Paralympics and conversion disorder.

To cite: David AS. J Neurol Neurosurg Psychiatry 2016;87:217–219. Anyone who follows or participates in Paralympic sport will be in no doubt that it provides as much drama, excitement, elation and despair as its Olympic counterpart. In addition, it has undoubtedly contributed to reducing stigma against disabled people. However, an ongoing challenge for the Paralympic movement is to decide which impairments can compete in which sports and how to group athletes to ensure fair competition. Understanding the effects of stigma around disability and dealing with them are part and parcel of work in medicine but especially the mental health field. Within the medical specialities there is a ‘race to the bottom’ for whose disorders are the most stigmatised. Psychiatry has a strong claim on this with mental illness generally regarded as among the most feared and least understood. And within psychiatry there is a similar hierarchy such that patients with ‘hysteria’ or conversion disorder (CD) are those found to be least satisfying to treat and are least liked by psychiatrists—the feeling is mutual of course. 3 Paralympics and CD (or functional neurological syndromes (FNS)) have recently come together over a number of well-publicised episodes. These are well-worth considering. First, and most simply, they might encourage a useful partnership between the organisers of such sport and the psychiatric profession, which might prevent individuals becoming targets of media speculation and reputational damage to the Paralympic Games. Second, they might tell us something about attitudes to disability and mental health which may not be evident in more measured discourse. Finally, these episodes may focus our minds on tightening up our concepts regarding the rights and obligations inherent in the sick role and the perennial debates around diagnostic criteria for CD. What is the process for deciding whether an athlete is eligible to compete in Paralympic sport? First, it should be noted that each of the 22 Summer and 5 Winter Paralympic sports, has its own classification rules. Clearly, the impact of an athlete’s impairment varies from sport to sport but there are some broad principles which apply. The first stage is to secure a medical diagnosis (which for athletes with a physical impairment does not include psychiatric diagnosis). This diagnosis must be seen as leading to 1 of 10 ‘eligible impairments’ recognised by the International Paralympic Committee (IPC): impaired muscle power, impaired passive range of movement, limb deficiency, leg length difference, short stature, hypertonia, ataxia, athetosis, vision impairment, and finally, intellectual impairment. Chronic pain and epilepsy are not eligible impairments. Following that, the athlete undergoes a series of bench tests and skill assessments relating to the sport to measure how their impairment affects them on the field of play, the athlete may then also be observed during competition to ensure their performance in the previous skill assessment is replicated in the competitive environment. In light of some recent cases, the IPC is looking to each of the International Federations of sport to increase their efforts to verify underlying impairment types, as well as reminding athletes and their support staff to disclose full medical diagnostic information prior to presenting for classification. There is no academic literature on the issue of FNS and Paralympic sport, only sporadic reports in the lay press and Wikipedia. In 2005 the Scottish Daily Record (28 April 2005) described a case of a 45-year-old man, Frank Duffy, who had been ‘wheelchair user for 10 years after falling just 4 feet from a ladder at work’. He became captain of the Great Britain wheelchair curling team that won silver at the Turin Games in 2006. The story came to light following an out-of-court settlement for personal injuries where the diagnosis of CD was revealed, a condition ‘where the brain converts emotional trauma into physical symptoms’. In 2012, the case of swimmer Victoria Arlen caused considerable controversy. According to the New York Times, she spent 3 years ‘in a vegetative state because of an autoimmune disorder and woke in 2010 with paralysed legs and other symptoms of the neurological condition transverse myelitis’. The IPC released a statement on 12 August 2013 saying that five independent medical experts reviewing her case agreed that there was insufficient evidence of an eligible impairment leading to permanent or verifiable activity limitation. The most recent and significant case to reach the headlines was of Dutch paracyclist Monique van der Vorst, a winner of two handcycling silver medals at the Beijing 2008 Paralympics. According to the IPC statement of 4 June 2013, van der Vorst experienced a ‘miraculous’ recovery following an accident in March 2010 and ‘started to feel tingling sensations in her paralysed limbs. By July of that year she was able to start walking again.’ It goes on to say that in late 2012, ‘the Head of the Spinal Cord Injury Unit at the Amsterdam Centre for Rheumatology and Rehabilitation diagnosed her with Conversion Disorder’. According to her website http://www. moniquevandervorst.com/Monique, Ms van der Vorst, born in 1984, had been in a wheelchair since 1998, “when her left leg was paralysed and her right knee stopped working properly ... During her rehabilitation period, she was introduced to handcycling.” During training in the USA on 20 April (2008) “Monique and her training partner were hit by a car. Monique was unconscious and had to be transported to the hospital by helicopter. Monique had