Cross Talk: Case Conferences From MGH November 2, 2021

Psychotherapy for Functional Neurological (Conversion) Disorder: A Case Bridging Mind, Brain, and Body

Ellen J. Godena, EdM, MSW; David L. Perez, MD, MMSc; Laura D. Crain, MD; Anne K. Fishel, PhD; Alice Flaherty, MD, PhD; Rebecca Harley, PhD; Jonah N. Cohen, PhD

J Clin Psychiatry 2021;82(6):21ct14246

 

ABSTRACT

Functional neurologic (conversion) disorder (FND) is a core neuropsychiatric condition directly at the intersection of psychiatry and neurology. Over the past several decades, renewed interest in FND has been catalyzed by use of a “rule-in” diagnostic approach leveraging positive clinical signs specific for the diagnosis. In parallel, advances have occurred in identifying mechanisms, etiologic factors, and evidence-based treatments for this population. While “one size fits all” formulations of the “conversion” of psychological distress into physical symptoms are no longer widely accepted, emotion processing and related psychological constructs (eg, alexithymia, dissociation, threat avoidance) remain central to the conceptual understanding of FND. Furthermore, the biopsychosocial model (foundational to psychiatry) is the prevailing model through which to guide longitudinal treatment, with psychotherapy as an emerging first line intervention for FND. Nonetheless, there is a striking dearth of psychotherapists and mental health providers more broadly that feel well versed in the clinical assessment and management of patients with FND. In this article, we seek to address this gap by presenting the psychotherapy treatment narrative of a woman experiencing paroxysmal functional speech and gait disorder symptoms who had a positive clinical outcome. Our goal with this case presentation and related discussion is to increase the proficiency of psychotherapists in providing treatment to patients with FND.

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  1. Perez DL, Aybek S, Nicholson TR, et al. Functional neurological (conversion) disorder: a core neuropsychiatric disorder. J Neuropsychiatry Clin Neurosci. 2020;32(1):1–3. PubMed CrossRef
  2. Espay AJ, Aybek S, Carson A, et al. Current concepts in diagnosis and treatment of functional neurological disorders. JAMA Neurol. 2018;75(9):1132–1141. PubMed CrossRef
  3. Baslet G, Bajestan SN, Aybek S, et al. Evidence-based practice for the clinical assessment of psychogenic nonepileptic seizures: a report from the American Neuropsychiatric Association Committee on Research. J Neuropsychiatry Clin Neurosci. 2021;33(1):27–42. PubMed CrossRef
  4. Perez DL, Aybek S, Popkirov S, et al; on behalf of the American Neuropsychiatric Association Committee for Research. A review and expert opinion on the neuropsychiatric assessment of motor functional neurological disorders. J Neuropsychiatry Clin Neurosci. 2021;33(1):14–26. PubMed CrossRef
  5. Stephen CD, Fung V, Lungu CI, et al. Assessment of emergency department and inpatient use and costs in adult and pediatric functional neurological disorders. JAMA Neurol. 2021;78(1):88–101. PubMed CrossRef
  6. Trimble M, Reynolds EH. A brief history of hysteria: from the ancient to the modern. Handb Clin Neurol. 2016;139:3–10. PubMed CrossRef
  7. Keynejad RC, Carson AJ, David AS, et al. Functional neurological disorder: psychiatry’s blind spot. Lancet Psychiatry. 2017;4(3):e2–e3. PubMed CrossRef
  8. Bègue I, Nicholson TR, Kozlowska K, et al. Psychiatry’s modern role in functional neurological disorder: join the renaissance. Psychol Med. 2021;1–3. PubMed
  9. Gutkin M, McLean L, Brown R, et al. Systematic review of psychotherapy for adults with functional neurological disorder [published online ahead of print November 5, 2020]. J Neurol Neurosurg Psychiatry. PubMed CrossRef
  10. Goldstein LH, Robinson EJ, Mellers JDC, et al; CODES study group. Cognitive Behavioural Therapy for Adults With Dissociative Seizures (CODES): a pragmatic, multicentre, randomised controlled trial. Lancet Psychiatry. 2020;7(6):491–505. PubMed CrossRef
  11. Espay AJ, Ries S, Maloney T, et al. Clinical and neural responses to cognitive behavioral therapy for functional tremor. Neurology. 2019;93(19):e1787–e1798. PubMed CrossRef
  12. Dallocchio C, Tinazzi M, Bombieri F, et al. Cognitive behavioural therapy and adjunctive physical activity for functional movement disorders (conversion disorder): a pilot, single-blinded, randomized study. Psychother Psychosom. 2016;85(6):381–383. PubMed CrossRef
  13. Stone J, LaFrance WC Jr, Levenson JL, et al. Issues for DSM-5: conversion disorder. Am J Psychiatry. 2010;167(6):626–627. PubMed CrossRef
  14. Nonnekes J, Růžička E, Serranová T, et al. Functional gait disorders: a sign-based approach. Neurology. 2020;94(24):1093–1099. PubMed CrossRef
  15. 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(2):180–190. PubMed CrossRef
  16. McKee K, Glass S, Adams C, et al. The inpatient assessment and management of motor functional neurological disorders: an interdisciplinary perspective. 2018;59(4):358–368. PubMed CrossRef
  17. Perez DL, LaFrance WC Jr. Nonepileptic seizures: an updated review. CNS Spectr. 2016;21(3):239–246. PubMed CrossRef
  18. Baker J, Barnett C, Cavalli L, et al. Management of functional communication, swallowing, cough and related disorders: consensus recommendations for speech and language therapy [published online ahead of print July 1, 2021]. J Neurol Neurosurg Psychiatry. 2021;jnnp-2021-326767. PubMed CrossRef
  19. Stone J, Smyth R, Carson A, et al. Systematic review of misdiagnosis of conversion symptoms and “hysteria.” BMJ. 2005;331(7523):989. PubMed CrossRef
  20. Gelauff JM, Carson A, Ludwig L, et al. The prognosis of functional limb weakness: a 14-year case-control study. Brain. 2019;142(7):2137–2148. PubMed CrossRef
  21. Perez DL, Hunt A, Sharma N, et al. Cautionary notes on diagnosing functional neurologic disorder as a neurologist-in-training. Neurol Clin Pract. 2020;10(6):484–487. PubMed CrossRef
  22. Ludwig L, Pasman JA, Nicholson T, et al. Stressful life events and maltreatment in conversion (functional neurological) disorder: systematic review and meta-analysis of case-control studies. Lancet Psychiatry. 2018;5(4):307–320. PubMed CrossRef
  23. Drane DL, Fani N, Hallett M, et al. A framework for understanding the pathophysiology of functional neurological disorder. CNS Spectr. 2020;1–7. PubMed CrossRef
  24. LaFaver K, LaFrance WC, Price ME, et al. Treatment of functional neurological disorder: current state, future directions, and a research agenda. CNS Spectr. 2020;1–7. PubMed CrossRef
  25. Perez DL, Edwards MJ, Nielsen G, et al. Decade of progress in motor functional neurological disorder: continuing the momentum. J Neurol Neurosurg Psychiatry. 2021;92(6):668–677. PubMed CrossRef
  26. Carson AJ, Brown R, David AS, et al; UK-FNS. Functional (conversion) neurological symptoms: research since the millennium. J Neurol Neurosurg Psychiatry. 2012;83(8):842–850. PubMed CrossRef
  27. Pick S, Goldstein LH, Perez DL, et al. Emotional processing in functional neurological disorder: a review, biopsychosocial model and research agenda. J Neurol Neurosurg Psychiatry. 2019;90(6):704–711. PubMed CrossRef
  28. Nielsen G, Stone J, Matthews A, et al. Physiotherapy for functional motor disorders: a consensus recommendation. J Neurol Neurosurg Psychiatry. 2015;86(10):1113–1119. PubMed CrossRef
  29. Sharpe M, Walker J, Williams C, et al. Guided self-help for functional (psychogenic) symptoms: a randomized controlled efficacy trial. Neurology. 2011;77(6):564–572. PubMed CrossRef
  30. Freud S. A Case of Hysteria, Three Essays on Sexuality and Other Works. In: The Complete Psychological Works of Sigmund Freud, vol 7. Hogarth Press; 1953.
  31. Griffith JL, Polles A, Griffith ME. Pseudoseizures, families, and unspeakable dilemmas. Psychosomatics. 1998;39(2):144–153. PubMed CrossRef
  32. Van der Feltz-Cornelis CM, Allen SF, Van Eck van der Sluijs JF. Childhood sexual abuse predicts treatment outcome in conversion disorder/functional neurological disorder: an observational longitudinal study. Brain Behav. 2020;10(3):e01558. PubMed CrossRef
  33. Keynejad RC, Frodl T, Kanaan R, et al. Stress and functional neurological disorders: mechanistic insights. J Neurol Neurosurg Psychiatry. 2019;90(7):813–821. PubMed CrossRef
  34. Rawlings GH, Reuber M. What patients say about living with psychogenic nonepileptic seizures: a systematic synthesis of qualitative studies. Seizure. 2016;41:100–111. PubMed CrossRef
  35. Nielsen G, Buszewicz M, Edwards MJ, et al. A qualitative study of the experiences and perceptions of patients with functional motor disorder. Disabil Rehabil. 2020;42(14):2043–2048. PubMed CrossRef
  36. Fishbane M. Healing intergenerational wounds: an integrative relational-neurobiological approach. Fam Process. 2019;58(4):796–818. PubMed CrossRef
  37. LaFrance WC Jr, Baird GL, Barry JJ, et al; NES Treatment Trial (NEST-T) Consortium. Multicenter pilot treatment trial for psychogenic nonepileptic seizures: a randomized clinical trial. JAMA Psychiatry. 2014;71(9):997–1005. PubMed CrossRef
  38. Perez DL. The CODES trial for dissociative seizures: a landmark study and inflection point. Lancet Psychiatry. 2020;7(6):464–465. PubMed CrossRef