Journal of Psychosomatic Research 129 (2020) 109907

Contents lists available at ScienceDirect

Journal of Psychosomatic Research

journal homepage: www.elsevier.com/locate/jpsychores

Symptoms of posttraumatic stress disorder in patients with functional T

neurological symptom disorder
⁎
Cordelia Graya,b, , Alex Calderbankb, Joy Adewusib, Rhiannon Hughesb, Markus Reuberb
a
Neurology Psychotherapy Service, Sheffield Teaching Hospital, Sheffield, UK
b
Academic Neurology Unit, University of Sheffield, Sheffield, UK

A R T I C LE I N FO A B S T R A C T

Keywords: Objective: To describe prevalence and relevance of Post-Traumatic Stress Disorder (PTSD) symptoms in
Post traumatic stress disorder Functional Neurological Symptom Disorder (FNSD) and explore differences in PTSD symptom scores between
Functional neurological symptom disorder subgroups with Psychogenic Non-Epileptic Seizures (PNES) or other FNSD.
Psychogenic non-epileptic seizures Methods: This cross-sectional study evaluated data from 430 consecutive patients referred to a specialist psy-
Anxiety
chotherapy service (69.3% female, 56% with PNES/44% with other FNSD). We analysed self-reported symptoms
Depression
Trauma
of Post-Traumatic Stress Disorder (PTSD Civilian Checklist, PCLeC), depression (PHQ-9), anxiety (GAD-7),
physical symptoms (PHQ-15), social functioning (WSAS), and health related quality of life (SF-36). Relationships
between PTSD scores, diagnosis and other measures were examined. Independent associations of PTSD scores
were identified using multilinear regression.
Results: Symptom scores likely to indicate clinical PTSD were reported by 60.7% of patients with no difference
between PNES and FNSD subgroups. Those potentially symptomatic of PTSD were less likely to be living with a
partner OR 2.95 (95% CI 1.83–4.04), or to be in employment OR 2.23 (95% CI 1.46–3.41) than less symptomatic
patients. There were higher levels of anxiety (r = 0.62), depression (r = 0.63) and somatic symptoms (r = 0.45)
and lower quality of life scores (r = 0.48) in patients with high PTSD symptom scores (p < .0001 for all
comparisons). Anxiety, depression and somatic symptoms made independent contributions to the variance of
PTSD symptoms.
Conclusion: There is a high prevalence of PTSD symptoms in patient with FNSD regardless of whether they have
PNES. Trauma and PTSD symptoms are negatively correlated with quality of life. Self-report instruments for
anxiety, depression and somatic symptoms may predict the presence of PTSD.

1. Introduction adulthood traumatic life events in FNSD patients compared to healthy

Functional neurological symptom disorders (FNSD) are one of the
most common reasons for referral to a neurological outpatient clinic
[1]. Functional neurological symptoms are as disabling as similar
symptoms attributable to pathologies related to structural or physio-
logical abnormalities but associated with more psychiatric comorbid-
ities [2,3].
Historically, two key criteria had to be met before a diagnosis of
conversion disorder (the name for FNSD in DSM-4) could be made: 1)
neurological symptoms could not be explained by neurological disease,
and 2) a precipitant likely to have caused significant distress such as a
traumatic life event or a personal dilemma had to be identified [4]. The
interpretation of FNSD as a physical manifestation of distress is sup-
ported by many studies demonstrating a higher frequency of child- or
or disease controls [5]. However, despite increased rates of trauma
across different patient populations with FNSD [2], some patients with
otherwise typical manifestations of FNSD do not report any potential
stressors in their lives [5]. Reflecting the development of recent thought
about FNSD, and in order to allow clinicians to formulate a diagnosis in
such circumstances, the DSM-5 has therefore dropped the mandatory
diagnostic criterion of a psychological precipitant. The diagnosis of
FNSD is now based on neurologically defined criteria such as the ob-
servation of incompatibility between illness manifestation and re-
cognised neurological or medical condition [6], e.g. the presence of
Hoover's sign in patients with unilateral leg weakness or resistance to
eye opening during a seizure [3].
Nevertheless, previous trauma continues to be an important aetio-
logical factor in modern accounts of FNSD [5,7,8], and it is a matter of

⁎
Corresponding author at: Neurology Psychotherapy Service, Sheffield Teaching Hospital, 12 Claremont Crescent, Sheffield S10 2TA, UK.
E-mail address: Cordelia.gray@nhs.net (C. Gray).

https://doi.org/10.1016/j.jpsychores.2019.109907
Received 15 April 2019; Received in revised form 16 December 2019; Accepted 16 December 2019
0022-3999/ © 2019 Elsevier Inc. All rights reserved.
C. Gray, et al.
continuing debate whether the inability of some patients' to recall po-
tentially relevant distressing experiences means that they never oc-
curred, that they are unwilling or unable to recall them, or that the
methods used to capture this information are inadequate [3].
The aim of the current study is to explore the potential relevance of
previous trauma in patients with FNSD by examining the prevalence
and clinical significance of symptoms considered characteristic of Post
Traumatic Stress Disorder (PTSD). In addition to using these symptoms
as an indirect indication of the possible relevance of trauma in FNSD,
our study examines whether differences in the levels of PTSD symptoms
could account for some of the phenomenological and aetiological dif-
ferences which have been described between subtypes of FNSD, namely
those with seizure-like presentations (Psychogenic Non-epileptic
Seizures, PNES) and other manifestations [2,9,10]. This exploration is
intended to contribute to the on-going debate about whether it makes
more sense to consider different presentations as distinct entities or to
approach them as minor variants of FNSD [11]. Last but not least this
study explores whether self-report instruments commonly used for
routine anxiety and depression screening in neurological patient po-
pulations could be used to predict the presence of PTSD symptoms
2. Method
2.1. Subjects and recruitment
Patients contributing to this study were referred consecutively to a
team of six psychotherapists and one psychotherapy manager working
within the Department of Neurology at the Royal Hallamshire Hospital
(RHH), Sheffield, United Kingdom, between October 2015 and October
2017. Referrals were made by fully trained Consultant Neurologists
working for neurology service for adults (over 16 years old). The neu-
rologists based at RHH reach out to hospitals in surrounding towns and
are the sole service provider in their medical speciality for the popu-
lation of South Yorkshire (population 1.39 million). Neurologists were
encouraged to refer all patients diagnosed with FNSD and willing to
access psychotherapy with the following exceptions:
1. Patients with serious on-going psychiatric problems.
2. Patients who are currently suicidal (e.g. persistent suicidal urges,
making plans etc.) or who have had a suicide attempt in the last
year.
3. Patients who are currently receiving psychotherapy elsewhere.
4. Patients who have already had two episodes of treatment from this
service.
5. Patients who are currently dependent on alcohol or opiate drugs.
Referrals for these patients were rejected because they initially re-
quire intervention from other treatment providers. In the United
Kingdom, National Health Service (NHS) patients are referred to
Neurologists by General Practitioners or Emergency Physicians based
on clinical need and have access to neurological assessment, in-
vestigations and treatment free of charge. Similarly, access to psy-
chotherapy is provided on the basis of clinical need, and treatment is
provided without the need for payment or insurance.
Prior to receiving their initial appointment with the psychotherapy
service, patients are routinely asked to complete a series of ques-
tionnaires to provide a baseline account of their symptoms and level of
impairment and to indicate that they are keen to opt in to psychological
intervention (see below).
Clinical data was extracted from hospital administration systems.
Diagnoses (FNSD, PNES) were formulated by referring neurologists on
the basis of all available clinical data focusing on positive signs rather
than the exclusion of other neurological disorders (including through
video-EEG recordings of typical events in those with PNES). PNES was
conceptualised as a subtype of FNSD. For some analyses, patients were
split into subgroups with PNES or “other FNSD”. Patients with a
2
Journal of Psychosomatic Research 129 (2020) 109907
diagnosis of PNES with additional other FNSD symptoms were included
in the PNES group. No patients with mixed epilepsy/PNES were in-
cluded. Apart from PNES, the range of FNSD symptoms included
weakness, abnormal movement, swallowing symptoms, speech
symptom, sensory loss, visual, olfactory or hearing disturbance. Almost
all patients had more than one symptom.
3. Routine baseline clinical measures
3.1. Demographic questionnaire
A simple demographic questionnaire was developed for the study to
collect information about gender, marital status, employment status
and education level.
3.2. Post-traumatic stress disorder civilian checklist (PCLeC)
The PCL-C is a 17-item Likert self-report questionnaire that aims to
identify PTSD and quantify its resultant symptoms [12]. The 17 items
reflect the DSM-IV PTSD symptoms criteria. Symptom severity is rated
on Likert scales ranging from 1 to 5 and a score is computed by sum-
ming the responses [13]. There are 3 types of the checklist – PCL -
Military, Civilian and specific trauma. The PCL-C has shown good in-
ternal consistency in 14 studies in clinical and non-clinical settings
including among patients with severe mental illness [12].
In line with guidance from the National Centre for PTSD (USA)
those with a PCL-C score ≥ 45 were considered “symptomatic” while
those with a score below this level were considered “asymptomatic”
[14]. While being “symptomatic” of PTSD does not equate to a clinical
diagnosis of PTSD the relatively high cut off point of ≥ 45 is the level
recommended for mental health rather than neurological settings and
may thus underestimate the true prevalence of clinical PTSD diagnoses
in this patient sample [14]. In light of this we refer to patients with a
score ≥ 45 as being potentially symptomatic of PTSD throughout the
paper.
3.3. Generalised anxiety disorder (GAD-7)
The GAD-7 is a 7-item self-report anxiety questionnaire assessing
anxiety symptoms experienced over the course of the past two weeks
with a maximum score of 21 [15]. The reliability and validity of the
GAD-7 have been tested and supported by a number of studies in both
the general population and patients with psychopathology [16–18].
The seven items of the GAD-7 were combined to produce a total score
(higher score reflects higher anxiety levels) out of 21. A score of ≥15
was interpreted as a marker of severe anxiety 15 and is the cut off used
for this paper.
3.4. Patient health questionnaire -9 (PHQ-9)
The PHQ-9 is a nine item self-report questionnaire measuring
symptoms of Major Depressive Disorder over the past two weeks with a
maximum score of 27 [19]. The PHQ-9 has a sensitivity of 88% and a
specificity of 88% for Major Depression. The PHQ-9 is a widely used
clinical measure and has been administered to patients with PNES [20].
A score of ≥ 15 was considered as indicative of moderately severe
depression and is the cut off used for this paper [ 19].
3.5. Patient health questionnaire -15 (PHQ-15)
The PHQ-15 is a 15-item self-report questionnaire assessing the
frequency and severity of somatic symptoms experienced over the last
four weeks with a maximum score of 30 [21]. The PHQ-15 has pre-
viously been administered to patients with PNES and other types of
FNSD. High severity levels of somatic symptoms would be indicated by
a score of 15 and above and is the cut off used for this paper [17,18].
C. Gray, et al. Journal of Psychosomatic Research 129 (2020) 109907

Table 1
Patient demographics.
a
N Total Population Symptomatic Asymptomatic Significance

430 261 162

Age in years (SD) 42.1 (15.7) 41.3 (15.1) 42.7 (15.6) 0.40 (z = −0.84)
Genderb 0.84 (χ2 = 0.35)
Male (%) 122 (28.4) 75 (28.7) 45 (27.7)
Female (%) 298 (69.3) 181 (69.3) 115 (71.0)
Marital statusb < 0.001 (χ2 = 12.24)
Living with Partner (%) 238 (55.3) 133 (49.0) 107 (66.0)
Not partner (%) 189 (44.0) 128 (51.0) 54 (33.3)
Employment statusb < 0.001 (χ2 = 14.10)
Employed (%) 137 (31.6) 67 (25.1) 68 (42.0)
Unemployed (%) 276 (64.2) 187 (71.6) 85 (52.5)
Coded diagnosis 0.28 (χ2 = 1.18)
PNES (%) 241 (56) 151 (57.9) 85 (52.5)
Other FNSD (%) 189 (44) 110 (42.1) 77 (47.5)

Abbreviations: PNES = Psychogenic Non-Epileptic Seizures, FNSD = Functional Neurological Symptom Disorder.
a
Potentially symptomatic PTSD subgroup defined by PTSD-C score ≥ 45, see methods section for details.
b
Missing Data: Gender: 10 (2.3%), Marital status: 3 (0.7%), employment status: 17 (4.0%).

3.6. Work and social adjustment scale (WSAS)
The WSAS is a 5-item measure of impaired functioning attributable
to a particular problem or disease [22]. The scale assesses impairment
in five areas including work, home management, social leisure activ-
ities, private leisure activities, family and relationships, with higher
values indicating greater impairment. The WSAS has been established
as a valid, reliable, and sensitive measure in a number of different
physical and psychiatric disorders [8,23–25].
The scores in the five items were combined into a total score, which
was found to have acceptable internal consistency reliability. The lower
the score the better the quality of life.
3.7. Short form 36 (SF-36)
correlations were entered into a multilinear regression model for con-
tinuous data to explore whether psychopathological variables could
independently predict the PTSD symptom score. We controlled for
other variables using hierarchical linear regression and determined the
amount of variance in PTSD score explained by the variables of interest.
The validity of the assumptions of linear regression was tested through
visual inspection of histograms of standardised residual and PeP plots
of expected against observed cumulative probabilities; visual inspection
of scatter plots of predicted against observed standardised residuals;
and assessing for multicollinearity using Variance Inflation Factors for
all independent variables. We identified potential outlying results by
calculating standardised residuals and Cook's distances for all data
points. Cronbach's alpha was calculated for all self-report ques-
tionnaires as a measure of internal consistency.

The Short Form 36-Item Health Survey (Version 2.0) (SF-36) is a
widely-used and well-validated self-report measure of health related
quality of life (HRQoL) consisting of 36 items [26,27]. The SF-36
comprises a set of quality of life items that are used to address health
concepts in 8 sub-scales (physical functioning; physical role limitations,
bodily pain; general health perceptions; vitality, social role functioning,
emotional role functioning, mental health/emotional well-being and
perceived change in health status over the last year). Scores were
analysed according to the procedure for the RAND SF-36. Each item
score is positively measured such that higher scores constitute better
health-related quality of life. The SF-36 scales can be combined to ob-
tain two summary measures; these are the Physical Health Component
score and the Mental Health Component score [28,29].
3.8. Statistical analysis
All questionnaire data were scored, and missing data handled ac-
cording to the respective questionnaire scoring manuals. Data was
analysed using SPSS (version 24; SPSS Inc., Chicago, IL, U.S.A.).
Distribution was assessed for normality using the Shapiro-Wilk test. As
almost all scores were not normally distributed, non-parametric tests
were used throughout. Frequencies and descriptive statistics were ex-
amined for each variable. Comparisons between the two patient groups
were made using Mann Whitney U test for continuous data and effect
sizes were calculated and reported as r-values. Chi squared tests were
used for categorical/nominal data and odds ratios were calculated.
Spearman's rho correlations were calculated to examine relations be-
tween PCL-C scores, diagnoses and the other measures. Significant
Spearman's rho correlation coefficients of > 0.3 were interpreted as
showing a moderate to high correlation [30]. Statistically significant
3.9. Regulatory approval
The data, which form the basis of this report, were collected as part
of the routine evaluation of our psychotherapy service required by the
funders of the service. The service evaluation was approved by the
Clinical Effectiveness Unit of Sheffield Teaching Hospitals NHS
Foundation Trust and conducted in full compliance with UK research
governance regulations.
4. Results
Table 1 summarises demographics and clinical characteristics of our
study population. Our cohort comprised 430 patients with a diagnosis
of FNSD, of whom 241 (56.0%) had PNES. The mean PCL score for the
whole cohort was 51. Of the whole group, 261 (60.7%) had PCL-C
scores above the cut off of 45 deemed potentially symptomatic of PTSD.
There were significant differences between the potentially symptomatic
PTSD and asymptomatic groups in terms of cohabitation (fewer people
in the symptomatic group were living with a partner) OR 2.95 (95% CI
1.83–4.04) and economic activity (fewer individuals in the sympto-
matic group were economically active) OR 2.23 (95% CI
1.46–3.41).The levels of PTSD symptoms reported by those in the FNSD
and PNES groups did not differ significantly (p = .28), with high PCL-C
scores found in both populations.
FNSD Patients above the clinical PTSD cut-off self-reported sig-
nificantly more distress and greater impairment on all of the measures
used apart from SF-36 for physical functioning. Those with a PCL score
below 45 had significantly lower levels of somatic symptoms, anxiety
and depression than the potentially symptomatic group (see Table 2).
All self-report measures used in this study had high levels of iinternal

3
C. Gray, et al. Journal of Psychosomatic Research 129 (2020) 109907

Table 2
– Comparison of median scores of the main measures of interest for the whole population, symptomatic PTSD and asymptomatic patient groups.
Measure Whole population Above potentially symptomatic of PTSD Below potentially ssymptomatic of PTSD Significance
threshold threshold

N 430 261 169 P (Z, r)

PCL-C Median a (range, minimum to 52 (85, 17–85) 64 (40, 45–85) 30 (27, 17–44) < 0.001
maximum) (−17.30, 0.83)
WSAS 27 (40, 0–40) 31 (40, 0–40) 21.5 (40, 0–40) < 0.001
(−6.17, 0.30)
PHQ-15 15 (29, 0–29) 18 (28, 1–29) 11 (25, 0–25) < 0.001
(−9.34, 0.45)
GAD-7 15 (21, 0–21) 18 (21, 0–21) 6 (21, 0–21) < 0.001
(−12.91, 0.62)
PHQ-9 18 (27, 0–27) 21 (27, 0–27) 10.5 (25, 0–25) < 0.001
(−13.11, 0.63)
SF36a
MCS 28.5 (62.6, 3.7–66.3) 24.3 (53.5) (3.7–57.1) 41 (54.7, 11.6–66.3) < 0.001
(−9.98, 0.48)
PCS 27.1 (61.5, 6.8–68.3) 27.7 (60, 8.4–68.3) 27.7 (59.4, 6.8–66.2) 0.93
(−0.09, 0.00)

Abbreviations: PCL-C = Post-Traumatic Stress Disorder Civilian Checklist, WSAS = Work and Social Adjustment Scale, PHQ-15 = Patient Health Questionnaire 15, GAD-
7 = Generalised Anxiety Disorder 7. PHQ-9 = Patient Health Questionnaire 9, SF36 = Short Form 36, MCS = Mental Component Score, PCS = Physical Component Score.
a
Missing Data: PCL: 7 (1.6%), SF-36: 36 (8.4%).

Table 3 first step of the hierarchical regression, the psychological variables

– Internal consistency for self-report measures. were added as the second step.
Measure Number of items Cronbach's Alpha
Demographic and psychological variables were independently as-
sociated with the PCL-C score (ANOVA for omnibus test of model
PCL-C 17 0.94 coefficients, p < .001). Psychological variables explained an addi-
PHQ-9 9 0.89 tional 59.5% of the variance in PCL-C score (ΔR [2] = 0.595,
GAD-7 7 0.93
PHQ-15 15 0.82
p < .001) after controlling for demographic variables. In our final
WSAS 5 0.87 model, relationship status, GAD-7 score, PHQ-9 score, and PHQ-15
SF36a 8 0.82 score were all significantly and independently associated with the level
of PTSD symptoms (PCL-C score). Full details of the model and re-
Abbreviations: PCL-C = Post-Traumatic Stress Disorder Civilian Checklist, gression coefficients are provided in Table 5.
WSAS = Work and Social Adjustment Scale, PHQ-15 = Patient Health
Questionnaire 15, GAD-7 = Generalised Anxiety Disorder 7. PHQ-9 = Patient
Health Questionnaire 9, MCS = Mental Component Score, PCS = Physical 5. Discussion
Component Score.
a
8 Standardised SF-36 subscales were used to calculate internal consistency. Sixty percent of our large consecutive cohort of patients with FNSD
were potentially symptomatic of PTSD as determined by a PCL-C score
consistency (see Table 3). of ≥45. A high PTSD symptom burden was associated with decreased
Anxiety (GAD-7), depression (PHQ-9), somatisation (PHQ-15), dis- quality of life, high levels of distress, anxiety, depression and poor so-
ease-related social dysfunction (WSAS) and mental HRQoL (SF36-MCS) cial functioning. This suggests that PTSD symptoms matter to the
showed high levels of correlation with PTSD symptom burden (PCL-C wellbeing of individuals with FNSD; although further research needs to
score) across the whole FND patient group (see Table 4 – Spearman Rho be done to clarify the direction of causality. The mean PTSD symptom
correlation coefficients and significance). burden level in this population (51) was much higher than that in
We sought to explore further whether these variables made in- studies of non-clinical populations, such as university staff or students
dependent contributions to the variance of the PTSD symptom burden where means of 29 were found [13,31]. In a study exploring the pre-
when controlling for demographic variables (age, gender, marital valence of PTSD in patients with chronic and severe mental health
status, employment status, and diagnosis). Using the PCL-C score as the Cusack et al. [2006] found that, although 87% of patients with severe
independent variable and demographic variables as predictors for the mental illness reported previous trauma, only 30% of these patients had

Table 4
Correlations between self-report measures across the whole FNSD group.
Measures PCL-C PHQ-9 GAD-7 PHQ-15 WSAS SF36 MCS SF36 PCS

PCL-Ca –
PHQ-9 0.747⁎ –
GAD-7 0.743⁎ 0.744⁎ –
PHQ-15 0.585⁎ 0.616⁎ 0.555⁎ –
WSAS 0.448⁎ 0.570⁎ 0.447⁎ 0.479⁎ –
MCS⁎ −0.578⁎ −0.641⁎ −0.611⁎ −0.360⁎ −0.372⁎ –
PCS⁎ −0.029 −0.172⁎ −0.034 −0.331⁎ −0.461⁎ −0.225⁎ –

Abbreviations: PCL-C = Post-Traumatic Stress Disorder Civilian Checklist, WSAS = Work and Social Adjustment Scale, PHQ-15 = Patient Health Questionnaire 15, GAD-
7 = Generalised Anxiety Disorder 7. PHQ-9 = Patient Health Questionnaire 9, MCS = Mental Component Score, PCS = Physical Component Score.
a
Missing Data: PCL: 7 (1.6%), SF-36: 36 (8.4%).
⁎
Correlation is significant at the level of P < .01.

4
C. Gray, et al. Journal of Psychosomatic Research 129 (2020) 109907

Table 5 the baseline questionnaires. Regardless of the possible effects of selec-

- Linear regression predicting PCL-C score. tion bias, our findings clearly demonstrate a high prevalence of symp-
Model Standardised β Sig. dif 95% CI (lower – upper toms likely to indicate previous traumatisation across the whole FNSD
bound) patient group regardless of predominant neurological manifestations.
Given that screening for PTSD is highly unusual in neurological
1 (constant) 33.6–59.2
settings, we explored to what extent other patient characteristics can
Age −0.044 0.41 −0.1–0.1
Gender −0.005 0.92 −3.9–3.5
help to predict a high PCL-C score. The linear regression analysis sug-
Marital Status −0.165 < 0.001 −10.0 to −2.4 gests that relationship status, anxiety, depression and PHQ15 scores
Employment Status 0.217 < 0.001 4.6–12.5 significantly predicted potentially symptomatic PTSD and explained
Diagnosis 0.044 0.40 −2.1–5.4 nearly 60% of the variance. This close relationship between symptoms
2 (constant) 16.6–36.5
of anxiety and depression and PTSD symptoms suggests that high scores
Age −0.003 0.92 −0.1–0.1
Gender −0.026 0.40 −3.2–1.3 on anxiety or depression screening instruments should alert clinicians
Marital Status −0.117 P < .001 −6.7 to −2.1 to the possible presence of PTSD in those with FNSD.
Employment Status −0.037 0.27 −4.1–1.2 Other studies have described the overlap between depression, an-
Diagnosis 0.012 0.70 −1.8–2.8
xiety and PTSD symptoms reflected in our data [44–49]. In a study of
GAD7 0.331 P < .001 0.6–1.2
PHQ9 0.360 P < .001 0.7–1.3
500 people recruited from community organisations and clinics, higher
SF36 MCS −0.053 0.23 −0.2–0.1 levels of trauma and adversity over a lifetime were associated with
WSAS 0.010 0.79 −0.1–0.1 more severe somatic and depressive symptoms [50]. In a longitudinal
PHQ15 0.173 P < .001 0.3–0.8 study of men who had experienced childhood sexual abuse (CSA), CSA
was positively related to both depressive and somatic symptoms [51].
Abbreviations: WSAS = Work and Social Adjustment Scale, PHQ-15 = Patient
Elhai et al. found that 48–55% of participants with a history of PTSD
Health Questionnaire 15, GAD-7 = Generalised Anxiety Disorder 7. PHQ-
9 = Patient Health Questionnaire 9, SF36 MCS = Short Form 36 Mental also met the criteria for a major depressive disorder [52]. There is
Component Score. overlap between criteria for depression and the ‘dysphoria’ symptoms
Note: ΔR2 = 0.595, p < .001. in the diagnostic criteria for PTSD [ 46,48]. However, even with
amendments to the criteria to account for this overlap, rates of de-
sufficiently severe post traumatic symptoms to pass their threshold of pression and anxiety were still high in those with PTSD [47]. Our cross-
potential clinical PTSD of 40. When the cut off was increased to 50 only sectional study design does not allow us to come to any conclusions
19% met this criterion [32]. The mean PCL score in their population about the direction of the relationship between these variables and it
was 35.5, i.e. much lower than in our population. remains unclear which precipitates the other. However, all interact and
The high PCL scores in our patient group may indicate a clinically are capable of causing significant distress.
important difference in psychological coping mechanisms between The fact that patients with potentially symptomatic PTSD were
those with FNSD and patients with other severe mental health illness. statistically less likely to be living with a partner than those without
Alternatively, symptoms of FNSD could overlap with those typically high PTSD symptom levels and were also less likely to be in paid em-
associated with PTSD. Indeed, FNSD has been interpreted as ‘somatic ployment may simply be a reflection of the severity of their symptoms.
dissociation’, for instance Fizman et al. (2004) described two subtypes However, previous research in patients with PNES suggests that trau-
of PTSD and suggested ‘PNES could be understood as a clinical ex- matisation (especially in early life) is also linked to problems with at-
pression of the dissociative subtype of PTSD’ [9]. Gupta also alluded to tachment and emotional processing in this patient group which may
PNES being a specific coping mechanism when he described dissocia- have reduced their ability to sustain stable personal relationships and
tion in the context of conversion as a ‘regulatory state involved in employment [53].
coping with extreme arousal in PTSD through the hyper-inhibition of
the limbic regions.’ [33]. 6. Limitations
The levels of PTSD symptoms in our patient cohort were as high in
those with PNES as they were in those with other manifestations of This study had several limitations. This service evaluation benefits
FNSD. The lack of a difference in PTSD symptom levels between these from truly consecutive case identification, i.e. a 'real life’ setting and
two FNSD subgroups is at variance with the findings of some previous very large patient numbers. However, our study is based on routine
studies which found that patients with PNES are likely to be more data and procedures, including clinical diagnoses rather than diagnoses
traumatised [2,34–38] and suggested important aetiological differences based on research criteria. Having said this, patients were only included
between FNSD and PNES [39–42]. However, other studies have shown in this study when fully trained consultant neurologists with an interest
that patients with ‘Psychogenic Movement Disorders’ (PMD) show in functional disorders and PNES had arrived at these diagnoses with
clinical overlap with those with PNES in that both groups have similar sufficient certainty to recommend psychotherapy and to withdraw any
psychological profiles characterised by increased somatisation, de- treatments for alternative diagnoses considered erroneous (such an
pression and anxiety ratings, [10,11,43,44]. In fact, Hopp et al. con- incorrect diagnosis of epilepsy in a person with PNES). In line with
cluded that PNES and PMD were so similar that ‘diagnosing and clinical practice in the UK, about 40% of PNES diagnoses at our centre
treating PNES and PMD as two separate processes may be detrimental are based video-EEG documented seizures, but diagnoses will also have
to progress in understanding and managing these challenging disorders’ been made on the basis of home video recordings or the observation of
[39]. seizures by clinicians in conjunction with other test findings available
Despite the fact that our findings are based on a large consecutive (such as brain imaging or interictal EEG findings) [54].
FNSD patient cohort, the failure of the current study to demonstrate Our case identification method means that no selection bias was
higher levels of PTSD symptoms in the subgroup with PNES may be the introduced through consenting procedures. Psychotherapy could be
result of patient selection bias. Although neurologists were able to refer offered to all patients referred, with no financial restrictions or condi-
any patient with FNSD to the departmental psychotherapy service, they tions, and our service is the only public provider of psychotherapy for
may preferentially have referred patients with a history of trauma. It is FNSD in the area we serve. However, all data analysed were provided
also possible that patients with no PTSD symptoms were less likely than by patients who had been referred to a psychotherapy service, and we
those with such symptoms to accept the referral for psychotherapy or to cannot be sure whether neurologists were more likely to refer particular
express an interest in the offer of psychological treatment by returning subgroups of FNSD patients (for instance those with high levels of
trauma).

5
C. Gray, et al.
Importantly, we made no attempt to measure trauma directly.
Instead we make inferences about previous trauma on the basis of
symptoms typically attributed to PTSD. Further, while our character-
isation of a subgroup potentially symptomatic of PTSD is likely to have
identified patients meeting the criteria for a clinical diagnosis of PTSD,
the gold standard examination for PTSD would have involved an in-
terview with a trained professional [5] rather than the questionnaire
used in this study. Although all patients seen for psychotherapy in our
service would have provided a detailed personal and medical history
during their treatment, and accounts of traumatic experiences would
have been sought by therapists, these data were not captured pro-
spectively in a standardised form throughout the period described in
this paper. When this information was captured in a methodical fashion
among patients with FNSD referred to our service between January
2003 and December 2004, 20.3% of all patients had experienced po-
tentially relevant sexual and 72.9% non-sexual trauma prior to devel-
oping FNSD [2]. What is more, the PCL-C is a well-validated instru-
ment, and we used a conservative measure of 45 as a cut-off of
potentially symptomatic PTSD. Nevertheless, there is debate about the
value of this measure as a diagnostic tool: Whereas Wilkins et al. sug-
gest that the PCL-C may overestimate the prevalence of PTSD and argue
that the overlap with symptoms of anxiety and depression makes it hard
to differentiate which symptoms are specifically related to PTSD [12],
Ruggerio et al. point out that, as the questionnaire included diagnostic
criteria B, C & D of the DSM-IV for PTSD, it ‘may yield information that
has a greater predictive value on a diagnostic level’ [13].
Next, our findings are based on patients referred to a single NHS
Neurosciences treatment provider. This limits generalisability, although
patients were referred by over 20 different neurologists from a range of
neurological clinic settings in secondary and tertiary care centres served
by specialists based at RHH.
Further limitations of the dataset available for this study include the
absence of information allowing a more fine-grained subdifferentiation
of FNSD presentations, and a standardised measure of dissociation.
7. Conclusion
Despite these limitations, the data demonstrate the high prevalence
of PTSD symptoms in patients with FNSD, adding to the evidence of a
link between trauma and the development of FNSD. Trauma and PTSD
symptoms were negatively correlated with the quality of life of patients
with FNSD and associated with other psychiatric comorbidities such as
anxiety and depression. High levels of anxiety and depression were
independently associated with higher levels of PTSD symptoms and
screening instruments for anxiety and depression could therefore in-
dicate which individuals would be at high risk of PTSD. Practitioners
working with this client group need to be capable of screening for
trauma and managing trauma in the treatment.
Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
All listed authors have approved the submission of the manuscript
to the journal, there are no other published, submitted or proposed
papers reporting the same or overlapping data.
Declaration of Competing Interest
‘All authors have completed the Unified Competing Interest form at
http://www.icmje.org/coi_disclosure.pdf and declare that: The authors
have no competing interests to report.
References
[1] J. Stone, A. Carson, R. Duncan, R. Roberts, C. Warlow, C. Hibberd, et al., Who is
6
Journal of Psychosomatic Research 129 (2020) 109907
referred to neurology clinics?—the diagnoses made in 3781 new patients, Clin.
Neurol. Neurosurg. 112 (9) (2010) 747–751.
[2] M. Reuber, S. Howlett, A. Khan, R. Grünewald, Non-epileptic seizures and other
functional neurological symptoms: predisposing, precipitating, and perpetuating
factors, Psychosomatics 48 (3) (2007) 230–238.
[3] M. Reuber, Trauma, traumatisation, and functional neurological symptom dis-
order—what are the links? Lancet Psychiatry 5 (4) (2018) 288–289.
[4] C. Bell, DSM-IV: diagnostic and statistical manual of mental disorders, JAMA 272
(10) (1994) 828.
[5] L. Ludwig, J. Pasman, T. Nicholson, S. Aybek, A. David, S. Tuck, et al., Stressful life
events and maltreatment in conversion (functional neurological) disorder: sys-
tematic review and meta-analysis of case-control studies, Lancet Psychiatry 5 (4)
(2018) 307–320.
[6] Diagnostic and statistical manual of mental disorders, DSM-5, 5th ed, American
Psychiatric Association, Washington, D.C., 2013.
[7] R. Brown, M. Reuber, Towards an integrative theory of psychogenic non-epileptic
seizures (PNES), Clin. Psychol. Rev. 47 (2016) 55–70.
[8] M. Edwards, R. Adams, H. Brown, I. Parees, K. Friston, A Bayesian account of
‘hysteria’, Brain 135 (11) (2012) 3495–3512.
[9] A. Fiszman, S. Alves-Leon, R. Nunes, I. D’ Andrea, I. Figueira, Traumatic events and
posttraumatic stress disorder in patients with psychogenic nonepileptic seizures: a
critical review, Epilepsy Behav. 5 (6) (2004) 818–825.
[10] E. Driver-Dunckley, C. Stonnington, D. Locke, K. Noe, Comparison of psychogenic
movement disorders and psychogenic nonepileptic seizures: is phenotype clinically
important? Psychosomatics 52 (4) (2011) 337–345.
[11] R. Erro, F. Brigo, E. Trinka, G. Turri, M. Edwards, M. Tinazzi, Psychogenic none-
pileptic seizures and movement disorders: a comparative review, Neurol.: Clin.
Pract. 6 (2) (2016) 138–149.
[12] K. Wilkins, A. Lang, S. Norman, Synthesis of the psychometric properties of the
PTSD checklist (PCL) military, civilian, and specific versions, Depress. Anxiety 28
(7) (2011) 596–606.
[13] K. Ruggiero, K. Ben, J. Scotti, A. Rabalais, Psychometric properties of the PTSD
checklist—civilian version, J. Trauma. Stress. 16 (5) (2003) 495–502.
[14] Using the PTSD Checklist (PCL) [Internet]. National Center for PTSD; 2012 [cited
22 January 2019]. Available from: https://www.ptsd.va.gov/professional/
assessment/documents/PCL_handoutDSM4.pdf
[15] R. Spitzer, K. Kroenke, J. Williams, B. Löwe, A brief measure for assessing gen-
eralized anxiety disorder, Arch. Intern. Med. 166 (10) (2006) 1092.
[16] B. Löwe, O. Decker, S. Müller, E. Brähler, D. Schellberg, W. Herzog, et al.,
Validation and standardization of the generalized anxiety disorder screener (GAD-
7) in the general population, Med. Care 46 (3) (2008) 266–274.
[17] M. Reuber, C. Burness, S. Howlett, J. Brazier, R. Grünewald, Tailored psy-
chotherapy for patients with functional neurological symptoms: a pilot study, J.
Psychosom. Res. 63 (6) (2007) 625–632.
[18] B. Novakova, S. Howlett, R. Baker, M. Reuber, Emotion processing and psychogenic
non-epileptic seizures: a cross-sectional comparison of patients and healthy con-
trols, Seizure. 29 (2015) 4–10.
[19] K. Kroenke, R. Spitzer, J. Williams, The PHQ-9, J. Gen. Intern. Med. 16 (9) (2001)
606–613.
[20] J. Chen, T. Caller, J. Mecchella, D. Thakur, K. Homa, C. Finn, et al., Reducing se-
verity of comorbid psychiatric symptoms in an epilepsy clinic using a colocation
model: results of a pilot intervention, Epilepsy Behav. 39 (2014) 92–96.
[21] A. Hinz, J. Ernst, H. Glaesmer, E. Brähler, F. Rauscher, K. Petrowski, et al.,
Frequency of somatic symptoms in the general population: normative values for the
patient health Questionnaire-15 (PHQ-15), J. Psychosom. Res. 96 (2017) 27–31.
[22] J. Mundt, I. Marks, M. Shear, J. Greist, The work and social adjustment scale: a
simple measure of impairment in functioning, Br. J. Psychiatry 180 (5) (2002)
461–464.
[23] G. Thandi, N. Fear, T. Chalder, A comparison of the Work and Social Adjustment
Scale (WSAS) across different patient populations using Rasch analysis and ex-
ploratory factor analysis, J. Psychosom. Res. 92 (2017) 45–48.
[24] D. Mataix-Cols, A. Cowley, M. Hankins, A. Schneider, M. Bachofen, M. Kenwright,
et al., Reliability and validity of the work and social adjustment scale in phobic
disorders, Compr. Psychiatry 46 (3) (2005) 223–228.
[25] M. Cella, M. Sharpe, T. Chalder, Measuring disability in patients with chronic fa-
tigue syndrome: reliability and validity of the work and social adjustment scale, J.
Psychosom. Res. 71 (3) (2011) 124–128.
[26] J. Brazier, R. Harper, N. Jones, A. O’Cathain, K. Thomas, T. Usherwood, et al.,
Validating the SF-36 health survey questionnaire: new outcome measure for pri-
mary care, BMJ. 305 (6846) (1992) 160–164.
[27] C. McHorney, J. Ware, J. Rachel Lu, C. Sherbourne, The MOS 36-ltem short-form
health survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability
across diverse patient groups, Med. Care 32 (1) (1994) 40–66.
[28] J. Ware, SF-36 Physical and Mental Health Summary Scales: A user’s Manual,
Boston, MA, Health Assessment Lab, New England Medical Center, 1999.
[29] J. Ware, SF-36 health survey update, Spine 25 (24) (2000) 3130–3139.
[30] M. Mukaka, Statistics corner: a guide to appropriate use of correlation coefficient in
medical research, Malawi Med. J. 24 (3) (2012) 69–71.
[31] D. Conybeare, E. Behar, A. Solomon, M. Newman, T. Borkovec, The PTSD checklist-
civilian version: reliability, validity, and factor structure in a nonclinical sample, J.
Clin. Psychol. 68 (6) (2012) 699–713.
[32] K. Cusack, A. Grubaugh, R. Knapp, B. Frueh, Unrecognized trauma and PTSD among
public mental health consumers with chronic and severe mental illness, Community
Ment. Health J. 42 (5) (2006) 487–500.
[33] M. Gupta, Review of somatic symptoms in post-traumatic stress disorder, Int. Rev.
Psychiatry 25 (1) (2013) 86–99.
C. Gray, et al.
[34] R. Keynejad, T. Frodl, R. Kanaan, C. Pariante, M. Reuber, T. Nicholson, Stress and
functional neurological disorders: mechanistic insights, J. Neurol. Neurosurg.
Psychiatry 7 (2019) 813–821.
[35] G. Akyuz, N. Kugu, A. Akyuz, O. Dogan, Dissociation and childhood abuse history in
epileptic and pseudoseizure patients, Epileptic Disorders 6 (3) (2004) 187–192.
[36] M. Kaplan, A. Dwivedi, M. Privitera, K. Isaacs, C. Hughes, M. Bowman, Comparisons
of childhood trauma, alexithymia, and defensive styles in patients with psychogenic
non-epileptic seizures vs. epilepsy: implications for the etiology of conversion dis-
order, J. Psychosom. Res. 75 (2) (2013) 142–146.
[37] A. Ozcetin, H. Belli, U. Ertem, T. Bahcebasi, A. Ataoglu, F. Canan, Childhood trauma
and dissociation in women with pseudoseizure-type conversion disorder, Nordic J.
Psychiatry (2009) 1–7.
[38] P. Salmon, S. Al-Marzooqi, G. Baker, J. Reilly, Childhood family dysfunction and
associated abuse in patients with nonepileptic seizures, Psychosom. Med. 65 (4)
(2003) 695–700.
[39] R.A.A. Kanaan, R. Duncan, L.H. Goldstein, J. Jankovic, A.E. Cavanna, Are psy-
chogenic non-epileptic seizures just another symptom of conversion disorder? J.
Neurol. Neurosurg. Psychiatry 88 (5) (2017) 425–429.
[40] V. Ekanayake, S. Kranick, K. Lafaver, A. Naz, A. Frank, W.C. Lafrance, et al.,
Personality traits in psychogenic nonepileptic seizures (PNES) and psychogenic
movement disorder (PMD): neuroticism and perfectionism, J. Psychosom. Res. 97
(2017) 23–29 November 2016.
[41] R. Jalilianhasanpour, B. Williams, I. Gilman, M.J. Burke, S. Glass, G.L. Fricchione,
et al., Resilience linked to personality dimensions, alexithymia and affective
symptoms in motor functional neurological disorders, J. Psychosom. Res. 107
(February) (2018) 55–61.
[42] N. Matin, S.S. Young, B. Williams, W.C. Lafrance, J.N. King, D. Caplan, et al.,
Neuropsychiatric associations with gender, illness duration, work disability, and
motor subtype in a U.S. functional neurological disorders clinic population, J.
Neuropsychiatr. Clin. Neurosci. 29 (4) (2017) 375–382.
[43] J. Hopp, K. Anderson, A. Krumholz, A. Gruber-Baldini, L. Shulman, Psychogenic
seizures and psychogenic movement disorders: are they the same patients? Epilepsy
Behav. 25 (4) (2012) 666–669.
Journal of Psychosomatic Research 129 (2020) 109907
[44] S. Kranick, V. Ekanayake, V. Martinez, R. Ameli, M. Hallett, V. Voon,
Psychopathology and psychogenic movement disorders, Mov. Disord. 26 (10)
(2011) 1844–1850.
[45] E. Lockwood, D. Forbes, Posttraumatic stress disorder and comorbidity: untangling
the Gordian knot, Psychological Injury and Law. 7 (2) (2014) 108–121.
[46] G. Rosen, S. Lilienfeld, Posttraumatic stress disorder: an empirical evaluation of
core assumptions, Clin. Psychol. Rev. 28 (5) (2008) 837–868.
[47] A. Van Emmerik, J. Kamphuis, Testing a DSM-5 reformulation of posttraumatic
stress disorder: impact on prevalence and comorbidity among treatment-seeking
civilian trauma survivors, J. Trauma. Stress. 24 (2) (2011) 213–217.
[48] R. Spitzer, M. First, J. Wakefield, Saving PTSD from itself in DSM-V, J. Anxiety
Disord. 21 (2) (2007) 233–241.
[49] J. Elhai, A. Contractor, M. Tamburrino, T. Fine, G. Cohen, E. Shirley, et al.,
Structural relations between DSM-5 PTSD and major depression symptoms in
military soldiers, J. Affect. Disord. 175 (2015) 373–378.
[50] T. Loeb, N. Joseph, G. Wyatt, M. Zhang, D. Chin, A. Thames, et al., Predictors of
somatic symptom severity: the role of cumulative history of trauma and adversity in
a diverse community sample, Psychol. Trauma Theory Res. Pract. Policy 10 (5)
(2018) 491–498.
[51] S. Easton, J. Kong, Mental health indicators fifty years later: a population-based
study of men with histories of child sexual abuse, Child Abuse Negl. 63 (2017)
273–283.
[52] J. Elhai, A. Grubaugh, T. Kashdan, B. Frueh, Empirical examination of a proposed
refinement to DSM-IV posttraumatic stress disorder symptom criteria using the
National Comorbidity Survey Replication Data, J. Clin. Psychiatry 69 (4) (2008)
597–602.
[53] N. Holman, A. Kirkby, S. Duncan, R. Brown, Adult attachment style and childhood
interpersonal trauma in non-epileptic attack disorder, Epilepsy Res. 79 (1) (2008)
84–89.
[54] R. Mayor, P. Smith, M. Reuber, Management of patients with nonepileptic attack
disorder in the United Kingdom: a survey of healthcare professionals, Epilepsy
Behav. 21 (2011) 402–406.