The issue of bullying prevention remains extremely urgent due to the fact that this phenomenon still exists in educational institutions and evolves to give rise to new forms, such as cyberbullying [1−4].

Today, a systematic approach to bullying prevention by teachers is still not being applied frequently enough: some teachers either do not pay enough attention to preventing this phenomenon or prefer to ignore manifestations of violence among children and adolescents. As a result, victims, as well as observers or initiators of bullying, are often left without timely help and support [5].

According to the research data, about a third of school students worldwide experience various forms of aggression from their peers [6−8].

At the same time, every third student in industrialized countries admits that they have repeatedly participated in bullying other children. Ninety percent of children surveyed identified bullying as a serious problem; two-thirds of respondents had been bullied themselves [9, 10]. However, only a third of them shared their situation with friends or parents, interpreting this phenomenon as an “inevitable evil”.

Bullying prevention at school represents one of the priority tasks of not only educational system, but also public health system, since bullying can trigger mental disorders in individuals involved [11, 12].

Preventive work is complicated by the hidden and often systematic nature of bullying, which requires professionals to use specialized knowledge and skills to promptly identify such cases and then stop them [13].

Here we present a clinical case of functional neurological disorder in a school-age female patient developed against the background of bullying in an educational institution in order to raise awareness of individuals involved in the training process about possible consequences of bullying.

CLINICAL CASE

In April 2017, a female patient M. aged 13 was re-admitted to the Psychoneurology Department of the Speransky Children's City Clinical Hospital No. 9 with complaints of a series of seizures and episodes of prolonged loss of consciousness.

Past medical history

The child is from the first pregnancy born full term (on week 41 of pregnancy), no birth injury reported. Her growth and development were age-appropriate, neurological and mental statuses were preserved. She started attending school at the age of 7. According to the mother, the girl was always sociable and calm. No problems with academic performance were reported at school. However, the patient mentioned conflicts with one of her teachers over the past few years. The family history is unburdened. Past infections: ARVI, childhood infections. The patient denies traumatic brain injury.

Disease history

The patient considers herself ill since 2016, when convulsive conditions accompanied by prolonged loss of consciousness were first noted (after the end of the attack the patient remained in a stunned state for 1.5−2 h).

The first attack with loss of consciousness, falling and convulsions was noted in October 2016. The patient was admitted to the Psychoneurology Department of the Speransky Children's City Clinical Hospital No. 9. The hospital’s neurologist prescribed non-drug therapy in the form of compliance with work and rest regime, daily routine, as well as drug therapy (glycine 200 mg three times a day, for a long time).

The second convulsive attack was reported one month after the previous hospital stay. The next attack of the presyncope type was reported two weeks after the second one. The patient continued regular treatment unabated.

It should be noted that all the patient’s episodes of hospital admission were associated with the child’s preceding contacts with one of the teachers. According to the child, the teacher exerted "systematic moral pressure" on her.

When staying at the Psychoneurology Department of the Speransky Children's City Clinical Hospital No. 9, the patient was consulted by a child neurologist and a child psychiatrist. Her neurological and mental statuses were determined during consultation.

Neurological status

At the time of examination, consciousness is clear. Orientation in space, time, and the patient’s own personality is preserved.

Speech is preserved. The ocular apertures are symmetrical. No meningeal syndrome detected. There is no nystagmus. Corneal reflexes are symmetrical (D = S).

At the time of examination, no extrapyramidal symptoms are observed. Muscle strength remains unchanged. Muscle tone is preserved, symmetrical. Tendon reflexes of the limbs are lively.

Mental status

Consciousness is not clouded. The patient is correctly oriented in place, time, her own personality and in the situation. At the time of examination, she looks calm, her posture is relaxed. She answers questions in detail, maintains eye contact, and has lively, expressive facial expressions. She is active in communication and interested in conversation. During the conversation, the patient answers questions thoughtfully, her voice is quiet. Shows interest in the surrounding environment. Attention is stable. Memory without any apparent significant alterations. Thinking at an accelerated pace. Emotionally labile. No suicidal or aggressive tendencies are detected at the time of examination. The patient is ready for treatment.

A number of laboratory and instrumental tests were performed when conducting differential diagnosis of the patient’s condition.

The analysis of the laboratory test results revealed no data confirming autoimmune or infectious etiology of the disease.

The main instrumental methods used to diagnose the patient’s condition were electroencephalography (ЭЭГ) and magnetic resonance imaging (MRI).

EEG findings

Cortical rhythms of wakefulness are age-appropriate. No typical epileptiform discharges have been found. No abnormalities of cortical rhythms have been reported when performing functional tests. No epileptic seizures or their EEG patterns have been recorded during the study.

MRI findings

The MRI findings suggest the lack of bulk neoplasms or structural brain tissue alterations.

Clinical diagnosis

Thus, based on medical history data, the results of the current objective inpatient examination, clinical analysis of the results obtained, differential diagnosis of psychopathological symptoms revealed in the clinical picture, the patient M.’s mental state should be defined as a dissociative (conversion) disorder in accordance with the diagnostic criteria of the item F44 of the International Classification of Diseases, 10th Revision (ICD-10).

Therapy provided and assessment of its efficacy

Patient М. received anticonvulsant therapy (carbamazepine at an initial dose of 100 mg once a day with a gradual increase in the dose to 300 mg twice a day) regularly, as well as therapy with neuroleptic drugs (sertraline 50 mg once a day) in extenso. She was consulted by child psychiatrists and attended psychotherapy sessions, but the treatment prescribed did not have the desired therapeutic effect. Conversion attacks were regular and resulted in frequent re-admissions to hospital.

Outcome and result of further follow-up

The above conversion attacks with re-admissions to hospital from school after contacting one of the teachers were reported throughout several years (2016−2020). However, after the girl entered another educational institution, manifestations of conversion attacks were no longer observed.

Upon re-examination, the patient's condition was satisfactory. She had no complaints at the time of examination.

After the regression of clinical symptoms, the patient continued her education at a new educational institution and demonstrated good academic performance; she was able to lead an active lifestyle and adapt to a new team.

CLINICAL CASE DISCUSSION

The patient M.’s mental status at admission was mental status at admission was determined by frequent recurrent non-epileptic (conversion) attacks with the prolonged loss of consciousness developed against the background of systematic bullying. Severity of the reported clinical symptoms throughout six months resulted in the adolescent’s maladaptation and disruption of functioning, which was the cause of seeking care. In the medical history, a striking correlation between the clinical manifestations of conversion attacks and cases of bullying by one of the teachers attracts attention: the patient was admitted to hospital exclusively from classes after contact with this teacher, which once again underlines the obvious role of bullying as a risk factor for the development of mental disorders in school students.

Thus, it can be concluded that the convulsive syndrome is in many cases not necessarily a manifestation of neurological disorder [14].

A number of papers show that the health of students in comprehensive schools directly depends on the health and psycho-emotional well-being of teachers [15].

Adverse educational environmental conditions, such as academic violence, victimization, and trauma, can have a significant impact on students' mental and physical health [16].

It is necessary to unite the efforts of specialists in various fields to develop and implement national state programs to combat bullying, mandatory for use in all country’s schools [17].

CONCLUSION

Here we consider a clinical case of the development and long course of functional neurological disorder against the background of systematic bullying in a 13-year-old female patient. The reported example emphasizes the importance of preventing bullying in educational institutions, as well as raising awareness among participants in the educational process about the possible consequences of bullying in educational institutions and the importance of creating a comfortable and safe psychological environment.