What's so special about conversion disorder? A problem and a proposal for diagnostic classification

Subjective versus objective measures of distress, arousal and symptom burden in patients with functional seizures and other functional neurological symptom disorder presentations: A systematic review

Symptoms and functioning can be measured subjectively using self-report measures or objectively, based on physiological changes. This raises the question whether subjective and objective measures are closely correlated and - if not - whether one is more accurate or meaningful than the other, especially in patients with Functional Seizures (FS) or other Functional Neurological Symptom Disorders (FND), where subjective and objective observations may be thought particularly likely to deviate. This systematic review explores these questions focussing on measures of distress, arousal and symptom burden. Eighteen studies (12 FS, 6 other FND) capturing 396 FND patients were included. Eleven reported no correlation between subjective and objective measures. Only four studies reported significant correlations (r's = -0.74-0.59, p's < 0.05). The small number of studies and diverse methodologies do not provide conclusive answers to the questions posed. Given that subjective and objective measures capture different aspects of current state or function, a combination of measurement approaches is likely to provide optimal information about patients' health state. In view of the attentional and perceptual alterations implicated in FND, the difference between objective and subjective measures may represent an interesting observation in its own right.

How Positive Are Conversion Disorder Diagnoses?: Patterns of Referral to a Functional Neurology Clinic

ABSTRACT

The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) diagnostic criteria for conversion disorder have replaced the criterion of evidence of a "psychogenic" etiology with a criterion that patients must be "positively" diagnosed on the basis of their neurological assessment. We retrospectively studied referrals to a specialist functional neurology clinic to see how commonly the new criteria were met since DSM-5's introduction. Positive signs were reported in a quarter of referrals (26.5%), which was associated with diagnosticians' confidence (p = 0.001) and with the clinic confirming the diagnosis (p = 0.01). Our clinic found positive signs in 28.6% of the referrals. In 13 (13.3%) patients, the new criterion was not met. In conclusion, positive signs are diagnostically helpful but are only reported in a minority of assessments. A significant group of those currently believed to have conversion disorder would not meet the revised diagnostic criteria based on this.

From Conversion Disorders to Functional Neurological Disorders. Overcoming the Rule-out Diagnosis?

Functional neurological disorders, formerly referred to as conversion disorders, are a frequent clinical problem in neurology, psychiatry and primary care departments. In the new diagnostic categories, emphasis is placed on the positive characteristics necessary to diagnose this disorder. A narrative review of the scientific medical literature related to the subject was performed in order to determine the differences and advantages that the new classification of functional neurological disorders gives to doctors and patients. Historical, diagnostic, clinical and treatment concepts related to functional neurological disorders are reviewed. The conceptual differences between conversion disorders and functional neurological disorders and the implications of these changes in the clinical approach are identified. The new proposed diagnosis for functional neurological disorders provides the opportunity to transform a diagnosis made by ruling out other pathologies to a diagnosis where the presence of neurological signs suggestive of the disorder are verified and can be taught to the patient, and based on them, treatment strategies posed.

Neural Substrate of Group Mental Health: Insights from Multi-Brain Reference Frame in Functional Neuroimaging

Contemporary mental health practice primarily centers around the neurobiological and psychological processes at the individual level. However, a more careful consideration of interpersonal and other group-level attributes (e.g., interpersonal relationship, mutual trust/hostility, interdependence, and cooperation) and a better grasp of their pathology can add a crucial dimension to our understanding of mental health problems. A few recent studies have delved into the interpersonal behavioral processes in the context of different psychiatric abnormalities. Neuroimaging can supplement these approaches by providing insight into the neurobiology of interpersonal functioning. Keeping this view in mind, we discuss a recently developed approach in functional neuroimaging that calls for a shift from a focus on neural information contained within brain space to a multi-brain framework exploring degree of similarity/dissimilarity of neural signals between multiple interacting brains. We hypothesize novel applications of quantitative neuroimaging markers like inter-subject correlation that might be able to evaluate the role of interpersonal attributes affecting an individual or a group. Empirical evidences of the usage of these markers in understanding the neurobiology of social interactions are provided to argue for their application in future mental health research.

Conversion disorder: A systematic review of current terminology

OBJECTIVE

It has been argued that the label given to unexplained neurological symptoms is an important contributor to their often poor acceptance, and there has been recent debate on proposals to change the name from conversion disorder. There have been multiple studies of layperson and clinician preference and this article aimed to review these.

DESIGN

Multiple databases were searched using terms including "conversion disorder" and "terminology", and relative preferences for the terms extracted.

RESULTS

Seven articles were found which looked at clinician or layperson preferences for terminology for unexplained neurological symptoms. Most neurologists favoured terms such as "functional" and "psychogenic", while laypeople were comfortable with "functional" but viewed "psychogenic" as more offensive; "non-epileptic/organic" was relatively popular with both groups.

CONCLUSIONS

"Functional" is a term that is relatively popular with both clinicians and the public. It also meets more of the other criteria proposed for an acceptable label than other popular terms - however the views of neither psychiatrists nor actual patients with the disorder were considered.

What should we say to patients with unexplained neurological symptoms? How explanation affects offence

OBJECTIVES

Unexplained neurological symptoms (UNS) are common presentations in neurology but there is no consensus as to what they should be called. This is important, as patient acceptance is a predictor of outcome and there is evidence that patients are unhappy with the terms used. Patient understanding of these terms may be limited, however, and, once explained, the terms may seem more or less offensive. We sought to elicit patients' views of 7 frequently used terms for UNS, and whether these changed once definitions were provided.

METHODS

185 participants were recruited from a medical outpatients' waiting area. They were given questionnaires outlining a hypothetical situation of leg weakness, with 7 possible labels. Participants were asked whether they endorsed 4 connotations for each label and the "number needed to offend" (NNO) calculated, before and after definitions were given.

RESULTS

It was found that "functional" was significantly less offensive than other terms used (NNO 17, compared with "Conversion Disorder" NNO 5, p<0.001). Reported understanding of the terms was generally low, however, and many terms became significantly more offensive once definitions were provided. Participants' reported understanding had a significant effect, with low understanding causing terms to be viewed as more offensive after explanation.

CONCLUSION

Much of the 'offence' in UNS lies not in the terminology but in the meaning those terms carry. This study replicated previous findings that "functional" was less offensive than other terms, even after explanation, but in common with most terms this was partly due to patients' limited understanding of its meaning.

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.

[Conversion disorder in an internal medicine department: A series of 37 cases]

OBJECTIVES

To describe the clinical characteristics of a series of patients presenting conversion disorder in a general internal medicine ward and outpatient clinic, the arguments retained by the physicians in favour of the diagnosis, the somatic and psychiatric co-morbidities, the management and the outcome of the disorder.

METHODS

We report the study of 37 patients diagnosed with conversion disorder in an internal medicine department of a French university hospital over a period of 14 years. We retrospectively reviewed the charts of the patients and contacted their primary care physicians to obtain follow-up data. No structured instrument was used for the diagnosis of conversion disorder or for the assessment of psychiatric comorbidities.

RESULTS

As expected, patients were mostly young females, although a great variety of age, gender, and socio-cultural background was observed. Motor symptoms predominated (62%). A relevant psychogenic factor was explicitly mentioned in only 43% of the cases. In many cases, organic disease was also present, and an organic cause for the symptom initially considered as conversion was suspected in 3 cases. Depressive and anxious disorders were present respectively in 38% and 35% of cases. A pain complaint was associated in half of the cases. Among patients for whom follow-up data is available, conversion symptoms persisted or recurred in 70% of cases and were associated with a poor quality of life.

CONCLUSION

This case series confirms that the DSM-IV-TR criterion of "psychogenicity" (later abandoned in DSM-5) is highly problematic in clinical practice. It suggests a close relationship between conversion disorder and unexplained chronic pain.

The role of psychiatrists in diagnosing conversion disorder: a mixed-methods analysis

OBJECTIVE

Since DSM-5 removed the requirement for a psychosocial formulation, neurologists have been able to make the diagnosis of conversion disorder without psychiatric input. We sought to examine whether neurologists and specialist psychiatrists concurred with this approach.

DESIGN

We used mixed methods, first surveying all the neurologists in the UK and then interviewing the neuropsychiatrists in a large UK region on the role of psychiatrists in diagnosing conversion disorder.

RESULTS

Of the surveyed neurologists, 76% did not think that psychiatrists were essential for the diagnosis and 71% thought that psychiatrists did not even consider conversion disorder when referred a case. The neuropsychiatrists who were interviewed held complex models of conversion disorder. They believed all cases could be explained psychosocially in theory, but the nature of the diagnostic encounter often prevented it in practice; all felt that psychosocial formulation could be very helpful and some felt that it was essential to diagnosis.

CONCLUSION

Although neurologists do not think psychiatrists are required for diagnosing conversion disorder, specialist psychiatrists disagree, at least in some cases.

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.

Specialist inpatient treatment for severe motor conversion disorder: a retrospective comparative study

BACKGROUND

Gold standard protocols have yet to be established for the treatment of motor conversion disorder (MCD). There is limited evidence to support inpatient, multidisciplinary intervention in chronic, severe cases.

AIMS

To evaluate the characteristics and outcomes of MCD patients admitted to a specialist neuropsychiatric inpatient unit.

METHODS

All patients admitted to the Lishman Unit (years 2007-2011) with a diagnosis of MCD were included. Data relevant to characteristics and status with regard to mobility, activities of daily living (ADLs) and Modified Rankin Scale (MRS) score at admission and discharge were extracted.

RESULTS

Thirty-three cases (78.8% female) were included; the median duration of illness was 48 months. In comparison with brain injury patients admitted to the same unit, more cases had histories of childhood sexual abuse (36.4%, n=12), premorbid non-dissociative mental illness (81.1%, n=27) and employment as a healthcare/social-care worker (45.5%, n=15). Cases showed significant improvements in MRS scores (p<0.001), mobility (p<0.001) and ADL (p=0.002) following inpatient treatment.

CONCLUSIONS

Patients with severe, long-standing MCD can achieve significant improvements in functioning after admission to a neuropsychiatry unit.

The value of 'positive' clinical signs for weakness, sensory and gait disorders in conversion disorder: a systematic and narrative review

Experts in the field of conversion disorder have suggested for the upcoming DSM-V edition to put less weight on the associated psychological factors and to emphasise the role of clinical findings. Indeed, a critical step in reaching a diagnosis of conversion disorder is careful bedside neurological examination, aimed at excluding organic signs and identifying 'positive' signs suggestive of a functional disorder. These positive signs are well known to all trained neurologists but their validity is still not established. The aim of this study is to provide current evidence regarding their sensitivity and specificity. We conducted a systematic search on motor, sensory and gait functional signs in Embase, Medline, PsycINfo from 1965 to June 2012. Studies in English, German or French reporting objective data on more than 10 participants in a controlled design were included in a systematic review. Other relevant signs are discussed in a narrative review. Eleven controlled studies (out of 147 eligible articles) describing 14 signs (7 motor, 5 sensory, 2 gait) reported low sensitivity of 8-100% but high specificity of 92-100%. Studies were evidence class III, only two had a blinded design and none reported on inter-rater reliability of the signs. Clinical signs for functional neurological symptoms are numerous but only 14 have been validated; overall they have low sensitivity but high specificity and their use should thus be recommended, especially with the introduction of the new DSM-V criteria.

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.

Hysteria, conversion and functional disorders: a neurological contribution to classification issues

Proposals by psychiatrists to reclassify conversion disorder in DSM-5 and ICD-11 are proving difficult and controversial. Patients with conversion disorder usually present initially to neurologists, who often use different concepts and terminology. History and clinical practice suggest that the way forward is to seek agreed principles and a common understanding between the two disciplines, preferably in a single universal classification.

Psychogenic nonepileptic seizures: a current overview

Psychogenic nonepileptic seizures (PNES) resemble epilepsy, but no pathophysiological explanation has been established. Although there have been recent advances in PNES research and various hypotheses as to the psychopathology, no theory has achieved general acceptance. In this overview of selected literature on PNES, we highlight the often contradictory findings that underline the challenges that confront both practitioner and researcher. We first provide a synopsis of the history, diagnosis, treatment, and outcomes, as well as patient characteristics of PNES and the relevance of communication in the clinical context. In the subsequent sections we discuss recent research that may advance the understanding and diagnosis of this disorder. These themes include the use of qualitative methods as a viable research option, the application of nonlinear methods to analyze heterogeneous observations during diagnosis, recent advances in neuroimaging of PNES, and the development of international databases.

The function of 'functional': a mixed methods investigation

OBJECTIVE

The term 'functional' has a distinguished history, embodying a number of physiological concepts, but has increasingly come to mean 'hysterical'. The DSM-V working group proposes to use 'functional' as the official diagnostic term for medically unexplained neurological symptoms (currently known as 'conversion disorder'). This study aimed to explore the current neurological meanings of the term and to understand its resilience.

DESIGN

Mixed methods were used, first interviewing the neurologists in a large UK region and then surveying all neurologists in the UK on their use of the term.

RESULTS

The interviews revealed four dominant uses--'not organic', a physical disability, a brain disorder and a psychiatric problem--as well as considerable ambiguity. Although there was much dissatisfaction with the term, the ambiguity was also seen as useful when engaging with patients. The survey confirmed these findings, with a majority adhering to a strict interpretation of 'functional' to mean only 'not organic', but a minority employing it to mean different things in different contexts - and endorsing the view that 'functional' would one day be a neurological construct again.

CONCLUSIONS

'Functional' embodies real divisions in neurologists' conceptualisation of unexplained symptoms and, perhaps, between those of patients and neurologists: its diversity of meanings allows it to be a common term while meaning different things to different people, or at different times, and thus conceal some of the conflict in a particularly contentious area. This flexibility may help explain the term's longevity.

Conversion disorder: current problems and potential solutions for DSM-5

Conversion disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) describes neurological symptoms, including weakness, numbness and events resembling epilepsy or syncope, which can be positively identified as not being due to recognised neurological disease. This review combines perspectives from psychiatry, psychology and neurology to identify and discuss key problems with the current diagnostic DSM-IV criteria for conversion disorder and to make the following proposals for DSM-5: (a) abandoning the label "conversion disorder" and replacing it with an alternative term that is both theoretically neutral and potentially more acceptable to patients and practitioners; (b) relegating the requirements for "association of psychological factors" and the "exclusion of feigning" to the accompanying text; (c) adding a criterion requiring clinical findings of internal inconsistency or incongruity with recognised neurological or medical disease and altering the current 'disease exclusion' criteria to one in which the symptom must not be 'better explained' by a disease if present, (d) adding a 'cognitive symptoms' subtype. We also discuss whether conversion symptoms are better classified with other somatic symptom disorders or with dissociative disorders and how we might address the potential heterogeneity of conversion symptoms in classification.