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

BMC Psychiatry

Case Report

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

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

DOI  :  10.1186/1471-244X-14-158

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

来源: Springer

【 摘 要 】

BackgroundThe 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 presentationA 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.ConclusionThe 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】

Unknown   
© Scheidt et al.; licensee BioMed Central Ltd. 2014. This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.