Psychiatry, Functional Neurological disorders

1. Mind Body connection: How our
mind controls our health
Natangwe Shimhanda
MBChB (UNAM)
29 March 2019

2. Objectives
• Insight into Mind – body interactions
• Most medical illnesses are potentially affected
by biological, psychological and social realms
• Overview of somatic symptom disorders
• Focus on Functional Neurological disorder
(conversion disorder)

3. Introduction
• Many patients that seek general medical
services do not suffer from demonstrable
physical ailments that require medical
treatment.
• They also do not view themselves
psychiatrically ill and do not seek psychiatric
help either.

4. Somatic symptom & Related disorders
• The tendency to experience bodily distress in
the face of psychological stress.
• DSM-V : A somatic symptom disorder is the
presence of somatic symptoms, suggesting a
medical condition that cannot be fully
explained by the presenting symptoms.

5. • Somatic symptom disorder
• Illness anxiety disorder
• Conversion disorder(functional neurological disorder)
• Factitious disorder
• Psychological factors affecting other medical conditions
• Other specified somatic symptom and related disorders
• Unspecified somatic symptom and related disorders
Somatic symptom disorders (DSM 5)

7. Case
• Ms T
• 32 years old; F; single; has no children;
Christian; from Omuthiya; Oshiwambo
speaker; Highest level of education grade 6;
unemployed
• Family history: the 1st born of 5 siblings; Both
parents are still alive but separated; has a
cousin and half brother with schizophrenia

8. Case Cont’d
• Personal History:
The patient was relatively well until at the age of 12, when she
was diagnosed with epilepsy. She was in grade 6 at the time. She
failed grade 6 and dropped out of school in 1998, because she
couldn’t cope because other learners were always making fun
out her condition and used to call her an abnormal person.
She says her family cared for her until the time she was
diagnosed with epilepsy. They would make her eat in a different
plate and use different kitchen utensils because they believed
that epilepsy was contagious. She faced a lot of stigma/
discrimination from both relatives & neighbors.

9. Case Cont’d
• She lived at her mother’s house for most of her
life & recently (past 2 years) she’s been living with
her maternal Aunt.
• She has been feeling hopeless, worthless and like
a failure for most of her life because of they way
she’s treated by the people around her.
• Her epilepsy was relatively well controlled until in
2010 when she would hear a female voice telling
her to kill herself usually after a seizure.
• She was on anti-seizure medications

10. Case Cont’d
• Since 2010, she would visit the hospital about 8-10 times a
month and would be admitted at least twice a month
(omuthiya hospital; KSH; IHO) with either poorly controlled
epilepsy and urinary retention.
• Anti-seizure medications have been adjusted multiple times
without improving in her condition despite normal blood –
drug levels.
• She has had an indwelling catheter since 2010 which is
changed every month. Biopsy of the detrusor muscle was
 lazy bladder. There were times she was able to urinate
on her own (periods lasting for up to 3/12).
• Since then, she has had about 10 suicidal attepmts (recent
2 in 2019 occurred in the Psychiatric ward).

11. Case Cont’d
• Was discharged on clozapine; sodium
valproate and amitriptyline.
• Has been doing well, no seizures reported in
the ward. Was voiding by herself.
• Has a very supportive aunt.

12. History
• Hysteria was used synonymously with
conversion & other instances of somatising
• Derived from the greek hyster (uterus)
• Ancient Greeks believed it hysteria to rise from
a uterus wandering from its anatomical position
into other parts of the body.

13. 16th Century
• Prof Thomas Sydenham
became aware of neurotic &
Hysterical symptoms amongst
his patients.
• He also noted that
psychological stress or
“antecedent sorrows” was
involved in causing hysterical
symptoms.

14. 18th century
• Prof Jean Martin Charcot,
proposed that hysteria arose
when patients predisposed by
heredity, were exposed to a
traumatic event that produced a
functional brain lesion.
• Charcot could evoke &
manipulate hysteria through
hypnosis and also emphasized its
role treating hysterical disorders.

16. Late 18th century
• Dr. Pierre Janet introduced the
concept of dissociation.
• He considered hysteria a
disturbance in selective
attention, where through
dissociation, selected mental
contents are removed from
consciousness while continuing
to produce motor and sensory
deficits.

17. 19th century
• Sigmund Freud came to suspect
a connection between hysterical
pathology and sexuality which
provided one of the points of
psychoanalysis.
• Freud introduced the term
conversion : believed to be the
defense mechanism responsible
for converting mental stress &
conflict into somatic symptoms.

18. Conversion Disorder/ Functional
Neurological Disorder

19. • The Hallmark of the disorder is that its mono-
symptomatic and pseudo-neurological in
nature.
• Commonest of the somatic symptom
disorders
• Transient conversion disorder symptoms
insufficient to raise medical concern are
common and encountered in nearly 1/3 of all
people.

20. Epidemiology
• Prevalence 5-15% among psychiatric patients.
• Commonly occurs in the youngest member of
the family, low socioeconomic groups, rural
areas, persons with sub-average intelligence
and educational underachievers.
• Females outnumber males 5:1
• Exposure to war or combat further increases
the risk

21. Leading theories on
Pathogenesis

22. Neural Information Processing insights
• Conversion appears to result from dynamic
restructuring of neural networks.
• This results in volition, sensory and motor
behavior to become functionally isolated,
disconnected or dissociated.
• Dissociation is conceptualized by
Compartmentalization & Detachment

23. Compartmentalization
• Inability to bring into conscious awareness
information that is typically accessible to
consciousness & susceptible to conscious
influence.
• Despite their disconnection from
consciousness, compartmentalized processes
continue to function.

24. Detachment/Dissociation
• Emotional detachment can be a positive
behavior that allows a person to remain calm
to a highly emotional circumstance.
• Survival Instinct, allows the person to
rationally choose whether or not to be
overwhelmed/manipulated by such feelings.
• Results in traumatic amnesia, analgesia-
anesthesia, etc.

25. • When exposed to abuse, a child may
defensively respond through
compartmentalization and detachment.
• With repeated trauma, the dissociative
response is strengthened and over time it
becomes the preferred response to threat.

26. Psychodynamic Theory
• Neurosis stems from unacceptable ID impulses
(sexual/aggression) attempting to break into
consciousness and stamp their influence on
behavior.
• This may give rise to anxiety against which
defenses develop.
• These defenses include regression, patient may
defend themselves against adult life anxieties by
regressing to the state of a sick child who wants
attention and support.

27. • In this situation, relief from anxiety is
achieved.
• Conversion symptoms block awareness and
expression of a forbiden ID impulse through
incapacitating the body part related to that
impulse
• Example of a sex before marriage

28. Behavioral theory
• Learning plays a significant role in modulation
and experience of bodily sensation.
• Research data suggests that parental interest
in bodily symptoms in a patient’s childhood
may promote the likelihood of somatising in
adulthood.

29. Other theories
• Hypersensitivity ANS
• Cognition: catastrophic
thinking
• Cultural: not allowed to
freely express feelings

30. Diagnostic criteria

31. CLINICAL FEATURES
• Paralysis, blindness, and mutism are the most
common conversion disorder symptoms.
• Conversion disorder may be most commonly
associated with passive- aggressive, dependent,
antisocial, and histrionic personality disorders.
• Depressive and anxiety disorder symptoms often
accompany the symptoms of conversion disorder, and
affected patients are at risk for suicide.

32. SENSORY SYMPTOMS
• In conversion disorder, anesthesia and paresthesia are
common, especially of the extremities. All sensory
modalities can be involved, and the distribution of the
disturbance is usually inconsistent with either central or
peripheral neurological disease.
• Thus, clinicians may see the characteristic stocking-and
glove anesthesia of the hands or feet or the hemi-
anesthesia of the body beginning precisely along the
midline.

33. SENSORY SYMPTOMS
• Conversion disorder symptoms may involve the organs of
special sense and can produce deafness, blindness, and
tunnel vision.
• These symptoms can be unilateral or bilateral, but
neurological evaluation reveals intact sensory pathways.
• In conversion disorder blindness, for example, patients walk
around without collisions or self-injury, their pupils react to
light, and their cortical-evoked potentials are normal.

34. Motor Symptoms
• Include abnormal movements, gait disturbance, weakness,
and paralysis.
• Gross rhythmical tremors, choreiform movements, tics, and
jerks may be present.
• The movements generally worsen when attention is called to
them.
• One gait disturbance seen in conversion disorder is astasia-
abasia, which is a wildly ataxic, staggering gait accompanied
by gross, irregular, jerky truncal movements and thrashing
and waving arm movements. Patients with the symptoms
rarely fall; if they do, they are generally not injured.

35. MOTOR SYMPTOMS
• Other common motor disturbances are paralysis and
paresis involving one, two, or all four limbs, although
the distribution of the involved muscles does not
conform to the neural pathways.
• Reflexes remain normal; the patients have no
fasciculations or muscle atrophy (except after long-
standing conversion paralysis); electromyography
findings are normal.

38. Differentials
• Neurological disorders:
• Myasthenis gravis
• Multiple sclerosis
• GB
• Optic Neuritis
• Parkinson’s disease
• Brain tumors
• Meniere’s disease
• Tardive dykinesia

39. Course and outcome
• Symptoms resolve within 2 weeks in 90-100%
• Recurrence in 25% of patients, often within a
year of first dignosis
• Chronic conversion may lead to muscle
atrophy, contractures and decubitus ulcers

40. Management
• Multidisciplinary approach
• Avoid unnecessary investigations
• Regular follow ups
• Avoid multiple Dr visits
• Explore Psychosocial stressors
• CBT: behavioral modification

41. • Hypnosis, anxiolytics, and behavioral relaxation
exercises are effective in some cases.
• Psychodynamic approaches include psychoanalysis and
insight- oriented psychotherapy, in which patients
explore intra-psychic conflicts and the symbolism of
the conversion disorder symptoms.
• The longer the duration of these patients' sick role and
the more they have regressed, the more difficult the
treatment.

42. References
• The Diagnostic and Statistical Manual of Mental Disorders (5th ed.;
DSM–5; (2013) American Psychiatric Association
• Conrad Visser, 2016, Textbook of Pyschiatry for Southern Africa:
Chapter 18, Somatic symptom & related Disorders
• Stone, J., Carson, A., Sharpe, M. (2005) Functional symptoms in
neurology management, Journal of Neurology, Neurosurgery and
Psychiatry
• Stone et al (2010) Issues for DSM-5: Conversion Disorder The
American Journal of psychiatry
• Townsend, E.A., Polatajko, H.J. (2007) Enabling occupation II:
advancing an occupational therapy vision for health, well-being,
and justice through occupation. Ottawa: CAOT Publications ACE
• Jurriaan Peters,02 Nov 2016, Notes: Boston children Hospital;
https://notes.childrenshospital.org/seizure-or-not-non-epileptic-
paroxysmal-events-in-pediatrics/