Predictors of suicide in patients with conversion disorder

doi:10.1016/j.comppsych.2013.10.009

Comprehensive Psychiatry

Volume 55, Issue 3, April 2014, Pages 457-462

https://doi.org/10.1016/j.comppsych.2013.10.009 Get rights and content

Abstract

Objective

Previous studies have shown that the ratio of suicide attempts is between 19.6 and 34.2% in patients with conversion disorder (CD), yet few studies have addressed this issue. The present study compared demographic and clinical variables and predictors of suicide attempts in patients with CD.

Methods

A total of 100 consecutive patients were recruited and divided into groups according to their history of suicide attempts. Socio-demographic variables such as economic status, age, gender, educational level, marital status, clinical variables such as the presence of psychiatric disorder in family, substance abuse, risky alcohol use, age of onset, subtype of CD, number of hospitalization were recorded. Participants also completed the Childhood Trauma Questionnaire (CTQ-28), Temperament and Character Inventory (TCI), Toronto Alexithymia Scale (TAS-20), Dissociative Experiences Scale (DES), Beck Anxiety Inventory (BAI), and Beck Depression Inventory (BDI).

Results

Suicide attempters had a higher rate of risky alcohol use, more hospitalizations, and higher mean scores on the BAI, BDI, DES/DES-taxon, TAS-total and CTQ-total than did non-suicide attempters or healthy control (NHC). Patients with CD had a higher harm-avoidance and a lower self-directedness rather than NHC. Risky alcohol use, number of hospitalizations, and mean DES-taxon and emotional abuse scores were independent predictors of suicide attempts.

Conclusion

Our findings indicate that clinicians should be aware of the prediction of suicide in patients with CD who show dissociation and risky alcohol use. Moreover, a history of childhood emotional abuse should be considered in the management of CD. The fact that clinical variables distinguished between suicide attempters and non-attempters suggests that a history of suicide attempts may be used to clarify the heterogeneous nature of CD.

Introduction

Conversion disorder (CD) has long been recognized as a psychiatric condition. However, few patients with CD are admitted to psychiatric hospitals, and the condition is rarely diagnosed in emergency departments. CD is characterized by somatic symptoms that have no apparent physical cause and are thought to be symbolic representations of underlying psychological conflict [1]. The symptoms are not intentional; thus, the patient is not malingering or seeking secondary gain. Accurate diagnosis is imperative because misdiagnosis may cause additional psychological distress, and the symptoms worsen in response to erroneous interventions [1].

The diagnosis of CD is controversial because classifications vary; however, the disorder is generally believed to be a cluster of heterogeneous disorders [2], [3]. The concept of psychological factors confuses the classification of the disorder. Moreover, the diagnostic validity of CD is poor [4], [5]. Medically unexplained physical symptoms (MUPS) are not necessarily related to a psychiatric disorder [4].

Few studies have investigated suicide in patients with CD; however, evidence suggests that the rate of suicide attempts is high, varying from 19.6 to 34.2% [6], [7], [8], [9], [10]. Suicide attempt rates are likely to be high in patients with CD who try to solve psychological conflicts by converting them into physical symptoms. Given that the CD diagnosis is delayed or not always diagnosed may increase the importance of suicidal behavior.

Several studies have highlighted the importance of childhood trauma and dissociative symptoms in the etiology of CD [7], [9], [11], [12], [13], [14], [15], [16], [17], [18], [19]. Furthermore, childhood trauma and dissociation are significantly correlated with suicidality [20], [21]. A previous study found that the suicide rate was 34.2% in patients with CD and significantly higher among those patients with comorbid dissociative disorder [9]. Personality and alexithymia play a role in developmental psychopathology and are viewed as phenomenological contributors to psychiatric disorders, with childhood maltreatment in a vicious cycle, together or one by one each of the other variables that may be associated or confounded with suicide [22], [23], [24], [25].

Given the high rate of suicide attempts among patients with CD, it is essential to identify the characteristics that define attempters. We planned to investigate the importance of childhood maltreatment and consecutive developmental deviations such as personality and alexithymia which are expectedly seen frequently in patients with CD. Also we consider, it is important in understanding the phenomenon of suicide which variables are contributing. Our hypothesis was that demographic and clinical variables related with childhood maltreatment and its sequelae may be predictors in patients with CD. The present study investigated childhood maltreatment, temperament and character, alexithymia, dissociation, and clinical and demographic variables in patients with CD to develop a profile of suicide attempters and identify predictors of suicide attempts.

Section snippets

Methods

We enrolled 100 consecutive patients with CD (85 female, 15 male) between the ages of 18 and 64 years who were admitted to the psychiatry clinic of the Erenköy Mental Health Research and Training Hospital. All participants were evaluated by the neurologists prior to study. The diagnosis of CD was made according to DSM-IV criteria. We excluded patients who were not able to understand the questions or were unwilling to complete the questionnaire as well as patients with a psychotic disorder,

Results

Demographic and clinical characteristics of the CD suicide attempters (SA; n = 33) and non-attempters (nSA; n = 61) and the NHC group (n = 50) are presented in Table 1, Table 2. The prevalence of married individuals was lower in the SA group than in the nSA and NHC groups (χ² = 15.43, p = 0.004). A family history of psychiatric illness was significantly more prevalent in patients with CD than in the NHC group. (χ² = 15.38, p < 0.001). Although the drug abuse was found to be the same in all groups (χ² = 1.381, p

Discussion

Many clinicians have a negative view of CD and, in the context of the social stigma surrounding psychological disorders, patients with CD often feel alienated [26]. Information concerning the prevalence and predictors of suicide attempts in patients with CD will be of use to clinicians and emergency department staff who treat patients with CD. Our findings show that suicide attempts are linked to active psychopathology and childhood maltreatment, which are associated with less cooperation from

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Fears of pain, injury, and death may represent key barriers to acting on suicidal thoughts. Dissociation, which involves a disconnection from one’s body, may reduce fears and sensations of pain associated with harming the body, in turn facilitating suicide attempts. This study examined whether dissociation differentiated individuals with a history of suicide attempts from those with a history of suicide ideation, and investigated whether other relevant constructs explain this relationship. Sample 1 included 754 undergraduates (M_age = 21, 79% female) who completed a battery of self-report measures. Sample 2 included 247 undergraduates (M_age = 19, 74% female) who completed a self-report measure of dissociation, a clinical interview regarding suicide history, and four counterbalanced behavioral pain tolerance tasks. In both samples, dissociation was elevated in lifetime attempters compared to ideators (d = 0.28; d = 0.46; ps = 0.01) and slightly elevated in lifetime ideators compared to nonsuicidal individuals (d = 0.19, p = .02; d = 0.24, p = .47), though this effect was non-significant in the latter sample. In Sample 1, dissociation no longer differentiated attempters from ideators after controlling for clinical covariates. In Sample 2, dissociation was unrelated to behavioral pain tolerance tasks, and these tasks did not account for the association between dissociation and attempts. Overall, dissociation differentiated individuals with a history of suicide attempts from those with ideation alone in both samples. Pain tolerance did not explain this association; instead, it is possible that the relationship of dissociation to suicide attempts is due to “third variables” associated with both phenomena, such as symptoms of borderline personality disorder or posttraumatic stress disorder.
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Somatoform disorder was the third most frequently diagnosed mental disorder in those with history of suicide attempts, behind depression and anxiety [10]. A cross-sectional study by Güleç and colleagues examined 100 consecutive patients with conversion disorder admitted to the psychiatry clinic following an evaluation by neurology and found a high frequency of prior suicide attempts in those who completed the survey (33/94 = 35%), while a history of suicide attempts was absent in the very healthy control group of hospital employees and their relatives without any past psychiatric or neurological history [24]. This very high frequency of past suicide attempts is supported by even higher estimates by Rechlin and colleagues in Germany [25].
We sought to determine the frequency of and risk factors for suicide outcomes in somatic symptom and related disorders and whether any risk was independent of co-occurring mental disorders.
We conducted a systematic review of studies on suicide death, suicide attempts, and suicidal ideation in those with somatic symptom disorders published prior to September 22, 2020 and indexed in PubMED, MEDLINE, PsycARTICLES, PsycINFO, EMBASE, or SCOPUS according to PRISMA guidelines.
Our search yielded 33 articles with significant heterogeneity in study design, sample selection, and assessment for suicide or risk factors. While suicide deaths have not been adequately studied, somatic symptom and related disorders are associated with increased risk for suicidal ideation and suicide attempts, with estimates ranging from 24 to 34% of participants who endorsed current active suicidal ideation and 13–67% of participants who endorsed a prior suicide attempt. The risk appeared independent of co-occurring mental disorders. Identified risk factors for suicide attempts in samples with somatic symptom and related disorders include scores on measures of anger, alexithymia, alcohol use, past hospitalizations, dissociation, and emotional abuse.
Although the literature is sparse, there exists evidence for an association, even independent of other mental disorders, between somatic symptom and related disorders and suicide outcomes. Practice guidelines for the management of these disorders should incorporate recommendations for the assessment and management of suicide risk. Future study is necessary to more fully elucidate potential unique risk factors for those suffering from these complex disorders.
Alexithymia and self-harm: A review of nonsuicidal self-injury, suicidal ideation, and suicide attempts
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One study found that this association was significant among a combined sample of individuals with substance use and eating disorders (Laget et al., 2006). Inconsistent findings between alexithymia and suicide attempts have been reported in conversion disorder (Güleç et al., 2014) and among substance use disorders (Evren and Evren, 2006; Ghorbani et al., 2017; Haviland et al., 1988). Bergmans and Links (2009) reported reduced alexithymia scores following a group intervention for people with recurrent suicide attempts.
Suicide attempts are a significant global public health concern. Research into non-traditional factors, such as the presence of alexithymia, may shed light on the prediction of suicidal behaviours, which can aid intervention and prevention strategies. To ascertain whether alexithymia is a unique risk factor for suicide attempts, this article reviews the evidence on alexithymia related to suicidal ideation, attempts, and non-suicidal self-injury (NSSI).
A literature search was conducted for original articles examining the general and psychiatric populations.
There is consistent evidence linking alexithymia with suicidal ideation and NSSI, but inconsistent evidence linking it to suicide attempts.
The relationship between alexithymia and suicidality seems to differ based on whether the research focuses on suicidal ideation, suicide attempts, or NSSI. The relationship between alexithymia and suicidality can be understood within the context of multiple code theory and childhood trauma. Future research should explore the whether alexithymia can reliably distinguish between those with a single attempt and those with multiple suicide attempts as well as alexithymia levels pre- and post-intervention with suicide-related behavior as outcomes in treatment studies.
A systematic review and meta-analysis of the association between alexithymia and suicide ideation and behaviour
2019, Journal of Affective Disorders
Alexithymia reflects a difficulty with identifying and expressing emotions. This experience has been proposed as having an association with suicide ideation and behaviour. This review aimed to synthesise the evidence to establish the bivariate and multivariate relationships between alexithymia, and its subcomponents, with suicide ideation and behaviour.
Search terms related to alexithymia and suicide ideation and behaviour were searched across nine prominent databases in May 2018. Studies were eligible for inclusion if they reported original empirical quantitative findings from adult samples, used a validated measure of alexithymia, and any measure of suicide ideation or behaviour.
Thirty-four studies were eligible for inclusion in this review. The review found a large effect size for the relationship between alexithymia and suicide ideation (r = 0.54, 95% CI= 0.40–0.65) and a small effect size for the relationship between alexithymia and suicide behaviour (r = 0.25, 95% CI = 0.16–0.34).
A high level of heterogeneity was found in the meta-analysis meaning that results should be interpreted with caution.
A positive association was found between alexithymia and suicide ideation and, to a lesser extent, behaviour across a range of clinical and general population samples. This review has potentially important clinical implications, and promotes the need for suicide prevention to focus on emotion regulation skills.
Avoidance in nonepileptic attack disorder: A systematic review and meta-analyses
2019, Epilepsy and Behavior
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The remaining 22 articles were read in full to determine eligibility. Eight articles were excluded: five did not consider constructs, which could be considered avoidance [3,33–35]; two used a mixed group with NEAD and functional neurological disorder [36,37], and one was excluded as only a summary was translated into English [38]. Thus, 14 papers were included in the narrative review; six of these articles were included in the meta-analysis comparing NEAD to an HC group; and four were included in the meta-analysis comparing NEAD to an EC group (Fig. 1).
Avoidance is the active process of trying to escape from or not experience situations, places, thoughts, or feelings. This can be done through behavioral or cognitive strategies, or more broadly, a combination of both, utilized in an attempt to disengage from private experiences referred to as experiential avoidance (EA). Avoidance is considered important in the development and maintenance of nonepileptic attack disorder (NEAD). This review aimed to understand avoidance in NEAD and evaluate its role as a contributory factor.
Fourteen articles were identified by searching Cumulative Index to Nursing and Allied Health (CINAHL), MEDLINE Complete, PsycINFO, and EMBASE and were combined in a narrative synthesis. Six of these articles were included in a meta-analysis comparing levels of EA for individuals with NEAD and healthy controls (HC), and four were included in a meta-analysis comparing EA in NEAD to epilepsy comparisons (EC).
Experiential avoidance appears to be a strategy that is used by a high proportion of the population with NEAD. The group with NEAD utilized significantly more avoidance compared with both the HC and EC. However, further research is needed to understand the extent and types of avoidance that are relevant.
Upper extremity conversion disorder in children
2019, Journal of Shoulder and Elbow Surgery
Conversion disorder in children presents a challenge to orthopedic surgeons. The condition is frequently associated with unnecessary diagnostic tests, treatments, and cost. The purpose of this study was to report a series of children with upper extremity conversion disorder to raise awareness for this uncommon condition and to assist with its diagnosis and management.
A retrospective review was conducted of 4 pediatric patients with upper extremity conversion disorder at a tertiary pediatric hospital from 2015 to 2017. Medical records were reviewed for patient demographics, including psychiatric history, clinical findings, diagnostic studies, treatment, and cost of care.
Patients presented with upper extremity muscle stiffness, unremitting dysmorphic muscle spasms, weakness, pain, very limited shoulder range of motion, and complaints of recurrent shoulder dislocations. All patients had been evaluated by multiple specialists and had an extensive prior diagnostic workup that was inconclusive. Two patients had a history of prior psychiatric illness and suicidal ideation, and all patients expressed despair and depression. All patients had normal physical examination findings under anesthesia. Two patients with muscle stiffness were treated with botulism injections and improved their shoulder range of motion. The average total charge for care since presentation was $42,729.
Conversion disorder should be considered in patients with an extensive prior diagnostic workup, deficits inconsistent with anatomic patterns or imaging findings, and a history of prior psychiatric illness. Examination under anesthesia is a successful diagnostic approach in children with suspected conversion disorder.

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Predictors of suicide in patients with conversion disorder

Abstract

Objective

Methods

Results

Conclusion

Introduction

Section snippets

Methods

Results

Discussion

J Psychosom Res

Psychiatr Clin North Am

Seizure

Epilepsy Behav

J Psychosom Res

Epilepsy Behav

Psychosomatics

Compr Psychiatry

Eur Psychiatry

Psychiatry Res

J Affect Disord.

J Psychiatr Res

J Psychosom Res

J Psychosom Res

Child Abuse Negl

Compr Psychiatry

J Psychosom Res

Somatoform Disorders

Managing somatization: medically unexplained should not mean medically ignored

J Gen Intern Med

Reassurance in the treatment of hypochondriasis

A comprehensive profile of clinical, psychiatric, and psychosocial characteristics of patients with psychogenic nonepileptic seizures

Epilepsia

Does Childhood Trauma History Effect the Psychiatric Symptoms of Conversion Disorder or Not?

Klinik Psikiyatri

Childhood trauma, dissociation, and psychiatric comorbidity in patients with conversion disorder

Am J Psychiatry