Jon Stone

Systematic review of misdiagnosis of conversion symptoms and “hysteria”

Abstract Objective Paralysis, seizures, and sensory symptoms that are unexplained by organic disease are commonly referred to as “conversion” symptoms. Some patients who receive this diagnosis subsequently turn out to have a disease that explains their initial presentation. We aimed to determine how frequently this misdiagnosis occurs, and whether it has become less common since the widespread availability of brain imaging. Design Systematic review. Data sources Medline, Embase, PsycINFO, Cinahl databases, and searches of reference lists. Review methods We included studies published since 1965 on the diagnostic outcome of adults with motor and sensory symptoms unexplained by disease. We critically appraised these papers, and carried out a multivariate, random effect, meta-analysis of the data. Results Twenty seven studies including a total of 1466 patients and a median duration of follow-up of five years were eligible for inclusion. Early studies were of poor quality. There was a significant (P < 0.02) decline in the mean rate of misdiagnosis from the 1950s to the present day; 29% (95% confidence interval 23% to 36%) in the 1950s; 17% (12% to 24%) in the 1960s; 4% (2% to 7%) in the 1970s; 4% (2% to 6%) in the 1980s; and 4% (2% to 6%) in the 1990s. This decline was independent of age, sex, and duration of symptom in people included in the studies. Conclusions A high rate of misdiagnosis of conversion symptoms was reported in early studies but this rate has been only 4% on average in studies of this diagnosis since 1970. This decline is probably due to improvements in study quality rather than improved diagnostic accuracy arising from the introduction of computed tomography of the brain.

Functional weakness and sensory disturbance

In the diagnosis of functional weakness and sensory disturbance, positive physical signs are as important as absence of signs of disease. Motor signs, particularly Hoovers sign, are more reliable than sensory signs, but none should be used in isolation and must be interpreted in the overall context of the presentation. It should be borne in mind that a patient may have both a functional and an organic disorder.

Conversion disorder: a problematic diagnosis

The diagnosis of conversion disorder is problematic. Since doctors have conceptually and practically differentiated the symptoms from neurological (‘organic’) disease it has been presumed to be a psychological disorder, but the psychological mechanism, and how this differs from feigning (conscious simulation), has remained elusive. Although misdiagnosis of neurological disease as conversion disorder is uncommon, it remains a concern for clinicians, particularly for psychiatrists who may be unaware of the positive ways in which neurologists can exclude organic disease. The diagnosis is anomalous in psychiatry in that current diagnostic systems require that feigning is excluded and that the symptoms can be explained psychologically. In practice, feigning is very difficult to either disprove or prove, and a psychological explanation cannot always be found. Studies of childhood and adult psychological precipitants have tended to support the relevance of stressful life events prior to symptom onset at the group level but they are not found in a substantial proportion of cases. These problems highlight serious theoretical and practical issues not just for the current diagnostic systems but for the concept of the disorder itself. Psychology, physiology and functional imaging techniques have been used in attempts to elucidate the neurobiology of conversion disorder and to differentiate it from feigning, but while intriguing results are emerging they can only be considered preliminary. Such work looks to a future that could refine our understanding of the disorder. However, until that time, the formal diagnostic requirement for associated psychological stressors and the exclusion of feigning are of limited clinical value. Simplified criteria are suggested which will also encourage cooperation between neurology and psychiatry in the management of these patients.

Physiotherapy for functional motor disorders: a consensus recommendation

Background Patients with functional motor disorder (FMD) including weakness and paralysis are commonly referred to physiotherapists. There is growing evidence that physiotherapy is an effective treatment, but the existing literature has limited explanations of what physiotherapy should consist of and there are insufficient data to produce evidence-based guidelines. We aim to address this issue by presenting recommendations for physiotherapy treatment. Methods A meeting was held between physiotherapists, neurologists and neuropsychiatrists, all with extensive experience in treating FMD. A set of consensus recommendations were produced based on existing evidence and experience. Results We recommend that physiotherapy treatment is based on a biopsychosocial aetiological framework. Treatment should address illness beliefs, self-directed attention and abnormal habitual movement patterns through a process of education, movement retraining and self-management strategies within a positive and non-judgemental context. We provide specific examples of these strategies for different symptoms. Conclusions Physiotherapy has a key role in the multidisciplinary management of patients with FMD. There appear to be specific physiotherapy techniques which are useful in FMD and which are amenable to and require prospective evaluation. The processes involved in referral, treatment and discharge from physiotherapy should be considered carefully as a part of a treatment package.

Functional symptoms in neurology: THE BARE ESSENTIALS

Correspondence to: Dr J Stone, Consultant Neurologist and Honorary Senior Lecturer in Neurology, Department of Clinical Neurosciences, Western General Hospital, Edinburgh EH4 2XU, UK; Jon.Stone@ed.ac.uk IS IT YOUR JOB AS A NEUROLOGIST TO DEAL WITH THIS PROBLEM? If you find people with ‘‘neurological symptoms but no disease’’ tiresome and not really what you came in to the specialty for, then you are going to find large parts of your job tiresome and—worse— your attitude will filter through in a negative way to the patients regardless of the form of words you use to talk to them. On the other hand, if you allow yourself to be interested by the complexity of the problem and can see the potential for benefit that you, as a neurologist, can make to some patients then you may discover that this is a worthwhile area in which to improve your knowledge and skills.

Functional weakness: clues to mechanism from the nature of onset

Background Functional weakness describes weakness which is inconsistent and incongruent with disease. It is also referred to as motor conversion disorder (DSM-IV), dissociative motor disorder (ICD-10) and ‘psychogenic’ paralysis. Studies of aetiology have focused on risk factors such as childhood adversity and life events; information on the nature and circumstance of symptom onset may shed light on the mechanism of symptom formation. Aim To describe the mode of onset, associated symptoms and circumstances at the onset of functional weakness. Methods Retrospective interviews administered to 107 adults with functional weakness of <2u2005years duration. Results The sample was 79% female, mean age 39u2005years and median duration of weakness 9u2005months. Three distinct modes of onset were discerned. These were: sudden (n=49, 46%), present on waking (or from general anaesthesia) (n=16, 13%) or gradual (n=42, 39%). In ‘sudden onset’ cases, panic (n=29, 59%), dissociative symptoms (n=19, 39%) and injury to the relevant limb (n=10, 20%) were commonly associated with onset. Other associated symptoms were non-epileptic attacks, migraine, fatigue and sleep paralysis. In six patients the weakness was noticed first by a health professional. In 16% of all patients, no potentially relevant factors could be discerned. Conclusions The onset of functional weakness is commonly sudden. Examining symptoms and circumstances associated closely with the onset suggests hypotheses for the mechanism of onset of weakness in vulnerable individuals.

Physiotherapy for functional motor disorders

Background Patients with functional motor disorder (FMD) including weakness and paralysis are commonly referred to physiotherapists. There is growing evidence that physiotherapy is an effective treatment, but the existing literature has limited explanations of what physiotherapy should consist of and there are insufficient data to produce evidence-based guidelines. We aim to address this issue by presenting recommendations for physiotherapy treatment. Methods A meeting was held between physiotherapists, neurologists and neuropsychiatrists, all with extensive experience in treating FMD. A set of consensus recommendations were produced based on existing evidence and experience. Results We recommend that physiotherapy treatment is based on a biopsychosocial aetiological framework. Treatment should address illness beliefs, self-directed attention and abnormal habitual movement patterns through a process of education, movement retraining and self-management strategies within a positive and non-judgemental context. We provide specific examples of these strategies for different symptoms. Conclusions Physiotherapy has a key role in the multidisciplinary management of patients with FMD. There appear to be specific physiotherapy techniques which are useful in FMD and which are amenable to and require prospective evaluation. The processes involved in referral, treatment and discharge from physiotherapy should be considered carefully as a part of a treatment package.

How "psychogenic" are psychogenic movement disorders?

What does the word ‘‘psychogenic’’ really mean in ‘‘psychogenic movement disorder’’ (PMD)? This is the term used most commonly in clinical practice by members of the Movement Disorder Society (MDS) and in scientific publications. In a survey of 519 MDS members, 83% said it was their preferred term with colleagues even if only 59% preferred to use it with patients. 1 Yet the same survey showed that only 18% of respondents used the presence of psychological factors to make the diagnosis and that psychiatrists often sent patients back querying the diagnosis. Just because an abnormal movement might be distractible, variable, or responsive to cognitive behavioral therapy or placebo, does that mean that the only possible mechanism for its production is psychological difficulty and distress? This seems an inappropriately narrow formulation, and yet use of the word psychogenic continues. So maybe it is more to do with the characteristics of the patient that makes the problem psychogenic? The clinical stereotype of the patient with a psychogenic movement disorder patient is a woman in her 30s or 40s with a history of many other physical symptoms, depression, and anxiety. A classic psychodynamic formulation might seek a history of childhood abuse, a tendency to dissociation and a recent life event to explain the reactivation of that tendency. Indeed, without a relevant psychological stressor, such a patient would not even qualify for a diagnosis of conversion disorder (300.11) in the psychiatric manual of diagnosis, Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV).

The bare essentials: Functional symptoms in neurology.

Correspondence to: Dr J Stone, Consultant Neurologist and Honorary Senior Lecturer in Neurology, Department of Clinical Neurosciences, Western General Hospital, Edinburgh EH4 2XU, UK; Jon.Stone@ed.ac.uk IS IT YOUR JOB AS A NEUROLOGIST TO DEAL WITH THIS PROBLEM? If you find people with ‘‘neurological symptoms but no disease’’ tiresome and not really what you came in to the specialty for, then you are going to find large parts of your job tiresome and—worse— your attitude will filter through in a negative way to the patients regardless of the form of words you use to talk to them. On the other hand, if you allow yourself to be interested by the complexity of the problem and can see the potential for benefit that you, as a neurologist, can make to some patients then you may discover that this is a worthwhile area in which to improve your knowledge and skills.

Functional neurologic disorders

Purpose of Review: Functional neurologic disorders, also called psychogenic, nonorganic, conversion, and dissociative disorders, are among the most common problems in neurologic practice. This article presents a practical guide to clinical assessment and treatment, incorporating emerging research evidence. This article places an emphasis on encouraging neurologists to use the assessment as treatment, take an active role in educating and treating the patient, and work in a multidisciplinary way with psychiatry, psychology, and physical therapy. Recent Findings: Classification of functional neurologic disorders now emphasizes the importance of positive diagnosis based on physical signs, not psychological features. Studies of mechanism have produced new clinical and neurobiological ways of thinking about these disorders. Evidence has emerged to support the use of physical therapy for functional movement disorders and psychotherapy for dissociative (nonepileptic) attacks. Summary: The diagnosis and management of functional neurologic disorders has entered a new evidence-based era and deserves a standard place in the neurologic curriculum.