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Story #5. Psychosomatic Conversion Disorder in Children

By Dr. Jorina Elbers, MD

I’m a Child Neurologist, and have been seeing children with psychosomatic symptoms for 6 years. I have seen children with symptoms including non-epileptic seizures, weakness, blindness, unstready gait, migraines, dizziness and sensory disturbances, with no underlying medical explanation. With the proper education and support these children have had full recoveries.

As a child neurologist, I have developed a particular interest in psychosomatic illness. I truly believe that these children need as much support and rehabilitation as any child with an underlying structural brain or nerve problem. The difficulty is, many physicians still don’t recognize psychosomatic illness for what it really is, and many children undergo test after test, and procedure after procedure, with no answers. I have found that once a family is given some information about psychosomatic symptoms, most of them will recognize this as occurring in their child, and be open to the proper treatment and support.

I hope you find the information provided helpful. This information is entirely from my own experience, with which I have had good success. It may not reflect the opinion of physicians elsewhere.


What is conversion disorder?

Conversion disorder is a complex of symptoms experienced by a patient that, instead of being attributable to a structural problem in the brain, spinal cord, nerves, muscles, or other tissues of the body, is caused by unresolved stress and psychological unrest.  These symptoms are the body’s way of “converting” underlying stress into physical symptoms that, in effect, distract the individual from dealing with their underlying issues.


What is known about conversion disorder?

Neurobiologists have hypothesized that conversion disorder stems from two protective, instinctive and adaptive behavioural responses present throughout the animal kingdom – called the “violent motor reaction” and “immobilization reflex.”  The belief is that animals experience symptoms such as a flurry of uncoordinated movement, or an immobilization response (or sham-death) in response to danger. This action presents a state of helplessness and defenselessness which would help to ward off the attack of a predator (Kretschmer, 1961 and Ludwig, 1972)

With the advent of new neuroimaging techniques, we are now able to not only visualize the structure of the brain, but also the function. Since most patients with conversion disorder will have a normal MRI, indicating no structural abnormality, there must be a functional abnormality to account for these symptoms. In fact, it appears this is the case. Studies using functional MRI, which measures regional changes in blood flow related to neural activity, have identified the pre-frontal cortex as a key player in patients with psychosomatic symptoms. While the studies have some limitations, there is a suggestion that the pre-frontal cortex, which is normally involved in organizing, planning and executing behaviour, is active in patients with conversion disorder and may be inhibiting certain parts of the brain responsible for movement and sensation. When the patient has been treated, these regions are no longer active (Vuilleumier , 2001)


Myths about conversion disorder

Patients with conversion disorder are not malingering, nor are they “faking it”.

Just as someone with an underlying structural abnormality such as multiple sclerosis or brain tumor experiences symptoms, the symptoms of conversion disorder are REAL. Patients with conversion disorder often experience their body functions in distressing and disturbing ways. Symptoms may consist of both subjective and objective sensations such as dizziness, headaches, body pain, weakness, visual changes/tunnel vision, and even seizures. Patients with conversion disorder require a comprehensive medical, psychiatric and psychological evaluation. Once a medical diagnosis is ruled out, a proper diagnosis of conversion disorder should be made, including explanation of their symptoms, and treatment should commence, which may include rehabilitation and counseling.

The stress underlying conversion disorder does not have to be a mental illness or major psychological distress. It is not necessarily the amount of stress that accounts for symptoms, and certainly childhood stress is different than adult stress. More importantly is the fact that the stress is unresolved.  Stresses may include school difficulties, bullying, the death of a loved one (this includes pets!), or parental divorce. Physical and sexual abuse should also be considered in children, but is often not disclosed.


Can children develop conversion disorder?

Children are a very particular subgroup of patients that are at risk for conversion disorder. Children in our current society are under great amounts of stress, and are particularly vulnerable to develop conversion disorder due to their inability to manage underlying stress. As a pediatric neurologist, approximately 10% of the patients I see have conversion symptoms.

While any person is at risk for developing psychosomatic symptoms or conversion disorder, there is a trend towards high-achieving and successful adolescents. While females are probably more commonly affected, males are also at risk, especially since they have been taught to suppress their emotions at a young age. Younger children, between 5-10 years of age, may also manifest conversion symptoms.


What are symptoms of conversion disorder in children?

The most common, and socially acceptable, conversion symptom is headache. There are few people who will argue that headaches are not a sign of stress. Young children, even under the age of 5 years, can develop headaches which may be resulting from unresolved stress. While children this age require thorough investigation to rule out an underlying structural lesion in the brain, conversion disorder should not be discounted based on young age.

Other symptoms which may be expressed in response to unresolved stress include dizziness, abdominal pain, tinnitus, ataxia, generalized weakness, focal weakness, paresthesias, blurry vision, vision loss, tunnel vision, and non-epileptic seizures.   Virtually any neurological symptom can be a manifestation of psychosomatic origin, and often multiple symptoms will co-exist.

There are several interesting features of conversion disorder and psychosomatic symptoms. The first is that symptoms often manifest in a manner which has already been established as a weakened part of the body. For example, a child may present with focal arm weakness in the same arm that was fractured several years prior. As another example, children with known epilepsy may present with additional seizures that are non-epileptic in nature, that is to say, they are not caused by abnormal electrical activity in the brain that can be picked up on EEG.

The other interesting feature of conversion disorder is symptom substitution or symptom imperative. Over time, if the underlying stress is not resolved, some symptoms may resolve, only to be replaced by different symptoms that still remain unexplained. It is only with proper treatment and counseling, that a child may be completely free of these symptoms.


Red Flags

As a physician, there are several red flags that alert me to the severity of the disorder, and the difficulty of treating it. Children who have stayed home from school due to the symptoms will have additional stress associated with returning to school, having other children tease and bully them because of their symptoms, and the amount of work that will be required of them to catch up academically.

Another red flag for the severity of the conversion disorder is the number of hospital admissions and repeated investigations to find the cause. This causes additional stress on the child, on the family and on the health care system. While a thorough evaluation may be necessary, repeated MRI’s and other investigations do not help the family. Once conversion disorder is confirmed, the family should be educated and the child should be “normalized”. This means “made as normal as possible”. The child should be encouraged to go back to school, to socialize, to engage in activities they enjoy, and the child should not be asked at every instant how they are feeling.

Parents can be highly invested in their children’s illness and in finding a structural cause for the symptoms. This can also make it difficult for a child to return to normal life. Obviously the parent is concerned about their child, and wants everything possible to be done, with no stone left unturned. Parents need to be reassured and reminded that not finding an underlying structural problem is a good thing, and that more trips to the hospital are not necessarily in their child’s best interest. Occasionally, parents may also exhibit psychosomatic symptoms or conversion disorder.  Their frustration at not finding a cause for their own symptoms may be magnified in their child, and they may lose faith in the medical team altogether. It is important not to alienate these families, and to listen to their concerns. With time and trust, these symptoms can be overcome, and families can return to their normal life.


The good news

Once a child has been diagnosed with psychosomatic symptoms or conversion disorder, the good news is there is not an incurable, underlying structural problem that is causing the symptoms. Patients should be reassured of this, and reminded of this frequently. The concern that there is an underlying medical problem may often contribute to the stress.  Young children will often not recognize the unresolved stress, but older children are able to acknowledge that their symptoms may be due to something unidentifiable.

How is conversion disorder treated?

The key to treatment of conversion disorder is not so much the identification of the stressor (which is often difficult in children), as it is to identify the unresolved feelings.  Whether or not the stressor can be identified, it is necessary for the child to identify and talk about their feelings. There are many books that help children identify their feelings of anger, sadness and fear. Art or music therapy may also be of benefit as an outlet for the child. Overly anxious children should be taught skills of relaxation, and other tools they can use to alleviate their anxiety. It is important for children to learn these skills as they get older, otherwise new psychosomatic symptoms may emerge over time.

For children who are severely disabled due to their symptoms, and have weeks or even months off from school, it is imperative that they return to school as soon as possible. This should be done in a gradual manner, with small goals to be achieved every few days. It is important for the child to set his/her goals, and to acknowledge individual achievement for these goals. For example, a child with chronic daily headache who has not been to school for several months, may decide to attend lunch hour for the first few days back to school. After that goal is achieved, the child decides whether they can manage a full class or half a class, and which class that will be. Occasionally, some children will have such an aversion to school, that the first goal may be just to get into the car and drive to the front door of the school. Again, the child should be responsible for setting the goals they believe will be achievable. The parents may guide and offer suggestions, and encourage the child, once a goal has been reached, to set a new goal. 

I have often referred patients to Dr. John Sarno’s book “The Divided Mind” (Sarno, 2006). Even though this deals primarily with Tension Myositis Sydrome, I feel that the principles described in this book are important for any patient or parent to understand psychosomatic symptoms. It also describes a treatment protocol which may or may not be appropriate, depending on the age of the child.


References
Kretschmer E. Hysteria, Reflex and Instinct. Transl. Baskin V & W. London. Peter Owen, 1961.

Ludwig AM. Hysteria: A neurobiological theory. Archives of General Psychiatry 1972;27:771-777.

Vuilleumier P, Chicherio C, Assal F. Functional neuroanatomical correlates of hysterical sensorimotor loss. Brain 2001;124(6):1077-1090.

Sarno JE. The Divided Mind: The Epidemic of Mindbody Disorders. Harper Collins, New York, 2006.

(Picture courtesy of http://alittleinsanity.com/)

Tagged: paresthesia,PsychosomaticConversion DisorderPediatric conversion disorderStress headachesnon-epileptic seizuresweaknessblindnessunsteady gaitchildrenmigrainesdizzinesstinitusJorina ElbersChild Neurology

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