Differentiating cerebral ischemia from functional neurological symptom disorder: a psychosomatic perspective

Abstract

BackgroundThe differential diagnosis of pseudo-neurological symptoms often represents a clinical challenge. The Diagnostic and Statistical Manual of Mental Disorders, DSM-5, made an attempt to improve diagnostic criteria of conversion disorder (functional neurological symptom disorder). Incongruences of the neurological examination, i.e. positive neurological signs, indicate a new approach - whereas psychological factors are not necessary anymore. As the DSM-5 will influence the International Classification of Diseases, ICD-11, this is of importance. In the case presented, a history of psychological distress and adverse childhood experiences coexisted with a true neurological disorder. We discuss the relevance of an interdisciplinary assessment and of operationalized diagnostic criteria.Case presentationA 32-year-old man presented twice with neurological symptoms without obvious pathological organic findings. A conversion disorder was considered early on at the second admission by the neurology team. Sticking to ICD-10, this diagnosis was not supported by a specialist for psychosomatic medicine, due to missing hints of concurrent psychological distress in temporal association with neurological symptoms. Further investigations then revealed a deep vein thrombosis (though D-dimers had been negative), which had probably resulted in a crossed embolus.ConclusionThe absence of a clear proof of biological dysfunction underlying neurological symptoms should not lead automatically to the diagnosis of a conversion disorder. In contrast, at least in more complex patients, the work-up should include repeated psychological and neurological assessments in close collaboration. According to ICD-10 positive signs of concurrent psychological distress are required, while DSM-5 emphasizes an incongruity between neurological symptoms and neurophysiological patterns of dysfunction. In the case presented, an extensive medical work-up was initially negative, and neither positive psychological nor positive neurological criteria could be identified. We conclude, that, even in times of more sophisticated operationalization of diagnostic criteria, the interdisciplinary assessment has to be based on an individual evaluation of all neurological and psychosocial findings. Prospective studies of inter-rater reliability and validity of psychological factors and positive neurological signs are needed, as evidence for both is limited. With respect to ICD-11, we suggest that positive neurological as well as psychological signs for functional neurological symptom disorder should be considered to increase diagnostic certainty.

Retracted: Ganoderic Acid A exerts the cytoprotection against hypoxia‐triggered impairment in PC12 cells via elevating microRNA‐153

“…Cerebral ischemia is divided into acute and chronic diseases (Zhao et al, ); acute cerebral ischemia is a familiar disease in the elderly, which has been paid more attention in clinic, but chronic cerebral ischemia has rarely attracted people's attention. The etiology of cerebral ischemia is closely linked to cerebral arteriosclerosis (Moroni et al, ), and chronic cerebral insufficiency is the most likely cause of dizziness, sleep disorders, and memory loss (Chen, Du, Xu, Liu, & Wang, ; Scheidt et al, ). Drug and operation are currently the cardinal treatments for cerebral ischemia (Powers et al, ; Zhang et al, ).…”

A Case with a History of Cerebrovascular Disease: Recurrent Stroke or a Pseudoneurological Dysorder?

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Chronic Functional Tremor: Positive Signs in the Management, Including Mirror Therapy

“…Nota bene: The diagnostic process is itself the “door-opener” to treatment, in particular in functional and somatoform disorders, i.e. diagnostic and treatment processes are tightly interwoven [14]. Here, psychoeducational approaches including demonstration of the signs to the patient and potential reversibility are important [8].…”