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https://storyset.com/illustration/woman-reading/bro

Abnormal Psychology

Conversion Disorder/ FND

Jason C., Paul, Jihun, Kenny, Francis, Micheal, Jason N.

Patient: Lisa

Our scenario...

  • We are health professionals treating Lisa

  • Lisa's issue: paralysis of both legs but no history of any physical injury
  • Husband ended 25yr relationship
  • Loved him
  • was financially dependent

  • later diagnosed with conversion disorder

https://storyset.com/illustration/hospital-wheelchair/bro

What is conversion disorder?

Introduction

A condition where a person experiences physical and/or sensory issues that cannot be explained neurologically.

(The Children Hospital of Philadelphia, 2017)

https://storyset.com/illustration/shrug/bro

Isn't a common problem

(Cleveland Clinic, 2022)

How common is it?

  • 4 to 12 people out of every 100,000 each year

  • only around 5% of patients in a hospital are diagnosed

  • estimates for the prevalence of conversion disorder are only between 0.011% and 0.5%

(Feinstein, 2011)

(Moini et al., 2021)

https://storyset.com/illustration/doctor/amico

Depends on several factors:

  • When it happens in your life

  • How severe it is

  • Whether or not you receive care for the condition

How long does it last

(Cleveland Clinic, 2017)

https://storyset.com/illustration/save-time/pana

Poorly understood...

(Peeling & Muzio, 2022)

Causes

  • Can occur with or without known psychological factors

  • Usually after a period of emotional or physical distress or psychological conflict

(Ada, 2022)

https://storyset.com/illustration/student-stress/rafiki

Loss of one or more bodily functions, for example...

Signs & Symptoms

  • Weakness or paralysis

  • Loss of balance or difficulty walking

  • Hearing problems or deafness

  • Difficulty speaking or inability to speak

Symptoms are usually acute, but can reoccur if the cause is not dealt with

(The Children Hospital of Philadelphia, 2017)

(Goodrich & Sharma, 2013)

  • Counseling — psychotherapy (talking therapy)

  • Physical therapy — maintain patient's movement

  • Medications — to supplement the counseling treatment for stress and anxiety

Treatments

(Varley et al., 2023)

What are some potential ways to treat/manage conversion disorder?

Treatments

https://storyset.com/illustration/injury/amico

Cognitive Behaviour Therapy

Cognitive Behavioural Therapy

(CBT)

What is CBT?

  • a type of psychotherapy

  • how you think and act affects how you feel.

  • It can help in many different situations — with both mental and physical health problems (Australian Association of Cognitive Behavioural Therapy).

What is it?

(National Social Anxiety Centre, 2016)

Pros

  • focused on changing the patient's thought patterns and behaviour to change how they feel

  • Highly structured -- able to be delivered across many formats

  • Skills learnt in CBT are applicable to daily life

Cons

General Pros and Cons

https://storyset.com/illustration/advantages/pana

  • patient's committment (and cooperation) is required for the treatment to be effective

  • progress cannot be seen immediately and requires time investment

Source: The CBT Clinic, 2016

https://storyset.com/illustration/bad-idea/rafiki

How does CBT work?

  • talking to therapists

  • learning ways to build productive habits

  • learning healthy stress release techniques to resolve source(s) of stress

How does it work?

(NHS, 2022)

https://storyset.com/illustration/marriage-counseling/cuate

  • Goal-setting: setting achievable, reasonable goals to resolve any troubling situations
  • Self-talk/Journalling: sharing thoughts and feelings, whilst keeping track of them through journals

Some approaches could include ...

  • Practicing self-awareness: helping the patient to become more aware of their own ways of thinking
  • Reflection: encouraging patient to challenge their old ways of thinking

Source: Mayoclinic, 2019

Ara. J (2019), Bangladesh

  • Patient X, 14-yo Muslim unmarried female

  • Grew up in a strict Muslim household

  • Often verbally abused by her father

Let's take a look at a case study...

  • Had an affair at 10 yo, relationship broke down shortly after

  • suffered physical abuse from parents

https://storyset.com/illustration/blaming/bro

  • later diagnosed with conversion disorder

CBT as her treatment...

  • psychoeducation - explaining how thoughts and emotions can influence feelings -> more optimistic about recovery

Undergoing CBT...

  • ventilation - allowed her to express her individual feelings and opinions on the situation -> reduce stress
  • Assertiveness training - trained to express thoughts and ideas openly, directly and honestly

https://storyset.com/illustration/psychologist/bro

Success!

  • case was terminated by the 11th session

  • stopped experiencing her initial symptoms

  • client rating of her condition had significantly decreased from 10 to 2 (on a scale of 10)

Result?

(Ara, J., 2019)

Medications

Medications

https://storyset.com/illustration/oncology-patient/bro

How is it different from CBT?

  • Frequently used in the emergency department

  • Helps aleviate immediate symptoms that CBT otherwise cannot
  • immediate symptoms could be physical, emotional or mental
  • CBT's focus is more long-term than short-term

(Marrow, 2023)

How is it different?

IV Haloperidol versus Midazolam in Management of Conversion Disorder

(Jafari et al., 2015)

Haloperidol vs Midazolam

  • Haloperidol is well-known to be used for conversion disorder symptoms

  • But Midazolam produced fewer side effects

  • Study was conducted to compare effectiveness of both drugs

Clinical Trial

How was it carried out?

  • Double-blind randomized clinical trial conducted (Jafari et al., 2015)

  • 140 patients with conversion disorder - aged 18-60 yrs old

  • Divided into 2 groups, one with haloperidol and the other midazolam

  • Effects of the drug recorded at 1 hour, 24 hours and 1 week time intervals

Haloperidol was more effective...

  • 92% of patients in the IV haloperidol group recovered from symptoms

  • only 64% with midazolam recovered from symptoms

How did it go?

BUT, more patients experienced side-effects with haloperidol...

  • 17% wth IV haloperidol experienced side-effects

  • only 4% with midazolam experienced side-effects

Nobay et al., 2003

  • Used both haloperidol and midazolam

A similar study...

  • conducted on 40 patients
  • identical efficacy of both on managing psychological stress

Evaluation

What are the reasons for these differences?

  • Different environments beween studies

  • The first study was done in a stressful environment

  • Sedation speed and severity of side-effects not investigated

Haloperidol was more effective than midozolam...

Wrapping up...

However, Midazolam came with fewer side effects compared to Haloperidol

An alternative to Haloperidol?

  • Haloperidol // traditional anti-psychotic but due to side effects it's use is restricted

(Nasrallah, 2013)

Quetiapine vs Haloperidol

  • Quetiapine // a newer anti-psychotic that can treat schizophrenia, bipolar disorder etc.
  • balances levels of dopamine and serotonin
  • improved mood and behaviour

(Ghanbarizadeh et al., 2018)

S. Ghanbarizadeh et al., 2017

  • single-blind trial conducted on 144 FND patients between ages 18-60
  • patients did not know which treatment they received
  • 73 for Haloperidol (5mg)
  • 71 for quetiapine (50mg)

A study done ...

  • some patients were given a placebo (control) treatment
  • used to compare results with the actual drugs

Quetiapine was a safer alternative to Haloperidol...

  • Quetiapine was slightly more effective (91.55% of patients)
  • only 90.41% of haloperidol patients relieved their symptoms

Results?

  • Quetiapine also had lower % of side-effects (7.04%) such as weariness and sleepiness
  • 9.59% with Haloperidol had side-effects
  • Extrapyrimidal side-effects include involuntary muscle contraction, body and facial movements

Physical Therapy

Physical Therapy

https://storyset.com/patient

What is physical therapy?

  • performed by licensed physical therapists

What is it?

  • type of treatment focused at improving movement and physical health
  • useful in managing physical symptoms such as paralysis, weakness etc.
  • many different types: orthopaedic, neurological, cardiovascular etc

https://storyset.com/illustration/physical-therapy-exercise/rafiki

Outpatient PT in treating motor FND symptoms

"adherence to outpatient physical therapy was associated with symptom improvement" (Maggio et al., 2019)

A study on outpatient PT...

  • hypothesised that they positively correlated with each other

50 patients

from Massachusetts General Hospital

How many particpated?

  • 40 females and 10 males
  • all diagnosed with conversion disorder

  • all patients experienced a motor-related symptom(s)
  • 42 had functional movement disorder (e.g. gait disorder, tremor etc)
  • 21 had limb weakness (with some having both)

(Maggio et al., 2019)

"an initial 1-hour assessment, including a clinical interview, focused neurologic examination, and mobility screening"

(Maggio et al., 2019)

Initial procedures

(Maggio et al., 2019)

Patients were encouraged to attend ...

Main process

  • 6-12 sessions a week
  • 60 minutes each session

  • attendance was tracked over 4 months

(Maggio et al., 2019)

https://storyset.com/illustration/orthopedic/pana

Marked improvement!

How did it turn out?

  • patients who attended more sessions showed greater improvement

  • marked improvement -- "substantially enhanced ability to manage motor-based activities of daily living or near-complete symptom resolution at the final session"

(Maggio et al., 2019)

Some limitations

Limitations

  • small sample size - only 50 participants, not representative of entire population

  • lack of patient self-report - could help see their psychological progress

  • lack of standardised treatments - each patient had treatment tailored to their own needs

(Maggio et al., 2019)

Almost there!

Summary & Conclusion

(Summary & Conclusion)

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Physical symptoms

but no neurological issues...

What was conversion disorder again?

  • usually caused by stressful events

  • psychological impact -> physical symptoms

  • can happen again if the cause is not resolved

https://storyset.com/illustration/overwhelmed/bro

What are some treatments available?

  • psychotherapy - guide and motivate patient to build a healthier mentality

  • medications - ideal for immediate relief of symptoms

  • physical therapy - enhance and/or maintain patient's physical range of movement

https://storyset.com/illustration/occupational-therapy/bro

A primary focus on ...

  • cause is likely psychological from her break-up

  • medications and physical therapy can accompany the CBT

Going back to Lisa...

Cognitive Behavioural Therapy (CBT)

<a href="https://storyset.com/happy">Happy illustrations by Storyset</a>

References

Thank you for listening!

:D

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