It is likely that PMDs bear a strong clinical resemblance to what psychiatrists call somatoform disorders [Diagnositc and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)]. These illnesses have attracted a number of different terms such as “functional somatic syndromes” (2) or “functional” disorders (3). It is becoming increasingly apparent that the multitude of functional syndromes such as IBS, chronic fatigue syndrome, and fibromyalgia share more similarities than differences (4).

It has also been suggested that some patients with PMDs are deliberately feigning or simulating their symptoms. It is extremely difficult, however, for physicians to infer levels of conscious awareness, the degree of consciously mediated intention, and the motivations that accompany the symptoms presented by patients (5). As pointed out by Miller (6), the distinction between hysteria and malingering “depends on nothing more infallible than one man’s assessment of what is going on in another man’s mind.”

Before treatment begins, however, a comprehensive psychosocial formulation must be established. It goes without saying that the assessment should be multidimensional, that is, involve an assessment of symptoms and signs, but also emotional distress, illness beliefs, and functional impairments.

A number of instruments are helpful in assessing these various health domains. They include the Symptom Checklist-12 (SCL-12) to measure somatic symptoms (12); the Hospital Anxiety and Depression Scale to measure anxiety and depression (13) (the Depression and Anxiety scales devised by Beck are also useful); and the Illness Beliefs Questionnaire, which provides a rating of illness attitudes and concerns (14). There are several measures of functional impairment, including the Dartmouth COOP (15) and the Barthel Index (16).

It is also essential to have working knowledge of the initiating factors and of the maintaining factors, as the latter will often be the focus for any intervention (see description of WHO ICF model below).

There are no large, randomized controlled studies of rehabilitation in patients with psychogenic movement disorders. Neither is there any good evidence to support the use of one specific intervention for patients with either conversion disorders or PMDs. A variety of different physical and psychological treatments have been used to treat motor conversion disorders, and these are shown in Table 35.2. Unfortunately, most of the available evidence consists of single cases or case series that have recently been reviewed by Wade (19). The shortcomings of these various “unimodal” therapies are that they tend to act on only one health domain. For example, functional electrical stimulation (FES) is directed toward movement; behavioral treatment at behavior, and so on. Although it is conceivable that one particular intervention may well have an effect on several areas, for example, FES may alter beliefs by showing that movement is possible and might reduce perceived disability (by allowing the patient to walk), it is unlikely to change the “disease label” used by the patient.

One recent exception is a randomized controlled trial in outpatients with motor conversion disorder (20). The study included 45 patients and the setting was a general psychiatric inpatient unit. The treatment involved group-based activities using cognitive and behavioral techniques as well as problem-solving and physiotherapy. Primary outcome measures were the Video Rating Scale for motor conversion symptoms (VRMC), the D (disabilities) code items from the International Classification of Impairments, Disabilities and Handicaps (ICIDH), and the Symptom Checklist-90 (SCL-90). The “experimental” condition consisted of eight weekly sessions of 1-hour hypnosis.