Conversion Disorder in Young People. Consultant Child and Adolescent Psychiatrist Southampton Children s Hospital

Size: px

Start display at page:

Download "Conversion Disorder in Young People. Consultant Child and Adolescent Psychiatrist Southampton Children s Hospital"

Kory Jenkins
5 years ago
Views:

1 Conversion Disorder in Young People Dr Anthony Crabb Dr Anthony Crabb Consultant Child and Adolescent Psychiatrist Southampton Children s Hospital

2 Conversion (noun) Pronunciation: /kənˈvəːʃ(ə)n/ The process of changing or causing something to change from one form to another Logic the transposition of the subject and predicate of a proposition according to certain rules to form a new proposition by inference. The fact of changing one s religion or beliefs or the action of persuading someone else to change theirs Rugby - a successful kick at goal after a try, scoring two points

5 Conversion disorder Concept around since Hippocrates Hysteria - the wandering uterus Briquet Charcot

6 Freud

7 DSM-IV defines conversion disorder as follows: One or more symptoms or deficits are present that affect voluntary motor or sensory function suggestive of a neurologic or other general medical condition. Psychological factors are judged, in the clinician's belief, to be associated with the symptom or deficit because conflicts or other stressors precede the initiation or exacerbation of the symptom or deficit. A diagnosis where the stressor precedes the onset of symptoms by up to 15 years is not unusual. The symptom or deficit is not intentionally produced or feigned (as in factitious disorder or malingering). The symptom or deficit, after appropriate investigation, cannot be explained fully by a general medical condition, the direct effects of a substance, or as a culturally ll sanctioned behavior or experience. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation. The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of somatization disorder, and is not better accounted for by another mental disorder.

8 Not to be confused with.. Medically unexplained symptoms Functional neurological disorders - NEAD Hysteria Somatoform disorders Psychosomatic disorders Pain syndromes eg CRPS, RSD Recurrent (functional)abdominal pain

9 Common? Ani et al (2013 BJPsych) 12 month incidence of 1.3/100,000 Most common sympts motor weakness and abnormal movements. Antecedant stressors in 80% F-up of 147/204 at 12 months all sympts reported as improved. Most families ii (91%) accepted non-medical explanation

10 Conversion Disorder in Children: <1 per 1000 (Fritz 1997, USA) Conversion Disorder in Children per 100,000 (Kozlowska et al 2007, Australia)

11 Spectrum One-third of all physical symptoms in primary care medically unexplained (Sumathipala, 2007,London) 6% of new neurology outpatients (Stone, Carson Edinburgh series, 2006) CRPS 1-2 % post any fracture to 25% post Collies CRPS 1-2 % post any fracture to 25% post Collies fracture (Feliu, North Carolina, 2010)

12 Misdiagnosis? Stone et al (2005) 29% 1950s 17% 1960s 4% 1970s-90s

13 Neuro-imaging Research PET, SPECT and fmri Able to illustrate functioning of particular areas in real time Area in its infancy but gaining i substantial interest Beginning to get clearer idea of neurobiological correlates of MUS

14 Neurobiological correlates Frontal cortical, limbic activation associated with emotional stress In turn acts via inhibitory basal ganglia- thalmocortical circuits Result is deficit of conscious sensory/motor processing (Harvey et al, Neuropsychiatric Disease and Treatment, 2006)

15 Areas of Interest Ventrolateral pre-frontal cortex (VLPFC) Dorsolateral pre-frontal cortex (DLPFC) Limbic system, esp anterior cingulate and thalamus

16 Areas of right LPFC appear to be involved in inhibitory control across multiple l domains: motor, memory, thought, emotion. VLPFC

17 DL-PFC serves as the highest cortical area responsible for motor planning, organization, and regulation. Plays an important role in the integration of sensory and mnemonic information and the regulation of intellectual function and action.

18 Limbic system Hypothalamus Cingulate Gyrus Amygdala Hippocampus Thalamus + others

19 Sensory deficits Associated with hypo-activation of the sensory corticies and disturbed functioning of DLPFC, VLPFC

20 Motor deficits Motor disturbance is associated with either excessive activation of (inhibitory) orbito-frontal cortices or suppression of activation in the DLPFC.

21 Anxiety Participants high in anxious apprehension show reduced left VLPFC recruitment during selection tasks. VLPFC functioning improved in anxiety states t with midazolam (GABA)

22 Functional neuroanatomical correlates of hysterical sensorimotor loss. Vuilleumier P, et al. Brain Jun;124(Pt 6): Single photon emission computerized tomography (SPECT) Consistent decrease of regional cerebral blood flow in the thalamus and basal ganglia contralateral to the deficit. Subcortical asymmetries ti were present in each subject. Contralateral basal ganglia and thalamic hypoactivation resolved after recovery.

23 Vuilleumier P, et al. Lower activation in contralateral t l caudate during hysterical conversion symptoms predicted poor recovery at follow-up. Functional disorder in striatothalamocortical circuits controlling sensorimotor function and voluntary motor behaviour. Basal ganglia especially the caudate nucleus may modulate motor Basal ganglia, especially the caudate nucleus may modulate motor processes based on emotional and situational cues from the limbic system.

24 Summary Conversion disorder rare Functional symptoms common Diagnosis still somewhat controversial Shared understanding still lacking Generally favourable outcome Neuro-biological correlates becoming clearer

Psychiatric Mis-Diagnosis in Pediatric Pain Problems

Psychiatric Mis-Diagnosis in Pediatric Pain Problems Richard Barnum, M.D. Somatization Disorders Conversion Disorder DSM IV Somatization Disorder A. A history of many physical complaints beginning before