Characteristics of men with conversion disorder.

OBJECTIVE: Women comprise the majority of subjects with conversion disorders in nearly all studies. The authors previously identified 96 subjects with psychogenic non-epileptic seizures (PNES) and found that female sex, alexithymia and childhood trauma were strongly correlated with the development of PNES. In order to characterize men with PNES, the authors collected questionnaire data on a series of male subjects recruited from an epilepsy monitoring unit (EMU). METHODS: Only male patients admitted to the EMU were asked to complete the Toronto Alexithymia Scale-20 (TAS-20) and the Childhood Trauma Questionnaire (CTQ). Results were correlated with diagnosis at discharge, either epileptic seizures (ES) or PNES. RESULTS: Ninety-two subjects submitted complete questionnaire data. Sixty-nine subjects (74%) were diagnosed with ES, 13 subjects (14%) were diagnosed with PNES and 10 subjects (11%) had an undetermined diagnosis. There were no significant differences on the TAS-20 or the CTQ by diagnosis. CONCLUSION: In this sample of men admitted to an EMU there was no difference in the extent of alexithymia or childhood trauma between men with ES and PNES. There was a small number of men with a PNES diagnosis, which may have limited our ability to identify differences in the groups. The clear correlation of childhood trauma and alexithymia with development of conversion disorder in women could not be demonstrated in men.

Clinical Considerations Regarding Regression in Psychotherapy with Patients with Conversion Disorder.

Regression is a ubiquitous phenomenon in psychodynamic psychotherapy and psychoanalysis, typically part of a reorganization that leads to progression, at least with respect to recruiting elements in the unconscious to consciousness. Regression in patients with conversion disorder (i.e., pseudo-neurological symptoms without an organic basis) is often itself somatic/physical rather than psychic in nature. Psychotherapists working with these patients must be prepared for confusing or frightening forms of regression that should be expected as part of the therapeutic process. In conversion disorder patients with adequate character structure, this regression, when handled effectively by the psychotherapist, ultimately leads to verbalized thoughts and feelings and a gradually strengthening alternative to physically experienced psychic conflict.

A psychodynamic perspective on treatment of patients with conversion and other somatoform disorders.

Conversion disorder, the development of symptoms of neurological disease with no organic basis, is a challenge for mental health professionals to diagnose and treat effectively. There are well-established predisposing factors, such as female sex, childhood trauma, and alexithymia, but less clear is how to approach the subjective suffering that is symbolized with the symptom rather than consciously recognized. While there are overlapping comorbidities such as depression and anxiety that may be treated with medication, psychotherapy is the primary effective treatment for patients with adequate capacity to engage in the process. This article addresses means of identifying patients who might benefit from psychotherapy (along with medication in some instances) as well as some guidelines for conducting psychotherapy, with case examples.

Comparisons of childhood trauma, alexithymia, and defensive styles in patients with psychogenic non-epileptic seizures vs. epilepsy: Implications for the etiology of conversion disorder.

BACKGROUND: It has been theorized that conversion disorder is the result of emotion that cannot be experienced consciously as feeling states or put into words (i.e., alexithymia), but there is little confirming empirical evidence. We sought to characterize subjects with conversion disorder compared to subjects with a distinct medical illness, using the model of psychogenic non-epileptic seizures (PNES) vs. epilepsy (ES), on measures of childhood traumatic experience, alexithymia and maturity of psychological defensive strategies. METHODS: All subjects admitted to the Epilepsy Monitoring Unit of the University of Cincinnati Medical Center were offered self-report questionnaires (Childhood Trauma Questionnaire, Toronto Alexithymia Scale-20 and Response Evaluation Measure-71) at the outset of evaluation. Diagnosis of each subject was confirmed by video-EEG and we compared subjects with PNES to those with ES on these measures. RESULTS: 82 subjects had ES AND 96 had PNES. Those with PNES were significantly more likely to have experienced childhood trauma in all domains (p=.005 to p=.05), and were significantly more likely to have alexithymia (p=.0267). There was a significant difference in the capacity to identify feelings, and a trend towards significance in capacity to describe feelings. There were no differences in defensive styles between the two groups. CONCLUSIONS: PNES diagnosis was associated with female sex, higher alexithymia scores and higher rates of childhood trauma, but not with differences in defensive styles compared to ES. These findings add empirical evidence for theories regarding the cause of conversion disorder and may aid in the design of prospective treatment trials in patients with conversion disorder.

A national survey of candidates: II: motivations, obstacles, and ideas on increasing interest in psychoanalytic training.

A national survey of candidates was conducted to identify motivations for pursuing psychoanalytic training, obstacles that prevent progression or completion, and candidates' ideas on how best to increase interest among potential trainees. In 2009-2010, 40 percent of candidates on the affiliate member e-mail list completed an anonymous web-based survey. Candidates strongly endorsed contact with a personal psychotherapist, psychoanalyst, or supervisor as the most important influence in discovering psychoanalysis and deciding to pursue training. They identified the total cost of analytic training as the greatest obstacle. This was followed by the cost of personal analysis, loss of income for low-fee cases, time away from family, and difficulty finding cases. To enhance training, local institutes should work to improve institute atmosphere and provide assistance with finding cases; national organizations should increase outreach activities and publicize psychoanalysis. Psychoanalytic institutes could recruit future candidates by working to increase personal contact with psychoanalysts, reducing the cost of training, improving institute atmosphere, assisting with case-finding, enhancing outreach activities, and widely publicizing psychoanalysis. Narrative comments from candidates and the implications of these findings regarding engagement of future trainees are discussed.

A national survey of candidates: I. demographics, practice patterns, and satisfaction with training.

To better focus efforts in recruiting psychoanalytic candidates, current candidates' demographics, practice patterns, and satisfaction with psychoanalytic training were investigated. An anonymous web-based survey was distributed by e-mail to all candidates subscribing to the affiliate member e-mail list in 2009-2010. Surveys were completed by 226 of 565 affiliate members, for a return rate of 40%. The majority of respondents were women 45 to 64 years of age, married, with a doctoral degree, in private practice, with an annual household income of over $100,000. Most candidates devoted 11 to 30 hours a week to training and had no analysts or candidates in their workplace. Almost half had considered training for more than four years before matriculation, with financial issues cited most frequently as delaying entry. Over 80% of respondents were satisfied with their training. The most frequently cited reasons for dissatisfaction were a negative institute atmosphere, concerns about teaching or the curriculum, and difficulty finding cases. Candidates in training for eight years or more accounted for almost 20% of the group and were more often dissatisfied with training. This study demonstrates that the majority of current candidates are satisfied with training but suggests that recruitment may become increasingly difficult unless factors related to time, cost, case finding, graduation requirements, and institute atmosphere can be addressed.

Can psychiatry residents be attracted to analytic training? A survey of five residency programs.

In the face of fewer psychiatrist applicants for psychoanalytic training, determining the interest of current psychiatric residents in psychoanalysis and psychodynamic psychiatry is a pressing concern. To gauge this interest, an anonymous online survey was sent to residents from five psychiatry residency programs in the Midwest and South. Seventy-five residents responded, for a return rate of 42%. The data suggest that residents value psychoanalytic concepts and most plan to incorporate the practice of psychodynamic psychotherapy into their careers after graduation; however, residents have little confidence in their level of skill and the adequacy of their training. While 46% express interest in further psychodynamic psychotherapy training, only 22% express interest in psychoanalytic training. Most cite the cost and time involved as reasons they would not pursue further training. This study demonstrates that psychiatric residents have strong interest in and respect for psychodynamic psychotherapy and psychoanalysis. The data suggest that psychiatric residents are a viable pool of applicants for psychoanalytic training, especially if barriers to training can be reduced and creative ways for psychoanalysts to engage residents can be fostered.

When worlds converge: Combining depth psychotherapy and psychotropic medications.

The use of medication further widens the scope for the psychoanalyst. The psychoanalyst attempting to combine disparate paradigms must balance maintenance of an analytic attitude with the activities necessary for appropriate diagnosis and treatment of psychiatric illness. Conflicting beliefs about the cause of symptoms, disdain for "quick fixes," lack of role models, and inexperience in using medication are among the issues that create obstacles for psychoanalysts attempting to achieve this balance. Implications for nonmedical analysts and psychoanalytic training are also considered.

Approaching sexual issues in primary care.

This article outlines the typical phases in the development and maintenance of healthy female sexual functioning, and highlights the problems related to sexual functioning that women may present in a primary care practice. The author discusses an approach to the sexual problems of women subjected to trauma and those with certain psychiatric illnesses, and the effect of psychotropic medications on sexual functioning.