Differentiating cerebral ischemia from functional neurological symptom disorder: a psychosomatic perspective

BMC Psychiatry

Andreas Joos²  Michael Wirsching²  Sebastian Rauer¹  Matthias Reinhard¹  Michael Katzev¹  Kathrin Baumann²  Carl E Scheidt² 

[1] Department of Neurology, University of Freiburg, Breisacher Straße 64, D - 79106 Freiburg, Germany;Department of Psychosomatic Medicine and Psychotherapy, University of Freiburg, Hauptstraße 8, D - 79104 Freiburg, Germany

关键词: ICD-11;    DSM-5;    Psychosomatic medicine;    Functional neurological symptom disorder;    Conversion disorder;   

Others  :  1123547
DOI  :  10.1186/1471-244X-14-158

 received in 2014-01-02, accepted in 2014-05-23,  发布年份 2014

【 摘 要 】

Background

The differential diagnosis of pseudo-neurological symptoms often represents a clinical challenge. The Diagnostic and Statistical Manual of Mental Disorders, DSM-5, made an attempt to improve diagnostic criteria of conversion disorder (functional neurological symptom disorder). Incongruences of the neurological examination, i.e. positive neurological signs, indicate a new approach - whereas psychological factors are not necessary anymore. As the DSM-5 will influence the International Classification of Diseases, ICD-11, this is of importance. In the case presented, a history of psychological distress and adverse childhood experiences coexisted with a true neurological disorder. We discuss the relevance of an interdisciplinary assessment and of operationalized diagnostic criteria.

Case presentation

A 32-year-old man presented twice with neurological symptoms without obvious pathological organic findings. A conversion disorder was considered early on at the second admission by the neurology team. Sticking to ICD-10, this diagnosis was not supported by a specialist for psychosomatic medicine, due to missing hints of concurrent psychological distress in temporal association with neurological symptoms. Further investigations then revealed a deep vein thrombosis (though D-dimers had been negative), which had probably resulted in a crossed embolus.

Conclusion

The absence of a clear proof of biological dysfunction underlying neurological symptoms should not lead automatically to the diagnosis of a conversion disorder. In contrast, at least in more complex patients, the work-up should include repeated psychological and neurological assessments in close collaboration. According to ICD-10 positive signs of concurrent psychological distress are required, while DSM-5 emphasizes an incongruity between neurological symptoms and neurophysiological patterns of dysfunction. In the case presented, an extensive medical work-up was initially negative, and neither positive psychological nor positive neurological criteria could be identified. We conclude, that, even in times of more sophisticated operationalization of diagnostic criteria, the interdisciplinary assessment has to be based on an individual evaluation of all neurological and psychosocial findings. Prospective studies of inter-rater reliability and validity of psychological factors and positive neurological signs are needed, as evidence for both is limited. With respect to ICD-11, we suggest that positive neurological as well as psychological signs for functional neurological symptom disorder should be considered to increase diagnostic certainty.

【 授权许可】

   
2014 Scheidt et al.; licensee BioMed Central Ltd.

【 参考文献 】

• [1]Stone J, Carson A, Duncan R, Coleman R, Roberts R, Warlow C, Hibberd C, Murray G, Cull R, Pelosi A, Cavanagh J, Matthews K, Goldbeck R, Smyth R, Walker J, Macmahon AD, Sharpe M: Symptoms “unexplained by organic disease” in 1144 new neurology out-patients: how often does the diagnosis change at follow-up? Brain 2009, 132:2878-2888.
• [2]Stone J, Hewett R, Carson A, Warlow C, Sharpe M: The “disappearance” of hysteria: historical mystery or illusion? J R Soc Med 2008, 101:12-18.
• [3]Kranick SM, Gorrindo T, Hallett M: Psychogenic movement disorders and motor conversion: a roadmap for collaboration between neurology and psychiatry. Psychosomatics 2011, 52:109-116.
• [4]American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 4th edition. Washington DC: American Psychiatric Association; 1994.
• [5]American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th edition. Arlington, VA: American Psychiatric Association; 2013.
• [6]WHO: The ICD-10 Classification of Mental and Behaviour Disorder. Geneva, Washington DC: WHO; 1992.
• [7]Frances AJ, Nardo JM: ICD-11 should not repeat the mistakes made by DSM-5. Br J Psychiatry 2013, 203:1-2.
• [8]Rief W, Martin A: How to Use the New DSM-5 Somatic Symptom Disorder Diagnosis in Research and Practice: A Critical Evaluation and a Proposal for Modifications. Annu Rev Clin Psychol 2014, 10:339-367.
• [9]Sisti D, Young M, Caplan A: Defining mental illnesses: can values and objectivity get along? BMC Psychiatry 2013, 13:346. BioMed Central Full Text
• [10]Tung CE, Olivot JM, Albers GW: Radiological examinations of transient ischemic attack. Front Neurol Neurosci 2014, 33:115-122.
• [11]Nicholson TRJ, Stone J, Kanaan RAA: Conversion disorder: a problematic diagnosis. J Neurol Neurosurg Psychiatry 2011, 82:1267-1273.
• [12]Breuer J, Freud S: [Studies on hyteria] Über den psychischen Mechanismus hysterischer Phänomene. Vorläufige Mittheilung. Neurol Zbl 1893, 12:4-10.
• [13]Hoffmann SO, Egle UT: Der psychogen und psychosomatisch Schmerzkranke - Entwurf zu einer psychoanalytisch orientierten Nosologie. Psychother Med Psychol 1989, 39:193-201.
• [14]Stone J, LaFrance WC Jr, Brown R, Spiegel D, Levenson JL, Sharpe M: Conversion disorder: current problems and potential solutions for DSM-5. J Psychosom Res 2011, 71:369-376.
• [15]Testa SM, Krauss GL, Lesser RP, Brandt J: Stressful life event appraisal and coping in patients with psychogenic seizures and those with epilepsy. Seizure 2012, 21:282-287.
• [16]Stone J, LaFrance WC Jr, Levenson JL, Sharpe M: Issues for DSM-5: Conversion disorder. Am J Psychiatry 2010, 167:626-627.
• [17]Stone J, Smyth R, Carson A, Warlow C, Sharpe M: La belle indifférence in conversion symptoms and hysteria: systematic review. Br J Psychiatry 2006, 188:204-209.
• [18]Stone J, Warlow C, Sharpe M: The symptom of functional weakness: a controlled study of 107 patients. Brain 2010, 133:1537-1551.
• [19]Daum C, Hubschmid M, Aybek S: The value of “positive” clinical signs for weakness, sensory and gait disorders in conversion disorder: a systematic and narrative review. J Neurol Neurosurg Psychiatry 2014, 85:180-190.
• [20]Hufschmidt A, Lücking CH, Rauer S: Neurologie compact: für Klinik und Praxis. 6 th. Stuttgart: Thieme; 2013.
• [21]Liberman AL, Prabhakaran S: Cryptogenic stroke: how to define it? How to treat it? Curr Cardiol Rep 2013, 15:423.
• [22]Nadarajan V, Perry RJ, Johnson J, Werring DJ: Transient ischaemic attacks: mimics and chameleons. Pract Neurol 2014, 14:23-31.
• [23]Kranick S, Ekanayake V, Martinez V, Ameli R, Hallett M, Voon V: Psychopathology and psychogenic movement disorders. Mov Disord 2011, 26:1844-1850.
• [24]Arbeitskreis OPD: Operationalisierte Psychodynamische Diagnostik OPD-2: Das Manual für Diagnostik und Therapieplanung. Bern: Hans Huber, Hogrefe AG; 2006.
• [25]Sirri L, Fabbri S, Fava GA, Sonino N: New strategies in the assessment of psychological factors affecting medical conditions. J Pers Assess 2007, 89:216-228.
• [26]Engel GL: The Need for a New Medical Model: A Challenge for Biomedicine. Science 1977, 196:129-136.
• [27]Lane RD: Is it possible to bridge the Biopsychosocial and Biomedical models? Biopsychosoc Med 2014, 8:3. BioMed Central Full Text
• [28]Förster A, Griebe M, Wolf ME, Szabo K, Hennerici MG, Kern R: How to identify stroke mimics in patients eligible for intravenous thrombolysis? J Neurol 2012, 259:1347-1353.
• [29]Carson AJ, Brown R, David AS, Duncan R, Edwards MJ, Goldstein LH, Grunewald R, Howlett S, Kanaan R, Mellers J, Nicholson TR, Reuber M, Schrag A-E, Stone J, Voon V, UK-FNS: Functional (conversion) neurological symptoms: research since the millennium. J Neurol Neurosurg Psychiatry 2012, 83:842-850.
• [30]Freud S: [A General Introduction to Psychoanalysis] Vorlesungen zur Einführung in die Psychoanalyse. Frankfurt am Main: Fischer Taschenbuch Verlag; 1991.
• [31]Gelauff J, Stone J, Edwards M, Carson A: The prognosis of functional (psychogenic) motor symptoms: a systematic review. J Neurol Neurosurg Psychiatry 2014, 85:220-226.
• [32]Koelen JA, Houtveen JH, Abbass A, Luyten P, Eurelings-Bontekoe EHM, Van Broeckhuysen-Kloth SAM, Bühring MEF, Geenen R: Effectiveness of psychotherapy for severe somatoform disorder: meta-analysis. Br J Psychiatry 2014, 204:12-19.
• [33]Hausteiner-Wiehle C, Schäfert R, Sattel H, Ronel J, Herrmann M, Häuser W, Martin A, Henningsen P: [New guidelines on functional and somatoform disorders]. Psychother Psychosom Med Psychol 2013, 63:26-31.