Stressful life events and maltreatment in conversion (functional neurological) disorder: systematic review and meta-analysis of case-control studies.

Lea Ludwig, Joëlle A Pasman, Timothy Nicholson, Selma Aybek, Anthony S David, Sharon Tuck, Richard A Kanaan, Karin Roelofs, Alan Carson, Jon Stone

Journal: The lancet. Psychiatry 2019;5(4):307-320

PMID: 29526521

Full Text on Elsevier Science View on PubMed

Abstract

BACKGROUND

Stressful life events and maltreatment have traditionally been considered crucial in the development of conversion (functional neurological) disorder, but the evidence underpinning this association is not clear. We aimed to assess the association between stressors and functional neurological disorder.

METHODS

We systematically reviewed controlled studies reporting stressors occurring in childhood or adulthood, such as stressful life events and maltreatment (including sexual, physical abuse, and emotional neglect) and functional neurological disorder. We did a meta-analysis, with assessments of methodology, sources of bias, and sensitivity analyses.

FINDINGS

34 case-control studies, with 1405 patients, were eligible. Studies were of moderate-to-low quality. The frequency of childhood and adulthood stressors was increased in cases compared with controls. Odds ratios (OR) were higher for emotional neglect in childhood (49% for cases vs 20% for controls; OR 5·6, 95% CI 2·4-13·1) compared with sexual abuse (24% vs 10%; 3·3, 2·2-4·8) or physical abuse (30% vs 12%; 3·9, 2·2-7·2). An association with stressful life events preceding onset (OR 2·8, 95% CI 1·4-6·0) was stronger in studies with better methods (interviews; 4·3, 1·4-13·2). Heterogeneity was significant between studies (I 21·1-90·7%). 13 studies that specifically ascertained that the participants had not had either severe life events or any subtype of maltreatment all found a proportion of patients with functional neurological disorder reporting no stressor.

INTERPRETATION

Stressful life events and maltreatment are substantially more common in people with functional neurological disorder than in healthy controls and patient controls. Emotional neglect had a higher risk than traditionally emphasised sexual and physical abuse, but many cases report no stressors. This outcome supports changes to diagnostic criteria in DSM-5; stressors, although relevant to the cause in many patients, are not a core diagnostic feature. This result has implications for ICD-11.

FUNDING

None.

Address: Department of Clinical Psychology and Psychotherapy, Universität Hamburg, Hamburg, Germany; Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.; Developmental Psychopathology, Radboud University, Nijmegen, Netherlands.; Section of Cognitive Neuropsychiatry, Institute of Psychiatry Psychology & Neuroscience, King's College London, London, UK.; Section of Cognitive Neuropsychiatry, Institute of Psychiatry Psychology & Neuroscience, King's College London, London, UK; Laboratory for Behavioral Neurology and Imaging of Cognition, Fundamental Neurosciences Department, Geneva University, Geneva, Switzerland.; Epidemiology and Statistics Core, Edinburgh Clinical Research Facility, Edinburgh, UK.; Department of Psychiatry, University of Melbourne, Austin Health, Heidelberg, VIC, Australia; Florey Institute for Neuroscience and Mental Health, Heidelberg, VIC, Australia.; Behavioural Science Institute, Radboud University, Nijmegen, Netherlands; Donders Institute for Brain Cognition and Behaviour, Radboud University, Nijmegen, Netherlands.; Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK; Department of Rehabilitation Medicine, NHS Lothian, Edinburgh, UK; Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK. Electronic address: [email protected].; Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK; Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.

DOI: 10.1016/S2215-0366(18)30051-8