From the Guidelines
La belle indifférence should not be considered a definitive indicator of conversion disorder, but rather as one aspect of a comprehensive evaluation that prioritizes ruling out organic causes and addressing the patient's overall well-being. When encountering a patient exhibiting la belle indifférence, it is crucial to approach the situation with empathy and a thorough medical workup to determine the underlying cause of their symptoms, as this sign can be present in both organic and functional disorders 1. The management of such patients may involve addressing psychosocial predisposing and perpetuating factors, as suggested in the consensus recommendations for speech and language therapy, which emphasize the importance of supportive discussions about anxiety and the impact of symptoms on daily life without necessarily requiring special training in counseling or psychotherapy 1. Key aspects of management include:
- Conducting a thorough medical evaluation to rule out organic causes
- Avoiding suggestions that symptoms are "all in their head" to maintain a positive therapeutic relationship
- Considering a multidisciplinary approach that may include psychotherapy and physical therapy
- Addressing psychological stressors and supporting the patient's reintegration into their social and work environments
- Being prepared to involve additional healthcare professionals, such as psychiatrists or mental health professionals, if the patient becomes distressed or psychiatrically unwell during treatment, as outlined in the management of functional communication, swallowing, cough, and related disorders 1.
From the Research
Definition and Diagnosis of La Belle Indifference
- La belle indifference refers to an apparent lack of concern shown by some patients towards their symptoms, often regarded as typical of conversion symptoms/hysteria 2.
- However, the available evidence does not support the use of la belle indifférence to discriminate between conversion symptoms and symptoms of organic disease 2.
- A diagnosis of conversion disorder should not be considered definitive if no improvement occurs in terms of physical, mental, and cognitive symptoms despite appropriate therapy 3.
Clinical Presentation and Misdiagnosis
- La belle indifférence may be a psychological sign in the context of conversion disorder, but it may also be an expression of lack of mimic due to Parkinsonism or of eye movement disorder in the context of neurological illness 3.
- Functional neurological symptom disorder may present without la belle indifference more commonly than previously believed 4.
- Misdiagnosis of a neurological disorder as conversion disorder still occurs, especially in cases with insidious onset, and misinterpretation of la belle indifférence may contribute to such misdiagnosis 3.
Treatment and Management
- Psychotherapy is an emerging first-line intervention for functional neurological symptom disorder, with a focus on emotion processing and related psychological constructs 5.
- A multidisciplinary approach to treatment is recommended, including clinician-patient proper communication, proper neurological/epilepsy evaluation, psychiatric therapy, psychotherapy, physical therapy, and pharmacotherapy 6.
- Clinicians should perform thorough history collection and physical examination prior to obtaining costly and time-consuming diagnostic studies whenever possible 4.