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

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

Research output: Contribution to journalArticlepeer-review

Abstract / Description of output

Background
Stressful life events and maltreatment have traditionally been considered critical in the development of conversion (functional neurological) disorder (FND), but the evidence underpinning this association is less clear. We aimed to systematically assess the association between stressors and FND.
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 FND. We conducted a meta-analysis, with assessments of methodology, sources of bias and sensitivity analyses.
Findings
Thirty-four case-control studies were eligible, including 1405 patients. Studies were of moderate to low quality. The frequency of childhood and adulthood stressors was increased in cases compared to controls. Odds ratios were higher for emotional neglect in childhood (49% vs 20% - OR 5·6[2·4-13·1 95% CI]) vs sexual (30% vs 12% - OR 3·3[2·2-4·8 95% CI]) or physical abuse (30% vs 12% - OR 3·9[2·2-7·2 95% CI]. An association with stressful life events preceding onset (OR 2·8[1.4-6.0 95% CI]) was stronger in studies with better methodology (OR 4·3[1·4-13·2 95% CI]). There was significant heterogeneity between studies. Thirteen studies that specifically examined the question all found a proportion of FND patients reporting no stressor.
Interpretation
Stressful life events and maltreatment are significantly more common in FND than in controls. Emotional neglect carried a higher risk than traditionally emphasised sexual and physical abuse, but many cases report no stressors. This supports DSM-5 changes to diagnostic criteria; stressors whilst aetiologically relevant are not a core diagnostic feature. This has implications for ICD-11.
Original languageEnglish
JournalThe Lancet Psychiatry
Early online date8 Mar 2018
DOIs
Publication statusE-pub ahead of print - 8 Mar 2018

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