Clinical characteristics of patients with motor disability due to conversion disorder: a prospective control group study

Physiotherapy for patients with functional movement disorder: a systematic review

INTRODUCTION

Functional movement disorder (FMD), a type of functional neurological disorder, is a common reason for consultation with the neurology department. The efficacy of physiotherapy for motor rehabilitation of these patients has been widely studied. The aim of this review is to analyse the available evidence on the effects of physiotherapy on motor symptoms, activity (gait, mobility, balance), perceived health, quality of life, and the cognitive/emotional state of patients with FMD.

METHODS

This review follows the PRISMA recommendations. Four electronic databases were searched for relevant articles. Our review included randomised controlled trials investigating the effects of a specialised physiotherapy intervention alone or in combination with other therapies as part of a multidisciplinary approach, with results compared against standard physiotherapy.

RESULTS

We reviewed 4 studies, including a total of 188 patients. We gathered data on the study population, outcome measures, protocols, and results. According to the Oxford quality scoring system, 3 studies had moderate methodological quality (3-4/5) and the remaining study presented poor methodological quality (< 3).

CONCLUSIONS

Physiotherapy improves motor symptoms, activity, perceived health, and quality of life in patients with FMD.

Cross-sectional evaluation of health resource use in patients with functional neurological disorders referred to a tertiary neuroscience centre

Introduction

Functional neurological disorder (FND) is a common cause of referral to neurology services. FND has been shown to lead to significant healthcare resource use and is associated with significant disability, comorbidity and distress. This leads to substantial direct, indirect and intangible costs to the patient and society.

Methods

We recruited consecutive patients with FND referred to a tertiary FND specialist clinic. We assessed health and social care resource use in the 6 months preceding their consultation through a modified version of the Client Service Receipt Inventory in the form of a postal questionnaire. The total cost was estimated by combining the number and frequency of health resource use with standard national unit costs. We also assessed indirect costs such as informal care and loss of income.

Results

We collected data on 118 subjects. Patients with comorbid anxiety or depression had higher costs in the preceding 6 months, as did patients who had a longer duration of FND symptoms. Indirect costs were higher than the already substantial direct costs and a large proportion of patients with FND were receiving government support.

Conclusion

This study highlights the high cost of FND to both patients and health systems. Adequate reform of the patient pathway and reorganisation of services to make diagnoses and initiate treatment more quickly would likely reduce these costs.

Understanding Functional Neurological Disorder: Recent Insights and Diagnostic Challenges

Functional neurological disorder (FND), formerly called conversion disorder, is a condition characterized by neurological symptoms that lack an identifiable organic purpose. These signs, which can consist of motor, sensory, or cognitive disturbances, are not deliberately produced and often vary in severity. Its diagnosis is predicated on clinical evaluation and the exclusion of other medical or psychiatric situations. Its treatment typically involves a multidisciplinary technique addressing each of the neurological symptoms and underlying psychological factors via a mixture of medical management, psychotherapy, and supportive interventions. Recent advances in neuroimaging and a deeper exploration of its epidemiology, pathophysiology, and clinical presentation have shed new light on this disorder. This paper synthesizes the current knowledge on FND, focusing on its epidemiology and underlying mechanisms, neuroimaging insights, and the differentiation of FND from feigning or malingering. This review highlights the phenotypic heterogeneity of FND and the diagnostic challenges it presents. It also discusses the significant role of neuroimaging in unraveling the complex neural underpinnings of FND and its potential in predicting treatment response. This paper underscores the importance of a nuanced understanding of FND in informing clinical practice and guiding future research. With advancements in neuroimaging techniques and growing recognition of the disorder's multifaceted nature, the paper suggests a promising trajectory toward more effective, personalized treatment strategies and a better overall understanding of the disorder.

[Diagnostic criteria, epidemiology and assessment of patients with functional neurological disorders]

Functional neurological disorders (FND) are symptoms that can affect a variety of functions including motor, sensory and cognitive. These symptoms are genuinely experienced by the patient and are related to a functional disorder rather than a structural one. There is little epidemiological data on these disorders, but their frequency is well established in clinical practice, it is the second most frequent reason for consultation in Neurology. Despite of the frequency of the disorder, general practitioners and specialists are insufficiently trained in the disease, and patients often suffer from stigmatization and/or unnecessary investigations. It is therefore important to be aware of the diagnostic approach to FND, which mostly relies on positive clinical signs. Psychiatric evaluation can help with the characterization of predisposing, precipitating and perpetuating factors of the symptoms (according to the 3P biopsychosocial model related to FND), and guide their management. Finally, diagnosis explanation is a crucial step in the management of the disease, which can in itself have a therapeutic effect, and allow the patient to adhere to the treatments.

[Functional neurological disorders: A clinical anthology]

Functional neurological disorders have a broad phenotypic spectrum and include different clinical syndromes, which are sometimes associated to each other or appear consecutively over the course of the disease. This clinical anthology provides details on the specific and sensitive positive signs that are to be sought in the context of a suspected functional neurological disorder. Beside these positive elements leading to the diagnosis of functional neurological disorder, we should keep in mind the possibility of an associated organic disorder as the combination of both organic and functional disorders is a relatively frequent situation in clinical practice. Here we describe the clinical characteristics of different functional neurological syndromes: motor deficits, abnormal hyperkinetic and hypokinetic movements, voice or speech disorders, sensory disorders, and functional dissociative seizures. The clinical examination and the identification of positive signs play a critical role in the diagnosis of functional neurological disorder. Knowledge of the specific signs associated with each phenotype render possible to make an early diagnosis. For that matter, it contributes to the improvement of patient care management. It allows to a better engagement in an appropriate care pathway, which influence their prognosis. Highlighting and discussing positive signs with patients can also be an interesting step in the process of explaining the disease and its management.

Costs of adult functional neurological disorders at a tertiary hospital in central South Africa

Background

Functional neurological disorders (FND) lead to increased care requirements and costs, negatively impacting healthcare budgets. Healthcare expenditure in FND has escalated beyond other neurologic disorders during the past decade.

Objectives

To assess inpatient costs in adults admitted to the neurology ward at Universitas Academic Hospital (UAH) in central South Africa.

Methods

A retrospective observational study with a comparative component was conducted on patients admitted during 2018 and 2019. All FND cases (n = 29) and a systematic sample of other neurological disorders were included in the comparison group (n = 29). Data were obtained from the Meditech billing system and clinical records.

Results

FND patients accounted for 5.5% of 530 admissions in the neurology ward during the study period. No significant differences regarding daily median cost, age categories, gender or medical comorbidity were observed between FND and the comparison group. However, the length of stay was significantly shorter for the FND patients (median of four versus eight days), translating to approximately half the total costs of patients admitted for other neurological disorders.

Conclusion

The daily median cost was similar for FND and other neurology-related admissions. The lower overall inpatient costs for FND patients were only related to significantly shorter durations of stay, which may reflect new diagnostic approaches resulting from changes in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) diagnostic criteria. The prevalence of FND was similar to those reported in previous studies conducted at neurology clinics.

Contribution

The study contributes towards better understanding the prevalence and cost of FND in local neurology inpatient care settings.

Neighborhood Social Determinants of Health in Patients Seen in Neurology Movement Disorders Clinics

Background and Objectives

Chronic health conditions are influenced by social determinants of health (SDH) including neighborhood-linked markers of affluence. We explored whether neighborhood socioeconomic factors differ in people with different types of clinical movement disorders (MDs).

Methods

We conducted a retrospective study of patients seen in MD clinics at our center in 2021. Patient data were linked to the US National Neighborhood Data Archive linked to US census tract data. We evaluated variations in neighborhood socioeconomic factors across 8 different categories of MDs.

Results

Compared with the neighborhoods of patients with Parkinson disease, neighborhoods of patients with cerebellar ataxias, functional movement disorders, and Huntington disease were characterized by higher proportions of people earning less than 15,000 US dollars/year, people receiving public assistance, and people with less than a high school diploma.

Discussion

Neighborhood-linked SDH vary among different MDs. These findings have implications for public health interventions aimed at improving the care of people affected by MDs.

Diagnosis of psychogenic (functional) gait disorders

Psychogenic gait is common in patients with medically unexplained neurological symptoms and provides significant challenges to healthcare providers. Clinicians may arrive at a correct diagnosis earlier if distinctive positive signs are identified and acknowledged. Psychogenic disorders of posture and gait are common and are the major manifestation in 8–10 % of patients with psychogenic movement disorders. Psychogenic movement disorders can present with varied phenomenology that may resemble organic movement disorders. The diagnosis is based on clinical evaluation with a supporting history and classic features on neurologic examination. In functional gait disorders, walking is often bizarre and does not conform to any of the usual patterns observed with neurologic gait disorders. Astasia-abasia, an inability to stand (astasia) or walk (abasia) in the absence of other neurologic abnormalities, was the term applied by investigators in the mid to late 19thcentury to describe certain patients with a frankly functional gait. Other descriptive terms include gaits that resemble walking on ice, walking a sticky surface, walking through water (bringing to mind excessive slowness), tightrope walking, habitual limping, and bizarre, robotic, knock-kneed, trepidant, anxious, and cautious gaits. Ancillary testing, such as imaging and neurophysiologic studies, can provide supplementary information but is not necessary for diagnosis. 

Moving Beyond Movement: Diagnosing Functional Movement Disorder

Functional movement disorder (FMD) is a complex neuropsychiatric syndrome, encompassing abnormal movements and weakness, and is a common cause of potentially disabling neurological symptoms. It is vital to recognize that FMD is a syndrome, with nonmotor manifestations negatively affecting a patient's quality of life. This review highlights a diagnostic algorithm, where a history suggestive of FMD is combined with the presence of positive signs on examination and appropriate investigations to make the diagnosis. Positive signs indicate internal inconsistency such as variability and distractibility, and clinical findings that are incongruent with other known neurological disease. Importantly, the clinical assessment acts as the first opportunity to allow patients to understand FMD as the cause for their symptoms. Accurate and early diagnosis of FMD is necessary given that it is a treatable and potentially reversible cause of disability, with significant risk of iatrogenic harm associated with misdiagnosis.

Functional Neurological Disorder-Old Problem New Perspective

Functional neurological disorder (FND) is a common issue in the pediatric population. The concept and our understanding of functional neurological disorders have changed over the past years, and new etiologic models and treatment plans have been explored. Knowledge about FND in the pediatric population, however, is lacking. The aim of this review is to provide an update on pediatric functional neurological disorder. We conducted a literature search of PubMed and SCOPUS databases and reviewed a total of 85 articles to gain insight into the current understanding of FND etiology, diagnosis, treatment, and prognosis in children and adolescents. Functional and high resolution MRI revealed abnormal connectivity and structural changes in patients with functional symptoms. The diagnostic criteria no longer require the presence of a psychological factor and instead focus on a rule-in diagnosis. Treatment of FND includes a clear communication of the diagnosis and the support of a multidisciplinary team. Although FND typically has a poor prognosis, better outcomes appear to have been achieved in children and young adults. We conclude that pediatric functional neurological disorder is a prevalent pathology and that this patient population has additional specific needs compared to the adult population.

Functional Neurological Disorders: Clinical Spectrum, Diagnosis, and Treatment

BACKGROUND

Functional neurological disorders (FNDs) are common but often misdiagnosed.

REVIEW SUMMARY

The incidence of FNDs is between 4 and 12 per 100,000, comparable to multiple sclerosis and amyotrophic lateral sclerosis, and it is the second most common diagnosis in neurology clinics. Some clues in the history are sudden onset, intermittent time course, variability of manifestation over time, childhood trauma, and history of other somatic symptoms. Anxiety and depression are common, but not necessarily more than in the general population. Although there are no tests currently capable of demonstrating whether symptoms are willfully produced, there may not be a clear categorical difference between voluntary and involuntary symptoms. The prognosis of an FND is linked to early diagnosis and symptom duration, but unfortunately, the majority of the patients are diagnosed after considerable delays.

CONCLUSIONS

A positive diagnosis of FNDs can be made on the basis of history and neurological signs without reliance on psychological stressors. Past sensitizing events and neurobiological abnormalities contribute to the pathogenesis of FNDs. Physical rehabilitation and psychological interventions alone or in combination are helpful in the treatment.

Consistency of inclusion criteria for functional movement disorder clinical research studies: A systematic review

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.

The relationship between types of life events and the onset of functional neurological (conversion) disorder in adults: a systematic review and meta-analysis

Adverse life events precede the onset of functional neurological disorder (FND, also known as conversion disorder) more commonly than other neuropsychiatric conditions, but their aetiological role is unclear. We conducted a systematic review and quantitative analysis of the type, timing and number of life events preceding the onset of FND in adults, and a meta-analysis of the proportions of types of events in controlled studies. Fifty-one studies of different designs, covering 4247 patients, were eligible for inclusion. There was no clear majority of any type of preceding event. Family problems were the most common category of events, followed by relationship problems. Females were more likely to experience preceding family/relationship problems than males, who reported more work problems. Family problems were the commonest type of preceding event in studies in developing countries, whereas family and health problems were equally common in developed countries. Abuse was associated with early symptom onset, while patients with later onset were more likely to report family problems. The median number of events was one, and the events occurred closer to onset than in controls. Meta-analysis found that family, relationship and work events were all relatively more common in patients than pathological controls, as were events where symptoms might provide a solution to the stressor. In conclusion, although a range of events precede the onset of FND, they do not appear to do so uniformly. This may support a different aetiological role for stressors than in other disorders, although the support is indirect and the quality generally low.

Diagnosis and management of functional neurological disorder

Functional neurological disorder (FND), previously regarded as a diagnosis of exclusion, is now a rule-in diagnosis with available treatments. This represents a major step toward destigmatizing the disorder, which was often doubted and deemed untreatable. FND is prevalent, generally affecting young and middle aged adults, and can cause severe disability in some individuals. An early diagnosis, with subsequent access to evidence based rehabilitative and/or psychological treatments, can promote recovery-albeit not all patients respond to currently available treatments. This review presents the latest advances in the use of validated rule-in examination signs to guide diagnosis, and the range of therapeutic approaches available to care for patients with FND. The article focuses on the two most frequently identified subtypes of FND: motor (weakness and/or movement disorders) and seizure type symptoms. Twenty two studies on motor and 27 studies on seizure type symptoms report high specificities of clinical signs (64-100%), and individual signs are reviewed. Rehabilitative interventions (physical and occupational therapy) are treatments of choice for functional motor symptoms, while psychotherapy is an emerging evidence based treatment across FND subtypes. The literature to date highlights heterogeneity in responses to treatment, underscoring that more research is needed to individualize treatments and develop novel interventions.

Illness-Related Cognition, Distress and Adjustment in Functional Stroke Symptoms, Vascular Stroke, and Chronic Fatigue Syndrome

Abstract. Background: High rates of psychological distress are reported in functional conditions and vascular stroke, but there is limited understanding of how patients with functional neurological symptoms in stroke settings respond to symptoms. Aims: This study compared patients with functional stroke symptoms to those with vascular stroke and chronic fatigue syndrome (CFS). Methods: A prospective cohort of 56 patients with functional stroke symptoms were age-gender matched to patients with vascular stroke and CFS. Analysis of variance compared groups on cognitive and behavioral responses to symptoms, psychological distress, and functioning. Sensitivity analyses controlled for known confounders. The proportions of clinical anxiety and depression were compared between groups. Results: The functional stroke symptom group had a higher proportion of clinical anxiety cases than the CFS group, and a higher proportion of clinical depression cases than the vascular stroke group. Patients with functional stroke symptoms reported the highest rate of “damage beliefs” and “all-or-nothing” behaviors and greater symptom focusing and resting behavior than patients with vascular stroke. Limitations: Larger cohorts and a longitudinal design would strengthen study findings. Conclusion: Compared to patients with vascular stroke or CFS, patients with functional stroke symptoms show a somewhat distinct profile of illness-related beliefs and behaviors, as well as higher rates of clinical anxiety. Understanding such group differences provides some insights into aetiology and cognitive-behavioral responses. Appropriate support and referral should be available to patients with functional stroke symptoms to address distress and reduce the likelihood of severe impairment.

A single-center series of 482 patients with functional motor disorders

Functional motor disorders (FMD) are common and disabling. They are known to predominantly affect women and young to middle-aged patients, although they also occur during childhood or in the elderly. Demographic and clinical characteristics of patients with FMD are poorly known, since large series of consecutive patients are scarce.

METHODS

In a chart review study, we retrospectively abstracted data from consecutive FMD patients who were referred to the Neurophysiology Department of the Salpêtrière University Hospital between 2008 and 2016 for treatment with repeated transcranial magnetic stimulation.

RESULTS

482 patients were included. Most patients were women (73.7%). Median age at symptoms onset was 35.5 years and symptoms were mostly characterized by acute (47.3%) or subacute (46%) onset. Only 23% of patients were active workers, while 58.3% were unemployed because of FMD. Half of the patients had functional motor weakness (n = 241) whereas the other half had movement disorders (n = 241), mainly with tremor (21.1%) or dystonia (20.5%). Among all patients, 66.4% had psychiatric comorbidity and 82.6% reported a history of trauma in the 6 months before symptoms onset. No difference was found in age or gender according to clinical phenotypes.

CONCLUSION

This large series will contribute to better characterize FMDs.

Postoperative tetraplegia due to conversion disorder upon emergence from general anesthesia

Background

Acute neurological deficit upon emergence from general anesthesia is a serious emergency. Conversion disorder, previously known as hysteria, is a somatoform disorder that causes neurological deficits without anatomical or physiological explanations. It is particularly rare after general anesthesia.

Case presentation

A 28-year-old healthy Japanese woman presented tetraplegia with normal sensory function upon waking from general anesthesia. She was evaluated for the causes of tetraplegia. There were no abnormal findings, and her symptoms were inconsistent with any anatomical or neurological pathology. Although she could not flex her knee actively, she could maintain the passive flexed position, suggesting that her paralysis was nonorganic. The most likely diagnosis was conversion disorder. After a 12-h observation, the patient fully recovered.

Conclusions

In patients with neurological deficits not correlating with neurological findings after general anesthesia, the presence of somatic disorders, such as conversion disorder, should be considered.

Predisposing Risk Factors for Functional Limb Weakness: A Case-Control Study

OBJECTIVE

Functional limb weakness is a common symptom of functional neurological disorder. Few controlled studies have examined possible predisposing factors to determine their specificity for this symptom.

METHODS

In this prospective case-control study, patients with functional limb weakness (<2 years duration, N=107) were compared with a control group (comprising patients with weakness attributable to neurological disease, N=46, and healthy individuals, N=39). A structured clinical interview and questionnaires assessed potential predisposing factors, including family structure and childhood abuse and neglect (Childhood Trauma Questionnaire [CTQ]), personality traits (NEO Five-Factor Inventory), medical and surgical comorbidity, and exposure to a symptom model.

RESULTS

The patients with functional limb weakness and the control subjects were similar in gender and age. Self-reported childhood sexual abuse (15% versus 5%, p<0.01), and physical abuse (18% versus 7%, p<0.01; CTQ "moderate or above") were more common in the functional limb weakness group, although the absolute frequency was lower than anticipated. In the functional limb weakness group, there were modest differences in two personality traits, compared with the control group: higher neuroticism (p=0.02) and lower openness (p=0.01). Medical comorbidity, including appendectomy (33% versus 5%), irritable bowel syndrome (36% versus 18%), and chronic back pain (40% versus 16%), was more frequent in the functional limb weakness group. There were no differences in birth order or exposure to a symptom model.

CONCLUSIONS

Medical and surgical comorbidity and adverse childhood experience are risk factors, but not essential, for the development of functional limb weakness. However, evidence for personality traits or exposure to a symptom model is less robust.

Psychosocial interventions for conversion and dissociative disorders in adults

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Functional stroke symptoms: A prospective observational case series

OBJECTIVE

Functional symptoms are a common mimic of stroke in acute stroke settings, but there are no guidelines on how to manage such patients and scant research on their clinical profile. We explore the presentation of patients with functional stroke symptoms at admission and 2-month follow-up.

METHODS

We conducted a prospective observational study across four SE London acute stroke units, with two-month follow-up. Demographic information, clinical data and GP attendances were recorded. Patients completed self-report measures: Cognitive Behavioural Responses Questionnaire short version, Brief Illness Perception Questionnaire, Hospital Anxiety and Depression Scale, Work and Social Adjustment Scale and Short Form Health Survey.

RESULTS

Fifty-six patients (mean age: 50.9 years) were recruited at baseline; 40 with isolated functional symptoms, the remaining functional symptoms in addition to stroke. Thirty-one completed self-report follow-up measures. Of 56 participants, 63% were female. Patients presented symptoms across modalities, with unilateral and limb weakness the most frequent. There was inconsistent and ambiguous recording of symptoms on medical records. Approximately 40% of patients reported levels of anxiety and depression above the threshold indicating a probable diagnosis. Higher anxiety was associated with greater resting or all-or-nothing behaviours, embarrassment avoidance and symptom focussing on the CBRQ. Only SF-36 physical functioning improved at follow-up. Less than 50% who responded at follow-up were accessing a treatment, though 82% had ongoing symptoms.

CONCLUSION

Patients with functional symptoms in stroke settings report substantial distress, associated with cognitive-behavioural responses to symptoms. Follow-up data suggest recovery can be slow, indicating access to supportive interventions should be improved.

Neurocognitive functioning in patients with conversion disorder/functional neurological disorder

Neurocognitive symptoms are common in individuals with somatic symptom and related disorders (SSRD), but little is known about the specific impairments in neurocognitive domains in patients with conversion disorder (CD)/functional neurological disorder (FND). This study examines neurocognitive functioning in patients with CD/FND compared to patients with other SSRD. The sample consisted of 318 patients. Twenty‐nine patients were diagnosed with CD/FND, mean age 42.4, standard deviation (SD) = 13.8 years, 79.3% women, and 289 patients had other SSRD (mean age 42.1, SD = 13.3, 60.2% women). Patients completed a neuropsychological test battery that addressed a broad range of neurocognitive domains, including information processing speed, attention and executive functioning. Patients with CD/FND had clinically significant neurocognitive deficits in all neurocognitive domains based on normative data comparison. Patients with CD/FND also performed significantly worse than patients with other SSRD on information processing speed (Digit Symbol Substitution Test (V = .115, p = .035), Stroop Color–Word Test (SCWT) card 1 (V = .190, p = .006), and SCWT card 2 (V = .244, p < .001). No CD/FND vs. other SSRD differences were observed in other neurocognitive domains. These findings indicate the patients with CD/FND perform worse on information processing speed tests compared to patients with other SSRD.

Characteristics of patients with motor functional neurological disorder in a large UK mental health service: a case-control study

BACKGROUND

Functional neurological disorder (FND), previously known as conversion disorder, is common and often results in substantial distress and disability. Previous research lacks large sample sizes and clinical surveys are most commonly derived from neurological settings, limiting our understanding of the disorder and its associations in other contexts. We sought to address this by analysing a large anonymised electronic psychiatric health record dataset.

METHODS

Data were obtained from 322 patients in the South London and Maudsley NHS Foundation Trust (SLaM) who had an ICD-10 diagnosis of motor FND (mFND) (limb weakness or disorders of movement or gait) between 1 January 2006 and 31 December 2016. Data were collected on a range of socio-demographic and clinical factors and compared to 644 psychiatric control patients from the same register.

RESULTS

Weakness was the most commonly occurring functional symptom. mFND patients were more likely to be female, British, married, employed pre-morbidly, to have a carer and a physical health condition, but less likely to have had an inpatient psychiatric admission or to receive benefits. No differences in self-reported sexual or physical abuse rates were observed between groups, although mFND patients were more likely to experience life events linked to inter-personal difficulties.

CONCLUSIONS

mFND patients have distinct demographic characteristics compared with psychiatric controls. Experiences of abuse appear to be equally prevalent across psychiatric patient groups. This study establishes the socio-demographic and life experience profile of this understudied patient group and may be used to guide future therapeutic interventions designed specifically for mFND.

Psychological comorbidities and functional neurological disorders in women with idiopathic urinary retention: International Consultation on Incontinence Research Society (ICI-RS) 2019

AIMS

Chronic urinary retention occurring in young women is poorly understood and a cause may not be found in a majority of cases. Different psychological comorbidities and functional neurological symptom disorders (FNDs) have been reported; however, these have been poorly explored.

METHODS

At the International Consultation on Incontinence Research Society meeting in 2019, a panel of clinicians generated a proposal to explore the relationship between psychological comorbidities, FNDs, and urinary retention in women with chronic idiopathic urinary retention.

RESULTS

Psychological comorbidities such as depression and anxiety, and FNDs such as leg weakness and loss of consciousness, have been reported in women with idiopathic urinary retention. Individuals react differently to physical and emotional stressors, and experimental models have demonstrated a relationship between the stress response and developing urinary retention. Trauma, particularly sexual trauma, may be a shared risk factor for developing psychological comorbidities and urinary retention. Children with voiding postponement often suffer from psychological comorbidities and behavioral disturbances; however, there is no evidence to suggest that this progresses to urinary retention in adulthood. "Psychogenic urinary retention" has been described in the urology and psychiatry literature in the past, and anecdotal cases of successful voiding following psychotherapy have been reported, though the true pathophysiology of this entity is uncertain.

CONCLUSION

Psychological and functional disorder comorbidities are reported in women with chronic urinary retention. The nature of the association between urinary retention and functional neurological disorder comorbidities needs to be further explored in terms of a disorder of bladder-brain interaction.

Current Concepts in Diagnosis and Treatment of Functional Neurological Disorders

Importance

Functional neurological disorders (FND) are common sources of disability in medicine. Patients have often been misdiagnosed, correctly diagnosed after lengthy delays, and/or subjected to poorly delivered diagnoses that prevent diagnostic understanding and lead to inappropriate treatments, iatrogenic harm, unnecessary and costly evaluations, and poor outcomes.

Observations

Functional Neurological Symptom Disorder/Conversion Disorder was adopted by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, replacing the term psychogenic with functional and removing the criterion of psychological stress as a prerequisite for FND. A diagnosis can now be made in an inclusionary manner by identifying neurological signs that are specific to FNDs without reliance on presence or absence of psychological stressors or suggestive historical clues. The new model highlights a wider range of past sensitizing events, such as physical trauma, medical illness, or physiological/psychophysiological events. In this model, strong ideas and expectations about these events correlate with abnormal predictions of sensory data and body-focused attention. Neurobiological abnormalities include hypoactivation of the supplementary motor area and relative disconnection with areas that select or inhibit movements and are associated with a sense of agency. Promising evidence has accumulated for the benefit of specific physical rehabilitation and psychological interventions alone or in combination, but clinical trial evidence remains limited.

Conclusions and Relevance

Functional neurological disorders are a neglected but potentially reversible source of disability. Further research is needed to determine the dose and duration of various interventions, the value of combination treatments and multidisciplinary therapy, and the therapeutic modality best suited for each patient.

Personality and Psychopathology in Patients With Mixed Sensory-Motor Functional Neurological Disorder (Conversion Disorder): A Pilot Study

The purpose of this pilot study was to explore differences in the level of personality functioning, symptom severity, and personality pathology in patients with mixed sensory-motor functional neurological disorder (conversion disorder). Individuals with psychogenic nonepileptic seizures were not included. We recruited 15 patients, mean age of 33.5 years (SD, 11.4 years), 13 females and 2 males, from an outpatient clinic for psychotherapeutic treatment. We assessed the patients using the Structured Clinical Interview for DSM-4 Axis II Personality Disorders, the SCL-90-R, the Karolinska Psychodynamic Profile, and the Defense Style Questionnaire. We were able to distinguish two levels of difficulty in relation to personality functioning as distinct subgroups: 1) "neurotic" with less severe or moderate personality psychopathology and 2) "borderline" with severe personality psychopathology. Furthermore, we concluded that all patients showed severe deficits in personality functioning. The study points out the clinical relevance of identifying personality functioning as part of an assessment in the preparation of a treatment strategy.

Quality of life in functional movement disorders is as altered as in organic movement disorders

OBJECTIVE

Patients with functional movement disorders (FMD) often report a disability and psychiatric comorbidities. However, few studies have compared these aspects in FMD and in organic movement disorders (OMD). The objectives were to compare QoL and psychiatric comorbidities of FMD and OMD patients.

METHODS

Twenty-one and 30 FMD patients were compared to 21 and 30 sex- and age-matched dystonia and Parkinson patients respectively. QoL was assessed using the Parkinson's Disease Summary Index (PDSI). Psychiatric comorbidities were screened with the Mini International Neuropsychiatric Interview, the Hospital Anxiety and Depression Scale and the Composite International Diagnostic Interview questionnaire.

RESULTS

QoL was more altered in FMD than in dystonia on PDSI (42.1 vs 25.1; p = .003). No significant difference was observed in QoL in FMD and Parkinson's disease on PDSI (38.3 vs 32.2; p = .61). Moreover, FMD patients were more often unemployed because of their condition than dystonia (61.9% vs 14.3%; p = .01) and Parkinson patients (53.3% vs 13.3%; p = .005). The occurrence of anxiety (p = .58 and > 0.99), depression (p = .77 and 0.77), and traumatic events (p = .58 and 0.75) was not different between groups. FMD patients reported more often sexual abuse than dystonia (28,6% vs 4.8%; p = .13) and Parkinson patients (23.3% vs 0.0%; p = .02).

CONCLUSION

FMD patients presented a significant alteration of QoL and no increased psychiatric comorbidities compared to OMD patients. These results highlight the impact of FMD and suggest that neurologists should be as involved in the management of FMD as they are in OMD.

Aversive stimuli exacerbate defensive motor behaviour in motor conversion disorder

Conversion disorder or functional neurological symptom disorder (FND) can affect the voluntary motor system, without an organic cause. Functional symptoms are thought to be generated unconsciously, arising from underlying psychological stressors. However, attempts to demonstrate a direct relationship between the limbic system and disrupted motor function in FND are lacking. We tested whether negative affect would exacerbate alterations of motor control and corresponding brain activations in individuals with FND. Ten patients and ten healthy controls produced an isometric precision-grip contraction at 10% of maximum force while either viewing visual feedback of their force output, or unpleasant or pleasant emotional images (without feedback). Force magnitude was continuously recorded together with change in brain activity using fMRI. For controls, force output decayed from the target level while viewing pleasant and unpleasant images. Patients however, maintained force at the target level without decay while viewing unpleasant images, indicating a pronounced effect of negative affect on force output in FND. This emotional modulation of force control was associated with different brain activation patterns between groups. Contrasting the unpleasant with the pleasant condition, controls showed increased activity in the inferior frontal cortex and pre-supplementary motor area, whereas patients had greater activity in the cerebellum (vermis), posterior cingulate cortex, and hippocampus. Engagement of a cerebellar-limbic network in patients is consistent with heightened processing of emotional salience, and supports the role of the cerebellum in freezing responses in the presence of aversive events. These data highlight a possible neural circuit through which psychological stressors elicit defensive behaviour and modulate motor function in FND.

Outlining the psychopathology behind a case of conversion syndrome: Is a holistic approach beneficial?

Conversion disorder refers to a set of symptoms where no relevant organic cause is found. These include sensory/motor disturbances, and other neurological symptoms, such as pseudoseizures. Patients with this condition may, by having it, achieve a primary or secondary gain. The condition should be diagnosed when all the relevant investigations are inconclusive. In this case, we use the bio-psycho-social model for the interpretation and guidance of treatment. We also demonstrate how a holistic approach is beneficial when it comes to a multi-dimensional interpretation of such a case. This review outlines a case of a patient with several neurological and orthopedic problems who failed to improve with several treatment plans and surgical interventions. After several years of medical and surgical consultations, a thorough analysis by psychiatrists was made, resulting in a diagnosis of conversion syndrome. The patient gradually improved on psychiatric treatment, including psychotherapy, and with the necessary psychiatric follow-ups.

Epidemiology

The epidemiology of functional neurologic disorders (FND) is complex and has been hampered over the years by a lack of clear definition, with previous definitions struggling with an uneasy mix of both physical and psychologic components. The recent changes in DSM-5 to a definition based on positive identification of physical symptoms which are incongruent and inconsistent with neurologic disease and the lack of need for any associated psychopathology represent a significant step forward in clarifying the disorder. On this basis, FND account for approximately 6% of neurology outpatient contacts and putative community incidence rates of 4-12 per 100 000 per annum. Comorbid neurologic disease occurs in around 10% of cases. The diagnosis is reliable, with revision rates less than 5%. Of note, this revision rate was consistent prior to the widespread utilization of computed tomography and magnetic resonance imaging. FND symptoms are disabling and associated with significant distress. They are more common in women and have a peak incidence between the ages of 35 and 50; however the presentation is common in men and throughout the lifespan. The issues surrounding case definition, ascertainment, misdiagnosis, and risk factors are discussed in detail.

Functional limb weakness and paralysis

Functional (psychogenic) limb weakness describes genuinely experienced limb power or paralysis in the absence of neurologic disease. The hallmark of functional limb weakness is the presence of internal inconsistency revealing a pattern of symptoms governed by abnormally focused attention. In this chapter we review the history and epidemiology of this clinical presentation as well as its subjective experience highlighting the detailed descriptions of authors at the end of the 19th and early 20th century. We discuss the relevance that physiological triggers such as injury and migraine and psychophysiological events such as panic and dissociation have to understanding of mechanism and treatment. We review many different positive diagnostic features, their basis in neurophysiological testing and present data on sensitivity and specificity. Diagnostic bedside tests with the most evidence are Hoover's sign, the hip abductor sign, drift without pronation, dragging gait, give way weakness and co-contraction.

Interoceptive awareness in patients with functional neurological symptoms

Historically, emotional factors, such as trauma or psychological conflict, have been suggested as causal factors of functional motor disorders (FMD). More recent approaches have instead stressed potential neural and cognitive abnormalities in the allocation and maintenance of attention. Yet these studies have mostly focused on how attention is allocated to exteroceptive signals about the state of the body. Given the proposed important role of interoception for emotion, the study of FMD patients' ability to monitor their interoceptive signals may serve as a useful, mechanistic link between studies that aim to identify key emotional factors in FMD, and those that examine specific sensorimotor or cognitive abnormalities. In the current study, we compared the interoceptive awareness of a group of individuals with FMD (N=16) with a group of healthy controls (N=17). We employed a commonly used heartbeat detection task which tracks the level of concordance between one's heart rate and its subjective perception, as a proxy for interoceptive awareness more generally. We found that FMD patients have lower interoceptive accuracy than healthy subjects, and such reduced interoceptive accuracy was predictive of their depressive symptoms, as well as their tendency to focus on the external features of their body (self-objectification). Contary to our predictions, interoceptive accuracy was not predictive of alexithymia. These results suggest a potental trade-off between the allocation of attention to internal versus external aspects of the body in FMD. More generally, they warrant further investigation of interoceptive awareness in this population, as a means to understand their emotional abnormalities at a more mechanistic level than studies concentrating on traumatic life events and related risk factors.

An atypical presentation of visual conversion disorder

Nonorganic vision loss accounts for up to 5% of patients and presents in two forms, malingering and visual conversion disorder (VCD). It is described a case of VCD in a new mother struggling both with her husband being deployed overseas and the recent death of her father. In addition, she had been evaluated for a concussion secondary to a motor vehicle accident three months prior. An inexpensive series of clinical tests were performed to rule out organic disease and obtained equivocal results. Some tests revealed intact vision in the affected eye while others supported a neurological cause for the vision loss. However, the patient quickly recovered normal visual acuity when encouraged to discuss situations that have been causing emotional stress. This almost immediate recovery of vision confirmed the diagnosis of VCD. This report should make primary eye care professionals more aware of visual conversion disorder and its clinical evaluation.

Functional (psychogenic) movement disorders associated with normal scores in psychological questionnaires: A case control study

OBJECTIVE

Functional movement disorders (FMDs) fall within the broader category called functional neurological symptom disorder (FNSD). New DSM-5 criteria for FNSD no longer require the presence of a 'psychological conflict' suggesting that some patients with FMD may not have obvious psychological comorbidity. We studied patients with FMD in comparison to patients with a neurological movement disorder (MD) and healthy controls (HC) to identify whether there is a subgroup of patients with FMD who have normal psychological test scores.

METHODS

We assessed self-rated measures of depression/anxiety (SCL-90), dissociation and personality disorder (PDQ-4) in patients attending neurological clinics and healthy controls. The proportion of patients scoring within normal ranges was determined, and the levels of somatic and psychological symptoms were compared between the three groups.

RESULTS

Among the FMD group, 39% (20/51) scored within the normal range for all measures compared to 38% (13/34) of MD subjects and 89% (47/53) of healthy controls. There were no differences in overall scores in the SCL-90 and PDQ-4 between FMD and MD patients. FMD patients also did not differ from controls on a self-rated measure of personality pathology.

CONCLUSION

Our data show that a substantial proportion of patients with FMD score within the normal range in psychological questionnaires, lending some support to the new DSM-5 criteria.

Psychiatric comorbidity in patients with conversion disorder and prevalence of dissociative symptoms

The 1st objective of the current study was to investigate the frequency and types of dissociative symptoms in patients with conversion disorder (CD). The 2nd objective of the current study was to determine psychiatric comorbidity in patients with and without dissociative symptoms. A total of 54 consecutive consenting patients primarily diagnosed with CD according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, criteria who were admitted to the psychiatric emergency outpatient clinic of Sisli Etfal Research and Teaching Hospital (Istanbul, Turkey) were included in the study. The Structured Clinical Interview for DSM-IV Axis I Disorders, Structured Interview for DSM-IV Dissociative Disorders, and Dissociative Experiences Scale were administered. Study groups consisted of 20 patients with a dissociative disorder and 34 patients without a diagnosis of any dissociative disorder. A total of 37% of patients with CD had any dissociative diagnosis. The prevalence of dissociative disorders was as follows: 18.5% dissociative disorder not otherwise specified, 14.8% dissociative amnesia, and 3.7% depersonalization disorder. Significant differences were found between the study groups with respect to comorbidity of bipolar disorder, past hypomania, and current and past posttraumatic stress disorder (ps = .001, .028, .015, and .028, respectively). Overall comorbidity of bipolar disorder was 27.8%. Psychiatric comorbidity was higher and age at onset was earlier among dissociative patients compared to patients without dissociative symptoms. The increased psychiatric comorbidity and early onset of conversion disorder found in patients with dissociative symptoms suggest that these patients may have had a more severe form of conversion disorder.

Caloric vestibular stimulation as a treatment for conversion disorder: a case report and medical hypothesis

Conversion disorder is a medical condition in which a person has paralysis, blindness, or other neurological symptoms that cannot be clearly explained physiologically. To date, there is neither specific nor conclusive treatment. In this paper, we draw together a number of disparate pieces of knowledge to propose a novel intervention to provide transient alleviation for this condition. As caloric vestibular stimulation has been demonstrated to modulate a variety of cognitive functions associated with brain activations, especially in the temporal-parietal cortex, anterior cingulate cortex, and insular cortex, there is evidence to assume an effect in specific mental disorders. Therefore, we go on to hypothesize that lateralized cold vestibular caloric stimulation will be effective in treating conversion disorder and we present provisional evidence from one patient that supports this conclusion. If our hypothesis is correct, this will be the first time in psychiatry and neurology that a clinically well-known mental disorder, long considered difficult to understand and to treat, is relieved by a simple or common, non-invasive medical procedure.

Physiotherapy for functional (psychogenic) motor symptoms: a systematic review

OBJECTIVE

Functional (psychogenic) motor symptoms (FMS), also called motor conversion disorder or non-organic motor symptoms are a common cause of disability and distress among patients attending neurology and neurorehabilitation services. Patients with FMS are often referred for physiotherapy but it is not clear whether this is effective. Here we aim to systematically review the literature regarding physiotherapy interventions for patients with functional motor symptoms.

METHODS

Systematic review of databases with reference search for period 1950 to September 2012.

RESULTS

There was only one controlled intervention study with a historical control group and 28 case series or reports describing interventions. The total number of patients in all studies was 373. Physiotherapy most commonly occurred in the context of multidisciplinary treatment and involved a motor learning approach. Novel approaches included the use of distraction techniques and transcutaneous electrical nerve stimulation (TENS) machine. Deceptive behavioural techniques have also been described. Most studies reported benefit from physical treatment, including some studies with long-term follow up.

CONCLUSIONS

Patients with FMS are commonly encountered in neurological practice and are often referred for physiotherapy. The existing data to guide physiotherapy treatment for FMS is of low quality and limited in scope. However, it suggests potential positive effects and provides a useful resource for developing and testing physiotherapy interventions in future studies.

The relationship between temperament and character in conversion disorder and comorbid depression

AIMS

The aim of this study was to compare conversion disorder patients with healthy controls in terms of temperament and character, and to determine the effect of these characteristics on comorbid depression, based on the idea that conversion disorder patients may have distinctive temperament and character qualities.

METHODS

The study involved 58 patients diagnosed with conversion disorder, based on the DSM-IV diagnostic criteria, under observation at the Bakırköy Psychiatric and Neurological Disorders Outpatient Center, Istanbul. The patients were interviewed with a Structured Clinical Interview (SCID-I) and 57 healthy volunteers, matched for age, sex and education level, were interviewed with a Structured Clinical Interview for people without a psychiatric disorder (SCID-I/NP). All the participants completed a sociodemographic form, the Hamilton Depression Rating Scale, the Hamilton Anxiety Scale and the Temperament and Character Inventory.

RESULTS

The conversion disorder patients displayed more harm avoidance (P<.001), more impulsivity (P<.01) and more sentimentality (P<.01) than the healthy controls, but were less persistent (P<.05). In terms of character qualities, conversion disorder patients had high self-transcendence (P<.05), but were inadequate in terms of self-directedness (P<.001) and took on less responsibility (P<.05) than the healthy controls.

CONCLUSION

Conversion disorder patients are significantly different from healthy controls on temperament and character measures of harm avoidance, persistence, self-transcendence and self-directedness.

Dissociative paraplegia after epidural anesthesia: a case report

Introduction

Clinicians are confronted with considerable difficulties in diagnosing conversion disorders such as dissociative paraplegia. In the literature, there is still no sufficient evidence regarding a typical pattern or general characteristics for this neuropsychiatric syndrome. Over the last decades case reports have described patients with similar personality traits, psychopathological characteristics, history and symptoms.

Case presentation

We present the case of a 67-year-old Caucasian woman of high economic status and educational level with no psychopathological symptoms and no history of mental disorders who developed dissociative paraplegia after epidural anesthesia. The neurological examination revealed incongruous features, and repeated spine magnetic resonance imaging was normal. Three years earlier the patient had transient paralysis of her left lower limb without detectable cause.

Conclusion

We identified an association between stressful life events and neurological anomalies. Crucial for the diagnosis of dissociative paraplegia is the neurological examination. Our case demonstrates that lack of psychopathological features and previous psychiatric diagnosis are not sufficient to exclude dissociative paraplegia. In patients with incongruous neurological findings and absent neurobiological correlates, clinicians should consider the presence of conversion disorders such as dissociative paraplegia.