"Objective The term functional has a distinguished history, embodying a number of physiological concepts, but has increasingly come to mean hysterical. The DSM-V working group proposes to use functional as the official diagnostic term for medically unexplained neurological symptoms (currently known as conversion disorder). This study aimed to explore the current neurological meanings of the term and to understand its resilience."
A few notes:
The revision of the existing DSM-IV category "Conversion Disorder" has been the purview of both the DSM-5 Work Group for "Somatic Symptom Disorders" and the Work Group for "Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders."
None of the authors of this paper (Richard A Kanaan, David Armstrong, Simon C Wessely) are members of either of these two Work Groups.
The paper was
Received July 18, 2011;
Revised October 12, 2011;
Accepted October 19, 2011.
Published March, 2012.
So the paper was first submitted last year, shortly after the second DSM-5 stakeholder review and comment period closed (May 4-July 15) and was likely in preparation* at the time of the second stakeholder review and based on proposals as they had stood when released in May 2011 for public review.
*Before the publication, on May 4, 2011, of the "Disorders Description" PDF that accompanies proposals, an interim PDF was posted on the DSM-5 Development site, dated January 14, 2011. A number of edits had been made to the February 2010 version of this document, including the proposed term "Functional Neurological Disorder" to replace "Conversion Disorder." So the term "Functional Neurological Disorder" had been proposed by the SSD Work Group since at least January 2011.
Current proposals for the revision of "Conversion Disorder" can be found here on the DSM-5 Development site:
http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=8
A new name for "Conversion Disorder" has remained under discussion. But the name proposed in May 2011, at the point of the second stakeholder review, was "Functional Neurological Disorder" and remains as such on the DSM-5 Development site.
The "Somatic Symptom Disorders" Work Group and the "Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders" Work Group have been discussing whether "Functional Neurological Disorder" (or whatever name is eventually decided upon) would be better placed under "Dissociative Disorders" rather than under "Somatic Symptom Disorders."
("Conversion Disorder" is currently located under "Dissociative Disorders" in ICD-10.)
The discussion paper below, which addresses the naming, location and criteria for "Conversion Disorder" was published in the December issue of the Journal of Psychosomatic Research.
http://www.jpsychores.com/article/S0022-3999(11)00213-3/abstract
Journal of Psychosomatic Research
Volume 71, Issue 6 , Pages 369-376, December 2011
Conversion Disorder: Current problems and potential solutions for DSM-5
Jon Stone, W. Curt LaFrance, Richard Brown, David Spiegel, James L. Levenson, Michael Sharpe.
Abstract
Conversion disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) describes neurological symptoms, including weakness, numbness and events resembling epilepsy or syncope, which can be positively identified as not being due to recognised neurological disease. This review combines perspectives from psychiatry, psychology and neurology to identify and discuss key problems with the current diagnostic DSM-IV criteria for conversion disorder and to make the following proposals for DSM-5: (a) abandoning the label conversion disorder and replacing it with an alternative term that is both theoretically neutral and potentially more acceptable to patients and practitioners; (b) relegating the requirements for association of psychological factors and the exclusion of feigning to the accompanying text; (c) adding a criterion requiring clinical findings of internal inconsistency or incongruity with recognised neurological or medical disease and altering the current disease exclusion criteria to one in which the symptom must not be better explained by a disease if present, (d) adding a cognitive symptoms subtype. We also discuss whether conversion symptoms are better classified with other somatic symptom disorders or with dissociative disorders and how we might address the potential heterogeneity of conversion symptoms in classification.
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I have a copy of this discussion paper.
James Levensen and Michael Sharpe are members of the Somatic Symptom Disorders Work Group.
Jon Stone and W. Curt LaFrance are external advisors to the Somatic Symptom Disorders work group.
W. Curt LaFrance is an external advisor to the Dissociative Disorders work group. Richard Brown and David Spiegel are members of the Dissociative Disorders work group.
So two of the co-authors of this paper are members of the DSM-5 SSD Work Group and two co-authors are external advisors to the DSM-5 SSD Work Group.
But this paper (like the Kanaan, Armstrong, Wessely paper) is not published on behalf of the DSM-5 SSD or Dissociative Disorders Work Group and does not represent the position of either Work Group.
This paper was received on January 17, 2011 (which predates the second DSM-5 stakeholder review of proposed changes to DSM-IV categories and criteria). It was resubmitted in revised form on July 10, 2011 (that is, towards the end of the second stakeholder review). It was accepted for publication on July 19, 2011, and published in the December edition of the Journal of Psychosomatic Research.
In the Introduction to the discussion paper,
"Conversion Disorder: Current problems and potential solutions for DSM-5" it states:
"In this article we discuss the diagnostic criteria for Conversion Disorder as described in the DSM-IV-TR [1] from the perspective of psychiatry, neurology and psychology and offer potential solutions for its description and classification in DSM-5. The article is authored by members of, and advisors to, DSM-5 work groups on somatoform and dissociative disorders. Whilst the article reflects discussion and debate that has taken place in these groups, it is not an official position statement of the American Psychiatric Association. The article highlights areas of agreement but is also intended to stimulate further discussion and debate [25] regarding those areas where there is no consensus."
The article discusses what term the current category "Conversion Disorder" might be renamed to.
In Box 1, the article sets out the current diagnostic criteria for Conversion Disorder in DSM-IV-TR.
It discusses the use of the term "medically unexplained symptoms," a term it considers problematic, in general, and also in the context of "conversion symptoms."
The SSD Work Group has already reported (in a progress report published in mid 2009 and in its first and second published draft proposals) that it proposes that the concept of "medically unexplained" should be "de-emphasized" for the SSD categories, for DSM-5.
The paper's authors propose that a new term should be considered for "Conversion Disorder," make various suggestions but consider that more discussion is required.
The article goes on to discuss where "Conversion Disorder" might best be placed within the classification and sets out that significant changes are being proposed to the existing "Somatoform Disorders" by the DSM-5 SSD Work Group (of which we have been aware since the publication of the first draft, and prior to that).
That these changes involve not just relabeling the "Somatoform Disorders" categories in DSM-IV to "Somatic Symptom Disorders," but merging somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder into a new category "Complex Somatic Symptom Disorder (CSSD)"; that discussion of the consequence of such a change for conversion disorder was deferred in a recent preliminary report but that others have proposed that "Conversion Disorder" be moved to the "Dissociative Disorders" section, where it resides in ICD-10; sets out the arguments for and against retaining "Conversion Disorder" in the equivalent of the "Somatoform Disorders," versus reclassifying it as a "Dissociative Disorder."
The authors considered that placing "Conversion Disorder" under "Somatic Symptom Disorders" would reduce the potentially useful associations with "Dissociative Disorders," which will be in a separate category in DSM-5.
The authors also noted that location under SSD would not be congruent with ICD-10 (and ICD-11 if it is not changed).
The authors discuss whether "Conversion Disorder" would be better placed within the "Dissociative Disorders" but do not reach consensus.
In conclusion, the authors propose that the following changes to the DSM-IV category of conversion disorder be considered for DSM-5: they set out their own proposals for criteria (but not those of the DSM-5 Work Group for ease of comparison);
propose that the name should be changed; that "Conversion Disorder" is not considered a useful term for this group of symptoms;
a number of alternative names ("Functional Neurological Symptom Disorder", "Dissociative Neurological Symptom Disorder" and "Psychogenic Neurological Symptom Disorder") are suggested as possible alternatives to the existing proposal, "Functional Neurological Disorder."
If readers obtain a copy of this paper, it needs to be read with the following in mind: like the Kanaan paper, the Stone et al paper is a discussion paper; whilst the article reflects discussion and debate that has taken place in the "Somatic Symptom Disorders" and the "Dissociative Disorder" Work Groups, it is not an official position statement of the Task Force or Work Groups.
Until the third draft is published (currently expected no later than May 2012), it won't be known what further decisions the Work Group for the "Somatic Symptom Disorders" section may have made for the categories currently proposed for DSM-5, since last May, which are here:
http://www.dsm5.org/ProposedRevision/Pages/SomaticSymptomDisorders.aspx
J 00 Complex Somatic Symptom Disorder (CSSD)
J 01 Simple Somatic Symptom Disorder (SSSD)
J 02 Illness Anxiety Disorder
J 03 Functional Neurological Disorder (Conversion Disorder)
(which may potentially be classified under Dissociative Disorders)
J 04 Psychological Factors Affecting Medical Condition
J 05 Other Specified Somatic Symptom Disorder
J 06 Unspecified Somatic Symptom Disorder
Also of interest may be this Scottish report on "Functional neurological symptoms":
http://www.healthcareimprovementsco...th_services/neurological_symptoms_report.aspx
PDF: http://www.healthcareimprovementsco...302668-ff12-4f53-b547-72c19531e37a&version=-1
Stepped care for functional neurological symptoms
A new approach to improving outcomes for a common neurological problem in Scotland
Report and recommendations February 2012
This report aims to support NHS boards improve neurological health services and achieve the Clinical Standards for Neurological Health Services.
These recommendations are published as part of the Neurological Services Implementation and Improvement Support Programme and contains some management recommendations that NHS boards may wish to consider in respect of their local position.
