Autonomy-Related Personality Factors in Patients with Functional Neurological Symptom Disorder

Abstract

Functional neurological disorder (FND), formerly called hysteria and conversion disorder, is a complicated condition that is empirically difficult to investigate. The study of personality factors in FND has a long tradition in which there is still uncertainty about which personality factors play an important role in FND. Only in recent years has there been more evidence of certain important personality factors. These factors are now hypothetically understood and summarized as ‘premorbid autonomy-related variables.’ This provides a research framework for more empirical research. Several premorbid autonomy-related variables such as insecure attachment, suggestibility, alexithymia, interoception, sense of agency, fear avoidance/openness to experience, and autonomy-connectedness are discussed. In addition, a hypothetical working model will be discussed in this chapter. This may provide important clues to the etiology, diagnosis, and treatment for patients with FND.

1. Introduction

Functional neurological disorder (FND), also known as conversion disorder, is a difficult condition to understand along with long tradition. The first symptoms were probably found by the neurologist Martin Charcot around 1850. He described different motor and sensory disorders. The motor disorders, for instance, corresponded with paralysis, extreme immobility, bizarre movements or difficulty walking, and convulsions of hands and legs. He also described sensory symptoms such as loss of taste, sight and feeling disorders, and pain. Further, he found behavioral problems that were associated with these symptoms such as memory loss, dissociation, doubling of the personality, kleptomania, and the urge to spend to excess [1]. An important personality trait he observed was suggestibility. This meant that patients were susceptible to another person’s suggestions. Patients could be docile and imitate the other person in an excessive way. This was later called ‘the chameleon syndrome’ by other authors, where patients could adopt the behavior of others [2]. Charcot characterized the personality of patients as la belle indifference by which he also indicated that patients could show a different exterior than the emotional inner world that might be experienced. Identity impersonation was immature with patients more likely to derive their identity from others and less in touch with their true authentic self, as was mentioned. The terminology associated with this was called infantile personality and hysteria [3]. Although the term hysteria was common during this period and was referred to as such several times in the literature, the stigmatizing effect of this diagnosis was probably not considered at the time.

Freud and Breuer [4] caused an eventual change in understanding with their studies on hysteria because they believed they saw an important etiological factor in the symptoms of these patients. According to Freud and Breuer, these were often traumatized people who needed to split off painful feelings in their lives in order to cope with painful memories and experiences. The traumatic effect had to be uncoupled in order to make life bearable. A consequence of this was a displacement of the affective experience to the body which Freud and Breuer believed was the explanation of the symptoms. A conversion from psychological traumata, such as sexual abuse unconsciously transformed into physical symptoms in motor and sensory areas.

Although Janet [5] gave a somewhat different description, he also explained the hysteria by a split-off where a fixed idea was needed to keep the personality afloat. This meant that patients developed a ‘traumatized part’ and a ‘survival part’ in their personalities that were disconnected. Patients pushed their traumatized parts away and held on by keeping a strong part upright in order to survive. Patients developed a phobic reaction as soon as they were confronted with memories that caused the disconnection of the different parts to become stronger and thus developed symptoms and complaints that refer to trauma.

The early authors thus saw an important explanation in the personality development of patients in which personality and trauma may play the most important role in the etiology of the condition. Later, empiricist authors found less evidence in their studies of a causal relationship between trauma and conversion disorder [6]. This was one of the reasons that the DSM 5 terminology shifted also to the term functional neurological disorder (FND). This may blur the role of stressors in the etiology of FND and equate the condition with a functional problem incompatible with a neurological disorder.

Since this change in the DSM 5, there is less clarity about the role of personality factors in FND. The questions that remain are as follows: What are the important personality factors in FND? How can these factors contribute to the development of FND? Which therapeutic strategies can be used to treat these premorbid personality factors? Although this area of research has only recently been revived, this chapter will formulate a possible answer to these questions.

2. Autonomy in FND

Based on clinical observations and recent empirical studies, it appears that the important premorbid factors in FND patients are characterized by autonomy-related problems. Autonomy is a broad term that is often used in developmental psychology. The term refers to autos (self) and nomos (laws), which in other words reflects the extent to which people are able to determine their own laws. This immediately presents a number of philosophical problems that have traditionally been addressed by philosophers. Do we actually have a self? And, can we determine our own laws? Or, are we rather slaves to the laws of others? Or slaves of the community? As been stated by Emanual Kant, for example. However, if we look at autonomy from a developmental psychological perspective, Mahler has presented a model that provides an understanding of infantile development and the moment when an infant first gains a self-experience, also called the separation-individuation phase [7]. This moment is an important moment when an infant begins to recognize himself in the mirror and has a notice of the first distance between the self and the other, as also stated by Lacan, for instance [8]. Then later in development, the drive and anger will cause the infant to distance himself further and thus be able to explore his own boundaries. The word that will be said often between the ages of two and three is the word ‘no.’. Mahler describes that the reunion after separation is important, where the infant learns to trust the caregiver and feels accepted when he distances himself and can return safely. An unsafe development occurs when the infant feels unsafe after distancing himself from the caregivers and is structurally rejected or ignored after the reunion.

John Bowlby named that this secure experience is necessary to develop a secure attachment. If an infant is not allowed to attach securely during reunification, for example, he has a greater chance of developing an insecure attachment [9]. In Ainsworth’s laboratory studies, she operationalized this insecure attachment in different attachment styles, namely, ambivalent-insecure attachment, anxious-preoccupied attachment, and avoidant-insecure attachment [10]. Avoidant-insecure attachment is characterized by a rejecting disposition in which the growing child learns that closeness feels less safe and therefore keeps distance of the caregivers and later to other people in life. The anxious-preoccupied attachment is characterized by continuous insecurity and an inability to trust oneself and distance oneself. The growing child is convinced that he or she cannot cope alone in life and is therefore clingingly attached to intimate relationships. The anxious-preoccupied attachment is often accompanied by autonomy difficulties where there is a belief that the person cannot do it themselves and will always need others. This can take physical forms that the person may experience not having access to his/her own body, resulting in limited body ownership. Also, there is difficulty defining oneself and there is often confusion about one’s own opinions and beliefs. The ambivalent attachment is a residual category and a combination of clinging and avoidance. This can be accompanied by feelings of disorganization as the growing child cannot maintain himself in either avoidant or preoccupied attachment.

3. Premorbid autonomy-related variables in FND

Only in recent years has there been more empirical research on the personality variables of patients with FND. Although research on premorbid factors is complicated and far from well researched, we attempt here to describe some important premorbid personality factors, summarized as premorbid autonomy-related variables. Knowing more about premorbid personality factors in FND may lead to more clarity about etiology and pathogenesis. This will allow us to make more accurate person-centered diagnosis and may turn into more effective treatments. The hypothesis we introduce in this chapter is that FND patients have a number of premorbid autonomy-related personality factors that may increase the risk of FND-related symptoms and psychopathology. We see within the FND group that patients often have established insecure attachment. This is strongly associated with experiencing adverse childhood experiences (ACE) in their lives [11]. We see that patients have often had inadequate coregulation in relation to their caregivers. This can lead to emotion regulation problems and an inability to mentalization and given language to affects and emotions. Importantly, these negative interpersonal early childhood experiences can lead to deficiencies on key personality factors. A systematic review of autonomy-related variables in FND specifically examined variables strongly associated with autonomy deficiencies [12]. Within clinical practice, limited autonomy is observed particularly in FND, although autonomy deficiencies are also transdiagnostic and visible in other mental disorders. Of course, autonomy deficiencies may be both a consequence of the disorder, but there is also evidence that these problems are already present before FND and psychopathology has developed. The autonomy-related variables we elaborate in this chapter are attachment, suggestibility, alexithymia, interoception, sense of agency, fear avoidance/openness to new experiences, and autonomy-connectedness. These factors have been scrutinized for the first time in recent years and provide initial evidence of autonomy deficiencies in FND.

3.1 Attachment in FND

Attachment in FND patients has also been studied more empirically only in recent years. Consequently, only a few studies are known. These do so far support an association between insecure attachment and FND. In clinical practice, we see that FND patients do not immediately see their problems in the light of problematic insecure attachment. They may see these problems as secondary to their symptoms. However, when we ask about past and present attachment relationships, it may become clear that patients have an inner working model that corresponds to problems with attachment. For example, patients mention that they have difficulty trusting themselves in relation to others or that they have difficulty making themselves dependent. Within partner relationships, problems are experienced during intimacy and patients are insecure and anxious in relation to others close to them. These problems often appear to have been present before the onset of FND symptoms, and this may mean that it is an important premorbid vulnerability factor. However, research that both before the pathology was present and after is still insufficient and should become an important area of research. Within FND, both avoidant attachment and anxious attachment have been demonstrated [13, 14] so far. In addition, it has also been shown that anxious attachment is associated with anxiety disorders and depression and also associated with alexithymia [15], which will be further explained below. In doing so, it appears that attachment affects the duration of FND-related symptoms [16]. Initial evidence that attachment may play a premorbid role is thus possibly explained.

In summary, there is evidence that there is an association between insecure attachment, alexithymia, and FND with other important related factors, such as depression and anxiety. Not enough longitudinal research has yet been done to make a statement about causality. Therefore, more research on attachment in FND needs to be done.

3.2 Suggestibility in FND

As earlier stated, probably one of the first persons to link the term suggestibility to FND (then called hysteria) was Martin Charcot around 1850 [1]. Although Charcot did not know how to explain this characteristic very well, he was able to characterize his patient population as ‘suggestible.’ Suggestibility refers to the capacity for suggestions to trigger automatized behavioral routines or mental representations and/or a tendency to form precise priors that override motor and perceptual systems [17]. Within the tradition, which we learned from historical literature [4], patients with ‘hysteria’ were treated, one of the first, by Freud and Breuer. Hypnotic suggestibility was a technique that was used. Breuer, in particular, believed in the hypnotic technique on which he could put patients under hypnosis and could expose patients in this way to traumatic effects. In this way, patients were able to integrate their effects and then become aware of feelings stored in their bodies. Those FND patients may be more susceptible to others’ suggestions were later confirmed in various ways also in empirical research. For example, previous research shows that there is a significant association between hypnotic suggestibility and FND compared to a control group [18]. This may mean that patients are much more sensitive to what others think and adapt to it more quickly. This was also confirmed in a meta-analysis where the association between suggestibility and FND was systematically assessed [17]. The authors therefore argued that suggestibility makes patients more sensitive and susceptible to misinterpretation of body signals. It is suggested that dissociation also plays an important role in susceptibility to suggestion [17, 19]. This can be imagined when patients do not really know what they feel and therefore more likely to rely someone else’s suggestions. So, hypnotic suggestibility and sensitivity to others’ suggestions may play a role in maintaining FND and dissociative symptoms.

3.3 Alexithymia in FND

The disruption of emotional awareness, or alexithymia, refers to the incapability to have words for mood. By now, this topic is a well-known research topic that has been further empirically developed. It is sometimes put forward as an important premorbid factor for various forms of psychopathology, and especially psychosomatic problems [20]. An important assumption here is that patients did not get the words to the intersubjective emotions in their past lives from their important caregivers. Also, when there is too little mirroring and also emotional neglect, then patients have not been able to learn from their emotions. A study found a correlation between insecure attachment, depressive feelings, anxiety, and alexithymia within FND patients [15] as also earlier stated. This can mean that patients spiral into anxiety and gloom while at the same time not understanding what is going on inside them. The most common instrument still used to measure alexithymia is the TAS-20 (20-item Toronto Alexithymia Scale). The TAS-20 comprises three scales: difficulty identifying feelings, difficulty describing feelings, and externally oriented thinking. Externally oriented thinking refers to a thought process that is focused externally rather than internally. Internal orientation is a necessity for recognizing one’s own feelings. However, the TAS-20 does not cover fantasizing conceived as another essential feature of alexithymia [21]. Therefore, it is necessary to investigate these factors of alexithymia also in FND in follow-up studies. Alexithymia is relatively common in FND and is estimated to be about 40% prevalent [22]. There is evidence that FND patients have difficulty identifying feelings and describing feelings [23]. However, too little is still known about which features of alexithymia are predominant in FND. In summary, there is evidence of an association between alexithymia and FND, but more research needs to be done to find out in what ways alexithymia plays a role.

3.4 Interoception in FND

Interoception includes how the nervous system experiences, interprets, and integrates signals from within the body. Interoception is believed to be a very important inner landscape that is considered a component of reflexes, urges, feelings, drives, adaptive responses, and cognitive and emotional experiences [24]. Interoception is a homeostatic feedback loop of the inner world—including the cardiovascular, pulmonary, gastrointestinal, genitourinary, nociceptive, chemosensory, osmotic, thermoregulatory, visceral, immune, and autonomic systems—on which people learn to trust and recognize what is experienced inside through reflections of the outer world [24]. This broad concept is difficult to operationalize because of its many aspects. A classification by Ricciardi et al. [25] works to operationalize three different facets of interoception in FND. For example, one can subdivide interoception into ‘interoceptive accuracy’ that refers to the accuracy of detecting bodily signals. In particular, this is operationalized by a heart rate task in which participants are asked to estimate their number of heartbeats. Here, it is assumed that if patients do not do very well, their degree of accuracy is limited. The second aspect refers to ‘interoceptive sensibility’ indicating a subjective report of one’s ability to sense bodily signals that is operationalized with self-reported confidence questions such as the BAQ (Body Awareness Questionnaire). Examples of questions include ‘I notice differences in the way my body reacts to various foods’ and ‘I am aware of a cycle in my activity level throughout the day’ [26]. The third aspect includes ‘interoceptive awareness’ referring to the metacognitive awareness of one’s interoceptive accuracy, usually calculated as the correspondence between accuracy and confidence. Recent results indicate that FND patients underperform on tasks measuring accuracy and sensitivity, but metacognitive aspects are intact [25]. This may mean that FND patients are aware of their inability of their interoceptive skills. Yet, these results are not uniform among FND patients. Indeed, other research shows no abnormalities in FND patients on accuracy, but does show abnormalities on sensibility [27]. Thus, although much research remains to be done on interoception in FND, there are initial indications of dysfunction in the area of sensibility among FND patients. Here, another interesting finding is that the increase in stress within this group does not matter much [14].

3.5 Sense of agency in FND

Sense of agency refers to the subjective experience of controlling our own thoughts and our bodily feelings. And, also important, it refers to a belief that self-generated action causes an event in the external environment. In movement disorders such as FND, this sense of agency process may be importantly affected [28]. A recent study shows that metabolic processes play a role in the decreased sense of agency of FND patients. This may also be related to patients’ difficulty in reflecting on themselves [29]. This in turn is visible through disruptions within the so-called default network mode, a brain network, that is believed to be an important contributor to reflection, daydreaming, and spending time in the inner world. An important assumption here may be that FND patients experience deficits in their reflective functioning and where they may experience limited control over this. Although the sense of agency is a difficult construct to explore, there are increasing attempts to explore the construct further. Such is the case with FND. There are several ways in which the sense of agency has been measured in FND patients. For example, FMRI [30] has been used where there was support for a limitation of sense of agency in FND, and subliminal computer tasks have been experimented with in which no differences were found between non-psychiatric people and FND patients [31]. Yet, another research method that has been tried in FND patients is the rubber hand illusion task [32]. In the rubber hand illusion task, patients are watching the rubber hand tapping while performing tapping movements with their own fingers. To measure the sense of ownership and sense of agency, a questionnaire (mRHI) is used to examine statements such as ‘I felt as if the rubber hand was my hand’ (ownership statements) and ‘I felt as if I caused the movement I saw’ (agency statements). This suggests that patients with FND have more of an experience that the movements of the rubber hand match with the movements of their own hand; when in reality, this is not the case. Nevertheless, it appears that FND patients do not differ in their responses according to self-report results compared with controls [32].

In summary, the relevant construct ‘sense of agency’ is difficult to operationalize. This is evident in the various studies where researchers use different methods to measure the construct. This may play a role in the ambiguous results found so far in FND patients.

3.6 Fear avoidance/openness to new experience in FND

One broad theory that is further elaborated in developing psychopathology is the extent in which patients seek new situations. When people have a fear-avoiding temperament, this could lead to more inhibition and less novelty seeking and may contribute to psychopathology and less creativity [33]. FND patients may be more sensitive to negative information and may have difficulties seeking new situations [34]. ‘More sensitivity to negative conditioning involves the progressive association of a neutral stimulus with fearful or negative outcomes, causing transference of negative saliency to the previous neutral stimulus’ [34]. This is the behavioral explanation the authors suggested to illustrate how fear-avoidance sensitivity can lead to the conditioning of increased fear for new situations. This may explain why FND patients react with avoidance and dissociative strategies more than people within the normal population. There is some evidence to support this statement. For example, it has been shown that there is an association between low openness to new experiences and FND. Sarisoy et al. [35] found evidence to support the hypothesis that FND patients have lower novelty seeking and higher harm avoidance than control groups. This was measured by a self-report list used to measure temperament with the temperament and character inventory (TCI). The researchers hypothesized also that high harm avoidance, low reward dependency, low self-directedness, and high self-transcendence may be associated with dissociation and FND symptoms.

In summary, evidence suggests that openness to new experiences and harm avoidance may play a role in FND. Again, the evidence that has been found and the number of studies that have been done is limited making it difficult to link an obvious conclusion to the findings. However, it does raise interesting hypotheses about important premorbid factors of FND patients which we will now further translate into an integrated working model for FND patients which we will further discuss.

3.7 Autonomy-connectedness and a working model for FND patients

The concept of autonomy-connectedness may be a working model that integrates several premorbid autonomy-related personality variables. As shown above, there is initial evidence of correlation between premorbid autonomy-related personality factors and dissociative and FND symptoms [14, 15, 17]. The variables discussed earlier may be strongly related to deficiencies in autonomy-connectedness [12]. We will present an integrated working model that will now be the subject of more research and could possibly fit well with the problems of FND patients.

Central to autonomy-connectedness is the ability to be oneself and the ability to connect with others. Autonomy-connectedness refers to the need and capacity for separation and individuation and the need and capacity for intimacy and functioning in intimate relationships [36]. These two polarizing needs may be seen as a recurring dilemma that people may find themselves in. On the one hand, people want to belong, and, on the other hand, they want to be themselves. Being in contact with our own authentic bodily needs while staying connected with others is essential for our emotional and physical health. When people cannot connect enough with themselves, cut themselves off, and ignore bodily needs, it can lead to stress multiplication and may also lead to various physical ailments [37].

Autonomy-connectedness is embedded in the attachment theory [7, 9] which includes the conditions under which an infant can safely discover the world under the watchful eye of her caregivers and develop her autonomy under safe conditions. From this safety, infants increasingly become more autonomous by testing, extending, and then reducing their distance from their caregivers. Under this condition, infants can understand their own wants and needs separate from and in connection with their caregivers and others.

Autonomy-connectedness consists of three domains: first, self-awareness which contains the ability to be aware of opinions, wants, and needs and the ability to express these aspects of autonomy in social interactions. Second, sensitivity to others refers to sensitivity to the opinions, wants, and needs of others and the ability to empathize with others. Third, the ability to handle new situations which concerns how comfortable individuals are in situations that are not common.

Only recently has this theory been further developed at FND [38]. An elaborated hypothesis describes that FND patients have premorbid vulnerability before pathology develops. Moderating stressors such as interpersonal trauma, illness, grief, physical trauma, and work−/study-related problems may enhance the relationship between autonomy-connectedness deficits and FND-related symptoms. These symptoms can manifest at different levels such as interpersonal, intrapersonal, and biological. At the interpersonal level, patients may show high levels of self-sacrifice [39], and at the intrapersonal level, they articulate autonomy-connectedness conflicts. For example, ‘on the one hand I want to live on my own, but on the other I don’t dare.’ At the biological level, this may result in hypoarousal. Hypoarousal is often related to the level of anxiety and depression [40]. Depression and anxiety disorders are often associated with FND (Figure 1) [41].

Figure 1.

A working model of autonomy-connectedness deficiencies in FND patients [38].

4. Treatment of autonomy in FND patients

Melanie is a patient with PNES symptoms that have been present for about two years. She described that her symptoms began at work. First, gradually, she could recognize in retrospect (not at the time) that she was becoming increasingly tired and experiencing mild dizziness that gradually got worse. Melanie worked within a hospital as a nurse and had worked her way up to a management position. As she gained this position, those around her noticed that she became increasingly direct and less friendly toward her colleagues. She explained that she needed to appear stronger and stronger. When Melanie was spoken to at work about her behavior, a short time later, an initial seizure occurred in which she fell off her chair and became unconscious. These attacks continued at work with fatigue, dizziness, and seizures eventually being classified by the neurologist as PNES. Melanie reports that, during a seizure, she can hear everything from her surroundings but is unable to respond. When Melanie talked about her past, she mentions that she never felt safe with her parents. The emphasis in her youth was always about strength and positivity. She was not allowed to whine in the face of adversity, and her mother denounced it when she could no longer hide her sadness when, for example, she was beaten by a classmate. According to her mother, she had to toughen herself up and stop being so ‘pathetic.’ This drama was repeated in her later relationships where Melanie was physically abused by her ex-partner who suffered from alcohol problems and had a short temper. Melanie mentions that she had to adapt to others very early on. She had to tiptoe around her parents and in later relationships to keep them from becoming angry with her. She never dared to think about her own physical and emotional signals, especially because these feelings were at odds with what those around her wanted from her. Melanie was always been anxious about seeking out new social situations. She was afraid of doing wrong to others. During the treatment, which focused on both psychological and psychomotor treatment, Melanie became aware of her autonomy-related problems. She recognized that she always looked at herself through someone else’s eyes and had difficulty having her own views and opinions. She had doubts about who she was and what she wanted. Her emotions had no right to exist, and with every decision (even the smallest), she was wondering if this was the will of herself or the other. When Melanie became more aware of her own emotions and when she was able to admit them in relation to others (she now also has a partner whom she could trust), she could allow herself to develop her autonomy in relation to others. We got the impression that this could lead to a reduction in PNES-related symptoms and no longer played a meaningful role in her life.

This clinical example shows how a therapeutic process can be initiated after a patient is aware of her autonomy-related problems and can gradually learn to shape them differently. Becoming aware of problems that had been present in a patient’s life for some time was an opening to develop a different narrative that is more focused on her own physical and emotional needs. This principle can be implemented within various therapeutic interventions.

There are different therapeutic ‘techniques’ that could be done for FND patients that are supportive for their autonomy. Think of the child who is repressed and rejected from the need for autonomy. Patients have often had the experience of having to adapt primarily and have not been seen in their needs to express themselves and gain experiences of direction and control. The question for therapy is How can patients increase their self-awareness a bit more again? Concepts such as those discussed earlier can help to clarify this. Patients have a limited ability to experience and describe and give language to what is happening inside them. Thus, they benefit from a therapeutic environment in which they can increase and integrate self-awareness.

An important question is whether this approach is so specific for patients with FND. An answer to this is that this is a transdiagnostic and person-oriented approach that is somewhat adapted to the underlying premorbid personality factors of patients with FND. Treatment can also be further specialized aimed at FND when physiotherapeutic, psychomotor, systemic, and psychological (such as catalepsy induction and medical hypnosis) interventions are used. However, it is expected that a therapeutic approach that focuses more on the underlying autonomy deficiencies and is integrated into a specific approach will be more durable and effective.