Treatment of Functional Neurological Disorders in Children and Adolescents

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1 Treatment of Functional Neurological Disorders in Children and Adolescents Dr. Kasia Kozlowska Child and Adolescent Psychiatrist The Children s Hospital at Westmead, The University of Sydney, Brain Dynamics Centre.

2 PhD sample Consecutive referrals to the team over 4 years at CHW Age-sex matched controls 57 also completed all clinical and laboratry assessments in the lab (41 girls and 16 boys) aged 8.5 to 18 years

3 7 Nonepileptic seizures n=29 (51%) 5 2 Motor n=38 (67%) Sensory n=31 (54%) 1 4 Pain n=33 (58%)

4 Non-specific symptoms Other somatic symptoms in addition to pain (54%) 14% nausea 30% dizziness 23% breathlessness 28% fatigue

5 Comorbid anxiety and depression 54% anxiety 14% depression 14% mixed anxiety and depression

6 Quality of attachment relationships

7 The rates of unresolved loss and trauma: 75%(n = 57/76) of children with conversion disorders versus 12%(n = 9/76) of controls. (Kozlowska et al, 2011) Copyright: Patricia M. Crittenden, 2001

8 ANTECEDENT LIFE EVENTS (range 1-10, mean 5.3) Family conflict Child physical illness Bullying Loss via separation from a loved one or a friend Loss via death of a loved one Maternal mental illness Paternal mental illness Maternal physical illness Moving house Domestic violence events Father physical illness Physical abuse Neglect Sexual abuse % 47% 47% 40% 33% 33% 30% 26% 23% 21% 16% 14% 11% 11%

9 Step 1 A good medical assessment Good = what is needed by the neurologist (science of medicine) + What is needed by the family (art of medicine)

10 The science and art of Medicine

11 Step 2 Provision of an explanation

12 Failed explanations The doctor is dismissing our concerns This doctor does not know, so we need to find a doctor who does know and who can help our child

13 Elevated arousal / autonomic dysregulation

14 From Kozlowska, K. (2013). "Stress, Distress, and Bodytalk: Co-constructing Formulations with Patients Who Present with Somatic Symptoms." Harv Rev Psychiatry 21(6):

15 Voon et al. 2010

16

17 Reaction time to emotion faces conversion control Happy Fear Sad Angry Disgust Neutral

18 Issue of resource allocation PFC is involved both in the regulation of emotional states and in cognitive control functions.

19 From Kozlowska et al. 2014

20 Brain arousal/renewal systems Fear circuits Circadian Clock Autonomic system HPA Axis Inflammatory / Immune system Kozlowska, K. (2013). "Stress, Distress, and Bodytalk: Co-constructing Formulations with Patients Who Present with Somatic Symptoms." Harv Rev Psychiatry 21(6):

21 Shaiba 11 year old girl middle class family intermittent loss of motor function in her legs limb jerking loss of sensation in her feet non-epileptic seizure events panic attacks.

22 The components within the explanation it fits the family story it addresses all the symptoms it normalises the symptoms it provides clear information that outcomes are good it uses positive suggestions

23

24 OUTCOME FULLY RECOVERED Range 2 weeks to 5 years Time to recovery (median) = 6 months Time to recovery (mean) = months RELAPSING IN THE CONTEXT OF NEW STRESS BUT WELL IN-BETWEEN (attending school or working) CHRONIC CONVERSION SYMPTOMS (non-epileptic events) CONVERSION DISORDER TRANSFORMED INTO A DIFFERENT CHRONIC ILLNESS Chronic pain (n=2) Chronic pain, fatigue, anxiety and depression (n=1) Chronic and debilitating anxiety (n=1) Eating disorder (n=1) Factitious presentations (n=2) Borderline personality disorder and severe family conflict (n=1) LOST TO FOLLOW UP (N=2) Discharge against medical advice following a child protection notification (n=1); Family not contactable (n=1) NUMBE PERCENTAG R E 35 61% % 1 2% 9 16% 2 3.5%

25 Treatment: Mind-body inpatient program Decrease physiological arousal Physiotherapy (reconditioning, recondition the stress system and prevent secondary complications) Continue normal function (e.g. school) Psychological interventions (address self regulation) Family and system interventions Treat comorbid anxiety and depression

26 Training with feedback in MyCalmBeat

27 Treatment: Mind-body inpatient program Decrease physiological arousal Physiotherapy (reconditioning, recondition the stress system and prevent secondary complications) Continue normal function (e.g. school) Psychological interventions (address self regulation) Family and system interventions Treat comorbid anxiety and depression

28 School intervention

29 Treatment: Mind-body inpatient program Decrease physiological arousal Physiotherapy (reconditioning, recondition the stress system and prevent secondary complications) Continue normal function (e.g. school) Psychological interventions (address self regulation) Family and system interventions Treat comorbid anxiety and depression

30 Clinical papers Kozlowska, K., M. English, et al. (2012). "Multimodal rehabilitation: A mind-body, family-based intervention for children and adolescents impaired by medically unexplained symptoms. Part 1: The program." American Journal of Family Therapy 40(5): Kozlowska, K., M. English, et al. (2013). "Multimodal rehabilitation: A mind-body, family-based intervention for children and adolescents impaired by medically unexplained symptoms. Part 2: Case studies and outcomes." American Journal of Family Therapy. Chudleigh, C., K. Kozlowska, et al. (2013). "Managing Non-epileptic Seizures and Psychogenic Dystonia in an Adolescent Girl with Preterm Brain Injury." Harv Rev Psychiatry 21(3): Kozlowska, K., S. Foley, et al. (2012). "Fabricated illness: Working within the family system to find a pathway to health " Family Process.

31 Breathing resources My calm beat biofeedback tool Respire-1 CD Slow down CD Qigong moving meditation Breath-Body-Mind workshops

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