Conversion disorder (‘hysteria’) was largely considered to be a neurological problem in the 19th century, but without a neuropathological explanation it was commonly assimilated with malingering. The theories of Janet and Freud transformed hysteria into a psychiatric condition, but as such models decline in popularity and a neurobiology of conversion has yet to be found, today's neurologists once again face a disorder without an accepted model. This article explores how today's neurologists understand conversion through in-depth interviews with 22 neurology consultants. The neurologists endorsed psychological models but did not understand their patients in such terms. Rather, they distinguished conversion from other unexplained conditions clinically by its severity and inconsistency. While many did not see this as clearly distinct from feigning, they did not feel that this was their problem to resolve. They saw themselves as ‘agnostic’ regarding non-neuropathological explanations. However, since neurologists are in some ways more expert in conversion than psychiatrists, their continuing support for the deception model is important, and begs an explanation. One reason for the model's persistence may be that it is employed as a diagnostic device, used to differentiate between those unexplained symptoms that could, in principle, have a medical explanation and those that could not.
conversion disorder; hysteria; malingering; deception; factitious disorder
Between 10 and 30% of patients seen by neurologists have symptoms for which there is no current pathophysiological explanation. The objective of this review is to answer questions many neurologists have about disorders characterised by unexplained symptoms (functional disorders) by conducting a multidisciplinary review based on published reports and clinical experience. Current concepts explain functional symptoms as resulting from auto-suggestion, innate coping styles, disorders of volition or attention. Predisposing, precipitating, and perpetuating aetiological factors can be identified and contribute to a therapeutic formulation. The sympathetic communication of the diagnosis by the neurologist is important and all patients should be screened for psychiatric or psychological symptoms because up to two thirds have symptomatic psychiatric comorbidity. Treatment programmes are likely to be most successful if there is close collaboration between neurologists, (liaison) psychiatrists, psychologists, and general practitioners. Long term, symptoms persist in over 50% of patients and many patients remain dependent on financial help from the government. Neurologists can acquire the skills needed to engage patients in psychological treatment but would benefit from closer working relationships with liaison psychiatry or psychology.
Objective: To investigate psychiatric and neurological morbidity, diagnostic stability, and indicators of prognosis in patients previously identified as having medically unexplained motor symptoms.
Design: Follow up study.
Setting: National Hospital for Neurology and Neurosurgery, London—a secondary and tertiary referral hospital for neurological disorders.
Subjects: 73 patients with medically unexplained motor symptoms admitted consecutively in 1989-91. 35 (48%) patients had absence of motor function (for example, hemiplegia) and 38 (52%) had abnormal motor activity (for example, tremor, dystonia, or ataxia).
Main outcome measures: Neurological clinical diagnosis at face to face reassessment by a neurologist and a psychiatric diagnosis after a standardised assessment interview—the schedule for affective disorders and schizophrenia—conducted by a psychiatrist.
Results: Good follow up data were available for 64 subjects (88%). Only three subjects had new organic neurological disorders at follow up that fully or partly explained their previous symptoms. 44/59 (75%) subjects had had psychiatric disorders; in 33 (75%) patients, the psychiatric diagnosis coincided with their unexplained motor symptoms. 31/59 (45%) patients had a personality disorder. Three subjects had developed new psychiatric illnesses at follow up, but in only one did the diagnosis account for the previous motor symptoms. Resolution of physical symptoms was associated with short length of symptoms, comorbid psychiatric disorder, and a change in marital status during follow up.
Conclusions: Unlike Slater’s study of 1965, a low incidence of physical or psychiatric diagnoses which explained these patients’ symptoms or disability was found. However, a high level of psychiatric comorbidity existed.
Key messages Motor symptoms that remain unexplained medically despite thorough investigation are a common clinical problem, but the emergence of a subsequent organic explanation for these symptoms is rare The prevalence of coexistent affective and anxiety disorders is high and many patients also have a personality disorder Patients with a shorter duration of symptoms and coexistent anxiety or depression are likely to do better at follow up Reinvestigation of these patients is both expensive and potentially dangerous and should be avoided where no clear clinical indication exists
There are a host of vague terms to describe psychologically-mediated symptoms that mimic neurological disease, such as “functional,” “non-organic,” “psychogenic,” or “medically unexplained.” None of these terms have a direct translation in psychiatric classification, and psychiatrists are often faced with patients who do not believe in a psychological origin for their symptoms.
Within the framework of psychogenic movement disorders, we discuss the roadblocks to effective collaboration and treatment in these patients and the current state of the literature regarding diagnosis and treatment.
We describe the approach to these patients from the perspective of neurology and psychiatry, illustrating the differences in terminology and categorization.
Psychogenic movement disorders represent a unique opportunity for these fields to collaborate in the care of a potentially curable but significantly disabling disorder.
Conversion Disorder; Hysteria; Psychogenic Movement Disorder; Stress - Psychological/psychology
The prevalence of psychiatric morbidity in inpatients with neurological disorders and the extent to which it is detected by neurologists were measured by using a two stage model of psychiatric assessment and from information recorded in the patients' medical notes. The prevalence of psychiatric morbidity was estimated as 39%, of which 72% was unrecognised by the neurologists. Only a minority of patients with an uncertain physical diagnosis had a psychiatric illness, showing the error in assuming that a patient's physical symptoms arise from a psychological disturbance if an organic aetiology cannot be determined. When the patients were interviewed on their discharge from hospital they were divided on whether they had wished to discuss their mood with neurologists while they were in hospital. The reasons that they gave suggested that interactions between patients and doctors and the lack of ward facilities for private consultations with doctors are important determinants of hidden psychiatric morbidity in medical inpatients.
Background: Although the symptoms of unilateral "medically unexplained" or "functional" weakness and sensory disturbance present commonly to neurologists, little is known about their long term prognosis.
Objective: To determine the long term outcome of functional weakness and sensory disturbance.
Patients: A previously assembled cohort of 60 patients seen as inpatients by consultant neurologists in Edinburgh between 1985 and 1992 and diagnosed as having unilateral functional weakness or sensory disturbance.
Methods: Current symptoms, disability, and distress were assessed by postal questionnaire to the patients and their family doctors.
Results: Follow up data relating to mortality were obtained in 56 patients (93%) and to current diagnosis in 48 patients (80%). Patient questionnaire data were obtained in 42 patients (70%). The median duration of follow up was 12.5 years (range 9 to 16). Thirty five of the 42 patients (83%) still reported weakness or sensory symptoms, and the majority reported limitation of physical function, distress, and multiple other somatic symptoms. Twenty nine per cent had taken medical retirement. An examination of baseline predictors indicated that patients who had sensory symptoms had better functioning at follow up than those who had weakness. Only one patient had developed a neurological disorder which, in hindsight, explained the original presentation. Another patient had died of unrelated causes.
Conclusions: Many patients assessed by neurologists with unilateral functional weakness and sensory symptoms as inpatients remain symptomatic, distressed, and disabled as long as 12 years after the original diagnosis. These symptoms are only rarely explained by the subsequent development of a recognisable neurological disorder in the long term.
determine the prevalence of anxiety and depressive disorders in
patients referred to general neurology outpatient clinics, to compare
disability and number of somatic symptoms in patients with and without
emotional disorder, the relation to neurological disease, and assess
the need for psychiatric treatment as perceived by patients and doctors.
cohort study set in a regional neurology service in Edinburgh,
Scotland. The subjects were 300 newly referred consecutive outpatients
who were assessed for DSM IV anxiety and depressive disorders
(PRIME-MD, and HAD), health status, and disability (SF-36), and
patients', GPs' and neurologists' ratings of the need for patient to
receive psychiatric or psychological treatment.
RESULTS—Of 300 new
patients, 140 (47%) met criteria for one or more DSM IV anxiety or
depressive diagnosis. Major depression was the most common (27%). A
comparison of patients with and without emotional disorder showed that
physical function, physical role functioning, bodily pain, and social
functioning were worse in patients with emotional disorders
(p<0.0005). The median number of somatic symptoms was greater in
patients with emotional disorders (p<0.0005). These differences were
independent of the presence of neurological disease. Few patients
wished to receive psychiatric or psychological treatments. Both general
practitioners and neurologists were more likely to recommend
psychiatric treatment when the patients' symptoms were medically unexplained.
half of new referrals to general neurology clinics met criteria for a
DSM IV psychiatric diagnosis. These patients were more disabled, and
had more somatic symptoms. They expressed little enthusiasm for
receiving psychiatric treatment.
Conversion disorder (CD) is a psychiatric disorder, yet the diagnosis cannot be established without the expertise of a neurologist, as distinguishing a functional from an organic symptom relies on careful bedside examination. Joseph Babinski considered the absence of pronator drift as a ‘positive sign’ for hysterical paresis but the validity of this sign has never been evaluated. The aim of this study was to examine the sensitivity and specificity of the “drift without pronation” sign.
Twenty-six patients with unilateral functional upper limb paresis diagnosed with CD (DSM-IV) and a control group of 28 patients with an organic neurological condition were consecutively included. The arm stabilisation test was performed with arms stretched out in full supination, fingers adducted, eyes closed for 10 seconds. A positive “drift without pronation” sign was defined by the presence of a downward drift without pronation.
All CD subjects (100%) displayed a positive sign when only 7.1% of organic subjects did (Fisher’s p < 0.001). The sign yielded a sensitivity of 100% (95% CI:84%-100%) and a specificity of 93% (95% CI:76%-98%).
The observation of a “drift without pronation” sign is specific for Conversion Disorder and can be of help in making a quick distinction between organic and functional paresis at the bedside.
Conversion disorder; Pronator drift; Arm paresis; Functional symptom
Patients on neurology wards have been shown to have high rates of psychiatric illness. Prevalence figures of 39–64% have been reported previously. However a low rate of recognition of psychiatric illness is also observed in this population.
To estimate the prevalence of psychiatric illness in neurology inpatients in a regional neuroscience centre and to assess the sensitivity and specificity of a batch of screening questionnaires.
Patients were assessed using the following screening questionnaires: Primary Care Evaluation of Mental Disorders, Mini Mental State Examination, Frontal Assessment Battery, Alcohol Use Disorders Identification Test and a neurologist‐rating scale of organicity. All patients also had a full psychiatric assessment using the Diagnostic and statistical manual of mental disorders, 4th edition (DSM‐IV). The screening questionnaires were then compared with our “gold standard”, the psychiatric assessment.
The prevalence of psychiatric illness (as determined by the psychiatric interview) in neurology inpatients in a tertiary referral centre was found to be 51.3% (95% confidence interval 44 to 58%). The sensitivity of this batch of screening questionnaires is 81.2% and the specificity is 77.1%.
A high prevalence of psychiatric disorder was observed in inpatients on a dedicated neurology ward. The screening questionnaires used had a high sensitivity and specificity and could therefore be used as a simple way of identifying those with psychiatric illness.
the prevalence of psychiatric comorbidity assessed by the use of a
structured clinical interview in a large, representative sample of
patients with spasmodic torticollis (ST) and to test the hypothesis
that social phobia would be highly prevalent.
consecutive cohort of 116 patients with ST treated with botulinum toxin
overall psychiatric comorbidity was studied prospectively with the
structured clinical interview (SCID) for DSM-IV axis I disorders.
Physical disability and psychosocial variables were also assessed with
standardised self rating questionnaires.
RESULTS—41.3% of the
subjects met DSM-IV clinical criteria A-G for current social phobia as
the primary psychiatric diagnosis. This figure rose to 56% including
secondary and tertiary psychiatric diagnosis. There was no correlation
between severity of disease (Tsui score, severity of pain, body image
dissatisfaction score) and psychiatric comorbidity. The only
significant predictor of psychiatric comorbidity was depressive coping
behaviour (logistic regression analysis, p<0.01; OR=10.8). Compared
with a representative sample of the general adult population, in the
patients with ST the prevalence of clinically relevant social phobia is
10-fold, of mood disorders 2.4-fold, and of lifetime psychiatric
comorbidity 2.6-fold increased.
particularly high prevalence of social phobia was found in the cohort
of patients with ST. The finding of a high prevalence of social phobia
and depressive coping behaviour as the main predictor of psychiatric
comorbidity may make a subgroup of patients with ST particularly
amenable to specific psychotherapeutic interventions.
The aim of this study was to investigate the prevalence of migraine, alexithymia, and post-traumatic stress disorder among medical students at Cumhuriyet University of Sivas in Turkey. A total of 250 medical students participated in this study and answered the questionnaires. The study was conducted in three stages: the self-questionnaire, the neurological evaluation, and the psychiatric evaluation. In the first stage, the subjects completed a questionnaire to assess migraine symptoms and completed the three-item Identification of Migraine Questionnaire, the Toronto Alexithymia Scale, and the Post-Traumatic Stress Disorder Checklist-Civilian Version Scale. The subjects who reported having a migraine underwent a detailed neurological evaluation conducted by a neurologist to confirm the diagnosis. In the final stage, the subjects with a migraine completed a psychiatric examination using the structured clinical interview for DSM-IV-R Axis I. The actual prevalence of migraine among these medical students was 12.6 %. The students with a migraine were diagnosed with alexithymia and post-traumatic stress disorder more frequently than those without migraine. The Migraine Disability Assessment Scale scores correlated with the post-traumatic stress disorder scores. The results of this study indicate that migraine was highly prevalent among medical students in Turkey and was associated with the alexithymic personality trait and comorbid psychiatric disorders including post-traumatic stress disorder. Treatment strategies must be developed to manage these comorbidities.
Prevalence; Migraine; Post-traumatic stress disorder; Alexithymia; Comorbidity; Medical students
Conversion disorder is largely managed by neurologists, for whom it presents
great challenges to understanding and management. This study aimed to
quantify these challenges, examining how neurologists understand conversion
disorder, and what they tell their patients.
A postal survey of all consultant neurologists in the UK registered with the
Association of British Neurologists.
349 of 591 practising consultant neurologists completed the survey. They saw
conversion disorder commonly. While they endorsed psychological models for
conversion, they diagnosed it according to features of the clinical
presentation, most importantly inconsistency and abnormal illness behaviour.
Most of the respondents saw feigning as entangled with conversion disorder,
with a minority seeing one as a variant of the other. They were quite
willing to discuss psychological factors as long as the patient was
receptive but were generally unwilling to discuss feigning even though they
saw it as their responsibility. Those who favoured models in terms of
feigning were older, while younger, female neurologists preferred
psychological models, believed conversion would one day be understood
neurologically and found communicating with their conversion patients easier
than it had been in the past.
Neurologists accept psychological models for conversion disorder but do not
employ them in their diagnosis; they do not see conversion as clearly
different from feigning. This may be changing as younger, female
neurologists endorse psychological views more clearly and find it easier to
discuss with their patients.
Although it is widely believed that women with heart disease have poorer adjustment than men, the term ‘adjustment’ has typically been narrowly defined as depression. Gender differences in adjustment more broadly defined to encompass functional limitations in addition to depression have seldom been investigated, especially in general population samples with an adequate number of women.
A nationally representative general population survey of 7434 New Zealanders (618 with cardiovascular disease: CVD; 335 women, 283 men). DSM-IV mental disorders were measured with the Composite International Diagnostic Interview (CIDI 3.0). Health-related disability (functional limitations) was measured using the World Mental Health-World Health Organization Disability Adjustment Schedule (WHODAS-II). CVD was ascertained by self-report of a physician’s diagnosis of heart disease, heart attack or stroke.
In age-adjusted analyses, cardiovascular disease was associated with significant functional limitations in a range of disability domains in both men and women, but there were no gender differences in the degree of disability.
In this general population sample, men and women with CVD reported similar degrees of disability, despite women’s higher prevalence of depression. This does not support earlier conclusions that women with heart disease cope less well than men.
cardiovascular; depression; disability; gender differences
To report the clinical features, surgical treatment, and long-term outcomes of adults with moyamoya phenomenon treated at a single institution in the United States.
Forty-three adult patients with moyamoya disease (mean age of 40+/−11 years; range 18 to 69) were treated with encephaloduroarteriosynangiosis (EDAS). Neurologists examined patients pre- and post-operatively. Follow-up was obtained in-person or by structured telephone interview (median 41 months; range 4 to 126). The following outcomes were collected: transient ischemic attack (TIA), infarction, graft collateralization, change in cerebral perfusion, and functional level according to the modified Rankin scale (mRS). Kaplan-Meier infarction risk was calculated between operated and contralateral hemispheres.
The majority of patients were women (65%), Caucasian (65%), presented with ischemic symptoms (98%), and had bilateral disease (86%). Nineteen patients underwent unilateral and 24 patients bilateral EDAS (n=67). Fifty of 52 (98%) patients with available imaging developed collateral vessels, and 41 of 50 (82%) had increased perfusion on SPECT scan. The incidence of peri-procedural hemisphere infarction (<48 hours) was 3%. In the follow-up period patients experienced 10 TIAs, 6 infarcts, and 1 intracranial hemorrhage. Although the hemisphere selected for surgery was based upon patient symptoms and severity of pathology, the five year infarction free survival rate was 94% in operated hemispheres versus less than 36% in non-operated hemispheres (p=0.007). After controlling for age and sex, operative hemispheres were 89% less likely to experience infarction than contralateral hemispheres (hazard ratio: 0.11; 95% CI 0.02–0.56). Thirty-eight of 43 patients (88%) had preserved or improvement in mRS over baseline status.
In this mixed race population of North American patients, indirect bypass promoted adequate pial collateral development and increased perfusion in the majority of adult patients with moyamoya disease. Patients had low rates of postoperative TIAs, infarction, and hemorrhage, and the majority of patients had preserved or improved functional status.
Indirect; bypass; encephaloduroarteriosynangiosis; moyamoya; outcome; stroke
Between 1944 and 1984 20 patients were admitted to a spinal injuries centre with a diagnosis of traumatic paraplegia. They subsequently walked out and the diagnosis was revised to hysterical paraplegia. A further 23 patients with incomplete traumatic injuries, who also walked from the centre, have been compared with them as controls. The features that enabled a diagnosis of hysterical paraplegia to be arrived at were: They were predominantly paraplegic, There was a high incidence of previous psychiatric illness and employment in the Health Service or allied professions, Many were actively seeking compensation. The physical findings were a disproportionate motor paralysis, non anatomical sensory loss, the presence of downgoing plantar responses, normal tone and reflexes. They made a rapid total recovery. In contrast, the control traumatic cases showed an incomplete recovery and a persistent residual neurological deficit. Investigations apart from plain radiographs of the spinal column were not warranted, and the diagnosis should be possible on clinical grounds alone.
Thirty patients diagnosed as Conversion Disorder and Somatization Disorder on DSM-III were investigated using IBQ and EPI. The patients differed with the controls on all the 7 factors of illness dimensions. They scored higher on neuroticism and low on extroversion.
Objectives: To elucidate the clinical condition which is associated with non specific visual field loss in children: so called, Hysterical Amblyopia.
Materials and Method: 25 children with visual field defect were assessed by means of a proforma questionnaire which scored their disability. The results obtained from these children were compared with the results of the questionnaire being applied to 95 school children, ages 10 - 12 years, from the local primary school.
Results: In nearly all the symptoms elucidated by the questionnaire, the children with the visual field loss were much more affected than the control group. Statistical analysis rated the findings as highly significant.
Conclusion: The presence of concentric narrowing of the visual fields indicates that the visually affected children are likely to be beset by many other ailments: such as headaches, blurred vision, photophobia, light headedness, poor concentration, personality defect, restlessness and growing pains.
Disorders of unexplained fatigue are researched globally and debated prominently concerning their biomedical and psychiatric comorbidity. Such studies are needed in India.
To identify biomedical markers and psychiatric morbidity of disorders of severe unexplained fatigue or weakness with disability, designated neurasthenia spectrum disorders (NSDs). To compare biomedical markers of patients with controls. To study correlation between biomedical markers and psychiatric morbidity.
Four specialty outpatient clinics of Psychiatry, Medicine, Dermatology, and Ayurved of an urban general hospital.
Case-control study for biomedical markers. Diagnostic interviews for assessment of psychiatric morbidity.
Materials and Methods:
Patients (N = 352) were recruited using screening criteria and Structured Clinical Interview for DSM-IV screening module. They were compared with controls (N = 38) for relevant biomedical markers. Psychiatric morbidity was assessed with SCID-I interviews, Hamilton scales, and Symptom Check List-90 (SCL-90). Correlations between a nutritional index and axis I morbidity were studied.
Frequencies and means of biomedical markers and psychiatric diagnoses were compared and associations assessed with regression analysis.
Corrected arm muscle area (CAMA) was significantly lower among patients (P < 0.001), but not anemia. Anxiety (73.0%) and somatoform (61.4%) disorders, especially nonspecific diagnoses, were more frequent than depressive disorders (55.4%). Generally, Hamilton and SCL scores were lowest in Ayurved clinic, and highest in Psychiatry clinic. Presence of Generalized Anxiety Disorder (GAD) and adjustment disorders correlated with low nutritional index.
Malnutrition or de-conditioning that may explain weakness need to be considered in the management of NSDs in India, particularly with comorbid GAD or adjustment disorders. Weakness and anxiety, rather than fatigue and depression, are distinct features of Indian patients. SCL may be more useful than categorical diagnoses in NSDs. NSDs are an independent entity with nonspecific psychiatric comorbidity. Cross clinic differences among patients with similar complaints highlight need for idiographic studies.
Anthropometry; anxiety disorders; malnutrition; neurasthenia; somatoform disorders
Neurological diseases are common disorders resulting in the loss of productive life and disability. Dementia is becoming a major public health problem in the developing world also.
To ascertain the prevalence of dementia among Kashmiri Pandit population aged 60 years and above.
Materials and Methods:
A cross-sectional survey was conducted among the elderly population of the Kashmiris living in a migrant camp. We developed and used a Kashmiri version of the Mini-Mental State Examination as the test instrument, and a score below 24 was considered indicative of dementia. A functional ability questionnaire was also administered to the subjects. A neurologist carried out the examinations.
A sample comprising 200 subjects (95 males and 105 females) were evaluated. The prevalence of dementia is 6.5% among the Kashmiri Pandit population aged 60 years and above, which is higher than that reported from other parts of India.
Dementia; Kashmiri migrants; prevalence
determine (a) the proportion of patients
referred to general neurology outpatient clinics whose symptoms are
medically unexplained; (b) why they were
referred; (c) health status and emotional
disorder in this group compared with patients whose symptoms are
explained by "organic" neurological disease.
prospective cohort study with case note follow up at 6 months was
carried out in the regional neurology service in Lothian, Scotland with
300 newly referred outpatients. Neurologists rated the degree to which
patients' symptoms were explained by organic disease (organicity),
GPs' reasons for referral, health status (SF-36), anxiety, and
depressive disorders (PRIME-MD),
RESULTS—Of 300 new
patients 11% (95% confidence interval (95% CI) 7%-14%) had
symptoms that were rated as "not at all explained" by organic
disease, 19% (15% to 23%) "somewhat explained", 27% (22% to
32%) "largely explained", and 43% (37% to 49%) "completely explained" by organic disease. Reason for referral was not associated with "organicity". Comparison of these groups showed that although physical function was similar, the median number of physical symptoms and pain were greater in patients with lower organicity ratings (p<0.0005, p<0.0005). Depressive and anxiety disorders were more common in patients with symptoms of lower organicity (70% of patients in the not at all group had an anxiety or depressive disorder compared
with 32% in the completely explained group (p<0.0005).
of new referrals to general neurology clinics have symptoms that are
poorly explained by identifiable organic disease. These patients were
disabled and distressed. They deserve more attention.
Somatoform disorders are common conditions, but the current diagnostic criteria are considered to be unreliable, based largely on medically unexplained symptoms. DSM-5 is considering other possible characteristics of somatizers including high utilization, dissatisfaction with care, and poor response to reassurance. This paper reviews the available literature for evidence to support these criteria, and evaluates if distinctive aspects of these characteristics exist in somatizers.
The Pubmed database was searched combining terms such as “somatoform disorder” with “reassurance,” “satisfaction,” and “utilization.” Articles were individually inspected.
Many studies report a deficit in long-term response to reassurance in somatizers; there was some evidence that patients respond initially to reassurance, followed by return of anxiety, leading to further reassurance seeking. There was insufficient evidence to support poor satisfaction with care as a characteristic of somatizers. While there is no standard criterion for high utilization, regardless of definition, evidence was found to support over-utilization, particularly in outpatient visits. However, no unique pattern of utilization was found that could identify somatizers within a broader group of high utilizers.
This review revealed evidence of over-utilization in many areas of healthcare, as well as poor long term response to reassurance in somatizers. Dissatisfaction with care, though, was not a consistent finding. It is difficult to study alternative diagnostic criteria for somatoform patients when the current criteria rest on so many problematic assumptions. Future research should attempt to validate criteria empirically in patient groups, with selection not based on medically unexplained symptoms.
Somatoform disorder; DSM; utilization; satisfaction; reassurance
Clinical neurologists in the health care system of the future should have a multifaceted role. Advances in the basic understanding of the nervous system and therapeutics of neurologic disease have created, for the first time in human history, an ethical imperative to correctly diagnose neurologic disease. In many situations, the neurologists may function as a consultant and principal physician for patients with primary nervous system disorders including Parkinson's disease, multiple sclerosis, Alzheimer's disease, epilepsy, migraine, cerebrovascular disease, movement disorders, and neuromuscular disease. Other important roles for neurologists include the training of future physicians, both neurologists and primary care physicians, the application of cost-effective approaches to care, and the support of health care delivery research and academic programs that link basic research efforts to the development of new therapy. To be successful, future residency training programs should include joint certification opportunities in both neurology and general medicine, and training programs for clinical investigators should be expanded. Despite its threats to specialists, managed care should also provide opportunities for new alliances among neurologists, other specialists, and primary care physicians that will both improve patient care and increase efficiency and cost-effectiveness.
Medically unexplained physical symptoms (MUPS) have a high prevalence in the general population and are associated with psychiatric morbidity. There are indications that MUPS are an important determinant of frequent and long-term disability.
The primary objective was to assess the prevalence of MUPS in sick-listed-employees and its associations with depressive disorders, anxiety disorders, health anxiety, distress and functional impairment. Secondary objectives were to investigate the classification of the occupational health physicians (OHPs), their opinions about the causes as well as the attributions of the employee.
In a cross-sectional study of 489 sick-listed employees from 5 OHP group practices, MUPS, depressive disorders, anxiety disorders, health anxiety, distress and functional impairment were assessed with the Patient Health Questionnaire (PHQ), the Whitely Index (WI), the Four- Dimensional Symptom Questionnaire (4DSQ) and the Short-Form 36 Health Survey (SF-36).
We used a cut off score of 15 on the PHQ for the categorisation of severe MUPS.
The opinions of the OHPs were evaluated by means of a separate questionnaire with regard to the presence of employees physical symptoms, and the symptoms attributions, and the diagnoses of the OHPs.
Severe MUPS had a prevalence of 15.1% in this population of sick-listed employees. These employees had 4-6 times more depressive and anxiety disorders, and were more impaired. Female gender and PHQ-9 scores were determinants of severe MUPS.
Most of the time the OHPs diagnosed employees with severe MUPS as having a mental disorder. The employees attributed their physical symptoms in 66% to mental or to both mental and physical causes.
The prevalence of severe MUPS is higher in long-term sick-listed employees than in the non-sick- listed working population and at least equals the prevalence in the general practice population.
Severe MUPS are associated with psychiatric morbidity and functional impairment and must therefore be specifically recognised as such. Validated questionnaires, such as the PHQ-15, are useful instruments in order to help OHPs to recognise severe MUPS.
To assess DSM-IV lifetime and current psychiatric disorder comorbidity in patients with binge eating disorder (BED) and to examine associations of comorbidity with gender, selected historical obesity-related variables, and current eating disorder psychopathology.
A consecutive series of 404 patients with BED (310 women, 94 men) were reliably administered semistructured diagnostic and clinical interviews to assess DSM-IV psychiatric disorders and features of eating disorders.
Overall, 73.8% of patients with BED had at least one additional lifetime psychiatric disorder and 43.1% had at least one current psychiatric disorder. Lifetime-wise, mood (54.2%), anxiety (37.1%), and substance use (24.8%) disorders were most common. In terms of current comorbidity, mood (26.0%) and anxiety (24.5%) were most common. Few gender differences were observed; men had higher lifetime rates of substance use disorders and current rates of obsessive compulsive disorder. Patients with BED with current psychiatric comorbidity reported earlier age at first diet and higher “lifetime-high” BMI. Patients with current comorbidity also had significantly higher levels of current eating disorder psychopathology and negative affect and lower self-esteem relative to patients with BED with either lifetime (noncurrent) or no psychiatric histories.
Among treatment-seeking patients with BED, the presence of current psychiatric comorbidity is associated with greater eating disorder psychopathology and associated distress.
eating disorders; obesity; psychopathology; gender differences; substance use; psychiatric disorder
Despite evidence that childhood adversities (CAs) are associated with increased risk of mental disorders, little is known about their associations with disorder-related impairment. We report the associations between CAs and functional impairment associated with 12-month DSM-IV disorders in a national sample.
Data come from the US National Comorbidity Survey-Replication. Respondents completed diagnostic interviews that assessed 12-month DSM-IV disorder prevalence and impairment. Associations of 12 retrospectively reported CAs with impairment among cases (n = 2,242) were assessed using multiple regression analysis. Impairment measures included a dichotomous measure of classification in the severe range of impairment on the Sheehan Disability Scale (SDS) and a measure of self-reported number of days out of role due to emotional problems in the past 12 months.
CAs were positively and significantly associated with impairment. Predictive effects of CAs on the SDS were particularly pronounced for anxiety disorders and were significant in predicting increased days out of role associated with mood, anxiety, and disruptive behavior disorders. Predictive effects persisted throughout the life-course and were not accounted for by disorder comorbidity. CAs associated with maladaptive family functioning (MFF) (parental mental illness, substance disorder, criminality, family violence, abuse, neglect) were more consistently associated with impairment than other CAs. The joint effects of comorbid MFF CAs were significantly sub-additive. Simulations suggest that CAs account for 19.6% of severely impairing disorders and 17.4% of days out of role.
CAs predict greater disorder-related impairment, highlighting the ongoing clinical significance of CAs at every stage of the life-course.
Childhood Adversity; Severity; Functional Impairment; Disability