Problems with diagnosing Conversion Disorder in response to variable and unusual symptoms

Self-reported anterograde memory loss in older persons that is not validated on neuropsychological assessment: Considerations for a dissociative diagnosis

The past decade has witnessed amplified public awareness of age-related dementias. This has resulted in a dramatic rise in the number of older persons referred to memory clinics with a primary complaint of self-reported memory loss without an antecedent neurological event (e.g., stroke) who produce neuropsychological test profiles that lack evidence of such impairment. Since the latter part of the 19th century, a confusing array of changing terminology, criteria, and perceived causation have been ascribed to patients with unverified medical symptoms to implicate psychological causation. Such terms are often misperceived by laypersons as reflecting character flaws or malingering. Of import for clinical neuropsychologists, the 11th edition of the International Classification of Diseases added cognitive to symptoms eligible for a diagnosis of the modern formulation, dissociative neurological symptom disorder. One dissociative option for referrals with self-reported neurocognitive symptoms not validated on neuropsychological testing is functional memory disorder, conceived as a psychological disorder where emotional distress is plausibly related to the perceived memory loss but is of less severity than would warrant a major depressive or anxiety diagnosis. If evidence of psychological distress or behavioral impairment is not present the referral likely reflects the increased public awareness of age-related dementias interacting with the high base rate of self-perceived memory loss in the general population. In such cases, a dissociative diagnosis should be avoided as there is evidence of neither a medical nor a psychological disorder. A summary statement of not dementia or similar is likely sufficient to help the patient.

A narrative review of the literature on illness uncertainty in hypermobile ehlers-danlos syndrome: implications for research and clinical practice

BACKGROUND

Hypermobile Ehlers-Danlos syndrome (hEDS) is characterized by joint and skin laxity, and often accompanied by chronic pain, dysautonomia, increased distress and, functional limitations. The journey to accurate diagnosis is often prolonged due to unclear etiology of symptoms. This manuscript is a narrative review of the literature on illness uncertainty (IU) in hEDS, highlighting the unique facets of IU in this population, as compared to the broader chronic pain population (given symptom overlap between these two disease groups), that warrant additional investigation. Additionally, we considered the unique challenges associated with IU in the context of the developmental nuances of pediatric populations. Specifically, we aimed to (1) map the extant literature of the IU experience in chronic pain conditions broadly including the pediatric and adult research to identify key concepts related to IU and incorporate potential developmental considerations in IU; (2) delineate and describe the IU experience specifically in patients with hEDS, with the goal of identifying gaps in the literature based on aspects of presentation in hEDS that do and do not differ from the broader chronic pain population; and (3) elucidate the potential areas of adverse impact of IU in both general chronic pain populations, and those with hEDS specifically, to provide actionable areas for future research and clinical care of individuals with hEDS. Results of this review indicate that IU has been well-studied in chronic pain generally, but inadequately evaluated in hEDS specifically. Specific features of hEDS (complexity of the disorder, involvement of multiple bodily systems, contribution of organic pathology) may uniquely contribute to IU in this population. This review suggests that ambiguities surrounding the diagnosis of hEDS, symptom course, and treatment recommendations, along with misdiagnosis, perceived dismissal of symptoms, or attribution of symptoms to mental health concerns might increase risk for IU and related distress in patients.

CONCLUSION

Findings from the present review suggest that distinct features of hEDS yield a set of driving factors for IU that may be somewhat different than those faced by patients with chronic pain or other medical conditions. The development of a validated measure of IU to appropriately assess this construct in patients with hEDS is a research priority. In the clinical setting, providers should be attentive to the potentially aversive diagnostic and treatment experiences reported by patients and attempt to provide clear explanations based on the extant knowledge of hEDS, and implement best-practice recommendations for multidisciplinary treatment.

Updates on the psychological and psychiatric aspects of the Ehlers-Danlos syndromes and hypermobility spectrum disorders

The field of the psychiatric and psychological aspects of Ehlers-Danlos syndromes (EDS) has been understudied and neglected for many years. People with EDS are often classified as "somatizers" by untrained clinicians. However, research on the biological basis of EDS is improving our understanding of the physiology and psychopathology of the disorder. In this article, we consider the literature on the psychopathological dimensions associated with EDS as well as the EDS symptoms in psychiatric conditions since our review in 2017. Literature confirms that psychological processes (i.e., fear, emotional distress, or negative emotions) in EDS have a significant impact on the outcomes of EDS. Common systemic associations are found between anxiety disorders and EDS as well as significant correlations with neurodevelopmental, eating, mood, and sleep disorders. There is limited but increasing evidence of an association between EDS and suicidal thoughts and behaviors, which should be further explored. The broad spectrum of human anxiety and associated somatic symptoms (beyond anxiety disorders) appears to be the core of the psychopathology in EDS and therefore, detecting and assessing EDS might be a new opportunity for psychiatric nosology to develop more inclusive phenotypes like the Neuroconnective Phenotype that include both somatic and psychological manifestations.

Psychiatric Manifestations of Ehlers-Danlos Syndrome in Adolescents: A Case Report and Literature Review

Background:

Ehlers-Danlos Syndromes (EDS) comprise a group of heterogeneous hereditary connective tissue disorders [1, 2]. Psychiatric disorders such as depression, anxiety, panic disorder, agoraphobia, schizophrenia, neurodevelopmental disorders, personality disorder, eating disorders, substance misuse and interpersonal issues have been reported in the literature to be associated with EDS [1-3].

Objectives:

The case of a 15-year old male who was hospitalized after a suicide attempt by gunshot, who was discovered to have symptoms suggestive of EDS, is presented in this paper along with the results of a literature search of psychiatric manifestations of EDS in children and adolescents.

Methods:

Literature review was conducted on the UpToDate website on March 11, 2020 to review symptoms of Ehlers-Danlos Syndrome for the purpose of preliminary diagnosis of this patient. Additional literature search was conducted on PubMed on 4/2/20 at 12:10 P.M. and on 4/9/20 at 10:51 P.M. and on the search engine Google on 4/2/20 at 12:25 P.M. On May 11, 2020 at 2 P.M., another web search was conducted with a review of 6 different websites pertaining to Ehlers-Danlos Syndrome.

Results:

A systematic review of psychiatric manifestations of Ehlers-Danlos Syndromes revealed a strong incidence of psychiatric symptoms.

Conclusion:

Our patient’s psychiatric symptoms of depression, suicidal ideations, anxiety and social and educational struggles may have been at least partially due to chronic pain- abdominal, headache and musculoskeletal, and social ostracization associated with Ehlers-Danlos Syndrome. Education regarding this illness helped our patient’s recovery as he came to understand why he was so “odd” and the cause of his multisystemic chronic pain.

Psychiatric and psychological aspects in the Ehlers-Danlos syndromes

There is increasing amount of evidence pointing toward a high prevalence of psychiatric conditions among individuals with hypermobile type of Ehlers-Danlos syndrome (JHS/hEDS). A literature review confirms a strong association between anxiety disorders and JHSh/hEDS, and there is also limited but growing evidence that JHSh/hEDS is also associated with depression, eating, and neuro-developmental disorders as well as alcohol and tobacco misuse. The underlying mechanisms behind this association include genetic risks, autonomic nervous system dysfunction, increased exteroceptive and interoceptive mechanisms and decreased proprioception. Recent neuroimaging studies have also shown an increase response in emotion processing brain areas which could explain the high affective reactivity seen in JHS/hEDS. Management of these patients should include psychiatric and psychological approaches, not only to relieve the clinical conditions but also to improve abilities to cope through proper drug treatment, psychotherapy, and psychological rehabilitation adequately coupled with modern physiotherapy. A multidimensional approach to this "neuroconnective phenotype" should be implemented to ensure proper assessment and to guide for more specific treatments. Future lines of research should further explore the full dimension of the psychopathology associated with JHS/hEDS to define the nature of the relationship. © 2017 Wiley Periodicals, Inc.

Psychogenic Explanations of Physical Illness

In some patients with chronic physical complaints, detailed examination fails to reveal a well-recognized underlying disease process. In this situation, the physician may suspect a psychological cause. In this review, we critically evaluated the evidence for this causal claim, focusing on complaints presenting as neurological disorders. There were four main conclusions. First, patients with these complaints frequently exhibit psychopathology but not consistently more often than patients with a comparable “organic” diagnosis, so a causal role cannot be inferred. Second, these patients report a high incidence of adverse life experiences, but again, there is insufficient evidence to indicate a causal role for any particular type of experience. Third, although psychogenic illnesses are believed to be more responsive to psychological interventions than comparable “organic” illnesses, there is currently no evidence to support this claim. Finally, recent evidence suggests that biological and physical factors play a much greater causal role in these illnesses than previously believed. We conclude that there is currently little evidential support for psychogenic theories of illness in the neurological domain. In future research, researchers need to take a wider view concerning the etiology of these illnesses.