Kasia Kozlowska

Adverse experiences in psychiatric training. Part 2

Objective: To examine the perceptions of New South Wales (NSW) psychiatric trainees in relation to their training, the adverse events they experienced and the role and quality of the consultant registrar relationship. Method: A self-report questionnaire was developed to probe trainee perceptions of the consultant-trainee relationship and adverse events during training in all those who had completed at least 1 year of training in psychiatry (n = 138) in NSW, as well as all consultants who had completed their training in the last 5 years (n = 95). All subjects were asked to rate the frequency and relative impact of 20 adverse experiences with the opportunity to proffer adversities not listed. They were also asked to rate their experience of their consultants in relation to the adversity. Results: The results from The Training Impact Study exploring adverse events experienced by NSW trainees are presented. Assault by a patient and suicide of a patient are identified as the most stressfull adversities of training in psychiatry. However, more general concerns such as educational and emotional neglect by upervisors, observing consultant maltreatment of patients, exam failure and conflict between consultants were also identified and discussed. Conclusions: The high response rate of both trainees and consultants gives these results a level of representative validity. Recommendations in relation to future training and research are put forward. Specific training in the management of potentially assaultive patients and facilitating trainee recovery from assault or threat of assault should be a priority of the Royal Australian and New Zealand College of Psychiatrists. Support and education in relation to patient suicide is also important. Training and recognition of teachers within the College should be encouraged.

Fear and the Defense Cascade: Clinical Implications and Management

AbstractEvolution has endowed all humans with a continuum of innate, hard-wired, automatically activated defense behaviors, termed the defense cascade. Arousal is the first step in activating the defense cascade; flight or fight is an active defense response for dealing with threat; freezing is a flight-or-fight response put on hold; tonic immobility and collapsed immobility are responses of last resort to inescapable threat, when active defense responses have failed; and quiescent immobility is a state of quiescence that promotes rest and healing. Each of these defense reactions has a distinctive neural pattern mediated by a common neural pathway: activation and inhibition of particular functional components in the amygdala, hypothalamus, periaqueductal gray, and sympathetic and vagal nuclei. Unlike animals, which generally are able to restore their standard mode of functioning once the danger is past, humans often are not, and they may find themselves locked into the same, recurring pattern of response tied in with the original danger or trauma. Understanding the signature patterns of these innate responses—the particular components that combine to yield the given pattern of defense—is important for developing treatment interventions. Effective interventions aim to activate or deactivate one or more components of the signature neural pattern, thereby producing a shift in the neural pattern and, with it, in mind-body state. The process of shifting the neural pattern is the necessary first step in unlocking the patient’s trauma response, in breaking the cycle of suffering, and in helping the patient to adapt to, and overcome, past trauma.

Healing the Disembodied Mind: Contemporary Models of Conversion Disorder

The cartesian separation of body and mind has underpinned medical conceptualization of conversion symptoms over the last four centuries. Eighteenth- and nineteenth-century models explained conversion symptoms on the basis of assumed organic lesions. Subsequent psychological formulations focused on mental phenomena, which were disembodied from underlying neurobiological processes. Contemporary theories challenge this disconnection. They place conversion symptoms within an evolutionary framework, arguing that mind is embodied in physical processes and confers significant survival advantage. Current neurobiological models explain conversation symptoms as part of the human emotional response to threat, reflecting either errors in how information about body state is processes and represented, or the motor component of an automatic emotional response. Patients with conversion disorder experience their body functions in a range of distressing and disturbing ways. In order to understand these phenomena, clinicians require conceptual models that expand the conventional dualistic mind-body paradigm, integrate multiple theoretical perspectives, and take into account environmental factors that shape evolutionary and individual development.

A prospective study of acute movement disorders in children.

Aim  The purpose of this study was to report a prospective cohort of children with acute‐onset movement disorders.

Assessing attachment in school-age children.

The School-age Assessment of Attachment (SAA) is a newly developed clinical tool to identify pattern of attachment using the Dynamic-Maturational Model of attachment and adaptation (DMM). Seven picture cards were used to elicit fantasy stories and recalled episodes. The transcribed discourse was analyzed to yield one of 13 DMM attachment classifications, together with possible unresolved traumas and losses, and modifiers (depression and intrusions). In this article, we outline the steps necessary to validate an assessment tool, describe the development of the SAA, and report data from a preliminary clinical study testing the SAA’s reliability, validity, and utility. Concurrent construct, familial, and discriminant validity were evaluated in terms of mental health status and exposure to danger on a sample of 5—12-year-old children, drawn from clinical ( n = 51) and normative (n = 40) populations. The SAA (a) differentiated children referred for psychiatric diagnosis from those in the normative population; (b) accounted for 31% of the variance (46% when family variables were added); (c) identified risk children in the normative sample; and (d) suggested risk factors associated with children’s psychiatric disorder.

Patterns of Emotional-cognitive Functioning in Pediatric Conversion Patients: Implications for the Conceptualization of Conversion Disorders

Objectives: To examine patterns of emotion processing in children and adolescents with conversion disorders and to determine whether those patterns are associated with particular clusters of conversion symptoms. Autobiographical narratives were used to investigate the organization of information about distressing feelings and memories. Methods: Structured interviews about attachment relationships and autobiographical events were administered to 76 controls and 76 matched subjects aged 6 to 18 years. Age-appropriate assessments of attachment were used: the School-aged Assessment of Attachment for children and the Transition to Adulthood Attachment Interview for adolescents. Patterns of emotion processing were identified using dynamic-maturational model discourse analysis and categorized into four clusters: inhibitory, normative/balanced, coercive-preoccupied, and mixed inhibitory and coercive-preoccupied. These clusters were then cross-tabulated with the sensorimotor characteristics of children with conversion disorders. Results: Emotion processing in children with conversion disorders was categorized as psychological inhibition (57%), psychological coercion-preoccupation (34%), and mixed (9%). Psychological inhibition was associated with negative conversion symptoms (discrete sensorimotor deficits, p = .003) and positive conversion symptoms (tremors and tics, p = .04). Psychological coercion-preoccupation was associated with all other disturbances of motor function: bizarre gaits and postures, whole-body floppiness, and refusals to move (p < .0001). Nonepileptic seizures occurred across both groups (56% versus 42%, p = .8). Conclusions: Contrary to the classic understanding of conversion disorder as a unified diagnostic entity with diverse symptoms, this study identified two distinct subtypes of conversion patients-those using psychological inhibition and those using psychological coercion-preoccupation-whose symptoms fell into discrete clusters. Further research is needed to determine the neural mechanisms underlying these processes.DMM = dynamic-maturational model; PFC = prefrontal cortex; PTSD = posttraumatic stress disorder; SAA = School-aged Assessment of Attachment; TAAI = Transition to Adulthood Attachment Interview

A Conceptual Model and Practice Framework for Managing Chronic Pain in Children and Adolescents

&NA; Pain is a complex phenomenon: a sensory experience originating in traumatized tissues; an emotional (affective) experience that signals danger in the internal (body) or external environment; and a “disposition to act” that results either in “action” that prioritizes escape or in “inhibition of action” to minimize injury or facilitate healing. Recent advances in our understanding of the affective components of pain have significant implications for the treatment of chronic pain in children and adolescents. This article describes a chronic pain clinic for children and adolescents developed by the pain service of a large pediatric teaching hospital. Pain is conceptualized and managed in terms of multiple, interrelating systems (the body level, the psychological level, and the social level). This model of care is illustrated with reference to the management of two cases of children with chronic pain and significant functional impairment. A brief overview of the care utilization of 62 children referred to the Chronic Pain Clinic is also provided, with the clinical characteristics of 40 children with somatoform pain disorder (SPD) being described in more detail. Of 28 children with SPD treated with our systems intervention, 82% reported significant reductions in pain intensity, 71% returned to school full time, and 29% part time. An advantage of this integrated, family‐based assessment and treatment approach is the overarching emphasis on identifying the contribution of each system to the childs subjective experience of pain, thereby avoiding the deleterious polarization of the pain as either physical or psychogenic in origin.

Self-protective organization in children with conversion and somatoform disorders.

OBJECTIVE Two centuries of clinical observations have suggested that conversion symptoms are associated with strong emotions or situations that threaten the individuals physical or psychological integrity. This study tested the hypothesis that childhood conversion reactions reflect the motor-sensory components of two distinct emotional responses (one inhibitory, one excitatory) that develop as adaptations to recurring threats within intimate relationships. METHOD Emotional responses to interpersonal threats were assessed in 28 children with conversion disorders using Dynamic-Maturational-Model (DMM) assessments of attachment. Attachment strategies (the inhibitory, Type A; the balanced, Type B; and the excitatory, Type C) provide information about (1) the childs behavioural (motor-sensory) organization in the face of interpersonal threats, and (2) the information processing that underpins this behavioural organization. RESULTS Twelve children (43%) used an inhibitory attachment strategy. Twelve (43%) used an excitatory attachment strategy. A smaller group (14%) alternated between inhibitory and excitatory strategies, their conversion symptoms reflecting the latter. DISCUSSION These data suggest that conversion reactions are not a single clinical entity and reflect the motor-sensory components of two distinct human emotional responses to threat. This distinction may help to account for the broad range of conversion symptoms seen in clinical practice, both those that involve loss of function and can be explained by a central inhibition hypothesis and those that involve positive symptoms and secondary gain.

Good Children Presenting with Conversion Disorder

Current conceptualizations of conversion disorder in childhood draw from a range of theoretical perspectives. A large subset of children afflicted with conversion disorder has recurrently been described as ‘good’, ‘helpful’, ‘compliant’, ‘high- achieving’ and ‘conscientious’. Family characteristics noted in this group include high family expectations, inarticulate family relationships and hostility towards psychological explanations with an over-emphasis on medical aetiology. Physicians experience parental displeasure and anxiety in the form of demands for investigations and treatment, and feel pressure to comply with parental requests. Like physicians, good children with conversion disorder also feel compelled to satisfy their parents. As children, they are even less able to openly disagree with parental views or expectations, and manage their fear of parental rejection, hostility, anger or displeasure through compulsive compliance. This article discusses the contributions of attachment theory to our understanding of relationship patterns in families of extremely good compliant children and expands Taylor’s concept of ‘intolerable predicaments’. The development of the ‘compulsive compliant’ attachment strategy is discussed, and its application to the theory and treatment of children with conversion disorder is examined. Case vignettes are presented.

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.