1
|
Datta V, Blum AW. Forensic assessment of somatoform and functional neurological disorders. Behav Sci Law 2024. [PMID: 38450761 DOI: 10.1002/bsl.2651] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 01/08/2024] [Accepted: 01/22/2024] [Indexed: 03/08/2024]
Abstract
Functional neurological disorders (FND) and somatization are common in clinical practice and medicolegal settings. These conditions are frequently disabling and, if arising following an accident, may lead to claims for legal compensation or occupational disability (such as social security disability insurance). However, distinguishing FND and somatization from symptoms that are intentionally produced (i.e., malingered or factitious) may pose a major forensic psychiatric challenge. In this article, we describe how somatoform disorders and FND lie along a spectrum of abnormal illness-related behaviors, including factitious disorder, compensation neurosis, and malingering. We provide a systematic approach to the forensic assessment of FND and conclude by describing common litigation scenarios in which FND may be at issue. Forensic testimony may play an important role in the resolution of such cases.
Collapse
Affiliation(s)
- Vivek Datta
- Private Practice, San Francisco, California, USA
| | - Austin W Blum
- Department of Psychiatry and Behavioral Neuroscience, University of Chicago, Chicago, Illinois, USA
- Department of Psychiatry and Behavioral Sciences, University of California, Sacramento, California, USA
| |
Collapse
|
2
|
Piliavska K, Dantlgraber M, Dettmers C, Jöbges M, Liepert J, Schmidt R. Functional neurological symptoms are a frequent and relevant comorbidity in patients with multiple sclerosis. Front Neurol 2023; 14:1077838. [PMID: 37114221 PMCID: PMC10126263 DOI: 10.3389/fneur.2023.1077838] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 03/20/2023] [Indexed: 04/29/2023] Open
Abstract
Introduction Functional neurological symptoms (FNS) in multiple sclerosis (MS) have shown to be underinvestigated even though neurological diseases such as MS represent a risk factor for developing FNS. Comorbidity of FNS and MS can produce high personal and social costs since FNS patients have high healthcare utilization costs and a quality of life at least as impaired as in patients with disorders with underlying structural pathology. This study aims to assess comorbid FNS in patients with MS (pwMS) and investigate whether FNS in pwMS are associated with poorer health-related quality of life and work ability. Methods Newly admitted patients (234) with MS were studied during their stay at Kliniken Schmieder, a neurological rehabilitation clinic in Konstanz, Germany. The degree to which the overall clinical picture was explained by MS pathology was rated by neurologists and allied health practitioners on a five-point Likert scale. Additionally, neurologists rated each symptom reported by the patients. Health-related quality of life was assessed using a self-report questionnaire and work ability was assessed using the mean number of hours worked per day and information regarding disability pension as reported by patients. Results In 55.1% of cases, the clinical picture was completely explained by structural pathology due to MS. 17.1% of pwMS presented an overall clinical picture half or less of which could be explained by underlying structural pathology. PwMS with a higher comorbid FNS burden had a lower health-related quality of life and reported fewer working hours per day than pwMS with symptoms explained by structural pathology. Furthermore, pwMS with a full disability pension had a higher comorbid FNS burden than pwMS with no or partial disability pension. Discussion These results show that FNS should be addressed diagnostically and therapeutically since such symptoms are an important comorbidity in MS that is related to poorer health-related quality of life and lower work ability.
Collapse
Affiliation(s)
- Katya Piliavska
- Lurija Institute for Rehabilitation Sciences and Health Research, Allensbach, Germany
- *Correspondence: Katya Piliavska,
| | | | - Christian Dettmers
- Lurija Institute for Rehabilitation Sciences and Health Research, Allensbach, Germany
- Kliniken Schmieder Konstanz, Konstanz, Germany
| | - Michael Jöbges
- Lurija Institute for Rehabilitation Sciences and Health Research, Allensbach, Germany
- Kliniken Schmieder Konstanz, Konstanz, Germany
| | - Joachim Liepert
- Lurija Institute for Rehabilitation Sciences and Health Research, Allensbach, Germany
- Kliniken Schmieder Allensbach, Allensbach, Germany
| | - Roger Schmidt
- Lurija Institute for Rehabilitation Sciences and Health Research, Allensbach, Germany
- Klinik für Psychosomatik und Konsiliarpsychiatrie, Kantonsspital, St. Gallen, Switzerland
| |
Collapse
|
3
|
Chudleigh C, Savage B, Cruz C, Lim M, McClure G, Palmer DM, Spooner CJ, Kozlowska K. Use of respiratory rates and heart rate variability in the assessment and treatment of children and adolescents with functional somatic symptoms. Clin Child Psychol Psychiatry 2019; 24:29-39. [PMID: 30354283 DOI: 10.1177/1359104518807742] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Functional somatic symptoms (FSS) emerge when the stress system is activated in response to physical or emotional stress that is either chronic or especially intense. In such cases, the heightened state of physiological arousal and motor activation can be measured through biological markers. Our team have integrated the use of biological markers of body state - respiratory rate, heart rate (HR) and heart rate variability (HRV) measurements - as a way of helping families to understand how physical symptoms can signal activation of the body's stress systems. This study measured respiratory rates, HR and HRV in children and adolescents with FSS (and healthy controls) during baseline assessment to determine whether these biological markers were effective at differentiating patients with FSS. The study also implemented a biofeedback intervention during the assessment to determine whether patients with FSS were able to slow their respiratory rates and increase HRV. Patients with FSS had faster respiratory rates, faster HR, and lower HRV, suggesting activation of the autonomic nervous system coupled with activation of the respiratory motor system. Like controls, patients were able to slow their respiratory rates, but in contrast to controls, they were unable to increase their HRV. Our findings suggest that patients with FSS present in a state of physiological activation and struggle to regulate their body state. Patients with FSS are likely to need ongoing training and practice to regulate body state coupled with interventions that target regulatory capacity across multiple systems.
Collapse
Affiliation(s)
- Catherine Chudleigh
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia
| | - Blanche Savage
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia
| | - Catherine Cruz
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia
| | - Melissa Lim
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia
| | - Georgia McClure
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia
| | - Donna M Palmer
- 2 Brain Dynamics Centre, The Westmead Institute for Medical Research, NSW, Australia.,3 The University of Sydney, NSW, Australia
| | | | - Kasia Kozlowska
- 1 Department of Psychological Medicine, The Children's Hospital at Westmead, NSW, Australia.,2 Brain Dynamics Centre, The Westmead Institute for Medical Research, NSW, Australia.,3 The University of Sydney, NSW, Australia
| |
Collapse
|
4
|
Abstract
Although exaggeration or amplification of symptoms is common in all illness, deliberate deception is rare. In settings associated with litigation/disability evaluation, the rate of malingering may be as high as 30%, but its frequency in clinical practice is not known. We describe the main characteristics of deliberate deception (factitious disorders and malingering) and ways that neurologists might detect symptom exaggeration. The key to establishing that the extent or severity of reported symptoms does not truly represent their severity is to elicit inconsistencies in different domains, but it is not possible to determine whether the reports are intentionally inaccurate. Neurological disorders where difficulty in determining the degree of willed exaggeration is most likely include functional weakness and movement disorders, post-concussional syndrome (or mild traumatic brain injury), psychogenic non-epileptic attacks and complex regional pain syndrome type 1 (especially when there is an associated functional movement disorder). Symptom amplification or even fabrication are more likely if the patient might gain benefit of some sort, not necessarily financial. Techniques to detect deception in medicolegal settings include covert surveillance and review of social media accounts. We also briefly describe specialised psychological tests designed to elicit effort from the patient.
Collapse
Affiliation(s)
- Christopher Bass
- Department of Psychological Medicine, John Radcliffe Hospital, Oxford, UK
| | - Derick T Wade
- Nuffield Orthopaedic Hospital, Oxford Centre for Enablement, Oxford, UK
| |
Collapse
|
5
|
Pleizier M, de Haan RJ, Vermeulen M. Management of patients with functional neurological symptoms: a single-centre randomised controlled trial. J Neurol Neurosurg Psychiatry 2017; 88:430-436. [PMID: 28302865 DOI: 10.1136/jnnp-2015-312889] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 02/22/2017] [Accepted: 02/28/2017] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Is health-related quality of life 12 months after randomisation in participants with functional neurological symptoms better after discussion of the diagnosis by trained neurologists who schedule at least two follow-up visits (intervention group) than after the same discussion of the diagnosis by these neurologists and immediate referral to the general practitioner (control group)? METHODS A single-centre randomised controlled trial at one academic outpatient department of neurology. Participants were randomised 1:1, stratified for type of functional symptoms. The study sample consisted of 100 participants in the intervention group, and 95 participants in the control group. Primary outcome was the mean change 36-Item Short Form Health Survery (SF-36) scores from baseline to 12 months. RESULTS Participants in both treatment groups showed improvements on most SF-36 subscales and secondary outcomes measures but without significant between-group differences in mean change scores. Neither was there a difference between the treatment arms with regard to the number of participants who reported their symptoms at 12 months to have greatly improved compared with baseline: 29 participants (29/98=29.6%; two missing values) in the intervention group versus 31 participants (31/95=32.6%) in the control group (95% CI of the difference between proportions: from -16.1% to 10%). CONCLUSION This study showed that after a neurologist has established the diagnosis and briefly explained and thereafter has sent the patient to a neurologist with a special training who scheduled half an hour to discuss the diagnosis, more sessions by this neurologist do not improve outcome. CLINICAL TRIAL REGISTRATION NUMBER NTR 2570.
Collapse
Affiliation(s)
- Marc Pleizier
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| | - Rob J de Haan
- Clinical Research Unit, Academic Medical Center, Amsterdam, The Netherlands
| | - Marinus Vermeulen
- Department of Neurology, Academic Medical Center, Amsterdam, The Netherlands
| |
Collapse
|
6
|
Abstract
Suggestion in hypnosis has been applied to the treatment of functional neurologic symptoms since the earliest descriptions of hypnosis in the 19th century. Suggestion in this sense refers to an intentional communication of beliefs or ideas, whether verbally or nonverbally, to produce subjectively convincing changes in experience and behavior. The recognition of suggestion as a psychologic process with therapeutic applications was closely linked to the derivation of hypnosis from earlier healing practices. Animal magnetism, the immediate precursor of hypnosis, arrived at a psychologic concept of suggestion along with other ideas and practices which were then incorporated into hypnosis. Before then, other forms of magnetism and ritual healing practices such as exorcism involved unintentionally suggestive verbal and nonverbal stimuli. We consider the derivation of hypnosis from these practices not only to illustrate the range of suggestive processes, but also the consistency with which suggestion has been applied to the production and removal of dissociative and functional neurologic symptoms over many centuries. Nineteenth-century practitioners treated functional symptoms with induction of hypnosis per se; imperative suggestions, or commands for specific effects; "medical clairvoyance" in hypnotic trance, in which patients diagnosed their own condition and predicted the time and manner of their recovery; and suggestion without prior hypnosis, known as "fascination" or "psychotherapeutics." Modern treatments largely involve different types of imperative suggestion with or without hypnosis. However, the therapeutic application of suggestion in hypnosis to functional and other symptoms waned in the first half of the 20th century under the separate pressures of behaviorism and psychoanalysis. In recent decades suggestion in hypnosis has been more widely applied to treating functional neurologic symptoms. Suggestion is typically applied within the context of other treatment approaches, such as cognitive-behavioral, rehabilitative, or psychodynamic therapy. Suggestions are generally symptom-focused (designed to resolve a symptom) or exploratory (using methods such as revivification or age regression to explore experiences associated with symptom onset). The evidence base is dominated by case studies and series, with a paucity of randomized controlled trials. Future evaluation studies should allow for the fact that suggestion with or without hypnosis is a component of broader treatment interventions adapted to a wide range of symptoms and presentations. An important role of the concept of suggestion in the management of functional neurologic symptoms is to raise awareness of how interactions with clinicians and wider clinical contexts can alter expectancies and beliefs of patients in ways that influence the onset, course, and remission of symptoms.
Collapse
Affiliation(s)
- Q Deeley
- Department of Forensic and Neurodevelopmental Sciences, Institute of Psychiatry, Kings College, London, UK.
| |
Collapse
|
7
|
Abstract
One important, but underreported, phenomenon in Tourette syndrome (TS) is the occurrence of "tic attacks." These episodes have been described at conferences as sudden bouts of tics and/or functional tic-like movements, lasting from 15 min to several hours. They have also been described by patients in online TS communities. To date, there are no reports of tic attacks in the literature. The aim of this article is to stimulate discussion and inform clinical practices by describing the clinical presentation of 12 children (mean age 11 years and 3 months; SD = 2 years and 4 months) with TS and tic attacks, with a detailed case report for one case (13-year-old male). These children commonly present acutely to casualty departments and undergo unnecessary medical investigations. Interestingly, all children reported comorbid anxiety, with worries about the tics themselves and an increased internal focus of attention on tics once the attacks had started. In keeping with other children, the index case reported a strong internal focus of attention, with a relationship between physiological sensations/tic urges, worries about having tic attacks, and behavioral responses (e.g., body scanning, situational avoidance, and other responses). In our experience, the attacks reduce with psychological therapy, for example, the index case attended 13 sessions of therapy that included metacognitive and attention training techniques, as well as cognitive-behavioral strategies. Following treatment, an improvement was seen across a range of measures assessing tics, mood, anxiety, and quality of life. Thus, psychological techniques used to treat anxiety disorders are effective at supporting a reduction in tic attacks through modifying attention, worry processes, and negative beliefs. It is hypothesized that an attentional style of threat monitoring, difficulties tolerating internal sensory urges, cognitive misattributions, and maladaptive coping strategies contribute to the onset and maintenance of tic attacks. These cases provide support for the view that tic attacks are triggered and maintained by psychological factors, thereby challenging the view that tic attacks merely reflect extended bouts of tics. As such, we propose that the movements seen in tic attacks may resemble a combination of tics and functional neurological movements, with tic attacks reflecting episodes of panic and anxiety for individuals with TS.
Collapse
Affiliation(s)
- Sally Robinson
- Tic and Neurodevelopmental Movements Service (TANDeM), Children's Neurosciences Centre, Evelina London Children's Hospital, Guys and St Thomas' NHS Foundation Trust , London , UK
| | - Tammy Hedderly
- Tic and Neurodevelopmental Movements Service (TANDeM), Children's Neurosciences Centre, Evelina London Children's Hospital, Guys and St Thomas' NHS Foundation Trust , London , UK
| |
Collapse
|
8
|
Abstract
In the 19th century it was recognized that neurologic symptoms could be caused by "morbid ideation" as well as organic lesions. The subsequent observation that hysteric (now called "functional") symptoms could be produced and removed by hypnotic suggestion led Charcot to hypothesize that suggestion mediated the effects of ideas on hysteric symptoms through as yet unknown effects on brain activity. The advent of neuroimaging 100 years later revealed strikingly similar neural correlates in experiments matching functional symptoms with clinical analogs created by suggestion. Integrative models of suggested and functional symptoms regard these alterations in brain function as the endpoint of a broader set of changes in information processing due to suggestion. These accounts consider that suggestions alter experience by mobilizing representations from memory systems, and altering causal attributions, during preconscious processing which alters the content of what is provided to our highly edited subjective version of the world. Hypnosis as a model for functional symptoms draws attention to how radical alterations in experience and behavior can conform to the content of mental representations through effects on cognition and brain function. Experimental study of functional symptoms and their suggested counterparts in hypnosis reveals the distinct and shared processes through which this can occur.
Collapse
|
9
|
Steffen A, Fiess J, Schmidt R, Rockstroh B. "That pulled the rug out from under my feet!" - adverse experiences and altered emotion processing in patients with functional neurological symptoms compared to healthy comparison subjects. BMC Psychiatry 2015; 15:133. [PMID: 26103961 PMCID: PMC4477601 DOI: 10.1186/s12888-015-0514-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 06/02/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Medically unexplained movement or sensibility disorders, recently defined in DSM-5 as functional neurological symptoms (FNS), are still insufficiently understood. Stress and trauma have been addressed as relevant factors in FNS genesis. Altered emotion processing has been discussed. The present study screened different types and times of adverse experiences in childhood and adulthood in patients with FNS as well as in healthy individuals. The relationship between stress profile, aspects of emotion processing and symptom severity was examined, with the hypothesis that particularly emotional childhood adversities would have an impact on dysfunctional emotion processing as a mediator of FNS. METHODS Adverse childhood experiences (ACE), recent negative life events (LE), alexithymia, and emotion regulation style were assessed in 45 inpatients diagnosed with dissociative disorder expressing FNS, and in 45 healthy comparison subjects (HC). RESULTS Patients reported more severe FNS, more (particularly emotional) ACE, and more LE than HC. FNS severity varied with emotional ACE and negative LE, and LE partially mediated the relation between ACE and FNS. Alexithymia and suppressive emotion regulation style were stronger in patients than HC, and alexithymia varied with FNS severity. Structural equation modeling verified partial mediation of the relationship between emotional ACE and FNS by alexithymia. CONCLUSIONS Early, emotional and accumulating stress show a substantial impact on FNS-associated emotion processing, influencing FNS. Understanding this complex interplay of stress, emotion processing and the severity of FNS is relevant not only for theoretical models, but, as a consequence also inform diagnostic and therapeutic adjustments.
Collapse
Affiliation(s)
- Astrid Steffen
- Department of Psychology, University of Konstanz, P.O.Box 905, Konstanz, 78457, Germany.
| | - Johanna Fiess
- Department of Psychology, University of Konstanz, P.O.Box 905, Konstanz, 78457, Germany.
| | - Roger Schmidt
- Neurological Rehabilitation Center Kliniken Schmieder, Eichhornstraße 68, Konstanz, 78464, Germany.
| | - Brigitte Rockstroh
- Department of Psychology, University of Konstanz, P.O.Box 905, Konstanz, 78457, Germany.
| |
Collapse
|
10
|
Demartini B, Batla A, Petrochilos P, Fisher L, Edwards MJ, Joyce E. Multidisciplinary treatment for functional neurological symptoms: a prospective study. J Neurol 2014; 261:2370-7. [PMID: 25239392 PMCID: PMC4242999 DOI: 10.1007/s00415-014-7495-4] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2014] [Revised: 08/29/2014] [Accepted: 08/31/2014] [Indexed: 01/09/2023]
Abstract
Although functional neurological symptoms are often very disabling there is limited information on outcome after treatment. Here we prospectively assessed the short- and long-term efficacy of an inpatient multidisciplinary programme for patients with FNS. We also sought to determine predictors of good outcome by assessing the responsiveness of different scales administered at admission, discharge and follow-up. Sixty-six consecutive patients were included. Assessments at admission, discharge and at 1 year follow-up (55%) included: the Health of the Nation Outcome Scale, the Hospital Anxiety and Depression Scale, the Patient Health Questionnaire-15, the Revised Illness Perception Questionnaire, the Common Neurological Symptom Questionnaire, the Fear Questionnaire and the Canadian Occupational Performance Measure. At discharge and at 1 year follow-up patients were also asked to complete five-point self-rated scales of improvement. There were significant improvements in clinician-rated mental health and functional ability. In addition, patients reported that their levels of mood and anxiety had improved and that they were less bothered by somatic symptoms in general and neurological symptoms in particular. Two-thirds of patients rated their general health such as "better" or "much better" at discharge and this improvement was maintained over the following year. Change in HoNOS score was the only measure that successfully predicted patient-rated improvement. Our data suggest that a specialized multidisciplinary inpatient programme for FNS can provide long-lasting benefits in the majority of patients. Good outcome at discharge was exclusively predicted by improvement in the HoNOS which continued to improve over the 1 year following discharge.
Collapse
Affiliation(s)
- Benedetta Demartini
- Sobell Department, UCL Institute of Neurology, Queen Square, London, WC1N 3BG UK
- Department of Psychiatry, San Paolo Hospital and University of Milan, Milan, Italy
| | - Amit Batla
- Sobell Department, UCL Institute of Neurology, Queen Square, London, WC1N 3BG UK
| | - Panayiota Petrochilos
- Department of Neuropsychiatry, The National Hospital for Neurology and Neurosurgery, UCL Institute of Neurology, Queen Square, Box 19, London, WC1N 3BG UK
| | - Linda Fisher
- Department of Neuropsychiatry, The National Hospital for Neurology and Neurosurgery, UCL Institute of Neurology, Queen Square, Box 19, London, WC1N 3BG UK
| | - Mark J. Edwards
- Sobell Department, UCL Institute of Neurology, Queen Square, London, WC1N 3BG UK
- Department of Neuropsychiatry, The National Hospital for Neurology and Neurosurgery, UCL Institute of Neurology, Queen Square, Box 19, London, WC1N 3BG UK
| | - Eileen Joyce
- Sobell Department, UCL Institute of Neurology, Queen Square, London, WC1N 3BG UK
- Department of Neuropsychiatry, The National Hospital for Neurology and Neurosurgery, UCL Institute of Neurology, Queen Square, Box 19, London, WC1N 3BG UK
| |
Collapse
|