What is La Belle Indifference?
“La belle indifference” is a French phrase that means “beautiful ignorance.” It refers to the unusual situation where a person doesn’t seem bothered or stressed even though they have a serious medical issue or symptoms. This situation is often seen with a mental health condition called conversion disorder. Conversion disorder, also known as functional neurologic symptom disorder (FNSD), is where a person experiences a neurological problem with no identifiable medical cause. This could be due to psychological stress or conflict appearing as a physical symptom.
It’s crucial to note that “la belle indifference” doesn’t diagnose conversion disorder, however it’s frequently seen in patients with this condition.
Regarding diagnosis standards, in the Diagnostic and Statistical Manual of Mental Disorders V (DSM 5), conversion disorder falls under the category of “somatic symptom and related disorders.” Some other disorders in this category include illness anxiety disorder, somatic symptom disorder, psychological factors impacting other medical conditions, and factitious disorder.
Common symptoms of conversion disorder can include weakness or paralysis on one or both sides of the body, unusual movements like shaking, tremors or rigid muscles, seizures that don’t have a neurological cause, difficulties swallowing or speaking, loss of sense of smell or vision, and fainting episodes.
What Causes La Belle Indifference?
Conversion disorder, also known as Functional Neurological Symptom Disorder (FNSD), has various causes. Many people who show signs of this disorder have been through some sort of stress. However, you could still have FNSD even if you can’t identify a specific stressful event. One thing to keep in mind is that it’s hard to say for sure whether psychological distress directly causes conversion disorder.
Brain studies using a tool called a functional magnetic resonance imaging, or fMRI, suggest a model for how conversion disorder works. They show a disconnect in the brain between two areas: the anterior cingulate and the prefrontal cortex. This finds supports for the idea that conversion disorder is a form of psychodynamic dissociation, or a disconnect between the mind and body. These studies also link conversion disorder with depression and post-traumatic stress disorder (PTSD). People often have conversion disorder alongside other conditions, including personality disorders, mood disorders, and anxiety disorders. Those who have unhealthy behaviors and don’t handle stress well are more likely to develop conversion disorder.
Social and psychological stressors play a role in conversion disorder, too. This includes experiences of neglect, physical abuse, or sexual abuse. For instance, people with PTSD often show dissociative phenomena (feeling detached from yourself) and motor symptoms (movement and coordination problems), both of which are also common in conversion disorder.
Risk Factors and Frequency for La Belle Indifference
Conversion disorder, a psychological condition causing physical symptoms, affects about 5% of general hospital patients. Another variant of this disorder, known as psychogenic non-epileptic seizures (PNES) affects 33 out of every 100,000 people. In a research, where over 350,000 individuals were observed for three years, it was found that every year, around 4.9 out of 100,000 people were affected by PNES. Based on a similar study conducted on the general population in New York, the rate of people affected by conversion disorders was between 11 and 22 for every 100,000 people.
- Conversion disorder affects more women than men.
- It is particularly prevalent among those with lower socioeconomic status, less education, and those living in rural areas.
- It commonly begins in late adolescence and early adulthood.
- Forty-seven percent of people with this condition also have anxiety or depression.
- In over two-thirds of cases, people with conversion disorder have a history of depression or trauma.
Signs and Symptoms of La Belle Indifference
A complete physical and neurological examination is needed to rule out severe medical and neurological conditions. These disorders can include conditions like multiple sclerosis, stroke, Guillain-Barré syndrome, myopathies, polymyositis, and myasthenia gravis. A targeted neurological exam should be done based on the symptoms shown. Certain tests are used specifically to detect signs of a conversion disorder, a mental condition where a person has blindness, paralysis, or other nervous system symptoms that cannot be explained by medical evaluation. These tests check for motor symptoms and have high accuracy and reliability.
Below are some of these tests:
- Hoovers Sign: This test is commonly used to distinguish between physical and mental causes of weakness or paralysis. The doctor places their hand beneath the patient’s affected heel and asks the patient to lift the other leg. If there are no physical disorders, there shouldn’t be any pressure on the doctor’s hand from the affected leg. Pressure suggests a possible mental health-related disorder.
- Variable Strength: Here, the weakness varies in strength at different locations.
- Inconsistencies in the exam: There’s inconsistency in a person’s signs and symptoms when performing activities and when being examined.
- Co-contraction: When asked to bend the elbow, both the triceps and biceps muscles contract.
For tremors, three common tests are used:
- Distraction affecting the Tremor: Here, the tremor changes when the person is distracted.
- Tremor Variability: This reflects variation in the tremor’s pattern.
- Tremor Entrainment: This involves the tremor syncing with rhythmic movements or sounds.
Testing for La Belle Indifference
If a person’s doctor suspects they may be experiencing seizures that are not related to epilepsy (PNES), they may use several tests to confirm this. Two of the tests they may use initially include an EEG (electroencephalogram) and a video-EEG. These help the doctors to rule out epileptic seizures, as they monitor brain activity.
They might also order an MRI (Magnetic Resonance Imaging) scan. MRI scans are able to give a detailed view of the brain and can be crucial in ruling out neurological conditions like multiple sclerosis (which affects the nervous system) or a stroke, which can cause varying levels of brain damage.
The doctor may also run blood tests to ensure that the symptoms the person is experiencing are not caused by diseases like Guillain-Barré syndrome (which affects the nerves), myopathies (muscle diseases), polymyositis (inflammation of the muscles), or myasthenia gravis (a chronic autoimmune, neuromuscular disease).
Interestingly, some people with PNES might also have seizures caused by epilepsy. Studies suggest that roughly 10% of people with PNES might have these epileptic seizures as well.
Finally, it’s important to note that in some cultures, seizure-like episodes are common during religious or cultural rituals. For this reason, medical providers need to carefully consider the possible connections between a patient’s symptoms and their religious or cultural practices when making a diagnosis.
Treatment Options for La Belle Indifference
Treating Functional Neurological Symptom Disorder (FNSD), a condition where patients experience physical symptoms that can’t be explained by medical conditions, can be pretty challenging due to a lack of extensive research and randomized trials. Usually, a team of different health professionals, including regular doctors (primary care providers), psychiatrists, neurologists, and psychologists, is needed to treat this condition best.
One suggested approach is called the ‘3Ps’, which involves identifying certain factors related to the patient’s symptoms. These include ‘predisposing’ factors (characteristics that made them more likely to develop the condition), ‘precipitating’ factors (triggers or stressful events that might have kick-started the symptoms), and ‘perpetuating’ factors (things that keep the symptoms going).
Cognitive-Behavioral Therapy (CBT), a type of therapy that helps patients understand and change their thought patterns, has been identified as a successful way to treat Somatic Symptom Disorder (SSD), a related condition where a person’s worries about their symptoms cannot be explained by any underlying medical condition. In a small pilot study, patients with Psychogenic Non-Epileptic Seizures (PNES), a kind of seizure caused by psychological factors, showed a significant decrease in symptoms six months after receiving CBT.
Antidepressants, a type of medication used to treat depression and other mental health disorders, have also shown positive results. In one study, 7 out of 10 patients with conversion disorder (another term for FNSD) saw improvements in their motor symptoms after taking these medications.
However, despite these approaches, we don’t yet have an evidence-based treatment that effectively works for all FNSD patients. So, health-care providers should focus on treating any other existing mental or physical health conditions the patient might have, managing stress, and dealing with any psychological trauma.
What else can La Belle Indifference be?
Functional Neurological Symptom Disorder (FNSD) can show up in people who also have physical health issues. For instance, people who experience epileptogenic seizures (a type of seizure related to epilepsy) may also suffer from Psychogenic Non-epileptic Seizures (PNES) at the same time. Those with serious and potentially life-threatening health conditions might also show signs of dissociative symptoms and conversion, a form of mental condition where the patient’s physical symptoms don’t match up with what healthcare providers can see on medical tests.
Interestingly, patients who exhibit a phenomenon known as ‘la belle indifference’ do not seem troubled by their symptoms. It is often observed in people who have two or more psychiatric conditions like depression, anxiety, Post Traumatic Stress Disorder (PTSD), and personality disorders.
In the process of diagnosis, it is equally important for the healthcare provider to rule out other medical conditions that might be responsible for the symptoms. The conditions to be considered include:
- Multiple Sclerosis
- Stroke
- Guillain-Barré Syndrome
- Myopathies (disease of the muscle tissue)
- Polymyositis (a type of muscle inflammation)
- Myasthenia Gravis (a neuromuscular disease that causes weakness and rapid fatigue of muscles)
What to expect with La Belle Indifference
The future health condition or ‘prognosis’ of Functional Neurological Symptom Disorder (FNSD), a condition where patients experience nervous system symptoms that cannot be explained by a biological cause, depends on how quickly symptoms start and how long they last. If symptoms appear suddenly and last only for a short period, especially if we can identify a stress trigger, the prognosis is generally good. About 25% of patients see these unexplained symptoms disappear within weeks.
However, a study focusing on patients experiencing unexplained movements (a type of symptom in FNSD) showed that those who also have psychiatric conditions may experience symptoms for a longer period. This means that if a patient with FNSD also suffers from conditions like anxiety or depression, their unexplained symptoms may last longer.
Possible Complications When Diagnosed with La Belle Indifference
Based on a study conducted by Stone and his team, there’s a meager 4% chance of wrongly diagnosing functional neurologic symptom disorder (FNSD). However, there’s still a slight risk that a real neurological or medical cause could be overlooked, leading to delayed treatment. That’s why it’s crucial for primary care physicians to immediately refer patients to psychiatric and neurological specialists for a thorough evaluation. This ensures a correct diagnosis in a reasonable time frame.
Key Points:
- Only a 4% chance of misdiagnosis of functional neurologic symptom disorder
- Risk of overlooking a true medical cause, leading to delayed treatment
- Immediate referral to psychiatric and neurological specialists is essential
- This will lead to accurate diagnosis in a reasonable amount of time
Preventing La Belle Indifference
Treating FNSD, or Functional Neurological Symptom Disorder, requires a team of medical professionals from various fields. This approach is crucial to properly diagnose and treat the condition.
Another key factor in successful treatment is actively involving the patient. The first stage of this is helping the patient to accept their diagnosis. It’s important to explain to the patient about their physical symptoms and how FNSD was diagnosed. Providing this education helps the patient understand their condition better and can lead to more positive results from the treatment.
