Occupational therapy for functional neurological disorders: a scoping review and agenda for research.

Functional neurological disorders (FND)-also called psychogenic, nonorganic, conversion, and dissociative disorders-constitute one of the commonest problems in neurological practice. An occupational therapist (OT) is commonly involved in management, but there is no specific literature or guidance for these professionals. Classification now emphasizes the importance of positive diagnosis of FND based on physical signs, more than psychological features. Studies of mechanism have produced new clinical and neurobiological ways of thinking about these disorders. Evidence has emerged to support the use of physiotherapy and occupational therapy as part of a multidisciplinary team for functional movement disorders (FMD) and psychotherapy for dissociative (nonepileptic) attacks. The diagnosis and management of FND has entered a new evidence-based era and deserves a standard place in the OT neurological curriculum. We discuss specific management areas relevant to occupational therapy and propose a research agenda.

Dying for love: An attachment problem with some perpetrator introjects.

This paper focuses on some problematic victim-perpetrator dynamics in psychotherapy with patients with Dissociative Identity Disorder where there has been longstanding multi-perpetrator organized abuse described, which also involves family members. Additionally, in this specific sample, there have been reported experiences of serious assaults from attachment figures in which the patient felt close to death. The clinical concern is expressed that only in the nearness of death is a connection felt to the attachment figure and this leads to extra suicidality in the patient and extra vulnerability to secondary traumatization for the therapist. This group faces not only relational betrayal dynamics with their reported external abusers, who provide toxic "love", but with internal perpetrators, victim-perpetrators, and victims too. The impact of an incestuous and rivalrous civil war in the body and mind that replicates the external system and is projected into the therapeutic encounter poses particular problems for therapists and patients. There are different problems for the treatment according to how the perpetrator-identified dissociative system is in need of a near-death connection.

Juggling-exposure therapy: an innovation in trauma treatment.

Three case studies are presented illustrating an innovative treatment approach that integrated a juggling task with exposure therapy for clients who had benefited from trauma therapy but had residual trauma symptoms. All 3 clients reported benefiting considerably from adding the juggling task to the exposure therapy. The effects appeared to be rapid and minimally stressful and generalized to in vivo situations. I suggest that the treatment may have enhanced the response flexibility in brain circuitry involved with preconscious threat detection.

Return to work: a case of PTSD, dissociative identity disorder, and satanic ritual abuse.

This case study investigated an intervention that enabled an individual with Posttraumatic Stress Disorder (PTSD), Dissociative Identity Disorder (DID), and satanic ritual abuse to return to work after discharge from psychiatric inpatient treatment. The Occupational Questionnaire [88] revealed past difficulties in organization, awareness of time, communication, cooperation, frustration tolerance, competition, stress management, goal setting, and amnesia resulting in incomplete tasks and sporadic attendance at work. The Role Checklist [72] identified alters valuing work and employed in the past. The Modified Interest Checklist [70] identified running as an interest that 24 alters shared. Based on the initial evaluations, three times a week treadmill running was used as an intervention that built work skills (as measured by the Clerical Work Sample of the Valpar Component Work Sample Series [97]) necessary to sustain gainful employment upon discharge. After intervention, this individual improved in awareness of time, stress management, and goal setting abilities and was less amnestic as per the Occupational Questionnaire [88] and four additional alters expressed an interest in work according to the Modified Interest Checklist [70].

Inpatient treatment for adult survivors of childhood sexual abuse: a preliminary outcome study.

The objective of this study was to examine the changes in psychiatric symptoms and interpersonal problems in 34 adults with a history of childhood sexual abuse and posttraumatic stress disorder who attended a 3-month inpatient treatment program. Levels of posttraumatic, depressive, and general psychiatric symptoms and interpersonal problems were assessed at pre-care evaluation, admission, discharge, and 1-year follow-up using the Impact of Event Scale, the Beck Depression Inventory, the Symptom Check List 90 Revised, and the Inventory of Interpersonal Problems. Work status was assessed at admission and at follow-up. Significant improvements were seen during treatment on the global scores of all instruments except the Beck Depression Inventory. At follow-up, patients had kept their gains on symptom measures and experienced further progress regarding interpersonal problems. At discharge, 3 of the previously 32 unemployed patients were able to return to work. Patients with comorbid somatization disorder tended to have higher levels of distress and less favorable treatment response. Future studies should include pre- and posttreatment assessment of dissociation to evaluate its association with outcome.

Testing the diagnosis of dissociative identity disorder through measures of dissociation, absorption, hypnotizability and PTSD: a Norwegian pilot study.

A total of 14 women meeting criteria for dissociative identity disorder (DID) based on the Diagnostic and Statistical Manual of Mental Disorders (4th ed. [DSM-IV]) were compared to a group of women (n = 10) with other dissociative diagnoses and a group of normal controls (n = 14) with regard to dissociativity, absorption, trauma related symptoms and hypnotizability. Both of the clinical groups reported histories of childhood trauma and attained high PTSD scores. The DID group differed significantly from the group with other dissociative diagnoses and the non-diagnosed comparison group with regard to hypnotizability, the variety of dissociative symptomatology, and the magnitude of dissociative symptomatology. However, no significant differences between the two clinical groups were detected with regard to absorption, general dissociative level, or symptoms related to traumatic stress. Results support the notion that DID can be regarded as a clinical entity which is separable from other dissociative disorders. Results also indicated that hypnotizability is the most important clinical feature of DID.

Self-mutilating behavior in patients with dissociative disorders: the role of innate hypnotic capacity.

BACKGROUND: Despite the fact that the assumption of a relationship between self-mutilation and dissociative disorders (DD) has a long history, there is little empirical evidence to support this premise. The present study examined this relationship and investigated whether this commonality is associated with innate hypnotic capacity. METHODS: Fifty patients diagnosed with DD and 50 control subjects with major depression were assessed by using a self-mutilation questionnaire, Dissociative Experiences Scale, Traumatic Experiences Checklist, and the Eye-Roll Sign for their self-mutilating behaviors, dissociative symptoms, early trauma, and innate hypnotic capacity, respectively. RESULTS: We have found that 82% of the present sample of patients with DD injured themselves. They had higher scores on trauma, dissociation and eye-roll measurements than controls. In addition, DD patients with self-mutilation were more likely to have high scores of trauma, dissociation and eye-roll than those without self-mutilation. Innate hypnotic capacity was a strong predictor of self-mutilating behavior in DD patients. CONCLUSIONS: This study strongly supports the assumption that patients with DD are at high risk for self-mutilating behavior and points to the necessity of routine screening for self-mutilating behavior as well as the hypnotic capacity which may constitute a high risk for self-injury in this patient group.

Dissociative experiences differentiate bipolar-II from unipolar depressed patients: the mediating role of cyclothymia and the Type A behaviour speed and impatience subscale.

BACKGROUND: Dissociative symptoms are often seen in patients with mood disorders, but there is little information on possible association with subgroups and temperamental features of these disorders. METHODS: The Dissociative Experience Scale was administered to 85 patients with a DSM-IV Major Depressive Disorder (MDD) or Bipolar-II Disorder (BP-II). Both broad-spectrum dissociation (DES total score) and clearly pathological forms of dissociation (DES-Taxon) were assessed. Temperament was assessed using Akiskal and Mallya;s criteria of Affective Temperaments and the Jenkins Activity Survey (JAS) for Type A Behaviour. RESULTS: Sixty-five patients gave valid answers to DES. The mean DES and DES-T scores were higher in BP-II (16.8 and 12.7 respectively) compared to MDD (9.0 and 5.7); DES odds ratio (OR)=1.58 (95% CI 1.15-2.18) and DES-T OR=1.60 (95% CI 1.14-2.25) using univariate logistic regression analyses. There was no significant difference in DES score in patients with (n=30) and without an affective temperament (n=35): mean (95% CI), 13.5 vs. 10.5 (-7.8 to 1.9), p=0.224. However the subgroup with a cyclothymic temperament (n=18) had higher DES scores (mean (95% CI): 17.8 vs. 9.7 (2.9-13.3), p=0.003), compared to patients without such a temperament. There was no significant difference in DES scores for patients with (n=35) or without (n=28) a Type A behaviour pattern (JAS>0): mean (95% CI) 12. 7 vs. 10.9 (-6.8 to 3.3), p=0.491), but a positive JAS factor S score (speed and impatience subscale) was associated with significantly higher DES scores than a negative S-score: mean (95% CI) 14.9 vs. 9.0 (1.1-10.7), p=0.017), and this was still significant (p=0.005) using multiple linear regression of DES scores vs. the JAS subscale scores. DES-T scores were significantly higher in patients with OCD (n=9) (mean (95% CI) 18.4 vs. 6.6 (6.0-17.7), p<0.001); eating disorder (n=13) (14.0 vs. 6.8 (1.8-12.6), p=0.009), psychotic symptoms during depressions (n=9) (16.6 vs. 6.9 (3.7-15.8), p=0.002), and in those with a history of suicide attempt (n=28) (11.9 vs. 5.4 (2.2-10.8), p=0.003), but only OCD was an independent predictor after multiple linear regression of DES-T scores vs. all co-morbid disorders (p=0.043). LIMITATIONS: The major limitation of the present study is a non-blind evaluation of affective diagnosis and temperaments, and assessment in a non-remission clinical status. CONCLUSIONS: Dissociative symptoms measured with the Dissociative Experience Scale are associated with bipolar features, using formal DSM-IV criteria, cyclothymic temperament and the speed and impatience subscale of the JAS.

Dissociative disorders in the psychiatric emergency ward.

OBJECTIVE: The aim of this study was to determine the prevalence of dissociative disorders among emergency psychiatric admissions. METHOD: Forty-three of the 97 consecutive outpatients admitted to the psychiatric emergency unit of a university hospital were screened using the Dissociative Experiences Scale (DES). Seventeen (39.5% of the 43 evaluated) patients with a DES score above 25.0 were then interviewed with the Dissociative Disorders Interview Schedule and the Structured Clinical Interview for Dissociative Disorders. RESULTS: Fifteen emergency unit patients (34.9% of the 43 evaluated participants) were diagnosed as having a dissociative disorder. Six (14.0%) patients had dissociative identity disorder, 6 (14.0%) had dissociative disorder not otherwise specified, and 3 (7.0%) had dissociative amnesia. The average DES score of dissociative patients was 43.7. A majority of them had comorbid major depression, somatization disorder, and borderline personality disorder. Most of the patients with dissociative disorder reported auditory hallucinations, symptoms associated with psychogenic amnesia, flashback experiences, and childhood abuse and/or neglect. CONCLUSIONS: Dissociative disorders constitute one of the diagnostic groups with high relevance in emergency psychiatry.

Dissociative disorders in Turkish inpatients with conversion disorder.

The aim of our study was to determine the frequency of dissociative disorders (DDs) among inpatients with conversion disorder (CD) in a university clinic settled in Eastern Turkey. During a period of 24 months, 59 consecutively admitted adult CD patients were screened with the Dissociative Experience Scale (DES). Patients who scored above 30 (DDs group) did not differ by age or gender from a group of inpatients who scored below 10 on the scale (comparison group). All patients in the two groups were then interviewed in a blind manner using the Dissociative Disorders Interview Schedule (DDIS) and Structured Interview for DSM-IV Dissociative Disorders (SCID-D). According to the SCID-D, 18 of 59 patients (30.5%) received a diagnosis of dissociative disorder; nine of these 18 patients (50%) were diagnosed as having dissociative identity disorder, eight (44.4%) were diagnosed as having dissociative disorder not otherwise specified (NOS), and one (5.6%) was diagnosed as having dissociative amnesia. Accordingly to the DDIS, borderline personality disorder was frequent in the DDs group, and all of the patients in the DDs group reported sexual abuse and neglect during childhood, latency, or adolescence. A high proportion of CD patients have significant dissociative pathology. The proper diagnosis of these patients has important implications for their clinical course.

Working with the center: psychiatric rehabilitation with people who dissociate.

Psychiatric rehabilitation is a model of health care helping that is useful in an increasing range of mental health situations. To date, little has been written about using this approach with persons who have survived more severe trauma and who may dissociate. This descriptive paper reviews dissociation, the impact of childhood trauma on rehabilitation and offers suggestions on how to increase the success of the process for these people.

Dissociative disorders in the Sultanate of Oman.

OBJECTIVE: To study the clinical manifestations and psychosocial aspects of dissociative (conversion) disorders (DD) in the Sultanate of Oman. METHOD: A retrospective analysis was made of data derived from case records of patients admitted as in-patients to the Sultan Qaboos University Hospital, Oman, over a period of 8 years. RESULTS: A higher prevalence of DD was noted in Oman compared to western countries. The female preponderance was less marked in Oman. The most common presentations were dissociative convulsions, dissociative motor and dissociative trance disorders. Interpersonal difficulties with family and academic problems were the important identified precipitants. CONCLUSION: The study highlights the characteristic clinical and psychosocial features of the dissociative phenomena in Oman.

Head injury, dissociation and the Ganser syndrome.

OBJECTIVE: To describe the clinical characteristics and psychiatric correlates of the Ganser syndrome following mild traumatic brain injury (TBI). METHOD: A retrospective chart review of patients with mild TBI assessed in a tertiary care outpatient clinic. RESULTS: Of 513 patients reviewed in a 1 year period, four subjects with a diagnosis of Ganser syndrome, with the hallmark syndrome of approximate answers ('vorbeigehen') were identified. In three of these patients, symptoms of Acute Stress Disorder (ASD) and/or Post-traumatic Stress Disorder (PTSD) were found. Only one patient was pursuing litigation. CONCLUSIONS: While no epidemiologic conclusions can be drawn from the data, clinicians should, nevertheless, be alert to the possibility of patients presenting with Ganser syndrome following TBI. The findings are discussed in the light of data linking the syndrome to dissociative and post-traumatic stress related disorders.

Reported sexual abuse and subsequent psychopathology among women attending psychology clinics: the mediating role of dissociation.

OBJECTIVE: While there is now a good clinical research base that outlines the links between reported sexual abuse and psychological symptoms and disorders, there is less of an understanding of the psychological processes mediating that relationship. This study assessed the role of dissociation as a mediator between reported sexual abuse and a range of psychopathological characteristics. DESIGN: A patient-series design was used. METHOD: Participants were an unselected sample of 45 women attending clinical psychology services. Each woman was interviewed regarding a reported history of sexual abuse, and completed standardized measures of general psychopathology, borderline personality disorder characteristics and dissociation. RESULTS: Sexual abuse per se was associated with the extent of depression, somatization, compulsive behaviour, phobic symptoms and borderline personality disorder characteristics. In each case, dissociation served as a complete mediator in that link. However, the same mediating relationship was not found when attempting to explain the greater psychopathological impact of more 'severe' forms of abuse (childhood experiences; intra-familial abuse). CONCLUSION: These findings suggest that the effective of clinical work with these psychopathological features would be enhanced if dissociation symptoms were addressed in women with a reported history of sexual abuse. However, the importance of that therapeutic target may be unrelated to the severity of the psychological disturbance.

Toward a more comprehensive medical anthropology: the case of adolescent psychopathology.

This article argues for a more comprehensive analytical approach in medical anthropology than is currently followed, one that combines attention to structural factors (political, economic, medical/psychiatric), experiential/symbolic expressions and meanings, and biological/bodily features of disorders. We show how subject matter that may be defined as "adolescent psychopathology" would be better understood by a comprehensive approach than by partial views. Three areas within adolescent psychopathology are chosen as illustrative: anorexia nervosa, dissociation, and social aggression. Each of these, like adolescence itself, is powerfully shaped by historical and contemporary cultural influences, and each implicates important theories in medical anthropology.

[Sprouting roots, growing and maturing. Agricultural occupational therapy as the favored non-pharmacologic method for treatment and rehabilitation of new chronic patients]. / Sich verwurzeln, wachsen und reifen. Landwirtschaftliche Arbeitstherapie als nichtpharmakologisches Mittel der ersten Wahl für die Behandlung und Rehabilitation der neuen Langzeitkranken.

The so-called young adult chronic patients suffer from mental disorders in the motivational and social sphere. Among others, work therapy is one of the methods of the treatment. The agricultural work therapy can supply with a large variety of gradually adapted working facilities. The demanding property of nature improves motivational disorders. Animals and plants as mediators help cure social disorders. Agricultural work therapy can contribute to find ones profession and can have psychotherapeutic effects.