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Functional Symptoms in Neurology: Questions and Answers M Reuber, a J Mitchell, S J Howlett, H L Crimlisk, R a Gru¨Newald

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Functional Symptoms in Neurology: Questions and Answers M Reuber, a J Mitchell, S J Howlett, H L Crimlisk, R a Gru¨Newald 307 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.2004.048280 on 16 February 2005. Downloaded from REVIEW Functional symptoms in neurology: questions and answers M Reuber, A J Mitchell, S J Howlett, H L Crimlisk, R A Gru¨newald ............................................................................................................................... J Neurol Neurosurg Psychiatry 2005;76:307–314. doi: 10.1136/jnnp.2004.048280 Between 10 and 30% of patients seen by neurologists have from several conceptual limitations. Firstly, the diagnosis depends on the exclusion of a medical symptoms for which there is no current pathophysiological explanation by clinical judgement or investiga- explanation. The objective of this review is to answer tion (which may be impossible in paroxysmal questions many neurologists have about disorders disorders like epilepsy, or in conditions like migraine, in which the diagnosis relies on characterised by unexplained symptoms (functional the subjective assessment of the examiner). disorders) by conducting a multidisciplinary review based Secondly, psychological distress is difficult to on published reports and clinical experience. Current measure or objectify. Thirdly, functional symp- toms can complicate medically explained disease concepts explain functional symptoms as resulting from processes which can cause difficulties with auto-suggestion, innate coping styles, disorders of volition delineation and diagnosis. or attention. Predisposing, precipitating, and perpetuating Functional symptoms can mimic those of most recognised neurological disorders (fig 1), man- aetiological factors can be identified and contribute to a ifest acutely or as a more indolent problem, and therapeutic formulation. The sympathetic communication of can be persistent or intermittent in nature. the diagnosis by the neurologist is important and all Functional symptoms can occur together with symptoms of neurologically explained disorders patients should be screened for psychiatric or or may be the defining manifestation of a psychological symptoms because up to two thirds have functional disorder. symptomatic psychiatric comorbidity. Treatment programmes are likely to be most successful if there is close WHAT NAME SHOULD WE USE FOR collaboration between neurologists, (liaison) psychiatrists, FUNCTIONAL SYMPTOMS? copyright. Functional symptoms have attracted many dif- psychologists, and general practitioners. Long term, ferent terminologies. Some diagnostic labels symptoms persist in over 50% of patients and many which were initially acceptable had to be patients remain dependent on financial help from the abandoned because they entered common usage as derogatory idioms.5 Appropriate terminology government. Neurologists can acquire the skills needed to is important because the explanation of func- engage patients in psychological treatment but would tional symptoms is an important part of treat- benefit from closer working relationships with liaison ment, and the acceptance of the explanation given is associated with a better prognosis.67This psychiatry or psychology. communication may be hindered if patients feel ........................................................................... that their symptoms are interpreted by the doctor as malingering or exaggeration. A recent study http://jnnp.bmj.com/ n a typical neurology outpatient clinic, 10–30% has demonstrated that ‘‘functional’’ is more of patients will have symptoms which are not acceptable to patients than the terms ‘‘psycho- somatic’’, ‘‘medically unexplained’’, or ‘‘stress explicable by demonstrable structural or 8 I 1 related’’. In case of seizures, ‘‘functional’’ proved pathophysiological abnormalities. Unexplained symptoms are particularly common amongst less offensive than ‘‘hysterical’’, ‘‘pseudo’’, 2 ‘‘stress related’’, and ‘‘psychogenic’’ or the frequent users of healthcare services. Up to 9 two thirds of these patients have symptomatic expression ‘‘non-epileptic attack disorder’’. The psychiatric comorbidity and many describe sui- term functional also lends itself to offering on September 30, 2021 by guest. Protected cidal ideation if asked.34Neurologists need to be patients a positive explanation of symptoms See end of article for able not only to diagnose symptoms as func- (for example, ‘‘there is no damage of nerve cells authors’ affiliations but a disruption of function’’). ....................... tional but also to communicate with and manage patients in whom no clear organic explanation In the current taxonomies (Diagnostic and Correspondence to: for symptoms can be found. This article Statistical Manual of Mental Disorder, 4th Markus Reuber, Academic edition (DSM-IV),10 International Statistical Neurology Unit, University addresses some of the common questions which neurologists face when they see patients with Classification of Diseases, 10th revision (ICD- of Sheffield, Royal 11 Hallamshire Hospital, functional symptoms. 10) ) functional symptoms can be classified as Glossop Road, Sheffield manifestations of somatoform disorders (physi- S10 2JF, UK; cal symptoms which suggest a general medical [email protected] WHAT ARE FUNCTIONAL SYMPTOMS? condition) or dissociative disorders (disruption Functional symptoms are physical complaints Received 25 June 2004 postulated to be associated with psychological Revised version received Abbreviations: DSM-IV, Diagnostic and Statistical 12 October 2004 distress, which are not primarily explained by Manual of Mental Disorder, 4th edition; ICD-10, Accepted 22 October 2004 pathophysiological or structural abnormalities. International Statistical Classification of Diseases, 10th ....................... This explanation sounds succinct but suffers revision www.jnnp.com 308 Reuber, Mitchell, Howlett, et al J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.2004.048280 on 16 February 2005. Downloaded from 14 12 10 8 6 Percentage 4 2 0 Pain Par-/ Hyp-/ vertigo vertigo Paresis Seizures Episodic Amnesia Persistent Headache anaesthesia dysaesthesia Astasia/abasia Figure 1 Distribution of 717 functional symptoms in 405 neurology patients.19 of the usually integrated functions of consciousness, mem- ARE THERE CLEAR DISTINCTIONS BETWEEN ory, identity, or perception). However, many functional FUNCTIONAL, FEIGNED, AND HYPOCHONDRIACAL neurological symptoms (like amnesia or seizures) fulfil SYMPTOMS? diagnostic criteria for both categories. Perhaps because The DSM-IV and the ICD-10 encourage clinicians to divide of this, the present clinical criteria in the ICD and DSM intentional symptoms into malingered symptoms (wilfully systems do not perform well diagnostically if relied upon produced for external gain) or factitious symptoms (wilfully alone.12 What is more, the term ‘‘somatoform’’ does not produced for internal gain). However, it is very difficult for a imply a positive explanation for the symptom, and there clinical observer to judge the internal or external reward for a have been increasing criticisms of the somatoform symptom. Similar problems arise with the concept of classification with more emphasis being placed on sympto- ‘‘secondary gain’’ (for example, benefits associated with copyright. matology.13 taking on a sick role).17 Functional symptoms were previously called ‘‘hysterical’’, The DSM-IV and ICD-10 further distinguish between but the term’s derogatory connotations and the ever somatoform disorders (which are characterised by functional widening meaning of the word (for example, mass hysteria, symptoms) and hypochondriasis, in which there is predomi- hysterical personality) make it inappropriate.5 Functional nant anxiety about illness, often in the presence of problems are sometimes called ‘‘psychogenic’’ or attributed to misinterpretation of physiological processes in the body. ‘‘conversion’’. However, in the ICD-10 the term ‘‘psycho- However, somatoform disorders are often also associated genic’’ is defined quite narrowly as signifying an association with anxiety about ‘‘serious’’ underlying pathology, and this with recent trauma,11 and the term ‘‘conversion’’ evokes an categorical distinction may be difficult to make. aetiological mechanism for which we have no evidence. This does not mean that there is no difference between These models are too simplistic in most cases. patients whose functional symptoms are unintentional, malingered, factitious, or hypochondriacal. The margins The term ‘‘medically unexplained’’ is a better representa- http://jnnp.bmj.com/ tion of scientific knowledge to date, but may make patients between these conditions are simply not as clear as the think that their symptom is not being taken seriously, is prototypical definitions in the DSM-IV and ICD-10 suggest. unlikely to inspire confidence, and may jeopardise engage- ment with future therapeutic endeavours. ARE FUNCTIONAL SYMPTOMS DISPROPORTIONATELY PREVALENT IN NEUROLOGY? ARE FUNCTIONAL SYMPTOMS WILFULLY Although many who have written about functional symp- PRODUCED? toms (Thomas Willis, Jean-Martin Charcot, Joseph Babinski, on September 30, 2021 by guest. Protected In line with the current classificatory systems of mental Sigmund Freud, to name but a few) had a neurological disorders (DSM-IV, ICD-10), most clinicians attempt to background, a comparative study found that functional distinguish between functional symptoms (which are not symptoms were similarly prevalent in other medical special- intentionally produced by the patient) from symptoms that ties.18 Within neurology, one
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