Conversion Disorder, Functional Neurological Symptom Disorder, and Chronic Pain: Comorbidity, Assessment, and Treatment.

PURPOSE OF REVIEW: This paper examines the overlap of conversion disorder with chronic pain conditions, describes ways to assess for conversion disorder, and provides an overview of evidence-based treatments for conversion disorder and chronic pain, with a focus on conversion symptoms. RECENT FINDINGS: Conversion disorder is a significant problem that warrants further study, given that there are not many well-established guidelines. Accurate and timely assessment should help move treatment in a more fruitful direction and avoid unnecessary medical interventions. Advances in neuroimaging may also help further our understanding of conversion disorder. Creating a supportive environment and a collaborative treatment relationship and improving understanding of conversion symptoms appear to help individuals diagnosed with conversion disorder engage in appropriate treatments. Novel uses of earlier treatments, such as hypnosis and psychodynamic approaches, could potentially be beneficial and require a more vigorous and systematic study. There are treatments that produce significant improvements in functioning and reduction of physical symptoms from conversion disorder even for very severe cases. Hypnotherapy, cognitive behavioral therapy, and inpatient multidisciplinary treatment with intensive physiotherapy for severe cases have the most evidence to support reduction of symptoms. Components of treatment for conversion disorder overlap with treatments for chronic pain and can be used together to produce therapeutic effects for both conditions. Treatment needs to be tailored for each individual's specific symptoms.

The communal coping model of catastrophizing: patient-health provider interactions.

OBJECTIVE: The study sought to elucidate and refine the interpersonal, communicative dimension of the communal coping model (CCM) of catastrophizing. The primary aim was twofold. First, we examined the relations among pain intensity, catastrophizing, and pain behaviors as they function within the patient-health provider relationship. Second, we investigated the role of catastrophizing and pain behaviors in potentially influencing patient satisfaction with the provider, provider attitudes, and provider behavior. Mediation models were examined. DESIGN: The study was cross-sectional design with repeated measures. SETTING: This study was conducted at a university-based family medicine clinic and a private practice rheumatology clinic. Nineteen health providers and 49 chronic pain patients receiving treatment in a medical setting completed the study. OUTCOME MEASURES: Patient outcome measures included pain intensity, catastrophizing, pain behaviors, and patient satisfaction with the provider. Health provider outcome measures were an assessment of provider attitudes and length of medical exam. RESULTS: The patient's level of catastrophizing entering the medical exam significantly predicted the interactive dynamics between the patient and the health provider during the exam and patient satisfaction after the exam. The patient's perceptions of pain and catastrophic thought processes may be interpersonally expressed to health providers via exaggerated pain behaviors. CONCLUSIONS: Current findings indicate suggestions for refining the CCM. Results suggest that alleviation of catastrophic cognitions may facilitate more effective interpersonal communication within the patient-health provider relationship. Identification of those factors that improve patient-provider dynamics has important implications for the advancement of treatment for chronic pain and reducing the costs associated with persistent pain.

A randomized clinical trial of targeted cognitive behavioral treatment to reduce catastrophizing in chronic headache sufferers.

UNLABELLED: This randomized clinical trial (RCT) examined the efficacy of a cognitive-behavioral treatment (CBT) specifically targeted toward reducing pain catastrophizing for persons with chronic headache. Immediate treatment groups were compared with wait-list control groups. Differential treatment gains based on the order of presentation of 2 components of CBT (cognitive restructuring and cognitive/behavioral coping) and the role of catastrophizing in treatment outcome were examined. Thirty-four participants enrolled in a 10-week group treatment and 11 completed a wait-list self-monitoring period. Participants reported significant reductions in catastrophizing and anxiety and increased self-efficacy compared with wait-list control subjects, and these were maintained at follow-up. Although we did not find overall differences in the reduction of headache frequency or intensity compared with wait-list control subjects, calculation of clinical significance on headache indicators suggest that approximately 50% of treated participants showed meaningful changes in headache indices as well. Order of treatment modules was not related to gains during treatment or at follow-up; however, almost all changes occurred during the second half of treatment, suggesting that duration of treatment participation is important. PERSPECTIVE: Cognitive-behavioral treatment targeting reduction of catastrophizing for chronic headache pain reduced negative cognitive and affective variables associated with recurrent headache, increased headache management self-efficacy, and in half of the participants, produced clinically meaningful reductions in headache indicators. Length of treatment is an important factor to consider when providing CBT for chronic pain.

Cognitive status and behavioral problems in older hospitalized patients.

OBJECTIVES: (a) To determine the quantity and quality of behavioral problems in older hospitalized patients on acute care units; (b) to determine the burden of these behaviors on staff; and (c) to identify predictors of behavioral problems. METHODS: Upon admission, patients performed the Mini-Mental State Exam (MMSE), the Geriatric Depression Scale (GDS), and information was obtained on age, ethnicity, level of education, living arrangement, and psychiatric history. Two days post-admission, a clinical staff member caring for each patient, performed the Neuropsychiatric Inventory-Questionnaire (NPI-Q) to assess patients' behavioral problems and staff distress. PARTICIPANTS AND SETTING : Forty-two patients, over 60 years of age, admitted to medical and surgical units of the Veterans Affairs Hospitals in Palo Alto and San Francisco, participated. RESULTS: Twenty-three of 42 (55%) patients exhibited behavioral problems. Anxiety, depression, irritability, and agitation/aggression were the most frequently observed behaviors. The severity of the behavioral problems was significantly correlated with staff distress. Lower performance on the MMSE at admission was significantly associated with higher NPI-Q ratings. Specifically, of those cases with scores less than or equal to 27 on the MMSE, 66% had behavioral problems during hospitalization, compared to only 31% of those with scores greater than 27. CONCLUSION: Behavioral problems in older hospitalized patients appear to occur frequently, are a significant source of distress to staff, and can result in the need for psychiatric consultation. Assessment of the mental status of older adults at admission to hospital may be valuable in identifying individuals at increased risk for behavioral problems during hospitalization.