General Hospital Psychiatry xxx (2015) xxx–xxx

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General Hospital Psychiatry

journal homepage: http://www.ghpjournal.com

Efficacy of brief interdisciplinary psychotherapeutic intervention for

motor conversion disorder and nonepileptic attacks☆
M. Hubschmid a, S. Aybek, MD b, G.E. Maccaferri, MD a, O. Chocron a, M.M. Gholamrezaee, PhD c,
A.O. Rossetti, MD b, F. Vingerhoets, MD b, A. Berney, MD a,⁎
a
Psychiatric Liaison Service, Department of Psychiatry, Lausanne University Hospital (CHUV), Rue du Bugnon 44, 1011 Lausanne, Switzerland
b
Department of Clinical Neurosciences, Lausanne University Hospital (CHUV), Rue du Bugnon 44, 1011 Lausanne, Switzerland
c
Department of Psychiatry, Lausanne University Hospital (CHUV), Rue du Bugnon 44, 1011 Lausanne, Switzerland

a r t i c l e i n f o a b s t r a c t

Article history: Objective: The objective was to compare a brief interdisciplinary psychotherapeutic intervention to standard care
Received 16 December 2014 as treatments for patients recently diagnosed with severe motor conversion disorder or nonepileptic attacks.
Revised 21 May 2015 Methods: This randomized controlled trial of 23 consecutive patients compared (a) an interdisciplinary psycho-
Accepted 22 May 2015 therapeutic intervention group receiving four to six sessions by a consultation liaison psychiatrist, the first and
Available online xxxx
last sessions adding a neurological consultation and a joint psychiatric and neurological consultation, and (b) a
standard care group. After intervention, patients were assessed at 2, 6 and 12 months with the Somatoform Dis-
Keywords:
Conversion disorder
sociation Questionnaire (SDQ-20), Clinical Global Impression scale, Rankin scale, use of medical care, global men-
Dissociative disorder tal health [Montgomery and Asberg Depression Rating Scale, Beck Depression Inventory, mental health
Functional neurological symptom disorder component of Short Form (SF)-36] and quality of life (SF-36). We calculated linear mixed models.
Nonepileptic attack Results: Our intervention brought a statistically significant improvement of physical symptoms [as measured by
Psychotherapeutic intervention the SDQ-20 (Pb.02) and the Clinical Global Impression scale (P=.02)] and psychological symptoms [better scores
on the mental health component of the SF-36 (Pb .05) and on the Beck Depression Inventory (Pb.05)] and a re-
duction in new hospital stays after intervention (Pb.05).
Conclusion: A brief psychotherapeutic intervention taking advantage of a close collaboration with neurology con-
sultants in the setting of consultation liaison psychiatry appears effective.
© 2015 Elsevier Inc. All rights reserved.

1. Introduction
Patients suffering (according to the International Classification of Dis-
eases, 10th Revision) from motor and convulsive dissociative disorders
(also called nonepileptic attacks) or conversion disorders [functional
neurological symptom disorder; according to the Diagnostic and Statisti-
cal Manual of Mental Disorders, Fifth Edition (DSM-5)] frequently present
to neurologists as up to 30% of new neurology outpatients present with
some functional symptoms [1], about 8% can be diagnosed with
☆ Author contribution: The study design and concept were elaborated by B.A., V.F., A.S.
and H.M. Patients were enrolled and assigned by H.M., A.S., M.G.E. and C.O. R.A.O. made the
NEA diagnoses. The psychotherapeutic intervention was conducted by H.M., M.G.E. and
C.O.; the neurological intervention was conducted by A.S. The outcome measures were
evaluated by H.M., M.G.E., C.O. and A.S. Data were collected by H.M., M.G.E., C.O. and A.S.
and computerized by H.M. Statistical analysis was done by G.M. Critical analysis of data
was done by H.M., A.S. and B.A. The first draft of the manuscript was written by H.M.
and reviewed by A.S., B.A., V.F., C.O., R.A.O., M.G.E. and GM.
⁎ Corresponding author at: Service de psychiatrie de liaison, DP-CHUV, Rue du Bugnon
44, CH-1011 Lausanne, Switzerland. Tel.: +41 21 314 11 05; fax: +41 21 314 10 98.
E-mail addresses: monica.hubschmid@vidymed.ch (M. Hubschmid),
selma.aybek@unige.ch (S. Aybek), giorgio.maccaferri@chuv.ch (G.E. Maccaferri),
oury.chocron@chuv.ch (O. Chocron), mehdi.gholam@chuv.ch (M.M. Gholamrezaee),
andrea.rossetti@chuv.ch (A.O. Rossetti), francois.vingerhoets@chuv.ch (F. Vingerhoets),
alexandre.berney@chuv.ch (A. Berney).
conversion disorder [2] and 10%–20% of patients with intractable epi-
lepsy suffer from nonepileptic attacks (NEAs) [3]. They represent a ther-
apeutic challenge and are considered to be more difficult to help than
patients with better characterized organic neurological diseases [4].
The prognosis is globally unfavorable, with long-lasting symptoms as
shown by a recent review (globally only 50% improving) [5–7] leading
to early work retirement (30% do not work anymore at an average age
of 44) [6]. A number of treatment strategies have been proposed rang-
ing from psychologically derived hypothesis using hypnosis [8], abreac-
tion [9], cognitive–behavioral approaches [10–12] to more physically
based approaches using physiotherapy [13], transcranial magnetic stim-
ulation [14] or drugs (antidepressants) [15]. A recent Cochrane review
of treatments for nonepileptic attacks concluded that the evidence
was scarce for any psychological or behavioral intervention and that
there is a lack of randomized controlled trials [16]. In the same year, a
randomized controlled trial (not included in the Cochrane review)
showed that patients included in the cognitive–behavioral therapy in-
formed psychotherapy (CBTit) arm had a 51% seizure reduction, where-
as another arm combining CBTit and sertraline had a 59% seizure
reduction, which was significant compared to both the treatment-as-
usual arm (follow-up by neurologist only) and the sertraline arm [17].
This argues for a systematic implementation of psychotherapy in the
care of NEA patients. For conversion disorder (all symptoms, not only

http://dx.doi.org/10.1016/j.genhosppsych.2015.05.007
0163-8343/© 2015 Elsevier Inc. All rights reserved.

Please cite this article as: Hubschmid M., et al, Efficacy of brief interdisciplinary psychotherapeutic intervention for motor conversion disorder and
nonepileptic attacks, Gen Hosp Psychiatry (2015), http://dx.doi.org/10.1016/j.genhosppsych.2015.05.007
2 M. Hubschmid et al. / General Hospital Psychiatry xxx (2015) xxx–xxx

NEA), the current trend and preferred therapeutic option, based on ex- Exclusion criteria were (a) lack of verbal fluency in French;
pert opinion [18], are a multidisciplinary approach, the first step being a (b) neurological comorbidity with motor or gait symptoms, or concom-
careful diagnostic evaluation and clear explanation to the patient by the itant epilepsy diagnosed by an experienced epileptologist;
neurologist. A second key milestone in the care of these patients is the (c) psychiatric comorbidity of psychosis, acute suicidality or current
involvement of psychiatrists [19]. Indeed, after a long-lasting separation substance abuse; or (d) current psychotherapy at the time of inclusion.
between neurology and psychiatry over the last century, there has been All data were prospectively collected in identical settings within the
a recent new collaboration between the two specialties in particular Neurology Department of the Lausanne University Hospital,
around this paradigmatic “neuropsychiatric” disorder [20]. The newly Switzerland. All patients had been assessed as in-patients in a neurolog-
released DSM-5 classification does not consider the presence of associ- ical unit and therefore presented with severe symptoms.
ated psychological factors as a required diagnostic criterion but as an ad-
ditional suggestive feature; however, literature does suggest a role for
2.3. Randomization
psychiatric stressors and/or comorbidities as either triggering or main-
taining factors [21,22]. A joint psychiatric–neurological consultation
Randomization to IPI or SC was done through 24 identical,
for patients presenting with conversion symptoms was created in our
nontransparent, sealed envelopes, half containing a paper stipulating
tertiary center in 2005. The evidence of an association between child-
“treatment” and the other half “standard.” The envelopes were indepen-
hood trauma and conversion disorder being meanwhile strong
dently prepared by H.M. and sealed, and then given to a third person un-
[23,24], we integrated basic psychotraumatology principles in our psy-
aware of their content to mix. They were numbered consecutively and
chotherapeutic intervention, hoping to increase patients’ treatment ad-
given in chronological order to patients as written informed consent
herence. A retrospective study showed that such early intervention
was signed.
involving both neurologists and psychiatrists was effective in reducing
physical symptoms, sick leave and health care use [25]. There are only
very few published data on the efficacy of therapeutic interventions 2.4. Treatment
for conversion disorders [26]. We present here the results of a pilot pro-
spective randomized controlled trial to compare the effect of our brief 2.4.1. Interdisciplinary psychotherapeutic intervention
interdisciplinary psychotherapeutic intervention (IPI) to standard care This four- to six-session brief psychotherapeutic intervention was
(SC) as treatments for patients recently diagnosed with severe motor based on a psychodynamic interpersonal treatment approach over a
conversion disorder or NEA. 2-month period, analogous to the psychodynamic interpersonal thera-
py by Guthrie [32]. The majority of patients received five sessions over
2. Material and methods a period of 2 months, spaced approximately every 10 days according
to the therapists’ schedule, but some unstable patients could receive
We conducted a parallel, randomized, controlled trial with an alloca- six sessions; so the intervention was tailored to patients. The interven-
tion ratio of 1:1. No changes were made to methods after the trial tion began by an interdisciplinary session of 2 h and 30 min, divided
started. into a 1-h neurological consultation, followed by a 1-h psychiatric con-
sultation and ending with a joint neurological and psychiatric consulta-
2.1. Standard protocol approvals, registrations and patient consents tion of 30 min (Fig. 1). During the initial psychiatric–psychotherapeutic
session, when the diagnosis was confirmed, focus was primarily on the
This trial was approved and registered by the Ethics Committee of patient’s reaction with respect to the psychiatric referral, her/his illness
Canton de Vaud, Switzerland, under Protocol 174/09. Patients received beliefs, fears, stress factors, potential conflicts and doubts about the di-
written information and gave written informed consent. We followed agnosis. In parallel, the presence of comorbid psychiatric disorders
CONSORT reporting guidelines [27]. was evaluated and medication was started, if indicated. With care, the
potential history of serious trauma (physical and sexual abuse, emotion-
2.2. Participants al negligence) was investigated, with respect of potential avoidance and
current coping mechanisms. Care was taken to remain within the toler-
Twenty-three consecutive patients were recruited from our Neurol- ance window [33] in order to avoid further dissociation. The diagnosis of
ogy Department from November 2010 to January 2013, with follow-up “functional neurological disorder” was then conveyed to the patient
ending December 2013. Inclusion criteria were (a) age: 16–65 years and during the joint consultation with the neurologist, allowing for
(b) newly diagnosed conversion disorder according to the Diagnostic
and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision
(DSM-IV-TR) (within 12 months) with motor or NEA symptoms
assessed by experienced neurologists. The diagnosis was established
after extensive history and clinical examination, including systematic
evaluation of “positive signs” of conversion disorder [28]. NEA patients
had a video-electroencephalogram (EEG) evaluation with provoking
maneuvers (verbal suggestion, hyperventilation, intermittent photic
stimulation, positioning of a tuning fork on the forehead and — in select-
ed cases — a NaCl nocebo injection) in order to obtain a typical clinical
event; diagnosis was made if this corresponded to the habitual spells,
was clinically suggestive of NEA and presented without any pathological
EEG alteration in accordance with our practice and recent guide-
lines[29,30]. Further investigations (computed tomography, magnetic
resonance imaging, positron emission tomography scan, electromyo-
graphic electrophysiology, transcranial magnetic stimulation) were
conducted to confirm diagnosis when necessary. Only patients meeting
the international diagnostic criteria for psychogenic movement disorder
A: documented, B: clinically established or C: probable were included
[31]. An experienced liaison psychiatrist confirmed the diagnosis. Fig. 1. Interdisciplinary psychotherapeutic intervention.

Please cite this article as: Hubschmid M., et al, Efficacy of brief interdisciplinary psychotherapeutic intervention for motor conversion disorder and
nonepileptic attacks, Gen Hosp Psychiatry (2015), http://dx.doi.org/10.1016/j.genhosppsych.2015.05.007
 M. Hubschmid et al. / General Hospital Psychiatry xxx (2015) xxx–xxx
immediate questions to be addressed. The presence of the neurologist
facilitated the access of the psychiatrist to patients generally reluctant
to engage in psychiatric follow-up. During sessions 2 to 4 (consisting
of 1 h with the psychiatrist), the therapeutic attitude was empathic, re-
specting the patient’s rhythm and his defense mechanisms, and wel-
coming feelings. A common exploration of predisposing, precipitating,
maintaining factors, as well as of consequences of symptoms in terms
of disability and dependence was undertaken. Emerging intrapersonal
or interpersonal conflicts were addressed when possible. The sessions
invited the patient to explore beyond their initial somatic explanation
of their symptoms, trying to reach a shared understanding of a revers-
ible “functional” cause. Exploration was individually tailored, depend-
ing on the presence of traumas, current life events and readiness of
the patient to “look inside.” Verbalization was encouraged as emotions
and conflicts surfaced. During sessions, the potential use of further psy-
chotherapy was addressed. The last session was again interdisciplinary
and identical in organization to the first (1 h with the neurologist, 1 h
with the psychiatrist and 30 min with both). This allowed for questions,
evaluation of understanding of illness, and common evaluation of
symptom improvement and need for further psychotherapy.
2.4.2. Standard care
After the diagnosis was established by both neurologist and psychi-
atrist, the SC group received a single joint neurological and psychiatric
diagnosis restitution of about 15 min. The patient was informed using
the terminology of “functional neurological disorder” [34] and advised
to seek psychiatric–psychotherapeutic treatment with a psychiatrist in
private practice. The general practitioner was also informed. Neither
further psychotherapeutic intervention nor systematic neurological
follow-up was offered.
2.4.3. Outcome measures
Evaluations for both groups took place at inclusion and after 2 (fol-
lowing intervention for the IPI group), 6 and 12 months. They were con-
ducted in identical settings (within the neurology department) and at
identical timings, meaning that they took place outside of the interven-
tion for the IPI group. The following outcome measures were adminis-
tered by the psychiatrist (Rankin by the neurologist) in about 60–90
min. Self-rated questionnaires could be completed at home and sent
back (about 30 min). Only validated French versions of the measures
were delivered. This trial was not blinded, as part of the measures was
rated by the therapists themselves, to try and limit the dropout rate.
Other measures were self-administered. No changes to trial outcomes
were made after trial started.
The following outcome measures were analyzed as per protocol:
1. Primary outcome-measure: conversion symptoms, as measured with
the Somatoform Dissociation Questionnaire (SDQ-20) [35]. The SDQ-
20 is a 20-item scale exploring different physical symptoms or body ex-
periences typical of conversion disorder, such as “I have an attack that
resembles an epileptic seizure,” “I am paralyzed for a while,” etc. Each
item is rated on a 5-point scale from 1 to 5, the total minimum score
being 20 and the highest 100. The higher the score, the more conversion
symptoms are present. We used a cutoff of ≥30, as it discriminates well
between mild and severe conversion symptoms [36,37].
The Clinical Global Impression Scale (Guy, W., 1976), a scale ranging
from 1 (normal, not at all ill) to 7 (among the most extremely ill patients)
focused on the severity of the conversion symptoms, was also used to
determine evolution with a cutoff of ≥4 (bad outcome), as was the
Rankin scale [38], a scale providing information about the patient’s dis-
ability with a score ranging from 0 (no disability) to 5 (severe disability
and need for constant skilled nursing attention), with a cutoff of ≥2
(bad outcome).
2. The use of medical care as measured by number of in-patient days
and number of outpatient visits to (a) emergency department,
(b) somatic clinic and (c) psychiatric follow-up.
Please cite this article as: Hubschmid M., et al, Efficacy of brief interdisciplinary psychotherapeutic intervention for motor conversion disorder and
nonepileptic attacks, Gen Hosp Psychiatry (2015), http://dx.doi.org/10.1016/j.genhosppsych.2015.05.007
3
3. Acceptance of psychiatric referral by asking the patients whether
they would agree to be seen by a psychiatrist.
4. Global mental health as measured by the French version of the Mont-
gomery and Asberg Depression Rating Scale (MADRS) [39] with a
cutoff of ≥20 (moderate depression), the Beck Depression Inventory
[40] with a cutoff of ≥ 15 (moderate depression) and the mental
health component of the Short Form (SF)-36.
5. Quality of life as measured by work ability, demand of financial aid
and the SF-36.
In addition, at baseline, the Mini International Neuropsychiatric In-
terview (MINI) DSM-IV, French Version 5.0.0 [41], was administered.
The Dissociative Experience Scale [42], a 28-item scale ranging from 0
(never) to 100 (always) investigating the presence of psychological
manifestations of dissociation (the higher the score, the more severe
the dissociation), was conducted to screen for possible additional psy-
chological dissociation like dissociative amnesia, fugue or dissociative
identity disorder (DSM-IV-TR). The Toronto Alexithymia Scale, French
version [43], was also administered, as alexithymia, a mental state
denoting an inability to identify emotions, has been shown to be fre-
quent among patients suffering from conversion symptoms [44]. It is a
self-report scale of 20 items, with scores of 1 to 5 (some scored in re-
verse) and with a total maximum score of 100, investigating the pres-
ence, absence and severity of alexithymia. History of trauma was
established during initial history taking by the psychiatrist (presence
of physical abuse, sexual abuse or emotional neglect) and confirmed
by question I1 of the MINI DSM-IV.
As it is well documented that conversion disorder tends to take a
chronic course [7], we chose 12 months as the end point of our outcome
measures even though treatment was only delivered until 2 months in
the intervention group. Furthermore, effects of psychotherapy often
last beyond the end of the therapy itself [45].
2.5. Statistical analysis
A series of classical statistical tests was performed at each time point
to make raw comparisons for scores and sociodemographic variables
among treatment and control groups. Independent-sample t test was
used to compare observed values of a continuous variable among two
groups, while the χ2 test of association was used to compare the associ-
ation between categorical variables and the group. If the expected fre-
quency was smaller than 5 in some cells (more than 20%), then the χ2
test was replaced by the Fisher’s Exact Test (FET) as the approximation
used to do inference for the former is no longer reliable in such a case.
Due to the longitudinal nature of our study, a linear mixed effects
model (LME) was used to identify the differences between two groups
for all continuous outcomes using the data collected at baseline and at
2, 6 and 12 months. The inclusion of a random effect in the levels of
each individual allows using several observations per individual in the
model. The fitted model can be used to identify the differences between
groups both in initial value and also in the evolution pattern. We did not
adjust our final results for multiple comparisons as each fitted model
was concerned with a different aspect of the study. All analyses were
conducted by initially assigned group.
3. Results
A total of 23 patients gave informed consent and were randomized
to SC (n=12) or IPI (n=11). Overall, data from 11 patients were ana-
lyzed in the SC group and 10 in the IPI. Please refer to the CONSORT
flow diagram of participants for details (Fig. 2).
3.1. Baseline characteristics
The patients did not differ in their baseline characteristics as illus-
trated in Table 1.
4 M. Hubschmid et al. / General Hospital Psychiatry xxx (2015) xxx–xxx

Eligible (n = 36)

Excluded (n = 13)
Enrollment Declined to participate (n = 11)
Other reasons (n = 2)

Randomized (n = 23)

Allocation
Standard Care
Allocated to intervention (n = 12)
Received allocated intervention (n = 11)
Did not receive allocated intervention(n = 1):
refused to participate post-
randomization
Interdisciplinary psychotherapeutic I.
Allocated to intervention (n = 11)
Received allocated intervention (n = 10)
Did not receive allocated intervention (n = 1):
refused to participate post-
randomization

Follow-Up 2/12
Patients with primary outcome measures Patients with primary outcome measures
at 2/12 (n = 10) at 2/12 (n = 9)

Discontinued intervention (n = 1): Discontinued intervention (n = 1):

refused to continue refused to continue

Follow-Up 6/12
Patients with primary outcome measures at Patients with primary outcome measures at
6/12 (n = 9) 6/12 (n = 8)

Discontinued intervention (n = 1) Lost to follow-up (came back at 12/12) (n = 1)

refused to continue

Follow-Up 12/12

Patients with primary outcome measures at Patients with primary outcome measures at
12/12 (n = 8) 12/12 (n = 8)

Discontinued intervention (n = 1) Lost to follow-up (n = 1)

lost contact with service Came back to follow-up (n = 1)

Analysis
Analysed (n = 11) Analysed (n = 10)
Excluded from analysis (n = 0) Excluded from analysis (n = 0)

Fig. 2. CONSORT flow diagram of participants.

3.2. Main results
The detailed results are presented in Table 2.
3.2.1. Evolution of conversion symptoms
We observed a significant time×group interaction [using an LME
model that took into account the measures made at all time points (0/
2/6/12)] for the SDQ-20 (cutoff ≥ 30) with a lower risk of having an
SDQ-20 ≥ 30 in the IPI group (Pb.02). Similarly, the Clinical Global
Index with a cutoff of ≥4 (bad outcome) showed a time×group interac-
tion with a significantly lower risk of having a bad outcome in the IPI
group (P=.02). For disability level, the Rankin scale showed no signifi-
cant differences among the two groups at any time point; fitting a lon-
gitudinal model was not possible due to the low variation of this
variable.
3.2.2. Use of medical care
We observed a time×group interaction for the use of medical care in
two groups, the IPI group being significantly less often treated as in-
patients after the IPI, in number of hospital days (Pb.05). There was
no difference in overall somatic outpatient visits and in number of acci-
dent and emergency visits. The SC group showed a significant increase
in psychiatric/psychological outpatient treatment use after 12 months
compared to the treatment group (Pb .02).
3.2.3. Acceptance of psychiatric referral
There were no significant differences between groups.
3.2.3.1. Global mental health. Global mental health as measured by the
mental health component of the SF-36 showed that the IPI group had
a better global mental health than the SC group with a significant
time×group interaction (Pb.05). The Beck Depression Inventory [40]
with a cutoff of ≥ 20 (moderate depression) showed a significant
time×group interaction after 12 months, with the probability of having
a BDI ≥20 being lower in the IPI group (Pb .05). The MADRS with a cut-
off of ≥15 showed no significant differences.
3.2.3.2. Quality of life. There was no significant difference on the physical
functioning, emotional and physical limitation, energy-vitality, social
functioning, pain and general health scales of the SF-36. No significant

Please cite this article as: Hubschmid M., et al, Efficacy of brief interdisciplinary psychotherapeutic intervention for motor conversion disorder and
nonepileptic attacks, Gen Hosp Psychiatry (2015), http://dx.doi.org/10.1016/j.genhosppsych.2015.05.007
 M. Hubschmid et al. / General Hospital Psychiatry xxx (2015) xxx–xxx 5

Table 1
Demographic data and baseline clinical data.

Demographic data SC group IPI group Statistics P value

Age [mean (S.E.)] 31.53 (3.17) 37.57 (4) t=−1.18 .25

Sex (%female) 90.91 60 χ2=1.32 .25
History of trauma (%#) 63.64 70 χ2=0 1
Work percentage before symptoms [mean (S.E.)] 0.82 (0.1) 0.88 (0,1) t=−0.38 .71
Work percentage at inclusion [mean (S.E.)] 0.31 (0.14) 0.15 (0.11) t =0.93 .37
Baseline clinical data
MINI DSM-IV
Major depressive disorder MDD (%#) 5 (45%) 4 (40%) FET 1
Panic disorder 3 (27%) 2 (18%) FET 1
Agoraphobia 1 (9%) 1 (9%) FET 1
Eating disorder 1 (9%) 0 (0%) FET 1
PTSD 1 (9%) 0 (0%) FET 1
No diagnosis 5 (45%) 4 (40%) FET 1
Antidepressant treatment 3 (27%) 3 (30%) FET 1
Antidepressant treatment for MDD 3/5 3/4 FET 1
MADRS of MDD [mean (S.E.)] 20.2 19.75 t=0.15 .8887
MADRS ≥15 [% (#)] 45.45 (5) 30 (3) FET .78
BDI ≥20 [% (#)] 10 (1) 40 (4) FET .30
SDQ-20 ≥30 [% (#)] 36.36 (4) 50 (5) FET .85
DES ≥25 [% (#)] 9.09 (1) 20 (2) FET .93
TAS-20 [mean (S.E.)] 48.1 (4.39) 49.5 (5.16) t=−0.21 .84
Accepting psychiatric referral (%#) 90% 80% FET 1

influence was seen with respect to secondary gains at 12 months as only
on average 31.25% of all patients were receiving financial benefits and
only 12.5% were awaiting decision concerning financial benefits, with
no significant differences among the two groups. The IPI group showed
however a clear trend towards a quicker increase in their work ability
than the SC group, the result being marginally significant (P=.05).
No harms were observed in each group.
4. Discussion
Our study shows that a brief IPI brings a significant improvement of
conversion symptoms as measured by the SDQ-20 and the CGI scale
after 12 months. In addition, patients in the intervention group (IPI)
were less frequently readmitted to hospital after the intervention and
showed better scores on the mental health component of the SF-36
and on the Beck Depression Inventory than patients in the SC group.
This means that a short psychotherapy of four to six sessions adapted
to patients’ needs, coupled with neurological consultations, not only is
beneficial to patients’ outcome but also seems cost-effective by reducing
hospital stays in the IPI group. Moreover, the SC group showed lower
symptom improvement and worse mental health despite higher use
of medical and psychiatric outpatient consultations at 12 months. This
suggests that a specific consultation liaison psychiatry approach in
close collaboration with neurology is more effective than a nonspecific
psychotherapeutic approach.
A very recent Cochrane review demonstrated the lack of evidence in
support of any treatment for conversion disorder [16]. Our psychother-
apeutic intervention differs from the four-session manualized
psychoeducational approach as described by Mayor for convulsive con-
version disorder [46], as our brief psychodynamic interpersonal inter-
vention is administered by consultation liaison psychiatrists in
combination with joint neurological–psychiatric consultations. A few
other groups have successfully applied brief psychodynamic interper-
sonal psychotherapy in the area of functional disorders, and a few
more trials have been conducted with cognitive–behavioral therapy or
paradoxical intervention [47–49]. However, none of these studies in-
cluded the liaison aspect of joint neurological and psychiatric consulta-
tions, which seems of great importance to bring a renewed sense of
coherence for the patient.
Our intervention is meant to be applicable to all conversion disorder
symptoms, as it is patient tailored. Our patient sample, presenting with
severe conversion symptoms needing inpatient evaluation, were
relatively newly diagnosed, as a diagnosis of over 12 months was an ex-
clusion criterion. The overall good prognosis might be linked to the
short duration of symptoms and early diagnosis with intensive treat-
ment, as was shown in the recent review by Gelauff et al. [7]. Further-
more, the good outcome measured at 12 months suggests that a
postpsychotherapeutic improvement took place as described by Sattel
[47]. Of interest, a significant number of patients accepted psychiatric
referral in our study, independently of the group allocation. This finding
is in concordance with results of our retrospective study where 73%–
83% of patients with conversion disorder accepted psychiatric referral
[25]. It must be pointed out that both groups benefited from meetings
with the psychiatrist and the neurologist for the diagnosis restitution
(which is standard care in our center since 2005) and the 2-, 6- and
12-month evaluations. Therefore, our SC group was not totally repre-
sentative of usual standard care but rather benefited from a reduced
form of therapeutic intervention, which can be understood as an unin-
tended effect. In keeping with this comment, it is interesting that signif-
icant results favoring the intervention group were obtained in spite of
the small number of patients in this study. A more powerful study
would include a larger number of patients with a comparison group
closer to the reality of standard care with fewer consultations, control-
ling for contact time. It would be interesting to compare four neurolog-
ical consultations vs. the intervention described in our trial. We believe
that the helpful part was the IPI in its whole. We decided to test a psy-
chodynamic therapy based on a trauma model, as past trauma has
been recognized a risk factor for conversion disorder [23,24] even
though a causal relationship between trauma and conversion disorder
has not been demonstrated. Our patient sample showed a two-thirds
prevalence of trauma history based on the question of previous trauma
from the MINI DSM-IV interview. The measurement of psychological
trauma is particularly difficult and was probably too limited in this
study. A more differentiated questionnaire would be useful in further
trials, for example, the Childhood Trauma Questionnaire [50]. Further
studies are needed to investigate the relationship between conversion
disorder, history of trauma and posttraumatic stress disorder (PTSD),
which would be of interest in the light of recent neuroimagery findings
[51]. Somewhat surprisingly, the Rankin scale showed no statistical sig-
nificance, probably as it is a measure with broad categorizations. The
physical health component of the SF-36 was not significant either, prob-
ably as it is not centered on specific conversion symptoms, in contrast to
the SDQ-20. One limitation of our study relates to the fact that the ther-
apists themselves rated some of the outcome measures. This was

Please cite this article as: Hubschmid M., et al, Efficacy of brief interdisciplinary psychotherapeutic intervention for motor conversion disorder and
nonepileptic attacks, Gen Hosp Psychiatry (2015), http://dx.doi.org/10.1016/j.genhosppsych.2015.05.007
6 M. Hubschmid et al. / General Hospital Psychiatry xxx (2015) xxx–xxx

Table 2
Results.

SC group IPI group Statistics P value LME LME standard LME P value
value error

1. Conversion symptoms Time by group-treatment interaction

with LME
SDQ-20 ≥30 [% (#) {obs.}] −0.524 0.217 Pb.02
Baseline 36.36 (4) {11} 50 (5) {10} χ2=0.04 .85
End of therapy 2 months 40 (4) {10} 11.11 (1) {9} FET=0.30 .36
Follow-up 6 months 22.22 (2) {9} 12.5 (1) {8} FET=1 1
Follow-up 12 months 37.5 (3) {8} 0 (0) {7} FET=0.2 .24
CGI ≥4 [% (#) {obs.}] −0.321 0.134 P=.02
Baseline 63.64 (7) {11} 60 (6) {10} FET=1 1
End of therapy 2 months 30 (3) {10} 66.67 (6) {9} χ2=1.3 .26
Follow-up 6 months 44.44 (4) {9} 50 (4) {8} FET=1 1
Follow-up 12 months 37.5 (3) {8} 28.57 (2) {7} FET=1 1
a a a
Rankin ≥2 [% (#) {obs.}]
Baseline 81.82 (9) {11} 70 (7) {10} FET=0.64 .90
End of therapy 2 months 40 (4) {10} 44.44 (4) {9} FET=1 1
Follow-up 6 months 33.33 (3) {9} 22.22 (2) {9} FET=1 1
Follow-up 12 months 12.5 (1) {8} 28.57 (2) {7} FET=0.57 .90
2. Use of medical care
Hospitalization days [mean (S.E.) {obs.}] −0.922 0.852 Pb.05
Baseline 8.6 (2.36) {10} 10.1 (2.85) {10} t=−0.41 .69
End of therapy 2 months 13.4 (6.31) {10} 20.56 (8.05) {9} t=−0.7 .49
Follow-up 6 months 10.33 (10.09) {9} 0 (0) {8} t=1.02 .34
follow-up 12 months 17.25 (11.23) {8} 0 (0) {8} t=1.54 .17
Accident and emergency use [mean (S.E.) {obs.}] −0.044 0.073 .56
Baseline 0.9 (0.31) {10} 1.67 (1.09) {9} t(9)=−0.67 .52
End of therapy 2 months 0.6 (0.5) {10} 0.44 (0.24) {9} t(13)=0.28 .78
Follow-up 6 months 0.22 (0.15) {9} 0 (0) {8} t(8)=1.51 .17
Follow-up 12 months 0 (0) {8} 0 (0) {8}
Somatic follow-up [mean (S.E.) {obs.}] −0.057 0.117 .63
Baseline 2 (0.63) {10} 3.89 (1.15) {9} t(13)=−1.44 .17
End of therapy 2 months 1.89 (0.73) {9} 2.56 (0.44) {9} t(13)=−0.78 .45
Follow-up 6 months 2.56 (0.85) {9} 4 (0.89) {8} t(15)=−1.18 .26
Follow-up 12 months 1.75 (0.98) {8} 2.5 (0.71) {8} t(13)=−0.62 .55
Psychiatric follow-up [mean (S.E.) {obs.}] −0.631 0.259 Pb.02
Baseline 0.36 (0.36) {11} 0 (0) {9} t(10)=1 .34
End of therapy 2 months 1.8 (1.08) {10} 5.22 (0.22) {9} t(10)=−3.09 .01
Follow-up 6 months 8.56 (3.51) {9} 3.62 (1.46) {8} t(11)=1.3 .22
Follow-up 12 months 7.75 (2.66) {8} 2.25 (1.58) {8} t(11)=1.78 .10
3. Acceptance of psychiatric referral [% (#) {obs.}] 0.064 0.125 .61
Baseline 90 (9) {10} 80 (8) {10} FET=1 1
End of therapy 2 months 90 (9) {10} 85.71 (6) {7} FET=1 1
Follow-up 6 months 88.89 (8) {9} 71.43 (5) {7} FET=0.55 .81
Follow-up 12 months 62.5 (5) {8} 57.14 (4) {7} FET=1 1
4. Mental health
BDI ≥20 [% (#) {obs.}] −0.289 0.127 Pb.05
Baseline 10 (1) {10} 40 (4) {10} FET=0.30 .30
End of therapy 2 months 22.22 (2) {9} 28.57 (2) {7} FET=1 1
Follow-up 6 months 22.22 (2) {9} 42.86 (3) {7} FET=0.60 .73
Follow-up 12 months 28.57 (2) {7} 28.57 (2) {7} FET=1 1
MADRS ≥15 [% (#) {obs.}] −0.014 0.130 .91
Baseline 45.45 (5) {11} 30 (3) {10} FET=0.66 .78
End of therapy 2 months 40 (4) {10} 44.44 (4) {9} FET=1 1
Follow-up 6 months 22.22 (2) {9} 37.5 (3) {8} FET=0.62 .88
Follow-up 12 months 28.57 (2) {7} 28.57 (2) {7} FET=1 1
Mental health component of SF-36 [mean (S.E.) {obs.}] 1.851 0.775 Pb.05
Baseline 64 (6.17) {10} 54.93 (6.3) {10} t(18)=1.03 .32
End of therapy 2 months 62.22 (9.48) {9} 61.71 (9.67) {7} t(14)=0.04 .97
Follow-up 6 months 63.11 (8.19) {9} 65.14 (8.67) {7} t(13)=−0.17 .87
Follow-up 12 months 61.71 (8.5) {7} 69.71 (7.75) {7} t(12)=−0.7 .5
5. Quality of life
% of work change (before sympt. onset–now) [mean (S.E.) {obs.}] −0.370 0.184 P=.05
Baseline −0.52 (0.15) {10} −0.73 (0.13) {10} t(18)=1.08 .30
End of therapy 2 months −0.29 (0.13) {10} −0.76 (0.12) {9} t(17)=2.63 .02
Follow-up 6 months −0.34 (0.15) {9} −0.61 (0.16) {8} t(15)=1.23 .24
Follow-up 12 months −0.31 (0.16) {8} −0.35 (0.15) {8} t(14)=0.17 .87
SF-36 general health [mean (S.E.) {obs.}] −0.265 0.610 .67
Baseline 52 (8.63) {10} 46.5 (5.27) {10} t(15)=0.54 .60
End of therapy 2 months 50.56 (9.11) {9} 43.57 (5.74) {7} t(13)=0.65 .53
Follow-up 6 months 56.67 (9.46) {9} 37.14 (8.08) {7} t(14)=1.57 .14
Follow-up 12 months 65 (9.76) {7} 53.57 (8) {7} t(12)=0.91 .38
a
Model fit not possible.

Please cite this article as: Hubschmid M., et al, Efficacy of brief interdisciplinary psychotherapeutic intervention for motor conversion disorder and
nonepileptic attacks, Gen Hosp Psychiatry (2015), http://dx.doi.org/10.1016/j.genhosppsych.2015.05.007
 M. Hubschmid et al. / General Hospital Psychiatry xxx (2015) xxx–xxx
decided in order to limit the dropout rate, as patients with severe con-
version disorder may have suffered severe abuse experiences [52] and
building a therapeutic alliance with them can be highly challenging.
However, a high number of outcome measures were self-
administered. Another limitation is that sessions were not recorded
and were not reviewed for model adherence, which should be imple-
mented in any further trial to improve quality control.
Finally, due to the relatively limited sample size, we did not differen-
tiate different subtypes of conversion disorders (NEA, motor paralysis,
gait disorder, movement disorders), as only a larger multicenter study
would allow making these distinctions. We, however, purposefully de-
fined our primary outcome measures as general measure (SDQ and
CGI) rather than tailoring them to the symptom presentation (like the
number of seizures in NEA patients) in order to be able to include and
measure outcomes in all subtypes of conversion disorders.
5. Conclusions
A brief IPI taking advantage of a close collaboration with neurology
in the setting of consultation liaison psychiatry appears effective and
warrants further exploration.
Funding
This trial was funded by the Psychiatric Liaison Service, Lausanne
University Hospital, Switzerland, and by the Department of Clinical
Neurosciences, Lausanne University Hospital. The trial also benefitted
from a feminine academic award grant from Lausanne University and
the “bourse pro-femme” from Lausanne University. These grants had
no involvement in study design; collection, analysis and interpretation
of data; writing of the report; and the decision to submit the article
for publication.
Disclosure
The authors have no competing interests to report.
Acknowledgments
We would like to thank all the patients who participated in the trial
and Ellert R.S. Nijenhuis for his comments on our study.
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Please cite this article as: Hubschmid M., et al, Efficacy of brief interdisciplinary psychotherapeutic intervention for motor conversion disorder and
nonepileptic attacks, Gen Hosp Psychiatry (2015), http://dx.doi.org/10.1016/j.genhosppsych.2015.05.007