Conversion disorder: A systematic review of current terminology

doi:10.1016/j.genhosppsych.2016.12.009

General Hospital Psychiatry

Volume 45, March–April 2017, Pages 51-55

https://doi.org/10.1016/j.genhosppsych.2016.12.009 Get rights and content

Highlights

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Labels for unexplained neurological symptoms contribute to their poor acceptance. We reviewed papers on label preferences.
•
Neurologists favoured “functional”, “psychogenic” or “non-epileptic/organic”; the public viewed “psychogenic” as offensive.
•
The views of neither psychiatrists nor patients with the disorder have been surveyed.

Abstract

Objective

It has been argued that the label given to unexplained neurological symptoms is an important contributor to their often poor acceptance, and there has been recent debate on proposals to change the name from conversion disorder. There have been multiple studies of layperson and clinician preference and this article aimed to review these.

Design

Multiple databases were searched using terms including “conversion disorder” and “terminology”, and relative preferences for the terms extracted.

Results

Seven articles were found which looked at clinician or layperson preferences for terminology for unexplained neurological symptoms. Most neurologists favoured terms such as “functional” and “psychogenic”, while laypeople were comfortable with “functional” but viewed “psychogenic” as more offensive; “non-epileptic/organic” was relatively popular with both groups.

Conclusions

“Functional” is a term that is relatively popular with both clinicians and the public. It also meets more of the other criteria proposed for an acceptable label than other popular terms – however the views of neither psychiatrists nor actual patients with the disorder were considered.

Introduction

Conversion disorder is a condition where neurological symptoms are present without an identifiable “organic” neurological cause, and which are instead understood to be psychiatric in origin [1]. The disorder is widely considered to be unpopular with patients and clinicians [2], with uncomfortable diagnostic encounters and patients feeling dismissed [3], [4]. It has been argued that the diagnostic labels used contribute to this - stigmatising patients and implying unhelpful aetiologies - and there has been intense recent debate over the need for a change [5], [6], [7], [8], [9].

Clearly this discussion is not new. The historical term, hysteria, was replaced by conversion disorder as recently as ICD-10 and DSM-III, presumably at least as much for its public connotations of emotional explosiveness as for its aetiological connotations of a wandering womb [10]. New terminology has flowered, but divided along aetiological lines (dissociation, stress) and those that shun aetiology (unexplained, non-epileptic); and between those of neurologists (functional, non-organic) and psychiatrists (conversion, psychosomatic). There is no consensus, even among the official diagnostic manuals, with both ICD and DSM hedging their bets, in “dissociative (conversion) disorder” and “conversion (functional neurological) disorder”, respectively. This proliferation of terms may of course be as unhelpful as the terms themselves.

There have been several attempts to clarify clinicians' and patients' preferences with empirical surveys. This article aims to systematically review those surveys to see whether a consensus can be found.

Section snippets

Methods

Internet databases were searched for articles examining the use of terminology in conversion disorder from inception to May 2015. This included PubMed and OVID combined searches of EMBASE, MEDLINE and PSYCINFO. The MeSH terms “conversion disorder” and “Terminology as topic” were used, with search terms (“conversion disorder” or “psychogenic motor” or “medically unexplained”) and “terminology”, returning 31 and 54 abstracts from PubMed and OVID respectively. Excluding duplicates left 55

Clinician perspectives

There were 4 studies identified that assessed clinician preferences, all by questionnaire (see Table 1).

The earliest study surveying clinician's preferences was by Mace & Trimble in 1991. This survey of 168 British neurologists found that the most popular terms used either informally/formally were “hysteria”, “functional” and “psychogenic” [11]. Notably, when questioned on what was classified as functional, the majority of neurologists considered Munchausen's syndrome should be and a minority

Discussion

This review found seven studies that investigated the use of terminology in conversion disorder with varying results. Though the seven studies had only partial overlap in the terms considered (see Table 3), many compared the terms “functional” and “psychogenic” and “non-neurological/organic/epileptic”, with few studies looking at any of the other terms. Classifying ‘endorsement’ and ‘rejection’ on the basis of terms' preference relative to other terms surveyed, ‘endorsed’ being those in the top

Conflicts of interest and source of funding

None declared.

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Physiotherapy for patients with functional movement disorder: A systematic review
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El trastorno del movimiento funcional (TMF) se engloba dentro de los trastornos neurológicos funcionales (TNF). Este constituye un motivo de consulta habitual en el ámbito de la neurología. La eficacia del tratamiento de fisioterapia en la rehabilitación motora de estos pacientes es un campo ampliamente estudiado. El objetivo de esta revisión es analizar la evidencia científica existente sobre los efectos del tratamiento fisioterápico en las manifestaciones motoras, la actividad (marcha, movilidad, equilibrio), la percepción de salud, la calidad de vida o el estado cognitivo-emocional de las personas con TMF.
Esta revisión se llevó a cabo siguiendo las recomendaciones de la declaración PRISMA. Se realizaron búsquedas sistemáticas en 4 bases de datos electrónicas para localizar resultados pertinentes. Se incluyeron ensayos controlados aleatorizados que investigasen los efectos de una intervención de fisioterapia especializada, de manera aislada o combinada con otras terapias dentro de un marco multidisciplinar; comparando su aplicación con el tratamiento fisioterápico estándar.
Se incluyeron 4 estudios con un total de 188 sujetos. Se extrajeron datos sobre la población, las medidas de resultado, los protocolos y los resultados. Se aplicó el sistema de puntuación de calidad de Oxford, obteniéndose 3 estudios con una calidad metodológica moderada (3-4/5) y un estudio con calidad metodológica baja (< 3).
El tratamiento de fisioterapia en personas diagnosticadas con TMF genera cambios positivos en su sintomatología motora, actividad, percepción de salud y calidad de vida.
Functional movement disorder (FMD), a type of functional neurological disorder, is a common reason for consultation with the neurology department. The efficacy of physiotherapy for motor rehabilitation of these patients has been widely studied. The aim of this review is to analyse the available evidence on the effects of physiotherapy on motor symptoms, activity (gait, mobility, balance), perceived health, quality of life, and the cognitive/emotional state of patients with FMD.
This review follows the PRISMA recommendations. Four electronic databases were searched for relevant articles. Our review included randomised controlled trials investigating the effects of a specialised physiotherapy intervention alone or in combination with other therapies as part of a multidisciplinary approach, with results compared against standard physiotherapy.
We reviewed 4 studies, including a total of 188 patients. We gathered data on the study population, outcome measures, protocols, and results. According to the Oxford quality scoring system, 3 studies had moderate methodological quality (3-4/5) and the remaining study presented poor methodological quality (<3).
Physiotherapy improves motor symptoms, activity, perceived health, and quality of life in patients with FMD.
Functional vision disorders in adults: a paradigm and nomenclature shift for ophthalmology
2022, Survey of Ophthalmology
Citation Excerpt :
The descriptor “conversion disorder” has overall remained stable. A more general review of preferred terms in functional neurological disorder broader than just vision suggests that the phrase “functional’ is patients” preferred descriptor [16]. Many FND diagnoses previously listed in DSM-4 are under the broader heading “somatic symptom and related disorders” in the DSM-5.
Vision loss with clinical findings that are incompatible with the symptoms and recognized neurological or ophthalmic conditions is a common presentation of patients to neurologists, ophthalmologists, and neuro-ophthalmologists. The accepted terminology to describe such patients has evolved over time, including functional visual disorder (FVD), non-organic vision loss, non-physiologic vision loss, functional vision loss, psychogenic, psychosomatic, and medically unexplained visual loss. Likewise, attitudes and recommended management options have changed over the years in the fields of psychiatry and neurology. FVD is a diagnosis of inclusion, and it is critical that the diagnosis be made and delivered efficiently and effectively to reduce patient and physician duress. We review the current Diagnostic and Statistical Manual (DSM V) terminology and the prior literature on FVD and describe how the approaches to diagnosis and management have changed. We provide recommendations on the appropriate techniques and diagnostic approach for patients with FVD. We also propose a protocol for consistent and standardized discussion with the patient of the diagnosis of FVD. We believe that the adoption of FVD as both a paradigm and nomenclature shift in ophthalmology will improve patient care.
Terminology for psychogenic nonepileptic seizures: Making the case for “functional seizures”
2020, Epilepsy and Behavior
Citation Excerpt :
“Functional” is a term that is relatively popular with both clinicians and the public [4]. It also meets more of the criteria proposed for an acceptable label than other popular terms in the field (Table 2) [26]. When presenting the diagnosis of this condition to a patient, a specific and clear label for the seizures should be provided at the beginning of the encounter along with an appropriate description of the condition to the patients and their families [18].
The purpose of the study was to review the literature on the terminologies for psychogenic nonepileptic seizures (PNES) and make a proposal on the terminology of this condition. This proposal reflects the authors' own opinions.
We systematically searched MEDLINE (accessed from PubMed) and EMBASE from inception to October 10, 2019 for articles written in English with a main focus on PNES (with or without discussion of other functional neurological disorders) and which either proposed or discussed the accuracy or appropriateness of PNES terminologies.
The search strategy reported above yielded 757 articles; 30 articles were eventually included, which were generally of low quality. “Functional seizures” (FS) appeared to be an acceptable terminology to name this condition from the perspective of patients. In addition, FS is a term that is relatively popular with clinicians.
From the available evidence, FS meets more of the criteria proposed for an acceptable label than other popular terms in the field. While the term FS is neutral with regard to etiology and pathology (particularly regarding whether psychological or not), other terms such as “dissociative”, “conversion”, or “psychogenic” seizures are not. In addition, FS can potentially facilitate multidisciplinary (physical and psychological) management more than other terms. Adopting a universally accepted terminology to describe this disorder could standardize our approach to the illness and facilitate communication between healthcare professionals, patients, their families, carers, and the wider public.
Upper extremity conversion disorder in children
2019, Journal of Shoulder and Elbow Surgery
Conversion disorder in children presents a challenge to orthopedic surgeons. The condition is frequently associated with unnecessary diagnostic tests, treatments, and cost. The purpose of this study was to report a series of children with upper extremity conversion disorder to raise awareness for this uncommon condition and to assist with its diagnosis and management.
A retrospective review was conducted of 4 pediatric patients with upper extremity conversion disorder at a tertiary pediatric hospital from 2015 to 2017. Medical records were reviewed for patient demographics, including psychiatric history, clinical findings, diagnostic studies, treatment, and cost of care.
Patients presented with upper extremity muscle stiffness, unremitting dysmorphic muscle spasms, weakness, pain, very limited shoulder range of motion, and complaints of recurrent shoulder dislocations. All patients had been evaluated by multiple specialists and had an extensive prior diagnostic workup that was inconclusive. Two patients had a history of prior psychiatric illness and suicidal ideation, and all patients expressed despair and depression. All patients had normal physical examination findings under anesthesia. Two patients with muscle stiffness were treated with botulism injections and improved their shoulder range of motion. The average total charge for care since presentation was $42,729.
Conversion disorder should be considered in patients with an extensive prior diagnostic workup, deficits inconsistent with anatomic patterns or imaging findings, and a history of prior psychiatric illness. Examination under anesthesia is a successful diagnostic approach in children with suspected conversion disorder.
What are the experiences of people with motor and sensory functional neurological disorder? A systematic review and thematic synthesis of qualitative studies
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View all citing articles on Scopus

View full text

Research paperConversion disorder: A systematic review of current terminology

Highlights

Abstract

Objective

Design

Results

Conclusions

Introduction

Section snippets

Methods

Clinician perspectives

Discussion

Conflicts of interest and source of funding

Progress in understanding conversion disorder

Neuropsychiatr Dis Treat

Patients whom neurologists find difficult to help

J Neurol Neurosurg Psychiatry

Limits to truth-telling: neurologists' communication in conversion disorder

Patient Educ Couns

Understanding the narratives of people who live with medically unexplained illness

Patient Educ Couns

From psychogenic movement disorder to functional movement disorder: it's time to change the name

Mov Disord

Conversion disorder: current problems and potential solutions for DSM-5

J Psychosom Res

What's so special about conversion disorder? A problem and a proposal for diagnostic classification

Br J Psychiatry

‘Psychogenic movement disorders’: they are what they are. movement disorders

‘Psychogenic’ versus ‘functional’ movement disorders? That is the question

Mov Disord

Women and hysteria in the history of mental health. Clinical practice and epidemiology in mental health: CP & EMH

‘Hysteria’, ‘functional’ or ‘psychogenic’? A survey of British neurologists' preferences

J R Soc Med

What is “treatment as usual” for nonepileptic seizures?

Epilepsy Behav

Opinions and clinical practices related to diagnosing and managing patients with psychogenic movement disorders: an international survey of movement disorder society members

Mov Disord

Research paper
Conversion disorder: A systematic review of current terminology