Trauma-related dissociative (conversion) disorders in children and adolescents – an overview of assessment tools and treatment principles

Abstract

A high proportion of patients in child and adolescent psychiatry with significant dissociative symptomatology after early childhood traumatization may go undiagnosed, be wrongly diagnosed and/or inappropriately treated. The diagnostics and treatment of dissociative disorders have been limited by lack of comprehensive, reliable and valid instruments and the ongoing polarization and fierce controversy regarding treatment. However, recent neurobiological findings of neurochemical, functional and structural cerebral consequences of early stressful childhood experiences point out a need for active, early and effective identification and treatment interventions. We present an update on assessment tools available in the Nordic countries, and an overview of different appropriate therapeutic intervention models for children and adolescents. A systematic overview of studies of dissociation in children and adolescent published over the last decade disclosed a total of 1019 references. The 465 papers describing aspects of assessment tools and/or treatment were studied in detail. Reliable and valid screening questionnaires and diagnostic interviews for children and adolescents now allow for effective early identification of dissociative disorders. A combination of individual psychotherapy, pharmacotherapy and family therapy are often required to handle dissociative disorders in children and adolescents. Cognitive-behavioural therapy, hypnotherapy, Eye-Movement Desensitization-Reprocessing (EMDR), psychodynamic therapy and an integrated approach are the main described psychotherapeutic approaches, but treatment of dissociation in children and adolescent does not require allegiance to any one particular treatment model. However, achievement of physical safety by providing a safe environment is a primary goal that supersedes any other therapeutic work. Assessments tools are now available, and appropriate therapeutic intervention models may hopefully contribute to reduce the risk of wrong diagnoses and inappropriate treatment of dissociative symptomatology in children and adolescents. However, controlled clinical trials of the various interventions and longitudinal outcome studies are needed.

Dissociation in children and adolescents as reaction to trauma – an overview of conceptual issues and neurobiological factors

“…The neurobiological findings also point out a need for specific assessment with reliable and valid tools and active, early, specific treatment interventions as described in a forthcoming paper (135). Childhood trauma related dissociative disorders may be regarded as complex environmentally induced developmental disorders (121).…”

The Korean Version of the Adolescent Dissociative Experience Scale: Psychometric Properties and the Connection to Trauma among Korean Adolescents

“…Among these, the A-DES has been developed solely for adolescents and its reliability and validity has been well-established 17. The other two scales cover adolescents and adults together and the DisQ has only satisfactory reliability and validity (32).…”

Estado actual de los trastornos somatomorfos y conversivos en niños y adolescentes

“…Suele necesitarse idealmente una combinación de psicoterapia individual/familiar y farmacoterapia para el tratamiento comórbido, sobre todo de ansiedad y depresión 56 . Los principales abordajes psicoterapéuticos son el cognitivo-conductual, psicodinámico-hipnoterapéutico, terapia por intención paradójica y la desensibilización y reprocesamiento por movimientos oculares 10 . Un metaanálisis demostró que la psicoterapia cognitivo-conductual era eficaz en el tratamiento de los TS 57 , sobre todo en áreas como atribución de dolencias somáticas sesgadas, percepción selectiva de estímulos interoceptivos, catastrofización como patrón de pensamiento y comportamiento evitativo 58 .…”

“…Por otra parte, un estudio francés verificó que los principales motivos de consulta en un servicio de emergencias psiquiátricas fueron los trastornos neuróticos y somatomorfos 6 , hecho corroborado para la población general británica, donde los desórdenes mentales más prevalentes en 2010 fueron los del espectro somatomorfo, ansioso y afectivo 7 , por lo que el gasto público y privado en salud es prominente 5 , al asociarse a consultas reiteradas a múltiples especialistas, encontrándo-se mayoritariamente hallazgos negativos 8 . Adicionalmente, los criterios diagnósticos son aún controversiales en su aplicación infantojuvenil 9 , considerando además una falta de instrumentos evaluativos confiables y válidos y el poco consenso en relación a su manejo 10 . Cabe precisar que la intercurrencia de desórdenes anímicos y ansiosos es alta, incluyéndose como factores de riesgo: mayor sensibilidad al estrés, vulnerabilidad biológica, trastornos mentales familiares, sobreprotección parental y una mentalización limitada de los sín-tomas físicos 1 .…”