individual intervention so as to extend each child's proximal level of development. We initially focus on the body in an effort to equip the child with a non-verbal, image-based language for identifying and communicating pain and other negative body states. Once the child has developed a non-verbal way of knowing her body, a range of cognitive-behavioural, narrative and other strategies are introduced. The intervention aims to increase the child's emotional functioning: her skill in identifying, symbolically representing, communicating and managing pain and other negative body states.

An exploratory investigation of abnormal pain response among preadolescent children in foster care

The present article describes a pattern of abnormal responses to pain (APR) among children in care, suggestive of pain insensitivity or failure to communicate felt pain. Exploratory analyses of caregiver-reported APR were conducted within a larger epidemiological study of 347 preadolescent children in foster and kinship care. APR items were generated from clinical assessment reports and a clinician survey, during development of a psychiatric rating scale for children in care. An APR construct was identified in factor analysis. Nine per cent of the sample had scores suggesting clinically meaningful APR, with a high level of corresponding psychological disturbance. Various analyses suggest the phenomenon may be a discrete, but integral component of complex, multifaceted psychopathology. Concurrent and retrospective measures of a large number of potential risk variables did not discriminate between APR scores and other estimates of psychopathology. However, moderate correlations between APR and ad hoc measures of impulsivity, dissociative behaviours, and inhibited-avoidant attachment difficulties suggest a number of hypothesized developmental mechanisms that might be explored in further studies.

Self-protective organization in children with conversion and somatoform disorders

OBJECTIVE

Two centuries of clinical observations have suggested that conversion symptoms are associated with strong emotions or situations that threaten the individual's physical or psychological integrity. This study tested the hypothesis that childhood conversion reactions reflect the motor-sensory components of two distinct emotional responses (one inhibitory, one excitatory) that develop as adaptations to recurring threats within intimate relationships.

METHOD

Emotional responses to interpersonal threats were assessed in 28 children with conversion disorders using Dynamic-Maturational-Model (DMM) assessments of attachment. Attachment strategies (the inhibitory, Type A; the balanced, Type B; and the excitatory, Type C) provide information about (1) the child's behavioural (motor-sensory) organization in the face of interpersonal threats, and (2) the information processing that underpins this behavioural organization.

RESULTS

Twelve children (43%) used an inhibitory attachment strategy. Twelve (43%) used an excitatory attachment strategy. A smaller group (14%) alternated between inhibitory and excitatory strategies, their conversion symptoms reflecting the latter.

DISCUSSION

These data suggest that conversion reactions are not a single clinical entity and reflect the motor-sensory components of two distinct human emotional responses to threat. This distinction may help to account for the broad range of conversion symptoms seen in clinical practice, both those that involve loss of function and can be explained by a central inhibition hypothesis and those that involve positive symptoms and secondary gain.