Clinical Neuropsychology: Open Access
Open Access

Neurodevelopmental Disorders; Psychotherapy; Neurologists; Somatization

Introduction

According to a recent Dutch guideline, patients with Operational Neurologic Disorders should undergo diagnosis and treatment by both a neurologist and a psychiatrist or psychologist [1]. This recommendation aligns with findings from Nicholson and colleagues, who emphasized the importance of comprehensive psychosocial evaluation for patients with Functional Neurological Disorder (FND) [2]. However, neurologists often face challenges in referring FND patients to therapists or psychologists, as these patients primarily experience physical symptoms and may not recognize the clinical significance of such referrals.

Despite symptoms persisting for several months, improvement without psychotherapy is possible, as demonstrated by a Dutch retrospective study over two decades ago [3]. In this study, 60% of patients showed improvement without the use of psychotherapy. Our study aimed to assess the impact of psychotherapy on patients' perceptions of improvement, building upon the findings of the retrospective study.

Conducted between 2009 and 2013 at the Academic Medical Center's outpatient neurology department in Amsterdam, Netherlands, our single-center, randomized, controlled trial included participants referred by their general practitioners for neurological symptom diagnosis [4]. Patients with symptoms persisting for over a year after their initial visit to the general practitioner were excluded from the study.

Participants were encouraged to gradually increase their daily activities, with referral to a physiotherapist if progress was slow. The decision to refer for psychotherapy was made by the neurologist or primary care physician. Sociodemographic and clinical data were collected at baseline, and participants completed self-reported health surveys at baseline and one year, including assessments for somatization, anxiety, and depression. The use of psychotherapy was documented during the one-year follow-up. Treatment strategies were concealed from participants, and at 12 months, participants categorized their perceived symptoms into six categories compared to baseline. Categories indicating improvement were considered favorable outcomes, while those indicating worsening were considered negative outcomes [5, 6].

Statistical analysis

We pooled the two treatment arms for this analysis due to the absence of differences in participants' baseline characteristics at study entry, as well as in the use of psychotherapy and a wide range of primary and secondary outcomes at 12 months.

Descriptive statistics were utilized to provide a summary of the outcome parameters and baseline characteristics. The Fisher's exact test or the two-group t-test, as appropriate, were employed to examine the univariable associations between participants' baseline characteristics, psychotherapy, and outcomes [7]. Multivariable logistic regression was subsequently utilized to further explore the impact of psychotherapy on outcomes, taking into account baseline variables that, in the univariable analyses, demonstrated an association with a p-value of 0.01. The adjusted odds ratio and its associated 95% confidence interval were used to describe the magnitude of the effect. A p-value of 0.05 on both sides was considered statistically significant. All analyses were conducted using IBM SPSS Statistics, version 22.

Results

The study included 193 participants in the study group. Among them, 60 participants reported a significant decrease in complaints compared to their baseline level after one year, indicating a favorable outcome. Additionally, 45 participants reported a moderate improvement in their grievances [8].

Psychotherapy was recommended for sixty participants. Of those with a positive outcome, 15 had undergone psychotherapy, while 45 of those with negative outcomes had also received psychotherapy. However, there was no statistically significant difference between these proportions. Although there was a trend observed for somatization, no significant associations were demonstrated between participants' baseline characteristics and the outcome. Specifically,among participants with a positive outcome, 21 had a high level of somatization, while 66 in the group without a favorable outcome had elevated somatization levels [9].

In multivariable logistic regression, including psychotherapy and somatization level in the model, an independent borderline effect of somatization on outcome was found. Participants with a high level of somatization were less likely to have a positive outcome compared to those with a normal level of somatization. However, a significant independent effect of psychotherapy on favorable outcomes was not demonstrated [10].

Discussion and Conclusion

During the 12-month follow-up period, 54% of participants with FND showed improvement, indicating that they either reported no complaints or experienced a significant or moderate improvement in the quality of their complaints. We combined these two categories as a favorable outcome, representing the best possible improvement that participants found difficult to differentiate between having no complaints and experiencing significant improvement. This favorable outcome was observed in 31% of participants.

In a few cases, decisions regarding psychotherapy referrals were made by either the neurologist or general physician. Typically, referrals were made for individuals who had not shown improvement or had shown gradual improvement after receiving an explanation of the diagnosis. Although the correlation between psychotherapy and a favorable outcome was not statistically significant, this practice likely contributed to the observed outcomes. Our findings support those of a retrospective study, which demonstrated that patients could improve without psychological treatment. This was evident in three-quarters of the subjects who showed improvement in our study. The relatively brief duration of symptoms could not explain this perceived improvement in the absence of psychotherapy. Even though 68% of patients in our study had experienced operational symptoms for at least six months, this duration is still too short to initiate psychotherapy. Thus, improvement without psychotherapy is possible even if symptoms persist for several months.

Acknowledgement

None

Conflict of Interest

None

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