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Conversion Disorder) Benedetta Demartini,1,2 Panayiota Petrochilos,3 Lucia Ricciardi,1,4 Gary Price,3 Mark J Edwards,1 Eileen Joyce1

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Conversion Disorder) Benedetta Demartini,1,2 Panayiota Petrochilos,3 Lucia Ricciardi,1,4 Gary Price,3 Mark J Edwards,1 Eileen Joyce1 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp-2013-307203 on 7 March 2014. Downloaded from Neuropsychiatry RESEARCH PAPER The role of alexithymia in the development of functional motor symptoms (conversion disorder) Benedetta Demartini,1,2 Panayiota Petrochilos,3 Lucia Ricciardi,1,4 Gary Price,3 Mark J Edwards,1 Eileen Joyce1 1The Sobell Department of ABSTRACT outcome has been a reduction in the emphasis on Motor Neuroscience and Background The mechanisms leading to the identifiable traumatic events (such as sexual abuse Movement Disorders, UCL Institute of Neurology, Queen development of functional motor symptoms (FMS) are of in childhood or adult life, remote or recent life Square, London, UK pathophysiological and clinical relevance, yet are poorly events) being antecedents to the development of 2Department of Psychiatry, San understood. FMS. Several studies have demonstrated that such Paolo Hospital and University Aim The aim of the present study was to evaluate traumatic events, although clearly important, might of Milan, Milan, Italy whether impaired emotional processing at the cognitive not play a unique role in the aetiology of FMS34, 3Department of Neuropsychiatry, The National Hospital for level (alexithymia) is present in patients affected by FMS. and, in the most recent revision of the Diagnostic Neurology and Neurosurgery, We conducted a cross-sectional study in a population of and Statistical Manual of Mental Disorders Queen Square, London, UK patients with FMS and in two control groups (patients (DSM-5),5 the presence of a psychological stressor 4 Department of Clinical and with organic movement disorders (OMD) and healthy has been downgraded from an essential to a sup- Experimental Medicine, University of Messina, volunteers). portive criterion for the diagnosis of conversion Messina, Italy Methods 55 patients with FMS, 33 patients affected disorder (functional neurological symptom by OMD and 34 healthy volunteers were recruited. The disorder).6 Correspondence to assessment included the 20-item Toronto Alexithymia Recent cognitive and neurobiological models of Professor Eileen Joyce, Sobell Scale (TAS-20), the Montgomery-Asberg Depression the pathophysiology of functional neurological Department, UCL Institute of ’ ‘ ’ Neurology, Queen Square, Rating Scale, the Reading the Mind in the Eyes Test and symptoms have concentrated more on how symp- London WC1N 3BG, UK; the Structured Clinical Interview for Personality Disorders. toms might be produced than on ‘why’. Research [email protected] Results Alexithymia was present in 34.5% of patients findings have identified three putative mechanistic with FMS, 9.1% with OMD and 5.9% of the healthy processes leading to functional movement disorders Received 9 November 2013 volunteers, which was significantly higher in the FMS (FMDs): abnormal attentional focus,7 abnormal Revised 20 January 2014 2 8 Accepted 22 January 2014 group (χ (2)=14.129, p<0.001), even after controlling beliefs and expectations, and abnormalities in Published Online First for the severity of symptoms of depression. Group sense of agency.9 These three processes have been 7 March 2014 differences in mean scores were observed on both the combined in recent neurobiological models where difficulty identifying feelings and difficulty describing abnormal predictions related to movement or per- feelings dimensions of the TAS-20, whereas the ception are triggered by self-focused attention, and externally orientated thinking subscale score was similar the resulting percept or movement is generated 10 11 across the three groups. Regarding personality disorder, without a normal sense of agency. http://jnnp.bmj.com/ χ2 analysis showed a significantly higher prominence of Recent aetiological work has highlighted a pos- obsessive-compulsive personality disorder (OCPD) in the sible role for physical precipitating factors in the FMS group (χ2 (2)=16.217, p<0.001) and 71.4% of triggering of functional neurological and other those with OCPD also reached threshold criteria for somatic symptoms, and in some cases clear links alexithymia. have been made between the nature of the physical Conclusions Because alexithymia is a mental state precipitant and the phenomenology of the resulting 12 denoting the inability to identify emotions at a cognitive functional symptom. However, the physical preci- on October 2, 2021 by guest. Protected copyright. level, one hypothesis is that some patients misattribute pitants identified (minor injury, flu-like illness, diar- autonomic symptoms of anxiety, for example, tremor, rhoea, migraine) are very common in the healthy paraesthesiae, paralysis, to that of a physical illness. population, and therefore why they should trigger Further work is required to understand the contribution functional symptoms in only a small proportion of of OCPD to the development of FMS. people remains unexplained. Therefore, the investi- Open Access gation of mechanistic factors in the development of Scan to access more free content functional neurological symptoms is of continued INTRODUCTION relevance and importance. Functional motor symptoms (FMS), which include One clue has been the observation that physio- abnormal movements and weakness, are part of the logical markers of panic or anxiety are often wide spectrum of functional neurological symp- reported at onset of FMSs (eg, in association with a toms, one of the commonest diagnoses made in physical trigger) or in a persistent manner through- neurological practice.1 Patients affected by FMS out the illness, but that patients only rarely report a have levels of disability, distress and healthcare concurrent emotional state of anxiety.13 These To cite: Demartini B, Petrochilos P, Ricciardi L, usage that equals, and in some cases surpasses, studies in patients with FMSs link to previous work 2 et al. J Neurol Neurosurg patients with neurodegenerative disease. in patients with non-epileptic attacks where often Psychiatry 2014;85: Recent years have seen a surge of research inter- patients will report or be observed to have physio- – 1132 1137. est in functional neurological symptoms. One logical changes seen in panic episodes but generally 1132 Demartini B, et al. J Neurol Neurosurg Psychiatry 2014;85:1132–1137. doi:10.1136/jnnp-2013-307203 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp-2013-307203 on 7 March 2014. Downloaded from Neuropsychiatry do not report feeling ‘panicked’. This phenomenon has been participant through a brief self-report questionnaire designed named as ‘non-fearful panic’.14 for the study. Failure to identify and describe emotions in oneself and a dif- ficulty in distinguishing and appreciating the emotions of others Assessments is called alexithymia, a term coined by Sifneos (1973) to ▸ The 20-item Toronto Alexithymia Scale (TAS-20): This is a describe certain clinical characteristics observed among patients well-validated and commonly used measure of alexithymia;20 with psychosomatic disorders who had difficulty engaging in it is a multidimensional self-report instrument with a three- insight-oriented psychotherapy.15 Most previous studies of alex- factor structure: difficulty identifying feelings (DIF), diffi- ithymia in patients with functional neurological symptoms have culty describing feelings (DDF) and externally orientated been restricted to non-epileptic seizures (NES).16 17 Here, both thinking (EOT). As well as comparing TAS scores across the patients with epilepsy and those with NES had similar but very groups, we took the suggested TAS criterion score of ≥61 as high rates of alexithymia. Only one recent study has assessed categorically denoting alexithymia. the prevalence of alexithymia in a general group of conversion ▸ The Montgomery-Asberg Depression Rating Scale disorders, and this found higher rates in patients compared with (MADRS): This is a 10-item semistructured clinician-rated controls.18 No studies have previously investigated the preva- interview widely used to measure levels of depression; it has lence of alexithymia in a population solely of patients affected been showed to yield reliable and internally consistent scores by FMSs. We were specifically interested in assessing this, as and to demonstrate criterion-related validity.21 high rates of alexithymia could help provide an explanation for ▸ The Reading the Mind in the Eyes’ Test (Eyes): This is an the clinical observation of a dissociation between patients’ advanced test of theory of mind. It is widely used to assess endorsement of physiological markers of panic/anxiety and their individual differences in social cognition and emotion recog- denial of the emotional experience of panic/anxiety. nition across different groups and cultures. Although it is not The aim of the present study was to evaluate the prevalence a diagnostic instrument, several studies indicate that the Eyes of alexithymia in patients affected by FMS and to clarify its is a reliable instrument for assessing social cognition in pathophysiological role. In addition, we determined the pres- adults.22 ence of other mental states that may confound the interpretation ▸ The Structured Clinical Interview for Personality Disorders of alexithymia, namely, personality disorder (PD), depression (SCID II): This is a semistructured assessment instrument for and deficits in theory of mind indicative of impaired social cog- PDs. Several studies have shown that it is reliable, internally nition. To do this we conducted a cross-sectional study in a consistent and valid.23 population
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