Breathing control training for functional seizures: A multi-site, open-label pilot study

There are no well-validated treatments for functional seizures. While specialist psychotherapy is usually recommended, the evidence for its benefit is qualified, and it can be difficult to obtain. Given the association between hyperventilation and functional seizures we explored an alternative modality, breathing control training, in a multi-site open label pilot trial. Participants with functional seizures over the age of 16 received an hour of breathing training from a respiratory physiotherapist, with a half-hour booster session a month later. Seizure frequency and Nijmegen scores (a measure of hyperventilation) were reported at baseline and follow-up, 3-4 months later. Eighteen subjects were recruited, and 10 completed follow-up. Seven of these 10 had improved seizure frequency, and 3 did not (Wilcoxon signed rank test, p = 0.09), with seizure frequency correlating with Nijmegen score (Spearman's rank correlation = 0.75, p = 0.034). The intervention was well tolerated, with no adverse events reported. These preliminary results support a potentially new approach to treating functional seizures that should prove cost-effective and acceptable, though require confirmation by a randomised controlled trial.

Beneficial effect of faradic stimulation treatment on the rehabilitation of hysterical paraplegia

Hysterical paralysis, a type of conversion disorder, presents with the loss of motor or sensory function. Although this disorder is nonorganic, it resembles the symptoms of a structural disease of the nervous system. It is generally associated with a traumatic or social event. The patients often require excessive testing and comprehensive assessment in exposing this psychogenic ailment. We reported the most dramatic type of conversion disorder, hysterical paralysis, in which full recovery was obtained with early recognition and rehabilitation approach including faradic stimulation.

Physical treatment of functional neurologic disorders

Physical interventions are widely considered an important part of treatment of functional neurologic disorders (FNDs). The evidence base for physical interventions has been limited to a collection of case series, but the recent publication of several large cohort studies and a randomized controlled trial have provided stronger evidence to support its use. While the evidence for efficacy appears to be promising, details on how this should be delivered remain limited, perhaps due to the dominance of psychologically focused etiologic models. A move towards understanding how the symptoms of FND are generated on a neurobiologic level has resulted in an expansion of pathophysiologic models providing a clearer rationale for physical treatment. In this context, the motor symptoms of FND can be considered as learnt patterns of movement, driven by attention and belief. Physical treatment aims to retrain movement by redirecting attention and addressing unhelpful illness beliefs and behaviors. The patient's problems should be considered in a broad biopsychosocial framework where symptom-predisposing, precipitating, and perpetuating factors can be addressed within a multidisciplinary environment as a gold standard. Further research is required to refine interventions and create evidence-based treatment guidelines.

Conversion disorder in stroke: a case report

Conversion disorder is caused by previous severe stress, emotional conflict, or an associated psychiatric disorder, and usually presents with one or more neurologic symptoms. Clinically, it is challenging to diagnose diseases such as transient ischemia attack, stroke, brain tumor, spinal cord injury, and neuropathy. In this case report, we present a male stroke patient who had a typical conversion disorder.

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.

Restrained rehabilitation: an approach to children and adolescents with unexplained signs and symptoms

The validation of treatment approaches for children and adolescents diagnosed with unexplained signs and symptoms is made difficult by the variety of clinical presentations and the different developmental levels of different patients. There is little evidence about what combination of approaches is most successful. This article uses what evidence is available to develop a coordinated multidisciplinary rehabilitation package that ensures consistency and can be evaluated. The package is organised around a psychologically informed physical rehabilitation programme. The need for coordination and a common approach between medical, allied health and psychological staff, and family is formally addressed. The approach is illustrated with a case study.

Conversion motor paralysis disorder: overview and rehabilitation model

It is important to consider a differential diagnosis between paralysis on an organic basis and paralysis and disability due to psychological mechanisms in people with physical impairment secondary to trauma, without evidence of organic etiology. We review the most dramatic type of conversion disorder (CD)-'Conversion Motor Paralysis'. Recent important medical literature concerning the accepted treatment and rehabilitation management will be reviewed and discussed. The inter-disciplinary in-patient team management approach in a rehabilitation setting offers the benefits of a comprehensive assessment and treatment. The diagnosis is temporary and conditional, since there may be a long delay until the appearance of organic findings. A complete medical assessment is essential in order to rule out any possibility of an organic etiology. In as many as 25% to 50% of patients diagnosed as conversion, an organic medical diagnosis was found.

Conversion motor paralysis disorder: analysis of 34 consecutive referrals

STUDY DESIGN

We present our cumulative experience with patients sustaining the most dramatic type of Conversion Disorder (CD) - Conversion Motor Paralysis.

SETTING

Rehabilitation departments, Reuth Medical Center, Tel-Aviv and Sheba Medical Center, Tel-Hashomer, Israel.

METHODS

During the period 1973-2000, 34 patients with neurological symptoms without any anatomical or physiological basis were admitted to both rehabilitation departments. This number consists of less than 1% of the total acute traumatic and non-traumatic spinal cord disorders admitted annually to these centers.

RESULTS

Twenty-five of the subjects were men (mean age of 30 years) and nine were women (mean age of 31.4 years). Neurological symptoms included: paraplegia (complete or incomplete) (18), hemiplegia or hemi paresis (11), tetraplegia (complete or incomplete) (three), monoplegia (one), triplegia (one). The final diagnosis on discharge was CD in 30 of the 34 cases, the remaining four being diagnosed as malingering. Functionally, nine patients had a complete recovery, 10 a partial recovery and 15 remained unchanged.

CONCLUSION

Disabled people who experienced traumatic events resulting in various disabilities are admitted usually to a rehabilitation center. However, some of them are later diagnosed as having Conversion Disorder or malingering. We believe that their participation in active regular and integrative rehabilitation process is beneficial to most of them. Most of these patients gain functional independence and return to the main stream of life.

Diagnosis and rehabilitation strategies for patients with hysterical hemiparesis: a report of four cases

Conversion disorder is a psychological disturbance that produces subconscious alterations in sensorimotor function. Hysterical hemiparesis is a relatively rare, and difficult to diagnose, form of conversion disorder presenting as unilateral motor weakness with or without sensory deficits. We report four patients who required inpatient rehabilitation for hysterical hemiparesis, a diagnosis for which there is little information regarding rehabilitation management. In all cases, an extensive acute care evaluation including multiple imaging studies failed to identify a new neurologic lesion. All patients had rapid functional improvement using functional and behavioral therapies and extensive psychosocial support (mean length of stay of 11 days; mean Functional Independence Measure [FIM] gain of 22; mean discharge FIM of 112), consistent with other published reports of rehabilitation of conversion disorder. Evaluation of these cases reveals consistencies regarding presentation, psychosocial history, and rehabilitation course that can aid clinicians in making the diagnosis. Rehabilitation strategies for hysterical hemiparesis are reviewed.

The inpatient treatment of patients suffering from (motor) conversion symptoms: a description of eight cases

This article presents a preliminary study that used two controlled randomized trials to study the effect of hypnosis in the treatment of eight patients with (motor) conversion symptoms. Controlled research into the treatment of conversion symptoms is scarce and can often be criticized on methodological grounds. It would appear, however, that both the use of suggestive and behavioral therapeutic techniques and eclectic treatment programs yield good results in the treatment of conversion symptoms. The results of the study suggest that comprehensive clinical treatment including hypnosis has enough promise to be studied in clinical trials. In the interpretation of the results, special attention is given to primary diagnosis, duration of complaints, traumatic experiences in childhood, dissociative capacity, and hypnotizability.

Conversion disorders in adolescents: a practical approach to rehabilitation

Young people with conversion disorders require a different treatment approach compared with those who have organic illness. This paper describes a team approach which is based on detailed assessment, explanation of the vicious cycle, accepting the patient's symptoms, working towards achievable goals, encouraging bravery, rewarding 'wellness' behaviour, ignoring abnormal behaviour and supervising re-integration into school.

[Psychodynamic aspects of patients in a neurologic rehabilitation clinic]

Starting out from the medical doctor's field of work in a neurological rehabilitation clinic, various determinants in subjective experience of a neurological disease and its sequels are dealt with, followed by brief case descriptions for concrete exemplification. Special attention is given to the individually different modes of coping with disease or conflict, and diagnostic and therapeutic measures are advocated to be based on a psychoanalytical approach. The practical relevancy of this aspect is pointed out, and integration of psychoanalytical thinking and activity with the hitherto prevailing therapy methods is recommended. A résumé of issues put forth is given in conclusion.

Successful rehabilitation in conversion paralysis

A rehabilitation programme for patients with conversion paralysis has been introduced in which they are offered physical rehabilitation. During an eight month period between October 1984 and May 1985 six patients who had been diagnosed as dependent on wheelchairs owing to conversion paralysis for a mean of 3 years (range 1-6 years) were entered into the inpatient neurorehabilitation programme. All six patients were able to walk within a mean of 41 days (range 10-70 days), and then relinquished a variety of aids and allowances as a result of their regained mobility. They continued to be independent at outpatient review for a mean of 10 months (range 8-15 months). Successful rehabilitation from wheelchair dependency can be achieved by a cost effective, prolonged, inpatient neurorehabilitation programme.

Hysterical paralysis in the upper extremity of chronic pain patients

The patient with chronic pain who develops the conversion symptom of hysterical paralysis in the upper extremity can be treated successfully by rehabilitation medicine services, using a shaping behavioral program. Four case reports illustrate the management of this condition and the basic ingredients for such a program are outlined. The approach is based upon learning principles and experience with conversion reactions affecting gait. Treatment outcome often is related directly to the care and skill with which psychological assessment is performed and to the coordinated effort of the various team members.

Behavior modification of abnormal gait and chronic pain secondary to somatization disorder

An interdisciplinary team, which included a physiatrist, psychologist, physical therapist, occupational therapist, social worker, and nursing staff, undertook the treatment of a 33-year-old woman with a 16-year history of gait problems and multiple somatic complaints. Previously, she had been followed by a number of physicians and had undergone both invasive and noninvasive diagnostic procedures as well as several surgical procedures. After limited response to such treatment, she was referred to the outpatient PM&R clinic for evaluation. Physical and psychologic study led to a primary diagnosis of somatization disorder, leading to inpatient treatment which combined a systematic gait-training program, withdrawal of reinforcement for maladaptive disability-related behavior, and reinforcement of increases in normal activities. The patient attained all of the goals in her program in 11 weeks.

The psychologically orientated pediatrician and the provision of psychoanalytic psychotherapy

The experiences of a consultant pediatrician attempting to introduce into his practice an additional mode of treatment that he wished to offer to some of his patients, namely psychoanalytical psychotherapy, is described. Having previously operated successfully as an analytic psychotherapist with patients referred to him by a child psychiatrist, he attempted to function formally as an analytic psychotherapist with selected patients from his own pediatric practice. However, this significant change of role was not accepted by the children and their parents. Reasons are looked for to explain this finding, the significance of which may be of importance to pediatric practice in general and may have wider implications in the whole area of the doctor/patient relationship.