Handbook of Consultation-Liaison Psychiatry

13. Psychological Factors Affecting Physical Conditions, Somatoform Disorders, Conversion, Dissociation, and Factitious Syndromes

Hoyle Leigh

CONTENTS

13.1 Vignettes

13.2 Psychiatric Syndromes

13.3 Conversion and Psychophysiologic Syndromes

13.3.1 Historical Considerations

13.3.2 Recognition and Diagnosis of Conversion and Psychophysiologic Syndromes

13.3.3 Use of Hypnosis and Lorazepam (or Sodium Amytal) in the Patient Interview

13.3.4 Treatment

13.4 Dissociation Syndromes

13.4.1 Depersonalization and Derealization

13.4.2 Dissociative (Psychogenic) Amnesia and Fugue

13.4.3 Dissociative Identity Disorder (Multiple Personality)

13.5 Factitious Syndromes (Munchausen Syndrome)

13.5.1 Diagnosis and Management

13.1 Vignettes

An 11-year-old girl was admitted to the pediatrics service for inability to walk due to paralysis of her left lower extremity. One morning, upon awakening, she found that she was unable to move her left thigh and leg and had to stay in bed. On admission, she had flaccid paralysis of her thigh and legs as well as stocking-like hypoesthesia. All labs and imaging studies were within normal limits except for slight anemia. The Hoover sign (see Chapter 29) was positive. The patient told the psychiatric consultant that she and her family had recently moved from another city, and she had enrolled in a new school where she had no friends. She missed her old friends, particularly a boy with whom she was close, which she kept a secret from her parents. As she talked about how much she missed her old school, she felt that she was beginning to feel some more sensation in her left leg and thigh. The consultant recommended physical therapy. In 2 days' time, the patient recovered enough movement and sensation in her left extremity that she was able to be discharged. In the meanwhile, she and her parents agreed that she could phone her old friends frequently. A psychiatric follow-up appointment was made.

A 35-year-old woman who works as a nurse's aide in a convalescent home was admitted to the medical service with high fever of unknown origin. Labs revealed neutrophilic leukocytosis with shift to left. Vital signs revealed sinus tachycardia with high fever (104°F). Blood culture revealed Escherichia coli septicemia. During the night, the nurse happened to notice that the patient was injecting something into her IV line. The syringe she used to inject into her IV line turned out to contain fecal material.

13.2 Psychiatric Syndromes

These vignettes depict patients who present to the general hospital with two different types of physical symptoms that are psychiatrically determined: the conversion syndrome (conversion disorder, conversion hysteria, hysterical paralysis), and the factitious syndrome (factitious disorder, Munchausen syndrome).

In addition to the above disorders, psychiatric syndromes presenting with physical symptoms include somatization syndrome (somatization disorder, Briquet's syndrome), pain syndrome (pain disorder, chronic pain syndrome, psychogenic pain), hypochondriasis, and body dysmorphic disorder (dysmorphophobia). The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) subsumes all these syndromes under the rubric of somatoform disorders, and includes, in addition, undifferentiated somatoform disorder (in which unexplained physical complaints that are not sufficient to be diagnosed as Briquet's last for more than 6 months) and somatoform disorder not otherwise specified.

All of these psychiatric syndromes have in common the fact that the symptoms cannot be explained by tissue pathology and do not have an obvious realistic purpose or gain. If such gain or purpose is present, then it is called malingering. Except for malingering, the motivation for the physical symptoms is not conscious, though for factitious illnesses, the patients may be aware that they are inducing them. Even for these instances, patients are unaware as to why they are inducing often painful and life-threatening diseases in themselves (as in the second vignette above).

In the sense that the physical symptoms are prominently contributed by psychological factors, all somatoform disorders may be considered to be a subset of psychological factors affecting a physical condition. The current DSM diagnosis of psychological factors affecting a medical condition, however, denotes what used to be called psychophysiologic or stress-induced medical syndromes, such as tension headache and irritable bowel syndrome. In any case, psychological factors affecting a medical condition presupposes a diagnosable medical condition. Psychological factors may then be identified that may have contributed or may be contributing to the precipitation, exacerbation, the course of the condition, and treatment/rehabilitation of the patient. The psychological factors may be psychiatric syndromes or symptoms, personality traits, or stress. Especially of note is the concept of somatosensory amplification, a personality trait that accentuates bodily feelings (Barsky, 1992), which may underlie many patients presenting with exaggerated somatic symptoms. The diagnosis of psychological factors affecting a medical condition (or symptom) is useful, as many medical conditions and symptoms are exacerbated or exaggerated by stress, anxiety, and depression, and, in fact, "psychogenic" symptoms may coexist with an organic disease. We recommend the use of the term psychological factors affecting a medical condition to include all somatoform conditions, particularly in consultation-liaison (CL) settings, as it tends to reduce the organic vs. psychogenic dichotomy in complex medical complaints. At the same time, making the diagnosis often helps to include the psychological factors in the overall treatment plan.

Dissociation is a phenomenon in which there is a lack of connection in a person's thoughts, memories, feelings, actions, or sense of identity. During the period of dissociation, certain information is dissociated from other information with which it is normally connected. Dissociative experience is probably a continuum, from complete absorption in a task with total unawareness of surroundings, to fugue states, to total amnesia. Dissociation is closely related to conversion syndrome (hysteria, hysterical dissociation), and some consider the latter to be a subset of dissociation syndrome. Hypnosis is a widely used technique to induce dissociation. There is evidence that identical functional brain changes occur in conversion paralysis and hypnotically induced paralysis of the lower limb (Halligan et al., 2000). Dissociation is an important symptom in posttraumatic stress disorder (PTSD), as well as in the borderline syndrome (see Chapter 15). Conversion, PTSD, and borderline syndromes, however, are not classified under the rubric of dissociative disorders in DSM-III/IV. Syndromes included in the DSM-IV as dissociative disorders are dissociative amnesia, dissociative fugue, dissociative identity disorder (multiple personality), and depersonalization syndrome, which will be discussed in this chapter.

13.3 Conversion and Psychophysiologic Syndromes

The conversion syndrome denotes psychologically determined physical symptoms that are associated with the somatosensory nervous system and organs of special senses. Common presentations include paralysis or paresis of a limb, glove-like anesthesia, seizures, blindness, and mutism. The diagnosis is often a diagnosis of exclusion of physical diseases that might explain the symptom. The conversion symptom itself is not associated with peripheral tissue pathology except for possible disuse atrophy.

Psychophysiologic syndrome (which is the term used in this chapter rather than psychological factors affecting a medical condition), on the other hand, does involve a physical condition that may be accompanied by tissue pathology, and usually involves the autonomic nervous system activation that may be associated with stress or psychological conflict. It includes what is sometimes called psychophysiologic disorders or psychosomatic disorders.

13.3.1 Historical Considerations

The older term for conversion is hysteria, which was postulated to be caused by a wandering uterus (hystera in Greek) by Hippocrates. It was considered to be confined to females. According to Hippocrates, various symptoms of hysteria, such as nervousness, depression, and hysterical fits, were caused by the interaction of the uterus with other organs. For example, if the uterus moves toward the liver, the female suddenly becomes speechless and clenches her teeth. The treatment entailed pushing beneath the liver with the hand, tightening a bandage below the ribs, and having the patient drink a fragrant wine, followed by the application of malodorous fumigations into the nostrils (Palis, 1985). More definitive treatments included attempts to tie down the uterus through pregnancy or keeping it moist through frequent intercourse so that it would not try to seek out the moisture of other organs (Meyer, 1997).

During the Dark Ages and the early Renaissance, irrationality and misogyny prevailed. Malleus Maleficarum (The Witch's Hammer, 1487) by Sprenger and Kramer, two Dominican inquisitors, set forth the procedure for diagnosis (torture) and treatment (execution) of witches, many of whom were suffering from mental disorders including hysteria. For example, a sign of being a witch was to have an anesthetic spot on the skin.

Hysteria became the subject of intense investigation in the 19th century, when it seems the prevalence was quite high. Jean-Martin Charcot, professor of neuropathology and physician in charge at Salpetriere Hospital in Paris, gained worldwide renown for his use of hypnosis in diagnosing and treating hysteria. He believed that susceptibility to hypnosis was pathognomonic of hysteria, a condition that he believed was caused by a degeneration of the brain. His pupils included Sigmund Freud, Joseph Babinski, Pierre Janet, Georges Gilles de la Tourette, and Alfred Binet.

Sigmund Freud learned hypnosis under Charcot, and returned to Vienna to practice its use in treating hysteria. With his colleague and mentor Josef Breuer, he wrote Studies on Hysteria (1895), which postulated that the patient's psychological traumas and conflicts caused the symptoms of hysteria. Freud eventually gave up the use of hypnosis in favor of free association, which led to the founding of psychoanalysis.

The term conversion is based on psychoanalytic theory. If an external stimulus or situation threatens to awaken a repressed psychological conflict, the ego converts the psychological conflict into a somatic symptom that represents a symbolic resolution of the conflict. For example, someone a person meets may unconsciously remind him of his father, toward whom he has murderous impulses. The impulse must be repressed because it can cause overwhelming anxiety if it became conscious. The patient's right arm becomes paralyzed, the arm with which the patient might have attacked the father figure. The resolution is that he cannot strike the person (father symbol) as the arm is paralyzed, appeasing the superego, but at the same time the paralysis draws attention to the instrument of aggression, thus partly seining the id. The primary gain in the conversion syndrome is the prevention of the overwhelming anxiety that would arise if the psychological conflict were to become conscious. The secondary gain, a commonly used term, is any potential benefit arising from being sick (in this case, paralyzed), such as attention or not having to go to work. Conversion disorder is the only diagnosis in the DSM-III/IV that presumes a psychodynamic etiology.

Conversion symptoms are now considered to be body-language expressions of a psychological distress that may be determined by many factors including psychodynamic, cultural, socioeconomic, and genetic-constitutional factors.

Psychophysiologic syndromes are what remains of the psychosomatic illnesses as well as newly recognized stress-related syndromes (see Chapter 1). While the classical psychosomatic illnesses such as ulcerative colitis and peptic ulcer are no longer believed to be any more psychosomatic than immunologic/infectious, there is wide acceptance of the notion that psychological factors such as stress and coping styles contribute to the state of immunocompetence and even cellular aging (Epel, 2004).

For both psychophysiologic syndromes and conversion syndromes, we find it useful to give the broader diagnosis of psychological factors affecting a medical condition (see above).

13.3.2 Recognition and Diagnosis of Conversion and Psychophysiologic Syndromes

Patients with physical symptoms that are not considered to be associated with a diagnosable physical disease, or the severity of which is considered exaggerated, are often referred to the psychiatric consultant for evaluation.

For psychophysiologic syndromes, a medical diagnosis is usually established, but an astute physician notices a connection of the psychological stress and anxiety/depression with the onset, exacerbation, or recurrence of the medical condition. The consultant can usually recognize and elucidate such psychological factors and help reduce the psychological contribution in the illness.

For conversion syndromes, if the symptom of anesthesia is incompatible with the dermatome, or paralysis of an extremity is positive for the Hoover sign (see Chapter 29), then a presumptive diagnosis of conversion may be made. The presence of stress, a past history of unexplained somatic symptoms, and an identifiable psychological conflict that may underlie the symptom are important considerations in making the diagnosis of conversion syndrome. It should be emphasized, however, that all of the above may also be present in and, in fact, may precipitate or exacerbate a medical disease. Conversion is largely a diagnosis of exclusion, and a retrospective one, as the symptoms often clear spontaneously. To be comfortable with the diagnosis, however, it is optimal if the CL psychiatrist can make a formulation in which the symptoms make psychological sense.

Conversion hysteria has been frequently misdiagnosed, as symptoms of a medical or a neurological disease, particularly multiple sclerosis, have been attributed to conversion. The rate of such misdiagnosis, however, has been declining (29% in 1950s, 17% in 1960s, and 4% since 1970s) (Stone et al., 2005).

Recent studies have shown that conversion symptoms are associated with functional brain changes (Burgmer et al., 2006; Vuilleumier, 2005). Functional neuroimaging studies indicate that there are selective decreases in the activity of frontal and subcortical circuits involved in motor control during conversion paralysis, decreases in somatosensory cortices during conversion anesthesia, and decreases in visual cortex activation during conversion blindness. There is also increased activation in limbic regions, such as the cingulate and orbitofrontal cortex in conversion syndrome.

13.3.3 Use of Hypnosis and Lorazepam (or Sodium Amytal) in the Patient Interview

Hypnosis is used today primarily as an adjunct in diagnosing the conversion component of a medical symptom. As hypnosis is a dissociative state in which memories and ideas that are not normally conscious can become accessible, the psychological meanings of physical symptoms may become clear. To the extent that psychological factors that may have caused the conversion symptoms might be attenuated in the hypnotic state (disinhibition), paralysis of muscles in the conversion syndrome may become functional during the hypnotic state (including reversal of mutism), as well as dysfunction of organs of special senses, such as conversion blindness or deafness. It is important to note, however; that any dysfunction, including organic ones, may be ameliorated to an extent under hypnosis due to the strong motivation hypnosis elicits. (See Chapter 29 for further discussion.) Likewise, sedative drugs such as lorazepam and sodium Amytal can be administered intravenously to induce a semiconscious state with reduced cortical inhibitory activity. As in hypnosis, psychological factors associated with a physical symptom may be elucidated in that state, as well as reversal of the dysfunction. When symptom removal has been demonstrated during either hypnosis or drug-induced semiconscious state, it is important to give the suggestion to patients that they will be able to maintain the function after the session to the extent the patient is able. This permits the patient to maintain, reduce, or be relieved of the symptom to the extent permitted by the psychological conflict that caused it.

13.3.4 Treatment

13.3.4.1 Conversion Syndromes

As conversion symptoms often resolve spontaneously, an important goal of treatment is to prevent secondary complications such as disuse atrophy or excessive secondary gain that may work against recovery.

Physical therapy is often the treatment of choice for paralysis or paresis. In addition to preventing disuse atrophy, it provides both a motivation and a facesaving reason for recovery. Likewise, speech therapy is indicated for mutism.

Psychotherapy is indicated both to deal with the underlying psychological conflicts and states (e.g., depression, anxiety) that may have resulted in the body language expression (symptom) as well as to reduce the noxious effects of stress.

Pharmacotherapy is indicated for underlying conditions such as depression.

13.3.4.2 Psychophysiologic Syndromes

Treatment should be geared for both the medical disease and the stress that contributes to it. Stress management, relaxation training, and supportive psychotherapy are some of the modalities that should be considered. If anxiety or depression is present, appropriate medications should be considered. Some patients with psychophysiologic syndromes may be physiologically hypersensitive to anxiety in the particular organ system, for example, resulting in diarrhea or tachycardia, and may respond well to relatively high doses of benzodiazepines. Sufficient doses of benzodiazepines should be prescribed for such patients as there is no evidence that they become habituated to it (Lasagna, 1977) (anecdotally, however, if benzodiazepines are given chronically, dependence becomes a very significant problem; the CL psychiatrist should make it clear that these drugs should be used only short term). For some patients with prominent cardiovascular symptoms associated with stress, or for performance anxiety, beta-blockers, particularly propranolol, may be helpful in relatively small doses (e.g., propranolol 10 mg t.i.d. prn either po or sublingually). Psychophysiologic syndromes and functional syndromes (e.g., irritable bowel syndrome) are best conceptualized as a neurobiologic syndrome requiring an integrated approach (Sharpe and Carson, 2001).

13.4 Dissociation Syndromes

13.4.1 Depersonalization and Derealization

Depersonalization refers to a psychological state in which the perception or experience of the self feels detached or unreal. One feels as if one is an outside observer of one's mental processes or body, as if in a dream. Derealization is an alteration in the perception or experience of the external world so that it seems strange or unreal. In depersonalization, there is increased alertness that may be associated with an activation of prefrontal attentional systems (right dorsolateral prefrontal cortex) and reciprocal inhibition of the anterior cingulate, leading to the experiences of "mind emptiness" and indifference to pain that are often seen in depersonalization. In derealization, there may be a leftsided prefrontal inhibition of the amygdala resulting in dampened autonomic output, hypoemotionality, and lack of emotional coloring, resulting in feelings of unreality or detachment. Derealization and depersonalization may be conceptualized as a syndrome of corticolimbic disconnection (Sierra and Berrios, 1998). Depersonalization and derealization may serve an evolutionarily adaptive function of intensifying alertness and dampening potentially disorganizing emotion.

Depersonalization and derealization experiences often occur in normal people in situations of severe anxiety, as in medical settings where a serious diagnosis or medical procedures may be discussed. Furthermore, many drugs, particularly analgesics and sedatives, as well as mild delirium that may be associated with a medical condition, may predispose patients to depersonalization/derealization. Specific neurological conditions such as partial complex seizures as well as encephalopathies and strokes may be associated with these phenomena. In the CL setting, psychological support and reassurance may alleviate the frightening aspect of these experiences. Reduction or change in a medication that might be associated with the condition, as well as treatment of delirium and the underlying medical condition may be therapeutic.

Depersonalization and derealization are common features of other psychiatric conditions, particularly borderline personality and posttraumatic stress disorder (PTSD). Cognitive-behavioral therapy (Hunter et al., 2005) and naltrexone (Simeon et al., 2005) have been reported to be somewhat effective to treat depersonalization/derealization per se.

13.4.2 Dissociative (Psychogenic) Amnesia and Fugue

Dissociative amnesia is characterized by a pervasive loss of memory of significant personal information, such as name, occupation, and residence. Aspects of dissociative amnesia may be present in dissociative identity disorder (multiple personality), factitious syndromes, psychosis, and the borderline syndrome. Dissociative amnesia is diagnosed when the amnesia cannot be directly attributed to a neurological cause such as trauma or to another major psychiatric condition, and is extensive enough to impair function. In head trauma, there may be localized amnesia that may be retrograde or antegrade.

The subtypes of dissociative amnesia include the following:

Selective amnesia: The patient can recall only small parts of events that happened during a defined period of time. For example, a victim of abuse may have only fragmentary memory of her abuse.

Generalized amnesia: The amnesia encompasses the person's entire life.

Continuous amnesia: The patient has no memory for events beginning from a certain point in the past continuing up to the present.

Systematized amnesia: A loss of memory for a specific category of information. For example, a person may have no memories about one particular family member.

In a dissociative fugue, the person leaves home suddenly and unexpectedly and goes off on a journey, often to distant places. The journey may last hours, days, months, or even years. A person in a fugue state is unaware of or confused about his/her identity, and in some cases will assume a new identity.

13.4.2.1 Differential Diagnosis

In the CL setting, patients who manifest a global amnesia are likely to be referred for a psychiatric consultation. Major differential diagnostic considerations in such cases include memory disturbance associated with delirium, dementia, ictal and postictal states, and head trauma. Amnestic syndromes associated with alcohol abuse (e.g., Korsakoff's psychosis) should also be considered.

Transient global amnesia is a neurologic condition that usually occurs in persons over the age of 50, and is characterized by abrupt anterograde memory loss with repeated questioning ("Where am I?" "What's my name?"). The duration is usually 1 to 8 hours, though durations of 15 minutes and of 24 hours have been reported (Quinette et al., 2006). Emotional and physical stress may precipitate these attacks, and in younger patients, migraine headaches appear to be a risk factor. In females, anxiety, depression, and emotional instability may be risk factors.

13.4.3 Dissociative Identity Disorder (Multiple Personality)

In this condition, two or more identities or personalities alternatively take over the person's behavior. One or more of the personalities may be aware of the other identities, while others may be totally unaware of the existence of other personalities. Patients with this condition often have amnestic periods during which another identity had taken over.

Many patients, in addition, have symptoms of anxiety, depression, derealization, and depersonalization. Substance abuse is common, as well as suicide attempts.

This condition is relatively common in acute psychiatric settings (3% to 4%), or very rare depending on the observer's orientation, and may cause serious functional impairment. The risk of suicide is high in patients suffering from dissociative identity disorder.

More than 90% of patients with dissociative identity disorder report experiencing childhood physical or sexual abuse. Dissociative identity disorder is currently conceptualized as a neurodevelopmental disorder caused by traumatic childhood that prevented an integration of the child's experiences and interactions (Forrest, 2001; Putnam, 1997).

There is evidence that specific brain functional differences in the medial prefrontal cortex and posterior association areas are associated with different personalities in dissociative identity disorder (Reinders et al., 2003). Smaller hippocampal and amygdalar volume has also been associated with dissociative identity disorder, as well as in PTSD and borderline syndrome with a history of childhood abuse and depression (Vermetten et al., 2006).

13.4.3.1 Diagnosis and Treatment

In the CL setting, psychiatric consultation may be requested on patients who have a known diagnosis of dissociative identity disorder (multiple personality), or in the course of an evaluation concerning amnesia, depersonalization, anxiety, depression, or unexplained physical symptoms.

Interviewing patients after placing them under hypnosis or after administering an intravenous sedative (see Chapter 29) may facilitate the diagnosis. The diagnosis is established when an alternate personality is demonstrated, either spontaneously or in an altered state. Great care must be taken not to subtly reinforce the development of altered states by expressing great interest in them.

The treatment of choice is psychotherapy on an outpatient basis, with antidepressants or antianxiety medications as indicated.

13.5 Factitious Syndromes (Munchausen Syndrome)

Baron von Munchausen was an 18th century German aristocrat who told fantastic and boastful adventure stories. In Munchausen syndrome, or factitious disorder, patients falsely present or self-induce symptoms or signs of a disease and seek medical help, often in the emergency department. They may move from hospital to hospital to receive care. Sick-role addiction may explain such behavior. Unlike in malingering, where there is clear and understandable gain by assuming the sick role, patients with factitious disorders often engage in very painful and potentially lethal self-induction of medical conditions (as in the second vignette cited at the beginning of this chapter). They often undergo painful medical procedures and treatments without any apparent gain other than being sick. Many patients seem to be in a trance-like state when they self-induce serious illness. They may develop complications from surgical procedure or scars ("geographic abdomen"), and are at risk of developing drug dependency. For many patients, being a patient with serial hospitalizations may practically become a lifelong career.

Factitious syndromes are often seen in individuals with childhood trauma and deprivation and who have few interpersonal relationships. The patients may have some knowledge of the health care setting either through occupation or in close contact with medical illness (e.g., caring for a chronically ill person). Many are comorbid for other psychiatric conditions including depression, anxiety, substance use, and the borderline personality syndrome.

Munchausen syndrome by proxy refers to a condition in which a parent or caregiver deliberately exaggerates, fabricates, or induces a physical or psychological-behavioral problems in a child or others. Through this symptom, the parent or caregiver receives attention as well as the victim.

13.5.1 Diagnosis and Management

The diagnosis of factitious syndrome is usually made by exclusion of other causes of the symptoms and signs, or observation of self-induction/contamination of a medical condition (e.g., infection, ingestion of poison, diuretics or other drugs) or specimen (e.g., stealing blood from a phlebotomist's cart and pouring it into a bedpan that the patient used).

Once the diagnosis of a factitious disorder is made and the patient has been informed of it, the patient usually leaves the hospital, often against medical advice, only to present again in another hospital.

Management is geared toward prevention of unnecessary and potentially harmful procedures and surgery once the diagnosis has been made. Self-induced illness, however, may be serious and require immediate medical treatment (as in the second vignette). Explaining to the patient that he or she may not be fully aware of the psychological factors that contribute to the factitious illness may help the physician develop a collaborative relationship with the patient. Psychotherapy geared to enhancing the patient's coping and interpersonal skills may be helpful, as well as treatment of often coexisting psychiatric conditions, especially anxiety, depression, and borderline personality.

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