Recognition
Initially, the condition of the adolescent girl was viewed as life threatening due to the marked loss of weight. A general medical examination and essential investigations had been conducted. However, no organic disease could be found that fully explained the presence of the symptoms. The adolescent did not show signs of moderate or severe depression, or of suicidal thoughts or self-harm. In the patient’s history, no exposure to extreme stressors was mentioned. Overall, the patient’s medical symptoms were unexplained. However, it was obvious that she was in severe distress. According to the WHOmhGAP, people with “significant emotional or mentally unexplained complaints” may have mental disorders not covered in the manual, such as somatoform disorders, generalised anxiety disorder, mild depression or others.
There are different languages and ways of thinking within the medical field between somatic-oriented professions and psychiatrists. Translation processes are therefore necessary, and additional chains of translation processes are necessary to communicate with patients in an adequate way. Observation, especially if supported by video documentation, is a direct approach, which can be shared across cultural views.
Even in a situation of high urgency, it is worthwhile to take time to observe the patient, from a supportive attitude approach. In the event of feeling lost in the evaluation process, and having little idea about the right diagnosis for a particular child, Lempp et al. [15] recommend getting back to the description of the problems. These authors strongly advise never to leave a family with just the diagnostic information but always to present treatment options and convey hope [15]. The young patient presented in this case report, her family, and local staff regained hope and were able to adopt a positive attitude towards the healing process.
In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5, 2013) a group of disorders has as a common feature the “prominence of somatic symptoms associated with significant distress and impairment” [16], which are summarised in the chapter “somatic symptom and related disorders”. The motor problems of the patient discussed in the case report were not consistent with medical psychopathology. Therefore, conversion disorder had to be considered. The criteria of conversion disorder are: (A) one or more symptoms of altered voluntary motor or sensory function; (B) clinical findings provide evidence of incompatibility between the symptom and recognised neurological or medical conditions; (C) the symptom or deficit is not better explained by another medical or mental disorder; (D) The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation [16].
In the previous version of the classification system DSM-IV, conversion disorder is a subcategory of the broad category “somatoform disorders” [17, 18]. In the International Classification of Diseases (ICD-10) classification of mental and behavioural disorders: clinical descriptions and diagnostic: World Health Organization, these symptoms are classified as “dissociative disorder or conversion disorder” with symptom types “motor symptom—weakness, swallowing symptoms and sensory symptoms” [19]. Conversion disorder is often associated with dissociative symptoms, such as depersonalisation, derealisation, and dissociative amnesia [16].
Conversion disorders are characterised by the partial or complete lack of the normally integrated functions of memory, identity, perception of the environment, and control of physical movements [19, 20]. The onset of these characteristics is known to occur in childhood or adulthood, and is often a result of traumatic life events such as childhood emotional, physical, or sexual abuse, or other adverse life events. In Sub-Saharan countries, one has to keep in mind the possibility of female circumcision in children [21]. A recent survey from Jimma town in Ethiopia showed that there is a positive attitude amongst the public towards female circumcision, despite it being prohibited by the law. From this perspective, the family of a child undergoing female circumcision would not necessarily regard it as a traumatic event [22]. For clinicians, it can be difficult, even impossible, to explore the issue, as doing so risks angering the family. For the young patient presented in the case report, no psychological stressor could be identified. The final diagnosis of the patient was conversion disorder.
The frequency of dissociative experiences peaks during latency years and declines between early adolescence and young adulthood [23]. Many epidemiological studies have shown that the incidence and prevalence of conversion/dissociative disorders in adults vary across countries and communities, and is generally more prevalent in developing countries than western developed communities [24]. In the clinic for child psychiatry in the Ethiopian capital of Addis Ababa, adolescents with dissociative disorder are seen and treated frequently (Baheretibeb, personal communication) [25].
The term “model” implies that particular phenomena can be represented (i.e., modelled) in multiple ways. Thus a DSM model may use different terms and criteria compared to an ICD model, but both may be useful for different purposes and/or in different systems of care [26]. The management of psychiatric disorders is not something that is included as part of the classification systems ICD 10 of the WHO, and the DSM-IV or V of the American Psychiatric Association. Hence, the WHOmhGAP was chosen over ICD and the DSM for training purposes, and for management in the MSc programme.
There are currently only a few case reports that discuss similar conditions in adolescents presented in this case report. Examples of similar reports include a 17-year-old male adolescent from Nigeria suffering from sickle cell anaemia, and who developed psychosis. A possible explanation given for the development of psychosis was brain infarcts, which may have induced this mental disorder [27]. The focus of this report was on the interaction between an organic disease and the mental disorder psychosis. Another example described a 14-year-old French girl who was admitted to a hospital for a rare form of Dissociative Disorder called “Ganser syndrome” [28]. The patient experienced two episodes, the second of which was accompanied by depressive symptoms. The French authors discuss whether—as in their patient—an episode of Dissociative Disorder, must be regarded as a precursor of depression or bipolar disorder. They stress that it can be difficult in adolescents to differentiate between derealisation as a phenomenon of normal development, schizophrenia, depression, and dissociative disorder. Their focus was course and development of dissociative disorder [28]. Finally, a 14-year-old male Kurdish student from Iraq was diagnosed as having Anorexia Nervosa [29]. He was hospitalised and responded well to medical and psychiatric treatment. In this particular case, contrasting cultural influences such as the Arabian Muslim culture on one hand, and a Western influence via television, Internet, and periodicals on the other hand, can be regarded as precipitating factors.
Management
The core problems of the patient presented in the case report were impairment of functions of memory, identity, perception of the environment, and control of physical movements. The basic principle of treatment was to provide a safe environment and restore autonomy, turning from passive to active.
Immediate and short-term psychosocial interventions
The management of the patient’s treatment made use of general principles of care and some elements of “advanced interventions”, such as relaxation training and social skills therapy, as described in the WHO MhGAP intervention guide [10]. Relaxation training involves training a person in techniques such as breathing exercises to elicit the relaxation response. Social skills therapy helps rebuild skills and coping in social situations to reduce distress in everyday life, and uses social tasks, encouragement, and positive social reinforcement to help improve ability in communication and social interactions [10]. Tasks are aimed at being meaningful and oriented to the interests of the person, and the difficulty and the duration of any task have to be adapted to the level of personal capacity to guarantee a successful performance. The challenge is to find the appropriate “dosage” and timing of psychosocial interventions. In terms of medication, after the withdrawal of haloperidol, no other medication was given to the patient [14].
The improvement of the patient in this case report was dramatic. She stayed in the psychiatric ward for 2 weeks, and the majority of the practical work was conducted by the children’s nurse, with assistance from the psychiatrists. Despite gaps in the patient’s history and uncertainty about the diagnosis at the initial stage, the development of the intervention was successful. Reflecting on the girl’s stay in the hospital, it can be noted that her hospitalisation was too short for stabilisation, and thorough examination for any psychological trauma that could have explained her condition. However, after returning to her home, the patient could rely on good parental support.
Similar recommendations for a rehabilitative approach in children are given from authors working in the field of paediatric liaison [17, 18]:
Steps for intervention include;
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A de-emphasis on a final diagnosis,
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Use of benign remedies,
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Reinforcement of wellness [17, 18],
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Reinforcement of well behaviour,
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Encouragement of participation in everyday activities [2].
These authors stress the importance of a close cooperation between all professionals involved, such as school teachers, practitioners, and the patient’s family.
In three women with conversion disorder, physical therapy was part of a rehabilitation program. Movement patterns were corrected using feedback and praise. The therapy program was progressively more difficult and resulted in symptom relief [30]. In child and adolescent conversion disorders, the evidence of physiotherapy is limited due to the lack of systematic studies [31].
Long-term management
Persons with conversion disorders can recover within a short time. In the long-term, however, relapses can occur. Therefore, it is preferable to have fixed follow-up appointments spaced apart by long intervals. The concern of the parents about a possible relapse in their child provides a starting point for further counselling, and an overprotective attitude may develop if parents are especially anxious about a relapse. In Ethiopia, severe mental illness is quite often attributed to spiritual factors such as possession, bewitchment, or the evil eye [6, 32]. Extending the case history during follow-up visit helps in the understanding of predisposing, precipitating, and protecting factors. The health professional has to ask, therefore, about the patient’s (and family’s) health beliefs. In the case of a reappearance of symptoms, further treatment can be offered.
Capacity building
Coming into a clinical setting from outside it can take time to be able to appreciate and understand the cultural aspects of another environment. For example, in Ethiopia relatives are expected to care for the patient by themselves, while nurses are responsible for distributing medication. The guest lecturers at JUTH had to find their place in the setting of the psychiatric clinic after they first arrived. Both of them, the child psychiatrist and children’s nurse, had to negotiate with clinicians and staff on the one hand and the family on the other hand to explain their ideas how to proceed. The role of the children’s nurse was unusual for the local nurses. She offered a relationship by sitting at the bedside of the patient without being anxious herself. Both guests observed what was going on with the patient and guided the perception of the staff. Both stressed the successes of even small interventions, and after initial improvement, the approach was accepted.
While the clinicians had considerable experience in drug treatment, there was inadequate time for practice, and little experience amongst them for psychosocial interventions for children and adolescents. The treatment approach to the health problems of this young patient was developed in successive discussions between the local clinicians, and the guest lecturers, and turned out to be successful. These two groups combined their knowledge of the cultural background, the local situation, and their experience and intuition in dealing with adolescents. During the course of treatment, the video recordings served to allow for observation, assessment, and management of the patient. In the work-up, key elements of the intervention could be identified by evaluation of the video recordings and shown for teaching purposes. The participants in the programme gave feedback, and stated that they felt no longer anxious but confident in treating child patients.
Confidence as a health care practitioner develops from training, and one’s own experience of successful interventions. To evaluate an intervention’s effectiveness, systematic follow-up is needed. Until now, only a small number of studies have attempted to evaluate the individual service processes necessary for successful implementation of community mental health care [33]. To test for generalisation, the intervention would have to be applied to other patients with a similar condition.
