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J Neurol Neurosurg Psychiatry doi:10.1136/jnnp-2012-304181
  • Neuropsychiatry
  • Review

A systematic review of transcranial magnetic stimulation in the treatment of functional (conversion) neurological symptoms

  1. Anthony S David1
  1. 1Section of Cognitive Neuropsychiatry, Department of Psychosis Studies, Institute of Psychiatry, King's College London, London, UK
  2. 2Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, University College London, London, UK
  1. Correspondence to Dr Thomas A Pollak, Section of Cognitive Neuropsychiatry, Department of Psychosis Studies, Institute of Psychiatry, King's College London, De Crespigny Park, London SE5 8AF, UK; thomas.pollak{at}kcl.ac.uk
  • Received 22 September 2012
  • Revised 10 December 2012
  • Accepted 12 December 2012
  • Published Online First 8 January 2013

Abstract

Functional (conversion) neurological symptoms (FNS) are commonly encountered in neurological and psychiatric clinical settings and represent a considerable burden on healthcare systems. There is a conspicuous paucity of evidence-based treatments for FNS. Transcranial magnetic stimulation (TMS) offers a safe, non-invasive method of probing changes in cortical excitability and/or connectivity. It has already had some success in demonstrating abnormalities of cortical excitability in patients with FNS, particularly when the functional symptom in question relates to movement. We reviewed the literature for studies in which TMS has been used in the treatment of FNS. All patients in the identified studies had motor symptoms (either weakness or movement disorder). There was considerable heterogeneity in terms of study quality, population sampled, study design, TMS parameters and outcome measures. No studies were placebo controlled. Despite the majority of studies claiming success for the technique, there is insufficient good quality evidence to establish TMS as an effective treatment modality for FNS. We outline the methodological considerations that should be taken into account in future studies of the efficacy of TMS in treating FNS and discuss mechanisms by which TMS, if efficacious, may exert a therapeutic effect, including: (a) via genuine neuromodulation, (b) via non-specific placebo effects and (c) by demonstrating, through its immediate effects on the motor system (eg, movement in a ‘paretic’ limb), that symptom improvement is possible, thus directly changing higher level beliefs that may be responsible for the maintenance of the disorder.

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