Original Article |
Corresponding author: Mehmet Hamdi Orum ( mhorum@hotmail.com ) © 2022 Mehmet Hamdi Orum, Murad Atmaca.
This is an open access article distributed under the terms of the Creative Commons Attribution License (CC BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Citation:
Orum MH, Atmaca M (2022) Motor and somatosensory symptoms determine cognitive error levels in functional neurological symptom disorder/conversion disorder. Folia Medica 64(4): 581-587. https://doi.org/10.3897/folmed.64.e62966
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Introduction: The level of cognitive error in functional neurological symptom disorder (FNSD, conversion disorder) subtypes [psychogenic non-epileptic seizure (PNES), motor (M), PNES plus motor (PM), motor plus somatosensory (MS)] have not yet been investigated.
Aim: We aimed to qualify the level of cognitive error in FNSD subtypes.
Materials and methods: The disorder symptoms were assessed via the somatoform dissociation questionnaire (SDQ), the symptom check list-90-revised (SCL-90-R), and the global assessment scale (GAS). The cognitive distortions scale (CDS) was used to evaluate cognitive errors.
Results: Mean ages of groups were 28.37±6.99 years (PNES, n=24), 27.90±6.22 years (M, n=21), 30.36±7.86 years (PM, n=19), 31.38±9.02 years (MS, n=21), and 30.87±7.17 years (control, n=48) (p=0.377). In terms of the global severity index of SCL-90-R, there were significant differences between PNES and PM (p=0.003); PNES and MS (p<0.001); M and MS (p<0.001); PM and MS (p=0.001). The scores of CDS-IP were similar between PM and M (p>0.999); PM and MS (p=0.172). There was no significant difference between the CDS-PA scores of the patient groups (p>0.05).
Conclusions: Our study demonstrated that in FNSD, the somatosensory symptoms were more associated with cognitive errors related to interpersonal relationships than the motor symptoms and the motor symptoms were more than PNES.
cognition, conversion disorder, functional neurological symptom disorder, psychogenic non-epileptic seizure
Functional neurological symptom disorder (FNSD), also known as conversion disorder (CD), as defined in the Fifth Edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5)[
Cognitive errors are simply the ways by which our mind convinces us of something that is not really true and they cause instant, unplanned negative automatic thoughts about an event. These negative interpretations have a fundamental role in the emergence of psychological problems.[
Studying cognitive errors in PNES, motor, somatosensory, and mixed FNSD may provide insights into whether subjects with one subtype of FNSD differ from those with other FNSD subtypes in certain cognitive error features, thence introducing possibilities for qualifying cognitive error profiles of these subtypes.
In this study, we aimed to compare the cognitive error levels of the FNSD subtypes and the control group. Cognitive error levels were determined on a scale, and ten different cognitive errors were questioned with the help of this scale (mindreading, catastrophizing, all-or-nothing thinking, emotional reasoning, labeling, mental filter, overgeneralization, personalization, should statements, minimizing the positive). Our hypothesis is that the FNSD group has a higher cognitive error level than the control group and that the cognitive error levels of the FNSD subtypes differed among themselves.
This is a single blind, cross-sectional study with female patients from the psychiatric outpatient clinic of our hospital. Patients admitted to our outpatient clinic due to the FNSD symptoms were included in the study. Patients whose somatoform dissociation questionnaire (SDQ) responses were compatible with admission complaints were divided into groups. In this way, four patient groups were formed: PNES, motor FNSD (M), PNES plus M (PM), and M plus somatosensory FNSD (MS). The control group consisted of healthy female volunteers. Interviews were conducted in an environment suitable for psychiatric examination. This study was carried out between October 1, 2019 and June 1, 2020. The study was conducted in compliance with the Declaration of Helsinki; the protocol was approved by the Ethics Committee of Adiyaman University and all study participants provided written informed consent (Project Identification Code: 2019/9-18).
Loss of touch or pain sensation, double vision, blindness, deafness, hallucination, anesthesia, hyperesthesia, and paresthesia were accepted as somatosensory symptoms. Coordination and balance disturbance, paralysis, localized weakness, difficulty swallowing, lump in the throat, aphonic, and urinary retention were accepted as motor symptoms.
The study included:
The following were excluded from the study:
All patients were directly interviewed by a psychiatrist. The research protocol included demographic data, family psychiatric history, and a range of other structured interviews. The main assessment instruments are briefly described below.
A form containing sociodemographic and clinical information was filled in by the researcher. Age, gender, education level, marital status, working status, and family psychiatric history were used as variables in the questionnaire.
SCL-90-R is a 90-item self-report of subjects’ symptoms and psychopathologic features on subscales: paranoid ideation (PAR), interpersonal sensitivity (I-S), hostility (HOS), psychoticism (PSY), phobic anxiety (PHOB), anxiety (ANX), somatization (SOM), depression (DEP), obsessive-compulsive (O-C), additional (AD) and global severity index (GSI). It can be filled in approximately 15 minutes. It is a measure of the current psychological symptom status with the time reference of “last 7 days, including today”. The scores for each of the nine factors are the average rating given to the symptoms of that factor. The remaining seven items do not measure any particular factor, but are evaluated qualitatively. Three “global” scores were also obtained. GSI is an average of 90 items. There is a scoring range from zero to four. The validity and reliability study of the Turkish version was conducted by Kilic.[
This is a 20-item self-report, Likert type scale instrument developed by Covin et al.[
SDQ is a 20-item self-report instrument that evaluates the severity of somatoform dissociation. Some of the items question the motor symptoms, some of them somatosensory symptoms and some question the PNES. It was developed by Nijenhuis et al.[
It is a grading scale that is applied in a short time and covers all aspects (psychological, social, and professional functionality) of changes in psychopathology. It was developed by Endicott[
Version 22.0 of SPSS (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp) was used for all statistical analyses. The numerical data were expressed as means and standard deviations, and the categorical data were expressed as frequencies and percentages. Normal distribution suitability was assessed using visual and analytical methods (Kolmogorov-Smirnov/Shapiro-Wilk test). Fisher’s exact test was used to analyze the categorical data. One-way ANOVA test was used for five independent groups with no normal distribution. A post-hoc Tamhane’s T2 test was used when a significant difference was found between the five independent groups. The relationship between the variables was assessed by the Spearman correlation test. Receiver operating characteristic (ROC) curve analysis was used to measure the diagnostic value of CDS-IP. A p value of less than 0.05 was considered statistically significant.
There were 133 female subjects (85 patients, 48 healthy controls) in the study. Twenty-four (28.23%) of the patients were PNES, 21 (24.70%) were M, 19 (22.35%) were PM, and 21 (24.72%) were MS. The mean age in the patient group was 29.44±7.57 (min=18; max=45) years, and in the control group, it was 30.87±7.17 years (min=18; max=41) (p=0.289). Age range of patient groups were 18-40 years for PNES, 19-38 years for M, 19-41 years for PM, and 20-45 years for MS. The disorder onset in the patient group was 21.37±4.48 years. There was no history of psychiatric hospitalization in the patient group. The education levels of the patient and control groups were similar (p=0.119). The rate of employment in the control group was higher than in the patient group (p=0.002). The comparison of the sociodemographic data of the patient and control groups is shown in Table
Variables | Patient n (%) | Control n (%) | p | |
Marital status | Married | 48 (56.5) | 30 (62.5) | 0.055 |
Single | 25 (29.4) | 18 (37.5) | ||
Widow | 5 (5.9) | 0 (0.0) | ||
Divorced | 7 (8.2) | 0 (0.0) | ||
Working status | Yes | 31 (36.5) | 31 (64.6) | 0.002* |
Housewife | 54 (63.5) | 17 (35.4) | ||
Family psychiatric history | Yes | 32 (37.6) | 7 (14.6) | 0.005* |
No | 53 (62.4) | 41 (85.4) |
In 40 (47.5%) of the patients, the SDQ score was 35 and above. There was no one in the PNES group with an SDQ score of 35 or above. In the M group, there were 2 subjects (5.0%) with an SDQ score of 35 and above. In the PM group, there were 17 subjects (42.5%) with an SDQ score of 35 and above. There were 21 people (52.5%) with an SDQ score of 35 and above in the MS group.
Correlation analysis performed after checking the effect of age and education level in the patient group is shown in Table
Comparison of patient subgroups and control groups in terms of various variables is shown in Table
ROC analysis was performed based on 42 subjects (21 M and 21 MS). The area under the ROC curve of the CDS-IP score for MS was 0.882 (p<0.001; 95% CI 0.758-1.000). The optimal cut-off score for CDS-IP was 55.5, and its sensitivity and specificity for the diagnosis of MS were 90.5% and 91.0%, respectively.
Onset of disorder r, p | GSI r, p | GAS r, p | CDS-PA r, p | SDQ r, p | |
CDS-IP | −0.226, 0.040* | 0.794, <0.001** | −0.753, <0.001** | −0.192, 0.081 | 0.772, <0.001** |
Comparison of GSI, CDS, GAS, and SDQ values of patient subgroups and control groups.
Variables | PNES (n=24) Mean±SD | M (n=21) Mean±SD | PM (n=19) Mean±SD | MS (n=21) Mean±SD | Control (n=48) Mean±SD | p |
Age (years) | 28.37±6.99 | 27.90±6.22 | 30.36±7.86 | 31.38±9.02 | 30.87±7.17 | 0.377 |
Education (years) | 6.79±2.321 | 9.33±3.42 | 8.47±2.93 | 8.23±2.60 | 9.04±3.461 | 0.037* |
GSI | 1.20±0.371 | 1.43±0.552 | 2.00±0.751,3 | 3.05±0.761,2,3,4 | 0.20±0.171,2,3,4 | <0.001** |
GAS | 74.62±5.581 | 73.38±6.382 | 61.78±9.141,2,3 | 55.90±7.751,2,4 | 89.33±4.641,2,3,4 | <0.001** |
CDS-IP | 45.50±6.291 | 51.71±4.741,2 | 52.57±6.001,3 | 57.47±6.601,2,4 | 26.64±3.021,2,3,4 | <0.001** |
CDS-PA | 27.91±3.67 | 26.38±4.39 | 28.31±3.46 | 27.71±3.43 | 25.70±2.88 | 0.068 |
CDS-T | 73.41±7.681 | 78.09±5.032 | 80.89±5.071,3 | 85.19±5.561,2,4 | 52.35±4.341,2,3,4 | <0.001** |
SDQ | 27.79±7.001 | 33.52±7.372 | 47.10±12.281,2,3 | 61.42±12.691,2,3,4 | 20.81±1.101,2,3,4 | <0.001* |
In this study, we investigated the level of cognitive errors in IP and PA domains of the FNSD subtypes and compared the results with healthy controls. The similarity of age and education levels between patient and control groups facilitated the interpretation of the findings.
Many psychiatric symptoms are often accompanied by FNSD.[
Dysfunctional beliefs in the cognitive structure shape the individual’s thinking and lead to cognitive errors specific to psychopathology.[
The specific findings of this study regarding the cognitive error levels contribute to further identifying discrete intragroup differences within FNSD subtypes. The findings will be relevant to clinicians attempting to treat FNSD symptoms with cognitive behavioral therapy and medication. Identifying the increased level of cognitive error will allow physicians to accurately select the treatment. Because cognitive behavioral therapy is a structured form of therapy that emphasizes how our thoughts determine what we feel and how we behave[
This is the first study examining the relationship between FNSD subtypes and cognitive error levels. In our study, FNSD, especially in the somatosensory subtype, was associated with high cognitive error levels. In the somatosensory and motor subtypes, cognitive error levels related to interpersonal relationships were higher than the psychogenic non-epileptic seizure. The psychiatric symptom-cognitive error correlation was prominent in the FNSD. The relationship of the personal achievement domain of cognitive errors with FNSD subtypes was not significant. Our study suggests that a detailed evaluation of symptoms and determination of FNSD subtypes will affect treatment outcomes. On the other hand, we also suggest that based on these findings, comments can be made about the cognitive error levels of FNSD subtypes. The fact that some scale scores are similar does not mean that the clinical characteristics of the patient subtypes are similar.
Our study has several limitations. There is a need to increase the sample size in further studies. Although the recovery of men diagnosed with FNSD takes longer, studies involving both genders can be conducted. Family psychiatric history was statistically different between the patient and control groups, and it was required to be considered as a confounding factor and stated as a limitation. In this study, cognitive error levels were examined only in terms of interpersonal relationships and individual achievement domains. Cognitive error types were not examined separately according to disease diagnoses. It is recommended that future studies should focus on the types of cognitive errors according to the diagnoses. It is thought that the results will be better interpreted by increasing the scale diversity, expanding the sociodemographic data, elaborating the FNSD history.
This study received no grant funding from any agency in the public, commercial or not-for profit sectors.
Statement of Ethics
The study was conducted in accordance with the provisions of the Declaration of Helsinki. The protocol was approved by the Ethics Committee of Adiyaman University. Written informed consent was obtained from all study participants (Project Identification Code: 2019/9-18).
Conflicts of Interest
The authors declare no conflict of interest.
Funding Sources
This research received no external funding.
Author Contributions
M.H.O.: conceptualization, methodology, software, validation, formal analysis, investigation, resources, data curation, writing - original draft preparation, writing - review and editing, visualization, supervision, project administration, and funding acquisition; M.A.: review and editing, supervision, project administration, methodology. The authors have read and agreed to the published version of the manuscript.