Catherine Chudleigh

Reduction of autonomic regulation in children and adolescents with conversion disorders.

Objective Conversion symptoms—functional neurological disturbances of body function—occur in association with extreme arousal, often in the context of emotional distress. The mechanisms that determine how and why such symptoms occur remain unknown. In this study, we used cardiac measures to assess arousal and cardiac autonomic regulation in children and adolescents who presented with acute conversion symptoms. Methods Heart rate was recorded in 57 children and adolescents (41 girls; 8.5–18 years old) with acute conversion symptoms and 57 age- and sex-matched healthy controls, during a resting condition and then during tasks involving cognitive and emotional activation. Arousal and autonomic regulation were assessed by measures of heart rate and heart rate variability. Psychological measures included attachment and emotional distress. Results Children and adolescents with conversion symptoms displayed higher autonomic arousal than did the controls, both at baseline and during task conditions (higher heart rate: baseline mean [standard deviation] = 82 [9.49] versus 74 [10.79] beats/min, p < .001; lower root mean squared successive differences–heart rate variability: 45.35 [27.97] versus 58.62 [25.69] ms2, p = .012; and lower high-frequency heart rate variability: 6.50 [1.19] versus 7.01 [0.95] ln[ms2] p = .017), and decreased autonomic regulation (attenuation of heart rate increases across tasks). The baseline pattern of increased autonomic arousal was especially pronounced in children with coercive-preoccupied patterns of attachment. Autonomic measures were not correlated with measures of emotional distress. Conclusions High autonomic arousal may be a precondition for generating conversion symptoms. Functional dysregulations of the cardiac, respiratory, and circulatory systems may mediate fainting episodes and nonepileptic seizures, and aberrant patterns of functional connectivity between motor areas and central arousal systems may be responsible for generating motor conversion symptoms.

Multimodal Rehabilitation: A Mind-Body, Family-Based Intervention for Children and Adolescents Impaired by Medically Unexplained Symptoms. Part 1: The Program

We describe a mind-body, family-based, multimodal rehabilitation program for children physically impaired by medically unexplained symptoms. In collaboration with the family, a multidisciplinary team identifies what is typically a diverse range of interconnected problems, and implements targeted interventions whose aim is to improve the childs physical, psychological, and social functioning and the psychological, emotional, and relational well-being of the family as a whole. The program is run in an inpatient hospital context and involves multiple modules—physical therapy, pharmacotherapy, individual therapy, family therapy, and an educational component—delivered concurrently. A companion article will present case studies and outcome data.

Conversion disorder in children and adolescents: A disorder of cognitive control

OBJECTIVE To assess cognitive function in children and adolescents presenting with acute conversion symptoms. METHODS Fifty-seven participants aged 8.5-18 years (41 girls and 16 boys) with conversion symptoms and 57 age- and gender-matched healthy controls completed the IntegNeuro neurocognitive battery, an estimate of intelligence, and self-report measures of subjective emotional distress. RESULTS Participants with conversion symptoms showed poorer performance within attention, executive function, and memory domains. Poorer performance was reflected in more errors on specific tests: Switching of Attention (t(79) = 2.17, p = .03); Verbal Interference (t(72) = 2.64, p = .01); Go/No-Go (t(73) = 2.20, p = .03); Memory Recall and Verbal Learning (interference errors for memory recall; t(61) = 3.13, p < .01); and short-delay recall (t(75) = 2.05, p < .01) and long-delay recall (t(62) = 2.24, p = .03). Poorer performance was also reflected in a reduced span of working memory on the Digit Span Test for both forward recall span (t(103) = -3.64, p < .001) and backward recall span (t(100) = -3.22, p < .01). There was no difference between participants and controls on IQ estimate (t(94) = -589, p = .56), and there was no correlation between cognitive function and perceived distress. CONCLUSIONS Children and adolescents with acute conversion symptoms have a reduced capacity to manipulate and retain information, to block interfering information, and to inhibit responses, all of which are required for effective attention, executive function, and memory.

Multimodal Rehabilitation: A Mind-Body Family-Based Intervention for Children and Adolescents Impaired by Medically Unexplained Symptoms. Part 2: Case Studies and Outcomes

In Part 2, we describe three cases implementing our mind-body, family-based, multimodal rehabilitation approach for treating children and adolescents presenting with medically unexplained symptoms. For each child and family, treatment interventions were selected and implemented, simultaneously or sequentially. In a cohort of 100 consecutively referred children, 56 suffered from, and were treated for, significant physical or chronic school absenteeism. Thirty-five of these children (63%) recovered fully, 10 (18%) had a relapsing course, 7 (12.5%) had chronic symptoms, and 4 (7%) were lost to follow-up. These outcomes suggest that mind-body multimodal rehabilitation is a successful, cost-effective model of treatment.

Managing Non-epileptic Seizures and Psychogenic Dystonia in an Adolescent Girl with Preterm Brain Injury

CASE HISTORY Aasha was a 17-year-old graphic arts student referred to the Department of Psychological Medicine for treatment of conversion symptoms. She was born prematurely,* adopted at birth, and lived with her adoptive parents (Mr. and Mrs. Riley). Throughout childhood, Aasha received remedial therapies for cognitive deficits and right hemiplegic cerebral palsy secondary to an intraventricular hemorrhage in utero. At 15 years of age, she underwent orthopedic surgery for a right equinus deformity. She recovered fully and went on to train as part of an elite athletic team for the disabled. Six months after the surgery, she began to suffer from sleep difficulties and pain in her right knee. A year later, new symptoms emerged: abdominal pain, menorrhagia, sensory loss and dystonia (persistent abnormal posturing) in her right foot, and nonepileptic seizures. At presentation, Aasha’s seizures occurred six to eight times a day and lasted up to 45 minutes each: she would become drowsy and be unable to talk, and her limbs would shake and stiffen. After all medical explanations for Aasha’s neurological symptoms had been excluded (Text Box 1), a multidisciplinary consultation-liaison team (comprising a child psychiatrist, clinical psychologists, a nurse consultant, and a

Psychogenic non-epileptic seizures in children and adolescents: Part II – explanations to families, treatment, and group outcomes

Psychogenic non-epileptic seizures (PNES) – time-limited disturbances of consciousness and motor-sensory control, not accompanied by ictal activity on electroencephalogram (EEG) – are best conceptualized as atypical neurophysiological responses to emotional distress, physiological stressors and danger. Patients and families find the diagnosis of PNES difficult to understand; the transition from neurology (where the diagnosis is made) to mental health services (to which patients are referred for treatment) can be a bumpy one. This study reports how diagnostic formulations constructed for 60 consecutive children and adolescents with PNES were used to inform both the explanations about PNES that were given to them and their families and the clinical interventions that were used to help patients gain control over PNES. Families were able to accept the diagnosis of PNES and engage in treatment when it was explained how emotional distress, illness and states of high arousal could activate atypical defence responses in the body and brain – with PNES being an unwanted by-product of this process. Patients and their families made good use of therapeutic interventions. A total of 75% of children/adolescents (45/60) regained normal function and attained full-time return to school. Global Assessment of Functioning scores increased from 41 to 67 (t(54) = 10.09; p < .001). Outcomes were less favourable in children/adolescents who presented with chronic PNES and in those with a chronic, comorbid mental health disorder that failed to resolve with treatment. The study highlights that prompt diagnosis, followed by prompt multidisciplinary assessment, engagement, and treatment, achieves improved outcomes in children/adolescents with PNES.

Psychogenic non-epileptic seizures in children and adolescents: Part I – Diagnostic formulations:

Psychogenic non-epileptic seizures (PNES) are a nonspecific, umbrella category that is used to collect together a range of atypical neurophysiological responses to emotional distress, physiological stressors and danger. Because PNES mimic epileptic seizures, children and adolescents with PNES usually present to neurologists or to epilepsy monitoring units. After a comprehensive neurological evaluation and a diagnosis of PNES, the patient is referred to mental health services for treatment. This study documents the diagnostic formulations – the clinical formulations about the probable neurophysiological mechanisms – that were constructed for 60 consecutive children and adolescents with PNES who were referred to our Mind-Body Rehabilitation Programme for treatment. As a heuristic framework, we used a contemporary reworking of Janet’s dissociation model: PNES occur in the context of a destabilized neural system and reflect a release of prewired motor programmes following a functional failure in cognitive-emotional executive control circuitry. Using this framework, we clustered the 60 patients into six different subgroups: (1) dissociative PNES (23/60; 38%), (2) dissociative PNES triggered by hyperventilation (32/60; 53%), (3) innate defence responses presenting as PNES (6/60; 10%), (4) PNES triggered by vocal cord adduction (1/60; 2%), (5) PNES triggered by activation of the valsalva manoeuvre (1/60; 1.5%) and (6) PNES triggered by reflex activation of the vagus (2/60; 3%). As described in the companion article, these diagnostic formulations were used, in turn, both to inform the explanations of PNES that we gave to families and to design clinical interventions for helping the children and adolescents gain control of their PNES.

The body comes to family therapy: Treatment of a school-aged boy with hyperventilation-induced non-epileptic seizures:

We present the case of a 10-year-old boy, Evan, where a knock to the head activated memories of past bullying, causing intense distress, activation of the body’s stress-regulation systems and recurrent hospital presentations with hyperventilation-induced non-epileptic seizures. We describe the initial assessment session that enabled Evan and his family to understand the context for Evan’s non-epileptic seizures, to engage with the therapeutic team and to collaborate in the implementation of a mind–body multimodal family-based intervention. Once the physical symptoms had been addressed therapeutically, we explored possible dangers within the family and school systems and we worked with Evan and his family to increase his ability to access comfort and protection from his parents. Our short hospital intervention highlighted the importance of ongoing therapeutic work with Evan and the family and laid the foundation stones for the next part of the family’s therapeutic journey.

Use of respiratory rates and heart rate variability in the assessment and treatment of children and adolescents with functional somatic symptoms

Functional somatic symptoms (FSS) emerge when the stress system is activated in response to physical or emotional stress that is either chronic or especially intense. In such cases, the heightened state of physiological arousal and motor activation can be measured through biological markers. Our team have integrated the use of biological markers of body state – respiratory rate, heart rate (HR) and heart rate variability (HRV) measurements – as a way of helping families to understand how physical symptoms can signal activation of the body’s stress systems. This study measured respiratory rates, HR and HRV in children and adolescents with FSS (and healthy controls) during baseline assessment to determine whether these biological markers were effective at differentiating patients with FSS. The study also implemented a biofeedback intervention during the assessment to determine whether patients with FSS were able to slow their respiratory rates and increase HRV. Patients with FSS had faster respiratory rates, faster HR, and lower HRV, suggesting activation of the autonomic nervous system coupled with activation of the respiratory motor system. Like controls, patients were able to slow their respiratory rates, but in contrast to controls, they were unable to increase their HRV. Our findings suggest that patients with FSS present in a state of physiological activation and struggle to regulate their body state. Patients with FSS are likely to need ongoing training and practice to regulate body state coupled with interventions that target regulatory capacity across multiple systems.