[Functional Neurological Disorders - A Common but Often Unrecognized Diagnosis]. / Funktionelle neurologische Störungen ­ eine häufige, aber häufig nicht erkannte Diagnose.

Functional Neurological Disorders - A Common but Often Unrecognized Diagnosis Abstract: Functional neurological disorders are frequent and diverse in the clinical presentation. Psychological factors are part of the development and perpetuation of symptoms; psychiatric comorbidities may be present, but are not an obligatory diagnostic criterion. The diagnosis is primarily made on the basis of anamnesis and positive clinical signs. The commonness and reversibility of the symptoms should be emphasised in the clinical consultation, and the positive clinical signs should be demonstrated. Science-based explanations as well as the bio-psycho-social model can help patients to understand their diagnosis, which is relevant for a successful therapeutic outcome. It is recommended to use the neutral and descriptive term "functional neurological disorder". Treatment of the potentially reversible disease will be interdisciplinary and multimodal.

Treatment of Psychogenic Nonepileptic Seizures.

PURPOSE OF REVIEW: Psychogenic nonepileptic seizures (PNES) are the most common Functional Neurological Disorder/Conversion Disorder subtype. Significant advances have been made related to diagnosis, neurobiology, and treatment. In this review, we summarize updates in diagnosis and management over the past 3 years. RECENT FINDINGS: Although evidence is mixed for the treatment of PNES, psychotherapeutic modalities remain a powerful instrument to empower patients and reduce seizures. A multidisciplinary, holistic approach is beneficial. While seizure freedom in all patients may not be the achieved endpoint in this chronic, paroxysmal disorder, quality of life can be improved with treatment. Additional treatment modalities and further research are needed for patients who are refractory to current treatment. Evidence-based therapies exist for PNES, and recent findings represent an increased understanding of the clinical and neurophysiologic aspects of PNES.

Repetitive transcranial magnetic stimulation for functional tremor: A randomized, double-blind, controlled study.

OBJECTIVES: The objective of this study was to compare the effect on functional tremor of active versus sham repetitive transcranial magnetic stimulation and investigate whether the addition of hypnosis might help to prolong any repetitive transcranial magnetic stimulation-induced therapeutic effect. METHODS: We compared the effect of 5 consecutive daily sessions of active/sham repetitive transcranial magnetic stimulation on functional tremor, at 1 and 2 months, in a randomized, double-blind, 2-arm, parallel-controlled study. In a second open-label phase, all patients underwent 3 weekly sessions of hypnosis combined with single sessions of real repetitive transcranial magnetic stimulation. The primary outcome was a change in the Psychogenic Movement Disorder Rating Scale at month 1 when compared with baseline. Secondary outcomes were changes in the Psychogenic Movement Disorder Rating Scale and Tremor subscores, the 36-item Short Form Health Survey, the Self-Report Hospital Anxiety and Depression Scale, the Hamilton Depression Rating Scale, and the Clinical Global Impression Scale assessed at months 1, 2, 6, and 12. RESULTS: A total of 33 outpatients affected by functional tremor were screened, and 18 outpatients fulfilling the inclusion criteria (8 men, 10 women) were randomized. One month after the intervention, the mean Psychogenic Movement Disorder Rating Scale score had decreased in both groups, but the differences from baseline were only significant in the active repetitive transcranial magnetic stimulation group (P < .001). This remained significant at month 2 (P < .001). The significant decrease of the Psychogenic Movement Disorder Rating Scale and Tremor subscores were maintained at months 6 and 12 for the active repetitive transcranial magnetic stimulation group. For the control group, the Psychogenic Movement Disorder Rating Scale score had returned almost to its baseline value by month 2 and remained unchanged at months 6 and 12. CONCLUSION: Repetitive transcranial magnetic stimulation could represent a valuable therapeutic option in the management of functional tremor. © 2019 International Parkinson and Movement Disorder Society.

The Visible and Less Visible in the Suffering of a Conversion Disorder in Children and Adolescents. A Qualitative Study of Illness Explanatory Models Presented to Caregivers of Children and Adolescents with Conversion Disorder. / Lo visible y lo menos visible en el padecimiento de un trastorno conversivo en niños y adolescentes. Un estudio cualitativo sobre los modelos explicativos de la enfermedad que ofrecen los cuidadores de niños y adolescentes con trastorno conversivo.

BACKGROUND: Conversion disorder is a challenge for clinicians due to the conceptual gaps as regards its pathogenesis, the way in which it converges with other psychiatric disorders, and the lack of approaches to the experiences of both patients and family members with the disease. OBJECTIVE: To describe Explanatory Models (EM) offered to caregivers of paediatric patients with conversion disorder who attended the Hospital de la Misericordia. METHODS: A qualitative study was conducted with a convenience sample of 10 patients who attended the Hospital de La Misericordia, ¿Bogota? between May 2014 and April 2015. The tool used was an in-depth interview applied to parents and/or caregivers. RESULTS: Caregivers have different beliefs about the origin of the symptoms, especially considering sickness, magical-mystical factors, and psychosocial factors. The symptoms are explained in each case in various ways and there is no direct relationship between these beliefs, the pattern of symptoms, and help-seeking behaviours. Symptomatic presentation is polymorphous and mainly interferes in the patient's school activities. The medical care is perceived as relevant, and psychiatric care as insufficient. Among the therapeutic routes, consultations with various agents are described, including medical care, alternative medicine, and magical-religious approaches. CONCLUSIONS: EMs in conversion disorder are varied, but often include magical-religious elements and psychosocial factors. The underlying beliefs are not directly related to help-seeking behaviours or other variables.

A case series of Acceptance and Commitment Therapy (ACT) for reducing symptom interference in functional neurological disorders.

There is limited high-quality evidence supporting psychological treatments for functional neurological disorders (FNDs), and what evidence exists suggests that the impact of such treatments could be improved. One way to increase effectiveness is to utilize approaches that can have impact across heterogeneous FND presentations. Acceptance and Commitment Therapy (ACT) targets a transdiagnostic process called psychological flexibility and is used effectively to integrate multidisciplinary treatments in other clinical contexts. Here, we present a consecutive case series (N = 8) of a relatively brief (6 to 10 sessions) ACT intervention, delivered face to face by a clinical psychologist in an outpatient neuropsychology service. Treatment aimed to reduce symptom interference and improve mood via improvements in psychological flexibility. Service users presented with a range of FND symptoms (e.g., syncope, limb paralysis, and paraesthesia). Following treatment, 5 participants showed reliable improvements in symptom interference (Work and Social Adjustment Scale), 2 to the extent of clinical significance; 4 had reliable improvements in mood (Clinical Outcomes in Routine Evaluation-10), and 2 within the range of clinical significance. There were no reliable deteriorations in symptom interference or mood. Marked variation was apparent on the measure of psychological flexibility (Acceptance and Action Questionnaire II), with 4 reliable improvements, 3 within the range of clinical significance, and also 2 reliable deteriorations. These promising results suggest that further investigation of an ACT approach to FND is warranted. Future studies should include measures of psychological flexibility with greater comprehensibility.

Downwards Vertical Attention Bias in Conversion Disorder vs Controls: A Pilot Study.

BACKGROUND: Conversion disorder (CD) is a largely enigmatic disorder, one that requires a thorough ruling-out process. Prior research suggests that metaphors and conceptualization are rooted in physical experience, and that we interpret our affective world through metaphors. Spatial metaphors (interaction of affect and vertical space) are a prominent example of the grounding of metaphors. This is a relatively unpaved direction of research of CD. OBJECTIVES: The present pilot study sought to explore this view by investigating the "healthy is up, sick is down" spatial metaphors (e.g., "fell ill" and "top shape") in patients with CD, examining the correlation between the processing of bodily-related words, CD, and vertical space. We hypothesized that patients with CD, who experience their bodies as ill, will demonstrate a downwards bias when processing bodily-related words; corresponding to the "healthy is up, sick is down" spatial metaphor. METHODS: A total of 8 female patients (ages M-38.13 SD-10.44) and 42 female controls (ages M-36.4 SD-14.57) performed a visual attention task. Participants were asked to identify a spatial probe at the top or the bottom of a screen, following either a bodily related (e.g., arm) or non-bodily related (e.g., clock) prime word. RESULTS: As predicted, when processing bodily-related words, patients with CD demonstrated a downwards attention bias. Moreover, the higher the patient's level of somatization, the faster the patient detected lower (vs upper) spatial targets. CONCLUSIONS: This study suggests that the changed health paradigm of patients with CD is grounded in sensorimotor perception. Further research could propose new diagnostic and treatment options for CD.

Orienting reaction may help recognition of patients with psychogenic nonepileptic seizures.

OBJECTIVE: Psychogenic nonepileptic seizures (PNES) are abrupt, paroxysmal changes in behavior or consciousness that may phenomenologically resemble epileptic seizures. Given the known association between anxiety and PNES, we hypothesized that in these subjects there may be evidence that the nervous system is hypersensitive to external stimuli. We aimed to test our hypothesis by means of the auditory startle reaction (ASR). By investigating ASR, we also had the opportunity to test presence of orienting reaction, which is generally defined as the second phase of response after the auditory stimulus, with longer latency. METHODS: We included 22 patients diagnosed as PNES and 25 age- and gender-matched healthy subjects. Clinical assessments and ASR recordings were performed. Electrophysiological findings were compared between patients with PNES and healthy subjects, including the presence of an orienting reaction. Orienting reaction was defined as a late response with latency between 100-1000ms. RESULTS: The mean ages of patients with PNES and healthy subjects were 34.9±12.3 years and 33.3±10.9 years, respectively (P=0.709). All patients were diagnosed as having conversion disorder. Additionally, 19 patients had depressive disorder and four had anxiety. The recruitment pattern of muscles and probability were similar between patients with PNES and healthy subjects. Orienting reaction was solely observed in patients with PNES (n=13, 59.1% of the patients vs. no healthy subject). The sequence and contribution of muscles in the orienting reaction changed almost in all patients. The duration of these responses was long, sometimes more than 200ms. CONCLUSION: PNES is associated with orienting reaction. This provides a possible electrophysiological marker of altered nervous system function in patients with PNES and may also reflect the distorted emotional processing in these patients.

Is high hypnotizability a necessary diathesis for pathological dissociation?

During the 19th century, high hypnotizability was considered to be a form of psychopathology that was inseparable from hysteria. Today, hypnotizability is considered to be a normal trait that has no meaningful relationship with psychopathology. Psychiatric patients generally manifest medium to low hypnotizability. Nevertheless, several psychiatric diagnoses are marked by an unexpectedly large proportion of patients with high hypnotizability. This is especially true of the diagnostic categories that were subsumed by the 19th-century concept of hysteria: dissociative identity disorder, somatization disorder, and complex conversion disorders. These hysteria-related modern diagnoses are also highly dissociative. A review and analysis of the literature regarding the relationship between hypnotizability and dissociation indicates that high hypnotizability is almost certainly a necessary diathesis for the development of a severe dissociative disorder. Such a diathesis has significant implications for (a) the psychiatric nosologies of the American Psychiatric Association and the World Health Organization, (b) the hypnosis field, and (c) the etiology and construct validity of dissociative identity disorder and other severe dissociative disorders. Specifically, the dissociative disorders (excepting depersonalization disorder, which is not classified as a dissociative disorder by the World Health Organization) are manifestations of hypnotic pathology.

Hypnosis as a model of functional neurologic disorders.

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.

[Conversion disorder in an internal medicine department: A series of 37 cases]. / Le trouble de conversion en médecine interne: 37 observations.

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.

Treatment of psychogenic nonepileptic seizures: updated review and findings from a mindfulness-based intervention case series.

Psychogenic nonepileptic seizures (PNES) were first described in the medical literature in the 19th century, as seizure-like attacks not related to an identified central nervous system lesion, and are currently classified as a conversion disorder, according to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). While a universally accepted and unifying etiological model does not yet exist, several risk factors have been identified. Management of PNES should be based on interdisciplinary collaboration, targeting modifiable risk factors. The first treatment phase in PNES is patient engagement, which is challenging given the demonstrated low rates of treatment retention. Acute interventions constitute the next phase in treatment, and most research studies focus on short-term evidence-based interventions. Randomized controlled pilot trials support cognitive-behavioral therapy. Other psychotherapeutic and psychopharmacological interventions have been less well-studied using controlled and uncontrolled trials. Within the discussion of acute interventions, we present a preliminary evaluation for feasibility of a mindfulness-based psychotherapy protocol in a very small sample of PNES patients. We demonstrated in 6 subjects that this intervention is feasible in real-life clinical scenarios and warrants further investigation in larger scale studies. The final treatment phase is long-term follow-up. Long-term outcome studies in PNES show that a significant proportion of patients remains symptomatic and experiences continued impairments in quality of life and functionality. We believe that PNES should be understood as a disease that requires different types of intervention during the various phases of treatment.

The neuropsychological and neurophysiological profile of women with pseudoseizure.

OBJECTIVE: Our aim in this study was to compare the assessments of neuropsychological tests and the p50 neurophysiological test of patients with seizure diagnosed as conversion disorder and healthy control subjects, and to investigate the neurological status in conversion disorder with pseudoseizure. METHODS: A total of 22 female conversion disorder patients with convulsions diagnosed according to SCID-I/CV and 22 healthy women were included in the assessment. The participants were administered WMS-R, the cancellation test, and the Stroop test as neuropsychological tests and p50 was assessed as a neurophysiological test. RESULTS: The patient's results for the neuropsychological tests were found to be significantly low compared to the control group. The p50 sensory gating ratios of the patient group were statistically significantly lower than the controls. There was no significant correlation between the neuropsychological test scores and gating ratios of the patient and control groups. CONCLUSIONS: This study is the first to check sensory gating in conversion disorder patients with pseudoseizure and its most important result is finding reduced p50 sensory gating in patients. Our results suggest that these patients have a neurological tendency to this disease due to functional neurophysiological features.

The mirror neuron system under hypnosis - brain substrates of voluntary and involuntary motor activation in hypnotic paralysis.

INTRODUCTION: The neurobiological basis of non-organic movement impairments is still unknown. As conversion disorder and hypnotic states share many characteristics, we applied an experimental design established in conversion disorder to investigate hypnotic paralysis. METHODS: Movement imitation and observation were investigated by functional magnetic resonance imaging (fMRI) in 19 healthy subjects with and without hypnotically induced paralysis of their left hand. Paralysis-specific activation changes were explored in a multivariate model and functional interdependencies of brain regions by connectivity analysis. RESULTS: Hypnotic paralysis during movement imitation induced hypoactivation of the contralateral sensorimotor cortex (SMC) and ipsilateral cerebellum and increased activation of anterior cingulate cortex (ACC), frontal gyrus and insula. No paralysis-specific effects were revealed during movement observation. CONCLUSIONS: Hyperactivation of ACC, middle frontal gyrus (MFG), and insula might reflect attention (MFG), conflict-detection (ACC) and self-representation processes (insula) during hypnotic paralysis. The lack of effects in movement observation suggests that early motor processes are not disturbed due to the transient nature of the hypnotic impairment.

Abreaction for conversion disorder: systematic review with meta-analysis.

BACKGROUND: The value of drug interviews in the treatment of conversion disorder is at present unknown. AIMS: To review all the available papers published in English that report on the use of drug interviews for treating conversion/dissociative disorder. METHOD: Databases (including EMBASE, MEDLINE and PsycINFO) were searched from 1920 to 2009. Selected publications had to report on the use of drug interviews in people diagnosed with a conversion/dissociative disorder. Qualitative and quantitative data were extracted. Predictors of a positive response were ascertained using meta-analytic techniques. RESULTS: Fifty-five papers meeting inclusion criteria were identified. No studies compared the intervention with a suitable control group. However, two studies reported high response rates when drug interview was used in individuals with treatment-resistant conversion disorder. In the meta-analysis, the use of suggestion and occurrence of emotional catharsis during the interview were positively associated with recovery. Combining two medications and comorbid psychiatric disorder were negatively associated with recovery. CONCLUSIONS: The evidence for effectiveness of drug interviews is of poor quality but it may be of benefit in the treatment of acute and treatment-resistant conversion disorder. A proactive approach during the interview, making suggestions the individual will respond, could influence outcome. Comorbid psychiatric disorder should be treated conventionally. Experimental studies to determine efficacy are required.

Clinical observations on 46 cases of globus hystericus treated with modified Banxia Houpu decoction.

OBJECTIVE: To observe the therapeutic effect and mechanism of modified Banxia Houpu decoction on globus hystericus. METHODS: The 95 patients with globus hystericus were randomly divided into a treatment group of 46 cases treated with modified Banxia Houpu decoction and a control group of 49 cases treated with Manyanshuning (Granula for Clearing the Throat). In addition, a normal group of 24 healthy people was set up. SCL-90 scale was adopted to observe the therapeutic effect, evaluate the psychological state of patients and build a database on combination of four diagnoses. RESULTS: The effect of the modified Banxia Houpo decoction was better than that of the control group in relieving depression, anxiety and improving the psychological state (P<0.05 or P<0.01). CONCLUSION: Modified Banxia Houpu decoction has definite therapeutic effect on globus hystericus. Its mechanism may be related to its function in relieving depression and anxiety and regulating the psychological state.