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Meta-Analysis
. 2020 Jul 17;7(7):CD005331.
doi: 10.1002/14651858.CD005331.pub3.

Psychosocial interventions for conversion and dissociative disorders in adults

Christina A Ganslev  1   2 , Ole Jakob Storebø  2   3   4 , Henriette E Callesen  2 , Rachel Ruddy  5 , Ulf Søgaard  1   2
Affiliations
Meta-Analysis

Psychosocial interventions for conversion and dissociative disorders in adults

Christina A Ganslev et al. Cochrane Database Syst Rev. .

Abstract

Background: Conversion and dissociative disorders are conditions where people experience unusual neurological symptoms or changes in awareness or identity. However, symptoms and clinical signs cannot be explained by a neurological disease or other medical condition. Instead, a psychological stressor or trauma is often present. The symptoms are real and can cause significant distress or problems with functioning in everyday life for the people experiencing them.

Objectives: To assess the beneficial and harmful effects of psychosocial interventions of conversion and dissociative disorders in adults.

Search methods: We conducted database searches between 16 July and 16 August 2019. We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and eight other databases, together with reference checking, citation searching and contact with study authors to identify additional studies. SELECTION CRITERIA: We included all randomised controlled trials that compared psychosocial interventions for conversion and dissociative disorders with standard care, wait list or other interventions (pharmaceutical, somatic or psychosocial). DATA COLLECTION AND ANALYSIS: We selected, quality assessed and extracted data from the identified studies. Two review authors independently performed all tasks. We used standard Cochrane methodology. For continuous data, we calculated mean differences (MD) and standardised mean differences (SMD) with 95% confidence interval (CI). For dichotomous outcomes, we calculated risk ratio (RR) with 95% CI. We assessed and downgraded the evidence according to the GRADE system for risk of bias, imprecision, indirectness, inconsistency and publication bias.

Main results: We included 17 studies (16 with parallel-group designs and one with a cross-over design), with 894 participants aged 18 to 80 years (female:male ratio 3:1). The data were separated into 12 comparisons based on the different interventions and comparators. Studies were pooled into the same comparison when identical interventions and comparisons were evaluated. The certainty of the evidence was downgraded as a consequence of potential risk of bias, as many of the studies had unclear or inadequate allocation concealment. Further downgrading was performed due to imprecision, few participants and inconsistency. There were 12 comparisons for the primary outcome of reduction in physical signs. Inpatient paradoxical intention therapy compared with outpatient diazepam: inpatient paradoxical intention therapy did not reduce conversive symptoms compared with outpatient diazepam at the end of treatment (RR 1.44, 95% CI 0.91 to 2.28; 1 study, 30 participants; P = 0.12; very low-quality evidence). Inpatient treatment programme plus hypnosis compared with inpatient treatment programme: inpatient treatment programme plus hypnosis did not reduce severity of impairment compared with inpatient treatment programme at the end of treatment (MD -0.49 (negative value better), 95% CI -1.28 to 0.30; 1 study, 45 participants; P = 0.23; very low-quality evidence). Outpatient hypnosis compared with wait list: outpatient hypnosis might reduce severity of impairment compared with wait list at the end of treatment (MD 2.10 (higher value better), 95% CI 1.34 to 2.86; 1 study, 49 participants; P < 0.00001; low-quality evidence). Behavioural therapy plus routine clinical care compared with routine clinical care: behavioural therapy plus routine clinical care might reduce the number of weekly seizures compared with routine clinical care alone at the end of treatment (MD -21.40 (negative value better), 95% CI -27.88 to -14.92; 1 study, 18 participants; P < 0.00001; very low-quality evidence). Cognitive behavioural therapy (CBT) compared with standard medical care: CBT did not reduce monthly seizure frequency compared to standard medical care at end of treatment (RR 1.56, 95% CI 0.39 to 6.19; 1 study, 16 participants; P = 0.53; very low-quality evidence). CBT did not reduce physical signs compared to standard medical care at the end of treatment (MD -4.75 (negative value better), 95% CI -18.73 to 9.23; 1 study, 61 participants; P = 0.51; low-quality evidence). CBT did not reduce seizure freedom compared to standard medical care at end of treatment (RR 2.33, 95% CI 0.30 to 17.88; 1 trial, 16 participants; P = 0.41; very low-quality evidence). Psychoeducational follow-up programmes compared with treatment as usual (TAU): no study measured reduction in physical signs at end of treatment. Specialised CBT-based physiotherapy inpatient programme compared with wait list: no study measured reduction in physical signs at end of treatment. Specialised CBT-based physiotherapy outpatient intervention compared with TAU: no study measured reduction in physical signs at end of treatment. Brief psychotherapeutic intervention (psychodynamic interpersonal treatment approach) compared with standard care: brief psychotherapeutic interventions did not reduce conversion symptoms compared to standard care at end of treatment (RR 0.12, 95% CI 0.01 to 2.00; 1 study, 19 participants; P = 0.14; very low-quality evidence). CBT plus adjunctive physical activity (APA) compared with CBT alone: CBT plus APA did not reduce overall physical impacts compared to CBT alone at end of treatment (MD 5.60 (negative value better), 95% CI -15.48 to 26.68; 1 study, 21 participants; P = 0.60; very low-quality evidence). Hypnosis compared to diazepam: hypnosis did not reduce symptoms compared to diazepam at end of treatment (RR 0.69, 95% CI 0.39 to 1.24; 1 study, 40 participants; P = 0.22; very low-quality evidence). Outpatient motivational interviewing (MI) and mindfulness-based psychotherapy compared with psychotherapy alone: psychotherapy preceded by MI might decrease seizure frequency compared with psychotherapy alone at end of treatment (MD 41.40 (negative value better), 95% CI 4.92 to 77.88; 1 study, 54 participants; P = 0.03; very low-quality evidence). The effect on the secondary outcomes was reported in 16/17 studies. None of the studies reported results on adverse effects. In the studies reporting on level of functioning and quality of life at end of treatment the effects ranged from small to no effect.

Authors' conclusions: The results of the meta-analysis and reporting of single studies suggest there is lack of evidence regarding the effects of any psychosocial intervention on conversion and dissociative disorders in adults. It is not possible to draw any conclusions about potential benefits or harms from the included studies.

PubMed Disclaimer

Conflict of interest statement

CAG: none.

OJS: none.

HEC: none.

RR: none.

US: none.

Figures

1
1
PRISMA flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
1.1
1.1. Analysis
Comparison 1: Inpatient paradoxical intention therapy versus outpatient diazepam, Outcome 1: Reduction in physical signs: no conversion symptoms in last 2 weeks
1.2
1.2. Analysis
Comparison 1: Inpatient paradoxical intention therapy versus outpatient diazepam, Outcome 2: Mental state – anxiety (Hamilton)
1.3
1.3. Analysis
Comparison 1: Inpatient paradoxical intention therapy versus outpatient diazepam, Outcome 3: Dropout rate
2.1
2.1. Analysis
Comparison 2: Inpatient treatment programme plus hypnosis versus inpatient treatment programme, Outcome 1: Reduction in physical signs: severity of impairment (VRMC)
2.2
2.2. Analysis
Comparison 2: Inpatient treatment programme plus hypnosis versus inpatient treatment programme, Outcome 2: Mental state (SCL‐90)
2.3
2.3. Analysis
Comparison 2: Inpatient treatment programme plus hypnosis versus inpatient treatment programme, Outcome 3: Dropout rate
3.1
3.1. Analysis
Comparison 3: Outpatient hypnosis versus wait list, Outcome 1: Reduction in physical signs: severity of impairment (VRMC)
3.2
3.2. Analysis
Comparison 3: Outpatient hypnosis versus wait list, Outcome 2: Dropout rate
4.1
4.1. Analysis
Comparison 4: Behavioural therapy plus routine clinical care versus routine clinical care, Outcome 1: Reduction in physical signs: number of weekly fits
4.2
4.2. Analysis
Comparison 4: Behavioural therapy plus routine clinical care versus routine clinical care, Outcome 2: Reduction in physical signs: symptom severity (Clinical Global Impression CGI)
4.3
4.3. Analysis
Comparison 4: Behavioural therapy plus routine clinical care versus routine clinical care, Outcome 3: Mental state – anxiety (HADS)
4.4
4.4. Analysis
Comparison 4: Behavioural therapy plus routine clinical care versus routine clinical care, Outcome 4: Mental state – depression (HADS)
4.5
4.5. Analysis
Comparison 4: Behavioural therapy plus routine clinical care versus routine clinical care, Outcome 5: Dropout rate
5.1
5.1. Analysis
Comparison 5: Cognitive behavioural therapy versus standard medical care, Outcome 1: Reduction in physical signs: monthly seizure frequency (reduction in %)
5.2
5.2. Analysis
Comparison 5: Cognitive behavioural therapy versus standard medical care, Outcome 2: Reduction in physical signs: monthly seizure frequency
5.3
5.3. Analysis
Comparison 5: Cognitive behavioural therapy versus standard medical care, Outcome 3: Reduction in physical sign: seizure freedom
5.4
5.4. Analysis
Comparison 5: Cognitive behavioural therapy versus standard medical care, Outcome 4: Level of functioning
5.5
5.5. Analysis
Comparison 5: Cognitive behavioural therapy versus standard medical care, Outcome 5: Quality of life (QOLIE31)
5.6
5.6. Analysis
Comparison 5: Cognitive behavioural therapy versus standard medical care, Outcome 6: Mental state – anxiety
5.7
5.7. Analysis
Comparison 5: Cognitive behavioural therapy versus standard medical care, Outcome 7: Mental state – depression
5.8
5.8. Analysis
Comparison 5: Cognitive behavioural therapy versus standard medical care, Outcome 8: Mental state (SCL‐90)
5.9
5.9. Analysis
Comparison 5: Cognitive behavioural therapy versus standard medical care, Outcome 9: Dropout rate
5.10
5.10. Analysis
Comparison 5: Cognitive behavioural therapy versus standard medical care, Outcome 10: Use of health services (number of general practitioner consultations)
6.1
6.1. Analysis
Comparison 6: Psychoeducational follow‐up programmes versus treatment as usual, Outcome 1: Reduction in physical signs: seizure frequency (self‐made scale)
6.2
6.2. Analysis
Comparison 6: Psychoeducational follow‐up programmes versus treatment as usual, Outcome 2: Reduction in physical signs: physical symptom load (SF‐36 – physical)
6.3
6.3. Analysis
Comparison 6: Psychoeducational follow‐up programmes versus treatment as usual, Outcome 3: Level of functioning (WSAS)
6.4
6.4. Analysis
Comparison 6: Psychoeducational follow‐up programmes versus treatment as usual, Outcome 4: Quality of life (QOLIE10‐P)
6.5
6.5. Analysis
Comparison 6: Psychoeducational follow‐up programmes versus treatment as usual, Outcome 5: Mental state – anxiety (HADS)
6.6
6.6. Analysis
Comparison 6: Psychoeducational follow‐up programmes versus treatment as usual, Outcome 6: Mental state – depression
6.7
6.7. Analysis
Comparison 6: Psychoeducational follow‐up programmes versus treatment as usual, Outcome 7: Dropout rate
6.8
6.8. Analysis
Comparison 6: Psychoeducational follow‐up programmes versus treatment as usual, Outcome 8: Use of health services (number hospital visits)
7.1
7.1. Analysis
Comparison 7: Specialised cognitive behavioural therapy‐based physiotherapy inpatient programme versus wait list, Outcome 1: Level of functioning (Functional Independence Measure Motor (FIM))
7.2
7.2. Analysis
Comparison 7: Specialised cognitive behavioural therapy‐based physiotherapy inpatient programme versus wait list, Outcome 2: Mental state (SF‐12)
7.3
7.3. Analysis
Comparison 7: Specialised cognitive behavioural therapy‐based physiotherapy inpatient programme versus wait list, Outcome 3: Dropout rate
8.1
8.1. Analysis
Comparison 8: Specialised cognitive behavioural therapy‐based physiotherapy outpatient intervention compared to treatment as usual (TAU), Outcome 1: Reduction in physical signs: physical symptom load (SF‐36 – Physical Component)
8.2
8.2. Analysis
Comparison 8: Specialised cognitive behavioural therapy‐based physiotherapy outpatient intervention compared to treatment as usual (TAU), Outcome 2: Level of functioning (WSAS)
8.3
8.3. Analysis
Comparison 8: Specialised cognitive behavioural therapy‐based physiotherapy outpatient intervention compared to treatment as usual (TAU), Outcome 3: Mental state – anxiety (HADS)
8.4
8.4. Analysis
Comparison 8: Specialised cognitive behavioural therapy‐based physiotherapy outpatient intervention compared to treatment as usual (TAU), Outcome 4: Mental state – depression (HADS)
8.5
8.5. Analysis
Comparison 8: Specialised cognitive behavioural therapy‐based physiotherapy outpatient intervention compared to treatment as usual (TAU), Outcome 5: Dropout rate
9.1
9.1. Analysis
Comparison 9: Brief psychotherapeutic intervention (psychodynamic interpersonal treatment approach) versus standard care, Outcome 1: Reduction in physical signs: conversions symptoms (SDQ20)
9.2
9.2. Analysis
Comparison 9: Brief psychotherapeutic intervention (psychodynamic interpersonal treatment approach) versus standard care, Outcome 2: Quality of life (SF‐36)
9.3
9.3. Analysis
Comparison 9: Brief psychotherapeutic intervention (psychodynamic interpersonal treatment approach) versus standard care, Outcome 3: Mental state – depression (BDI‐II)
9.4
9.4. Analysis
Comparison 9: Brief psychotherapeutic intervention (psychodynamic interpersonal treatment approach) versus standard care, Outcome 4: Dropout rate
9.5
9.5. Analysis
Comparison 9: Brief psychotherapeutic intervention (psychodynamic interpersonal treatment approach) versus standard care, Outcome 5: Use of health services (emergency department visits)
10.1
10.1. Analysis
Comparison 10: Cognitive behavioural therapy plus adjunctive physical activity versus cognitive behavioural therapy alone, Outcome 1: Reduction in physical signs: overall physical impact (Psychogenic Movement Disorder Scale (PMDRS)
10.2
10.2. Analysis
Comparison 10: Cognitive behavioural therapy plus adjunctive physical activity versus cognitive behavioural therapy alone, Outcome 2: Mental state – anxiety (BAI)
10.3
10.3. Analysis
Comparison 10: Cognitive behavioural therapy plus adjunctive physical activity versus cognitive behavioural therapy alone, Outcome 3: Mental state – depression (Hamilton)
10.4
10.4. Analysis
Comparison 10: Cognitive behavioural therapy plus adjunctive physical activity versus cognitive behavioural therapy alone, Outcome 4: Dropout rate
11.1
11.1. Analysis
Comparison 11: Hypnosis versus diazepam, Outcome 1: Reduction in physical signs: symptom freedom
12.1
12.1. Analysis
Comparison 12: Outpatient motivational interviewing and mindfulness‐based psychotherapy compared with psychotherapy alone, Outcome 1: Reduction in physical signs: decrease in seizure frequency
12.2
12.2. Analysis
Comparison 12: Outpatient motivational interviewing and mindfulness‐based psychotherapy compared with psychotherapy alone, Outcome 2: Changes in monthly visits
12.3
12.3. Analysis
Comparison 12: Outpatient motivational interviewing and mindfulness‐based psychotherapy compared with psychotherapy alone, Outcome 3: Quality of life
12.4
12.4. Analysis
Comparison 12: Outpatient motivational interviewing and mindfulness‐based psychotherapy compared with psychotherapy alone, Outcome 4: Dropout rate
See this image and copyright information in PMC

Update of

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References to ongoing studies

DRKS00012997 {published data only}
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DRKS00014251 {published data only}
    1. DRKS00014251. Evaluation of the effect of a psychotherapy program with body movement focus for patients with dissociative seizures. www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DR... (first received 6 April 2018).
Goldstein 2015 {published data only}
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    1. Goldstein LH, Chalder T, Carson AJ, Landau S, McCrone P, Medford N, et al. Cognitive behavioural therapy vs. standardised medical care for adults with dissociative non-epileptic seizures (codes): progress in a randomised controlled trial. Epilepsia 2016;57(Suppl 2):28-9. [DOI: [DOI: 10.1111/epi.13609]]
Goldstein 2017 {published data only}
    1. Goldstein LH, Chalder T, Carson AJ, Landau S, McCrone P, Medford N, Murray J, et al. Cognitive behavioural therapy vs standardised medical care for adults with dissociative non-epileptic seizures (codes): update on a pragmatic randomised controlled trial. Journal of Neurology, Neurosurgery, and Psychiatry 2017;88(8):e26. [DOI: 10.1136/jnnp-2017-BNPA.56] - DOI
ISRCTN05681227 {published data only}
    1. ISRCTN05681227. Cognitive behavioural therapy vs standardised medical care for dissociative non-epileptic seizures. www.isrctn.com/ISRCTN05681227 (first received 2 March 2014).
NCT01590992 {published data only}
    1. NCT01590992. Treatment of globus sensations with psychotherapy. clinicaltrials.gov/ct2/show/NCT01590992 (first received 3 May 2012).
NCT02325544 {published data only}
    1. NCT02325544. Comparing different treatments in reducing dissociative seizure occurrence (CODES). clinicaltrials.gov/ct2/show/NCT02325544 (first received 25 December 2014).
NCT02450617 {published data only}
    1. NCT02450617. Stabilizing group treatment of complex trauma: a randomized controlled trial (STAB). clinicaltrials.gov/ct2/show/NCT02450617 (first received 21 May 2015).
NCT02764476 {published data only}
    1. NCT02764476. Embodied virtual reality therapy for functional neurological symptom/conversion disorder. clinicaltrials.gov/ct2/show/NCT02764476 (first received 6 May 2016).
NCT02801136 {published data only}
    1. NCT02801136. Treatment outcomes of CBT for PNES. clinicaltrials.gov/ct2/show/NCT02801136 (first received 15 June 2016).
Robinson 2017 {published data only}
    1. Robinson EJ, Goldstein LH, McCrone P, Perdue I, Chalder T, Mellers JD, et al. Cognitive behavioural therapy versus standardised medical care for adults with dissociative non-epileptic seizures (CODES): statistical and economic analysis plan for a randomised controlled trial. Trials 2017;18(1):258. - PMC - PubMed

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