Ambushed by Memories of Trauma: Memory-Processing Interventions in an Adolescent Boy with Nocturnal Dissociative Episodes

Evidence-Based Mind-Body Interventions for Children and Adolescents with Functional Neurological Disorder

LEARNING OBJECTIVES

• Develop and implement treatment plans for children and adolescents with functional neurological disorder (FND)• Outline a plan to increase awareness and standardize the care for patients with FND using evidence-based interventions.

ABSTRACT

Functional neurological disorder (FND) in children and adolescents involves the biological embedding of lived experience in the body and brain. This embedding culminates in stress-system activation or dysregulation and in aberrant changes in neural network function. In pediatric neurology clinics, FND represents up to one-fifth of patients. Current research shows good outcomes with prompt diagnosis and treatment using a biopsychosocial, stepped-care approach. At present, however-and worldwide-FND services are scarce, the result of long-standing stigma and ingrained belief that patients with FND do not suffer from a real ("organic") disorder and that they therefore do not require, or even deserve, treatment. Since 1994, the Mind-Body Program for children and adolescents with FND at The Children's Hospital at Westmead in Sydney, Australia-run by a consultation-liaison team-has delivered inpatient care to hundreds of patients with FND and outpatient care to hundreds of others. For less-disabled patients, the program enables community-based clinicians to implement biopsychosocial interventions locally by providing a positive diagnosis (by a neurologist or pediatrician), a biopsychosocial assessment and formulation (by clinicians from the consultation-liaison team), a physical therapy assessment, and clinical support (from the consultation-liaison team and the physiotherapist). In this Perspective we describe the elements of a biopsychosocial mind-body program intervention capable of providing, as needed, effective treatment to children and adolescents with FND. Our aim is to communicate to clinicians and institutions around the world what is needed to establish effective community treatment programs, as well as hospital inpatient and outpatient interventions, in their own health care settings.

A series of 8 cases of sleep-related psychogenic dissociative disorders and proposed updated diagnostic criteria

STUDY OBJECTIVES

To identify the most relevant clinical and video-polysomnographic characteristics of patients with sleep-related dissociative disorders (SRDDs) and to propose a framework for new diagnostic criteria.

METHODS

We searched potential SRDD cases from the scientific literature and from a database of patients referred for clinical and video-polysomnographic assessment in a single sleep disorders center for disruptive nocturnal behaviors (n = 731). The most relevant clinical and neurophysiological characteristics of the cases were extracted and a descriptive analysis was performed.

RESULTS

Twenty-six SRDD cases (8 new and 18 previously published cases) were reviewed. Almost all cases of SRDDs occurred in a context of past traumatic events or abuse and were associated with at least 1 comorbid psychiatric disorder. We highlighted 4 relevant clinical characteristics of SRDD useful for the differential diagnosis with parasomnias: episodes of long duration of more than 1 hour (90.9%), self-inflicted injuries (83.3%), occurrence while awake close to bedtime (35.7%), and the presence of daytime dissociative symptoms (72.7%). The video-polysomnography documented typical episodes of SRDD with prolonged wakefulness before, during, and after the event in 11/26 cases. New diagnostic criteria for SRDD were proposed, with 3 levels of certainty for the diagnosis based on clinical, video-polysomnographic, and homemade video findings.

CONCLUSIONS

More than 30 years after its formal identification, SRDD is not currently recognized as an official diagnostic entity. We better delineate the clinical and neurophysiological features of SRDD and propose a framework for its reinstatement in the next revisions of the sleep and psychiatric disorders classifications.

CITATION

Lopez R, Lefevre L, Barateau L, Micoulaud-Franchi J-A, Dauvilliers Y, Schenck CH. A series of 8 cases of sleep-related psychogenic dissociative disorders and proposed updated diagnostic criteria. J Clin Sleep Med. 2022;18(2):563-573.

Sleep-related (psychogenic) dissociative disorders as parasomnias associated with a psychiatric disorder: update on reported cases

STUDY OBJECTIVES

To update the literature on the diagnostic category of sleep-related dissociative disorders (SRDDs), involving psychogenic dissociation, since the time of their inclusion in the parasomnias section of the International Classification of Sleep Disorders, second edition, in 2005; to summarize the most salient clinical and video-polysomnographic (vPSG) findings and typical clinical profile from all reported cases; and to provide the rationale for the re-inclusion of the group of SRDDs in future editions of the International Classification of Sleep Disorders.

METHODS

A systematic computerized literature search was conducted searching for SRDDs, nocturnal dissociative disorders, and nocturnal dissociation.

RESULTS

Nine additional cases were identified, with sufficient clinical history and vPSG findings to justify the diagnosis of SRDDs, supplementing the 11 cases cited in the International Classification of Sleep Disorders, second edition, for a total of 20 cases. Twenty-six other cases with vPSG testing were found, with 18 cases reported in abstracts and 8 cases reported in a publication with compelling histories of SRDDs and 2 consecutive vPSG studies, but without the vPSG findings explicitly reported for any case. In more than half of all reported cases, there was objective diagnostic confirmation for SRDDs consisting of the hallmark finding of abnormal nocturnal behaviors arising from sustained electroencephalography wakefulness, or during wake-sleep transitions, without epileptiform activity. These nocturnal behaviors often replicated daytime psychogenic dissociative behaviors. A history of trauma (physical, sexual, emotional) was an almost universal finding, along with major psychopathology. All patients, except for one, had prominent histories of daytime dissociative disorders. Many of the patients were referred on account of a presumed parasomnia.

CONCLUSIONS

Cases of SRDDs continue to be reported, often as a "parasomnia mimic," with psychogenic dissociation being clearly distinguished from physiologic sleep-wake dissociation as found in primary sleep disorders such as narcolepsy, rapid eye movement sleep behavior disorder, etc. Eleven reasons are provided for why the category of SRDDs should be re-included in future editions of the International Classification of Sleep Disorders, and in the parasomnias section.