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Logo of jnnpsycJournal of Neurology, Neurosurgery and PsychiatryCurrent TOCInstructions for authors
J Neurol Neurosurg Psychiatry. Mar 2005; 76(3): 307–314.
PMCID: PMC1739564

Functional symptoms in neurology: questions and answers


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.

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Selected References

These references are in PubMed. This may not be the complete list of references from this article.
  • Carson AJ, Ringbauer B, Stone J, McKenzie L, Warlow C, Sharpe M. Do medically unexplained symptoms matter? A prospective cohort study of 300 new referrals to neurology outpatient clinics. J Neurol Neurosurg Psychiatry. 2000 Feb;68(2):207–210. [PMC free article] [PubMed]
  • Reid Steven, Wessely Simon, Crayford Tim, Hotopf Matthew. Frequent attenders with medically unexplained symptoms: service use and costs in secondary care. Br J Psychiatry. 2002 Mar;180:248–253. [PubMed]
  • Carson AJ, Ringbauer B, MacKenzie L, Warlow C, Sharpe M. Neurological disease, emotional disorder, and disability: they are related: a study of 300 consecutive new referrals to a neurology outpatient department. J Neurol Neurosurg Psychiatry. 2000 Feb;68(2):202–206. [PMC free article] [PubMed]
  • Carson AJ, Best S, Warlow C, Sharpe M. Suicidal ideation among outpatients at general neurology clinics: prospective study. BMJ. 2000 May 13;320(7245):1311–1312. [PMC free article] [PubMed]
  • Carton Simone, Thompson Pamela J, Duncan John S. Non-epileptic seizures: patients' understanding and reaction to the diagnosis and impact on outcome. Seizure. 2003 Jul;12(5):287–294. [PubMed]
  • Ettinger AB, Devinsky O, Weisbrot DM, Ramakrishna RK, Goyal A. A comprehensive profile of clinical, psychiatric, and psychosocial characteristics of patients with psychogenic nonepileptic seizures. Epilepsia. 1999 Sep;40(9):1292–1298. [PubMed]
  • Stone Jon, Wojcik Wojtek, Durrance Daniel, Carson Alan, Lewis Steff, MacKenzie Lesley, Warlow Charles P, Sharpe Michael. What should we say to patients with symptoms unexplained by disease? The "number needed to offend". BMJ. 2002 Dec 21;325(7378):1449–1450. [PMC free article] [PubMed]
  • Stone Jon, Campbell Karen, Sharma Neelom, Carson Alan, Warlow Charles P, Sharpe Michael. What should we call pseudoseizures? The patient's perspective. Seizure. 2003 Dec;12(8):568–572. [PubMed]
  • Rief W, Hiller W. Toward empirically based criteria for the classification of somatoform disorders. J Psychosom Res. 1999 Jun;46(6):507–518. [PubMed]
  • de Waal Margot W M, Arnold Ingrid A, Eekhof Just A H, van Hemert Albert M. Somatoform disorders in general practice: prevalence, functional impairment and comorbidity with anxiety and depressive disorders. Br J Psychiatry. 2004 Jun;184:470–476. [PubMed]
  • Fink P. Physical complaints and symptoms of somatizing patients. J Psychosom Res. 1992 Feb;36(2):125–136. [PubMed]
  • Miller E. Conversion hysteria: is it a viable concept? Cogn Neuropsychiatry. 1999 Aug;4(3):181–191. [PubMed]
  • Bordini Ernest J, Chaknis Manuel M, Ekman-Turner Rose M, Perna Robert B. Advances and issues in the diagnostic differential of malingering versus brain injury. NeuroRehabilitation. 2002;17(2):93–104. [PubMed]
  • Nimnuan C, Hotopf M, Wessely S. Medically unexplained symptoms: an epidemiological study in seven specialities. J Psychosom Res. 2001 Jul;51(1):361–367. [PubMed]
  • Lempert T, Dieterich M, Huppert D, Brandt T. Psychogenic disorders in neurology: frequency and clinical spectrum. Acta Neurol Scand. 1990 Nov;82(5):335–340. [PubMed]
  • Reuber Markus, Qurishi Assadulah, Bauer Jurgen, Helmstaedter Christoph, Fernandez Guillen, Widman Guido, Elger Christian E. Are there physical risk factors for psychogenic non-epileptic seizures in patients with epilepsy? Seizure. 2003 Dec;12(8):561–567. [PubMed]
  • Caplan LR, Nadelson T. Multiple sclerosis and hysteria. Lessons learned from their association. JAMA. 1980 Jun 20;243(23):2418–2421. [PubMed]
  • Merskey H, Trimble M. Personality, sexual adjustment, and brain lesions in patients with conversion symptoms. Am J Psychiatry. 1979 Feb;136(2):179–182. [PubMed]
  • Oakley DA. Hypnosis and conversion hysteria: a unifying model. Cogn Neuropsychiatry. 1999 Aug;4(3):243–265. [PubMed]
  • Muris Peter, Meesters Cor. Children's somatization symptoms: correlations with trait anxiety, anxiety sensitivity, and learning experiences. Psychol Rep. 2004 Jun;94(3 Pt 2):1269–1275. [PubMed]
  • Salmon Peter, Al-Marzooqi Suad M, Baker Gus, Reilly James. Childhood family dysfunction and associated abuse in patients with nonepileptic seizures: towards a causal model. Psychosom Med. 2003 Jul-Aug;65(4):695–700. [PubMed]
  • Yamasue H, Kasai K, Iwanami A, Ohtani T, Yamada H, Abe O, Kuroki N, Fukuda R, Tochigi M, Furukawa S, et al. Voxel-based analysis of MRI reveals anterior cingulate gray-matter volume reduction in posttraumatic stress disorder due to terrorism. Proc Natl Acad Sci U S A. 2003 Jul 22;100(15):9039–9043. [PMC free article] [PubMed]
  • Bremner J Douglas, Vythilingam Meena, Vermetten Eric, Southwick Steven M, McGlashan Thomas, Nazeer Ahsan, Khan Sarfraz, Vaccarino L Viola, Soufer Robert, Garg Pradeep K, et al. MRI and PET study of deficits in hippocampal structure and function in women with childhood sexual abuse and posttraumatic stress disorder. Am J Psychiatry. 2003 May;160(5):924–932. [PubMed]
  • Ron M. Explaining the unexplained: understanding hysteria. Brain. 2001 Jun;124(Pt 6):1065–1066. [PubMed]
  • Vuilleumier P, Chicherio C, Assal F, Schwartz S, Slosman D, Landis T. Functional neuroanatomical correlates of hysterical sensorimotor loss. Brain. 2001 Jun;124(Pt 6):1077–1090. [PubMed]
  • Spence SA, Crimlisk HL, Cope H, Ron MA, Grasby PM. Discrete neurophysiological correlates in prefrontal cortex during hysterical and feigned disorder of movement. Lancet. 2000 Apr 8;355(9211):1243–1244. [PubMed]
  • Wessely S, Nimnuan C, Sharpe M. Functional somatic syndromes: one or many? Lancet. 1999 Sep 11;354(9182):936–939. [PubMed]
  • Sharpe Michael. Medically unexplained symptoms and syndromes. Clin Med. 2002 Nov-Dec;2(6):501–504. [PubMed]
  • Reuber M, Pukrop R, Bauer J, Derfuss R, Elger CE. Multidimensional assessment of personality in patients with psychogenic non-epileptic seizures. J Neurol Neurosurg Psychiatry. 2004 May;75(5):743–748. [PMC free article] [PubMed]
  • Bowman ES, Markand ON. The contribution of life events to pseudoseizure occurrence in adults. Bull Menninger Clin. 1999 Winter;63(1):70–88. [PubMed]
  • Stone J, Zeman A, Sharpe M. Functional weakness and sensory disturbance. J Neurol Neurosurg Psychiatry. 2002 Sep;73(3):241–245. [PMC free article] [PubMed]
  • Lempert T, Brandt T, Dieterich M, Huppert D. How to identify psychogenic disorders of stance and gait. A video study in 37 patients. J Neurol. 1991 Jun;238(3):140–146. [PubMed]
  • Keane JR. Hysterical gait disorders: 60 cases. Neurology. 1989 Apr;39(4):586–589. [PubMed]
  • Reuber Markus, Elger Christian E. Psychogenic nonepileptic seizures: review and update. Epilepsy Behav. 2003 Jun;4(3):205–216. [PubMed]
  • Cragar Dona E, Berry David T R, Fakhoury Toufic A, Cibula Jean E, Schmitt Frederick A. A review of diagnostic techniques in the differential diagnosis of epileptic and nonepileptic seizures. Neuropsychol Rev. 2002 Mar;12(1):31–64. [PubMed]
  • Bortz JJ, Prigatano GP, Blum D, Fisher RS. Differential response characteristics in nonepileptic and epileptic seizure patients on a test of verbal learning and memory. Neurology. 1995 Nov;45(11):2029–2034. [PubMed]
  • Meyer BU, Britton TC, Benecke R, Bischoff C, Machetanz J, Conrad B. Motor responses evoked by magnetic brain stimulation in psychogenic limb weakness: diagnostic value and limitations. J Neurol. 1992 May;239(5):251–255. [PubMed]
  • Howard JE, Dorfman LJ. Evoked potentials in hysteria and malingering. J Clin Neurophysiol. 1986 Jan;3(1):39–49. [PubMed]
  • Stone J, Sharpe M, Rothwell PM, Warlow CP. The 12 year prognosis of unilateral functional weakness and sensory disturbance. J Neurol Neurosurg Psychiatry. 2003 May;74(5):591–596. [PMC free article] [PubMed]
  • Crimlisk HL, Bhatia K, Cope H, David A, Marsden CD, Ron MA. Slater revisited: 6 year follow up study of patients with medically unexplained motor symptoms. BMJ. 1998 Feb 21;316(7131):582–586. [PMC free article] [PubMed]
  • Couprie W, Wijdicks EF, Rooijmans HG, van Gijn J. Outcome in conversion disorder: a follow up study. J Neurol Neurosurg Psychiatry. 1995 Jun;58(6):750–752. [PMC free article] [PubMed]
  • Nimnuan C, Hotopf M, Wessely S. Medically unexplained symptoms: how often and why are they missed? QJM. 2000 Jan;93(1):21–28. [PubMed]
  • Reuber M, Fernández G, Bauer J, Helmstaedter C, Elger CE. Diagnostic delay in psychogenic nonepileptic seizures. Neurology. 2002 Feb 12;58(3):493–495. [PubMed]
  • Kanner AM, Parra J, Frey M, Stebbins G, Pierre-Louis S, Iriarte J. Psychiatric and neurologic predictors of psychogenic pseudoseizure outcome. Neurology. 1999 Sep 22;53(5):933–938. [PubMed]
  • Mace CJ, Trimble MR. Ten-year prognosis of conversion disorder. Br J Psychiatry. 1996 Sep;169(3):282–288. [PubMed]
  • Gunatilake SB, De Silva HJ, Ranasinghe G. Twenty-seven venous cutdowns to treat pseudostatus epilepticus. Seizure. 1997 Feb;6(1):71–72. [PubMed]
  • Smith PE, Saunders J, Dawson A, Kerr MP. Intractable seizures in pregnancy. Lancet. 1999 Oct 30;354(9189):1522–1522. [PubMed]
  • Reuber M, Baker GA, Gill R, Smith DF, Chadwick DW. Failure to recognize psychogenic nonepileptic seizures may cause death. Neurology. 2004 Mar 9;62(5):834–835. [PubMed]
  • Lipsitt DR. The factitious patient who sues. Am J Psychiatry. 1986 Nov;143(11):1482–1482. [PubMed]
  • Alsaadi Taoufik M, Thieman Catherine, Shatzel Alan, Farias Sarah. Video-EEG telemetry can be a crucial tool for neurologists experienced in epilepsy when diagnosing seizure disorders. Seizure. 2004 Jan;13(1):32–34. [PubMed]
  • Glick TH, Workman TP, Gaufberg SV. Suspected conversion disorder: foreseeable risks and avoidable errors. Acad Emerg Med. 2000 Nov;7(11):1272–1277. [PubMed]
  • Prashanth LK, Taly AB, Sinha S, Arunodaya GR, Swamy HS. Wilson's disease: diagnostic errors and clinical implications. J Neurol Neurosurg Psychiatry. 2004 Jun;75(6):907–909. [PMC free article] [PubMed]
  • Tait RC, Chibnall JT. Physician judgments of chronic pain patients. Soc Sci Med. 1997 Oct;45(8):1199–1205. [PubMed]
  • Page LA, Wessely S. Medically unexplained symptoms: exacerbating factors in the doctor-patient encounter. J R Soc Med. 2003 May;96(5):223–227. [PMC free article] [PubMed]
  • Gask Linda, Usherwood Tim. ABC of psychological medicine. The consultation. BMJ. 2002 Jun 29;324(7353):1567–1569. [PMC free article] [PubMed]
  • Aboukasm A, Mahr G, Gahry BR, Thomas A, Barkley GL. Retrospective analysis of the effects of psychotherapeutic interventions on outcomes of psychogenic nonepileptic seizures. Epilepsia. 1998 May;39(5):470–473. [PubMed]
  • Shen W, Bowman ES, Markand ON. Presenting the diagnosis of pseudoseizure. Neurology. 1990 May;40(5):756–759. [PubMed]
  • Creed F, Guthrie E. Techniques for interviewing the somatising patient. Br J Psychiatry. 1993 Apr;162:467–471. [PubMed]
  • Jackson JL, Kroenke K. The effect of unmet expectations among adults presenting with physical symptoms. Ann Intern Med. 2001 May 1;134(9 Pt 2):889–897. [PubMed]
  • Goldberg D, Gask L, O'Dowd T. The treatment of somatization: teaching techniques of reattribution. J Psychosom Res. 1989;33(6):689–695. [PubMed]
  • Katon W, Sullivan M, Walker E. Medical symptoms without identified pathology: relationship to psychiatric disorders, childhood and adult trauma, and personality traits. Ann Intern Med. 2001 May 1;134(9 Pt 2):917–925. [PubMed]
  • Binzer M, Andersen PM, Kullgren G. Clinical characteristics of patients with motor disability due to conversion disorder: a prospective control group study. J Neurol Neurosurg Psychiatry. 1997 Jul;63(1):83–88. [PMC free article] [PubMed]
  • van Hemert AM, Hengeveld MW, Bolk JH, Rooijmans HG, Vandenbroucke JP. Psychiatric disorders in relation to medical illness among patients of a general medical out-patient clinic. Psychol Med. 1993 Feb;23(1):167–173. [PubMed]
  • Henningsen Peter, Zimmermann Thomas, Sattel Heribert. Medically unexplained physical symptoms, anxiety, and depression: a meta-analytic review. Psychosom Med. 2003 Jul-Aug;65(4):528–533. [PubMed]
  • Reuber Markus, House Allan O, Pukrop Ralf, Bauer Jürgen, Elger Christian E. Somatization, dissociation and general psychopathology in patients with psychogenic non-epileptic seizures. Epilepsy Res. 2003 Dec;57(2-3):159–167. [PubMed]
  • Goldstein Laura H, Deale Alicia C, Mitchell-O'Malley Sara J, Toone Brian K, Mellers John D C. An evaluation of cognitive behavioral therapy as a treatment for dissociative seizures: a pilot study. Cogn Behav Neurol. 2004 Mar;17(1):41–49. [PubMed]
  • Hiller Wolfgang, Fichter Manfred M, Rief Winfried. A controlled treatment study of somatoform disorders including analysis of healthcare utilization and cost-effectiveness. J Psychosom Res. 2003 Apr;54(4):369–380. [PubMed]
  • Allen Lesley A, Escobar Javier I, Lehrer Paul M, Gara Michael A, Woolfolk Robert L. Psychosocial treatments for multiple unexplained physical symptoms: a review of the literature. Psychosom Med. 2002 Nov-Dec;64(6):939–950. [PubMed]
  • Kroenke K, Swindle R. Cognitive-behavioral therapy for somatization and symptom syndromes: a critical review of controlled clinical trials. Psychother Psychosom. 2000 Jul-Aug;69(4):205–215. [PubMed]
  • Speckens AE, van Hemert AM, Spinhoven P, Hawton KE, Bolk JH, Rooijmans HG. Cognitive behavioural therapy for medically unexplained physical symptoms: a randomised controlled trial. BMJ. 1995 Nov 18;311(7016):1328–1332. [PMC free article] [PubMed]
  • Bleichhardt Gaby, Timmer Barbara, Rief Winfried. Cognitive-behavioural therapy for patients with multiple somatoform symptoms--a randomised controlled trial in tertiary care. J Psychosom Res. 2004 Apr;56(4):449–454. [PubMed]
  • Barsky Arthur J, Ahern David K. Cognitive behavior therapy for hypochondriasis: a randomized controlled trial. JAMA. 2004 Mar 24;291(12):1464–1470. [PubMed]
  • Speckens AE, van Hemert AM, Spinhoven P, Hawton KE, Bolk JH, Rooijmans HG. Cognitive behavioural therapy for medically unexplained physical symptoms: a randomised controlled trial. BMJ. 1995 Nov 18;311(7016):1328–1332. [PMC free article] [PubMed]
  • Creed Francis, Fernandes Lakshmi, Guthrie Elspeth, Palmer Stephen, Ratcliffe Joy, Read Nicholas, Rigby Christine, Thompson David, Tomenson Barbara. The cost-effectiveness of psychotherapy and paroxetine for severe irritable bowel syndrome. Gastroenterology. 2003 Feb;124(2):303–317. [PubMed]
  • Guthrie E, Creed F, Dawson D, Tomenson B. A controlled trial of psychological treatment for the irritable bowel syndrome. Gastroenterology. 1991 Feb;100(2):450–457. [PubMed]
  • Whorwell PJ, Prior A, Faragher EB. Controlled trial of hypnotherapy in the treatment of severe refractory irritable-bowel syndrome. Lancet. 1984 Dec 1;2(8414):1232–1234. [PubMed]
  • Reilly J, Baker GA, Rhodes J, Salmon P. The association of sexual and physical abuse with somatization: characteristics of patients presenting with irritable bowel syndrome and non-epileptic attack disorder. Psychol Med. 1999 Mar;29(2):399–406. [PubMed]
  • Schilte AF, Portegijs PJ, Blankenstein AH, van Der Horst HE, Latour MB, van Eijk JT, Knottnerus JA. Randomised controlled trial of disclosure of emotionally important events in somatisation in primary care. BMJ. 2001 Jul 14;323(7304):86–86. [PMC free article] [PubMed]
  • Sharpe M, Peveler R, Mayou R. The psychological treatment of patients with functional somatic symptoms: a practical guide. J Psychosom Res. 1992 Sep;36(6):515–529. [PubMed]
  • O'Malley PG, Jackson JL, Santoro J, Tomkins G, Balden E, Kroenke K. Antidepressant therapy for unexplained symptoms and symptom syndromes. J Fam Pract. 1999 Dec;48(12):980–990. [PubMed]
  • Soloff PH. Algorithms for pharmacological treatment of personality dimensions: symptom-specific treatments for cognitive-perceptual, affective, and impulsive-behavioral dysregulation. Bull Menninger Clin. 1998 Spring;62(2):195–214. [PubMed]
  • Russo J, Katon W, Sullivan M, Clark M, Buchwald D. Severity of somatization and its relationship to psychiatric disorders and personality. Psychosomatics. 1994 Nov-Dec;35(6):546–556. [PubMed]
  • Paykel ES, Tylee A, Wright A, Priest RG, Rix S, Hart D. The Defeat Depression Campaign: psychiatry in the public arena. Am J Psychiatry. 1997 Jun;154(6 Suppl):59–65. [PubMed]
  • Stone J, Durrance D, Wojcik W, Carson A, Sharpe M. What do medical outpatients attending a neurology clinic think about antidepressants? J Psychosom Res. 2004 Mar;56(3):293–295. [PubMed]
  • Soloff PH. Psychopharmacology of borderline personality disorder. Psychiatr Clin North Am. 2000 Mar;23(1):169–ix. [PubMed]
  • Binder LM, Salinsky MC, Smith SP. Psychological correlates of psychogenic seizures. J Clin Exp Neuropsychol. 1994 Aug;16(4):524–530. [PubMed]
  • Kristensen O, Alving J. Pseudoseizures--risk factors and prognosis. A case-control study. Acta Neurol Scand. 1992 Mar;85(3):177–180. [PubMed]
  • Fink Per, Rosendal Marianne, Toft Tomas. Assessment and treatment of functional disorders in general practice: the extended reattribution and management model--an advanced educational program for nonpsychiatric doctors. Psychosomatics. 2002 Mar-Apr;43(2):93–131. [PubMed]
  • Smith GR, Jr, Monson RA, Ray DC. Psychiatric consultation in somatization disorder. A randomized controlled study. N Engl J Med. 1986 May 29;314(22):1407–1413. [PubMed]
  • Morriss RK, Gask L, Ronalds C, Downes-Grainger E, Thompson H, Goldberg D. Clinical and patient satisfaction outcomes of a new treatment for somatized mental disorder taught to general practitioners. Br J Gen Pract. 1999 Apr;49(441):263–267. [PMC free article] [PubMed]
  • Binzer M, Kullgren G. Motor conversion disorder. A prospective 2- to 5-year follow-up study. Psychosomatics. 1998 Nov-Dec;39(6):519–527. [PubMed]
  • Carson AJ, Best S, Postma K, Stone J, Warlow C, Sharpe M. The outcome of neurology outpatients with medically unexplained symptoms: a prospective cohort study. J Neurol Neurosurg Psychiatry. 2003 Jul;74(7):897–900. [PMC free article] [PubMed]
  • Reuber Markus, Pukrop Ralf, Bauer Jürgen, Helmstaedter Christoph, Tessendorf Natalie, Elger Christian Erich. Outcome in psychogenic nonepileptic seizures: 1 to 10-year follow-up in 164 patients. Ann Neurol. 2003 Mar;53(3):305–311. [PubMed]
  • Crimlisk HL, Bhatia KP, Cope H, David AS, Marsden D, Ron MA. Patterns of referral in patients with medically unexplained motor symptoms. J Psychosom Res. 2000 Sep;49(3):217–219. [PubMed]
  • Coia P, Morley S. Medical reassurance and patients' responses. J Psychosom Res. 1998 Nov;45(5):377–386. [PubMed]
  • Richardson Ralph D, Engel Charles C., Jr Evaluation and management of medically unexplained physical symptoms. Neurologist. 2004 Jan;10(1):18–30. [PubMed]

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