Comparative studies of conversion disorders in childhood and adolescence

An Evaluation of Gender Differences in Self-Reported Internalizing Symptoms of Elementary-Age Children

Gender differences in self-reported internalizing symptoms of children in grades 3-6 were investigated. Using the Internalizing Symptoms Scale for Children (ISSC), and normative data from a large, nationwide sample, self-reported internalizing symptom scores of boys (n = 876) were compared to those of girls (n = 840). Total internalizing scores of girls were significantly (p < .001) larger than those of boys, indicating a higher degree of self-reported internalizing symptoms. The average scores of the girls were approximately one third of a standard deviation higher than the average scores of the boys. Using a discriminant function analysis, the ISSC item scores were found to be reasonably effective in classifying subjects by gender. Seven critical self-report items that contributed the most to the separation of subjects by gender were identified. Implications of this study for psychoeducational assessment practice, early identification of internalizing problems, and subsequent intervention efforts are discussed.

[Conversion Disorder in Children and Adolescents]

BACKGROUND

Conversion disorder is diagnosed late, by exclusion and with a high risk of complications. There is a wide experience in adults that is not extrapolated to paediatric patients. According to the literature, the prognosis is better in children, but this changes when other variables such are included, such as comorbidities, late diagnosis and a very convincing social image of the neurological disease.

OBJECTIVE

To review the medical literature on the clinical features, diagnosis, comorbidities and treatment of this disorder.

METHODS

A literature research was performed on Medline and Pubmed, the terms used were "conversion disorder", pseudoseizures, treatment, clinic, children ("conversion disorder" OR hysteria OR hysterical) (child OR children OR childhood OR pediatric OR paediatric). The most relevant material found is included in this review.

CONCLUSIONS

Conversion disorder is often an imprecise diagnosis in high complexity paediatric services. No consensus was found in the literature search on how to treat patients after the initial diagnosis. The evidence that it becomes chronic is not strong enough, just as the evidence is not convincing enough to argue that comorbidity factors are those maintained over time. Clearly, there is no medical experience of the natural history of this disorder in children and adolescents. It is only known is that it is a complex condition, on which there is experience only in the diagnosis and treatment of the acute state, but not so in the long-term care. It is proposed that each patient is studied in detail in order to define the psychiatric diagnosis and its treatment.

Long-term outcome and prognosis of dissociative disorder with onset in childhood or adolescence

BACKGROUND

In the majority of cases short-term treatment outcome of juvenile dissociative disorder is rather favourable. In contrast, the long-term course seems to be less positive, but meaningful results are still fragmentary. The aim of this follow-up study is to bridge this gap to some extent describing the long-term outcome of juvenile dissociative disorder in a clinical sample. To our knowledge there is no comparable other long-term follow-up study which is based on a case definition according to actual classification systems using standardized interviews for individual assessment of the patients at the time of follow-up.

METHODS

The total study group was made up of all patients treated for dissociative disorder at our department for child and adolescent psychiatry between 1983 and 1992 (N = 62). Two of these former patients committed suicide during the follow-up period (3%). We got information on the clinical course of 27 former patients (44%). 17 out of these 27 former patients were female (63%). The mean age of onset of dissociative disorder was 11.7 years and the mean follow-up time was 12.4 years. Most of the patients were reassessed personally (n = 23) at a mean age of 24.8 years using structured interviews covering dissociative disorders, other Axis I disorders and personality disorders (Heidelberg Dissociation Inventory HDI; Expert System for Diagnosing Mental Disorders, DIA-X; Structured Clinical Interview for DSM-IV, SCID-II). Social adjustment was assessed by a semi-structured interview and by patient self report (Social Adjustment Scale - Self Report, SAS-SR). Psychosocial outcome variables were additionally assessed in 36 healthy controls (67% female, mean age = 22.9 years).

RESULTS

At the time of follow-up investigation 82.6% of the patients met the criteria for some form of psychiatric disorder, while 26.1% were still suffering from dissociative disorder. A total of 56.5% presented with an Axis I disorder (especially anxiety, dissociative and somatoform disorders). Personality disorders were seen in 47.8% (especially borderline, obsessive-compulsive and negativistic personality disorders). More dissociative symptoms and inpatient treatment in childhood or adolescence were significantly related to a lower level of psychosocial adjustment in adulthood.

CONCLUSION

Treatment strategies have to consider that in a significant portion of young patients initial recovery may not be stable over time. Limitations of the study refer to the small sample size and the low rate of former patients taking part in the follow-up investigation.

[Headache in children: also a problem for child and adolescent psychiatry? Pathogenesis, comorbidity, therapy]

Headache is a recurrent somatic complaint in childhood and adolescence. In recent decades headache prevalence has increased while the age of onset has decreased. In most cases headache can be categorized as migraine or tension-type headache without significant organic pathology, i.e. head trauma, structural lesion, etc. Diagnosis according to the criteria of the International Headache Society is based on subjective reports by patients and their parents. The basic tools of clinical assessment are history, physical examination and a headache diary. Laboratory tests, including electroencephalography and imaging studies should not, as a rule, be undertaken routinely. Pathophysiological models with an impact on therapeutic interventions will be discussed. Childhood headache is often treated inappropriately in daily practice despite the availability of various options (including environmental, drug, and psychological therapy). Psychological therapy (relaxation training, biofeedback, stress management, etc.) as well as medication can be applied for prophylaxis. Minimal therapeutic interventions have been shown to be equally effective in a remarkable number of patients. Chronic Headache shows relevant comorbidity with anxiety and depression and is associated with somatization and school disorders. A careful investigation and an adequate therapy of eventual psychiatric comorbidity is therefore strongly recommended.

Highly somatizing young adolescents and the risk of depression

OBJECTIVE

To determine if high levels of somatization symptoms in 13- to 16-year-olds from the general population predict risk of major depression and other psychiatric disorders 4 years later.

METHOD

Cohort study, using interview and self-report survey data from the 1983 Ontario Child Health Study (OCHS) and 1987 OCHS Follow-up. The study population included 1015 13- to 16-year-olds from the general community within Ontario. Baseline levels of somatization and emotional disorder were measured by the Survey Diagnostic Instrument, a checklist based on DSM-III criteria. Data were also collected for a range of sociodemographic factors, as well as the presence of chronic health problems. Major depression, anxiety disorders, and substance abuse and dependency at follow-up were measured using a self-administered questionnaire derived from the Diagnostic Interview Schedule. Bivariate and multiple logistic regression techniques were used to assess the relationship between high levels of somatization symptoms (>90th percentile) and later emotional morbidity, with adjustment for potential confounding factors, including gender and baseline disorders.

RESULTS

Highly somatizing adolescents are at increased risk of major depression 4 years later, an association that is not explained by detectable emotional disorder at baseline or gender differences between groups. There is an important interaction between somatization and emotional disorder in predicting risk of major depression. It is primarily the group of 13- to 16-year-olds not recognized as being emotionally disordered at the initial OCHS survey in which somatization symptoms increased risk of later depression. The young teen with high levels of somatic complaints had as much risk of later depression as his/her peer with more typical symptoms of emotional disorder. Highly somatizing adolescents were also more likely to describe panic attacks at 4-year follow-up. There was no increased risk of substance abuse/dependency in the highly somatizing group or in generalized anxiety.

CONCLUSIONS

High levels of somatic symptoms identified in young adolescents in the community represent a significant risk factor for major depression 4 years later, particularly in those individuals who do not present with more typical symptoms of emotional disorder. To detect the emergence of this serious emotional morbidity, adequate follow-up and continuity of care for these challenging patients are needed.

Somatoform disorders in children and adolescents: a review of the past 10 years

OBJECTIVE

To review the literature on somatoform disorders in children and adolescents relevant to recertification by the American Board of Psychiatry and Neurology.

METHOD

The psychiatric, pediatric, and psychological literatures were searched for clinical or research articles in the past 10 years dealing with somatization and somatoform disorders.

RESULTS

Somatizing presentations are organized conceptually; somatization disorder, body dysmorphic disorder, hypochondriasis, conversion disorder, vocal cord dysfunction, pain disorder, and recurrent abdominal pain are described in children and adolescents; empirical evidence for treatment efficacy is scant, but clinically reasonable approaches are applied.

CONCLUSION

More developmentally appropriate diagnostic schemas and better outcome studies are needed in all the somatoform disorders for children and adolescents.

Behavioral treatment of conversion disorder in adolescence. A case example of Globus Hystericus

The present single case study evaluated the efficacy of a cognitive-behavioral intervention for the treatment of a patient diagnosed with globus hystericus, a conversion disorder characterized by a perceived lump in the throat. The patient was a non-mentally retarded 12-year-old female who refused to swallow solids because she thought that her throat muscles would involuntarily constrict and result in choking. She lost approximately .5 lbs. per week during the 6 months prior to treatment. Improvements in weight gain were demonstrated consequent to the implementation of behavior therapy, with weight gain being particularly pronounced after contingency contracting was added to therapy. Weight gain was maintained at 1, 6, and 10 months posttreatment.

Somatization in children and adolescents

OBJECTIVE

To review the empirical literature on somatization in the pediatric age group, emphasizing prevalence, influence on health care utilization, issues in the development of somatization, comorbidity with other psychiatric disorders, assessment, and treatment.

METHOD

One hundred nineteen studies and reports addressing medically unexplained somatic symptoms in children and adolescents were compiled via MEDLINE search and extensive cross-referencing. All available controlled studies were included, as were selected case reports and collections of cases. Selected citations from the adult literature were chosen for relevance to pediatric somatization.

RESULTS

Recurrent, medically unexplained physical symptoms are common in the pediatric age group, are often associated with other psychiatric symptoms, and may represent a common presentation of psychiatric disorder in the primary care setting. DSM-III-R-defined somatization disorder is rare, and pseudoneurological symptoms are unusual. Patients may be at risk for potentially dangerous, costly, and unnecessary medical investigations and treatments, and they may excessively utilize health care services.

CONCLUSION

Our current understanding of pediatric somatization and its consequences is limited. Collaboration between mental health professionals and primary health care providers is essential. Consistent terminology, developmentally appropriate classification, and systematic future research will be necessary for the development of successful prevention and treatment strategies.

Somatisation in neurological practice

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Characteristics of a child inpatient population with hysteria in India

OBJECTIVE

This study examined the rate, correlates, and clinical outcome of childhood hysteria in a sample of inpatients in India. For comparison, the rate of this disorder among outpatients was computed.

METHOD

Data were derived from case records of inpatient (n = 143) and outpatient admissions (n = 640) during a 1-year interval at the Child and Adolescent Psychiatry Unit of the National Institute of Mental Health and Neurosciences, Bangalore, South India.

RESULTS

The diagnosis of hysteria was made in 30.8% (n = 44) of the inpatient and 14.8% (n = 95) of the outpatient samples. The inpatients with hysteria were mostly postpubertal, their gender distribution was approximately even, and pseudo-seizure was the most frequent presentation. These inpatients had a brief duration of illness at admission and short-term outcome was generally positive.

CONCLUSIONS

Children with hysterical symptoms form a notable proportion of cases in child guidance and psychiatry clinics in India. It could be that, in this culture, having a "medical" illness is one of the more acceptable means of seeking psychiatric help. The use of a structured and intensive inpatient treatment package appeared to bring about rapid symptom remission. Some of the present findings could be the basis to explore subtypes of childhood hysteria.

Conversion disorder (DSM-III 300.11): symptomatology and course in childhood and adolescence

The incidence, age and sex distribution, symptomatology, psychosocial stress factors and course of conversion symptoms in a child and adolescent psychiatric patient sample were studied. Under the age of 10 conversion symptoms are comparatively rare and consequently require careful diagnosis, particularly regarding visual and hearing defects. Predominant conversion symptoms are seizures, gait problems and paralysis.