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Issues for DSM-5: Conversion disorder
... Malingering does not need to be refuted as part of establishing the diagnosis. 12 In contrast, the World Health Organization's ICD-10 Classification of Mental and Behavioural Disorders groups diagnostic criteria for FND among the dissociative disorders 13 : ...
... 6 Any disorder or condition in these areas that is in the differential diagnosis can be precipitated or exacerbated by stress; most, however, do not involve loss of physical function. 12 In addition, the diagnosis of an FND does not necessarily exclude an organic disorder. ...
... 25 However, coexisting psychiatric diagnosis might more likely be associated with distress from the presenting functional neurological symptoms, not linked to the FND diagnosis itself. 12 This shift in understanding is reflected in the description of FND in the DSM-5. 11 ...
The complexity of this disorder poses a clinical challenge like few others.
... A renaissance has occurred in the last two decades, catalyzed by emphasis on "rule-in" physical signs guiding diagnosis (Stone et al., 2010b), a growing repertoire of evidence-based treatments, establishment of a multidisciplinary FND Society (www.fndsociety.org), and the publication of authoritative textbooks Kozlowska et al., 2020). ...
... Pilot studies provide initial evidence that baseline intrinsic functional and structural profiles in FND relate to 6-month clinical outcomes Perez et al., 2018b). For more details on the pathophysiology of FND, see several recent reviews (Baizabal-Carvallo et al., 2019; sensory findings providing "evidence of incompatibility between the symptom and recognized neurological or medical conditions" (American Psychiatric Association, 2013;Stone et al., 2010b). The symptom must impair social and/or occupational functioning or lead individuals to seek a medical opinion. ...
Functional neurological (conversion) disorder (FND) was of great interest to early clinical neuroscience leaders. During the 20th century, neurology and psychiatry grew apart - leaving FND a borderland condition. Fortunately, a renaissance has occurred in the last two decades, fostered by increased recognition that FND is prevalent and diagnosed using “rule-in” examination signs. The parallel use of scientific tools to bridge brain structure - function relationships has helped refine an integrated biopsychosocial framework through which to conceptualize FND. In particular, a growing number of quality neuroimaging studies using a variety of methodologies have shed light on the emerging pathophysiology of FND. This renewed scientific interest has occurred in parallel with enhanced interdisciplinary collaborations, as illustrated by new care models combining psychological and physical therapies and the creation of a new multidisciplinary FND society supporting knowledge dissemination in the field. Within this context, this article summarizes the output of the first International FND Neuroimaging Workgroup meeting, held virtually, on June 17th, 2020 to appraise the state of neuroimaging research in the field and to catalyze large-scale collaborations. We first briefly summarize neural circuit models of FND, and then detail the research approaches used to date in FND within core content areas: cohort characterization; control group considerations; task-based functional neuroimaging; resting-state networks; structural neuroimaging; biomarkers of symptom severity and risk of illness; and predictors of treatment response and prognosis. Lastly, we outline a neuroimaging-focused research agenda to elucidate the pathophysiology of FND and aid the development of novel biologically and psychologically-informed treatments.
... However, FND is no longer a "diagnosis of exclusion" due to the emergence of specific physical signs and semiologic features which can be screened for and recorded during routine bedside clinical examinations. [8][9][10] The Diagnostic and Statistical Manual of Mental Disorders was revised for its fifth edition in 2013 to emphasize identifying positive features, predominantly on neurological examination, that are typical of FND. 9 This revision also dropped the requirement of an acute (proximal) psychological stressor, which may not be consistently identifiable or present. Another change in the diagnostic criteria for FND was the removal of the need to explicitly exclude malingering or feigning. ...
... [8][9][10] The Diagnostic and Statistical Manual of Mental Disorders was revised for its fifth edition in 2013 to emphasize identifying positive features, predominantly on neurological examination, that are typical of FND. 9 This revision also dropped the requirement of an acute (proximal) psychological stressor, which may not be consistently identifiable or present. Another change in the diagnostic criteria for FND was the removal of the need to explicitly exclude malingering or feigning. ...
Functional neurological disorders (FND) are complex and prevalent neuropsychiatric conditions. Importantly, some patients with FND develop acute onset symptoms requiring emergency department (ED) evaluations. Historically, FND was a “rule-out” diagnosis, making assessment and management in the ED difficult. While the rapid triage of potential neurological emergencies remains the initial task, advancements have altered the approach to FND. FND is now a “rule-in” diagnosis based on validated neurological examination signs and semiological features. In this perspective article, we review signs and semiological features that can help guide the initial assessment of FND in the acute setting. Thereafter, we outline potential approaches to introduce a suspected diagnosis of FND to patients in the ED, while emphasizing the need for a comprehensive neurological evaluation. Physical and occupational therapy may be useful adjunct assessments in some individuals. Notably, clinicians in the ED setting are important members of the interdisciplinary approach to FND.
... Another limitation is the name of CD in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-4). Although that name refers to the hypothesis based on psychoanalytic etiology and has not been accepted by either nonpsychiatrists or patients [18,19]. erefore, as Stone et al. and Cosci et al. suggested, we might rename CD "functional neurological symptom disorder" according to DSM, Fifth Edition (DSM-5) [19,20]. ...
... Although that name refers to the hypothesis based on psychoanalytic etiology and has not been accepted by either nonpsychiatrists or patients [18,19]. erefore, as Stone et al. and Cosci et al. suggested, we might rename CD "functional neurological symptom disorder" according to DSM, Fifth Edition (DSM-5) [19,20]. ...
Patients with conversion disorder (CD) present with weakness or unexplained movement disorder that may evolve from inciting psychological events, but presentation with rigid deformity is rare. Only one case of CD presenting as foot deformity with atraumatic rigid psychogenic equinovarus has been reported previously. Here we describe a rare case of psychogenic equinovarus in a physically healthy 10-year-old boy. He had noticed left equinovarus deformity upon waking abruptly but had no history of preceding trauma and no relevant medical history. Computed tomography (CT) images revealed dislocation of the left Chopart joint complex, but clinical examination did not suggest an organic neurologic disorder. On further history taking, he reported that he was under psychological stress because of being required to play baseball against his will. When he was given permission to withdraw from this stressful situation, the equinovarus improved without the need for surgical invention. This report highlights the importance of early and accurate diagnosis of psychogenic equinovarus, so that unnecessary surgery can be avoided. This is the first report of psychogenic equinovarus caused by dislocation of the Chopart joint complex that was confirmed with CT.
... For example, arm tremors might disappear when the person is asked to move the arm rhythmically. Leg weakness might not be consistent when tested with resistance (Stone, LaFrance, Levenson, & Sharpe, 2010). In one form of conversion disorder, people report tunnel vision, which is incompatible with the biology of the visual system. ...
... In one form of conversion disorder, people report tunnel vision, which is incompatible with the biology of the visual system. In another example, people might show a seizure-like event at the same time that a normal EEG pattern is recorded (Stone et al., 2010). ...
Dissociative disorders are characterised by the disruption and discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control and behaviour. In depersonalisation/derealisation disorder, the person’s perception of the self and surroundings is altered and they may feel detached from their body or may perceive the world as being unreal. Dissociative amnesia is defined by inability to recall important personal experiences of a traumatic or highly stressful nature. The person with dissociative identity disorder (DID) has two or
more distinct personalities, each with unique memories, behaviour patterns and relationships, whereas in subclinical DID the personality states intrude on the person’s thoughts, feelings and actions, but are not developed enough to take full control of the individual. Dissociative disorders are related to childhood abuse, neglect, insecure attachment to the primary caregiver, and exposure to traumatic and stressful events. The aetiology of dissociative disorders continues to be debated, though over time, given the increased data available on familial and institutional child abuse, allied with intriguing neuro-physiological findings, most experts see trauma as a major factor. The trauma model suggests that dissociation becomes a reflex coping strategy when the options of fighting or fleeing are not possible, as is frequently the case in young children, living with
inescapable repetitive trauma. The fantasy model suggests that fantasy-prone and suggestible individuals, often with genuine histories of abuse, have poor sleep and this combination of factors results in two false beliefs — first, in ‘recovered’ memories of (more) childhood abuse, and second, that they have a dissociative disorder, when in reality the symptoms and stories of dissociation and trauma are borrowed from the media or other people. The fantasy model has been demonstrated to lack robust empirical support. It is not uncommon for people with histories of a trauma to experience an extended period of time in which they cannot recall it; that all types of memory are open to distortion and recovered memories of trauma are found to be as accurate as continuous memories of trauma. Furthermore, differences in brain activity can be witnessed between alters, yet no differences are seen in people role-playing DID.
In the safe, supportive context of therapy, patients are encouraged to learn new strategies for coping with emotions, so as to gain better control over tendencies to rely on dissociation.
The common feature of somatic symptom and related disorders is the excessive focus on physical symptoms. The nature of the concern, however, varies by disorder. Somatic symptom disorder is defined by excessive thought, distress and behaviour related to somatic symptoms or health concerns. Illness anxiety disorder is defined by fears of a serious disease when no more than mild somatic symptoms are present. Conversion disorder is characterised by sensory and motor dysfunctions that are incompatible with recognised neurological or medical conditions. Somatic symptom and related disorders may arise suddenly in stressful situations. Factitious disorder can be distinguished from the other somatic symptom disorders as the person compulsively seeks unnecessary medical attention, not because they believe they are unwell, but in a conscious or subconscious attempt to garner care, concern and support from medical staff.
A growing body of research confirms that adverse experiences in childhood are closely linked to a range of illnesses and medical conditions, including those associated with somatic symptom and conversion disorder. Neurobiological models suggest that some people may have a propensity towards hyperactivity in those regions of the brain involved in evaluating the unpleasantness of somatic sensations, including the anterior cingulate and the anterior insula. Cognitive–behavioural models focus on attention to and interpretation of somatic symptoms as a way of understanding why some people experience such intense anxiety about their health. Psychodynamic theories of conversion disorder have focused on the idea that psychological stress following a traumatic or stressful experience converts to a physical impairment, yet most people are unaware of the subconscious motivation for their symptoms. Cognitive–behavioural therapy is the most evidenced-based approach for reducing the physical symptoms of somatic symptom and conversion disorder, as well as reducing anxiety in people with illness anxiety disorder.
... Conversion disorder can present as blindness, mutism, paralysis, dissociative anesthesia, aphonia, ataxia, sensory loss, hysterical seizure, or psychogenic deafness according to DSM-5. 8 But a rare symptom of conversion can be catatonia which is not included in DSM-5. Therefore, according to DSM-5, such cases can be classified as unspecified catatonia. ...
Catatonia is characterized by marked psychomotor disturbance and was first described by Karl Ludwig Kaulbaum in 1874.1 Later, it was evaluated as a subtype of schizophrenia. After the 1960s, it was revealed that other conditions can also cause catatonia.2 Gelenberg (1976) said there could be more than 40 cases that could cause catatonia and many new ones have emerged since then.3 Previous data suggest that catatonia is more common in mood disorders than in schizophrenia. The other causes of catatonia can be due to medical causes like endocrine disorders, infections, electrolyte imbalance, epilepsy, and traumatic brain injury. An excessive dosage of drugs or substances like cocaine, ecstasy, disulfiram, and levetiracetam can also result in catatonia.4,5
... As with most of the other terms, the physiopathologic theory behind it has been subjected to debates, without enough evidence to either confirm or reject it. For example, Cretton et al. [20] present neurophysiological arguments in support of the conversion mechanism whereas Stone et al. [21] also use functional neuroimaging findings to make the case against the term conversion disorder, considering the proposed psychological etiology incorrect. Nevertheless, the fact that the term has been steadily used over time and the percentage of highly cited articles it yields reflect the fact that it is to some extent accepted by the medical community. ...
Background
Functional neurological disorders (FND), a subtype of functional disorders (FD), are a frequent motive for neurology referrals. The various presentations and the unknown physiopathology of FD have led to the multiplication of terms describing these disorders over the years.Methods
We examined the FD-related articles published from 1960 to 2020 in PubMed and PsycINFO databases. We searched for: psychogenic, somatization, somatoform, medically unexplained symptoms, hysteria, conversion disorder, dissociative, functional neurological disorder, and functional disorder. Use rates in the title, abstract, keyword, or MeSH fields were collected over successive 5-year periods. After correcting for off-topic results, we examined proportional distribution over time, term associations, and disciplinary fields (neurology and psychiatry). Term impact was estimated via H-index and number of citations.ResultsWe found that none of the terms is prevailing in the recent medical literature. We observed three trends in the use rates: stability, increase, and decrease of use over time. While most of the terms were present in a stable proportion of the publications, hysteria and psychogenic lost popularity over time. We found a differential preference for terminology between disciplines. Functional neurological disorder showed the highest citation impact, yielding 10% of highly cited publications.Conclusion
We found a dynamic and evolving use of the different terms describing FD in the last 60 years. Despite the tendency to use the term functional in the recent highly cited publications, its low prevalence and coexistence with several other terms suggest that a precise, explanatory and non-offensive term remains yet to be found.
... 7 Renewed interest in FND has been promoted by the use of positive "rule-in" signs specific for the diagnosis. [8][9][10] Furthermore, an international, multidisciplinary professional FND Society has been created with physical therapists among its founding members, and an authoritative FND textbook has been published. 11 In this context, physical therapy (PT) is at the forefront of emerging first-line treatments for motor functional neurological disorder (mFND), which includes the spectrum of functional movement disorder and functional weakness. ...
Background and purpose:
Motor functional neurological disorder is a prevalent and costly condition at the intersection of neurology and psychiatry that is diagnosed using positive "rule-in" signs. Physical therapy is a first-line treatment and consensus recommendations exist to guide clinical care. Nonetheless, optimal outpatient treatment of adults with functional motor symptoms requires an expanded physical therapy tool kit to effectively guide care.
Summary of key points:
In this article, lessons learned from a physical therapist practicing in a multidisciplinary and interdisciplinary outpatient functional neurological disorder clinic are highlighted. In doing so, we discuss how use of the biopsychosocial model and neuroscience constructs can inform physical therapy interventions. The importance of team-based care and the delivery of physical therapy through video telehealth services are also outlined.
Recommendations for clinical practice:
Use of the biopsychosocial formulation to triage clinical challenges and guide longitudinal care, coupled with application of neuroscience to aid intervention selection, allows for patient-centered physical therapy treatment across the spectrum of functional motor symptoms.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A400).
... Los TNF presentan aproximadamente un 5-10% de las consultas primarias de neurología 7 . El diagnóstico de TNF está basado en la presencia de alteraciones de movilidad y sensibilidad con relevante impacto psicosocial, pero que son incompatibles con enfermedades neurológicas conocidas 8 . Su diagnóstico en pacientes post-COVID-19 puede ser desafiante debido a la novedad de la infección y el conocimiento limitado de sus efectos neurológicos. ...
... In addition to myoclonic jerking, past medical history is positive for right sided flank pain associated with Lyme disease, hypertension, nephrolithiasis and past diagnosis of a chronic, central sensitivity pain syndrome for which she was inappropriately treated with high dose opioids over an extended period of time. 13 Family history positive for hypertension, heart disease, and diabetes. Musculoskeletal and neurological exams performed by the physical medicine physician and neurologist were all normal. ...
Background: Conversion disorder (CD) is a relatively common psychiatric disorder likely encountered by clinical pharmacists but probably not easily identified by pharmacists.
Case Summary: This is a patient case where a patient with a tremor was referred to the pharmacist led, polypharmacy, pharmacogenomics (PGx) service to rule out a PGx cause due to medication metabolism. No pharmacologic or PGx cause was found for the tremor which helped support and confirm a diagnosis of CD.
Practice Implications: By working collaboratively with psychiatrists, neurologists, physical medicine colleagues, clinical pharmacists may add value to patient care by assisting with diagnoses and appropriate treatment.
... " 7 This is in contrast to renewed interest occurring among some neurologists-as well as observations that psychotherapy is an emerging first line treatment and that the biopsychosocial model (foundational to psychiatry) is the prevailing conceptual framework for FND. [8][9][10][11][12] The renaissance occurring in some circles within the FND field has been catalyzed by the ability to use positive "rule-in" signs on examination (eg, variability and distractibility, Hoover's sign) to make the diagnosis 4,[13][14][15] (Table 1). Data have accumulated that certain neurologic examination signs and features are specific to the diagnosis of FND, 4,14,15,18 with historical concerns for high misdiagnosis rates no longer supported by the available evidence. ...
Functional neurologic (conversion) disorder (FND) is a core neuropsychiatric condition directly at the intersection of psychiatry and neurology. Over the past several decades, renewed interest in FND has been catalyzed by use of a "rule-in" diagnostic approach leveraging positive clinical signs specific for the diagnosis. In parallel, advances have occurred in identifying mechanisms, etiologic factors, and evidence-based treatments for this population. While "one size fits all" formulations of the "conversion" of psychological distress into physical symptoms are no longer widely accepted, emotion processing and related psychological constructs (eg, alexithymia, dissociation, threat avoidance) remain central to the conceptual understanding of FND. Furthermore, the biopsychosocial model (foundational to psychiatry) is the prevailing model through which to guide longitudinal treatment, with psychotherapy as an emerging first line intervention for FND. Nonetheless, there is a striking dearth of psychotherapists and mental health providers more broadly that feel well versed in the clinical assessment and management of patients with FND. In this article, we seek to address this gap by presenting the psychotherapy treatment narrative of a woman experiencing paroxysmal functional speech and gait disorder symptoms who had a positive clinical outcome. Our goal with this case presentation and related discussion is to increase the proficiency of psychotherapists in providing treatment to patients with FND.
... Psychological comorbidities appear to have a definite impact on patients' interpretation of symptoms, resultant health seeking and disease-related behaviours, as well as prognosis. 31 Furthermore, there is ample evidence in the medical literature on the biological effect of stress and anxiety on gut sensorimotor function. [32][33][34] Early life adverse events may impact on gut permeability and microbiota contributing to the development of GI symptoms, particularly pain and dysmotility. ...
This article offers a framework in history taking for functional gastrointestinal disorders (FGIDs). Clinicians rely on history taking and knowledge of the latest 'Rome IV criteria' rather than biomarkers to make a positive diagnosis of FGIDs. Improving one's history-taking skills is imperative, as early diagnosis can improve patient outcomes by avoiding over investigation and/or chronicity.Our suggested structure for history taking adopts the bio-psycho-social model of disease. We describe the assessment of gastrointestinal symptoms with open and closed questions, the importance of ruling out 'alarm' signs or symptoms, the use of a multi-system approach to identify coexisting functional disorders and eliciting patients' nutritional history. We explore the increased psychological comorbidity present in FGIDs and the significance of the social history in identify predisposing, precipitating, perpetuating and protective factors, which will ultimately guide treatment recommendations.We believe history taking should be used to build rapport with patients while, at the same time, validating their problems and reducing stigma. Reattribution of symptoms is then achieved through education of the gut-brain axis and can be used to provide reassurance to patients at the first encounter. Success of treatment depends on engagement and acceptance of such explanations.
... Recently, emphasis on diagnosing FND-seiz based on rule in semiological features helped renew interest in this condition and related FND subtypes (Espay et al. 2018;Avbersek and Sisodiya 2010). In parallel, an etiologically neutral perspective was incorporated in the latest diagnostic criteria for FND-seiz in DSM-5 where the requirement for a proximal psychological stress was removed, challenging the role of psychological factors in mechanistic explanations of FND-seiz (American Psychiatric Association 2013; Stone et al. 2010). ...
Functional [psychogenic nonepileptic/dissociative] seizures (FND-seiz) and related functional neurological disorder subtypes were of immense interest to early founders of modern-day neurology and psychiatry. Unfortunately, the divide that occurred between the both specialties throughout the mid-twentieth century placed FND-seiz at the borderland between the two disciplines. In the process, a false Cartesian dualism emerged that labeled psychiatric conditions as impairments of the mind and neurological conditions as disturbances in structural neuroanatomy. Excitingly, modern-day neuropsychiatric perspectives now consider neurologic and psychiatric conditions as disorders of both brain and mind. In this article, we aim to integrate neurologic and psychiatric perspectives in the conceptual framing of FND-seiz. In doing so, we explore emerging relationships between symptoms, neuropsychological constructs, brain networks, and neuroendocrine/autonomic biomarkers of disease. Evidence suggests that the neuropsychological constructs of emotion processing, attention, interoception, and self-agency are important in the pathophysiology of FND-seiz. Furthermore, FND-seiz is a multi-network brain disorder, with evidence supporting roles for disturbances within and across the salience, limbic, attentional, multimodal integration, and sensorimotor networks. Risk factors, including the magnitude of previously experienced adverse life events, relate to individual differences in network architecture and neuroendocrine profiles. The time has come to use an integrated neuropsychiatric approach that embraces the closely intertwined relationship between physical health and mental health to conceptualize FND-seiz and related functional neurological disorder subtypes.
... Criticisms related to the term hysteria refer to the disparaging impact on consumers and the gender bias associated with the term (Edwards, Stone, & Lang, 2014). Subsequent research has also suggested that the term CD defined as the conversion of emotional conflicts into physical symptomsis considered an outdated and stigmatising term that has limited supportive research (Stone, LaFrance, Levenson, & Sharpe, 2010). Following on from this, the term FNSD, adopted by the DSM-5 in parentheses alongside CD, is considered a more acceptable, neutral diagnostic term (Edwards et al., 2014). ...
Functional neurological symptom disorder, alternatively termed conversion disorder (FNSD‐CD) (Although the DSM‐5 utilises the term 'conversion disorder', practitioners and consumers consider this to be an outdated, unsubstantiated and often stigmatising term. In accordance with this, the current terminology used in the field is 'functional neurological symptom disorder'), involves symptoms of altered voluntary motor or sensory functions without identifiable nervous system disease or pathology. It is considered a psychiatric disorder and is, thus, listed in the Diagnostic and Statistical Manual of Mental Disorders (5th Ed.; DSM‐5). As per the nosology of the DSM‐5, the discrete behavioural or psychological syndrome or pattern observed in FNSD‐CD is assumed to be a function of a problem of, or a disorder within, the individual. Accordingly, the psychiatric approach to FNSD‐CD, as set out in the DSM‐5, invokes an assumption common to the medical model which is that of lineal (i.e., straight‐line) causality, namely, causal events are arranged in a lineal sequence. The interactional approach, however, which is a development of general system theory in the field of family therapy, offers an alternative approach to understanding psychiatric disorders. Specifically, this approach places the emphasis on the relationships between individuals and their reciprocal influences on – including their psychological and emotional wellbeing with – one another. It draws on the assumption of nonlineal (i.e., circular) causality, namely, causal events are arranged in a circular sequence. From an interactional approach, therefore, FNSD‐CD is thought to be a function of a problem of, or a deficit within, the individuals’ relationship/s, rather than within an individual, per se. This article utilises a composite case study to investigate FNSD‐CD from an interactional approach.
... 9,10 However, some patients with FND do not have a comorbid psychiatric diagnosis or trauma history, and for the ones who do, it is unclear if (and if yes, how) it is related to the etiology of their FND. 11,12 This suggests trauma and/or psychopathology may not be the most effective targets for PNES intervention. ...
Objective
Our aim was to conduct a pilot randomized controlled trial of a novel cognitive behaviorally based intervention for pediatric PNES called Retraining and Control Therapy (ReACT).
Methods
Participants were randomized to receive either eight sessions of ReACT or supportive therapy, and participants completed follow‐up visits at 7‐ and 60‐days posttreatment. The primary outcome measure was PNES frequency at 7‐days posttreatment. Eligibility criteria included children with video‐EEG confirmed PNES and participant/parent or guardian willingness to participate in treatment. Exclusion criteria included substance use, psychosis, and severe intellectual disability. Forty‐two patients were assessed for eligibility and 32 were randomized. ReACT aimed to retrain classically conditioned, involuntary PNES by targeting catastrophic symptom expectations and a low sense of control over symptoms using principles of habit reversal. Supportive therapy was based on the assumption that relief from stress or problems can be achieved by discussion with a therapist.
Results
Twenty‐nine participants (M age = 15.1 years, SDage = 2.5; 72.2% female; 57.1% Caucasian, 28.6% African American) completed 7‐days postprocedures. For PNES frequency, the Wilcoxon Rank Sum test statistic was 273.5 yielding a normal approximation of Z = 4.725 (P < 0.0001), indicating a significant improvement in PNES frequency for ReACT at 7‐days posttreatment compared to supportive therapy. Participants with PNES in the 7‐days posttreatment were removed from the study for additional treatment, resulting in no 60‐day follow‐up data for supportive therapy.
Interpretation
ReACT resulted in significantly greater PNES reduction than supportive therapy, with 100% of patients experiencing no PNES in 7 days after ReACT. Additionally, 82% remained PNES‐free for 60 days after ReACT.
... was described as a physical manifestation of psychological distress [2]. Yet, there is limited empirical evidence to support this explanation, and patients may respond negatively to the explanation of a psychiatric cause for their symptoms [35]. Furthermore, while prior research showed that rates of trauma, stress, and psychiatric diseases were higher in patients with FNSD, recent research reveals a low incidence of psychiatric diagnoses in this patient population [36,37]. ...
A rare manifestation during the post-anesthetic period may include the occurrence of functional neurological symptom disorder (FNSD). FNSD is described as neurological symptoms that are not consistently explained by neurological or medical conditions. We report a case series consisting of six patients who underwent a general anesthetic at a tertiary referral hospital and experienced FNSD in the immediate post-anesthetic period. Life-threatening causes were excluded based on benign physical exam findings and knowledge of past history. Five of six cases manifested with FNSD only in the immediate post-operative setting after exposure to anesthesia, and never otherwise experienced these symptoms during their normal daily lives. MEDLINE and Google Scholar were searched through October 2019 using a highly-sensitive search strategy and identified 38 published cases of post-anesthetic FNSD. Meta-analysis of pooled clinical data revealed that a significant proportion of patients were females (86%), reported a history of psychiatric illness (49%), reported a prior history of FNSD (53%), and underwent general anesthesia as the primary anesthetic (93%). The majority of patients were exposed to diagnostic studies (66% received radiographic tests and 52% received electroencephalogram) as well as pharmacologic therapy (57%). While no deaths occurred, many patients had unanticipated admission to the hospital (53%) or to the intensive care unit (25%). These data may help inform the anesthesia literature on presentation, risk factors, and treatment outcomes of FNSD in the context of anesthetic administration. We contemplate whether anesthetic agents may predispose a vulnerable brain to manifest with involuntary motor and sensory control seen in FNSD.
... Entsprechend der 2013 publizierten fünften Auflage des «Diagnostic and Statistical Manual of Mental Disorders» (DSM-5) [13] werden psychische Faktoren aufgrund begrenzter Reliabilität und Validität [14][15][16] für die Diagnose nicht mehr benötigt, und die «International Classification of Diseases» (ICD-11) geht in ihrer elften Revision densel-ben Weg [17]. Obwohl psychische Faktoren im zeitlichen Zusammenhang mit den Symptomen nicht mehr als conditio sine qua non gefordert werden, finden sich zunehmend Untersuchungen, die zeigen, dass eine ausführliche psychosoziale Anamnese Belastungen und Konflikte sehr häufig zu Tage bringt [18][19][20][21]. ...
... Thirty-two subjects with FND (22 women, 10 men; mean age = 40.9 ± 13.1; average illness duration = 3.5 ± 4.5 years) were recruited from the Massachusetts General Hospital FND Clinic between 2014 and 2018 following a 'rule-in' FND diagnosis in accord with the Diagnostic and Statistical Manual of Mental Disorders 5th Edition criteria (American Psychiatric Association, 2013;Stone, LaFrance, Levenson, & Sharpe, 2010b). Four additional patients were enrolled but excluded following image acquisition and preprocessing (see online Supplementary Methods). ...
Background
Functional neurological disorder (FND) is a condition at the intersection of neurology and psychiatry. Individuals with FND exhibit corticolimbic abnormalities, yet little is known about the role of white matter tracts in the pathophysiology of FND. This study characterized between-group differences in microstructural integrity, and correlated fiber bundle integrity with symptom severity, physical disability, and illness duration.
Methods
A diffusion tensor imaging (DTI) study was performed in 32 patients with mixed FND compared to 36 healthy controls. Diffusion-weighted magnetic resonance images were collected along with patient-reported symptom severity, physical disability (Short Form Health Survey-36), and illness duration data. Weighted-degree and link-level graph theory and probabilistic tractography analyses characterized fractional anisotropy (FA) values across cortico-subcortical connections. Results were corrected for multiple comparisons.
Results
Compared to controls, FND patients showed reduced FA in the stria terminalis/fornix, medial forebrain bundle, extreme capsule, uncinate fasciculus, cingulum bundle, corpus callosum, and striatal-postcentral gyrus projections. Except for the stria terminalis/fornix, these differences remained significant adjusting for depression and anxiety. In within-group analyses, physical disability inversely correlated with stria terminalis/fornix and medial forebrain bundle FA values; illness duration negatively correlated with stria terminalis/fornix white matter integrity. A FND symptom severity composite score did not correlate with FA in patients.
Conclusions
In this first DTI study of mixed FND, microstructural differences were observed in limbic and associative tracts implicated in salience, defensive behaviors, and emotion regulation. These findings advance our understanding of neurocircuit pathways in the pathophysiology of FND.
... Functional neurologic disorder (FND) is a common neuropsychiatric condition defined by neurologic symptoms that are incompatible with other medical-neurologic conditions and that encompasses functional weakness (FW), functional movement disorders (FMD), psychogenic nonepileptic seizures (PNES, also known as dissociative seizures), functional speech, and/or nondermatomal sensory deficits (functional numbness) among other symptoms (Espay et al., 2018a). With the Diagnostic and Statistical Manual of Mental Disorders-5th edn, FND was redefined as a "rule-in" condition based on neurologic exam signs, removing the need to identify a proximal stressor (Stone et al., 2010b(Stone et al., , 2011. Importantly, FND is the second-most common referral to outpatient neurology (Stone et al., 2010a), and somatic symptom disorders more broadly account for approximately 256 billion dollars a year in healthcare expenses (Barsky et al., 2005). ...
Functional neurologic disorder (FND)/conversion disorder is a prevalent and disabling condition at the intersection of neurology and psychiatry. Clinicians often report feeling ill-equipped treating patients with FND, perpetuated by a historically limited understanding of neurobiologic disease mechanisms. In this review, we summarize the neuroimaging literature across the spectrum of sensorimotor FND, including functional imaging studies during rest, sensorimotor performance, and emotional-processing tasks as well as structural magnetic resonance imaging findings. Particular attention is given to studies implicating the anterior and middle cingulate cortex and related salience network structures (insula, amygdala, and periaqueductal gray) in the neurobiology of FND. Neuroimaging studies identify cingulo-insular functional alterations during rest, motor performance, and emotion processing in FND populations. The literature also supports that patients with FND exhibit heightened amygdalar and periaqueductal gray reactivity to emotionally valenced stimuli, enhanced coupling between amygdalar and motor control areas, and increased amygdalar volumes. The structural neuroimaging literature also implicates cingulo-insular areas in the pathophysiology of FND, though these findings require replication and clarification. While more research is needed to fully elucidate the pathophysiology of FND, salience network alterations appear present in some FND populations and can be contextualized using biopsychosocial models for FND.
... The fact that the patient's unexplained symptoms appeared after her son's suicide rendered them representative of an antiquated but common understanding of conversion disorder and likely also conferred a high degree of confidence in the diagnosis despite recent changes to the diagnostic criteria intended to address such errors. DSM-5 removed the criterion requiring association with a traumatic stressor, relegating it to the accompanying text because of concern that it had "not been shown to be either diagnostically reliable or predictive of outcome" (24,25). DSM-5 also added the new criterion requiring positive evidence of symptoms incompatible with a known medical illness-not just the absence of an alternative diagnosis. ...
... But the transition led to removal of this term in order to classify disorder based on clinical phenomenology. It was categorized under somatoform disorder in DSM IV [4] and recently renamed as function neurological disorder, with function referring to a symptom without organic cause [5]. The primary characteristic feature of conversion disorder is impaired motor or sensory functions as explained ...
... The sensation occurs when the neck is moved in a wrong way or rather flexed. Demyelination and hyperexcitability are the main causes of Lhermitte's sign [12], along with vertigo, bladder problems, limb ataxia, acute transverse myelopathy, and pain. The onset is often polysymptomatic and the typical patient is a young adult with two or more clinically distinct episodes of central nervous system dysfunction with at least partial resolution with time. ...
Conversion disorder, also referred to as functional neurological symptom disorder, is a DSM-5 identified somatic disorder that presents with one or more neurological symptoms that does not clinically correlate with recognized neurological or medical conditions brought on by intense stress, emotions, or an associated psychiatric disorder. Multiple sclerosis (MS) is the most common immune-mediated inflammatory demyelinating disease of the central nervous system and usually presents in young adults with clinical manifestations that range from cognitive abnormalities, eye movement problems, motor and sensory impairments such as weakness and numbness, bowel/bladder dysfunction, fatigue, and/or pain. This case report presents a patient with functional neurological symptom disorder presenting with clinical signs associated with MS.
... Despite an apparent consensus to properly name the disorder, the recent psychiatric classification system DSM-5 proposed two different alternatives: "conversion disorder" (CD) or "functional neurological symptom disorder with attacks or seizures" (FNSDa) [7]. "Conversion disorder" referring to a psychoanalytic hypothesis was largely debated [8] and this term is now poorly used in the modern neurological and psychiatric literature. ...
... average illness duration=3.0±3.8 years; 24 right handed, 6 ambidextrous or left handed) were recruited from the Massachusetts General Hospital (MGH) FND Clinic following a 'rule-in' FND diagnosis in accord with the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition criteria. 3 An additional five patients were enrolled but excluded following imaging preprocessing (see online supplementary methods). Given the overlap across the motor FND spectrum, 30 we used a transdiagnostic approach that included those with clinically established functional movement disorders (n=16), 31 functional weakness (n=12) 32 and documented (n=12) or clinically established (n=1) psychogenic non-epileptic seizures (PNES). ...
Objective
Some individuals with functional neurological disorder (FND) exhibit motor and affective disturbances, along with limbic hyper-reactivity and enhanced motor-limbic connectivity. Given that the multimodal integration network (insula, dorsal cingulate, temporoparietal junction (TPJ)) is implicated in convergent sensorimotor, affective and interoceptive processing, we hypothesised that patients with FND would exhibit altered motor and amygdalar resting-state propagation to this network. Patient-reported symptom severity and clinical outcome were also hypothesised to map onto multimodal integration areas.
Methods
Between-group differences in primary motor and amygdalar nuclei (laterobasal, centromedial) were examined using graph-theory stepwise functional connectivity (SFC) in 30 patients with motor FND compared with 30 healthy controls. Within-group analyses correlated functional propagation profiles with symptom severity and prospectively collected 6-month outcomes as measured by the Screening for Somatoform Symptoms Conversion Disorder subscale and Patient Health Questionnaire-15 composite score. Findings were clusterwise corrected for multiple comparisons.
Results
Compared with controls, patients with FND exhibited increased SFC from motor regions to the bilateral posterior insula, TPJ, middle cingulate cortex and putamen. From the right laterobasal amygdala, the FND cohort showed enhanced connectivity to the left anterior insula, periaqueductal grey and hypothalamus among other areas. In within-group analyses, symptom severity correlated with enhanced SFC from the left anterior insula to the right anterior insula and TPJ; increased SFC from the left centromedial amygdala to the right anterior insula correlated with clinical improvement. Within-group associations held controlling for depression, anxiety and antidepressant use.
Conclusions
These neuroimaging findings suggest potential candidate neurocircuit pathways in the pathophysiology of FND.
... Traditionally, the etiology of FNSD has been explained in the context of psychoanalytic theory as a phys ical manifestation of psychological distress, and many phys icians continue to use this as a simple explanation in clinical settings. However, there is little supporting empirical evi dence for this hypothesis, 9 and patients have been found to respond negatively to psychiatric explanations for physical symptoms. 10 There is evidence that rates of trauma, stress and psychiatric comorbidities are higher in patients with FNSD, but recent research has demonstrated low incidence of physical or psychiatric diagnoses to directly explain pa tients' symptoms, 11,12 and trauma is present in only about onethird of patients. ...
Functional neurological symptom disorder (FNSD) is characterized by neurological symptoms that are unexplained by other traditional neurological or medical conditions. Both physicians and patients have limited understanding of FNSD, which is often explained as a physical manifestation of psychological distress. Recently, diagnostic criteria have shifted from requiring a preceding stressor to relying on positive symptoms. Given this shift, we have provided a review of the etiology of FNSD. Predisposing factors include trauma or psychiatric symptoms, somatic symptoms, illness exposure, symptom monitoring and neurobiological factors. Neurobiological research has indicated that patients with FNSD have a decreased sense of agency and abnormal attentional focus on the affected area, both of which are modulated by beliefs and expectations about illness. Sick role and secondary gain may reinforce and maintain FNSD. The integrated etiological summary model combines research from various fields and other recent etiological models to represent the current understanding of FNSD etiology. It discusses a potential causal mechanism and informs future research and treatment. 10.1503/jpn.170190
... But some of the challenges to Freud's ideas remain. Leading researchers have expressed doubts about the claim that most hysterical symptoms owe to a psychological cause (Sharpe & Faye, 2006;Stone & Edwards, 2011), about the plausibility of a conversion mechanism (Brown, 2004;Stone, LaFrance, Levenson, & Sharpe, 2010), and about the role of repression . Some argue that the attempt among therapists to uncover events that may have provoked a symptom can be, not only ineffective, but also dangerous to the patient (ibid.). ...
Hysteria (or conversion disorder) is once again attracting concerted scientific attention. This paper looks at the extent to which recent scientific research supports Freud’s theory of hysteria, which posits that repressed impulses are converted into physical or behavioral symptoms. Specifically, it looks at two prominent empirical studies, representing the most rigorous direct efforts to date to test Freud’s key ideas about hysteria, in conjunction with an important new theoretical account. The empirical studies are Nicholson et al.’s (2016. Life events and escape in conversion disorder. Psychological Medicine, 46(12), 2617–2626.) survey-based study, which examines the impact of life events on hysteric patients, and Aybek et al.’s (2014. Neural correlates of recall of life events in conversion disorder. JAMA Psychiatry, 71(1), 52–60.) brain-imaging study, which looks at the neural correlates of the recall of such life events. The theoretical account is Edwards et al.’s (2012. A Bayesian account of “hysteria”. Brain, 135(11), 3495–3512.) Bayesian account of hysteria, in which somatic symptoms are seen as the result of the entrenchment of prior expectations that appear to explain (by predicting) otherwise unexplained bodily sensations. The conclusions of the present paper are that the empirical studies offer considerable evidence in support of key aspects of Freud’s theory of hysteria, that this theory is compatible with the Bayesian account of hysteria, and that reservations about Freud’s theory expressed by the authors of the Bayesian account are allayed by the empirical studies.
... Conversion disorder is a diagnosis of exclusion. Conversion disorder may be present with ataxia, aphonia, mutism, paralysis, tremor, hysterical seizure, dissociative anesthesia, sensory loss, psychogenic deafness, and mixed symptoms, according to DSM-5 [11]. While catatonia may be seen as a rare symptom of conversion, it is interesting that it is not included in DSM-5. ...
... Traditionally, the etiology of FNSD has been explained in the context of psychoanalytic theory as a phys ical manifestation of psychological distress, and many phys icians continue to use this as a simple explanation in clinical settings. However, there is little supporting empirical evi dence for this hypothesis, 9 and patients have been found to respond negatively to psychiatric explanations for physical symptoms. 10 There is evidence that rates of trauma, stress and psychiatric comorbidities are higher in patients with FNSD, but recent research has demonstrated low incidence of physical or psychiatric diagnoses to directly explain pa tients' symptoms, 11,12 and trauma is present in only about onethird of patients. ...
Functional neurological symptom disorder (FNSD) is characterized by neurological symptoms that are unexplained by other traditional neurological or medical conditions. Both physicians and patients have limited understanding of FNSD, which is often explained as a physical manifestation of psychological distress. Recently, diagnostic criteria have shifted from requiring a preceding stressor to relying on positive symptoms. Given this shift, we have provided a review of the etiology of FNSD. Predisposing factors include trauma or psychiatric symptoms, somatic symptoms, illness exposure, symptom monitoring and neurobiological factors. Neurobiological research has indicated that patients with FNSD have a decreased sense of agency and abnormal attentional focus on the affected area, both of which are modulated by beliefs and expectations about illness. Sick role and secondary gain may reinforce and maintain FNSD. The integrated etiological summary model combines research from various fields and other recent etiological models to represent the current understanding of FNSD etiology. It discusses a potential causal mechanism and informs future research and treatment.
... Conversion disorder is a diagnosis of exclusion. Conversion disorder may be present with ataxia, aphonia, mutism, paralysis, tremor, hysterical seizure, dissociative anesthesia, sensory loss, psychogenic deafness, and mixed symptoms, according to DSM-5 [11]. While catatonia may be seen as a rare symptom of conversion, it is interesting that it is not included in DSM-5. ...
Objective: To describe two cases of electroconvulsive therapy for hysterical catatonia.
Case Descriptions
Mrs A was 62 years old, was married for 42 years, and was in the postmenopausal period. She was being followed at a psychiatry
outpatient clinic for 35 years, with a diagnosis of conversion disorder and somatization disorder. She has not been on medication
for the last three months. Previously used drugs were duloxetine, venlafaxine, sulpride, olanzapine, and amisulpride. Ten days
before admission, she had suddenly stopped talking and eating. There was a physical inactivity and decreased need for sleep. In
history, her first complaints were weakness of muscles, pseudoseizure, and tremor. Symptoms of the disease were exacerbated
Methods: A 62-years-old female patient with a diagnosis of conversion disorder and somatization disorder and a 20-years-old female
patient with a diagnosis of conversion disorder were treated on electroconvulsive therapy. Electroconvulsive therapy was performed
in 8 sessions with anaesthesia.
Results: 62-years-old patient began to recover after the sixth session of electroconvulsive therapy once every two days. Complete
remission in catatonic symptoms also sustained during follow-up. The catatonic symptoms of the 20-years-old patient were completely
terminated after the second session of the ECT once every two days. The treatments were completed in 8 sessions.
Conclusion: We suggested that electroconvulsive therapy may be an effective treatment technique for conversion disorder earlier
than drug treatment. It is thought that hysterical catatonia or another term expressing this condition may be used in psychiatric
classification systems such as DSM.
... 11,12 Different explanations have been proposed for the presence of psychiatric symptoms in mitochondrial disorders. In fact its high prevalence allows suspecting that could be a neurological manifestation of lack of energy in brain tissue because of the influence of epigenetic and environmental factors [13][14][15] . ...
... 11,12 Different explanations have been proposed for the presence of psychiatric symptoms in mitochondrial disorders. In fact its high prevalence allows suspecting that could be a neurological manifestation of lack of energy in brain tissue because of the influence of epigenetic and environmental factors [13][14][15] . ...
... 11,12 Different explanations have been proposed for the presence of psychiatric symptoms in mitochondrial disorders. In fact its high prevalence allows suspecting that could be a neurological manifestation of lack of energy in brain tissue because of the influence of epigenetic and environmental factors [13][14][15] . ...
... 1,2 The requirement to exclude feigning has been removed, along with the prerequisite of identifying an acute stressor. 3,4 Patients with FND are commonly diagnosed with affective and trauma-related disorders, 5,6 and the presence of psychiatric comorbidities is linked to prognosis. 7 Despite advances in diagnosis and treatment, 8 clinicians across neurology and psychiatry report feeling ill-equipped managing patients with FND. ...
Despite advancements in the assessment and management of functional neurological disorder (FND), the feasibility of implementing a new standard of care remains unclear. Chart reviews were performed for 100 patients with motor FND to investigate factors related to treatment adherence and clinical improvement over an average follow-up of 7 months. Of 81 patients who returned for follow-up, a history of chronic pain disorder inversely correlated with improvement. Of the 50 individuals newly referred for treatment, adherence correlated with improvement, while having abnormal neuroimaging inversely correlated with improvement. This study supports the feasibility of applying a new standard of care for FND.
... Suggestions are advanced to replace the term 'conversion disorder' with 'functional neurological disorder'. Commenting on the diagnosis of conversion disorder in new editions of ICD and DSM, Dimsdale & Creed (2009) and Stone et al (2010) and others have suggested abandoning the term. The points against the diagnosis of conversion are, among others: (1) 'conversion' is based on a questionable psychoanalytic concept; (2) it is not widely used by non-psychiatrists and is not liked by patients; and (3) current diagnostic criteria require a psychosocial association with symptom onset that is difficult to find in some patients, and when present is of questionable value. ...
A woman in the care of the author 40 years ago was reported to have been sleeping for 2 days. We treated her condition as conversion hysteria. Her private psychiatrist was the renowned R. D. Laing; he was unhappy with our line of management, on the grounds of the arbitrariness of the diagnosis, the labelling of the woman with a diagnosis of hysteria and the treatment of the patient without her consent. In retrospect, I wonder if she was in a state of yogic sleep (yoga nidra).
Conversion disorder, also known as functional neurological symptom disorder, typically manifests as altered voluntary motor or sensory function that does not appear to be caused by recognized neurological or medical conditions.
Educational interventions aimed at improving healthcare professionals’ (HCPs) knowledge and confidence in managing complex conditions are widely recommended. However, there is limited evidence regarding the impacts of such interventions on HCP confidence and knowledge in relation to the management of Functional Neurological Disorder (FND). This investigation aimed to ascertain whether a two-hour FND training session, delivered online in group format, improved HCP confidence and knowledge in FND management, using a pre-post repeated measures design. Responses from 25 HCPs from community-based rehabilitation services at Whittington Health NHS Trust were included in the analysis. The findings indicated significant improvements in participant confidence and knowledge scores following training, suggesting the potential value of accessible low-cost training within the NHS. Future studies could adopt a randomised controlled trial design to reliably determine the effectiveness of delivering the training.
Background
As a group, individuals with functional neurological disorder (FND) report an approximately 3-fold increase in adverse life experiences (ALEs) compared to healthy controls. In patients with FND, studies have identified a positive correlation between symptom severity and the magnitude of ALEs. While not all individuals with FND report ALEs, such findings raise the possibility of a trauma-subtype of FND.
Objective
This study investigated if patients with FND, with or without probable post-traumatic stress disorder (PTSD) and/or significant childhood maltreatment, differed in their symptom severity and physical health.
Materials and methods
Seventy-eight patients with FND were recruited (functional seizures, n = 34; functional movement disorder, n = 56). Participants completed self-report measures of symptom severity [Somatoform Dissociation Questionniare-20 (SDQ-20), Screening for Somatoform Disorders: Conversion Disorder subscale (SOMS:CD), Patient Health Questionniare-15 (PHQ-15)], physical health [Short Form Health Survey-36 (SF36-physical health)], childhood maltreatment [Childhood Trauma Questionnaire (CTQ)], and PTSD [PTSD Checklist-5 (PCL-5)]; a psychometric battery of other common predisposing vulnerabilities was also completed. To adjust for multiple comparisons, a Bonferroni correction was applied to all univariate analyses.
Results
Patients with FND and probable PTSD ( n = 33) vs. those without probable PTSD ( n = 43) had statistically significant increased scores on all symptom severity measures – as well as decreased physical health scores. In secondary post-hoc regression analyses, these findings remained significant adjusting for age, sex, race, college education, and: pathological dissociation; alexithymia; attachment styles; personality characteristics; resilience scores; functional seizures subtype; or moderate-to-severe childhood abuse and neglect scores; SOMS:CD and SDQ-20 findings also held adjusting for depression and anxiety scores. In a separate set of analyses, patients with FND and moderate-to-severe childhood abuse ( n = 46) vs. those without moderate-to-severe childhood abuse ( n = 32) showed statistically significant increased SDQ-20 and PHQ-15 scores; in post-hoc regressions, these findings held adjusting for demographic and other variables. Stratification by childhood neglect did not relate to symptom severity or physical health scores.
Conclusion
This study provides support for a possible trauma-subtype of FND. Future research should investigate the neurobiological and treatment relevance of a FND trauma-subtype, as well as continuing to delineate clinical characteristics and mechanisms in individuals with FND that lack a history of ALEs.
Functional neurological disorder (FND) is the latest name for the ancient malady at the brain–mind intersection previously known as ‘hysteria’. Though never an official term, ‘FND’ has come to dominate the field, and perhaps best captures the very substantial recent changes in the conceptualisation of the disorder. Early leaders in both neurology and psychiatry were fascinated by hysteria, but for much of the 20th century it was neglected by both disciplines and became highly stigmatised, with a psychiatric foundation that was poorly supported and widespread suspicions of feigning. In DSM-5, the need for a psychological formulation and all mention of feigning were removed from the diagnostic criteria, and emphasis was placed on neurological signs in guiding the diagnosis. Accompanied by its new terminology, this neurological shift has proven very popular, and FND is experiencing a transformation in public awareness and acceptability. Potential risks to this shift are discussed, however, and an appreciation of both neurological signs and psychiatric formulation are likely to remain important in the assessment and management of this neuropsychiatric disorder.KeywordsFunctional movement disorderFunctional neurological disorderConversion disorder
Background:
Functional Movement Disorders (FMDs) are a common cause of disability. With an increasing research interest in FMD, including the emergence of intervention trials, it is crucial that research methodology be examined, and standardized protocols be developed.
Objective:
To characterize the current inclusion criteria used to select patients for FMD research studies and review the consistency and appropriateness of these criteria.
Methods:
We identified studies of potential biomarkers for FMD that were published over the last two decades and performed a qualitative analysis on the finally included studies.
Results:
We identified 79 articles and found inconsistent inclusion criteria. The Fahn-Williams and DSM-IV criteria were the most commonly applied, but neither accounted for the majority (Fahn-Williams 46%, DSM-IV 32% of the total). The selection of the inclusion criteria depended in part on the phenotype of FMD under investigation. We also identified inclusion methodologies that were not appropriate, such as the inclusion of low-certainty diagnoses and diagnosing by excluding specific biomarkers rather than including patients based on clinical characteristics that commonly are thought to suggest FMD.
Conclusions:
Significant variability exists with the inclusion criteria for FMD research studies. This variability could limit reproducibility and the appropriate aggregation of data for meta-analysis. Advancing FMD rehabilitation research will need standardized inclusion criteria. We make some suggestions.
Functional neurological disorders are characterized by neurologic symptoms not consistent with a primary neurologic pathology. Although neurological disorders are commonly associated with poor sleep, alpha intrusion of slow-wave sleep is not described in cases of functional neurological disorder. We describe a case demonstrating an alpha-delta sleep pattern in a patient presenting with a functional neurological disorder and no perception of sleep. Although alpha-delta sleep is more commonly associated with fibromyalgia, this pattern may be a potential biomarker for the physiology of sleep misperception and potentially functional neurologic symptoms disorder. It is important to recognize this pattern via close sleep electroencephalogram or spectral analysis for patients with concerning clinical histories.
Citation:
Christian F, Pollak A, Sullivan L. Alpha-delta sleep pattern in an acute functional neurological patient with no perception of sleep. J Clin Sleep Med. 2022;18(6):1711-1715.
Objective
The contribution of psychological and psychiatric symptoms in the development of Functional Neurological Disorders (FND) is unclear. We therefore aimed to investigate the role of different attachment styles (AS) and their relationship with psychiatric symptoms in FND patients as compared with both subjects with neurological disorders (ND) and healthy controls (HC); and the possible differences between patients with functional movement disorders (FMD) and with functional seizures.
Methods
In this case-control study, forty-six patients with FND were compared to 34 with ND and 30 HC, by means of an extensive battery to investigate the presence of alexithymia, depression, anxiety, dissociation and to explore their AS using the Revised Experiences in Close Relationships instrument (ECR-R).
Results
Patients with FND had higher depression and alexithymia as well as an avoidant pattern on the ECR-R than patients with ND. In the FND group, ECR-R avoidance was an independent predictor of psychiatric symptoms and, altogether, ECR-R avoidance, the somatic-affective component of depression and difficulty identifying feelings were independent predictors of FND. Gender, anxiety and difficulty identifying feelings predicted the presence of functional seizures.
Conclusion
The avoidant AS may be an important psychological factor influencing the presence of mood disorders and alexithymia. Their co-occurence might drive maladaptive responses underlying the presence of FND. Although we demonstrated a large overlap between FND phenotypes, patients with functional seizures might have higher alexithymia, which in turn could explain a defensive response less anchored to body reactions and physical symptoms.
With the creation of the Somatic Symptom and Related Disorders category of the Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition (DSM-5) in 2013, the functional neurological (symptom) disorder diagnostic criteria underwent transformative changes. These included an emphasis on “rule-in” physical examination signs/semiological features guiding diagnosis and the removal of a required proximal psychological stressor to be linked to symptoms. Additionally, the DSM–Fourth Edition (DSM-IV) somatization disorder, somatoform pain disorder and undifferentiated somatoform disorder conditions were eliminated and collapsed into the DSM-5 somatic symptom disorder diagnosis. With somatic symptom disorder, emphasis was placed on a cognitive-behavioral (psychological) formulation as the basis for diagnosis in individuals reporting distressing bodily symptoms such as pain and fatigue; the need for bodily symptoms to be “medically unexplained” was removed, and the overall utility of this diagnostic criteria remains debated. A consequence of the DSM-5 restructuring is that the diagnosis of somatization disorder that encompassed individuals with functional neurological (sensorimotor) symptoms and prominent other bodily symptoms, including pain, was eliminated. This change negatively impacts clinical and research efforts because many patients with functional neurological disorder experience pain, supporting that the DSM-5 would benefit from an integrated diagnosis at this intersection. We seek to revisit this with modifications, particularly since pain (and a DSM-IV somatization disorder comorbidity, more specifically) is associated with poor clinical prognosis in functional neurological disorder. As a first step, we systematically reviewed the DSM-IV somatization disorder literature to detail epidemiologic, healthcare utilization, demographic, diagnostic, medical and psychiatric comorbidity, psychosocial, neurobiological and treatment data. Thereafter, we propose a preliminary revision to DSM-5 allowing for the specifier functional neurological disorder “with prominent pain”. To meet this criteria, core functional neurological symptoms (e.g., limb weakness, gait difficulties, seizures, non-dermatomal sensory loss, and/or blindness) would have “rule-in” signs and pain (> 6 months) impairing social and/or occupational functioning would also be present. Two optional secondary specifiers assist in characterizing individuals with cognitive-behavioral (psychological) features recognized to amplify or perpetuate pain and documenting if there is a pain-related comorbidity. The specifier of “with prominent pain” is etiologically neutral, while secondary specifiers provide additional clarification. We advocate for a similar approach to contextualize fatigue and mixed somatic symptoms in functional neurological disorder. While this preliminary proposal requires prospective data and additional discussion, these revisions offer the potential benefit to readily identify important functional neurological disorder subgroups - resulting in diagnostic, treatment and pathophysiology implications.
Functional neurological (conversion) disorder (FND) is a condition at the interface of neurology and psychiatry. A “software” vs. “hardware” analogy describes abnormal neurobiological mechanisms occurring in the context of intact macroscopic brain structure. While useful for explanatory and treatment models, this framework may require more nuanced considerations in the context of quantitative structural neuroimaging findings in FND. Moreover, high co-occurrence of FND and somatic symptom disorders (SSD) as defined in DSM-IV (somatization disorder, somatoform pain disorder, and undifferentiated somatoform disorder; referred to as SSD for brevity in this article) raises the possibility of a partially overlapping pathophysiology. In this systematic review, we use a transdiagnostic approach to review and appraise the structural neuroimaging literature in FND and SSD. While larger sample size studies are needed for definitive characterization, this article highlights that individuals with FND and SSD may exhibit sensorimotor, prefrontal, striatal-thalamic, paralimbic, and limbic structural alterations. The structural neuroimaging literature is contextualized within the neurobiology of stress-related neuroplasticity, gender differences, psychiatric comorbidities, and the greater spectrum of functional somatic disorders. Future directions that could accelerate the characterization of the pathophysiology of FND and DSM-5 SSD are outlined, including “disease staging” discussions to contextualize subgroups with or without structural changes. Emerging neuroimaging evidence suggests that some individuals with FND and SSD may have a “software” and “hardware” problem, although if structural alterations are present the neural mechanisms of functional disorders remain distinct from lesional neurological conditions. Furthermore, it remains unclear whether structural alterations relate to predisposing vulnerabilities or consequences of the disorder.
Background:
The relationships between baseline neuropsychiatric factors and clinical outcome in patients with functional neurological disorder (FND)/conversion disorder remain poorly understood.
Objective:
This prospective, naturalistic pilot study investigated links between predisposing vulnerabilities (risk factors) and clinical outcome in patients with motor FND engaged in usual care within a subspecialty FND clinic.
Methods:
Thirty-four patients with motor FND were enrolled and completed baseline and 6-month follow-up psychometric questionnaires. Univariate screening tests followed by multivariate linear regression analyses were used to investigate neuropsychiatric predictors of 6-month clinical outcome in patients with motor FND.
Results:
In univariate analyses, baseline secure attachment traits and depression as measured by the Relationship Scales Questionnaire and Beck Depression Inventory-II positively correlated with improved Patient Health Questionnaire-15 scores. In a multivariate linear regression analysis adjusting for the interval time between baseline and follow-up data collection, baseline secure attachment and depression scores independently predicted improvements in Patient Health Questionnaire-15 scores. In additional analyses, patients with a diagnosis of psychogenic nonepileptic seizures compared to individuals with other motor FND subtypes showed a trend toward worse 6-month physical health outcomes as measured by the Short Form Health Survey-36.
Conclusion:
Future large-scale, multi-site longitudinal studies are needed to comprehensively investigate neuropsychiatric predictors of clinical outcome in patients with motor FND, including functional weakness, functional movement disorders, and psychogenic nonepileptic seizures.
Background:
Psychogenic pseudo-syncope (PPS) frequently mimics syncope. The aim of this study was to assess the prevalence and clinical features of PPS and its relationship to vasovagal syncope (VVS).
Methods:
We examined retrospectively the medical records of 1401 consecutive patients referred to a syncope unit. We identified patients who had the final diagnosis of PPS. In these patients, we retrieved the initial diagnosis made during their first visit and the subsequent tests performed leading to the final diagnosis.
Results:
Fourteen (1.0%) patients (mean age 35±14; 11 females) were diagnosed as having PPS: 7 had a diagnosis of PPS alone and 7 had both VVS and PPS. High frequency of attacks (53±35 attacks during the previous year), prolonged loss of consciousness (LOC)(minutes to > 1 hour), and a history of psychiatric disorders characterized PPS patients. Tilt test reproduced a PPS attack in the presence of normal blood pressure and heart rate in 7 patients (50%), and induced VVS in another 3 patients who had the final diagnosis of both PPS and VVS. In 2 patients, one or more events occurred during the clinic visits and were directly witnessed by the clinic personnel.
Conclusions:
We have shown that 1% of referrals to a syncope unit have the final diagnosis of PPS and that 50% of cases presented with a different initial diagnosis, namely VVS. Our findings suggest that causality between syncope and psychiatric disorders is likely bi-directional. The presence of a multidisciplinary team is important to address this often unrecognized relationship. This article is protected by copyright. All rights reserved.
Clinicians throughout history have painstakingly provided us with classification and nomenclature of the several movement disorders that obscure diagnosis. As we come to understand, several of these movement disorders overlap with one another as part of the course of the syndrome or illness.
We review the concept and importance of functional somatic symptoms and syndromes such as irritable bowel syndrome and chronic fatigue syndrome. On the basis of a literature review, we conclude that a substantial overlap exists between the individual syndromes and that the similarities between them outweigh the differences. Similarities are apparent in case definition, reported symptoms, and in non-symptom association such as patients' sex, outlook, and response to treatment. We conclude that the existing definitions of these syndromes in terms of specific symptoms is of limited value; instead we believe a dimensional classification is likely to be more productive.
Hysterical conversion disorders refer to functional neurological deficits such as paralysis, anaesthesia or blindness not caused by organic damage but associated with emotional "psychogenic" disturbances. Symptoms are not intentionally feigned by the patients whose handicap often outweighs possible short-term gains. Neural concomitants of their altered experience of sensation and volition are still not known. We assessed brain functional activation in seven patients with unilateral hysterical sensorimotor loss during passive vibratory stimulation of both hands, when their deficit was present and 2-4 months later when they had recovered. Single photon emission computerized tomography using (99m)Tc-ECD revealed a consistent decrease of regional cerebral blood flow in the thalamus and basal ganglia contralateral to the deficit. Independent parametric mapping and principal component statistical analyses converged to show that such subcortical asymmetries were present in each subject. Importantly, contralateral basal ganglia and thalamic hypoactivation resolved after recovery. Furthermore, lower activation in contralateral caudate during hysterical conversion symptoms predicted poor recovery at follow-up. These results suggest that hysterical conversion deficits may entail a functional disorder in striatothalamocortical circuits controlling sensorimotor function and voluntary motor behaviour. Basal ganglia, especially the caudate nucleus, might be particularly well situated to modulate motor processes based on emotional and situational cues from the limbic system. Remarkably, the same subcortical premotor circuits are also involved in unilateral motor neglect after organic neurological damage, where voluntary limb use may fail despite a lack of true paralysis and intact primary sensorimotor pathways. These findings provide novel constraints for a modern psychobiological theory of hysteria.
Paralysis, seizures, and sensory symptoms that are unexplained by organic disease are commonly referred to as "conversion" symptoms. Some patients who receive this diagnosis subsequently turn out to have a disease that explains their initial presentation. We aimed to determine how frequently this misdiagnosis occurs, and whether it has become less common since the widespread availability of brain imaging.
Systematic review.
Medline, Embase, PsycINFO, Cinahl databases, and searches of reference lists.
We included studies published since 1965 on the diagnostic outcome of adults with motor and sensory symptoms unexplained by disease. We critically appraised these papers, and carried out a multivariate, random effect, meta-analysis of the data.
Twenty seven studies including a total of 1466 patients and a median duration of follow-up of five years were eligible for inclusion. Early studies were of poor quality. There was a significant (P < 0.02) decline in the mean rate of misdiagnosis from the 1950s to the present day; 29% (95% confidence interval 23% to 36%) in the 1950s; 17% (12% to 24%) in the 1960s; 4% (2% to 7%) in the 1970s; 4% (2% to 6%) in the 1980s; and 4% (2% to 6%) in the 1990s. This decline was independent of age, sex, and duration of symptom in people included in the studies.
A high rate of misdiagnosis of conversion symptoms was reported in early studies but this rate has been only 4% on average in studies of this diagnosis since 1970. This decline is probably due to improvements in study quality rather than improved diagnostic accuracy arising from the introduction of computed tomography of the brain.
Visits by patients with psychogenic disorders make up a significant percentage of neurology specialty appointments,1 but these patients are often treated differently from other patients. About 2% to 3% of new visits to movement disorder specialists are for psychogenic movement disorders,2,3 most of which are conversion disorders.4 Up to 30% of patients referred to epilepsy monitoring units have diagnoses of psychogenic nonepileptic seizures. Conversion symptoms, a subset of somatoform disorders, have been documented in the medical literature for millennia5,6 and are thought to have similar etiologies and similar presentations across cultures but with cultural variations.7
If you find people with “neurological symptoms but no disease” tiresome and not really what you came in to the specialty for, then you are going to find large parts of your job tiresome and—worse—your attitude will filter through in a negative way to the patients regardless of the form of words you use to talk to them. On the other hand, if you allow yourself to be interested by the complexity of the problem and can see the potential for benefit that you, as a neurologist, can make to some patients then you may discover that this is a worthwhile area in which to improve your knowledge and skills.
None of the current terms is perfect. It is best to choose words based on (a) how you see the cause or mechanism of the symptoms and (b) how this affects your ability to communicate the diagnosis helpfully to the patients (preferably also including copying your clinic letter to them). Ultimately the label is not as important as the neurologist’s attitude to the patient.
### Psychiatric terminology
Criteria 2 and …
Five hundred and nineteen members of the Movement Disorder Society completed a 22-item questionnaire probing diagnostic and management issues in psychogenic movement disorders (PMD). When patients showed definite evidence of PMD with no other unexplained clinical features, approximately 20% said they informed patients of the diagnosis and requested no further neurological testing. The 51% who reported conducting standard neurological investigations to rule out organic causes before presenting the diagnosis to such patients had fewer years of fellowship training and fewer PMD patients seen per month. A non-PMD diagnosis was correlated with patients' normal social or personal functioning, little or no employment disruption, lack of non-physiologic findings, and lack of psychiatric history. Ongoing litigation was more predictive of the PMD diagnosis for US compared to non-US respondents. Two thirds of respondents, more commonly younger and academic clinician researchers, refer PMD patients to a psychiatrist or mental health specialist while also providing personal follow up. Physician reimbursement, insurability of PMD patients, and ongoing litigation interfered with managing PMD patients to a greater extent in the US compared to non-US countries. Acceptance of the diagnosis by the patient and identification and management of psychological stressors and concurrent psychiatric disorders were considered most important for predicting a favorable prognosis. These findings suggest that expert opinions and practices related to diagnosing and managing PMD patients differ among movement disorders neurologists. Some of the discrepancies may be accounted for by factors such as training, type of practice, volume of patients, and country of practice, but may also reflect absence of practice guidelines.
Although the presence of psychological stress factors in the evolution of conversion symptoms forms an important criterion for the DSM-IV diagnosis of conversion disorder, little is known about the nature and timing of these stress factors. Fifty-four patients with conversion disorder and 50 control patients with an affective disorder were screened for life events experienced in the year before the symptom onset. Conversion patients did not differ from control patients in the number or severity of life events, but showed a significant relation between the recent life events and the severity of conversion symptoms. Especially life events with respect to work and relationships contributed to this effect. These results remained when controlling for the previously found effects of childhood traumatization on the severity of conversion symptoms. The findings imply that conversion symptoms may be elicited by a complex of early and later negative life events and that traditional unifactorial trauma-theories of conversion disorder should be replaced by multifactorial stress models.