Reviewer's report
Title:Medically unexplained illness and the diagnosis of hysterical conversion
reaction (HCR) in women's medicine wards of Bangladeshi hospitals: a record
review and qualitative study
Version: 2Date:11 June 2012
Reviewer: Jon Stone
Reviewer's report:
"I found this an interesting study which made some of its point well but was let
down by inadequate analysis and understanding of the literature.
The main points of the study, that
1. 'HCR' is diagnosed frequently in Bangladeshto cover a multitude of
different physical and psychiatric diagnoses
2. Maybe the doctors could try harder to make more specific diagnoses
Are all well made.
The point that "Some organic disease may be missed" is probably true but not
well made by the data presented
The comments from physicians are interesting, although it doesn't appear as if
any standardised techniques for qualitative research have been applied to
reduce the possibility of bias from the authors perspective.
In terms of misdiagnosis, its not clear whether the final diagnoses are necessarily
correct, sometimes physicians apply a physical disease incorrectly in a patient
who does have a "non-organic"/somatoform/ functional problem. Costochondritis
for example, was one of the commoner 'organic' discharge diagnoses, but this is
a label frequently given to patients with "functional" chest pain. Likewise, was
there clear evidence of pelvic inflammatory disease or was that just an
assumption based on a history of pelvic pain? A diagnosis of 'convulsion' is
meaningless in this study as a discharge organic diagnosis - was it epileptic
convulsion or a psychogenic non-epileptic convulsion!
Misdiagnoses go in both directions as the authors Table 2 shows. Presumably
some of those misdiagnosed with a disease on arrival, experienced
psychological harm from being told that they might have a stroke, or epilepsy for
example.
So from the point of view of a study of diagnostic change, Its difficult to know
what the study tells us, it may be that admission diagnoses in general are apt to
change by quite a large degree, and HCR is not different in that respect. It may
be that using the criteria of HCR in Bangladesh a rate of 6% is about right (or
may even be much too low!)
I was disappointed that the authors only managed to find one very old study of
misdiagnosis 60 or so patients (which is British by the way not US) when there
has been a systematic review of 27 studies and a subsequent study of
1144 patients looking at this issue. (Stone J, Smyth R, Warlow C, Carson A,
Sharpe M. The misdiagnosis of conversion symptoms / hysteria - a systematic
review. BMJ 2005; 331:989.Stone J, Carson A, Sharpe M et al. Symptom
unexplained by disease in neurology outpatients: How often does the diagnosis
change at follow up? Brain 2009: 132: 2878-88) which refute the 1960s data
(whilst accepting that misdiagnosis is inevitable to some degree in medicine and
clearly practice may vary across the world).
Looking at the neurological symptoms there seemed to be more patients with an
initial uncertain diagnosis of 'convulsions' who ended up with an HCR diagnosis
(9) than those who ended up with a diagnosis of 'convulsion (3) suggesting that
true conversion disorder was under-diagnosed initially.
Perhaps the authors could separate out those cases that were neurological in
nature (weakness, seizures etc) and describe how commonly those diagnoses
were changed.
What is more relevant is to hear that HCR is still used so widely.
Hysterical conversion has not been a descriptive term for non-neurological
symptoms since DSM II in the 1960s. This is therefore a truly outmoded term
which no doubt for historical reasons has survived the onslaught of other
possible terms 'non-organic/psychogenic/somatisation/medically
unexplained/functional' that have been introduced since. The practices of the
physicians are not that different to many physicians and A&E staff I know in the
UK, neither are the attitudes or lack of training. (see Kanaan JNNP 2011)
So although I agree with the points made, Im not sure they are that specific to
Bangladesh except the HCR label. I am worried that this study will be seen as a
diagnostic study of conversion disorder, when really it's a study showing that an
outmoded term is used in Bangladesh to describe a problem that is common all
over the world and which is hard to diagnose, especially acutely."