Published in

Brain Communications, 2020

DOI: 10.1093/braincomms/fcaa156

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Briquet syndrome revisited: implications for functional neurological disorder

Distributing this paper is prohibited by the publisher
Distributing this paper is prohibited by the publisher

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Abstract

Abstract With the creation of the Somatic Symptom and Related Disorders category of the Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition (DSM-5) in 2013, the functional neurological (symptom) disorder diagnostic criteria underwent transformative changes. These included an emphasis on “rule-in” physical examination signs/semiological features guiding diagnosis and the removal of a required proximal psychological stressor to be linked to symptoms. Additionally, the DSM–Fourth Edition (DSM-IV) somatization disorder, somatoform pain disorder and undifferentiated somatoform disorder conditions were eliminated and collapsed into the DSM-5 somatic symptom disorder diagnosis. With somatic symptom disorder, emphasis was placed on a cognitive-behavioral (psychological) formulation as the basis for diagnosis in individuals reporting distressing bodily symptoms such as pain and fatigue; the need for bodily symptoms to be “medically unexplained” was removed, and the overall utility of this diagnostic criteria remains debated. A consequence of the DSM-5 restructuring is that the diagnosis of somatization disorder that encompassed individuals with functional neurological (sensorimotor) symptoms and prominent other bodily symptoms, including pain, was eliminated. This change negatively impacts clinical and research efforts because many patients with functional neurological disorder experience pain, supporting that the DSM-5 would benefit from an integrated diagnosis at this intersection. We seek to revisit this with modifications, particularly since pain (and a DSM-IV somatization disorder comorbidity, more specifically) is associated with poor clinical prognosis in functional neurological disorder. As a first step, we systematically reviewed the DSM-IV somatization disorder literature to detail epidemiologic, healthcare utilization, demographic, diagnostic, medical and psychiatric comorbidity, psychosocial, neurobiological and treatment data. Thereafter, we propose a preliminary revision to DSM-5 allowing for the specifier functional neurological disorder “with prominent pain”. To meet this criteria, core functional neurological symptoms (e.g., limb weakness, gait difficulties, seizures, non-dermatomal sensory loss, and/or blindness) would have “rule-in” signs and pain (> 6 months) impairing social and/or occupational functioning would also be present. Two optional secondary specifiers assist in characterizing individuals with cognitive-behavioral (psychological) features recognized to amplify or perpetuate pain and documenting if there is a pain-related comorbidity. The specifier of “with prominent pain” is etiologically neutral, while secondary specifiers provide additional clarification. We advocate for a similar approach to contextualize fatigue and mixed somatic symptoms in functional neurological disorder. While this preliminary proposal requires prospective data and additional discussion, these revisions offer the potential benefit to readily identify important functional neurological disorder subgroups - resulting in diagnostic, treatment and pathophysiology implications.