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Lars de Vroege, 1, 2 Anne Vergeest, 1, 2 Willem Johan Kop 1, 3 1Clinical Center of Excellence for Body, Mind and Health, GGz Breburg, Tilburg, the Netherlands; 2Tilburg School of Behavioral and Social Sciences, Tranzo Department, Tilburg University, Tilburg, the Netherlands; 3Department of Medical and Clinical Psychology, Center of Research on Psychological and Somatic Disorders (CoRPS), Tilburg University, Tilburg, the NetherlandsCorrespondence: Lars de Vroege Lage Witsiebaan 4, Tilburg, 5042 DA, the NetherlandsTel +31 13 01 61555Fax +31 13 01 61699Email L.deVroege@ggzbreburg.nl We have read the article written by Saxena et al “Towards an Outpatient Model of Care for Motor Functional Neurological Disorders: A Neuropsychiatric Perspective” with great interest. The authors address relevant information and provide a sound outpatient model.1 However, some significant issues concerning patients with functional neurological disorders (FND) may be missing in their model which we want to discuss in more detail. The authors focus on patients with FND, especially the spectrum of motor FND (mFND). They introduce a practical guide and refer to this guide as a neuropsychiatric approach to the assessment and management of mFND with “[…] a comprehensive assessment guiding the development of a patient-centered treatment plan benefits from interdisciplinary neurologic, psychiatric, allied mental health and rehabilitation perspectives.” Furthermore, they state that specialized tertiary care centers as well as community-based care have to be included in this approach to offer the aforementioned patient-centered care. The authors thus provide an approach that is very useful for clinicians in which the value of stateof-the-art diagnostics including neuropsychiatric screening and a “rule-in” neurological examination is emphasized. Also, they provide assistance in how to deliver the diagnosis of (m)FND and offer an overview of several psychotherapy modalities for mFND. Therefore, their perspective paper is of substantial importance for clinicians working in the field of FND. However one pivotal clinical characteristic of patients with (m)FND, cognitive impairments, is only marginally addressed and should, in our opinion, play a more central role in the neuropsychiatric evaluation and treatment of (m)FND. View the original paper by Saxena and colleagues

Petra J van Meerkerk-Aanen,1 Lars de Vroege,1,2 David Khasho,1 Aziza Foruz,1 J Thies van Asseldonk,3 Christina M van der Feltz-Cornelis1,2 1Clinical Center of Excellence for Body, Mind, and Health, GGz Breburg, 2Department Tranzo, Tilburg School of Behavioral and Social Sciences, Tilburg University, 3Department of Neurology, Elisabeth Hospital, Tilburg, the Netherlands Background: Since the advent of computed tomography and magnetic resonance imaging scans, neurological disorders have less often been falsely labeled as conversion disorder (CD). However, misdiagnosis of a neurological disorder as CD still occurs, especially in cases with insidious onset. Misinterpretation of la belle indifférence may contribute to such misdiagnosis. Here, we describe a case of progressive supranuclear palsy/Richardson’s syndrome (PSPS) misdiagnosed as a case of CD.Case: A 62-year-old woman consulted two different neurologists in 2012 because of falling spells since 2009 and was diagnosed with CD. She was referred to the Clinical Center of Excellence for Body, Mind, and Health for treatment of CD. After neurological examination, blood tests, and psychiatric examination, in which la belle indifférence and a history of incest were found, CD was confirmed. However, despite treatment for CD, the patient’s physical symptoms deteriorated over a year. After repeated physical and psychiatric examinations, neurocognitive assessment, and consultation with a third neurologist because of suspicion of neurological disease, the patient was diagnosed with PSPS.Conclusion: La belle indifférence may be a psychological sign in the context of CD, but it may also be an expression of lack of mimic due to Parkinsonism or of eye movement disorder in the context of neurological illness. A diagnosis of CD should not be considered definitive if no improvement occurs in terms of physical, mental, and cognitive symptoms despite appropriate therapy. In case of deterioration, neurological reexamination and reinterpretation of la belle indifférence should be considered. Keywords: conversion disorder, consultation, misdiagnosis, progressive supranuclear palsy, la belle indifférence, neurology