Download Conversion Disorder in Young People

Conversion Disorder in Young People
Dr Anthony Crabb
Consultant Child and Adolescent Psychiatrist
Southampton Children’s Hospital
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 rrules
les to form a new
ne
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
Conversion disorder
• Concept around since Hippocrates
• Hysteria - the “wandering uterus”
• Briquet
• Charcot
Freud
DSM-IV defines conversion disorder as follows:
•
•
•
•
•
•
One or more symptoms or deficits are present that affect voluntary motor or
sensory function
f
ti
suggestive
ti off a neurologic
l i or other
th generall medical
di l
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
y p
or deficit is not intentionally
yp
produced or feigned
g
((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
lt
ll sanctioned
ti
d behavior
b h i or experience.
i
The symptom or deficit causes clinically significant distress or impairment in
social, occupational, or other important areas of functioning or warrants
medical evaluation.
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
y another mental disorder.
accounted for by
Not to be confused with……..
with
• Medically unexplained symptoms
• Functional neurological disorders - NEAD
• Hysteria
• Somatoform disorders
• Psychosomatic disorders
• Pain syndromes – eg CRPS, RSD
• Recurrent (functional)abdominal pain
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
F up of 147/204 at 12 months – all sympts
reported as improved.
• Most families
f
i i ((91%)
%) accepted non-medical
i
explanation
• Conversion Disorder in Children: <1 per 1000 (Fritz
1997, USA)
• Conversion Disorder in Children 2.3-4.2 per 100,000
((Kozlowska et al 2007, Australia))
Spectrum
p
• One-third of all physical symptoms in primary care
medically unexplained (Sumathipala, 2007,London)
• 6% of new neurology outpatients (Stone, Carson
Edinburgh series,
series 2006)
• CRPS – 1-2 % post any fracture to 25% post Collies
fracture (Feliu, North Carolina, 2010)
Misdiagnosis?
•Stone
St
ett all (2005)
• 29% 1950s
•17% 1960s
•4% 1970s-90s
Neuro-imaging
Neuro
imaging Research
• PET, SPECT and fMRI
• Able to illustrate functioning of
particular areas in real time
• Area
A
iin it
its infancy
i f
b
butt gaining
i i
substantial interest
• Beginning to get clearer idea of
neurobiological correlates of MUS
Neurobiological correlates
• Frontal cortical, limbic activation
associated with emotional stress
• In turn acts via inhibitory basal gangliathalmocortical circuits
• Result is deficit of conscious
sensory/motor processing
•
(Harvey et al, Neuropsychiatric Disease and Treatment, 2006)
Areas of Interest
• Ventrolateral pre-frontal cortex
(
(VLPFC)
)
• Dorsolateral pre-frontal cortex (DLPFC)
• Limbic
Li bi system,
t
esp anterior
t i cingulate
i
l t
and thalamus
• Areas
eas o
of right
g
LPFC appear to
be involved in
inhibitory control
across multiple
lti l
domains: motor,
memory,
g ,
thought,
emotion.
VLPFC
• 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.
Limbic system
• Hypothalamus
• Cingulate Gyrus
• Amygdala
• Hippocampus
• Thalamus + others
Sensory deficits
• Associated with hypo-activation of the
y corticies and disturbed
sensory
functioning of DLPFC, VLPFC
Motor deficits
• Motor disturbance is associated with
either excessive activation of
(inhibitory) orbito-frontal cortices or
suppression of activation in the DLPFC.
DLPFC
Anxiety
y
• Participants high in anxious
pp
show reduced left
apprehension
VLPFC recruitment during selection
tasks.
tasks
• VLPFC functioning improved in anxiety
states
t t with
ith midazolam
id
l
(G
(GABA)
)
Functional neuroanatomical
correlates of hysterical
sensorimotor loss.
• Vuilleumier P, et al. Brain. 2001 Jun;124(Pt 6):1077-90.
• Single photon emission computerized tomography (SPECT)
• Consistent decrease of regional cerebral blood flow in the thalamus
and basal ganglia contralateral to the deficit.
• Subcortical
S b
ti l asymmetries
t i were presentt in
i each
h subject.
bj t
• Contralateral basal ganglia and thalamic hypoactivation resolved
after recovery.
Vuilleumier P, et al.
• LLower activation
ti ti
iin contralateral
t l t
l caudate
d t during
d i
h
hysterical
t i l
conversion symptoms predicted poor recovery at follow-up.
• Functional disorder in striatothalamocortical circuits controlling
sensorimotor function and voluntary
y motor behaviour.
• Basal ganglia,
ganglia especially the caudate nucleus may modulate motor
processes based on emotional and situational cues from the limbic
system.
Summary
• Conversion disorder rare
• Functional symptoms common
• Diagnosis still somewhat controversial
• Shared understanding still lacking
• Generally favourable outcome
• Neuro-biological correlates becoming
clearer