Functional Neurological Symptom Disorder (FNSD) is a psychiatric condition that presents with neurological symptoms without medical explanation or knowledge. Conversion Disorder is interchangeably used in the paper as Functional Neurological Symptom Disorder. As with other disorders, the impairment of life functions or involvement in physical and social activities is typical of the condition description. The loss of function or impairment in CD indicates a natural presentation that is expressive of some underlying psychological desire or conflict in a person such as mood disorders (Hurwitz, 2003). The symptomatology of the disease is not under the voluntary control of the patient. The physical symptoms are usually without any explainable cause. Symptoms of the disorder include involuntary movements, disruption of sensory perceptions, muscular strength, and motor effects such as seizures. Often, a combination of these symptoms exists in a single clinical case. Psychodynamic explanations maintain that the symptoms evolve from unconsciousness of psychological conflict and stressors which eventually appear as physical features or symptoms. Thus, the symptoms are assumed to decrease the effect of anxiety in an individual by blocking the consciousness of the underlying mental desire or conflict. This result is regarded as the primary gain of FNSD.
There are other mechanisms that people with FNSD apply to cope or benefit from the symptoms. These are unique for every individual. Attention and support from friends and family is a common benefit. Avoidance of responsibilities and reward acceptance also form part of the symptomatic benefit or secondary gain. CD's symptoms are known to originate from unconsciousness. Thus, they are not intentionally faked. The findings cannot be accounted for by a known medical condition. When a medical examination is unable to find a physical reason for presenting symptoms FNSD becomes a likely diagnosis. It is estimated that about two third of FNSD diagnosed individuals have conditions of neurological etiology. The symptoms of CD are distinct from drug induce and any cultural or religious approved behavior or ritual.
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In North America, the main reference system is the Diagnostic and Statistical Manual of Mental Disorders (DSM). It provides sufficient diagnostic criteria for psychiatric disorders and conditions, and Conversion Disorder (CD) is one. Conversion Disorder has gone through debates and changes. In the Text Revision of DSM-IV (DMS-IV-TR), the disorder was under somatoform disorders. Among this group of disorders are the somatization, pain, body dysmorphic, and hypochondriasis disorder. The American Psychiatric Association (APA) reviewed DSM-IV. The review introduced and modified disorders classification. This modification and wording brought new categorization of certain disorders in the DSM-5. Thus, Conversion Disorder is Code 300.11. The alternative name is Functional Neurological Symptom Disorder (FNSD), classified under the Somatic Symptom and Related Disorders section. The Diagnostic Criteria for Conversion Disorder include the following:
A. One or more symptoms of altered voluntary motor or sensory function.
B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions.
C. The symptom or deficit is not better explained by another medical or mental disorder.
D. The symptom or deficit caused clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation (APA, 2013).
It is important to specify symptom types such as weakness or paralysis, abnormal movement, swallowing (F44.4); speech symptoms; attacks or seizures (F44.5); sensory loss or anesthesia (F44.6); special sensory symptom; or mixed symptoms” (F44.7). Also, one has to specify if symptoms are acute (present for less than six months, or persistent (present for six months or more). Additionally, it should be indicated if symptoms are associated with a stressor or without a stressor (American Psychiatric Association, 2013).
Diagnosis of FNSD/CD is fundamental to demonstrate findings that are incompatible and inconsistent with medically accepted parameters or knowledge. Anatomical and physiological explanations of numbness and paralysis should reveal normal functioning that contrast physical symptoms. Different physical examinations techniques can help the person performing the tests to separate conversion symptoms from physical causations. Thus, neurological investigations are standard in each test. Also, tests such as Electromyogram (EMG) of muscles and nerve conduction velocity testing should reveal standardize figures and patterns. Electroencephalogram (EEG) must be normal in seizures of CD. Somatosensory evoked potential testing must be within normal in extremities with no sensory perception or loss. Thus, exclusion is critical to arriving at a diagnosis.
FNSD has some known causal factors. People in the lower socioeconomic strata of the society have greater risk indices of the disorder. Prior experience of physical disorders, psychosocial stressors of severe impact and exposure to people who possess physical symptoms constitute the predominant causes of CD. Risk factors are mostly a history of childhood abuse or neglect and maladaptive personality traits. The age of onset ranges from 10-35, and it is believed to affect the female gender than the male. From DSM-IV-TR, research reveals that CD may be between 1-14% of the surgical and medical inpatient cases. The prevalence of FNSD/CD is not well-known. However, neurological clinics have about 5% referrals of CD cases in Secondary care. An estimate of specific, persistent conversion disorder symptoms is the ratio of about 2-5 per 100,000 per year (APA, 2013).
The treatment modalities for FNSD take into consideration a multidisciplinary approach. This method involves psychotherapists and pharmacotherapy. There is a possibility of a better outcome with an interdisciplinary approach to treatment (Wald, Taylor, & Scamvougeras, 2004). The primary treatment for conversion disorder has been psychotherapy. Claims on successful treatment outcomes are associated with psychoanalysis, family therapy, behavioral modifications and Cognitive behavior therapy (CBT). The use of CBT to treat certain unexplained disorders makes it a potential treatment option for CD. According to Allin, Streeruwitz, and Curtis (2005) “A combination of treatment with antidepressant medication and appropriate psychotherapy and multidisciplinary rehabilitation focusing on improving the patient’s level of functioning and reducing their subjective distress may be the most effective treatment at present” (p.208). Quick recovery is possible if the onset of the condition is acute and when the therapeutic intervention swift. There is sufficient literature suggesting the treatment of CD with Co-morbidity in perspective. This approach will allow a CD patient to benefit from the treatment of a co-occurring condition (Feinstein, 2011).
CBT may be appropriate in assisting individuals with CD resolve the underlying causes of the symptoms. The purpose of CBT approach in treatment is to help the person unlearn the maladaptive behaviors and in the process learn better ways of responding to stress or risk factors. A sound therapeutic relationship based on tactfulness in presenting diagnosis, reassurance, and explanation of intended outcomes, goals, and intervention(Stonnington et al., 2006). Physical therapy and stress management training may help reduce symptoms and lead to recovery. Hypnotherapy does not have sufficient research information to support its use in the treatment of FNSD. However, physical rehabilitation, physiotherapy has shown promise in treating FNSD/CD in youths (Ness, 2007).
Family and physiotherapy are great combinations in a collaborative treatment system. The literature on occupational therapy and physiotherapy is limited and inadequate, but available research focuses on the adult population. A small level of successful outcomes is documented. However, there is a lack of therapeutic guidelines regarding the role of physiotherapy. The role of the family is essential to recovery. Families contribute and give sufficient time and resources by helping their members deal with any psychiatric disorders that they may encounter. This involvement of the family is enhanced through psychoeducation. This enlightenment will allow the family come to term with the diagnosis and assist as much as they can in the recovery pathway.
One area of research involving CD is the use of functional imaging technique to study the brain activity of people with CD. The study supported the fact that traumatic events are processed cognitively and can be associated with the symptomatology of CD, especially the physical symptoms. This finding was published online, in JAMA Psychiatry , November 20, 2013. Thus, brain imaging studies are in the forefront of investigating the relationship between the neurological symptoms and Conversion Disorder.
Research in the area of treatment is one recently carried by researchers at the Rhode Island Hospital, led by LaFrance (2014). The team sought to explore the effect of different treatment on seizures in patients with psychogenic nonepileptic seizures (PNES). They focused on four treatment modalities, medication only, Cognitive Behavior Therapy informed psychotherapy (CBT-ip), CBT-ip with drugs, and the ordinary medical care. The combination of CBT-ip with drug revealed a significant seizure reduction of 59% with improvement in some secondary measures.This research reinforces the importance of CBT in many psychiatric disorders including CD. The research finding is on
Conversion Disorder or Functional Neurological Symptom Disorder is among the exclusive mental disorders with complex etiology. The diagnostic criteria are in the DSM-5 and can be treated with a multifaceted or interdisciplinary approach. A proper patient-doctor or therapist relationship is critical to the treatment outcome. The use of CBT as a combination therapy in a system with other treatment option has received more support. There is no specific treatment for Conversion Disorder. The disorder requires further research to establish a more practical understanding of the mental condition. To arrive at a diagnosis, a therapist has to exclude other relative symptoms.
References
Allin, M., Streeruwitz, A., & Curtis, V. (2005). Progress in understanding conversion disorder. Neuropsychiatric Disease and Treatment , 1 (3), 205–209
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. (5th ed.). Washington, D.C.: American Psychiatric Association. ISBN 0890425558.
Feinstein, A. (2011). Conversion disorder: advances in our understanding. Journal of the Canadian Medical Association,183, 8, 915-920,
Hurwitz, T. A. (2004). Somatization and conversion disorder. Canadian Journal of Psychiatry, 49, 172-178 .
LaFrance, W. C.et al., (2014).Multicenter Pilot Treatment Trial for Psychogenic Nonepileptic Seizures. JAMA Psychiatry , DOI: 10.1001/jamapsychiatry.2014.817
Ness, D. (2007). Physical Therapy Management for Conversion Disorder: Case Series . Journal of Neurologic Physical Therapy, 31, 30-39.
Stonnington, C.M., Barry, J.J., & Fisher, R.S. (2006). Conversion Disorder . American Journal of Psychiatry, 163, 9, 1510-1517.
Wald. J., Taylor, S., & Scamvougeras, A. (2004). Cognitive behavioural and neuropsychiatric treatment of post-traumatic conversion disorder: a case study. Cogn Behav Ther.33 , 12–20. [PubMed]
