Download Functional disorders: a neurologist`s account

doi:10.1093/brain/awv299
BRAIN 2016: 139; 300–302
| 300
DORSAL COLUMN
Book Review
Functional disorders: a neurologist’s account
The back cover of this book states that ‘a neurologist
explores the very real world of psychosomatic illness’,
although I note that in the current real world the internet
bloggers are already firing off irate responses to the provocative title with its imputation that they have ‘imaginary’
illnesses. Despite this avalanche of online abuse (to which
psychiatrists working in this field have become inured), the
book has received favourable reviews in the national press,
which suggests a considerable interest in the subject and is
also a testament to good writing.
In the introductory chapter, O’Sullivan defines the problem clinicians have in classifying the diverse manifestations
of functional neurology. She describes the recently introduced definitions listed in the Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition, the prevalence
of these disorders and the enormous cost to the health care
system. There are a few errors: somatic symptom disorder
is not a ‘rare and devastating problem’, it affects 5–7% of
the population; illness is not ‘a response to a disease’, it is a
collection of diverse symptoms; and patients do not ‘unconsciously think themselves ill’, they really believe that they
are. There is also excessive use of the word ‘subconscious’
with its Freudian connotations.
The bulk of the book involves descriptions of case histories with complex somatoform disorders familiar to most
neurologists (and liaison psychiatrists like myself who have
to treat them). These include a young polysymptomatic
wheelchair-user who is self-catheterizing; a woman with
functional blindness; a young man convinced that he has
multiple sclerosis despite evidence to the contrary; a patient
who develops a functional movement disorder after a trivial
limb injury; another with functional blepharospasm; as well
as chronic fatigue syndrome and many patients with nonepileptic seizures. The accounts of the various illnesses (and
abnormal illness behaviour) are interesting and written in
an engaging style. O’Sullivan is clearly a good listener and
her formulations of her patients’ complex presentations are
accessible and plausible. She explains the dilemmas faced
by neurologists in managing these clinical conundrums:
how to deliver news of reassuringly negative results,
IT’S ALL IN YOUR HEAD:
TRUE STORIES OF
IMAGINARY ILLNESS
By Suzanne O’Sullivan, 2015
London: Chatto and Windus
EAN: 9780701189266
Price: £16.99
managing patients and families in denial, attempts to explain the nature of dissociation, dealing with demands for
more tests etc. O’Sullivan is keenly aware of the role that
developmental factors, previous illness experience and beliefs and expectations can have in shaping a functional
neurological disorder.
My main criticism is the excessive reference to the term
‘subconscious’ and to the writings of Freud, Charcot and
Janet and their influence on thinking in this field. She might
have mentioned that Russell Reynolds, a neurologist writing in the British Medical Journal in 1869, noted that ‘. . .
some of the most important disorders of the nervous system. . . may depend on the morbid condition of an idea, or
of idea and emotion together. . . Such symptoms often exist
for a long time and disappear entirely on the removal of
the erroneous idea’. Just so. I have never forgotten a mischievous lecture by the late Sean Spence to a mixed audience of North American psychiatrists and neurologists as
he calmly announced that the Freudian contribution to
functional neurology was a diversion that lasted over
half a century. I would have liked more discussion of
modern theories and explanatory models, for example as
outlined by Spence and the recently proposed broader
Received August 14, 2015. Accepted August 14, 2015
ß The Author (2015). Published by Oxford University Press on behalf of the Guarantors of Brain. All rights reserved.
For Permissions, please email: [email protected]
Book Review
BRAIN 2016: 139; 300–302
| 301
Figure 1 A simple cognitive model of physical symptoms. From Price and Leaver (2002). Reproduced with permission from BMJ
Publishing.
biopsychosocial models, which include psychological concepts such as attentional bias, expectations, prior experience and cultural beliefs (e.g. Edwards et al. 2012).
Far from being arcane disorders ignored by neurologists,
there has been a resurgence of interest in functional disorders, driven by collaborative research between neurologists, psychiatrists and neuropsychologists (Fig. 1). Two
meetings on functional movement disorders in 2005 and
2011, both held in the USA, led to the publication of influential textbooks and an awareness that these disorders
are much more common than had previously been thought
(Hallett et al., 2006, 2011). The subject is alive and well in
the UK, where the UK Functional Neurological Symptoms
Group (UK-FNS) was established in 2011 and now meets
annually in October. These meetings are multidisciplinary
and involve discussions of recent research and free exchange of ideas as well as a web forum (Carson et al.,
2012). O’Sullivan can be reassured that there is now a
cohort of young neurologists (and psychiatrists/neuropsychologists) with an active interest in these disorders, who
have made a major contribution to our understanding of
them in the last decade.
Finally, O’Sullivan asks the $64 000 question: ‘Why,
when neurologists know that conversion disorders are so
common, are we so ill-equipped to deal with them’? This
leads to a discussion of the stigma associated with medically unexplained symptoms (MUS) and a lack of understanding by doctors of mind-body interactions. But in
what other profession would education be so decontextualized, allowing neurologists to train without any curriculum
time devoted to the detection and management of one third
of their outpatient case load? Regrettably, the situation in
medical school is not encouraging, as doctors in training
are currently taught medicine and psychiatry as if they were
different disciplines, perpetuating the mind-body split that
permeates our health care system. Attitudes to teaching are
relevant because patients with MUS comprise one-fifth of
the workload in primary care and one-third to one-half of
all patients attending specialist outpatient clinics. It is regrettable therefore that teaching of MUS across medical
schools remains highly variable, with little evidence that
formal teaching on this topic takes place in medical or
surgical specialties (Howman et al., 2012). In the absence
of formal teaching it is not surprising that the outcome for
these patients is often negative.
This book is a constructive contribution and should lead
to a greater awareness and understanding of these common
and neglected clinical problems. It deserves to be widely
read, not only by patients and relatives, but also by neurologists and doctors in training.
Christopher Bass
Consultant in Liaison psychiatry,
John Radcliffe Hospital,
Oxford OX3 9DU, UK
E-mail: [email protected]
Advance Access publication October 21, 2015
References
Carson A, Brown R, David A, Duncan R, Edwards MJ, Goldstein LH,
et al. Functional (conversion) neurological symptoms: research since
the millennium. J Neurol Neurosurg Psychiatry 2012; 83:842–50.
302
| BRAIN 2016: 139; 300–302
Edwards M, Adams RA, Brown H, Pareés I, Friston KJ. A Bayesian
account of hysteria. Brain 2012; 135: 3495–12.
Hallett M, Fahn F, Jankovic J, Lang AE, Cloninger CB, Yudofsky SC,
editors. Psychogenic movement disorders: neurology and neuropsychiatry. Philadelphia, PA: Lippincott Williams and Wilkins; 2006.
Hallett M, Lang A, Jankovic J, Fahn S, Halligan PW, Voon V, et al.
editors. Psychogenic movement disorders and other conversion disorders. Cambridge: Cambridge University Press; 2011.
Book Review
Howman M, Walters K, Rosenthal J, Good M, Busziewicz M.
Teaching about medically unexplained symptoms at medical schools
in the United Kindgdom. Med Teach 2012; 34: 327–29.
Price J, Leaver L. Beginning treatment. BMJ 2002; 325: 33–5.
Russell Reynolds J. Certain forms of paralysis depending on idea. BMJ
1869; 2; 378–80.