Dissociative disorder, conversion disorder and the use of abreaction in a 22 year old male.
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Abreaction↗
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Clinical Manifestations and Management of Conversion Disorders.
Conversion disorder, the acute onset of sensory or motor loss unexplained by physical findings, has long been reported in the neurologic and psychiatric literature. It was once thought to be largely covariate with the "hysterical" (now referred to as "histrionic") personality, but recent work finds that conversion disorder more often presents in the absence of this personality disorder. Conversion disorder may also be part of a chronic pattern of physical expression of psychologic distress known as somatization disorder. Other psychiatric illnesses (particularly mood and anxiety disorders) are frequently comorbid, and conversion disorder and their treatment may affect the prognosis of conversion disorder symptoms. The neurologist suspecting a case of conversion disorder is advised to complete a thorough neurologic evaluation, and to have a low threshold for psychiatric consultation, which facilitates prompt comanagement that may increase the likelihood of a return to premorbid function.
Journal Article↗
Management of conversion disorder.
Conversion disorder is a psychologically produced alteration or loss of physical functioning suggestive of a physical disorder. Conversion symptoms are often superimposed on organic disease and can be overlooked. Psychological techniques are central to the management of conversion symptoms. Principles of psychological management include the following: avoiding confrontation with the patient; avoiding reinforcement or trivializing the symptoms; reviewing results of tests and exams and creating an expectation of recovery; educating the patient by providing a benign explanatory model of symptoms; evaluating the patient's emotional adjustment and referring for psychotherapy when possible. Use of behavior therapy reinforcement and double-bind psychotherapy strategies may be helpful with more chronic or resistant symptoms, especially when there is a history of vague or excessive somatic complaints or significant secondary gain. Four case studies are presented to illustrate these principles.
Adult↗
[Conversion syndromes in neurology. A psychopathological and psychodynamic differentiation of conversion disorder, somatization disorder and factitious disorder].
Conversion syndromes are frequent among medically unexplained somatic symptoms in neurology. A careful differential diagnosis must be carried out in a psychiatric consultation service. In a prospective study lasting for over four years 169 patients with pseudoneurological signs of conversion were included. From a clinical point of view the following conversion syndromes were presented: astasia/abasia: 27.2%, paresis/plegia: 24.3%, aphonia: 1.8%, hyp-/anaesthesia: 21.9%, blindness: 5.3%, non-epileptic seizures: 19.5%. According to the diagnostic criteria of DSM-III-R three subgroups were differentiated: conversion disorder (n = 132), somatisation disorder (n = 28), factitious disorder (n = 9). Intermittent courses of illness were prevailing in conversion disorder, whereas chronic courses predominated in the other two subgroups. High rates of psychiatric comorbidity were typical signs of somatisation disorder. Frequent autodestructive motives (suicidality, deliberate and covert self-harm, chronic pain, high rate of operations) in illness behaviour had to be registered in somatisation and factitious disorder. Both subgroups were characterised by frequent traumatic events during early development. Important socio-economic aspects of illness behaviour above all in somatisation and factitious disorder were underlined. The results are discussed in terms of psychiatric differential diagnosis and psychiatric comorbidity, psychodynamic evaluation, illness behaviour and therapeutic options in a C/L-service.
Adult↗
Hypnotic susceptibility in patients with conversion disorder.
Conversion disorder has been associated with hypnotic susceptibility for over a century and is currently still believed to be a form of autohypnosis. There is, however, little empirical evidence for the relation between hypnotic susceptibility and conversion symptoms. The authors compared 50 patients with conversion disorder with 50 matched control patients with an affective disorder on measures of hypnotic susceptibility, cognitive dissociation, and somatoform dissociation. Conversion patients were significantly more responsive to hypnotic suggestions than control patients. In addition, conversion patients showed a significant correlation between hypnotic susceptibility and the number of conversion complaints. These results provide the first evidence of a relationship between hypnotic susceptibility and the presence and number of conversion symptoms.
Adult↗
When neurological symptoms are not what they appear: the challenge of caring for patients with conversion disorders.
Conversion Disorders involve the psychogenic loss or disturbance of sensory, motor or other physical functions in a manner suggestive of neurologic or other somatic disease but without any actual finding of the latter. These problems are subconscious, with patients not being able to control their symptoms. Jean-Marie Charcot, in the 19th century, was fascinated with this disorder and his work, followed by that of Sigmund Freud, laid the foundation for our modern concept of Conversion Disorder. Multiple Sclerosis, with its fluctuating and unpredictable symptoms has frequently been erroneously diagnosed in these cases. The often bizarre, flamboyant presentations, while interesting, pose many difficult and complex management problems. This paper will describe three of the more severe and disabled examples of this condition seen in the London Multiple Sclerosis Clinic and an attempt will be made to uncover common patient characteristics. Current thoughts regarding the management of these patients will be outlined, the emphasis being on helping neuroscience nurses develop an approach which is informed, positive and compassionate.
Adult↗
[A case of myasthenia gravis diagnosed as conversion disorder].
Conversion disorder is a difficult diagnosis. The patients' psychiatric backgrounds and the complexity of the diagnosis of some neurologic diseases are the main reasons for diagnostic errors. Based on one observation, the diagnostic criteria and the differential diagnosis of conversion disorder are addressed.
Aged↗
Psychosocial interventions for conversion disorder.
BACKGROUND: Conversion disorder is an alteration or loss of physical functioning suggestive of a physical disorder that is thought to be due to a psychological stressor or conflict. The fact that many theories about the cause of conversion disorder focus on psychological and social factors would suggest that a psychosocial intervention might be of most benefit. OBJECTIVES: To investigate the efficacy of psychosocial interventions on people diagnosed with conversion disorder compared with standard care, a biological intervention or another psychosocial intervention. SEARCH STRATEGY: We searched the Cochrane Depression, Anxiety and Neurosis Group Trials Register (May 2004), various databases on OVID (February 2004), handsearched reference lists and textbooks on conversion disorder and contacted relevant authors. SELECTION CRITERIA: We included all randomised controlled trials that compared psychosocial interventions for conversion disorder with standard care or other interventions (biological or psychosocial). DATA COLLECTION AND ANALYSIS: We reliably selected, quality assessed and extracted data from the studies. For dichotomous outcomes we calculated a relative risk with its associated 95% confidence interval and a number needed to treat. For continuous data we calculated a weighted mean difference. MAIN RESULTS: The search identified 260 references, 217 were clearly not relevant to this review and excluded on the basis of their titles and abstracts, 40 more were excluded after reading the full papers (the reasons are given in the excluded studies tables) and only three studies (total n =119) met the inclusion criteria. One study was concerned with paradoxical injunction therapy and the other two studied the value of hypnosis. The three studies had different interventions and control groups so the results could not be combined. All of the studies were of poor methodological quality and it is therefore difficult to place much value on the results of the studies. We were unable to include some data because of poor reporting. AUTHORS' CONCLUSIONS: Randomised studies are possible in this field. The use of psychosocial interventions for conversion disorder requires more research and it is not possible to draw any conclusions about their potential benefits or harms from the included studies.
Anti-Anxiety Agents↗
Conversion disorder revisited.
Conversion disorder is defined as a psychiatric illness whose symptoms or deficits, affecting voluntary motor or sensory function, cannot be explained by a neurological or general medical condition. Proposing a strategy in the search for the neural mechanisms underlying conversion disorder is a difficult task, partly because key features of the illness inherently lie on a continuum with other psychiatric disorders, such as depression and posttraumatic stress disorder. Recent brain imaging studies have revealed neural circuits involved in complex mental processes potentially related to conversion disorder. These studies are reviewed, together with neuroimaging work in conversion disorder and brain imaging studies that have enriched the conceptualization of memory and emotion in posttraumatic stress disorder and major depression. Analysis of this information from a symptom-based rather than a disease-category perspective leads to a brain-based cognitive model of conversion disorder. This model suggests that disconnected crosstalk between the individual subdivisions of the anterior cingulate and the prefrontal cortex might provide a neuroscientific basis for the psychodynamic dissociation hypothesis, traditionally the bedrock explanation of the relationship between internal conflict and physical deficit. The model also suggests novel research approaches, as well as opportunities for potential therapeutic interventions.
Brain↗
Somatization and conversion disorders: comorbidity and demographics at presentation.
Although somatization disorder and conversion disorder are linked in DSM-III and DSM-III-R, they have very different histories. To directly compare these disorders, we reviewed the records accrued for 2 years at a large medical center and identified 65 somatization disorder patients and 51 conversion disorder patients. They differed substantially. The large majority (78%) of conversion disorder patients and nearly all (95%) of the somatization disorder patients were women. Ages at onset occurred throughout the life span among conversion disorder patients but mostly before the age of 21 among the somatization disorder patients. Somatization disorder patients were more likely to have had a history of depression, attempted suicide, panic disorder and divorce.
Adolescent↗
Conversion disorder.
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Conversion Disorder↗
Polysymptomatic conversion disorder in childhood and adolescence in Japan. Early manifestation or incomplete form of somatization disorder?
BACKGROUND: In conversion disorder in childhood and adolescence, polysymptomatic (PS) presentations are reportedly commoner than monosymptomatic (MS) ones. Somatization disorder is also associated with pseudoneurological symptoms, but is extremely rare in childhood. This occurs despite the age of onset peaking in the teens among adult somatization disorder patients. METHOD: We reviewed the records of 44 children and adolescents with pseudoneurological symptoms. They were categorized as MS cases (19) or PS cases (25), and their psychological backgrounds and clinical courses were compared. RESULTS: PS patients had a poorer prognosis and more past psychiatric and family problems. While none met the DSM-IV criteria for somatization disorder, 2 PS patients met all but the sexual symptoms criteria. CONCLUSION: PS conversion disorder in childhood and adolescence may constitute a different entity from MS conversion disorder and may be an early manifestation or incomplete form of somatization disorder.
Adolescent↗
[Early onset conversion disorder: a case report].
Conversion disorder is defined as the presence of functional impairment in motor, sensory and neurovegetative systems that cannot be fully explained by a general medical condition. In western countries, conversion disorder is rare in children and adolescents. However, clinical studies from our country demonstrated a high frequency of conversion disorder diagnosis in child and adolescent psychiatry clinics. Conversion disorder is more frequently seen in adolescents and young adults compared to children. The likelihood of this disorder in children younger than five years of age is very low. This case report presents an 8 years old patient with conversion disorder diagnosis whose complaints started at three years of age. Her clinical condition had been continuous and resistant to non-psychiatric treatment approaches. Her complaints included inability to stand up and walk, complete bed dependence, presence of jerking type of movements in both legs, contractures as a result of decreased muscle movements and joint use, and presence of curving in her back due to continuous sitting bent to one side. Therapeutic interventions had been successful and the patient completely recovered. In this paper, the clinical presentation of conversion disorder, possible etiological factors and how these factors were handled, concrete treatment strategies and the follow-up of this patient are discussed. In addition, importance of early diagnosis and treatment of conversion disorder in children in our country and requirement of interdisciplinary cooperation in treatment are emphasized.
Child↗
Dissociative disorders in Turkish inpatients with conversion disorder.
The aim of our study was to determine the frequency of dissociative disorders (DDs) among inpatients with conversion disorder (CD) in a university clinic settled in Eastern Turkey. During a period of 24 months, 59 consecutively admitted adult CD patients were screened with the Dissociative Experience Scale (DES). Patients who scored above 30 (DDs group) did not differ by age or gender from a group of inpatients who scored below 10 on the scale (comparison group). All patients in the two groups were then interviewed in a blind manner using the Dissociative Disorders Interview Schedule (DDIS) and Structured Interview for DSM-IV Dissociative Disorders (SCID-D). According to the SCID-D, 18 of 59 patients (30.5%) received a diagnosis of dissociative disorder; nine of these 18 patients (50%) were diagnosed as having dissociative identity disorder, eight (44.4%) were diagnosed as having dissociative disorder not otherwise specified (NOS), and one (5.6%) was diagnosed as having dissociative amnesia. Accordingly to the DDIS, borderline personality disorder was frequent in the DDs group, and all of the patients in the DDs group reported sexual abuse and neglect during childhood, latency, or adolescence. A high proportion of CD patients have significant dissociative pathology. The proper diagnosis of these patients has important implications for their clinical course.
Adolescent↗
Associated features of conversion disorder in Turkish adolescents.
BACKGROUND: Conversion disorder in adolescents has not been studied extensively. A limited number of studies have focused on the features related to conversion disorder in adolescents. However, most of these studies used either retrospective data or did not have a control group that would allow comparison with the index cases. METHODS: Fifty-two Turkish adolescent patients diagnosed with conversion disorder were compared with a control group of 52 adolescents diagnosed with psychiatric disorders other than conversion disorder. The data were collected from the adolescent subjects and their mothers by various questionnaires, inventories, and psychiatric interviews. RESULTS: In the present study, pseudoseizures were the most common subtype of conversion disorder, followed by motor symptoms or deficits. Coming from a rural area, having a broken family, long-term separation from parents, problems related to communication and expression of emotions in the family, higher anxiety scores, conversion disorder in the proximal environment, and conversion disorder or other psychiatric disorders in the mother were significantly associated with conversion disorder in adolescents. CONCLUSIONS: The findings of the present study are in accordance with existing findings, and amplify the importance of problems in family functioning in the etiology of conversion disorder.
Adolescent↗
Cognitive behavioural and neuropsychiatric treatment of post-traumatic conversion disorder: a case study.
Conversion disorder consists of involuntary sensory or motor symptoms and deficits that cannot be explained by a general medical condition. There are several treatment options, although none has emerged as the treatment of choice. The present case study examined the effects of adding cognitive behaviour therapy to neuropsychiatric management of conversion disorder (motor subtype). The patient, a retired emergency services worker, presented with a history of intermittent episodes of speech disruption (inability to speak or difficulty speaking properly). Although episodes of speech disturbance sometimes occurred unexpectedly, they were more likely to occur under conditions of stress and fatigue, and were triggered by reminders of work-related traumatic events. The patient was treated with pharmacotherapy and psychoeducation from a neuropsychiatrist. With the aim of improving treatment outcome, cognitive behaviour therapy was added, involving imaginal exposure to trauma memories, along with cognitive restructuring. The frequency of between- and within-session speech disturbance episodes declined over the course of cognitive behaviour therapy to the point that the patient was essentially symptom-free. Within-session distress ratings also decreased, which suggested habituation to trauma-related memories. This case study demonstrates how particular cognitive behaviour therapy interventions can be usefully applied to one form of conversion disorder.
Adaptation, Psychological↗
Motor conversion disorders reviewed from a neuropsychiatric perspective.
BACKGROUND: Conversion disorder is a somatoform disorder defined by the presence of pseudoneurologic symptoms relating to voluntary sensory or motor function. The correct diagnosis of conversion disorder presenting with motor symptoms is complicated by the lack of gold-standard diagnostic tests and the absence of a universally accepted set of positive diagnostic criteria. This article reviews the epidemiology, pathophysiology, presentation, differential diagnosis, treatment, and prognosis of motor conversion, placing emphasis on diagnostic validity, reliability, and utility, while evaluating the empirical evidence supporting diagnostic and treatment strategies. DATA SOURCES AND STUDY SELECTION: Literature searches were carried out in PubMed using the keywords conversion disorder, motor conversion, dystonia, psychogenic, hysteria, somatization, motion disorder, movement disorder, and patho-physiology. Articles and book chapters in the author's personal collection were also utilized. CONCLUSIONS: Advances in neuropsychiatric research are leading to significant improvements in the diagnosis and understanding of motor conversion disorders. Positive, objective, and quantitative diagnostic criteria show significant promise for enhancing diagnostic accuracy. Current pathophysiologic research has begun to provide mechanistic explanations for conversion symptoms, thus blurring the distinction between psychogenic and organic motor disorders.
Cerebral Cortex↗
Anxiety and depressive symptoms in patients with conversion disorder.
OBJECTIVE: To determine symptom pattern of conversion disorder and its association with co-existent anxiety and depressive symptoms. DESIGN: Descriptive, cross-sectional study. PLACE AND DURATION OF STUDY: The study was conducted in the Department of Psychiatry, Services Hospital, Lahore from August 2003 to January 2004. MATERIALS AND METHODS: One hundred patients, suffering from conversion disorder, diagnosed on the basis of DSM-IV criteria, were assessed for severity of anxiety and depressive symptoms by using hospital anxiety and depression scale (HADS). A semi-structured interview was used for demographic details. RESULTS: Anxiety was seen to be present in 35% of cases, depression in 29% and 31% of the patients had both anxiety and depressive symptoms. Overall co-morbidity of anxiety and depressive symptoms in conversion disorder was high i.e. 95% and only 5% of the patients were without any co-morbid anxiety and depressive symptoms. A significant association was found between depressive and sensory symptoms (p=<0.05) in patients with conversion disorders. CONCLUSION: The patients with a diagnosis of conversion disorder need to be managed for anxiety and depressive symptoms appropriately for better outcome.
Adult↗