20: Conversion Disorders in Canadian Children & Youth: A National Survey of Prevalence Estimate and Clinical Features

Conversion Disorder (CD) is categorized within the group of disorders known as Somatoform disorders in the Diagnostic and Statistical Manual (DSM-IV). In the past, CD has been classified within the term ‘hysteria’ or ‘hysterical conversion reactions’. Children and adolescents presenting with CD describe symptoms that are suggestive of a medical illness but on further history, examination and investigation cannot be explained in terms of known pathology and pathophysiology. Most commonly, the symptoms represent neurological disease. Frequently reported symptoms include pseudo seizures, paraesthesias, paresis, abnormal gait and other abnormal movements. The symptoms are not intentionally produced. According to the DSM-IV definition, there must be a recognized psychological stress that can be related to the onset of symptoms; however, this may not be immediately evident at presentation. There are no epidemiological studies to provide an estimate of the prevalence of paediatric CDs in Canada. Further, there are no clear guidelines for the management of children and youth presenting with this difficult diagnosis. Many children require admission to hospital for costly investigations and consultations with a range of health professionals including general paediatricians, paediatric neurologists, psychiatrists, physiotherapists and occupational therapists. Failure of aggressive treatment can lead to serious long-term complications such as muscle wasting, osteoporosis, scoliosis or even contractures. Deteriorating academic function, social isolation and psychological distress are also commonly seen. Several barriers currently exist to the prompt diagnosis of CD in children and youth: 1) Knowledge of the clinical symptoms of pediatric CD is limited; 2) a diagnosis of CD is often only considered as a diagnosis of exclusion after extensive and costly medical work-up; 3) systematic clinical surveillance of children at risk for CD (ie. Children who have either experienced a previous attack or have predisposing psycho-social factors); and 4) clinical, epidemiological, or biological risk markers predictive of CD have yet to be defined consistently. Basic descriptive, epidemiological research is crucial to informing policy on appropriate investigation, management and resource allocation for care provision. To estimate prevalence and describe the clinical features of children and adolescents presenting with a Conversion Disorder to specialists across Canada. National surveillance methodology through the CPSP was used to study the incidence and clinical characteristics of paediatric conversion disorder in Canada. From September 1, 2011 to August 31, 2013, a total of 195 cases were reported to the CPSP with 130 of those confirmed. The detailed questionnaire completion rate at the time of analysis was 76%. Twenty-one cases were excluded either because of duplication or not meeting eligibility criteria. Of the 130 confirmed cases, 28% were male and 72% were female, with an average age of 14 years (range 8–18 years). Approximately 10% of cases were children 10 years of age or younger and only four of these 13 children were male. The minimal estimated incidence of conversion disorder is approximately 58 cases per year in the Canadian paediatric population. Demographically, 55% of cases originated in Ontario, 25% in Western Canada and 12% in Quebec. The remaining 8% of cases were in Atlantic Canada 75% of cases were Caucasian, 9% were Black, 7% were First Nations, with the remaining 9% being Asian, Middle Eastern or of unknown ethnicity. 87% of cases had multiple conversion symptoms, which varied widely across the spectrum but included, altered motor function, altered sensation, altered or loss of consciousness, visual changes, speech disturbances, psychosis and dizziness. The most common presentations were disturbance of voluntary motor function (56%), abnormal movements (45%), pseudo-seizures (42%), sensory symptoms (38%), visual deficits (27%), speech disturbance (11%) and hearing deficits (7%). The majority of cases (63%) required hospital admission to determine diagnosis, with an average stay of 13 days (range 1–110; SD ± 20.3). On average, five specialists and subspecialists were involved in the diagnostic work-up of these youth (range 1–13; SD ± 2.5). The specialists consulted most frequently were paediatricians followed by child psychiatrists. The most common subspecialty consulted was paediatric neurology followed by adolescent medicine. There were also multiple consults within specialties. The average number of investigations done per case was 3.5 (range 0–9; SD ± 1.7), typically consisting of extensive blood work, brain imaging (>90% had MRI/CT scans), EEG and EMG studies. Antecedent stressors (family conflict, bullying, academic pressure, peer pressure, abuse, and a personal and/or family history of depression and/or anxiety) were reported in 95% of cases. A prior history of mental health concerns was reported in 37% of cases and 38% of cases had a family history of anxiety and/or depression. In terms of functional impairment, approximately 65% of affected adolescents had missed school for an average of 36 days (range 1–300; SD ± 58). Psychotropic medications for anxiety or depression had been previously prescribed in approximately 28% of cases. The average duration of symptoms, from time of onset to diagnosis, was between one and six months, with most cases (72%) confirmed by the six-month time point. Conversion disorder is a significant burden for affected children and adolescents, their families, and the Canadian health system, with a minimum estimated incidence of 1.7 cases per 10,000 children. CPSP results indicate a female gender preponderance and an adolescent age distribution that are consistent with the literature. The identified association of CD with anxiety and depression highlights the potential impact of more common life stressors. Identifiable stressors were found in 95% of cases, which is higher than the 60% to 70% range reported in the literature. However, the types of stressors reported are consistent with Australian and British surveillance studies. There was a considerable time delay of between one to six months from onset to diagnosis and many patients saw several health professionals with numerous investigations performed prior to being definitively diagnosed. The delay suggests a potential lack of awareness and also a reluctance to consider conversion disorder as a positive diagnosis as opposed to a diagnosis of exclusion.

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