Personality and Psychopathology in Patients With Mixed Sensory-Motor Functional Neurological Disorder (Conversion Disorder) A Pilot Study Ulf Søgaard, MD,*†‡ Birgit B. Mathiesen, PhD,§ and Erik Simonsen, MD, PhD†‡ Abstract: The purpose of this pilot study was to explore differences in the level of personality functioning, symptom severity, and personality pathology in pa- tients with mixed sensory-motor functional neurological disorder (conversion disorder). Individuals with psychogenic nonepileptic seizures were not included. We recruited 15 patients, mean age of 33.5 years (SD, 11.4 years), 13 females and 2 males, from an outpatient clinic for psychotherapeutic treatment. We assessed the patients using the Structured Clinical Interview for DSM-4 Axis II Personality Disorders, the SCL-90-R, the Karolinska Psychodynamic Profile, and the De- fense Style Questionnaire. We were able to distinguish two levels of difficulty in relation to personality functioning as distinct subgroups: 1) “neurotic” with less severe or moderate personality psychopathology and 2) “borderline” with se- vere personality psychopathology. Furthermore, we concluded that all patients showed severe deficits in personality functioning. The study points out the clin- ical relevance of identifying personality functioning as part of an assessment in the preparation of a treatment strategy. Key Words: Functional neurological disorder, conversion disorder, personality disorder, levels of personality functioning (J Nerv Ment Dis 2019;207: 546–554) T he terms functional neurological disorder (FND) and conversion disorder (CD) designate the same clinical condition, as defined in DSM-5 (American Pyschiatric Association, 2013). FND is characterized by voluntary motor or sensory function deficits that suggest a neurologic condition, but clinical findings provide evidence of incompatibility be- tween the symptom and recognized neurologic conditions. FND must be diagnosed based on what is present, such as specific patterns of signs and symptoms, and not just by what is absent, summarized as “positive” clinical signs by Daum et al. (2014) and most recently as a “rule in” ap- proach (McKee et al., 2018). In this pilot study, the patient group consists of a mixed sensory-motor FND sample that excludes individuals with psychogenic nonepileptic seizures (PNES). In ICD-10 (World Health Organization, 1993), FND is included in the category of dissociative disor- ders, and the diagnosis of the subjects in the present study is equivalent to the concept of somatoform dissociation, that is, cognitive or psychoform dissociation is excluded. A relevant psychological stressor is often pres- ent, but it is not a requirement to establish the diagnosis of FND. FND is not a rare condition, although a certain cultural and geo- graphical variation may exist. Deveci et al. (2007) found the FND prevalence to be 5.6%, and Stone et al. (2009) found conversion symp- toms in 18% of referred neurological patients in outpatient clinics in the United Kingdom. FND patients have intrigued clinicians since the first scientific studies of Jean-Martin Charcot, Josef Breuer, Sigmund Freud, and Pierre Janet (Charcot et al., 1887; Freud, 1962; Freud et al., 2001; Janet, 1907). Over the last few decades, studies on dissociation and conversion, as part of pathological psychological development, have expanded in an effort to understand the basic mechanisms of the disorder. In this context, the phe- nomenon has been understood as 1) a structural dissociation of the person- ality due to traumatic experiences (Nijenhuis et al., 2010), 2) a dissociation as a defense mechanism (Howell, 2005), 3) linked to disorganized attach- ment (Bradfield, 2011; Liotti, 2006; Williams et al., 2018), or 4) a part of a fragmented self-image (Bromberg, 2009). Psychologic theories have been comprehensively reviewed by Carson et al. (2016). In addition, neuroimag- ing techniques have contributed to the understanding of the basic mecha- nisms of FND, and on some points pathophysiological equivalents exist for these psychological theories (Aybek et al., 2014; Perez, 2015; Perez et al., 2017). Comorbidity in FND has been investigated in various studies. Major depression has been reported in 32% to 43% of cases (Feinstein et al., 2001; Stone et al., 2010), anxiety disorder in 62% to 79% (Feinstein et al., 2001; Sar et al., 2004; Stone et al., 2010), posttraumatic stress disor- der (PTSD) in 23% (Scevola et al., 2013), dissociative disorders (FND ex- cluded) in 47% (Sar et al., 2004), and somatization disorders in 27% (Stone et al., 2010). Personality disorder (PD) is reported in 45% to 74% of the cases in FND cohorts (Binzer et al., 1997; Direk et al., 2012; Feinstein et al., 2001), and Sar et al. (2009) reported borderline person- ality disorder (BPD) in 34% of FND patients. An important work deal- ing with symptom severity is that of Williams et al. (2018). For motor FND, they found fearful attachment style to be associated with adverse life event burden, alexithymia, dissociation, depression, anxiety, im- paired coping style, and functional neurologic symptom severity. For trauma and stressful life events, several studies pointed out that childhood trauma, specifically physical or sexual abuse, emotional or physical neglect, and a greater number of stressful life events and traumatic episodes characterize FND (Kranick et al., 2011; Roelofs et al., 2002; Sar et al., 2009). In addition, a meta-analysis showed that stressful life events and maltreatment are substantially more common in people with FND than in healthy controls and patient controls. Emotional neglect was related to a higher risk than traditionally emphasized sexual and physical abuse, but many cases report no stressors (Ludwig et al., 2018). With regard to personality traits in FND, studies including Cloninger's Temperament and Character Inventory show in particular, high harm-avoidance, low self-directedness, and high novelty seeking (Erten et al., 2013; Gulec et al., 2014; Sarisoy et al., 2015). Using the Defense Mechanism Test, Sundbom et al. (1999) concluded that FND patients were characterized by a lateness of perception, spe- cific constellations of defensive maneuvers, and a much more nonemotionally adapted pattern compared with a control group. *Department of Specialized Treatment, Psychiatry Region Zealand, Koege; †Psychiatric Research Unit, Psychiatry Region Zealand, Slagelse; and ‡Institute of Clinical Medicine, Faculty of Health and Medical Sciences, and §Department of Psychol- ogy, University of Copenhagen, Copenhagen, Denmark. Send reprint requests to Ulf Søgaard, MD, Department of Specialized Treatment, Psychiatry Region Zealand, Glaeisersvej 50, 4600 Koege, Denmark. E‐mail: us@regionsjaelland.dk. This work was funded by the Regional Scientific Research Fund in Region Zealand. Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. ISSN: 0022-3018/19/20707–0546 DOI: 10.1097/NMD.0000000000001015 ORIGINAL ARTICLE 546 www.jonmd.com The Journal of Nervous and Mental Disease • Volume 207, Number 7, July 2019 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.