Which are appropriate long-term treatment outcomes for clients who have somatic symptom illness

Abstract

Somatic Symptom Disorder (SSD) represents a novel diagnosis that was first introduced in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. SSD is characterized by at least one persistent somatic symptom accompanied by dysfunctional cognitive, affective, or behavioral reactions. With the exact causes and maintaining factors still being unknown, multidisciplinary theoretical approaches (i.e., biological, psychological, social explanatory) are necessary for understanding the development and maintenance of SSD. Regarding the psychotherapeutic treatment of SSD, modular cognitive behavioral treatment approaches which focus on cognitive restructuring, stress reduction, emotion regulation, and changes of illness behavior are currently most promising.

Somatic Symptom Disorders

Somatic symptom disorders describe physical health complaints and accompanying psychological distress or impairment related to these complaints. Somatic symptom disorders are prominently present in medical settings and may be incompletely or entirely unexplained by known medical conditions, although the emphasis of these disorders is the interpretation of physical symptoms rather than the medical etiology of the symptoms (APA, 2013). Females tend to report greater and more frequent physical symptoms than males, which may be due to factors such as genetic differences in somatic perception, gender socialization, prevalence rates of comorbid disorders, and a greater likelihood for females to seek medical services (Barsky et al., 2001; Kessler et al., 2008). Females are more likely to be diagnosed with every somatic symptom disorder except illness anxiety disorder, which demonstrates equivalent gender prevalence, and disorders with unknown prevalence rates such as factitious disorder. The prevalence of DSM-IV-TR somatoform disorders in general medical settings is estimated at 12.6% in adolescence (Lieb et al., 2000) and 16.1–21.9% in adulthood (de Waal et al., 2004), although some studies report prevalence rates as high as 57.5% in adulthood (Fink et al., 1999).

Somatic symptom disorders arise throughout the lifespan and often follow a discrete stressor, such as a medical diagnosis (APA, 2013). The course of somatic symptom disorders widely varies due to its diversity of symptoms and high comorbidity with other disorders, with females reporting more stable and chronic symptom courses (Lieb et al., 2002). Females tend to report greater distress in response to bodily sensations and focus more attention on their bodies, which may partially explain the gender difference across most somatic symptoms disorders (Asmundson et al., 2012; Kroenke and Spitzer, 1998). For both genders, risk factors include temperamentally high negative emotionality, childhood illness, sensitivity to pain and bodily sensations, comorbid depressive and anxiety symptoms, high environmental stress exposure, low socioeconomic status, limited formal education, older age, and known physical health difficulties (APA, 2013; Asmundson et al., 2012). Somatic symptom disorders represent a holistic view of psychopathology as maladaptive interactions between the mind and body, with females generally reporting greater distress and impairment from somatic symptoms.

7 Outlook and future perspectives

The Tinnitus Research Initiative (TRI) is a multidisciplinary, international research initiative exclusively addressing tinnitus and associated auditory dysfunctions, such hyperacusis, misophonia, phonophobia and others. Based on the well-known analogy between chronic tinnitus and chronic pain, the TRI would be well placed to create a taskforce to further develop the definitions for all these terms, and to evaluate the usefulness, benefits and disadvantages of aligning the definitions with existing classification and coding systems, such as the WHO's ICD and the American Psychiatric Association's DSM. The major advantage would be that tinnitus could become recognized as an entity and/or disorder in its own right.

As an example, the current description of tinnitus in the ICD may benefit from some adjustments. The WHO, via the ICD11 defines tinnitus as “A nonspecific symptom of hearing disorder characterized by the sensation of buzzing, ringing, clicking, pulsations, and other noises in the ear in the absence of appropriate corresponding external stimuli and in the absence of what the examiner can hear with a stethoscope.”

This definition is suboptimal for many reasons. First of all, chronic tinnitus is not only a symptom, but possibly a disorder in its own right, as discussed above. Secondly, tinnitus can occur in the absence of a clinically detectable hearing disorder. Thirdly, there are many other kinds of sounds that people with tinnitus hear, such as sea or electricity-like noise, crickets etc. And fourth, this definition excludes what is now still called objective tinnitus, pulsatile tinnitus and somatosounds. It can be argued that this should indeed not be incorporated under the term tinnitus, but for the reasons mentioned earlier we do suggest that for now included in the definition.

In order to make the ICD11 definition align more with the current definitions proposed in this manuscript it could be rephrased as follows: Tinnitus is the conscious awareness of a tonal or composite noise for which there is no identifiable corresponding external acoustic source, which when associated with emotional distress, cognitive dysfunction, and/or autonomic arousal, leading to behavioral changes and functional disability becomes a disorder.

Whereas most tinnitus specialists would agree on aligning with the WHO, not everybody would agree to align a definition with the DSM. The task force could investigate the advantages and disadvantages of collaborating with the American Psychiatry Association to evaluate the usefulness of incorporating a definition of tinnitus in the DSM. A pragmatic approach could for example be to align the diagnostic criteria for tinnitus disorder with those developed for pain disorder, a part of Somatic Symptom Disorder in DSM-5.

The diagnostic criteria for Somatic Symptom Disorder noted in DSM 5 are:

One or more somatic symptoms that are distressing or result in significant disruption of daily life.

Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns as manifested by at least one of the following:

disproportionate and persistent thoughts about the seriousness of one's symptoms,

persistently high level of anxiety about health or symptoms,

excessive time and energy devoted to these symptoms or health concerns.

Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically more than 6 months).

The somatic symptom disorder can be specified as “with predominant pain” (previously pain disorder) for individuals whose somatic symptoms predominantly involve pain.

Based on the pathophysiological, clinical and treatment analogies between chronic pain and chronic tinnitus it is proposed that tinnitus disorder falls under the somatic symptom disorder specified as “with predominant tinnitus”. The other specifications could also be maintained:

Persistent: A persistent course is characterized by severe symptoms, marked impairment, and long duration (more than 6 months; Criterion C) > it would make sense to change this into 3 months (see above).

Mild: Only one of the symptoms specified in Criterion B is fulfilled.

Moderate: Two or more of the symptoms specified in Criterion B are fulfilled.

Severe: Two or more of the symptoms specified in Criterion B are fulfilled, plus there are multiple somatic complaints (or one very severe somatic symptom).

Aligning a DSM classification with pain and other somatic symptom disorders makes sense for multiple reasons: (1) The pathophysiology, clinical picture, co-morbidities and some forms of treatments of tinnitus and pain show similarities (De Ridder and Van de Heyning, 2007; De Ridder et al., 2011a; Llinas et al., 1999; Moller, 1997, 2000, 2007a; Rauschecker et al., 2015; Tonndorf, 1987; Vanneste et al., 2018a, 2019). (2) It makes it easier to extend tinnitus research to other disciplines and thereby grow interest in tinnitus research. (3) It permits a simple adaptation of the DSM to recognize and integrate tinnitus as a clinical entity.

It could be questioned whether the grading in tinnitus in mild, moderate and severe according to the presence of 1, 2 or 3 or the symptoms in criterion B is valuable, and that tinnitus specific questionnaires should be used. Yet, the simplicity of this approach has its merits. The first symptom under criterion B, a disproportionate and persistent thoughts about the seriousness of one's tinnitus, reflects a dysfunctional cognitive response to the phantom sound, whereas the second symptom, namely a persistently high level of anxiety about health or symptoms reflects more an emotional response, and the third symptom, excessive (time and) energy devoted to the tinnitus more an autonomic and behavioral response, it does reflect a layered response and thus some grading to the severity. Of course many patients with excessive thoughts will also become anxious or vice versa, and inherently spent much time paying attention to their tinnitus, but a pragmatic approach suggests that the benefits of proposing this definition may outweigh the negatives.

A major criticism on the proposal to align the tinnitus disorder definition with the DSM is that it seems to imply that tinnitus disorder would become a psychiatric diagnosis and that psychiatrists would become the main health care providers for tinnitus disorder. Furthermore, the grading is deemed insufficient. While these are understandable objections, the example of chronic pain may somewhat moderate these remarks. Chronic pain is also coded within the DSM, and most patients are treated by pain physicians, not psychiatrists. Eventually the classification of chronic pain in the DSM may have contributed to advances in pain management in the sense, that patients are treated by multidisciplinary teams, which involve also psychologists and psychiatrists. Such an approach might be desirable for tinnitus as well. Furthermore, most pain patients would not consider themselves psychiatric and, analogous to tinnitus, there exist questionnaires to grade pain associated suffering.

A consensus on definitions for tinnitus may facilitate acceptance of tinnitus as a disorder in its own right within the DSM classification. Yet it is up to a task force and a wider consensus within the tinnitus research community to decide on whether ICD and DSM definitions would be beneficial or not. In addition, the capacity to measure the incidence, prevalence, and impact will help in identification of human, financial, and educational needs required to address acute tinnitus as a symptom and chronic tinnitus as a disorder. This outweighs the imperfections of the grading within the current classification, which is being revised every couple of years anyway, depending on developing and novel insights.

An operational definition of “tinnitus” and some of its subforms are presented in Box 1. A hypothetical pragmatic definition of “tinnitus disorder” is proposed as an example of how this definition could be based on the current DSM 5 “somatic symptom disorder,” analogous to pain, but then specified as tinnitus (see Box 2).

The subdivision between tinnitus as a sound percept without a corresponding external sound source and tinnitus disorder, which is tinnitus with its associated suffering, will be beneficial both for clinicians and researchers.

Somatic symptom and related disorders

This diagnostic class includes individuals with a diagnosis of somatic symptom disorder, factitious disorder, illness anxiety disorder, or conversion disorder. These disorders share the feature of predominant somatic (body) symptoms that are associated with a disproportionate degree of patient distress and impairment.3 Somatic symptom disorder diagnostic criteria include at least one somatic complaint (most patients have more than one) that is distressing or causes a disruption in daily life. According to DSM-V3, at least one of the following symptoms must also be present:

Disproportionate and persistent thought about the seriousness of one’s symptoms.

Persistently high level of anxiety about health or symptoms.

Excessive time and energy devoted to these symptoms or health concerns.

The U.S. prevalence of this disorder is estimated at 5% to 7%, and it is more common in females.

5.26.5.1 Somatic Symptom Disorder

Conditions dominated by persistent physical symptoms which cause significant suffering and disruption of everyday life, SSD, is the most common clinical presentation of SSRD in children and adolescents. Symptoms can be specific (e.g., localized pain such as headache or backpain), or nonspecific (e.g., fatigue). Abdominal pain and headache are the most common presenting symptoms, followed by backpain, limb pain and fatigue (Andresen et al., 2011; Bujoreanu et al., 2014). Younger children will frequently present with a single symptom (e.g., abdominal pain). Further, worries and concerns about symptoms are rarely present in younger children. Rather, help seeking behavior as well as impairment, such as absence from school and health care contact, is closely connected to parental levels of anxiety and parental help seeking behavior in the youngest age groups (APA, 2013). Through adolescence, multisymptomatic and more complex clinical presentations become more frequent.

The clinical case about Sam is illustrative of a typical presentation of monosymptomatic SSD in a younger child:

5.26

Clinical case 1: Somatic symptom disorder. “Sam”

11-year old Sam was referred to family-based treatment in a child and adolescent mental health setting (CAMHS) for functional abdominal pain. Sam had a long medical history with multiple pediatric contacts, starting when he was 6 years old. Sam had been thoroughly examined and a number of gastrointestinal disorders including celiac disease, lactose intolerance and inflammatory bowel disease had been excluded. Sam had undergone surgery as appendicitis was expected, however not confirmed. He had received treatment for suspected obstipation for several years without clear effect on his symptoms. Recently, the pediatric gastroenterologist had diagnosed Sam with SSD.

At point of referral Sam had 80%–100% absence from school. When the parents tried to get Sam to school in the mornings, he would cry and scream, complain about severe abdominal pain and nausea. He had stopped playing football and he rarely saw his friends anymore, even though they called asking for playdates. Sam's mother was currently on leave from work to be able to care for Sam. On the weekends and during holidays, Sam would appear less affected by symptoms.

Somatic Symptom and Related Disorders

98.

The diagnosis of somatoform disorder in DSM-IV has been replaced with somatic symptom disorder (SSD) in DSM-5. What is the difference?

The new diagnostic scheme focuses on the presence of symptoms and the excessive distress and abnormal/maladaptive emotional, cognitive, and behavioral responses to the symptoms rather than the absence of a medical explanation. Indeed, SSD is highly comorbid with medical disorders (DSM-5, p 309). As an example, patients with known neuropathologically based movement disorders commonly also have conversion disorder (functional neurologic disorder) features/symptoms (altered sensory or motor function incompatible with known neurologic disorders)—these are not mutually exclusive.

Lichter DG: Frontal-subcortical circuits. In Arciniegas DB, Anderson CA, Filley CM (eds): Behavioral neurology & neuropsychiatry. New York: Cambridge University Press, 2013, p 69.

Greist JH, Jefferson JW: Obsessive-compulsive disorder. In Gabbard GO (ed): Gabbard’s treatments of psychiatric disorders. Washington, DC: American Psychiatric Publishing, 2014, pp 409-410.

Youngner CG, Rothbaum BO, Friedman MJ: Posttraumatic stress disorder. In Gabbard GO (ed): Gabbard’s treatments of psychiatric disorders. Washington, DC: American Psychiatric Publishing, 2014, pp 479-503.

Flaherty A, Ivkovic A: Movement disorders. In Stern TA, Fava M, Wilens TE, Rosenbaum JF (eds): Massachusetts General Hospital comprehensive clinical psychiatry. London: Elsevier, 2016, pp 871-882.

What are some major factors that are thought to contribute to SSDs?

Genetic and biological susceptibilities (e.g., decreased pain tolerance)

Childhood trauma (e.g., physical, sexual, and emotional abuse)

Operant conditioning—learning (i.e., somatic complaints gain attention)

Sociocultural norms (e.g., if somatic complaints are valued over emotional complaints)

SSDs are differentiated from factitious disorder and malingering by what key feature(s)?

In SSD, symptoms are not intentionally (consciously) produced. Symptoms produced intentionally to assume the sick role (i.e., “primary gain”) or without obvious external reward are characteristic of factitious disorder. Symptoms produced intentionally for monetary or other “secondary gain” are consistent with malingering. Reporting to the appropriate legal authorities may be necessary in cases of malingering (considered fraud) and factitious disorder imposed on another (a.k.a. Münchausen syndrome by proxy).

What treatment for SSD has been shown to decrease rates of hospitalization and reduce patient’s health care spending by 50%? What additional strategies should be employed?

Individual and group psychotherapy. Additional strategies include scheduling frequent follow-up visits with a single provider (establishing a “medical home”) and following a collaboratively developed treatment plan. Use of psychotropic medications for SSD is generally not helpful and may be problematic due to the compliance issues typical in this population.

Somatic symptom disorders

With DSM V the old concept of somatoform disorders was overturned, being newly reclassified as “somatic symptom disorders” (American Psychiatric Association, 2013). Since then, a link between somatization and poor outcomes has been documented in CLBP (Ailliet et al., 2016), supporting earlier reports of a greater association between somatization and pain in such patients (Bacon et al., 1994; Chen et al., 2007), who were also more likely to experience headache (Khan et al., 2003), migraine (Grassini and Nordin, 2015), and FM (Sarzi-Puttini et al., 2012). In fact, there is such a large overlap of clinical and somatization features in FM that some researchers have suggested that FM is, in fact, a somatoform disorder (Häuser and Henningsen, 2014). Indeed, while investigating DSM V criteria for the new classification of somatoform disorders, Wolfe et al. (2014) found an increased, “disproportionate” or “excessive” perception of symptoms (DSMV criterion B for somatic symptom disorder) in FM subjects, as compared to those with rheumatoid arthritis or osteoarthritis, but recommend a cautious approach to interpretation of this criterion. In this context, scales to measure the illness behavior component of chronic pain in CLBP have been proposed (Main and Waddell, 1987). Interestingly, experimental and clinical pain studies have shown a gender-related difference in the prevalence of somatization (Fillingim et al., 2009), with females tending to somatize more, tolerate pain less (i.e., they have a lower pain threshold), and display a greater number of clinical pain syndromes (Karvonen et al., 2007). That being said, somatization, general hypochondriasis, and disease conviction negatively affected the pain threshold and tolerance, irrespective of gender or age, in patients referred to a psychosomatic clinic because of their resistance to conventional treatment for pain (Ciaramella, 2016).

Conclusion

Hypochondriasis as a diagnostic entity is present being questioned, and is in DSM-IV replaced by “Illness anxiety disorder” and “Somatic symptom disorder.” Whether it is best conceptualized as a Somatoform or an Anxiety disorder in ICD-11 remains to be seen, but with the development of a cognitive-behavioral model of the disorder, the similarity to the anxiety disorders has been emphasized. The addition of mindfulness techniques to CBT is promising, but more research on the possible added effect is needed. Health anxiety, also when it has not developed into full-blown hypochondriasis, has been found to be a strong, independent, and underrecognized risk factor for health disability pension award in a Western society.

Somatic Symptoms and Treatment Goals

Major diagnostic classifications now separately recognize the importance of somatic symptoms. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) recognizes somatic symptom disorder.22 The 2018 ICD-10-CM Manual23 includes specific codes for many FSSs (Table 39.1). Somatic symptom burden is increasingly recognized as a separate domain of health-related quality of life.24

The Somatic Symptom Scale-8 (SSS-8)24 uses an 8-symptom survey asking respondents to indicate how much they have been “bothered by” each symptom in the past week, with options ranging from 0 (not at all) to 4 (very much). Somatic symptom burden is indicated by the sum of responses, with a possible range of 0 to 32. Most respondents are expected to report a minimal or low symptom burden (summary score 0–7). Scores of 8 to 32 indicate medium, high, or very high symptom burden. Summary scores predicted the incidence of healthcare visits in the past 12 months.

Each 1-point increase in the SSS-8 summary score was associated with a 12% increase in the number of health care visits in the past month.24 If therapy can reduce the client’s symptom burden, two favorable outcomes may result: (1) the client’s health-related quality of life could increase, and (2) the client’s utilization of health care services could decrease. These findings suggest that symptoms may be important “in and of themselves,”25 independent of any and all comorbid conditions. Given the “high prevalence and functional impairment associated with somatic symptoms,”24 including a functional goal of symptom reduction in hand therapy treatment plans for clients with FSSs could result in greater independence and health-related quality of life.

Medical facts of the matter

The nature of the patient’s symptoms and signs of weakness was inconsistent with known anatomical and physiological facts. In other words, based on a very long history of neurological research and clinical experience, giving rise to fundamental principles and facts, there is no location in the nervous system that, when damaged, would produce the patient’s symptoms and signs. Then what is causing the patient’s symptoms and signs? The presumption was that if the weakness was not physical, then what nonphysical entity could cause the patient’s symptoms and signs? Whatever the cause, the presumption is that it is not physical, hence the necessity of inventing something that is not physical, yet still, it must affect the physical body. Is it the mind, spirit, or soul? If it is a disorder of the mind, spirit, or soul, how are physicians and healthcare professionals to deal with it?

A full discussion of mental illness is far beyond the scope of this text. However, certain themes seem to characterize the many and varied conceptions of mental illness. Throughout history, supernatural, somatic (a physical cause), and psychogenic (a nonphysical cause) have been considered as possible causes. The first two are clearly different from the last. A supernatural cause, such as demonic possession, has a cause outside the person that comes to “infect” the person and, generally, the patient has no control. The somatic notion holds that these types of illness are caused by abnormal physiological processes within the person, generally of the type over which the patient has no control. Increasingly, the population appreciates that many psychiatric disorders, such as schizophrenia and major depression, follow the medical model of some as a yet unidentified physical process. A corollary to the medical model is that the symptoms and signs manifest by the patient may be inconsistent with known fundamental neurological facts and principles, yet the faith is that the issue will be resolved with further scientific research. In the case of the patient presented, the presumption is there is no physical cause and any amount of research will not demonstrate a physical cause. If the possibility of a physical cause was considered, how would anyone countenance the behavior of the physician in the case presented? Those holding a phenomenological, care, or virtue ethic might expect the physician to act with grace and compassion toward the patient as any other patient according to what a patient-centered ethic might require (see Chapter 2). Yet, it cannot be presumed that such ethics are necessarily the controlling force in the ethics of everyday medicine (see Chapter 4).

Psychogenic places the cause in the sociological and psychological conditions of the patient, for example, how the patient was raised or what they have experienced. Perhaps most importantly, many may hold that it is up to the patient to “rise above” those conditions. Patients fail to do so because of some intrinsic weakness or imperfection, and thus the “blame” appears to revert to the individual patient despite the sociological or psychological situations or circumstances. With respect to psychogenic disorders, attitudes vary as to the control the patient has in the development of the psychogenic disorder. To the degree that patients are seen as in control or that their condition is a consequence of their voluntary choice, such as drug addiction, many persons hold stigmatizing attitudes toward the patient (Barry et al., 2014). As discussed later, feigning illness in the context of seeking some benefit is likely to be viewed as unjust (Chapter 1).

The clinical examination provided strong support for a presumptive diagnosis of a disorder commonly thought to be psychological in origin. Yet, there is a conundrum. If the patient’s disorder was thought to be the result of neurological dysfunction, then the neurological facts and principles would have to be modified to accommodate those of the patient. This issue is addressed later.

In the case presented, the discussion addressed the syndrome of the patient presenting with neurological symptoms and signs and was diagnosed as having a functional neurological disorder. The term functional neurological disorder can be understood by the alternative diagnosis, which is an organic neurological disorder. The terminology itself presupposes that it was a functional neurological disorder, meaning without evidence of histopathology and not explainable by neurophysiology or pathophysiology, and more largely not physical, real, or organic. What remains is artificial. The wider issues of mental, psychological, and psychiatric disorders are not discussed but the issues related to functional neurological disorders are illuminated.

There could be multiple causes or disorders associated with the patient’s symptoms and signs. In view of the examination, consideration of organic or physical causes, in a sense of physical injury to the nervous system, does not seem necessary. Indeed, pursuing them inappropriately could lead to maleficence, such as exposing the patient to the risks of unnecessary testing. However, there is a differential diagnosis related to a functional neurological disorder. Some of the possible diagnoses can be associated with a severe prognosis and most are treatable (Espay et al., 2019; Zeuner and Sidiropoulos, 2019). Some of the elements of differential diagnoses are listed here from Michael B. First in “DSM-5 Handbook of Differential Diagnosis” (American Psychiatric Association Publishing; https://doi-org.ezproxy.library.wisc.edu/10.1176/appi.books.9781585629992):

Differential Diagnosis for Conversion Disorder (Functional Neurological Symptom Disorder)

Occult neurological or other medical conditions, or substance/medication-induced disorders

Somatic Symptom Disorder—is characterized by distressing somatic symptoms accompanied by excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns without regard to whether the somatic symptoms are adequately explained by a medical condition. In contrast, in Conversion Disorder (typically functional neurological disorder), clinical and/or laboratory findings must provide evidence that the neurological symptoms are incompatible with recognized neurological or general medical conditions (author—the notion of what is recognizable poses serious problems as discussed in Cases 6 and 9)

Illness Anxiety Disorder—is characterized by a focus on the “serious disease” underlying the pseudoneurological symptoms

Depressive Disorders

Factitious Disorder or Malingering

Dissociative Disorders—involve neurological functions (e.g., memory and consciousness) other than voluntary motor or sensory functioning

The differential diagnoses of dissociative disorders, which must be considered in the differential diagnosis of the patient in the case presented, are listed here (from First, “DSM-5 Handbook of Differential Diagnosis,” American Psychiatric Association Publishing; https://doi-org.ezproxy.library.wisc.edu/10.1176/appi.books.9781585629992):

Depersonalization/derealization disorder experiences of depersonalization

Dissociative symptoms due to a general medical condition

Substance intoxication or substance withdrawal

Depersonalization/derealization symptoms attributable to the physiological effects of substances during acute intoxication or withdrawal

Dissociative identity disorder

Panic attacks

Posttraumatic stress disorder or acute stress disorder

Psychotic disorders (e.g., Schizophrenia)

Major depressive disorder

“Normal” symptoms of depersonalization or derealization

As can be readily appreciated, some of the elements in differential diagnoses to be considered require the expertise of a psychiatrist, who was not made available to the patient in the case presented, and some of the disorders that are reasonable to consider are associated with a significant risk of harm. The disorders in the differential diagnoses are treatable, at least in the sense that the associated disabilities can be managed and risks anticipated and prevented. However, this first would require a diagnosis to be established, which would require evaluation by a psychiatrist as well. In terms of functional neurological disorders, diagnostic criteria are quite sound, with an estimated misdiagnosis rate of approximately 4% (Gelauff and Stone, 2016). Thus, the ability to make the correct diagnosis is not the issue; the critical question is once the diagnosis is made, how is the differential diagnosis pursued and treated?