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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