J. Indian Assoc. Child Adolesc. Ment. Health 2010; 6(3): Original Article

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1 49 J. Indian Assoc. Child Adolesc. Ment. Health 2010; 6(3):49-54 Original Article Clinical Features and Outcome of Conversion Disorders in Children and Adolescents Sujata Sethi, Raghu Gandhi*, Dharmendra**, Department Psychiatry, PGIMS, Rohtak *Junior Resident, ** Senior Resident Address for Correspondence: Dr. Sujata Sethi, 122/8, Shivaji Colony Rohtak , Haryana, INDIA. Abstract Background: To study the prevalence, clinical correlates and outcome of Conversion Disorders (CD) in children and adolescents. Methods: All the children and adolescents receiving ICD-10 diagnosis of Conversion Disorder during the period of July 2008 to June 2009 constituted the study sample. Results: During the 12 months period, a total of 332 children and adolescents were evaluated. 41 (12.5%) received the ICD-10 diagnosis of CD. 53% of the subjects were in the age group of years. Majority (61%) of them were girls. 56% had an acute onset of illness (<2 weeks). Most common conversion symptom noticed was convulsions (pseudoseizures) followed by dissociative motor symptoms. About ninety percent of the subjects had one or more significant psychosocial stressor. 12 (30%) had positive family history of mood disorder and dissociative disorder. 93% showed remission within a month. During the period of next 18 months a total of 6 children were lost to follow-up. Out of remaining 35 children, 3 had relapsed; 2 presented with the same symptoms as that of initial presentation and one with different symptoms. Rest of the children were functioning normally and had resumed schooling. Conclusion: CD in Indian children and adolescents is not uncommon as is shown by Western literature. It has a good outcome. Early diagnosis and presence of precipitating factor are predictors of good outcome. Key words: conversion disorder, prevalence, pseudoseizures, outcome. Conflict of Interest : The authors declare that they have no competing interests. Introduction Studies from developed countries show that Conversion Disorders (CD) are uncommon in children and adolescents 1,2. This is in contrast to studies from India (3-6). These studies further show a difference in the prevalence rates between clinic based and inpatient based studies. However, there is not much work done on the outcome of CD. This study was undertaken to examine the prevalence, clinical correlates and outcome of CD in children and adolescents.

2 50 Methods This is a prospective clinic based study conducted in the Department of Psychiatry, Post Graduate Institute of Medical Sciences (PGIMS), Rohtak, India. The department runs a special Child Guidance Clinic as an outpatient service for children up to age of 16 years. All the patients are seen in detail by a resident and then discussed with consultant for diagnosis and management. All the children and adolescents receiving ICD-10 diagnosis of conversion disorder during the period of July 2008 to June 2009 constituted the study sample. After obtaining assent from children and adolescents and informed consent from parents, information was gathered using a specially designed semi-structured proforma. Adolescents of >16 years at the time of presentation and a known / suspected history of organic disorders were excluded. All subjects received treatment based on NIMHANS model which included normalization of daily routine, cutting down secondary gains, family crisis resolution, individual psychotherapy and family counseling 3. All children were followed up for the next 18 months to study the outcome of initial presentation. Results During the 12 months period (July 2008 to June 2009), a total of 332 children and adolescents were evaluated at outpatient level. Forty one (12.5%) children received the ICD-10 diagnosis of CD. Table 1 presents the socio-demographic and illness variables of the study sample Table 1 : Demographic and clinical characteristics of the sample Characteristic Distribution (n=41 ) Mean age at the presentation (years) ± Gender n (%) Male 16 (39%) Female 25 (61%) Residence n (%) Urban 12 (29%) Rural 29 (71%) Family type n (%) Nuclear 27 (66%) Non nuclear 14 (34%) Educational status Enrolled in school 35 (85 %) Non enrolled 6 (15%) Illness variables Mean duration of illness (weeks) Presence of precipitating factors n (%) Prior non psychiatric consultations n (%) Family history of psychiatric illness -Mood disorder -Dissociative disorder -Both mood & dissociative disorders Outcome Drop out n (%) Complete remission -at 1 month n (%) -at 18 months n (%) Mean time to remission (weeks) Relapse same symptom n (%) Relapse symptom substitution n (%) ± (90%) 25 (60%) 12 (30%) 4 (10%) 6 (15%) 2 (05%) 6 (14%) 38 (93%) 32 (80%) ± (5%) 1 (2%)

3 51 Demographic characteristics Frequency analysis showed 53% of the subjects to be post-pubertal in the age group of years. Majority (61%) of them were girls; residing in rural setting (71 %) and living in nuclear family setting (66 %). Most (85 %) of the children were school goers. Illness variables 56% of children had an acute onset of illness (less than 2 weeks). About 60% had consulted local faith-healer and/or general practitioner before seeking psychiatric consultation and almost every child was referred to psychiatric services either by the Department of Paediatric Medicine or emergency services. Common conversion symptom noticed was convulsions (pseudoseizures) (49%) followed by dissociative motor symptoms (18%). About 90% percent of the subjects had one or more psychosocial stressor (Table 2). Twelve (30%) children had positive family history of mood disorder and/or dissociative disorder as shown in Table 2. Table 2: Nature of stressor Stressor n* Intrafamilial Death in the family Parental discord Punishment Extrafamilial Quarrels with neighbors Academic difficulties Trouble with peers Others Febrile illness (self) Road side accident (minor) Impending marriage *A child may have reported more than one stressor

4 52 Table 3a: Overall univariate analysis of association of socio-demographic and clinical variables. Variables Duration of index episode( weeks) Lost on followup Χ 2 P value Age (years) Up to > Duration of illness <2 weeks weeks weeks >12 weeks Stress Factor Yes No Diagnosis DMD DMS DS PS TP DMS+DS DMS+DS TP+DS Majority of children (72%) were symptom free within a week of consultation and initiation of therapeutic work and by the end of fourth week 93 % showed total remission. However 3 children continued to have symptoms with variable intensity for next 6 months and were eventually lost to follow up. During the period of next 18 months a total of 6 children (including 3 children mentioned above) were lost to follow-up. Out of the remaining 35 children 3 had relapsed; 2 presented with the same symptom as that of the initial presentation and one with different symptoms (symptom substitution). Rest of the children were functioning adequately and had resumed schooling. Multivariate analysis (Tables 3a & 3b) showed a positive correlation between the outcome and the presence of psychosocial stressor (p 0.002) and short duration of illness (p ) Table 3b: Overall multivariate analysis of association of socio-demographic and clinical variables. Model Standardized Coefficient β P Value Constant 0.47 Age Duration of illness Stress Factor Diagnosis

5 Discussion This study is one of the very few studies on the outcome of conversion disorders in children and adolescents from India. Various sample characteristics such as age, gender and residential status (urban/rural) are generally in agreement with other reports from India 3-9 and other countries 1, 2. Cultural anthropologists report that conversion disorders are quite common in complex and restrictive societies like India 10, 11. Conversion reactions are probably implicit behavior components to communicate stress in restrictive and conservative environment. Indian society is a restrictive society wherein restrictions are much higher for female gender and in rural setting. This may explain higher rates in girls and in rural population. Pseudoseizures were the most common clinical presentation followed by dissociative motor symptoms as has been reported by previous studies 3, 6, 12, 13. Though no particular sub-diagnosis correlated with outcome but dramatic presentation could be one of the reasons that theses subjects were brought to clinical attention early and more frequently. Remission in 93% of subjects within a month reflects good outcome as has been shown by previous studiers 3, 5, 6, 14. This improvement was maintained by majority of children over the next 18 months as evident by relapse in only 3 (8%) children. This favorable outcome could be due to acute presentation, comprehensive treatment plan that rapidly controlled the symptoms, and continuity of care including support. The limitations of the study include small sample size, absence of a structured assessment of the dissociative / conversion symptoms, absence of blind rating during follow up of the subjects; thus generalization of the results to other population even within India has to be done with caution. Conclusion In conclusion, Conversion Disorder in children and adolescents is not that uncommon in India as is shown by Western literature and it seems to have a good outcome. Short duration of symptoms before seeking help and presence of precipitating factor are predictors of good outcome. References 1. Lehmkuhl GB, Lehmkul V, Scharm BH: Conversion disorder (DSM-III ): symptomatology and course in childhood and adolescence. Eur Arch Psychiatr Neurol Sci 1989, 238: Tomasson K, Kent D, Geryell W: Somatization and conversion disorder: comorbidity and demographics at presentation. Acta Psychiatr Scand 1991, 84: Srinath S, Bharat S, Girimaji S, Seshadri S: Characteristics of a child inpatient population with hysteria in India. J Am Acad Child Adolesc Psychiatry 1993, 32: Chadda RK, Saurabh: Patterns of psychiatric morbidity in children attending a general psychiatry unit. Indian J Pediatr 1994, 61: Srinath S, Girimaji SC, Gururaj G, Seshadri S, Subbakrishna DK, Bhola P et al: Epidemiological study of child and adolescent psychiatric disorders in urban and rural areas of Bangalore, India. Ind J Med Res 2005, 122: Prabhuswamy M, Jairam R, Srinath S, Girimaji S, Seshadari S: A systematic chart review of inpatient population with childhood dissociative disorder. J Ind Assoc Child Adolesc Ment Health 2006, 2(3): Malhotra S, Singh G, Mohan A: Somatoform and dissociative disorders in children and adolescents: a comparative study. Indian J Psychiatry 2005, 47:

6 8. Sharma I, Giri D, Dutta A, Mazumder P: Psychosocial factors in children and adolescents with conversion disorder. J Ind Assoc Child Adolesc Ment Health 2005, 1(4): Chaturvedi S K, Desai G, Shaligram D: Dissociative disorders in a psychiatric institute in India- a selected reviews and patterns over a decade. Int J Soc Psychiatry 2010, 56 (5): Bourguignon E: World distribution and patterns of possession states. In Trance and possession states. Edited by R. Prince, Montreal: R.M. Bucke Memorial Society; 1968: Greenbaum L: Possession trance in Sub-Saharan Africa: A descriptive analysis of fourteen societies. In Religion, altered states of consciousness, and social change. Edited by E. Bourguignon, Columbus: Ohio State University Press; 1973: Gunmundsson O, Reykjavik D, Prendergast M, Foreman D, Cowley S: Outcome of pseudoseizures in children and adolescents: a 6-year symptom survival analysis. Dev Med Child Neurol 2001, 43: Pehlivanturk B, Unal F: Conversion disorder in children and adolescents: A 4-yer follow-up study. J Psychosom Res 2002, 52: Turgay A: Treatment outcome for children and adolescents with conversion disorder. Can J Psychiatry 1990, 35: