Poliklinikte Konversiyon Atağına Yaklaşım
Özet
Konversiyon bozukluğu, psikolojik çatışma veya ihtiyaçların organik bir temeli olmayan ancak hastanın işlevselliğini önemli ölçüde etkileyen bedensel belirtilerle ortaya çıkmasıdır. Tarihsel süreçte histeri gibi farklı isimlerle anılan bu rahatsızlıkta semptomlar kasti değildir ve bilinçli olarak kontrol edilemez. Yıllık insidansı 100.000'de 4-12 olan hastalık; kadınlarda, düşük sosyoekonomik ve eğitim düzeyine sahip bireylerde ve çocukluk çağı travması öyküsü olanlarda daha sık görülür. Etyolojisinde psikodinamik, bilişsel ve sinir devresi işlev bozukluklarını gösteren nörobiyolojik etkenler rol oynar. DSM-5'te bedensel belirti bozuklukları altında sınıflandırılan hastalıkta motor, duyusal, konuşma bozuklukları ve psikojen non-epileptik nöbetler (PNEN) yaygındır. Ayırıcı tanıda epilepsi, MS ve inme gibi nörolojik hastalıklar ekarte edilmelidir. Tedavide ilk adım hasta ile ön yargısız ve güvene dayalı güçlü bir terapötik ittifak kurmaktır. En etkili birinci basamak tedavi yöntemi Bilişsel Davranışçı Terapi (BDT) olup, motor semptomlar için fizik tedavi eklenmelidir. Eşlik eden psikiyatrik komorbiditeler varlığında veya belirli semptomları kontrol altına almada antidepresanlar, anksiyolitikler ve antipsikotikler (ketiapin, haloperidol) gibi farmakoterapi seçeneklerinden yararlanılır.
Conversion disorder is the manifestation of psychological conflicts or needs as bodily symptoms that cannot be explained by an organic disease but significantly affect the patient's functionality. Historically referred to by various names such as hysteria, the symptoms in this condition are not intentional and cannot be consciously controlled. The disease, which has an annual incidence of 4-12 per 100,000, is more common in women, individuals with low socioeconomic and education levels, and those with a history of childhood trauma. Psychodynamic, cognitive, and neurobiological factors indicating neural circuit dysfunction play a role in its etiology. Classified under somatic symptom disorders in DSM-5, motor, sensory, speech disturbances, and psychogenic non-epileptic seizures (PNES) are common. Nortological diseases like epilepsy, MS, and stroke must be ruled out in the differential diagnosis. The first step in treatment is to establish a strong, non-judgmental, and trust-based therapeutic alliance with the patient. Cognitive Behavioral Therapy (CBT) is the most effective first-line treatment, and physical therapy should be added for motor symptoms. In the presence of accompanying psychiatric comorbidities or to control specific symptoms, pharmacotherapy options such as antidepressants, anxiolytics, and antipsychotics (quetiapine, haloperidol) are utilized.
Referanslar
Doğan O. Konversiyon Bozukluğu. In: Psikiyatri Temel Kitabı. Ankara: HYB Basım Yayın; 2007. p. 377–85.
Freud S. The Psychotherapy of Hysteria from Studies on Hysteria. Stand Ed Complet Psychol Work Sigmund Freud, Vol II Stud Hysteria. 1955;II(1893).
Raynor G, Baslet G. A historical review of functional neurological disorder and comparison to contemporary models. Epilepsy Behav Reports. 2021;16.
Stone J, Smyth R, Carson A, Lewis S, Prescott R, Warlow C, et al. Systematic review of misdiagnosis of conversion symptoms and “hysteria.” Vol. 331, British Medical Journal. 2005.
Ali S, Jabeen S, Pate RJ, Shahid M, Chinala S, Nathani M, et al. Conversion disorder— Mind versus body: A review. Vol. 12, Innovations in Clinical Neuroscience. 2015.
Espay AJ, Aybek S, Carson A, Edwards MJ, Goldstein LH, Hallett M, et al. Current concepts in diagnosis and treatment of functional neurological disorders. Vol. 75, JAMA Neurology. 2018.
Peeling JL MM. Conversion Disorder. StatPearls [Internet]. Treasure Island (FL); 2019.
Harris JC. Exorcism: The miracles of st ignatius of loyola peter paul rubens. Vol. 71, JAMA Psychiatry. 2014.
Freud, Sigmund; Breuer J. The Psychotherapy of Hysteria from Studies on Hysteria. Stand Ed Complet Psychol Work Sigmund Freud, Vol II Stud Hysteria. 1955;II(1893).
Freud S. Introductory lectures on psychoanalysis (Part III). In: The Standard Edition vol 16. 1917.
Kaplan M. Clinical considerations regarding regression in psychotherapy with patients with conversion disorder. Psychodyn Psychiatry. 2016;44(3).
Kaplan MJ. A psychodynamic perspective on treatment of patients with conversion and other somatoform disorders. Psychodyn Psychiatry. 2014;42(4).
Pick S, Goldstein LH, Perez DL, Nicholson TR. Emotional processing in functional neurological disorder: A review, biopsychosocial model and research agenda. Vol. 90, Journal of Neurology, Neurosurgery and Psychiatry. 2019.
Spence ND, Pilowsky I, Minniti R. The attribution of affect in pain clinic patients: A psychophysiological study of the conversion process. Int J Psychiatry Med. 1985;15(1).
Harvey SB, Stanton BR, David AS. Conversion disorder: Towards a neurobiological understanding. Vol. 2, Neuropsychiatric Disease and Treatment. 2006.
Nicholson TR, Aybek S, Craig T, Harris T, Wojcik W, David AS, et al. Life events and escape in conversion disorder. Psychol Med. 2016;46(12).
American Psychiatric Association. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders Fifth Edition. Arlington. 2013.
Erratum: Tilt-induced vasovagal syncope and psychogenic pseudosyncope: Overlapping clinical entities (Neurology (2015) 85 (2006-2010)). Vol. 88, Neurology. 2017.
Reuber M, Kurthen M. Consciousness in non-epileptic attack disorder. Behav Neurol. 2011;24(1).
Reuber M, Howlett S, Khan A, Grünewald RA. Non-epileptic seizures and other functional neurological symptoms: Predisposing, precipitating, and perpetuating factors. Psychosomatics. 2007;48(3).
Syed TU, Lafrance WC, Kahriman ES, Hasan SN, Rajasekaran V, Gulati D, et al. Can semiology predict psychogenic nonepileptic seizures? a prospective study. Ann Neurol. 2011;69(6).
Lafrance WC, Baker GA, Duncan R, Goldstein LH, Reuber M. Minimum requirements for the diagnosis of psychogenic nonepileptic seizures: A staged approach: A report from the International League Against Epilepsy Nonepileptic Seizures Task Force. Epilepsia. 2013;54(11).
O’Neal MA, Baslet G. Treatment for patients with a functional neurological disorder (conversion disorder): An integrated approach. Am J Psychiatry. 2018;175(4).
Tsui P, Deptula A, Yuan DY. Conversion Disorder, Functional Neurological Symptom Disorder, and Chronic Pain: Comorbidity, Assessment, and Treatment. Vol. 21, Current Pain and Headache Reports. 2017.
Cuomo A, Bimonte S, Forte CA, Botti G, Cascella M. Multimodal approaches and tailored therapies for pain management: The trolley analgesic model. J Pain Res. 2019;12.
Ghanbarizadeh SR, Dinpanah H, Ghasemi R, Salahshour Y, Sardashti S, Kamali M, et al. Quetiapine versus Haloperidol in Controlling Conversion Disorder Symptoms; a Randomized Clinical Trial. Emerg (Tehran, Iran). 2018;6(1).
