Abstract
Functional neurological symptoms, or conversion disorders, have been described since the beginning of written medicine. Although originally attributed to a uterine disorder and first described as in a gynaecological text by the Middle Ages they were recognised as disorder of brain then of psyche. In the nineteenth century Charcot described them as being caused by a functional neurological lesion; one that evaded the availbel techniques of the day. A century on the technique shave become available that allow a search for these putative mechansims. In this chapter we review diagnosis and clinical presentation of functional symptoms which allows to speculate on potential mechanisms and hypothesise about potential target areas and paradigms for imaging. We then review all the imaging studies up until the end of 2012. To date the imaging conducted, both structural and functional, allow to be reasonably secure in concluding that functional neurological symptms are a genuine entity and not simply feigned. We cannot however make any claims that the underpinning mechansims of FNS have been resolved. We speculate that there are overly sensitive amygdala fear responses (i.e. abnormal response to stimuli (even objectively neutral stimuli), possibly conditioned by previous learning experiences) that drive changes in networks mediating perceptual experiences and/or movement plans. These changes, in the presence of abnormal self-directed attention (cf. prefrontal activations in functional imaging studies), are capable of producing movements or perceptual experiences which are not associated with a normal sense of self-agency and are therefore interpreted by patients as involuntary symptoms of an underlying disease.
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References
American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders, 4th edn. American Psychiatric Association, Washington DC
Atmaca M, Aydin A, Tezcan E, Poyraz AK, Kara B (2006) Volumetric investigation of brain regions in patients with conversion disorder. Prog Neuropsychopharmacol Biol Psychiatry 30:708–713
Aybek S, Nicholson T, Draganski B, Daly E, Murphy D, David A, Kanaan R (2012) Grey matter changes in motor conversion disorder. J Neurol Neurosurg Psychiatry J Neurol Neurosurg Psychiatry doi:10.1136/jnnp-2012-304158
Bakvis P, Roelofs K, Kuyk J, Edelbroek PM, Swinkels WA, Spinhoven P (2009a) Trauma, stress, and preconscious threat processing in patients with psychogenic nonepileptic seizures. Epilepsia 50:1001–1011
Bakvis P, Spinhoven P, Roelofs K (2009b) Basal cortisol is positively correlated to threat vigilance in patients with psychogenic nonepileptic seizures. Epilepsy Behav 16:558–560
Berna C, Leknes S, Holmes EA, Edwards RR, Goodwin GM, Tracey I (2010) Induction of depressed mood disrupts emotion regulation neurocircuitry and enhances pain unpleasantness. Biol Psychiatry 67:1083–1090
Breuer JE, Freud S (1955) Studies in hysteria (1893-95). Hogarth Press, London
Briquet P (1859) Traité clinique et thérapeutique de l’hystérie (Treatise on Hysteria). J-B. Baillière et Fils, Paris
Brown RJ (2004) Psychological mechanisms of medically unexplained symptoms: an integrative conceptual model. Psychol Bull 130:793–812
Burgmer M, Konrad C, Jansen A, Kugel H, Sommer J, Heindel W, Ringelstein EB, Heuft G, Knecht S (2006) Abnormal brain activation during movement observation in patients with conversion paralysis. Neuroimage 29:1336–1343
Carson A, Stone J, Hibberd C, Murray G, Duncan R, Coleman R, Warlow C, Roberts R, Pelosi A, Cavanagh J, Matthews K, Goldbeck R, Hansen C, Sharpe M (2011) Disability, distress and unexployment in neurology outpatients with symptoms ‘unexplained by disease’. J Neurol Neurosurg Psychiatry 82:810–813
Carson A, Brown R, David AS et al (2012) Functional (conversion) neurological symptoms: research since the millennium. J Neurol Neurosurg Psychiatry. doi:10.1136/jnnp-2011-301860
Charcot JM (1877) Lectures on the diseases of the nervous system delivered at the Salpêtrière. New Sydenham Society, London
Cojan Y, Waber L, Carruzzo A, Vuilleumier P (2009) Motor inhibition in hysterical conversion paralysis. Neuroimage 47:1026–1037
de Lange FP, Roelofs K, Toni I (2007) Increased self monitoring during imagined movements in conversion paralysis. Neuropsychologia 45:2051–2058
de Lange FP, Toni I, Roelofs K (2010) Altered connectivity between prefrontal and sensorimotor cortex in conversion paralysis. Neuropsychologia 48:1782–1788
Edwards MJ, Adams RA, Brown H, Parees I, Friston KJ (2012) A Bayesian account of hysteria. Brain 135(11):3495–3512
Ferrari R, Obelieniene D, Russell AS, Darlington P, Gervais R, Green P (2001) Symptom expectation after minor head injury. A comparative study between Canada and Lithuania. Clin Neurol Neurosurg 103:184–190
Ghaffar O, Staines WR, Feinstein A (2006) Unexplained neurologic symptoms: an fMRI study of sensory conversion disorder. Neurology 67:2036–2038
Goldstein LH, Chalder T, Chigwedere C, Khondoker MR, Moriarty J, Toone BK, Mellers JD (2010) Cognitive-behavioral therapy for psychogenic nonepileptic seizures: a pilot RCT. Neurology 74:1986–1994
Green A, Payne S, Barnitt R (2004) Illness representations among people with non-epileptic seizures attending a neuropsychiatry clinic: a qualitative study based on the self-regulation model. Seizure 13:331–339
Hennig-Fast K, Meister F, Frodl T et al (2008) A case of persistent retrograde amnesia following a dissociative fugue: neuropsychological and neurofunctional underpinnings of loss of autobiographical memory and self-awareness. Neuropsychologia 46:2993–3005
Hoedeman R, Blankenstein AH, van der Feltz-Cornelis CM, Krol B, Stewart R, Groothoff JW (2010) Consultation letters for medically unexplained physical symptoms in primary care. Cochrane Database Syst Rev (8):CD006524
Kanaan RA, Craig TK, Wessely SC, David AS (2007) Imaging repressed memories in motor conversion disorder. Psychosom Med 69:202–205
Kanaan RA, Carson A, Wessely SC, Nicholson TR, Aybek S, David AS (2010) What’s so special about conversion disorder? A problem and a proposal for diagnostic classification. Br J Psychiatry 196:427–428
Kenney C, Diamond A, Mejia N, Davidson A, Hunter C, Jankovic J (2007) Distinguishing psychogenic and essential tremor. J Neurol Sci 263:94–99
Kranick S, Ekanayake V, Martinez V, Ameli R, Hallett M, Voon V (2011) Psychopathology and psychogenic movement disorders. Mov Disord 26:1844–1850
Kroenke K (2007) Efficacy of treatment for somatoform disorders: a review of randomized controlled trials. Psychosom Med 69:881–888
Labate A, Cerasa A, Mula M, Mumoli L, Gioia MC, Aguglia U, Quattrone A, Gambardella A (2012) Neuroanatomic correlates of psychogenic nonepileptic seizures: a cortical thickness and VBM study. Epilepsia 53:377–385
Langer N, Hanggi J, Muller NA, Simmen HP, Jancke L (2012) Effects of limb immobilization on brain plasticity. Neurology 78:182–188
Lorenzetti V, Allen NB, Fornito A, Yücel M (2009) Structural brain abnormalities in major depressive disorder: a selective review of recent MRI studies. J Affect Disord 117:1–17
Mailis-Gagnon A, Giannoylis I, Downar J, Kwan CL, Mikulis DJ, Crawley AP, Nicholson K, Davis KD (2003) Altered central somatosensory processing in chronic pain patients with “hysterical” anesthesia. Neurology 60:1501–1507
Marshall JC, Halligan PW, Fink GR, Wade DT, Frackowiak RS (1997) The functional anatomy of a hysterical paralysis. Cognition 64:B1–B8
McAuley J, Rothwell J (2004) Identification of psychogenic, dystonic, and other organic tremors by a coherence entrainment test. Mov Disord 19:253–267
McWhirter L, Stone J, Sandercock P, Whiteley W (2011) Hoover’s sign for the diagnosis of functional weakness: a prospective unblinded cohort study in patients with suspected stroke. J Psychosom Res 71:384–386
Merskey H (1995) The analysis of hysteria. Gaskell, London
Moene FC, Spinhoven P, Hoogduin KA et al (2002) A randomised controlled clinical trial on the additional effect of hypnosis in a comprehensive treatment programme for in-patients with conversion disorder of the motor type. Psychother Psychosom 71:66–76
Pareés I, Saifee TA, Kassavetis P, Kojovic M, Rubio-Agusti I, Rothwell JC et al (2012) Believing is perceiving: mismatch between self-report and actigraphy in psychogenic tremor. Brain 135:117–123
Pennebaker JW (1982) The psychology of physical symptoms. Springer, New York
Raethjen J, Kopper F, Govindan RB, Volkmann J, Deuschl G (2004) Two different pathogenetic mechanisms in psychogenic tremor. Neurology 63:812–815
Roelofs K, Spinhoven P (2007) Trauma and medically unexplained symptoms towards an integration of cognitive and neuro-biological accounts. Clin Psychol Rev 27:798–820
Roelofs K, Van Galen GP, Eling P, Keijsers GP, Hoogduin CA (2003) Endogenous and exogenous attention in patients with conversion paresis. Cogn Neuropsychol 20:733–745
Roelofs K, Spinhoven P, Sandijck P, Moene FC, Hoogduin KA (2005) The impact of early trauma and recent life-events on symptom severity in patients with conversion disorder. J Nerv Ment Dis 193:508–514
Schrag A, Trimble M, Quinn N, Bhatia K (2004) The syndrome of fixed dystonia: an evaluation of 103 patients. Brain 127:2360–2372
Sharpe M, Carson A (2001) “Unexplained” somatic symptoms, functional syndromes, and somatization: do we need a paradigm shift? Ann Intern Med 134:926–930
Sharpe M, Stone J, Hibberd C, Warlow C, Duncan R, Coleman R, Roberts R, Cull R, Pelosi A, Cavanagh J, Matthews K, Goldbeck R, Smyth R, Walker A, Walker J, Macmahon A, Murray G, Carson A (2010) Neurology out-patients with symptoms unexplained by disease: illness beliefs and financial benefits predict 1-year outcome. Psychol Med 40(4):689–698
Sharpe M, Walker J, Williams C, Stone J, Cavanagh J, Murray G, Butcher I, Duncan R, Smith S, Carson A (2011) Guided self-help for functional (psychogenic) symptoms: a randomized controlled efficacy trial. Neurology 77:564–572
Slater E (1965) Diagnosis of “hysteria”. BMJ 1:1395–1399
Spence SA, Crimlisk HL, Cope H, Ron MA, Grasby PM (2000) Discrete neurophysiological correlates in prefrontal cortex during hysterical and feigned disorder of movement. Lancet 355:1243–1244
Spence SA, Farrow TFD, Herford AE et al (2001) Behavioural and functional anatomical correlates of deception in humans. Neuroreport 12:2849–2853
Stone J, Carson A (2012) Functional and dissociative (psychogenic) neurological symptoms. In: Daroff RB, Fenichel GM, Jankovic J, Mazziotta JC (eds) Bradley’s neurology in clinical practice, 6th edn. Philadelphia, Elsevier
Stone J, Edwards M (2012) Trick or treat? Showing patients with functional (psychogenic) motor symptoms their physical signs. Neurology 79:282–284
Stone J, Sharpe M, Rothwell P, Warlow C (2003) The 12 year prognosis of unilateral functional weakness and sensory disturbance. J Neurol Neurosurg Psychiatry 74:591–596
Stone J, Smyth R, Carson A, Lewis S, Prescott R, Warlow C, Sharpe M (2005) Systematic review of misdiagnosis of conversion symptoms and “hysteria”. BMJ 331:989
Stone J, Zeman A, Simonotto E, Meyer M, Azuma R, Flett S, Sharpe M (2007) FMRI in patients with motor conversion symptoms and controls with simulated weakness. Psychosom Med 69:961–969
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 (2009) Symptoms ‘unexplained by organic disease’ in 1144 new neurology out-patients: how often does the diagnosis change at follow-up? Brain 132:2878–2888
Stone J, Carson A, Duncan R, Roberts R, Warlow C, Hibberd C, Coleman R, Cull R, Murray G, Pelosi A, Cavanagh J, Matthews K, Goldbeck R, Smyth R, Walker J, Sharpe M (2010) Who is referred to neurology clinics? – The diagnoses made in 3781 new patients. Clin Neurol Neurosurg 112:747–751
Stone J, LaFrance WC Jr, Brown R, Spiegel D, Levenson JL, Sharpe M (2011) Conversion disorder: current problems and potential solutions for DSM-5. J Psychosom Res 71:369–376
Stone J, Gelauff J, Carson AJ (2012) A “twist in the tale”: altered perception of ankle position in psychogenic dystonia. Mov Disord 27:585–586
Tanaka Y, Albert ML, Miyazaki M (2007) Pseudohysterical hemiparesis. J Nerv Ment Dis 195:874–876
Testa SM, Krauss GL, Lesser RP, Brandt J (2012) Stressful life event appraisal and coping in patients with psychogenic seizures and those with epilepsy. Seizure 21:282–287
Thomas-Aterion C, Guedj E, Decousus M et al (2010) Can we see personal identity loss? A functional imaging study of typical ‘hysterical amnesia’. J Neurol Neurosurg Psychiatry 81:468–469
Tiihonen J, Kuikka J, Viinamaki H, Lehtonen J, Partanen J (1995) Altered cerebral blood flow during hysterical paresthesia. Biol Psychiatry 37:134–135
van Beilen M, de Jong BM, Gieteling EW, Renken R, Leenders KL (2011) Abnormal parietal function in conversion paresis. PLoS One 6(10):e25918. doi:10.1371/journal.pone.0025918
van der Kruijs SJ, Bodde NM, Vaessen MJ et al (2012) Functional connectivity of dissociation in patients with psychogenic non-epileptic seizures. J Neurol Neurosurg Psychiatry 83:239–247
van Poppelen D, Saifee TA, Schwingenschuh P, Katschnig P, Bhatia KP, Tijssen MA, Edwards MJ (2011) Attention to self in psychogenic tremor. Mov Disord 26:2575–2576
Voon V, Brezing C, Gallea C, Ameli R, Roelofs K, LaFrance WC Jr, Hallett M (2010a) Emotional stimuli and motor conversion disorder. Brain 133:1526–1536
Voon V, Gallea C, Hattori N, Bruno M, Ekanayake V, Hallett M (2010b) The involuntary nature of conversion disorder. Neurology 74:223–228
Voon V, Brezing C, Gallea C, Hallett M (2011) Aberrant supplementary motor complex and limbic activity during motor preparation in motor conversion disorder. Mov Disord 26:2396–2403
Vrij A, Mann S (2001) Telling and detecting lies in a high stake situation: the case of a convicted murder. Appl Cogn Psychol 15:187–203
Vuilleumier P, Chicherio C, Assal F et al (2001) Functional neuroanatomical correlates of hysterical sensorimotor loss. Brain 124:1077–1090
Werring DJ, Weston L, Bullmore ET, Plant GT, Ron MA (2004) Functional magnetic resonance imaging of the cerebral response to visual stimulation in medically unexplained visual loss. Psychol Med 34:583–589
Yazici KM, Kostakoglu L (1998) Cerebral blood flow changes in patients with conversion disorder. Psychiatry Res 83:163–168
Zeuner KE, Shoge RO, Goldstein SR, Dambrosia JM, Hallett M (2003) Accelerometry to distinguish psychogenic from essential or parkinsonian tremor. Neurology 61:548–550
Ziv I, Djaldetti R, Zoldan Y, Avraham M, Melamed E (1998) Diagnosis of “non-organic” limb paresis by a novel objective motor assessment: the quantitative Hoover’s test. J Neurol 245:797–802
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Carson, A., Edwards, M., Stone, J. (2013). Neuroimaging of Functional Neurological Symptoms. In: Cavanna, A., Nani, A., Blumenfeld, H., Laureys, S. (eds) Neuroimaging of Consciousness. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-37580-4_12
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DOI: https://doi.org/10.1007/978-3-642-37580-4_12
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