Study Finds Evidence Supporting a Trauma Subtype of Functional Neurological Disorder

Not all patients with functional neurological disorder (FND) report adverse life events. According to the DSM-5, a proximal stressor is not required to diagnose FND. However, a half-dozen cohort studies have reported positive ties between the magnitude of previously experienced adverse life events and the severity of FND symptoms.

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In Frontiers in Psychiatry, researchers at Massachusetts General Hospital report evidence for a clinically significant trauma subtype of FND, based on the high symptom burden of comorbid PTSD or childhood abuse, and the low physical health of comorbid PTSD.

The authors are Sara Paredes-Echeverri, MD, a fellow in the Functional Neurological Disorder Unit and Research Group, Andrew J. Guthrie, a research assistant in the same group, and David L. Perez, MD, MMSc, founder and director of the Functional Neurological Disorders Treatment Program in the Department of Neurology and Department of Psychiatry.

Methods

The researchers prospectively recruited 78 adults (68% female; mean age 43; mean illness duration 4 years) who had been diagnosed with FND and attended the outpatient FND Unit at Mass General between 2014 and 2020. 56 had functional movement disorder, 34 had functional seizures, and 12 had both.

Participants were stratified according to three self-report measures:

• The PTSD Checklist for DSM-5—33 participants had a total score ≥33, indicative of probable PTSD
• The abuse subscales of the Childhood Trauma Questionnaire—46 participants had scores indicating moderate to severe abuse (≥13 for emotional abuse, ≥10 for physical abuse, and/or ≥8 for sexual abuse)
• The neglect subscale of the Childhood Trauma Questionnaire—33 participants had scores indicating moderate-to-severe neglect (≥15 for emotional neglect and/or ≥10 for physical neglect)

The participants also completed three self-report measures of FND symptom severity and a measure of physical health:

• Somatoform Dissociation Questionnaire-20 (SDQ-20)
• Conversion Disorder subscale of the Screening for Somatoform Symptoms–7 (SOMS:CD)
• Patient Health Questionnaire–15 (PHQ-15; measures functional somatic symptoms)
• Physical health subscales of the Short Form Health Survey–36 (SF-36)

Results

FND symptom severity and physical health measures were significantly different between FND patients stratified by PTSD or abuse:

• FND-PTSD—All three symptom severity scores were significantly increased, and the SF-36 physical health scores were significantly decreased in the high-scoring group compared with the low-scoring group
• FND-Abuse—The SDQ-20 and PHQ-15 scores (symptom severity measures) were significantly increased in the high-scoring group
• FND-Neglect—The high- and low-scoring groups did not significantly differ in symptom severity or physical health scores

Implications for Psychotherapy

Framing a trauma subtype of FND has potential implications for treatment, especially psychotherapy. A trauma subtype could benefit from treatment modalities that have been piloted in FND like prolonged exposure therapy, dialectical behavioral therapy, eye movement desensitization and reprocessing, acceptance and commitment therapy, and mindfulness training have all been piloted in FND populations, and other skills-based psychotherapies.

Increased efforts to recognize and research the FND trauma subtype might increase success in pairing a given patient with FND to the psychotherapy most likely to benefit them.

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