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Beharry J, Palmer D, Wu T, Wilson D, Le Heron C, Mason D, Reimers J, Fink J, Mulder R, Duncan R. Functional neurological disorders presenting as emergencies to secondary care. Eur J Neurol 2021; 28:1441-1445. [PMID: 33426732 DOI: 10.1111/ene.14728] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 12/25/2020] [Accepted: 12/30/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Functional neurological disorders (FND) represent a significant proportion of presentations to outpatient adult neurology services. There is little information relating to patients presenting to acute inpatient care. METHODS We identified patients presenting as acute admissions with FND to Christchurch Hospital, Christchurch, New Zealand, from 2016 to 2018. We analyzed relevant demographic and clinical data from electronic records and measured incidence of presentation to secondary care and healthcare utilization. RESULTS One hundred sixty-two patients presented on 173 occasions with FND, representing 9% of all admissions to the neurology service during the 3-year study period. The mean age was 40 (SD 17) years, 111 (69%) patients were female and the median length of stay was 3 (IQR 2-4) days. A total of 92 computed tomography brain scans, 77 magnetic resonance imaging brain scans and 42 electroencephalograms were carried out. On 22 (13%) occasions, patients were referred for outpatient psychological therapy. In the 3 years prior to each patient's last presentation in the study period, these 162 patients had a total of 671 presentations to the emergency department. Healthcare demand did not decrease after the index admission. The rate of acute inpatient admission for FND was 10 per 100,000 per year for the total Christchurch Hospital catchment, 6/100,000/year in rural areas, and 11/100,000/year in urban areas. CONCLUSION FND represented almost 1 in 10 acute neurology admissions with significant inpatient healthcare resource utilization.
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Affiliation(s)
- James Beharry
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - David Palmer
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Teddy Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand.,New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Duncan Wilson
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand.,New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Campbell Le Heron
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand.,New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Deborah Mason
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand.,New Zealand Brain Research Institute, Christchurch, New Zealand
| | - Jon Reimers
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - John Fink
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Roger Mulder
- Department of Psychiatry, Christchurch Hospital, Christchurch, New Zealand
| | - Roderick Duncan
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
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52
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Trinidade A, Harman P, Stone J, Staab JP, Goebel JA. Assessment of Potential Risk Factors for the Development of Persistent Postural-Perceptual Dizziness: A Case-Control Pilot Study. Front Neurol 2021; 11:601883. [PMID: 33551961 PMCID: PMC7859446 DOI: 10.3389/fneur.2020.601883] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 12/29/2020] [Indexed: 12/21/2022] Open
Abstract
Objectives: (1) To assess whether neuroticism, state anxiety, and body vigilance are higher in patients with persistent postural-perceptual dizziness (PPPD) compared to a recovered vestibular patient group and a non-dizzy patient group; (2) To gather pilot data on illness perceptions of patients with PPPD. Materials and Methods: 15 cases with PPPD and two control groups: (1) recovered vestibular patients (n = 12) and (2) non-dizzy patients (no previous vestibular insult, n = 12). Main outcome measures: Scores from the Big Five Inventory (BFI) of personality traits, Generalized Anxiety Disorder - 7 (GAD-7) scale, Body Vigilance Scale (BVS), Dizziness Handicap Inventory (DHI), modified Vertigo Symptom Scale (VSS) and Brief Illness Perception Questionnaire (BIPQ). Results: Compared to non-dizzy patients, PPPD cases had higher neuroticism (p = 0.02), higher introversion (p = 0.008), lower conscientiousness (p = 0.03) and higher anxiety (p = 0.02). There were no differences between PPPD cases and recovered vestibular patients in BFI and GAD-7. PPPD cases had higher body vigilance to dizziness than both control groups and their illness perceptions indicated higher levels of threat than recovered vestibular patients. Conclusion: PPPD patients showed statistically significant differences to non-dizzy patients, but not recovered vestibular controls in areas such as neuroticism and anxiety. Body vigilance was increased in PPPD patients when compared with both recovered vestibular and non-dizzy patient groups. PPPD patients also exhibited elements of negative illness perception suggesting that this may be the key element driving the development of PPPD. Large scale studies focusing on this area in the early stages following vestibular insult are needed.
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Affiliation(s)
- Aaron Trinidade
- Southend University Hospital NHS Foundation Trust, Southend-on-Sea, United Kingdom
| | - Paula Harman
- Southend University Hospital NHS Foundation Trust, Southend-on-Sea, United Kingdom
| | - Jon Stone
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | | | - Joel A Goebel
- Washington University in St. Louis School of Medicine, St. Louis, MO, United States
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53
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Yerneni K, Wadhwa H, Fatemi P, Zygourakis CC. Functional neurological disorders in patients undergoing spinal surgery: illustrative case. JOURNAL OF NEUROSURGERY: CASE LESSONS 2021; 1:CASE2068. [PMID: 35854933 PMCID: PMC9241316 DOI: 10.3171/case2068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 10/30/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND “Conversion disorder” refers to bodily dysfunction characterized by either sensory or motor neurological symptoms that are unexplainable by a medical condition. Given their somatosensory context, such disorders often require extensive medical evaluation, and the diagnosis can only be made after structural disease is excluded or fails to account for the severity and/or spectrum of the patient’s deficits. OBSERVATIONS The authors briefly review functional psychiatric disorders and discuss the comprehensive workup of a patient with a functional postoperative neurological deficit, drawing from their recent experience with a patient who presented with conversion disorder immediately after undergoing anterior cervical discectomy and fusion. LESSONS Conversion disorder has been found to be associated with bodily stress, requiring surgeons to be aware of this condition in the postoperative setting. This is especially true in neurosurgery, given the overlap of true neurological pathology, postoperative complications, and manifestations of conversion disorder. Although accurately diagnosing and managing patients with conversion disorder remains challenging, an understanding of the multifactorial nature of its etiology can help clinicians develop a methodical approach to this condition.
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Affiliation(s)
- Ketan Yerneni
- Department of Neurological Surgery, Stanford University, Palo Alto, California
| | - Harsh Wadhwa
- Department of Neurological Surgery, Stanford University, Palo Alto, California
| | - Parastou Fatemi
- Department of Neurological Surgery, Stanford University, Palo Alto, California
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54
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Tinazzi M, Geroin C, Erro R, Marcuzzo E, Cuoco S, Ceravolo R, Mazzucchi S, Pilotto A, Padovani A, Romito LM, Eleopra R, Zappia M, Nicoletti A, Dallocchio C, Arbasino C, Bono F, Pascarella A, Demartini B, Gambini O, Modugno N, Olivola E, Bonanni L, Antelmi E, Zanolin E, Albanese A, Ferrazzano G, de Micco R, Lopiano L, Calandra-Buonaura G, Petracca M, Esposito M, Pisani A, Manganotti P, Stocchi F, Coletti Moja M, Antonini A, Ercoli T, Morgante F. Functional motor disorders associated with other neurological diseases: Beyond the boundaries of "organic" neurology. Eur J Neurol 2021; 28:1752-1758. [PMID: 33300269 DOI: 10.1111/ene.14674] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 12/03/2020] [Accepted: 12/06/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND PURPOSE The aims of this study were to describe the clinical manifestations of functional motor disorders (FMDs) coexisting with other neurological diseases ("comorbid FMDs"), and to compare comorbid FMDs with FMDs not overlapping with other neurological diseases ("pure FMDs"). METHODS For this multicenter observational study, we enrolled outpatients with a definite FMD diagnosis attending 25 tertiary movement disorder centers in Italy. Each patient with FMDs underwent a detailed clinical assessment including screening for other associated neurological conditions. Group comparisons (comorbid FMDs vs. pure FMDs) were performed in order to compare demographic and clinical variables. Logistic regression models were created to estimate the adjusted odds ratios (95% confidence intervals) of comorbid FMDs (dependent variable) in relation to sociodemographic and clinical characteristics (independent variables). RESULTS Out of 410 FMDs, 21.7% of patients (n = 89) had comorbid FMDs. The most frequent coexisting neurological diseases were migraine, cerebrovascular disease and parkinsonism. In the majority of cases (86.5%), FMDs appeared after the diagnosis of a neurological disease. Patients with comorbid FMDs were older, and more frequently had tremor, non-neurological comorbidities, paroxysmal non-epileptic seizures, major depressive disorders, and benzodiazepine intake. Multivariate regression analysis showed that diagnosis of comorbid FMDs was more likely associated with longer time lag until the final diagnosis of FMD, presence of tremor and non-neurological comorbidities. CONCLUSIONS Our findings highlight the need for prompt diagnosis of FMDs, given the relatively high frequency of associated neurological and non-neurological diseases.
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Affiliation(s)
- Michele Tinazzi
- Neurology Unit, Movement Disorders Division, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Christian Geroin
- Neurology Unit, Movement Disorders Division, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Roberto Erro
- Department of Medicine, Surgery and Dentistry -Scuola Medica Salernitana, Center for Neurodegenerative Diseases (CEMAND), University of Salerno, Baronissi, SA, Italy
| | - Enrico Marcuzzo
- Neurology Unit, Movement Disorders Division, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Sofia Cuoco
- Department of Medicine, Surgery and Dentistry -Scuola Medica Salernitana, Center for Neurodegenerative Diseases (CEMAND), University of Salerno, Baronissi, SA, Italy
| | - Roberto Ceravolo
- Neurology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Sonia Mazzucchi
- Neurology Unit, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Andrea Pilotto
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy.,FERB Onlus, Ospedale S. Isidoro, Trescore Balneario, Bergamo, Italy
| | - Alessandro Padovani
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Luigi Michele Romito
- Parkinson and Movement Disorders Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Roberto Eleopra
- Parkinson and Movement Disorders Unit, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - Mario Zappia
- Section of Neurosciences, Department G.F. Ingrassia, University of Catania, Catania, Italy
| | - Alessandra Nicoletti
- Section of Neurosciences, Department G.F. Ingrassia, University of Catania, Catania, Italy
| | - Carlo Dallocchio
- Neurology Unit, Department of Medical Area, ASST Pavia, Pavia, Italy
| | - Carla Arbasino
- Neurology Unit, Department of Medical Area, ASST Pavia, Pavia, Italy
| | - Francesco Bono
- Botulinum Toxin Center, Neurology Unit, A.O.U. Mater Domini, Catanzaro, Italy
| | - Angelo Pascarella
- Botulinum Toxin Center, Neurology Unit, A.O.U. Mater Domini, Catanzaro, Italy
| | - Benedetta Demartini
- Aldo Ravelli Research Center for Neurotechnology and Experimental Brain Therapeutics - Department of Health Sciences, University of Milan, Milan, Italy
| | - Orsola Gambini
- Aldo Ravelli Research Center for Neurotechnology and Experimental Brain Therapeutics - Department of Health Sciences, University of Milan, Milan, Italy
| | | | | | - Laura Bonanni
- Department of Neuroscience, Imaging and Clinical Sciences, University G. d'Annunzio, Chieti-Pescara, Italy
| | - Elena Antelmi
- Neurology Unit, Movement Disorders Division, Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Elisabetta Zanolin
- Unit of Epidemiology and Medical Statistics, Department of Diagnostics and Public Health, University of Verona, Verona, Italy
| | - Alberto Albanese
- Department of Neurology, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Gina Ferrazzano
- Department of Human Neurosciences, Università La Sapienza, Rome, Italy
| | - Rosa de Micco
- Department of Advanced Medical and Surgery Sciences, University of Campania - Luigi Vanvitelli, Naples, Italy
| | - Leonardo Lopiano
- Department of Neuroscience - Rita Levi Montalcini, University of Turin, Turin, Italy
| | - Giovanna Calandra-Buonaura
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,Institute of Neurological Sciences of Bologna, IRCCS, Bologna, Italy
| | - Martina Petracca
- Movement Disorder Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Paolo Manganotti
- Clinical Neurology Unit, Department of Medical, Surgical and Health Services, University of Trieste, Trieste, Italy
| | - Fabrizio Stocchi
- University and Institute of Research and Medical Care San Raffaele, Roma, Italy
| | | | - Angelo Antonini
- Movement Disorders Unit, Department of Neuroscience, University of Padua, Padua, Italy
| | - Tommaso Ercoli
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Francesca Morgante
- Neurosciences Research Centre, Molecular and Clinical Sciences Neurosciences Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK.,Department of Experimental and Clinical Medicine, University of Messina, Messina, Italy
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55
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Lidstone SC, Nassif W, Juncos J, Factor SA, Lang AE. Diagnosing functional neurological disorder: seeing the whole picture. CNS Spectr 2020; 26:1-8. [PMID: 33161935 DOI: 10.1017/s1092852920001996] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Functional neurological disorder (FND) is a complex neuropsychiatric syndrome with many phenotypes that are commonly encountered in clinical practice. Despite the heterogeneity of FND, the rate of misidentification is consistently low. For the more common motor subtypes, there are clear positive clinical, electrophysiological, and rarely imaging criteria that can establish the diagnosis in the traditional sense. For nonmotor subtypes, the characterization may be less clear. Here, we argue that the current diagnostic criteria are not reflective of the current shared neuropsychiatric understanding of FND, and, as a result, provide an incomplete picture of the diagnosis. We propose a three-step diagnostic triad for FND, in which the traditional neurological diagnosis is only the first element. Other steps include psychiatric/psychological formulation, integration, and follow-up. We advocate that this diagnostic approach should be the shared responsibility of neurology and mental health professionals. Finally, a research agenda is proposed to address the missing factors in the field.
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Affiliation(s)
- Sarah C Lidstone
- Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital and the University of Toronto, Toronto, Ontario, Canada
| | - Walid Nassif
- Department of Psychiatry, Emory University, and the Veterans Affairs Medical Center, Atlanta, Georgia, USA
| | - Jorge Juncos
- Department of Neurology, Jean and Paul Amos Parkinson's Disease and Movement Disorders Program, Emory University, Atlanta, Georgia, USA
| | - Stewart A Factor
- Department of Neurology, Jean and Paul Amos Parkinson's Disease and Movement Disorders Program, Emory University, Atlanta, Georgia, USA
| | - Anthony E Lang
- Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital and the University of Toronto, Toronto, Ontario, Canada
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56
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Stone J, Warlow C, Deary I, Sharpe M. Predisposing Risk Factors for Functional Limb Weakness: A Case-Control Study. J Neuropsychiatry Clin Neurosci 2020; 32:50-57. [PMID: 31466514 DOI: 10.1176/appi.neuropsych.19050109] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Functional limb weakness is a common symptom of functional neurological disorder. Few controlled studies have examined possible predisposing factors to determine their specificity for this symptom. METHODS In this prospective case-control study, patients with functional limb weakness (<2 years duration, N=107) were compared with a control group (comprising patients with weakness attributable to neurological disease, N=46, and healthy individuals, N=39). A structured clinical interview and questionnaires assessed potential predisposing factors, including family structure and childhood abuse and neglect (Childhood Trauma Questionnaire [CTQ]), personality traits (NEO Five-Factor Inventory), medical and surgical comorbidity, and exposure to a symptom model. RESULTS The patients with functional limb weakness and the control subjects were similar in gender and age. Self-reported childhood sexual abuse (15% versus 5%, p<0.01), and physical abuse (18% versus 7%, p<0.01; CTQ "moderate or above") were more common in the functional limb weakness group, although the absolute frequency was lower than anticipated. In the functional limb weakness group, there were modest differences in two personality traits, compared with the control group: higher neuroticism (p=0.02) and lower openness (p=0.01). Medical comorbidity, including appendectomy (33% versus 5%), irritable bowel syndrome (36% versus 18%), and chronic back pain (40% versus 16%), was more frequent in the functional limb weakness group. There were no differences in birth order or exposure to a symptom model. CONCLUSIONS Medical and surgical comorbidity and adverse childhood experience are risk factors, but not essential, for the development of functional limb weakness. However, evidence for personality traits or exposure to a symptom model is less robust.
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Affiliation(s)
- Jon Stone
- The Centre for Clinical Brain Sciences, University of Edinburgh, Royal Infirmary, Edinburgh, United Kingdom (Stone, Warlow); the Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, United Kingdom (Deary); the Department of Psychological Medicine Research, University of Oxford, United Kingdom (Sharpe)
| | - Charles Warlow
- The Centre for Clinical Brain Sciences, University of Edinburgh, Royal Infirmary, Edinburgh, United Kingdom (Stone, Warlow); the Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, United Kingdom (Deary); the Department of Psychological Medicine Research, University of Oxford, United Kingdom (Sharpe)
| | - Ian Deary
- The Centre for Clinical Brain Sciences, University of Edinburgh, Royal Infirmary, Edinburgh, United Kingdom (Stone, Warlow); the Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, United Kingdom (Deary); the Department of Psychological Medicine Research, University of Oxford, United Kingdom (Sharpe)
| | - Michael Sharpe
- The Centre for Clinical Brain Sciences, University of Edinburgh, Royal Infirmary, Edinburgh, United Kingdom (Stone, Warlow); the Centre for Cognitive Ageing and Cognitive Epidemiology, University of Edinburgh, United Kingdom (Deary); the Department of Psychological Medicine Research, University of Oxford, United Kingdom (Sharpe)
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57
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Jones A, O'Connell N, David AS, Chalder T. Functional Stroke Symptoms: A Narrative Review and Conceptual Model. J Neuropsychiatry Clin Neurosci 2020; 32:14-23. [PMID: 31726918 DOI: 10.1176/appi.neuropsych.19030075] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Stroke services have been reconfigured in recent years to facilitate early intervention. Throughout stroke settings, some patients present with functional symptoms that cannot be attributed to a structural cause. Emphasis on fast diagnosis and treatment means that a proportion of patients entering the care pathway present with functional symptoms that mimic stroke or have functional symptoms in addition to vascular stroke. There is limited understanding of mechanisms underlying functional stroke symptoms, how the treatment of such patients should be managed, and no referral pathway or treatment. Predisposing factors vary between individuals, and symptoms are heterogeneous: onset can be acute or insidious, and duration can be short-lived or chronic in the context of new or recurrent illness cognitions and behaviors. This article proposes a conceptual model of functional symptoms identified in stroke services and some hypotheses based on a narrative review of the functional neurological disorder literature. Predisposing factors may include illness experiences, stressors, and chronic autonomic nervous system arousal. Following the onset of distressing symptoms, perpetuating factors may include implicit cognitive processes, classical and operant conditioning, illness beliefs, and behavioral responses, which could form the basis of treatment targets. The proposed model will inform the development of theory-based interventions as well as a functional stroke care pathway.
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Affiliation(s)
- Abbeygail Jones
- The Department of Psychological Medicine, King's College London (Jones, Chalder); the Institute of Population Health, Trinity College Dublin (O'Connell); and the Institute of Mental Health, University College London (David)
| | - Nicola O'Connell
- The Department of Psychological Medicine, King's College London (Jones, Chalder); the Institute of Population Health, Trinity College Dublin (O'Connell); and the Institute of Mental Health, University College London (David)
| | - Anthony S David
- The Department of Psychological Medicine, King's College London (Jones, Chalder); the Institute of Population Health, Trinity College Dublin (O'Connell); and the Institute of Mental Health, University College London (David)
| | - Trudie Chalder
- The Department of Psychological Medicine, King's College London (Jones, Chalder); the Institute of Population Health, Trinity College Dublin (O'Connell); and the Institute of Mental Health, University College London (David)
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Maggio JB, Ospina JP, Callahan J, Hunt AL, Stephen CD, Perez DL. Outpatient Physical Therapy for Functional Neurological Disorder: A Preliminary Feasibility and Naturalistic Outcome Study in a U.S. Cohort. J Neuropsychiatry Clin Neurosci 2020; 32:85-89. [PMID: 31564236 DOI: 10.1176/appi.neuropsych.19030068] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Despite promising research and consensus recommendations on the important therapeutic role of physical therapy for motor functional neurological disorder (FND), little is known about the feasibility and potential efficacy of implementing physical therapy for this population in a U.S.-based outpatient program. Given health care system differences internationally, this is an important gap in the literature. METHODS In this retrospective cohort study, the authors investigated the relationship between treatment adherence and clinical outcome in a hospital-based outpatient physical therapy clinical program. Medical records of 50 consecutive patients with motor FND referred from an FND clinical program were reviewed. The physical therapy intervention included a 1-hour initial assessment and the development of individualized treatment plans guided by published consensus recommendations. Statistical analyses included nonparametric, univariate screening tests followed by multivariate regression analyses. RESULTS In univariate analyses, there was a statistically significant positive correlation between the number of sessions attended and clinical improvement. This relationship held when adjusting for demographic variables, concurrent psychogenic nonepileptic seizures, and other major neurological comorbidities. In a post hoc analysis of the subset of individuals with available gait speed data, posttreatment 10-meter gait speed times improved compared with baseline measurements. Baseline neuropsychiatric factors did not correlate with clinical improvement. CONCLUSIONS This preliminary, retrospective cohort study demonstrated that treatment adherence to a U.S.-based outpatient physical therapy program was associated with clinical improvement. Prospective observational and randomized controlled trials are needed to further optimize physical therapy for patients with functional motor symptoms in the outpatient setting.
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Affiliation(s)
- Julie B Maggio
- The Department of Physical Therapy (Maggio), Department of Neurology (Maggio, Ospina, Callahan, Hunt, Stephen, Perez), and Department of Psychiatry (Perez), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Juan Pablo Ospina
- The Department of Physical Therapy (Maggio), Department of Neurology (Maggio, Ospina, Callahan, Hunt, Stephen, Perez), and Department of Psychiatry (Perez), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Janet Callahan
- The Department of Physical Therapy (Maggio), Department of Neurology (Maggio, Ospina, Callahan, Hunt, Stephen, Perez), and Department of Psychiatry (Perez), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Ann L Hunt
- The Department of Physical Therapy (Maggio), Department of Neurology (Maggio, Ospina, Callahan, Hunt, Stephen, Perez), and Department of Psychiatry (Perez), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Christopher D Stephen
- The Department of Physical Therapy (Maggio), Department of Neurology (Maggio, Ospina, Callahan, Hunt, Stephen, Perez), and Department of Psychiatry (Perez), Massachusetts General Hospital, Harvard Medical School, Boston
| | - David L Perez
- The Department of Physical Therapy (Maggio), Department of Neurology (Maggio, Ospina, Callahan, Hunt, Stephen, Perez), and Department of Psychiatry (Perez), Massachusetts General Hospital, Harvard Medical School, Boston
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59
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Nicholson TR, Carson A, Edwards MJ, Goldstein LH, Hallett M, Mildon B, Nielsen G, Nicholson C, Perez DL, Pick S, Stone J, Aybek S, Baslet G, Bloem BR, Brown RJ, Chalder T, Damianova M, David AS, Epstein S, Espay AJ, Garcin B, Jankovic J, Joyce E, Kanaan RA, Kozlowska K, LaFaver K, LaFrance WC, Lang AE, Lehn A, Lidstone S, Maurer C, Morgante F, Myers L, Reuber M, Rommelfanger K, Schwingenshuh P, Serranova T, Shotbolt P, Stebbins G, Tijssen MAJ, Tinazzi M. Outcome Measures for Functional Neurological Disorder: A Review of the Theoretical Complexities. J Neuropsychiatry Clin Neurosci 2020; 32:33-42. [PMID: 31865871 DOI: 10.1176/appi.neuropsych.19060128] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The development and selection of optimal outcome measures is increasingly recognized as a key component of evidence-based medicine, particularly the need for the development of a standardized set of measures for use in clinical trials. This process is particularly complex for functional neurological disorder (FND) for several reasons. FND can present with a wide range of symptoms that resemble the full spectrum of other neurological disorders. Additional physical (e.g., pain, fatigue) and psychological (e.g., depression, anxiety) symptoms are commonly associated with FND, which also can be highly disabling with implications for prognosis, and warrant concurrent assessment, despite an unclear etiological relationship with FND. Furthermore, several unique clinical aspects of FND make it likely that the usual prioritization of "objective" (or clinician-rated) over "subjective" (or patient-rated) measures might not be appropriate. Self-report measures may be more clinically meaningful in this patient population. Despite being a common and disabling disorder, there has been little research into outcome measures in FND, and to date trials have largely used measures designed for the assessment of other disorders. An international FND Core Outcome Measure group (FND-COM) has been established to develop a consensus battery of outcomes for FND: a "core outcome set." In this perspective article, the authors reviewed the process of outcome measure development and selection before considering the specific features of FND affecting the development of a core outcome set, as well as a research agenda to optimize outcome measurement in this complex neuropsychiatric disorder.
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Affiliation(s)
- Timothy R Nicholson
- The Institute of Psychiatry, Psychology and Neuroscience, King's College London (T. Nicholson, Goldstein, Pick); the Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom (Carson, Stone); the Department of Rehabilitation Medicine, Astley Ainslie Hospital, Edinburgh, United Kingdom (Carson); the Neuroscience Research Centre, St. George's University of London (Edwards, Nielsen); Human Motor Control Section, the National Institute of Neurological Disorders and Stroke, Bethesda, Md. (Hallett); FND Hope International, Banbury, United Kingdom (Mildon); the National Hospital for Neurology and Neurosurgery, University College London, and Hospitals National Health Service Foundation Trust, London (C. Nicholson); and the Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Perez)
| | - Alan Carson
- The Institute of Psychiatry, Psychology and Neuroscience, King's College London (T. Nicholson, Goldstein, Pick); the Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom (Carson, Stone); the Department of Rehabilitation Medicine, Astley Ainslie Hospital, Edinburgh, United Kingdom (Carson); the Neuroscience Research Centre, St. George's University of London (Edwards, Nielsen); Human Motor Control Section, the National Institute of Neurological Disorders and Stroke, Bethesda, Md. (Hallett); FND Hope International, Banbury, United Kingdom (Mildon); the National Hospital for Neurology and Neurosurgery, University College London, and Hospitals National Health Service Foundation Trust, London (C. Nicholson); and the Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Perez)
| | - Mark J Edwards
- The Institute of Psychiatry, Psychology and Neuroscience, King's College London (T. Nicholson, Goldstein, Pick); the Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom (Carson, Stone); the Department of Rehabilitation Medicine, Astley Ainslie Hospital, Edinburgh, United Kingdom (Carson); the Neuroscience Research Centre, St. George's University of London (Edwards, Nielsen); Human Motor Control Section, the National Institute of Neurological Disorders and Stroke, Bethesda, Md. (Hallett); FND Hope International, Banbury, United Kingdom (Mildon); the National Hospital for Neurology and Neurosurgery, University College London, and Hospitals National Health Service Foundation Trust, London (C. Nicholson); and the Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Perez)
| | - Laura H Goldstein
- The Institute of Psychiatry, Psychology and Neuroscience, King's College London (T. Nicholson, Goldstein, Pick); the Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom (Carson, Stone); the Department of Rehabilitation Medicine, Astley Ainslie Hospital, Edinburgh, United Kingdom (Carson); the Neuroscience Research Centre, St. George's University of London (Edwards, Nielsen); Human Motor Control Section, the National Institute of Neurological Disorders and Stroke, Bethesda, Md. (Hallett); FND Hope International, Banbury, United Kingdom (Mildon); the National Hospital for Neurology and Neurosurgery, University College London, and Hospitals National Health Service Foundation Trust, London (C. Nicholson); and the Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Perez)
| | - Mark Hallett
- The Institute of Psychiatry, Psychology and Neuroscience, King's College London (T. Nicholson, Goldstein, Pick); the Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom (Carson, Stone); the Department of Rehabilitation Medicine, Astley Ainslie Hospital, Edinburgh, United Kingdom (Carson); the Neuroscience Research Centre, St. George's University of London (Edwards, Nielsen); Human Motor Control Section, the National Institute of Neurological Disorders and Stroke, Bethesda, Md. (Hallett); FND Hope International, Banbury, United Kingdom (Mildon); the National Hospital for Neurology and Neurosurgery, University College London, and Hospitals National Health Service Foundation Trust, London (C. Nicholson); and the Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Perez)
| | - Bridget Mildon
- The Institute of Psychiatry, Psychology and Neuroscience, King's College London (T. Nicholson, Goldstein, Pick); the Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom (Carson, Stone); the Department of Rehabilitation Medicine, Astley Ainslie Hospital, Edinburgh, United Kingdom (Carson); the Neuroscience Research Centre, St. George's University of London (Edwards, Nielsen); Human Motor Control Section, the National Institute of Neurological Disorders and Stroke, Bethesda, Md. (Hallett); FND Hope International, Banbury, United Kingdom (Mildon); the National Hospital for Neurology and Neurosurgery, University College London, and Hospitals National Health Service Foundation Trust, London (C. Nicholson); and the Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Perez)
| | - Glenn Nielsen
- The Institute of Psychiatry, Psychology and Neuroscience, King's College London (T. Nicholson, Goldstein, Pick); the Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom (Carson, Stone); the Department of Rehabilitation Medicine, Astley Ainslie Hospital, Edinburgh, United Kingdom (Carson); the Neuroscience Research Centre, St. George's University of London (Edwards, Nielsen); Human Motor Control Section, the National Institute of Neurological Disorders and Stroke, Bethesda, Md. (Hallett); FND Hope International, Banbury, United Kingdom (Mildon); the National Hospital for Neurology and Neurosurgery, University College London, and Hospitals National Health Service Foundation Trust, London (C. Nicholson); and the Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Perez)
| | - Clare Nicholson
- The Institute of Psychiatry, Psychology and Neuroscience, King's College London (T. Nicholson, Goldstein, Pick); the Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom (Carson, Stone); the Department of Rehabilitation Medicine, Astley Ainslie Hospital, Edinburgh, United Kingdom (Carson); the Neuroscience Research Centre, St. George's University of London (Edwards, Nielsen); Human Motor Control Section, the National Institute of Neurological Disorders and Stroke, Bethesda, Md. (Hallett); FND Hope International, Banbury, United Kingdom (Mildon); the National Hospital for Neurology and Neurosurgery, University College London, and Hospitals National Health Service Foundation Trust, London (C. Nicholson); and the Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Perez)
| | - David L Perez
- The Institute of Psychiatry, Psychology and Neuroscience, King's College London (T. Nicholson, Goldstein, Pick); the Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom (Carson, Stone); the Department of Rehabilitation Medicine, Astley Ainslie Hospital, Edinburgh, United Kingdom (Carson); the Neuroscience Research Centre, St. George's University of London (Edwards, Nielsen); Human Motor Control Section, the National Institute of Neurological Disorders and Stroke, Bethesda, Md. (Hallett); FND Hope International, Banbury, United Kingdom (Mildon); the National Hospital for Neurology and Neurosurgery, University College London, and Hospitals National Health Service Foundation Trust, London (C. Nicholson); and the Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Perez)
| | - Susannah Pick
- The Institute of Psychiatry, Psychology and Neuroscience, King's College London (T. Nicholson, Goldstein, Pick); the Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom (Carson, Stone); the Department of Rehabilitation Medicine, Astley Ainslie Hospital, Edinburgh, United Kingdom (Carson); the Neuroscience Research Centre, St. George's University of London (Edwards, Nielsen); Human Motor Control Section, the National Institute of Neurological Disorders and Stroke, Bethesda, Md. (Hallett); FND Hope International, Banbury, United Kingdom (Mildon); the National Hospital for Neurology and Neurosurgery, University College London, and Hospitals National Health Service Foundation Trust, London (C. Nicholson); and the Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Perez)
| | - Jon Stone
- The Institute of Psychiatry, Psychology and Neuroscience, King's College London (T. Nicholson, Goldstein, Pick); the Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom (Carson, Stone); the Department of Rehabilitation Medicine, Astley Ainslie Hospital, Edinburgh, United Kingdom (Carson); the Neuroscience Research Centre, St. George's University of London (Edwards, Nielsen); Human Motor Control Section, the National Institute of Neurological Disorders and Stroke, Bethesda, Md. (Hallett); FND Hope International, Banbury, United Kingdom (Mildon); the National Hospital for Neurology and Neurosurgery, University College London, and Hospitals National Health Service Foundation Trust, London (C. Nicholson); and the Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Perez)
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- The Institute of Psychiatry, Psychology and Neuroscience, King's College London (T. Nicholson, Goldstein, Pick); the Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom (Carson, Stone); the Department of Rehabilitation Medicine, Astley Ainslie Hospital, Edinburgh, United Kingdom (Carson); the Neuroscience Research Centre, St. George's University of London (Edwards, Nielsen); Human Motor Control Section, the National Institute of Neurological Disorders and Stroke, Bethesda, Md. (Hallett); FND Hope International, Banbury, United Kingdom (Mildon); the National Hospital for Neurology and Neurosurgery, University College London, and Hospitals National Health Service Foundation Trust, London (C. Nicholson); and the Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston (Perez)
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Maggio J, Alluri PR, Paredes-Echeverri S, Larson AG, Sojka P, Price BH, Aybek S, Perez DL. Briquet syndrome revisited: implications for functional neurological disorder. Brain Commun 2020; 2:fcaa156. [PMID: 33426523 PMCID: PMC7784044 DOI: 10.1093/braincomms/fcaa156] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 08/21/2020] [Accepted: 08/25/2020] [Indexed: 12/13/2022] Open
Abstract
With the creation of the Somatic Symptom and Related Disorders category of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition in 2013, the functional neurological (symptom) disorder diagnostic criteria underwent transformative changes. These included an emphasis on ‘rule-in’ physical examination signs/semiological features guiding diagnosis and the removal of a required proximal psychological stressor to be linked to symptoms. In addition, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition somatization disorder, somatoform pain disorder and undifferentiated somatoform disorder conditions were eliminated and collapsed into the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition somatic symptom disorder diagnosis. With somatic symptom disorder, emphasis was placed on a cognitive-behavioural (psychological) formulation as the basis for diagnosis in individuals reporting distressing bodily symptoms such as pain and/or fatigue; the need for bodily symptoms to be ‘medically unexplained’ was removed, and the overall utility of this diagnostic criteria remains debated. A consequence of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition restructuring is that the diagnosis of somatization disorder that encompassed individuals with functional neurological (sensorimotor) symptoms and prominent other bodily symptoms, including pain, was eliminated. This change negatively impacts clinical and research efforts because many patients with functional neurological disorder experience pain, supporting that the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition would benefit from an integrated diagnosis at this intersection. We seek to revisit this with modifications, particularly since pain (and a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition somatization disorder comorbidity, more specifically) is associated with poor clinical prognosis in functional neurological disorder. As a first step, we systematically reviewed the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition somatization disorder literature to detail epidemiologic, healthcare utilization, demographic, diagnostic, medical and psychiatric comorbidity, psychosocial, neurobiological and treatment data. Thereafter, we propose a preliminary revision to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition allowing for the specifier functional neurological disorder ‘with prominent pain’. To meet this criterion, core functional neurological symptoms (e.g. limb weakness, gait difficulties, seizures, non-dermatomal sensory loss and/or blindness) would have ‘rule-in’ signs and pain (>6 months) impairing social and/or occupational functioning would also be present. Two optional secondary specifiers assist in characterizing individuals with cognitive-behavioural (psychological) features recognized to amplify or perpetuate pain and documenting if there is a pain-related comorbidity. The specifier of ‘with prominent pain’ is etiologically neutral, while secondary specifiers provide additional clarification. We advocate for a similar approach to contextualize fatigue and mixed somatic symptoms in functional neurological disorder. While this preliminary proposal requires prospective data and additional discussion, these revisions offer the potential benefit to readily identify important functional neurological disorder subgroups—resulting in diagnostic, treatment and pathophysiology implications.
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Affiliation(s)
- Julie Maggio
- Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Priyanka R Alluri
- Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sara Paredes-Echeverri
- Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Anna G Larson
- Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Petr Sojka
- Department of Psychiatry, University Hospital Brno, Czech Republic
| | - Bruce H Price
- Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Selma Aybek
- Department of Neurology, Inselspital University Hospital Bern and Clinical Neurosciences Bern, Bern University, Switzerland
| | - David L Perez
- Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Tinazzi M, Morgante F, Marcuzzo E, Erro R, Barone P, Ceravolo R, Mazzucchi S, Pilotto A, Padovani A, Romito LM, Eleopra R, Zappia M, Nicoletti A, Dallocchio C, Arbasino C, Bono F, Pascarella A, Demartini B, Gambini O, Modugno N, Olivola E, Di Stefano V, Albanese A, Ferrazzano G, Tessitore A, Zibetti M, Calandra-Buonaura G, Petracca M, Esposito M, Pisani A, Manganotti P, Stocchi F, Coletti Moja M, Antonini A, Defazio G, Geroin C. Clinical Correlates of Functional Motor Disorders: An Italian Multicenter Study. Mov Disord Clin Pract 2020; 7:920-929. [PMID: 33163563 DOI: 10.1002/mdc3.13077] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 08/04/2020] [Indexed: 12/21/2022] Open
Abstract
Background Functional motor disorders (FMDs) are abnormal movements that are significantly altered by distractive maneuvers and are incongruent with movement disorders seen in typical neurological diseases. Objective The objectives of this article are to (1) describe the clinical manifestations of FMDs, including nonmotor symptoms and occurrence of other functional neurological disorders (FND); and (2) to report the frequency of isolated and combined FMDs and their relationship with demographic and clinical variables. Methods For this multicenter, observational study, we enrolled consecutive outpatients with a definite diagnosis of FMDs attending 25 tertiary movement disorders centers in Italy. Each patient underwent a detailed clinical evaluation with a definition of the phenotype and number of FMDs (isolated, combined) and an assessment of associated neurological and psychiatric symptoms. Results Of 410 FMDs (71% females; mean age, 47 ± 16.1 years) the most common phenotypes were weakness and tremor. People with FMDs had higher educational levels than the general population and frequent nonmotor symptoms, especially anxiety, fatigue, and pain. Almost half of the patients with FMDs had other FNDs, such as sensory symptoms, nonepileptic seizures, and visual symptoms. Patients with combined FMDs showed a higher burden of nonmotor symptoms and more frequent FNDs. Multivariate regression analysis showed that a diagnosis of combined FMDs was more likely to be delivered by a movement disorders neurologist. Also, FMD duration, pain, insomnia, diagnosis of somatoform disease, and treatment with antipsychotics were all significantly associated with combined FMDs. Conclusions Our findings highlight the need for multidimensional assessments in patients with FMDs given the high frequency of nonmotor symptoms and other FNDs, especially in patients with combined FMDs.
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Affiliation(s)
- Michele Tinazzi
- Neurology Unit, Movement Disorders Division, Department of Neurosciences Biomedicine and Movement Sciences University of Verona Verona Italy
| | - Francesca Morgante
- Neurosciences Research Centre, Molecular and Clinical Sciences Neurosciences Research Centre Molecular and Clinical Sciences Research Institute, St George's University of London London United Kingdom.,Department of Experimental and Clinical Medicine University of Messina Messina Italy
| | - Enrico Marcuzzo
- Neurology Unit, Movement Disorders Division, Department of Neurosciences Biomedicine and Movement Sciences University of Verona Verona Italy
| | - Roberto Erro
- Center for Neurodegenerative Diseases, Department of Medicine, Surgery and Dentistry-Scuola Medica Salernitana University of Salerno Baronissi Italy
| | - Paolo Barone
- Center for Neurodegenerative Diseases, Department of Medicine, Surgery and Dentistry-Scuola Medica Salernitana University of Salerno Baronissi Italy
| | - Roberto Ceravolo
- Neurology Unit, Department of Clinical and Experimental Medicine University of Pisa Pisa Italy
| | - Sonia Mazzucchi
- Neurology Unit, Department of Clinical and Experimental Medicine University of Pisa Pisa Italy
| | - Andrea Pilotto
- Department of Clinical and Experimental Sciences University of Brescia Brescia Italy.,FERB Onlus, Ospedale S. Isidoro, Trescore Balneario Bergamo Italy
| | - Alessandro Padovani
- Department of Clinical and Experimental Sciences University of Brescia Brescia Italy
| | - Luigi M Romito
- Parkinson and Movement Disorders Unit Fondazione IRCCS Istituto Neurologico Carlo Besta Milan Italy
| | - Roberto Eleopra
- Parkinson and Movement Disorders Unit Fondazione IRCCS Istituto Neurologico Carlo Besta Milan Italy
| | - Mario Zappia
- Department G.F. Ingrassia, Section of Neurosciences University of Catania Catania Italy
| | - Alessandra Nicoletti
- Department G.F. Ingrassia, Section of Neurosciences University of Catania Catania Italy
| | - Carlo Dallocchio
- Department of Medical Area Neurology Unit, ASST Pavia Pavia Italy
| | - Carla Arbasino
- Department of Medical Area Neurology Unit, ASST Pavia Pavia Italy
| | - Francesco Bono
- Botulinum Toxin Center Neurology Unit A.O.U. Mater Domini Catanzaro Italy
| | - Angelo Pascarella
- Botulinum Toxin Center Neurology Unit A.O.U. Mater Domini Catanzaro Italy
| | - Benedetta Demartini
- Aldo Ravelli Research Center for Neurotechnology and Experimental Brain Therapeutics, Department of Health Sciences University of Milan Milan Italy
| | - Orsola Gambini
- Aldo Ravelli Research Center for Neurotechnology and Experimental Brain Therapeutics, Department of Health Sciences University of Milan Milan Italy
| | | | | | - Vincenzo Di Stefano
- Department of Neuroscience, Imaging and Clinical Sciences University G. d'Annunzio Chieti-Pescara Italy
| | - Alberto Albanese
- Department of Neurology IRCCS Humanitas Research Hospital Rozzano Italy
| | - Gina Ferrazzano
- Department of Human Neurosciences Università La Sapienza Rome Italy
| | - Alessandro Tessitore
- Department of Advanced Medical and Surgery Sciences University of Campania - Luigi Vanvitelli Naples Italy
| | - Maurizio Zibetti
- Department of Neuroscience-Rita Levi Montalcini University of Turin Turin Italy
| | - Giovanna Calandra-Buonaura
- Department of Biomedical and Neuromotor Sciences University of Bologna Bologna Italy.,IRCCS, Institute of Neurological Sciences of Bologna Bologna Italy
| | - Martina Petracca
- Movement Disorder Unit Fondazione Policlinico Universitario A. Gemelli IRCCS Rome Italy
| | - Marcello Esposito
- Clinical Neurophysiology Unit Cardarelli Hospital Naples Italy.,Department of Neurosciences Reproductive and Odontostomatological Sciences, University of Naples-Federico II Naples Italy
| | - Antonio Pisani
- Department of Systems Medicine University of Rome Tor Vergata Rome Italy
| | - Paolo Manganotti
- Clinical Neurology Unit, Department of Medical Surgical and Health Services, University of Trieste Trieste Italy
| | - Fabrizio Stocchi
- University and Institute of Research and Medical Care San Raffaele Roma Rome Italy
| | | | - Angelo Antonini
- Movement Disorders Unit, Department of Neuroscience University of Padua Padua Italy
| | - Giovanni Defazio
- Department of Medical Sciences and Public Health University of Cagliari Cagliari Italy
| | - Christian Geroin
- Neurology Unit, Movement Disorders Division, Department of Neurosciences Biomedicine and Movement Sciences University of Verona Verona Italy
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Saxena A, Godena E, Maggio J, Perez DL. Towards an Outpatient Model of Care for Motor Functional Neurological Disorders: A Neuropsychiatric Perspective. Neuropsychiatr Dis Treat 2020; 16:2119-2134. [PMID: 32982250 PMCID: PMC7509337 DOI: 10.2147/ndt.s247119] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 08/26/2020] [Indexed: 12/17/2022] Open
Abstract
Functional neurological disorder (FND), a condition at the intersection of neurology and psychiatry, is a common and disabling outpatient referral to neurology and neuropsychiatry clinics. In this perspective article, we focus on the motor spectrum of FND (mFND), including individuals with functional movement disorders (FND-movt), functional limb weakness/paresis (FND-par) and functional [psychogenic non-epileptic/dissociative] seizures (FND-seiz). Over the past several decades, there have been dedicated efforts within the neurologic and psychiatric communities to create "rule-in" diagnostic criteria, as well as thoughtful approaches to the clinical interview, delivery of the diagnosis and the development of a patient-centered treatment plan. These advances allow the promotion of good clinical practices in the outpatient assessment and management of mFND. Informed by the literature and our prior clinical experiences, we provide suggestions on how to evaluate individuals with suspected functional motor symptoms - including conducting sensitive psychiatric and psychosocial screenings. Additional sections discuss common "rule-in" neurological examination and semiologic signs of motor FND, as well as approaches to deliver the diagnosis and formulate a treatment plan based on individual patient needs. To aid the development of shared (partially overlapping) expertise that catalyzes an interdisciplinary approach to mFND, the use of physiotherapy for therapeutic motor retraining and cognitive behavioral therapy to examine relationships between symptoms, thoughts, behaviors and emotions are also discussed. Additional clinical research is needed to further refine and operationalize the assessment and management of mFND, across clinics, healthcare settings and countries.
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Affiliation(s)
- Aneeta Saxena
- Functional Neurological Disorder Clinical and Research Program, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Epilepsy Division, Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Ellen Godena
- Functional Neurological Disorder Clinical and Research Program, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Julie Maggio
- Functional Neurological Disorder Clinical and Research Program, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Physical Therapy, Massachusetts General Hospital, Boston, MA, USA
| | - David L Perez
- Functional Neurological Disorder Clinical and Research Program, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Division of Neuropsychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Functional neurological disorders miming a stroke: management in the acute phase. Clin Neurol Neurosurg 2020; 196:105840. [DOI: 10.1016/j.clineuro.2020.105840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/31/2020] [Accepted: 04/06/2020] [Indexed: 11/18/2022]
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Ganslev CA, Storebø OJ, Callesen HE, Ruddy R, Søgaard U. Psychosocial interventions for conversion and dissociative disorders in adults. Cochrane Database Syst Rev 2020; 7:CD005331. [PMID: 32681745 PMCID: PMC7388313 DOI: 10.1002/14651858.cd005331.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Conversion and dissociative disorders are conditions where people experience unusual neurological symptoms or changes in awareness or identity. However, symptoms and clinical signs cannot be explained by a neurological disease or other medical condition. Instead, a psychological stressor or trauma is often present. The symptoms are real and can cause significant distress or problems with functioning in everyday life for the people experiencing them. OBJECTIVES To assess the beneficial and harmful effects of psychosocial interventions of conversion and dissociative disorders in adults. SEARCH METHODS We conducted database searches between 16 July and 16 August 2019. We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and eight other databases, together with reference checking, citation searching and contact with study authors to identify additional studies. SELECTION CRITERIA: We included all randomised controlled trials that compared psychosocial interventions for conversion and dissociative disorders with standard care, wait list or other interventions (pharmaceutical, somatic or psychosocial). DATA COLLECTION AND ANALYSIS: We selected, quality assessed and extracted data from the identified studies. Two review authors independently performed all tasks. We used standard Cochrane methodology. For continuous data, we calculated mean differences (MD) and standardised mean differences (SMD) with 95% confidence interval (CI). For dichotomous outcomes, we calculated risk ratio (RR) with 95% CI. We assessed and downgraded the evidence according to the GRADE system for risk of bias, imprecision, indirectness, inconsistency and publication bias. MAIN RESULTS We included 17 studies (16 with parallel-group designs and one with a cross-over design), with 894 participants aged 18 to 80 years (female:male ratio 3:1). The data were separated into 12 comparisons based on the different interventions and comparators. Studies were pooled into the same comparison when identical interventions and comparisons were evaluated. The certainty of the evidence was downgraded as a consequence of potential risk of bias, as many of the studies had unclear or inadequate allocation concealment. Further downgrading was performed due to imprecision, few participants and inconsistency. There were 12 comparisons for the primary outcome of reduction in physical signs. Inpatient paradoxical intention therapy compared with outpatient diazepam: inpatient paradoxical intention therapy did not reduce conversive symptoms compared with outpatient diazepam at the end of treatment (RR 1.44, 95% CI 0.91 to 2.28; 1 study, 30 participants; P = 0.12; very low-quality evidence). Inpatient treatment programme plus hypnosis compared with inpatient treatment programme: inpatient treatment programme plus hypnosis did not reduce severity of impairment compared with inpatient treatment programme at the end of treatment (MD -0.49 (negative value better), 95% CI -1.28 to 0.30; 1 study, 45 participants; P = 0.23; very low-quality evidence). Outpatient hypnosis compared with wait list: outpatient hypnosis might reduce severity of impairment compared with wait list at the end of treatment (MD 2.10 (higher value better), 95% CI 1.34 to 2.86; 1 study, 49 participants; P < 0.00001; low-quality evidence). Behavioural therapy plus routine clinical care compared with routine clinical care: behavioural therapy plus routine clinical care might reduce the number of weekly seizures compared with routine clinical care alone at the end of treatment (MD -21.40 (negative value better), 95% CI -27.88 to -14.92; 1 study, 18 participants; P < 0.00001; very low-quality evidence). Cognitive behavioural therapy (CBT) compared with standard medical care: CBT did not reduce monthly seizure frequency compared to standard medical care at end of treatment (RR 1.56, 95% CI 0.39 to 6.19; 1 study, 16 participants; P = 0.53; very low-quality evidence). CBT did not reduce physical signs compared to standard medical care at the end of treatment (MD -4.75 (negative value better), 95% CI -18.73 to 9.23; 1 study, 61 participants; P = 0.51; low-quality evidence). CBT did not reduce seizure freedom compared to standard medical care at end of treatment (RR 2.33, 95% CI 0.30 to 17.88; 1 trial, 16 participants; P = 0.41; very low-quality evidence). Psychoeducational follow-up programmes compared with treatment as usual (TAU): no study measured reduction in physical signs at end of treatment. Specialised CBT-based physiotherapy inpatient programme compared with wait list: no study measured reduction in physical signs at end of treatment. Specialised CBT-based physiotherapy outpatient intervention compared with TAU: no study measured reduction in physical signs at end of treatment. Brief psychotherapeutic intervention (psychodynamic interpersonal treatment approach) compared with standard care: brief psychotherapeutic interventions did not reduce conversion symptoms compared to standard care at end of treatment (RR 0.12, 95% CI 0.01 to 2.00; 1 study, 19 participants; P = 0.14; very low-quality evidence). CBT plus adjunctive physical activity (APA) compared with CBT alone: CBT plus APA did not reduce overall physical impacts compared to CBT alone at end of treatment (MD 5.60 (negative value better), 95% CI -15.48 to 26.68; 1 study, 21 participants; P = 0.60; very low-quality evidence). Hypnosis compared to diazepam: hypnosis did not reduce symptoms compared to diazepam at end of treatment (RR 0.69, 95% CI 0.39 to 1.24; 1 study, 40 participants; P = 0.22; very low-quality evidence). Outpatient motivational interviewing (MI) and mindfulness-based psychotherapy compared with psychotherapy alone: psychotherapy preceded by MI might decrease seizure frequency compared with psychotherapy alone at end of treatment (MD 41.40 (negative value better), 95% CI 4.92 to 77.88; 1 study, 54 participants; P = 0.03; very low-quality evidence). The effect on the secondary outcomes was reported in 16/17 studies. None of the studies reported results on adverse effects. In the studies reporting on level of functioning and quality of life at end of treatment the effects ranged from small to no effect. AUTHORS' CONCLUSIONS The results of the meta-analysis and reporting of single studies suggest there is lack of evidence regarding the effects of any psychosocial intervention on conversion and dissociative disorders in adults. It is not possible to draw any conclusions about potential benefits or harms from the included studies.
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Affiliation(s)
- Christina A Ganslev
- Clinic of Liaison Psychiatry, Region Zealand, Denmark
- Psychiatric Research Unit, Psychiatry of Region Zealand, Slagelse, Denmark
| | - Ole Jakob Storebø
- Psychiatric Research Unit, Psychiatry of Region Zealand, Slagelse, Denmark
- Child and Adolescent Psychiatric Department, Region Zealand, Roskilde, Denmark
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | | | | | - Ulf Søgaard
- Clinic of Liaison Psychiatry, Region Zealand, Denmark
- Psychiatric Research Unit, Psychiatry of Region Zealand, Slagelse, Denmark
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Stone J. Functional neurological disorder 2.0? Brain Commun 2020. [PMCID: PMC7756098 DOI: 10.1093/braincomms/fcaa217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
This scientific commentary refers to ‘Briquet syndrome revisited: implications for functional neurological disorder’, by Maggio et al. (https://doi.org/10.1093/braincomms/fcaa156)
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Affiliation(s)
- Jon Stone
- Centre for Clinical Brain Sciences, University of Edinburgh, EH16 4SB, UK
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Jones A, Smakowski A, O'Connell N, Chalder T, David AS. Functional stroke symptoms: A prospective observational case series. J Psychosom Res 2020; 132:109972. [PMID: 32126339 DOI: 10.1016/j.jpsychores.2020.109972] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 02/18/2020] [Accepted: 02/19/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Functional symptoms are a common mimic of stroke in acute stroke settings, but there are no guidelines on how to manage such patients and scant research on their clinical profile. We explore the presentation of patients with functional stroke symptoms at admission and 2-month follow-up. METHODS We conducted a prospective observational study across four SE London acute stroke units, with two-month follow-up. Demographic information, clinical data and GP attendances were recorded. Patients completed self-report measures: Cognitive Behavioural Responses Questionnaire short version, Brief Illness Perception Questionnaire, Hospital Anxiety and Depression Scale, Work and Social Adjustment Scale and Short Form Health Survey. RESULTS Fifty-six patients (mean age: 50.9 years) were recruited at baseline; 40 with isolated functional symptoms, the remaining functional symptoms in addition to stroke. Thirty-one completed self-report follow-up measures. Of 56 participants, 63% were female. Patients presented symptoms across modalities, with unilateral and limb weakness the most frequent. There was inconsistent and ambiguous recording of symptoms on medical records. Approximately 40% of patients reported levels of anxiety and depression above the threshold indicating a probable diagnosis. Higher anxiety was associated with greater resting or all-or-nothing behaviours, embarrassment avoidance and symptom focussing on the CBRQ. Only SF-36 physical functioning improved at follow-up. Less than 50% who responded at follow-up were accessing a treatment, though 82% had ongoing symptoms. CONCLUSION Patients with functional symptoms in stroke settings report substantial distress, associated with cognitive-behavioural responses to symptoms. Follow-up data suggest recovery can be slow, indicating access to supportive interventions should be improved.
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Affiliation(s)
- Abbeygail Jones
- Department of Psychological Medicine, King's College London, United Kingdom
| | - Abigail Smakowski
- Persitent Physical Symptoms Clinical Research and Treatment Unit, South London and Maudsley NHS Foundation Trust, United Kingdom
| | - Nicola O'Connell
- Department of Public Health and Primary Care, Institute of Population Health, Trinity College Dublin, Ireland
| | - Trudie Chalder
- Department of Psychological Medicine, King's College London, United Kingdom
| | - Anthony S David
- UCL Institute of Mental Health, University College London, United Kingdom.
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67
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Popkirov S, Stone J, Buchan AM. Functional Neurological Disorder: A Common and Treatable Stroke Mimic. Stroke 2020; 51:1629-1635. [PMID: 32295508 DOI: 10.1161/strokeaha.120.029076] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Stoyan Popkirov
- From the Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Germany (S.P.).,Wissenschaftskolleg zu Berlin-Institute for Advanced Study, Germany (S.P., A.M.B.)
| | - Jon Stone
- Centre for Clinical Brain Sciences, University of Edinburgh, Royal Infirmary of Edinburgh, United Kingdom (J.S.)
| | - Alastair M Buchan
- Wissenschaftskolleg zu Berlin-Institute for Advanced Study, Germany (S.P., A.M.B.).,Acute Stroke Programme, Radcliffe Department of Medicine, University of Oxford, United Kingdom (A.M.B.)
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68
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Gilmour GS, Nielsen G, Teodoro T, Yogarajah M, Coebergh JA, Dilley MD, Martino D, Edwards MJ. Management of functional neurological disorder. J Neurol 2020; 267:2164-2172. [PMID: 32193596 PMCID: PMC7320922 DOI: 10.1007/s00415-020-09772-w] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 02/19/2020] [Accepted: 02/20/2020] [Indexed: 01/24/2023]
Abstract
Functional neurological disorder (FND) is a common cause of persistent and disabling neurological symptoms. These symptoms are varied and include abnormal control of movement, episodes of altered awareness resembling epileptic seizures and abnormal sensation and are often comorbid with chronic pain, fatigue and cognitive symptoms. There is increasing evidence for the role of neurologists in both the assessment and management of FND. The aim of this review is to discuss strategies for the management of FND by focusing on the diagnostic discussion and general principles, as well as specific treatment strategies for various FND symptoms, highlighting the role of the neurologist and proposing a structure for an interdisciplinary FND service.
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Affiliation(s)
- Gabriela S Gilmour
- Department of Clinical Neurosciences, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Glenn Nielsen
- Neuroscience Research Centre, Institute of Molecular and Clinical Sciences, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Tiago Teodoro
- Neuroscience Research Centre, Institute of Molecular and Clinical Sciences, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK.,Faculdade de Medicina, Instituto de Medicina Molecular, Universidade de Lisboa, Hospital de Santa Maria, Lisbon, Portugal.,Atkinson Morley Regional Neuroscience Centre, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Mahinda Yogarajah
- Neuroscience Research Centre, Institute of Molecular and Clinical Sciences, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Jan Adriaan Coebergh
- Atkinson Morley Regional Neuroscience Centre, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Michael D Dilley
- Atkinson Morley Regional Neuroscience Centre, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Davide Martino
- Department of Clinical Neurosciences, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Mark J Edwards
- Neuroscience Research Centre, Institute of Molecular and Clinical Sciences, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK.
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69
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Van der Feltz-Cornelis CM, Allen SF, Van Eck van der Sluijs JF. Childhood sexual abuse predicts treatment outcome in conversion disorder/functional neurological disorder. An observational longitudinal study. Brain Behav 2020; 10:e01558. [PMID: 32031757 PMCID: PMC7066336 DOI: 10.1002/brb3.1558] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 12/19/2019] [Accepted: 01/14/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE Explore trauma, stress, and other predictive factors for treatment outcome in conversion disorder/functional neurological disorder (CD/FND). METHODS Prospective observational design. Clinical cohort study among consecutive outpatients with DSM-IV CD/FND in a specialized mental health institution for somatic symptom disorders and related disorders (SSRD), presented between 1 February 2010 and 31 December 2017. Patient files were assessed for early childhood trauma, childhood sexual abuse, current stress, and other predictive factors. Patient-related routine outcome monitoring (PROM) data were evaluated for treatment outcome at physical (Patient Health Questionnaire [PHQ15], Physical Symptoms Questionnaire [PSQ]) level as primary outcome, and depression (Patient Health Questionnaire [PHQ9]), anxiety (General Anxiety Disorder [GAD7]), general functioning (Short Form 36 Health Survey [SF36]), and pain (Brief Pain Inventory [BPI]) as secondary outcome. RESULTS A total of 64 outpatients were included in the study. 70.3% of the sample reported childhood trauma and 64.1% a recent life event. Mean scores of patients proceeding to treatment improved. Sexual abuse in childhood (F(1, 28) = 30.068, β = 0.608 p < .001) was significantly associated with worse physical (PHQ15, PSQ) treatment outcome. 42.2% reported comorbid depression, and this was significantly associated with worse concomitant depressive (PHQ9) (F[1, 39] = 11.526, β = 0.478, p = .002) and anxiety (GAD7) (F[1,34] = 7.950, β = 0.435, p = .008) outcome. CONCLUSION Childhood sexual abuse is significantly associated with poor treatment outcome in CD/FND. Randomized clinical trials evaluating treatment models addressing childhood sexual abuse in CD are needed.
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Affiliation(s)
- Christina M Van der Feltz-Cornelis
- Clinical Centre of Excellence for Body, Mind and Health, GGz Breburg, Tilburg, The Netherlands.,Tranzo Department, Tilburg University, Tilburg, The Netherlands.,Department of Health Sciences, HYMS, University of York, York, UK
| | - Sarah F Allen
- Department of Health Sciences, HYMS, University of York, York, UK
| | - Jonna F Van Eck van der Sluijs
- Clinical Centre of Excellence for Body, Mind and Health, GGz Breburg, Tilburg, The Netherlands.,Tranzo Department, Tilburg University, Tilburg, The Netherlands
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70
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O'Connell N, Nicholson TR, Wessely S, David AS. Characteristics of patients with motor functional neurological disorder in a large UK mental health service: a case-control study. Psychol Med 2020; 50:446-455. [PMID: 30773149 DOI: 10.1017/s0033291719000266] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Functional neurological disorder (FND), previously known as conversion disorder, is common and often results in substantial distress and disability. Previous research lacks large sample sizes and clinical surveys are most commonly derived from neurological settings, limiting our understanding of the disorder and its associations in other contexts. We sought to address this by analysing a large anonymised electronic psychiatric health record dataset. METHODS Data were obtained from 322 patients in the South London and Maudsley NHS Foundation Trust (SLaM) who had an ICD-10 diagnosis of motor FND (mFND) (limb weakness or disorders of movement or gait) between 1 January 2006 and 31 December 2016. Data were collected on a range of socio-demographic and clinical factors and compared to 644 psychiatric control patients from the same register. RESULTS Weakness was the most commonly occurring functional symptom. mFND patients were more likely to be female, British, married, employed pre-morbidly, to have a carer and a physical health condition, but less likely to have had an inpatient psychiatric admission or to receive benefits. No differences in self-reported sexual or physical abuse rates were observed between groups, although mFND patients were more likely to experience life events linked to inter-personal difficulties. CONCLUSIONS mFND patients have distinct demographic characteristics compared with psychiatric controls. Experiences of abuse appear to be equally prevalent across psychiatric patient groups. This study establishes the socio-demographic and life experience profile of this understudied patient group and may be used to guide future therapeutic interventions designed specifically for mFND.
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Affiliation(s)
- N O'Connell
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - T R Nicholson
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - S Wessely
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - A S David
- UCL Institute of Mental Health Studies, University College London, London, UK
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71
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O'Connell N, Jones A, Chalder T, David AS. Experiences and Illness Perceptions of Patients with Functional Symptoms Admitted to Hyperacute Stroke Wards: A Mixed-Method Study. Neuropsychiatr Dis Treat 2020; 16:1795-1805. [PMID: 32801714 PMCID: PMC7399446 DOI: 10.2147/ndt.s251328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 07/07/2020] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION A proportion of patients admitted to acute-stroke settings have not had a stroke, but have conditions mimicking a stroke. Approximately 25% of suspected stroke cases are "stroke mimics" and 2% are patients with functional symptoms - "functional stroke mimics". This study aimed to explore experiences and illness perceptions of patients with functional symptoms admitted to hyperacute stroke wards. METHODS This study used mixed methods. Patients with functional stroke symptoms participated in semistructured qualitative interviews immediately after admission to one of two acute-stroke units in London and again 2 months after hospital discharge. Qualitative data were assessed using thematic analysis. The Brief Illness Perception Questionnaire (Brief-IPQ) measured illness perceptions at admission and at 2-month follow-up. RESULTS A total of 36 participants completed baseline interviews and 25 completed follow-up. Six themes emerged: physical symptom experience, emotional and coping responses, symptom causes, hospital experiences, views on the future, and uncertainty after hospital discharge. Mean Brief-IPQ score at admission was 49.3 (SD: 9.9), indicating a moderate-high level of perceived illness threat. Participants presented with a range of functional symptoms. At baseline, participants were highly concerned about their symptoms, but this had decreased at 2-month follow-up. Two months later, many were confused as to the cause of their admission. CONCLUSION This is the first study to examine functional stroke patients' experiences of acute-stroke admission. At admission, patients expressed confusion regarding their diagnosis, experienced high levels of emotional distress, and were concerned they were perceived as time wasting by stroke clinicians. While most participants experienced symptom recovery, there was a significant subgroup for whom symptoms persisted or worsened. A lack of care guidelines on the management of functional stroke patients may perpetuate functional symptoms.
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Affiliation(s)
- Nicola O'Connell
- Department of Public Health and Primary Care, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Abbeygail Jones
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Trudie Chalder
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Anthony S David
- UCL Institute of Mental Health, University College London, London, UK
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72
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Gelauff JM, Rosmalen JGM, Gardien J, Stone J, Tijssen MAJ. Shared demographics and comorbidities in different functional motor disorders. Parkinsonism Relat Disord 2019; 70:1-6. [PMID: 31785442 DOI: 10.1016/j.parkreldis.2019.11.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Revised: 11/19/2019] [Accepted: 11/21/2019] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Functional motor disorders are often delineated according to the dominant motor symptom. In a large cohort, we aimed to find if there were differences in demographics, mode of onset, pain, fatigue, depression and anxiety and levels of physical functioning, quality of life and social adjustment between patients with different dominant motor symptoms. METHODS Baseline data from the Self-Help and Education on the Internet for Functional Motor Disorders Trial was used. Patients were divided into dominant motor symptom groups based on the diagnosis of the referring neurologist. Data on the above topics were collected by means of an online questionnaire and compared between groups using parametric and nonparametric statistics. RESULTS In 160 patients a dominant motor symptom could be determined, 31 had tremor, 45 myoclonus, 23 dystonia, 30 paresis, 31 gait disorder. No statistical differences between groups were detected for demographics, mode of onset and severity of pain, fatigue, depression and anxiety. Physical functioning was worse in the gait disorder group (median 20, IQR 25) compared to tremor (50 (55), p = 0.002) and myoclonus (50 (52), p = 0.001). Work and social adjustment was less impaired in the myoclonus group (median 20, IQR 18) compared to gait disorder (median 30, IQR18, p < 0.001) and paresis (28, IQR 10, p = 0.001). Self-report showed large overlap in motor symptoms. CONCLUSION No differences were detected between groups of functional motor symptoms, regarding demographics, mode of onset, depression, anxiety, pain and fatigue. The large overlap in symptoms contributes to the hypothesis of shared underlying mechanisms of functional motor disorders.
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Affiliation(s)
- J M Gelauff
- University of Groningen, University Medical Center Groningen, Department of Neurology, the Netherlands
| | - J G M Rosmalen
- University of Groningen, University Medical Center Groningen, Department of Psychiatry, the Netherlands; University of Groningen, University Medical Center Groningen, Department of Internal Medicine, the Netherlands
| | - J Gardien
- University of Groningen, University Medical Center Groningen, Department of Neurology, the Netherlands
| | - J Stone
- University of Edinburgh, Centre for Clinical Brain Sciences, Edinburgh, United Kingdom
| | - M A J Tijssen
- University of Groningen, University Medical Center Groningen, Department of Neurology, the Netherlands.
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73
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Kiselica AM, Rosen S, Benge JF. Functional neurological symptoms masquerading as Wernicke encephalopathy following bariatric surgery. Proc AMIA Symp 2019; 32:607-609. [PMID: 31656438 PMCID: PMC6794007 DOI: 10.1080/08998280.2019.1651149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 07/26/2019] [Accepted: 07/30/2019] [Indexed: 10/26/2022] Open
Abstract
Wernicke encephalopathy (WE), caused by thiamine deficiency, is classically associated with alcoholism but is increasingly recognized among patients who have undergone bariatric surgery. As with other neurocognitive conditions, alternative explanations for symptoms, such as psychiatric, neurological, and motivational factors, must be considered before arriving at a diagnosis of WE. We present a patient after sleeve gastrectomy who was presumed to have WE; after detailed neuropsychological assessment, the condition was better conceptualized as a conversion disorder. The case illustrates the heretofore unrecognized role of bariatric surgery in the development of functional symptoms and demonstrates the importance of neuropsychological assessment in detecting functional symptoms.
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Affiliation(s)
| | - Sabra Rosen
- Division of Neuropsychology, Baylor Scott & White HealthTempleTexas
| | - Jared F. Benge
- Division of Neuropsychology, Baylor Scott & White HealthTempleTexas
- Plummer Movement Disorders CenterTempleTexas
- Texas A&M College of MedicineBryanTexas
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74
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Survey of the perceptions of health practitioners regarding Functional Neurological Disorders in Australia. J Clin Neurosci 2019; 67:114-123. [DOI: 10.1016/j.jocn.2019.06.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 05/25/2019] [Accepted: 06/09/2019] [Indexed: 11/20/2022]
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75
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Functional Neurological Disorder Responds Favorably to Interdisciplinary Rehabilitation Models. PSYCHOSOMATICS 2019; 60:556-562. [PMID: 31399207 DOI: 10.1016/j.psym.2019.07.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 06/28/2019] [Accepted: 07/01/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND Functional neurological disorder (FND) is difficult to treat and costly. Interdisciplinary chronic pain rehabilitation programs (iCPRPs) are multidimensional functional restoration interventions for pain; their impact on FND specifically has not been assessed. OBJECTIVE The purpose of this study was to assess iCPRP's impact on functioning in FND. METHODS Data were examined retrospectively from an Institutional Review Board-approved registry capturing admission and discharge data from patients participating in an outpatient iCPRP. Subjective measures included pain-related disability, depression, anxiety, and stress scores, whereas objective measures included physical functioning measures (timed up and go, stair climbing test, and 6-min walk test). Pre-iCPRP and post-iCPRP measures were compared using a paired t-test approach. RESULTS Forty-nine FND patients completed care and showed pre-measures and postmeasures. Statistically significant reductions in subjective measures of pain-related disability (46.40-20.91; P < 0.001, d = 1.92), depression (20.38-4.81; P < 0.001, d = 1.53), anxiety (15.09-6.29; P < 0.001, d = 1.18), and stress (21.96-9.70; P < 0.001, d = 1.21) scores were observed. Statistically significant changes in objective measures of mean timed up and go scores (decreased from 15.96 to 8.87 s), stair climbing test scores (increased from 40.98 to 71.93 steps), and mean 6-minute walk test scores (increased from 0.21 to 0.30 miles) were also observed across the group. CONCLUSIONS While preliminary and based on a small patient sample, these findings support the use of interdisciplinary care models for FND treatment. Clinical and investigational implications are explored.
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76
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Personality and Psychopathology in Patients With Mixed Sensory-Motor Functional Neurological Disorder (Conversion Disorder): A Pilot Study. J Nerv Ment Dis 2019; 207:546-554. [PMID: 31206424 DOI: 10.1097/nmd.0000000000001015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The purpose of this pilot study was to explore differences in the level of personality functioning, symptom severity, and personality pathology in patients with mixed sensory-motor functional neurological disorder (conversion disorder). Individuals with psychogenic nonepileptic seizures were not included. We recruited 15 patients, mean age of 33.5 years (SD, 11.4 years), 13 females and 2 males, from an outpatient clinic for psychotherapeutic treatment. We assessed the patients using the Structured Clinical Interview for DSM-4 Axis II Personality Disorders, the SCL-90-R, the Karolinska Psychodynamic Profile, and the Defense Style Questionnaire. We were able to distinguish two levels of difficulty in relation to personality functioning as distinct subgroups: 1) "neurotic" with less severe or moderate personality psychopathology and 2) "borderline" with severe personality psychopathology. Furthermore, we concluded that all patients showed severe deficits in personality functioning. The study points out the clinical relevance of identifying personality functioning as part of an assessment in the preparation of a treatment strategy.
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77
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Keynejad RC, Frodl T, Kanaan R, Pariante C, Reuber M, Nicholson TR. Stress and functional neurological disorders: mechanistic insights. J Neurol Neurosurg Psychiatry 2019; 90:813-821. [PMID: 30409887 DOI: 10.1136/jnnp-2018-318297] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 10/11/2018] [Accepted: 10/11/2018] [Indexed: 11/04/2022]
Abstract
At the interface between mind and body, psychiatry and neurology, functional neurological disorder (FND) remains poorly understood. Formerly dominant stress-related aetiological models have been increasingly challenged, in part due to cases without any history of past or recent trauma. In this perspective article, we review current evidence for such models, and how research into the role of traumatic stress in other disorders and the neurobiology of the stress response can inform our mechanistic understanding of FND. First, we discuss the association between stress and the onset or exacerbation of a variety of physical and mental health problems. Second, we review the role of hypothalamic-pituitary-adrenal axis dysfunction in the neurobiology of ill-health, alongside evidence for similar mechanisms in FND. Third, we advocate a stress-diathesis model, in which biological susceptibility interacts with early life adversity, where FND can be precipitated by traumatic events later in life and maintained by psychological responses. We hypothesise that greater biological susceptibility to FND is associated with less severe remote and recent stress, and that FND precipitated by more severe stress is associated with lower biological vulnerability. This would explain clinical experience of variable exposure to historical and recent traumatic stress among people with FND and requires empirical investigation. A testable, evidence-based stress-diathesis model can inform nuanced understanding of how biological and psychological factors interact at the individual level, with potential to inform personalised treatment pathways. Much-needed research to establish the aetiology of FND will enhance clinical care and communication, facilitate effective treatment and inform prevention strategies.
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Affiliation(s)
- Roxanne C Keynejad
- Section of Women's Mental Health, Health Service and Population Research Department, Institute of Psychiatry Psychology & Neuroscience, King's College London, London, UK
| | - Thomas Frodl
- Department and Hospital of Psychiatry and Psychotherapy, Otto von Guericke University Magdeburg, Magdeburg, Germany
| | - Richard Kanaan
- Section of Cognitive Neuropsychiatry, Institute of Psychiatry Psychology & Neuroscience, King's College London, UK, London.,Department of Psychiatry, University of Melbourne, Austin Health, Austin, Heidelberg, Australia.,Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria, Australia
| | - Carmine Pariante
- Stress Psychiatry and Immunology Lab, Institute of Psychiatry Psychology & Neuroscience, King's College London, London, UK
| | - Markus Reuber
- Academic Neurology Unit, University of Sheffield, Royal Hallamshire Hospital, Sheffield, UK
| | - Timothy R Nicholson
- Section of Cognitive Neuropsychiatry, Institute of Psychiatry Psychology & Neuroscience, King's College London, London, UK
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78
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Gelauff JM, Carson A, Ludwig L, Tijssen MAJ, Stone J. The prognosis of functional limb weakness: a 14-year case-control study. Brain 2019; 142:2137-2148. [DOI: 10.1093/brain/awz138] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 02/28/2019] [Accepted: 03/27/2019] [Indexed: 11/14/2022] Open
Abstract
Abstract
Reliable data on the prognosis of functional motor disorder are scarce, as existing studies of the prognosis of functional motor disorder are nearly all retrospective, small and uncontrolled. In this study we used a prospectively recruited, controlled cohort design to assess misdiagnosis, mortality and symptomatic and health outcome in patients with functional limb weakness compared to neurological disease and healthy control subjects. We also carried out an exploratory analysis for baseline factors predicting outcome. One hundred and seven patients with functional limb weakness, 46 neurological and 38 healthy control subjects from our previously studied prospective cohort were traced for follow-up after an average of 14 years. Misdiagnosis was determined in a consensus meeting using information from records, patients and their GPs. Numbers and causes of death were collected via death certificates. Outcome of limb weakness, physical and psychiatric symptoms, disability/quality of life and illness perception were recorded with self-rated questionnaires. Outcome measures were compared within and between groups. Seventy-six patients (71%) with functional limb weakness, 31 (67%) neurological and 23 (61%) healthy controls were included in follow-up. Misdiagnosis was found in one patient in the functional limb weakness group (1%) and in one neurological control (2%). Eleven patients with functional limb weakness, eight neurological control subjects and one healthy control subject had died. Weakness had completely remitted in 20% of patients in the functional limb weakness group and in 18% of the neurological controls (P = 0.785) and improved in a larger proportion of functional limb weakness patients (P = 0.011). Outcomes were comparable between patient groups, and worse than the healthy control group. No baseline factors were independent predictors of outcome, although somatization disorder, general health, pain and total symptoms at baseline were univariably correlated to outcome. This study is the largest and longest follow-up study of functional limb weakness. Misdiagnosis in functional limb weakness is rare after long-term follow-up. The disorder is associated with a higher mortality rate than expected, and symptoms are persistent and disabling. It appears difficult to predict outcome based on common baseline variables. These data should help inform clinicians to provide a more realistic outlook of the outcome and emphasize the importance of active and targeted therapy.
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Affiliation(s)
- Jeannette M Gelauff
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellors Building, Edinburgh, UK
- University Medical Centre Groningen, University of Groningen, Department of Neurology, Hanzeplein 1, RB, The Netherlands
| | - Alan Carson
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellors Building, Edinburgh, UK
| | - Lea Ludwig
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellors Building, Edinburgh, UK
| | - Marina A J Tijssen
- University Medical Centre Groningen, University of Groningen, Department of Neurology, Hanzeplein 1, RB, The Netherlands
| | - Jon Stone
- Centre for Clinical Brain Sciences, University of Edinburgh, Chancellors Building, Edinburgh, UK
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79
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Hanzlíková Z, Kofler M, Slovák M, Věchetová G, Fečíková A, Kemlink D, Sieger T, Růžička E, Valls‐Solé J, Edwards MJ, Serranová T. Prepulse inhibition of the blink reflex is abnormal in functional movement disorders. Mov Disord 2019; 34:1022-1030. [DOI: 10.1002/mds.27706] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 04/03/2019] [Accepted: 04/07/2019] [Indexed: 01/28/2023] Open
Affiliation(s)
- Zuzana Hanzlíková
- Department of Neurology and Center of Clinical NeuroscienceCharles University in Prague, 1st Faculty of Medicine and General University Hospital Prague Czech Republic
| | - Markus Kofler
- Department of NeurologyHochzirl Hospital Hochzirl Austria
| | - Matěj Slovák
- Department of Neurology and Center of Clinical NeuroscienceCharles University in Prague, 1st Faculty of Medicine and General University Hospital Prague Czech Republic
| | - Gabriela Věchetová
- Department of Neurology and Center of Clinical NeuroscienceCharles University in Prague, 1st Faculty of Medicine and General University Hospital Prague Czech Republic
| | - Anna Fečíková
- Department of Neurology and Center of Clinical NeuroscienceCharles University in Prague, 1st Faculty of Medicine and General University Hospital Prague Czech Republic
| | - David Kemlink
- Department of Neurology and Center of Clinical NeuroscienceCharles University in Prague, 1st Faculty of Medicine and General University Hospital Prague Czech Republic
| | - Tomáš Sieger
- Department of Neurology and Center of Clinical NeuroscienceCharles University in Prague, 1st Faculty of Medicine and General University Hospital Prague Czech Republic
- Department of Cybernetics, Faculty of Electrical EngineeringCzech Technical University in Prague Prague Czech Republic
| | - Evžen Růžička
- Department of Neurology and Center of Clinical NeuroscienceCharles University in Prague, 1st Faculty of Medicine and General University Hospital Prague Czech Republic
| | - Josep Valls‐Solé
- Neurology Service, Hospital Clíınic, Facultad de MedicinaUniversitat de Barcelona Barcelona Spain
| | - Mark J. Edwards
- Neuroscience Research Centre, Institute of Molecular and Clinical SciencesSt George's University of London London United Kingdom
| | - Tereza Serranová
- Department of Neurology and Center of Clinical NeuroscienceCharles University in Prague, 1st Faculty of Medicine and General University Hospital Prague Czech Republic
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Barnett C, Armes J, Smith C. Speech, language and swallowing impairments in functional neurological disorder: a scoping review. INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS 2019; 54:309-320. [PMID: 30592118 DOI: 10.1111/1460-6984.12448] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 11/27/2018] [Accepted: 12/04/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND Functional neurological disorder (FND) is common across healthcare settings. The Diagnostic and Statistical Manual of Mental Disorders states that speech and swallowing symptoms can be present in FND. Despite this, there is a dearth of guidelines for speech and language therapists (SLTs) for this client group. AIMS To address the following question in order to identify gaps for further research: What is known about speech, language and swallowing symptoms in patients with FND? METHODS & PROCEDURES A scoping review was conducted. Six healthcare databases were searched for relevant literature: CINAHL PLUS, MEDLINE, ProQuest Nursing and Allied Health Professionals, Science Citation Index, Scopus, and PsychINFO. The following symptoms were excluded from the review: dysphonia, globus pharyngeus, dysfluency, foreign accent syndrome and oesophageal dysphagia. MAIN CONTRIBUTION A total of 63 papers were included in the final review; they ranged in date from 1953 to 2018. Case studies were the most frequent research method (n = 23, 37%). 'Psychogenic' was the term used most frequently (n = 24, 38%), followed by 'functional' (n = 21, 33%). Speech symptoms were reported most frequently (n = 41, 65%), followed by language impairments (n = 35, 56%) and dysphagia (n = 13, 21%). Only 11 publications comment on the involvement of SLTs. Eight papers report direct speech and language therapy input; however, none studied the effectiveness of speech and language therapy. CONCLUSIONS & IMPLICATIONS Speech, language and swallowing symptoms do occur in patients with FND, yet it is a highly under-researched area. Further research is required to create a set of positive diagnostic criteria, gather accurate data on numbers of patients with FND and speech, language or swallowing symptoms, and to evaluate the effectiveness of direct speech and language therapy involvement.
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Affiliation(s)
- Caroline Barnett
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jean Armes
- Birmingham Community Healthcare NHS Trust, Birmingham, UK
| | - Christina Smith
- Department of Language and Cognition, University College London, London, UK
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81
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O'Connell N, Nicholson T, Blackman G, Tavener J, David AS. Medication prescriptions in 322 motor functional neurological disorder patients in a large UK mental health service: A case control study. Gen Hosp Psychiatry 2019; 58:94-102. [PMID: 31031213 DOI: 10.1016/j.genhosppsych.2019.04.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/01/2019] [Accepted: 04/02/2019] [Indexed: 01/26/2023]
Abstract
OBJECTIVE This study describes medication prescribing patterns in patients with motor functional neurological disorder (mFND) treated in South London and Maudsley NHS Foundation Trust (SLaM), comparing outcomes to a control group of psychiatric patients from the same hospital trust. METHOD This is a retrospective case-control study using a psychiatric case register. Cross-sectional data were obtained from 322 mFND patients and 644 psychiatry controls who had had contact with SLaM between 1st January 2006 and 31st December 2016. RESULTS A slightly lower proportion of mFND patients received medication compared to controls (76.6% v. 83.4%, OR: 0.59, CI: 0.39-0.89, p < 0.05). Of medication recipients, mFND patients were prescribed a higher number of agents (mean: 4.7 v 2.9, p = 0.001) and had higher prescription rates of antidepressants, anti-epileptics, analgesics, and certain non-psychotropic medications. Higher numbers of prescriptions were associated with co-morbid physical conditions, and previous psychiatric admissions. CONCLUSIONS This is the first study to describe medication prescriptions in a large cohort of mFND patients. Patients were prescribed a wide range of psychiatric and physical health medications, with higher rates of polypharmacy than controls. Psychotropic medication prescription is not necessarily the first line treatment for mFND, where physiotherapy and psychotherapy may be offered initially. There is limited, early-phase evidence for pharmacological therapies for mFND, and as such, the benefit-to-risk ratio of prescribing in this complex and poorly understood disorder should be carefully assessed.
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Affiliation(s)
- Nicola O'Connell
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 DeCrespigny Park, London SE5 8AF, United Kingdom. nicola.k.o'
| | - Timothy Nicholson
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 DeCrespigny Park, London SE5 8AF, United Kingdom.
| | - Graham Blackman
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 DeCrespigny Park, London SE5 8AF, United Kingdom.
| | - Jennifer Tavener
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 DeCrespigny Park, London SE5 8AF, United Kingdom.
| | - Anthony S David
- Institute of Mental Health, UCL Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London W1T 7BN, United Kingdom.
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Popkirov S, Hoeritzauer I, Colvin L, Carson AJ, Stone J. Complex regional pain syndrome and functional neurological disorders - time for reconciliation. J Neurol Neurosurg Psychiatry 2019; 90:608-614. [PMID: 30355604 DOI: 10.1136/jnnp-2018-318298] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 09/27/2018] [Accepted: 09/28/2018] [Indexed: 12/17/2022]
Abstract
There have been many articles highlighting differences and similarities between complex regional pain syndrome (CRPS) and functional neurological disorders (FND) but until now the discussions have often been adversarial with an erroneous focus on malingering and a view of FND as 'all in the mind'. However, understanding of the nature, frequency and treatment of FND has changed dramatically in the last 10-15 years. FND is no longer assumed to be only the result of 'conversion' of psychological conflict but is understood as a complex interplay between physiological stimulus, expectation, learning and attention mediated through a Bayesian framework, with biopsychosocial predisposing, triggering and perpetuating inputs. Building on this new 'whole brain' perspective of FND, we reframe the debate about the 'psychological versus physical' basis of CRPS. We recognise how CRPS research may inform mechanistic understanding of FND and conversely, how advances in FND, especially treatment, have implications for improving understanding and management of CRPS.
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Affiliation(s)
- Stoyan Popkirov
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Ingrid Hoeritzauer
- Centre for Clinical Brain Sciences, Western General Hospital, NHS Lothian and University of Edinburgh, Edinburgh, UK
| | - Lesley Colvin
- Division of Population Health Sciences and Genomics, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Alan J Carson
- Centre for Clinical Brain Sciences, Western General Hospital, NHS Lothian and University of Edinburgh, Edinburgh, UK
| | - Jon Stone
- Centre for Clinical Brain Sciences, Western General Hospital, NHS Lothian and University of Edinburgh, Edinburgh, UK
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Structural alterations in functional neurological disorder and related conditions: a software and hardware problem? NEUROIMAGE-CLINICAL 2019; 22:101798. [PMID: 31146322 PMCID: PMC6484222 DOI: 10.1016/j.nicl.2019.101798] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/20/2019] [Accepted: 03/26/2019] [Indexed: 01/01/2023]
Abstract
Functional neurological (conversion) disorder (FND) is a condition at the interface of neurology and psychiatry. A “software” vs. “hardware” analogy describes abnormal neurobiological mechanisms occurring in the context of intact macroscopic brain structure. While useful for explanatory and treatment models, this framework may require more nuanced considerations in the context of quantitative structural neuroimaging findings in FND. Moreover, high co-occurrence of FND and somatic symptom disorders (SSD) as defined in DSM-IV (somatization disorder, somatoform pain disorder, and undifferentiated somatoform disorder; referred to as SSD for brevity in this article) raises the possibility of a partially overlapping pathophysiology. In this systematic review, we use a transdiagnostic approach to review and appraise the structural neuroimaging literature in FND and SSD. While larger sample size studies are needed for definitive characterization, this article highlights that individuals with FND and SSD may exhibit sensorimotor, prefrontal, striatal-thalamic, paralimbic, and limbic structural alterations. The structural neuroimaging literature is contextualized within the neurobiology of stress-related neuroplasticity, gender differences, psychiatric comorbidities, and the greater spectrum of functional somatic disorders. Future directions that could accelerate the characterization of the pathophysiology of FND and DSM-5 SSD are outlined, including “disease staging” discussions to contextualize subgroups with or without structural changes. Emerging neuroimaging evidence suggests that some individuals with FND and SSD may have a “software” and “hardware” problem, although if structural alterations are present the neural mechanisms of functional disorders remain distinct from lesional neurological conditions. Furthermore, it remains unclear whether structural alterations relate to predisposing vulnerabilities or consequences of the disorder. Transdiagnostic systematic review of structural MRI studies in FND and SSD Sensorimotor-striatothalamic-limbic-paralimbic circuits implicated in both conditions. Some small sample size FND studies did not show group-level structural alterations. MRI alterations may relate to risk factors, compensatory changes or disease mechanisms. Early-phase discussion on disease-staging algorithms outlined as a future direction.
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84
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Nielsen G, Buszewicz M, Edwards MJ, Stevenson F. A qualitative study of the experiences and perceptions of patients with functional motor disorder. Disabil Rehabil 2019; 42:2043-2048. [DOI: 10.1080/09638288.2018.1550685] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Glenn Nielsen
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London, UK
- Motor Control and Movement Disorders Group, Institute of Molecular and Clinical Sciences, St Georges University of London, London, UK
| | - Marta Buszewicz
- Research Department of Primary Care and Population Health, UCL, London, UK
| | - Mark J. Edwards
- Motor Control and Movement Disorders Group, Institute of Molecular and Clinical Sciences, St Georges University of London, London, UK
| | - Fiona Stevenson
- Research Department of Primary Care and Population Health, UCL, London, UK
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85
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Serranová T, Slovák M, Kemlink D, Šonka K, Hallett M, Růžička E. Prevalence of restless legs syndrome in functional movement disorders: a case-control study from the Czech Republic. BMJ Open 2019; 9:e024236. [PMID: 30670516 PMCID: PMC6347872 DOI: 10.1136/bmjopen-2018-024236] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES The prevalence of restless legs syndrome (RLS) in functional movement disorders (FMD) is not known. Patients with FMD often present with multiple motor and sensory symptoms. Some of these symptoms might be due to comorbid RLS. Therefore, our objective was to evaluate possible association between FMD and RLS. DESIGN Case-control study. SETTING Movement Disorders Center, 1st Faculty of Medicine and General University Hospital in Prague, Czech Republic. PARTICIPANTS 96 consecutive patients with clinically established FMD (80 females, mean age (SD) 45.0 (13) years), and 76 matched controls. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome measure was prevalence of RLS based on updated International RLS Study Group criteria. Secondary outcome measures included prevalence of periodic limb movements (PLM) using actigraphy; pain, motor and sensory symptoms in lower limbs; organic comorbidities and medication affecting RLS. RESULTS RLS criteria were fulfilled in 43.8% of patients (95% CI 34 to 54) and in 7.9% of controls (95% CI 3 to 17, p<0.00001). Both RLS and PLM indices (PLMi) ≥22.5/hour were found in 21.2% of patients with FMD and 2.6% of controls. Patients with FMD with RLS had a higher mean PLMi (p<0.001) and a higher proportion of PLMi ≥22.5/hour (p<0.01) than RLS-negative patients. Patients with RLS had higher prevalence of pain and sensory symptoms in lower limbs, no difference was found in medication and prevalence of organic comorbidities in patients with FMD with and without RLS. CONCLUSIONS We found an increased prevalence of RLS in patients with FMD. Clinical diagnosis of RLS was supported by actigraphic measurement of clinically relevant PLM in a significant proportion of patients with FMD. Although functional motor and sensory symptoms may mimic RLS, RLS may be unrecognised in patients with FMD. This finding may have clinical implications in management of FMD, and it raises the possibility of common pathophysiological mechanisms of FMD and RLS/PLM.
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Affiliation(s)
- Tereza Serranová
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, 1st Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic
| | - Matěj Slovák
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, 1st Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic
| | - David Kemlink
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, 1st Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic
| | - Karel Šonka
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, 1st Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic
| | - Mark Hallett
- Human Motor Control Section, Medical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Evžen Růžička
- Department of Neurology and Center of Clinical Neuroscience, Charles University in Prague, 1st Faculty of Medicine and General University Hospital in Prague, Prague, Czech Republic
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Gendre T, Carle G, Mesrati F, Hubsch C, Mauras T, Roze E, Houot M, Degos B, Garcin B. Quality of life in functional movement disorders is as altered as in organic movement disorders. J Psychosom Res 2019; 116:10-16. [PMID: 30654984 DOI: 10.1016/j.jpsychores.2018.11.006] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 10/15/2018] [Accepted: 11/10/2018] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Patients with functional movement disorders (FMD) often report a disability and psychiatric comorbidities. However, few studies have compared these aspects in FMD and in organic movement disorders (OMD). The objectives were to compare QoL and psychiatric comorbidities of FMD and OMD patients. METHODS Twenty-one and 30 FMD patients were compared to 21 and 30 sex- and age-matched dystonia and Parkinson patients respectively. QoL was assessed using the Parkinson's Disease Summary Index (PDSI). Psychiatric comorbidities were screened with the Mini International Neuropsychiatric Interview, the Hospital Anxiety and Depression Scale and the Composite International Diagnostic Interview questionnaire. RESULTS QoL was more altered in FMD than in dystonia on PDSI (42.1 vs 25.1; p = .003). No significant difference was observed in QoL in FMD and Parkinson's disease on PDSI (38.3 vs 32.2; p = .61). Moreover, FMD patients were more often unemployed because of their condition than dystonia (61.9% vs 14.3%; p = .01) and Parkinson patients (53.3% vs 13.3%; p = .005). The occurrence of anxiety (p = .58 and > 0.99), depression (p = .77 and 0.77), and traumatic events (p = .58 and 0.75) was not different between groups. FMD patients reported more often sexual abuse than dystonia (28,6% vs 4.8%; p = .13) and Parkinson patients (23.3% vs 0.0%; p = .02). CONCLUSION FMD patients presented a significant alteration of QoL and no increased psychiatric comorbidities compared to OMD patients. These results highlight the impact of FMD and suggest that neurologists should be as involved in the management of FMD as they are in OMD.
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Affiliation(s)
- Thierry Gendre
- Department of Neurology, Henri Mondor University Hospital, AP-HP, Créteil, France; Department of Neurology, Movement Disorders Unit, Pitié-Salpêtrière University Hospital, AP-HP, Paris, France.
| | - Guilhem Carle
- Department of Neurology, Movement Disorders Unit, Pitié-Salpêtrière University Hospital, AP-HP, Paris, France; Brain and Spine Institute, UPMC UMRS 1127, INSERM U1127, CNRS UMR 7225, Paris, France
| | - Francine Mesrati
- Department of Neurophysiology, Pitié-Salpêtrière University Hospital, AP-HP, Paris, France
| | - Cécile Hubsch
- Department of Neurology, Movement Disorders Unit, Pitié-Salpêtrière University Hospital, AP-HP, Paris, France
| | - Thomas Mauras
- Department of Neurology, Movement Disorders Unit, Pitié-Salpêtrière University Hospital, AP-HP, Paris, France
| | - Emmanuel Roze
- Department of Neurology, Movement Disorders Unit, Pitié-Salpêtrière University Hospital, AP-HP, Paris, France; Brain and Spine Institute, UPMC UMRS 1127, INSERM U1127, CNRS UMR 7225, Paris, France
| | - Marion Houot
- Sorbonne University, GRC n°21, Alzheimer Precision Medicine (APM), Pitié-Salpêtrière University Hospital, AP-HP, Paris, France
| | - Bertrand Degos
- Centre for Interdisciplinary Research in Biology, Collège de France, INSERM U1050, CNRS UMR7241, Labex Memolife, Paris Sciences et Lettres, Paris, France; Department of Neurology, Avicenne University Hospital, Paris - Seine Saint-Denis University Hospitals, Bobigny, France
| | - Béatrice Garcin
- Brain and Spine Institute, UPMC UMRS 1127, INSERM U1127, CNRS UMR 7225, Paris, France; Department of Neurology, Avicenne University Hospital, Paris - Seine Saint-Denis University Hospitals, Bobigny, France
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87
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Aboud O, Al-Salaimeh A, Kumar Raina S, Sahaya K, Hinduja A. Positive clinical signs in neurological diseases - An observational study. J Clin Neurosci 2018; 59:141-145. [PMID: 30467051 DOI: 10.1016/j.jocn.2018.10.113] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 10/27/2018] [Indexed: 11/26/2022]
Abstract
Many patients with organic neurological disease have symptoms and signs that are unexplained by their disease condition. We attempted to explore the prevalence of positive clinical signs in patients with various organic neurological diseases. We performed a prospective uncontrolled observational study on the presence of 7 positive signs in adults with various organic neurological diseases that were admitted to our tertiary care hospital. This observation was performed during their neurological examination in those who provided consent, could comprehend and lacked terminal illness or profound weakness that limited their ability to perform these tasks. We dichotomized them into two groups based on the presence of these signs. Out of 190 patients that were evaluated between 2014 and 2015, 37 patients had at least one positive sign. On univariate analysis: young age, female gender, prior anxiety, history of childhood abuse, identification of sensory deficits on examination and lack of imaging correlation with clinical localization were identified as risk factors for these positive signs. On multivariate analysis, anxiety (OR 2.88, 95% CI 1.11-7.49, p = 0.03) and presence of sensory deficits on examination (OR 5.81, 95% CI 2.36-14.32, p ≤ 0.001) were associated with these positive signs. Positive signs are common in patients with organic neurological diseases that have anxiety or sensory deficits and may imply a component of functional overlay. Large studies are required to understand its pathophysiology and impact on future outcomes.
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Affiliation(s)
- Orwa Aboud
- Department of Neuro-Oncology Branch, National Institutes of Health, Bethesda, MD, USA; Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Sunil Kumar Raina
- Department of Community Medicine, Dr RP Government Medical College, Tanda, India
| | - Kinshuk Sahaya
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Archana Hinduja
- Department of Neurology, Ohio State University Wexner Medical Center, Columbus, OH, USA.
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Williams B, Botero JPO, Jalilianhasanpour R, Fricchione GL, Perez DL. Fearful Attachment Linked to Childhood Abuse, Alexithymia, and Depression in Motor Functional Neurological Disorders. J Neuropsychiatry Clin Neurosci 2018; 31:65-69. [PMID: 30376786 PMCID: PMC6349486 DOI: 10.1176/appi.neuropsych.18040095] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Insecure attachment is a predisposing risk factor for the development of functional neurological disorder (FND). There is limited research investigating connections between attachment styles, other predisposing vulnerabilities, and symptom severity in patients with motor FND. By using a within-group design with prospective data collection, the authors performed univariate tests followed by multivariate linear regressions to investigate neuropsychiatric factors associated with four attachment styles (secure, fearful, preoccupied, and dismissing) among 56 patients with motor FND (mean age=40.2 years [SD=13.0]; women, N=41; men, N=15). In univariate analyses, fearful attachment style was associated with self-reported adverse life event burden, alexithymia, dissociation, depression, anxiety, impaired stress coping skills, functional neurologic symptom severity, and marital status. In a multivariate stepwise linear regression analysis, childhood abuse, alexithymia, depression, and not being married independently predicted fearful attachment. In a post hoc analysis, childhood sexual and emotional abuse were each independently associated with fearful attachment tendencies. There were no independent predictors of secure, preoccupied, or dismissing attachment styles in this study population. Future studies with larger cohorts are needed to investigate nuanced relationships among predisposing vulnerabilities for the development of FND, as well as potential links between risk factors, functional neurologic symptom severity, and clinical outcomes.
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Affiliation(s)
- Benjamin Williams
- Department of Neurology, Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Juan Pablo Ospina Botero
- Department of Neurology, Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Rozita Jalilianhasanpour
- Department of Neurology, Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory L. Fricchione
- Department of Psychiatry, Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - David L. Perez
- Department of Neurology, Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Psychiatry, Neuropsychiatry Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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89
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Rancourt D, Darkes J. Conversion Disorder (Functional Neurological Symptom Disorder) in Primary Care Mental Health. Clin Case Stud 2018. [DOI: 10.1177/1534650118808388] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
This case report describes the application of a dialectical behavioral therapy–informed psychotherapy approach to treating conversion disorder (functional neurological symptom disorder) with motor dysfunction in a Veterans Administration Health System Primary Care–Mental Health Integration Clinic. “Jane,” a 30-year-old veteran, was diagnosed with conversion disorder, major depressive disorder (MDD), and posttraumatic stress disorder (PTSD). She completed 25 sessions of treatment focused on improving emotion regulation and interpersonal skills over an 8-month period. At the end of treatment, Jane demonstrated improved motor ability and clinically significant improvements in her reported symptoms of MDD (per the Patient Health Questionnaire–9) and PTSD (per the PTSD Checklist–Civilian Version). This case report supports the conceptualization of conversion disorder as a function of emotion dysregulation and the application of a dialectical behavior therapy–informed treatment approach.
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90
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A Case of Functional Dystonia with Associated Functional Neurological Symptoms: Diagnostic and Therapeutic Challenges. Harv Rev Psychiatry 2018. [PMID: 28650853 DOI: 10.1097/hrp.0000000000000135] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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91
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Sojka P, Bareš M, Kašpárek T, Světlák M. Processing of Emotion in Functional Neurological Disorder. Front Psychiatry 2018; 9:479. [PMID: 30344497 PMCID: PMC6182079 DOI: 10.3389/fpsyt.2018.00479] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 09/13/2018] [Indexed: 01/25/2023] Open
Abstract
Emotions have traditionally been considered crucial in the development of functional neurological disorder, but the evidence underpinning this association is not clear. We aimed to summarize evidence for association between functional neurological disorder and emotions as formulated by Breuer and Freud in their conception of hysterical conversion. Based on a systematic literature search, we identified 34 controlled studies and categorized them into four groups: (i) autonomic arousal, (ii) emotion-motion interactions, (iii) social modulation of symptoms, and (iv) bodily awareness in FND. We found evidence for autonomic dysregulation in FND; convergent neuroimaging findings implicate abnormal limbic-motor interactions in response to emotional stimuli in FND. Our results do not provide enough empirical evidence for social modulation of the symptoms, but there is a clinical support for the role of suggestion and placebo in FND. Our results provide evidence for abnormal bodily awareness in FND. Based on these findings, we propose that functional neurological symptoms are forms of emotional reactions shaped into symptoms by previous experience with illness and possibly reinforced by actual social contexts. Additional research should investigate the effect of social context on the intensity of functional neurological symptoms and associated brain regions.
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Affiliation(s)
- Petr Sojka
- Department of Neurology, Faculty of Medicine, Masaryk University and St Anne's University Hospital Brno, Brno, Czechia
| | - Martin Bareš
- Department of Neurology, Faculty of Medicine, Masaryk University and St Anne's University Hospital Brno, Brno, Czechia
- Department of Psychiatry, Faculty of Medicine, Masaryk University and University Hospital Brno, Brno, Czechia
| | - Tomáš Kašpárek
- Department of Neurology, Faculty of Medicine, Masaryk University and St Anne's University Hospital Brno, Brno, Czechia
- Department of Psychiatry, Faculty of Medicine, Masaryk University and University Hospital Brno, Brno, Czechia
| | - Miroslav Světlák
- Department of Neurology, Faculty of Medicine, Masaryk University and St Anne's University Hospital Brno, Brno, Czechia
- Department of Psychology and Psychosomatics, Faculty of Medicine, Masaryk University and University Hospital Brno, Brno, Czechia
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Secure Attachment and Depression Predict 6-Month Outcome in Motor Functional Neurological Disorders: A Prospective Pilot Study. PSYCHOSOMATICS 2018; 60:365-375. [PMID: 30342702 DOI: 10.1016/j.psym.2018.08.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 08/03/2018] [Accepted: 08/12/2018] [Indexed: 12/16/2022]
Abstract
BACKGROUND The relationships between baseline neuropsychiatric factors and clinical outcome in patients with functional neurological disorder (FND)/conversion disorder remain poorly understood. OBJECTIVE This prospective, naturalistic pilot study investigated links between predisposing vulnerabilities (risk factors) and clinical outcome in patients with motor FND engaged in usual care within a subspecialty FND clinic. METHODS Thirty-four patients with motor FND were enrolled and completed baseline and 6-month follow-up psychometric questionnaires. Univariate screening tests followed by multivariate linear regression analyses were used to investigate neuropsychiatric predictors of 6-month clinical outcome in patients with motor FND. RESULTS In univariate analyses, baseline secure attachment traits and depression as measured by the Relationship Scales Questionnaire and Beck Depression Inventory-II positively correlated with improved Patient Health Questionnaire-15 scores. In a multivariate linear regression analysis adjusting for the interval time between baseline and follow-up data collection, baseline secure attachment and depression scores independently predicted improvements in Patient Health Questionnaire-15 scores. In additional analyses, patients with a diagnosis of psychogenic nonepileptic seizures compared to individuals with other motor FND subtypes showed a trend toward worse 6-month physical health outcomes as measured by the Short Form Health Survey-36. CONCLUSION Future large-scale, multi-site longitudinal studies are needed to comprehensively investigate neuropsychiatric predictors of clinical outcome in patients with motor FND, including functional weakness, functional movement disorders, and psychogenic nonepileptic seizures.
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Abstract
Functional neurological disorders (FND)-also called psychogenic, nonorganic, conversion, and dissociative disorders-constitute one of the commonest problems in neurological practice. An occupational therapist (OT) is commonly involved in management, but there is no specific literature or guidance for these professionals. Classification now emphasizes the importance of positive diagnosis of FND based on physical signs, more than psychological features. Studies of mechanism have produced new clinical and neurobiological ways of thinking about these disorders. Evidence has emerged to support the use of physiotherapy and occupational therapy as part of a multidisciplinary team for functional movement disorders (FMD) and psychotherapy for dissociative (nonepileptic) attacks. The diagnosis and management of FND has entered a new evidence-based era and deserves a standard place in the OT neurological curriculum. We discuss specific management areas relevant to occupational therapy and propose a research agenda.
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Bègue I, Blakemore R, Klug J, Cojan Y, Galli S, Berney A, Aybek S, Vuilleumier P. Metacognition of visuomotor decisions in conversion disorder. Neuropsychologia 2018; 114:251-265. [PMID: 29698734 DOI: 10.1016/j.neuropsychologia.2018.04.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 04/19/2018] [Accepted: 04/20/2018] [Indexed: 12/21/2022]
Abstract
Motor conversion disorder (CD) entails genuine disturbances in the subjective experience of patients who maintain they are unable to perform a motor function, despite lack of apparent neurological damage. Abilities by which individuals assess their own capacities during performance in a task are called metacognitive, and distinctive impairment of such abilities is observed in several disorders of self-awareness such as blindsight and anosognosia. In CD, previous research has focused on the recruitment of motor and emotional brain systems, generally linking symptoms to altered limbic-motor interactions; however, metacognitive function has not been studied to our knowledge. Here we tested ten CD patients and ten age-gender matched controls during a visually-guided motor paradigm, previously employed in healthy controls (HC), allowing us to probe for motor awareness and metacognition. Participants had to draw straight trajectories towards a visual target while, unbeknownst to them, deviations were occasionally introduced in the reaching trajectory seen on the screen. Participants then reported both awareness of deviations and confidence in their response. Activity in premotor and cingulate cortex distinguished between conscious and unconscious movement corrections in controls better than patients. Critically, whereas controls engaged the left superior precuneus and middle temporal region during confidence judgments, CD patients recruited bilateral parahippocampal and amygdalo-hippocampal regions instead. These results reveal that distinct brain regions subserve metacognitive monitoring for HC and CD, pointing to different mechanisms and sources of information used to monitor and form confidence judgments of motor performance. While brain systems involved in sensory-motor integration and vision are more engaged in controls, CD patients may preferentially rely on memory and contextual associative processing, possibly accounting for how affect and memories can imbue current motor experience in these patients.
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Affiliation(s)
- Indrit Bègue
- Laboratory of Neurology and Imaging of Cognition, Department of Fundamental Neurosciences, University of Geneva, Switzerland; Swiss Center for Affective Studies, University of Geneva, Switzerland; Department of Mental Health and Psychiatry, University Hospitals of Geneva, Switzerland; Geneva Neuroscience Center, University of Geneva, Switzerland.
| | - Rebekah Blakemore
- Laboratory of Neurology and Imaging of Cognition, Department of Fundamental Neurosciences, University of Geneva, Switzerland
| | - Julian Klug
- Laboratory of Neurology and Imaging of Cognition, Department of Fundamental Neurosciences, University of Geneva, Switzerland
| | - Yann Cojan
- Laboratory of Neurology and Imaging of Cognition, Department of Fundamental Neurosciences, University of Geneva, Switzerland
| | - Silvio Galli
- Laboratory of Neurology and Imaging of Cognition, Department of Fundamental Neurosciences, University of Geneva, Switzerland
| | - Alexandre Berney
- Service of Consultation-Liaison Psychiatry, Lausanne University Hospital, Lausanne, Switzerland
| | - Selma Aybek
- Laboratory of Neurology and Imaging of Cognition, Department of Fundamental Neurosciences, University of Geneva, Switzerland; Geneva Neuroscience Center, University of Geneva, Switzerland; Neurology Department, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Patrik Vuilleumier
- Laboratory of Neurology and Imaging of Cognition, Department of Fundamental Neurosciences, University of Geneva, Switzerland; Swiss Center for Affective Studies, University of Geneva, Switzerland; Department of Mental Health and Psychiatry, University Hospitals of Geneva, Switzerland; Geneva Neuroscience Center, University of Geneva, Switzerland
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95
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Distinctive neuropsychological profiles differentiate patients with functional memory disorder from patients with amnestic-mild cognitive impairment. Acta Neuropsychiatr 2018; 30:90-96. [PMID: 28714423 DOI: 10.1017/neu.2017.21] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Patients with functional memory disorder (FMD) report significant memory failures in everyday life. Differentiating these patients from those with memory difficulties due to early stage neurodegenerative conditions is clinically challenging. The current study explored whether distinctive neuropsychological profiles could be established, suitable to differentiate patients with FMD from healthy individuals and those experiencing amnestic mild cognitive impairment (a-MCI). METHODS Patients with a clinical diagnosis of FMD were compared with patients with a-MCI, and healthy matched controls on several tests assessing different cognitive functions. Patients with clinically established mood disorders were excluded. Patients with FMD and a-MCI were broadly comparable on the level of their subjective memory complaints as assessed by clinical interview. RESULTS The neuropsychological profile of the FMD patients, although they expressed subjective memory and attention concerns during their clinical interview was distinct from patients with a-MCI on tests of memory [semantic fluency, age of acquisition (AoA) analysis of semantic fluency, verbal and non-verbal memory]. FMD patients did not differ significantly from healthy controls, but their scores on the letter fluency and digit cancellation tasks were not significantly different from those of the a-MCI patients indicating a possible sub-threshold deficit on these tasks. CONCLUSION Whilst subjective complaints are common within the FMD population, no objective impairment could be detected, even on a sensitive battery of tasks designed to detect subtle deficits caused by an early neurodegenerative brain disease. This study indicates that FMD patients can be successfully differentiated from patients with neurodegenerative memory decline by characterising their neuropsychological profile.
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96
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Ludwig L, Pasman JA, Nicholson T, Aybek S, David AS, Tuck S, Kanaan RA, Roelofs K, Carson A, Stone J. Stressful life events and maltreatment in conversion (functional neurological) disorder: systematic review and meta-analysis of case-control studies. Lancet Psychiatry 2018; 5:307-320. [PMID: 29526521 DOI: 10.1016/s2215-0366(18)30051-8] [Citation(s) in RCA: 223] [Impact Index Per Article: 37.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 01/18/2018] [Accepted: 01/24/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND Stressful life events and maltreatment have traditionally been considered crucial in the development of conversion (functional neurological) disorder, but the evidence underpinning this association is not clear. We aimed to assess the association between stressors and functional neurological disorder. METHODS We systematically reviewed controlled studies reporting stressors occurring in childhood or adulthood, such as stressful life events and maltreatment (including sexual, physical abuse, and emotional neglect) and functional neurological disorder. We did a meta-analysis, with assessments of methodology, sources of bias, and sensitivity analyses. FINDINGS 34 case-control studies, with 1405 patients, were eligible. Studies were of moderate-to-low quality. The frequency of childhood and adulthood stressors was increased in cases compared with controls. Odds ratios (OR) were higher for emotional neglect in childhood (49% for cases vs 20% for controls; OR 5·6, 95% CI 2·4-13·1) compared with sexual abuse (24% vs 10%; 3·3, 2·2-4·8) or physical abuse (30% vs 12%; 3·9, 2·2-7·2). An association with stressful life events preceding onset (OR 2·8, 95% CI 1·4-6·0) was stronger in studies with better methods (interviews; 4·3, 1·4-13·2). Heterogeneity was significant between studies (I2 21·1-90·7%). 13 studies that specifically ascertained that the participants had not had either severe life events or any subtype of maltreatment all found a proportion of patients with functional neurological disorder reporting no stressor. INTERPRETATION Stressful life events and maltreatment are substantially more common in people with functional neurological disorder than in healthy controls and patient controls. Emotional neglect had a higher risk than traditionally emphasised sexual and physical abuse, but many cases report no stressors. This outcome supports changes to diagnostic criteria in DSM-5; stressors, although relevant to the cause in many patients, are not a core diagnostic feature. This result has implications for ICD-11. FUNDING None.
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Affiliation(s)
- Lea Ludwig
- Department of Clinical Psychology and Psychotherapy, Universität Hamburg, Hamburg, Germany; Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Joëlle A Pasman
- Developmental Psychopathology, Radboud University, Nijmegen, Netherlands
| | - Timothy Nicholson
- Section of Cognitive Neuropsychiatry, Institute of Psychiatry Psychology & Neuroscience, King's College London, London, UK
| | - Selma Aybek
- Section of Cognitive Neuropsychiatry, Institute of Psychiatry Psychology & Neuroscience, King's College London, London, UK; Laboratory for Behavioral Neurology and Imaging of Cognition, Fundamental Neurosciences Department, Geneva University, Geneva, Switzerland
| | - Anthony S David
- Section of Cognitive Neuropsychiatry, Institute of Psychiatry Psychology & Neuroscience, King's College London, London, UK
| | - Sharon Tuck
- Epidemiology and Statistics Core, Edinburgh Clinical Research Facility, Edinburgh, UK
| | - Richard A Kanaan
- Department of Psychiatry, University of Melbourne, Austin Health, Heidelberg, VIC, Australia; Florey Institute for Neuroscience and Mental Health, Heidelberg, VIC, Australia
| | - Karin Roelofs
- Behavioural Science Institute, Radboud University, Nijmegen, Netherlands; Donders Institute for Brain Cognition and Behaviour, Radboud University, Nijmegen, Netherlands
| | - Alan Carson
- Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK; Department of Rehabilitation Medicine, NHS Lothian, Edinburgh, UK; Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
| | - Jon Stone
- Department of Clinical Neurosciences, NHS Lothian, Edinburgh, UK; Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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Jalilianhasanpour R, Williams B, Gilman I, Burke MJ, Glass S, Fricchione GL, Keshavan MS, LaFrance WC, Perez DL. Resilience linked to personality dimensions, alexithymia and affective symptoms in motor functional neurological disorders. J Psychosom Res 2018; 107:55-61. [PMID: 29502765 PMCID: PMC5856107 DOI: 10.1016/j.jpsychores.2018.02.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 02/11/2018] [Accepted: 02/11/2018] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Reduced resilience, a construct associated with maladaptive stress coping and a predisposing vulnerability for Functional Neurological Disorders (FND), has been under-studied compared to other neuropsychiatric factors in FND. This prospective case-control study investigated self-reported resilience in patients with FND compared to controls and examined relationships between resilience and affective symptoms, personality traits, alexithymia, health status and adverse life event burden. METHODS 50 individuals with motor FND and 47 healthy controls participated. A univariate test followed by a logistic regression analysis investigated group-level differences in Connor-Davidson Resilience Scale (CD-RISC) scores. For within-group analyses performed separately in patients with FND and controls, univariate screening tests followed by multivariate linear regression analyses examined factors associated with self-reported resilience. RESULTS Adjusting for age, gender, education status, ethnicity and lifetime adverse event burden, patients with FND reported reduced resilience compared to controls. Within-group analyses in patients with FND showed that individual-differences in mental health, extraversion, conscientiousness, and openness positively correlated with CD-RISC scores; post-traumatic stress disorder symptom severity, depression, anxiety, alexithymia and neuroticism scores negatively correlated with CD-RISC scores. Extraversion independently predicted resilience scores in patients with FND. In control subjects, univariate associations were appreciated between CD-RISC scores and gender, personality traits, anxiety, alexithymia and physical health; conscientiousness independently predicted resilience in controls. CONCLUSION Patients with FND reported reduced resilience, and CD-RISC scores covaried with other important predisposing vulnerabilities for the development of FND. Future research should investigate if the CD-RISC is predictive of clinical outcomes in patients with FND.
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Affiliation(s)
- Rozita Jalilianhasanpour
- Department of Neurology, Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Benjamin Williams
- Department of Neurology, Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Isabelle Gilman
- Department of Neurology, Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Matthew J Burke
- Berenson-Allen Center for Noninvasive Brain Stimulation, Division of Cognitive Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Sean Glass
- Department of Neurology, Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Psychiatry, Neuropsychiatry Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Gregory L Fricchione
- Department of Psychiatry, Benson-Henry Institute for Mind Body Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Matcheri S Keshavan
- Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - W Curt LaFrance
- Neuropsychiatry and Behavioral Neurology Division, Rhode Island Hospital, Departments of Psychiatry and Neurology, Brown University, Alpert Medical School, Providence, RI, USA
| | - David L Perez
- Department of Neurology, Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA; Department of Psychiatry, Neuropsychiatry Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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98
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Garcin B. Motor functional neurological disorders: An update. Rev Neurol (Paris) 2018; 174:203-211. [DOI: 10.1016/j.neurol.2017.11.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 11/28/2017] [Accepted: 11/29/2017] [Indexed: 11/26/2022]
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99
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DeLaroche AM, Sivaswamy L, Farooqi A, Kannikeswaran N. Pediatric Stroke and Its Mimics: Limitations of a Pediatric Stroke Clinical Pathway. Pediatr Neurol 2018; 80:35-41. [PMID: 29429783 DOI: 10.1016/j.pediatrneurol.2017.10.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Revised: 09/29/2017] [Accepted: 10/06/2017] [Indexed: 02/01/2023]
Abstract
BACKGROUND Acute stroke protocols improve delivery of care but it is unclear whether these resource intensive protocols are able to differentiate stroke from mimics in children. The aim of this study is to describe our institution's experience with stroke mimics identified through our pediatric stroke clinical pathway (PSCP). METHODS The PSCP was implemented in our level 1 pediatric emergency department in June 2014 for children aged one month to 18 years. For patients managed using the PSCP from June 2014 to December 2016, demographic and clinical data were compared for patients diagnosed with stroke or a stroke mimic. RESULTS A total of 59 children were evaluated with the PSCP. Fourteen children were identified as having a stroke and 45 children had stroke mimics. The most common stroke mimics were functional neurological disorders (20.0%), transient neurological deficits (17.8%), migraine (15.6%), and seizure (11.1%). Patient demographics and time to neuroimaging did not differ between patients with and without stroke. Vomiting was commonly reported by patients with stroke (odds ratio: 4.00, 95% confidence interval: 1.12 to 14.35), whereas weakness was not (odds ratio: 0.7, 95% confidence interval: 0.07 to 0.90), but the physical examination did not differ between patients with and without stroke. CONCLUSIONS The PSCP ensures timely evaluation of patients presenting with neurological deficits but fails to reliably differentiate between patients with stroke and patients with stroke mimics. Further multicentered studies are needed to develop a "stroke screen" that reliably distinguishes pediatric stroke from its mimics.
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Affiliation(s)
- Amy M DeLaroche
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan.
| | - Lalitha Sivaswamy
- Division of Neurology, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
| | - Ahmad Farooqi
- School of Medicine, Wayne State University, Detroit, Michigan
| | - Nirupama Kannikeswaran
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital of Michigan, Detroit, Michigan
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100
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Stephenson CP, Baguley IJ. Functional neurological symptom disorder (conversion disorder): A role for microglial-based plasticity mechanisms? Med Hypotheses 2018; 111:41-48. [DOI: 10.1016/j.mehy.2017.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 11/12/2017] [Accepted: 12/03/2017] [Indexed: 10/18/2022]
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