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Věchetová G, Slovák M, Kemlink D, Hanzlíková Z, Dušek P, Nikolai T, Růžička E, Edwards MJ, Serranová T. The impact of non-motor symptoms on the health-related quality of life in patients with functional movement disorders. J Psychosom Res 2018; 115:32-37. [PMID: 30470314 DOI: 10.1016/j.jpsychores.2018.10.001] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 09/27/2018] [Accepted: 10/09/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Pain, fatigue, cognitive complaints and psychiatric comorbidities are common in patients with functional movement disorder and may significantly affect their quality of life. The aim of the study was to assess the impact of motor and non-motor symptoms on health-related quality of life in patients with functional movement disorder. METHODS Sixty-one patients with clinically established functional movement disorder and 61 matched healthy controls completed standardized questionnaires for depression, anxiety, cognitive complaints, fatigue, pain, sleepiness, apathy and health-related quality of life. Motor disorder severity was assessed using The Simplified Functional Movement Disorders Rating Scale. Personality traits were assessed using the 44-Item Big Five Inventory. RESULTS Compared to controls, patients reported significantly lower health-related quality of life and higher levels of all assessed non-motor symptoms except for apathy. No difference was found in personality traits. In both groups, health-related quality of life scores negatively correlated with depression, anxiety, pain, cognitive complaints, apathy, and neuroticism. No correlation was found between health-related quality of life and motor symptom severity in patients with functional movement disorder. Multiple regression analysis of the predictors of health-related quality of life showed significant impact of trait anxiety and cognitive complaints scores. CONCLUSIONS Multiple non-motor symptoms but not motor symptom severity correlated with impaired health-related quality of life in patients with functional movement disorder. Impaired health-related quality of life was predicted by anxiety and cognitive complaints. Our results highlight the importance of assessing and treating both motor and non-motor symptoms in patients with functional movement disorder.
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Affiliation(s)
- Gabriela Věchetová
- Department of Neurology and Centre of Clinical Neuroscience, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Matěj Slovák
- Department of Neurology and Centre of Clinical Neuroscience, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - David Kemlink
- Department of Neurology and Centre of Clinical Neuroscience, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Zuzana Hanzlíková
- Department of Neurology and Centre of Clinical Neuroscience, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Pavel Dušek
- Department of Neurology and Centre of Clinical Neuroscience, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Tomáš Nikolai
- Department of Neurology and Centre of Clinical Neuroscience, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Evžen Růžička
- Department of Neurology and Centre of Clinical Neuroscience, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic
| | - Mark J Edwards
- Neuroscience Research Centre, Institute of Molecular and Clinical Sciences, St George's University of London, United Kingdom
| | - Tereza Serranová
- Department of Neurology and Centre of Clinical Neuroscience, General University Hospital and First Faculty of Medicine, Charles University, Prague, Czech Republic.
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152
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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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153
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Hyperventilation-Induced Non-epileptic Seizures in an Adolescent Boy with Pediatric Medical Traumatic Stress. Harv Rev Psychiatry 2018; 25:180-190. [PMID: 28471819 DOI: 10.1097/hrp.0000000000000131] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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154
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Park JE. Clinical Characteristics of Functional Movement Disorders: A Clinic-based Study. TREMOR AND OTHER HYPERKINETIC MOVEMENTS (NEW YORK, N.Y.) 2018; 8:504. [PMID: 30191082 PMCID: PMC6123835 DOI: 10.7916/d81n9hk4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 06/18/2018] [Indexed: 12/02/2022]
Abstract
Background Functional movement disorders are recognized as a “crisis” in neurology. We aimed to determine the rate of incidence of functional movement disorder patients at a university outpatient neurology clinic in South Korea, and highlight the clinical and phenomenological characteristics. Methods Patients who were assessed by a movement disorders neurologist at a university hospital between March 2016 and May 2017 were screened for functional movement disorders. Demographic and clinical data were reviewed, and the phenomenology of movements was studied. Results Of 321 patients evaluated for the chief complaint of a movement abnormality, approximately 10% (31 patients) were diagnosed with a functional movement disorder. The female to male ratio was 7:1 (27 females to four males). The mean age at presentation was 53 years (standard error 3.6 years), and the mean disease duration was 5 years (standard error 1.4 years). Sixty-one percent (19 out of 31 patients) had a past medical history of depression, anxiety, or other psychiatric illnesses. Tremor and speech abnormalities were most prevalent (19 and 12 patients, respectively). Onset was reported to be abrupt in 14 patients (45%). Thirteen (42%) patients were found to have improvement at a follow-up visit, 10 (32%) had no improvement, and eight (26%) were lost to follow-up. Discussion Functional movement disorders are not uncommon in the outpatient neurology clinic. Our results confirm that tremor is the most frequent movement occurring in functional movement disorders, and the most commonly affected body parts were found to be the upper and lower extremities. Speech was also found to be frequently involved (39%). Patients with no improvement at follow-up had longer mean disease duration (6.2 years), consistent with previous observations that prolonged symptom duration is associated with poor clinical outcome. Our study results obtained from a Korean population suggest that previous observations on functional movement disorders from other regions hold true in Eastern Asia.
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Affiliation(s)
- Jung E Park
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
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155
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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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156
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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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157
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Jacob AE, Kaelin DL, Roach AR, Ziegler CH, LaFaver K. Motor Retraining (MoRe) for Functional Movement Disorders: Outcomes From a 1-Week Multidisciplinary Rehabilitation Program. PM R 2018; 10:1164-1172. [PMID: 29783067 DOI: 10.1016/j.pmrj.2018.05.011] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 05/04/2018] [Accepted: 05/08/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Functional movement disorders (FMDs) are conditions of abnormal motor control thought to be caused by psychological factors. These disorders are commonly seen in neurologic practice, and prognosis is often poor. No consensus treatment guidelines have been established; however, the role of physical therapy in addition to psychotherapy has increasingly been recognized. This study reports patient outcomes from a multidisciplinary FMD treatment program using motor retraining (MoRe) strategies. OBJECTIVE To assess outcomes of FMD patients undergoing a multidisciplinary treatment program and determine factors predictive of treatment success. DESIGN Retrospective chart review. SETTING University-affiliated rehabilitation institute. PATIENTS Thirty-two consecutive FMD patients admitted to the MoRe program from July 2014-July 2016. INTERVENTION Patients participated in a 1-week, multidisciplinary inpatient treatment program with daily physical, occupational, speech therapy, and psychotherapy interventions. MAIN OUTCOME MEASUREMENTS Primary outcome measures were changes in the patient-rated Clinical Global Impression Scale (CGI) and the physician-rated Psychogenic Movement Disorder Rating Scale (PMDRS) based on review of standardized patient videos. Measurements were taken as part of the clinical evaluation of the program. RESULTS Twenty-four of the 32 patients were female with a mean age of 49.1 (±14.2) years and mean symptom duration of 7.4 (±10.8) years. Most common movement phenomenologies were abnormal gait (31.2%), hyperkinetic movements (31.2%), and dystonia (31.2%). At discharge, 86.7% of patients reported symptom improvement on the CGI, and self-reported improvement was maintained in 69.2% at the 6-month follow-up. PMDRS scores improved by 59.1% from baseline to discharge. Longer duration of symptoms, history of abuse, and comorbid psychiatric disorders were not significant predictors of treatment outcomes. CONCLUSIONS The majority of FMD patients experienced improvement from a 1-week multidisciplinary inpatient rehabilitation program. Treatment outcomes were not negatively correlated with longer disease duration or psychiatric comorbidities. The results from our study are encouraging, although further long-term prospective randomized studies are needed. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Alexandra E Jacob
- Department of Neurology, University of Louisville, Louisville, KY(∗)
| | - Darryl L Kaelin
- Division of Physical Medicine and Rehabilitation, University of Louisville, Louisville, KY(†)
| | - Abbey R Roach
- Division of Psychology and Neuropsychology, Frazier Rehab Institute, Louisville, KY(‡)
| | - Craig H Ziegler
- School of Medicine, University of Louisville, Louisville, KY(§)
| | - Kathrin LaFaver
- Department of Neurology, University of Louisville, 220 Abraham Flexner Way, Suite 606, Louisville, KY, 40202(¶).
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158
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Breen DP, Rohani M, Moro E, Mayberg HS, Zurowski M, Lozano AM, Fasano A. Functional movement disorders arising after successful deep brain stimulation. Neurology 2018; 90:931-932. [PMID: 29653985 DOI: 10.1212/wnl.0000000000005530] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Accepted: 02/12/2018] [Indexed: 11/15/2022] Open
Affiliation(s)
- David P Breen
- From the Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (D.P.B., A.F.), Department of Psychiatry (M.Z.), and Department of Neurosurgery (A.M.L.), Toronto Western Hospital, Toronto, Canada; Department of Neurology (M.R.), Hazrat Rasool Hospital, Iran University of Medical Sciences, Tehran, Iran; Service de Neurologie (E.M.), Centre Hospitalier Universitaire de Grenoble, Grenoble Alpes University, INSERM U1214, Grenoble, France; and the Departments of Neurology and Neurosurgery (H.S.M.), Icahn School of Medicine at Mount Sinai, New York.
| | - Mohammad Rohani
- From the Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (D.P.B., A.F.), Department of Psychiatry (M.Z.), and Department of Neurosurgery (A.M.L.), Toronto Western Hospital, Toronto, Canada; Department of Neurology (M.R.), Hazrat Rasool Hospital, Iran University of Medical Sciences, Tehran, Iran; Service de Neurologie (E.M.), Centre Hospitalier Universitaire de Grenoble, Grenoble Alpes University, INSERM U1214, Grenoble, France; and the Departments of Neurology and Neurosurgery (H.S.M.), Icahn School of Medicine at Mount Sinai, New York
| | - Elena Moro
- From the Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (D.P.B., A.F.), Department of Psychiatry (M.Z.), and Department of Neurosurgery (A.M.L.), Toronto Western Hospital, Toronto, Canada; Department of Neurology (M.R.), Hazrat Rasool Hospital, Iran University of Medical Sciences, Tehran, Iran; Service de Neurologie (E.M.), Centre Hospitalier Universitaire de Grenoble, Grenoble Alpes University, INSERM U1214, Grenoble, France; and the Departments of Neurology and Neurosurgery (H.S.M.), Icahn School of Medicine at Mount Sinai, New York
| | - Helen S Mayberg
- From the Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (D.P.B., A.F.), Department of Psychiatry (M.Z.), and Department of Neurosurgery (A.M.L.), Toronto Western Hospital, Toronto, Canada; Department of Neurology (M.R.), Hazrat Rasool Hospital, Iran University of Medical Sciences, Tehran, Iran; Service de Neurologie (E.M.), Centre Hospitalier Universitaire de Grenoble, Grenoble Alpes University, INSERM U1214, Grenoble, France; and the Departments of Neurology and Neurosurgery (H.S.M.), Icahn School of Medicine at Mount Sinai, New York
| | - Mateusz Zurowski
- From the Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (D.P.B., A.F.), Department of Psychiatry (M.Z.), and Department of Neurosurgery (A.M.L.), Toronto Western Hospital, Toronto, Canada; Department of Neurology (M.R.), Hazrat Rasool Hospital, Iran University of Medical Sciences, Tehran, Iran; Service de Neurologie (E.M.), Centre Hospitalier Universitaire de Grenoble, Grenoble Alpes University, INSERM U1214, Grenoble, France; and the Departments of Neurology and Neurosurgery (H.S.M.), Icahn School of Medicine at Mount Sinai, New York
| | - Andres M Lozano
- From the Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (D.P.B., A.F.), Department of Psychiatry (M.Z.), and Department of Neurosurgery (A.M.L.), Toronto Western Hospital, Toronto, Canada; Department of Neurology (M.R.), Hazrat Rasool Hospital, Iran University of Medical Sciences, Tehran, Iran; Service de Neurologie (E.M.), Centre Hospitalier Universitaire de Grenoble, Grenoble Alpes University, INSERM U1214, Grenoble, France; and the Departments of Neurology and Neurosurgery (H.S.M.), Icahn School of Medicine at Mount Sinai, New York
| | - Alfonso Fasano
- From the Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic (D.P.B., A.F.), Department of Psychiatry (M.Z.), and Department of Neurosurgery (A.M.L.), Toronto Western Hospital, Toronto, Canada; Department of Neurology (M.R.), Hazrat Rasool Hospital, Iran University of Medical Sciences, Tehran, Iran; Service de Neurologie (E.M.), Centre Hospitalier Universitaire de Grenoble, Grenoble Alpes University, INSERM U1214, Grenoble, France; and the Departments of Neurology and Neurosurgery (H.S.M.), Icahn School of Medicine at Mount Sinai, New York
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159
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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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160
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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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161
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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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162
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Graham CD, O'Hara DJ, Kemp S. A case series of Acceptance and Commitment Therapy (ACT) for reducing symptom interference in functional neurological disorders. Clin Psychol Psychother 2018; 25:489-496. [DOI: 10.1002/cpp.2174] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Revised: 11/16/2017] [Accepted: 12/20/2017] [Indexed: 11/12/2022]
Affiliation(s)
- Christopher D. Graham
- Leeds Institute of Health Sciences; University of Leeds; Leeds UK
- Department of Clinical Neuropsychology; Leeds Teaching Hospitals NHS Trust, St James University Hospital; Leeds UK
| | - Daniel J. O'Hara
- Department of Clinical Neuropsychology; Leeds Teaching Hospitals NHS Trust, St James University Hospital; Leeds UK
| | - Steven Kemp
- Department of Clinical Neuropsychology; Leeds Teaching Hospitals NHS Trust, St James University Hospital; Leeds UK
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163
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The Inpatient Assessment and Management of Motor Functional Neurological Disorders: An Interdisciplinary Perspective. PSYCHOSOMATICS 2018; 59:358-368. [PMID: 29628294 DOI: 10.1016/j.psym.2017.12.006] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Revised: 12/22/2017] [Accepted: 12/26/2017] [Indexed: 11/23/2022]
Abstract
BACKGROUND Motor functional neurologic disorders (FND)-previously termed "hysteria" and later "conversion disorder"-are exceedingly common and frequently encountered in the acute hospital setting. Despite their high prevalence, patients with motor FND can be challenging to diagnose accurately and manage effectively. To date, there is limited guidance on the inpatient approach to the neuropsychiatric evaluation of patients with functional (psychogenic) neurologic symptoms. OBJECTIVE The authors outline an inpatient multidisciplinary approach, involving neurology, psychiatry, and physical therapy, for the assessment and acute inpatient management of motor FND. METHODS A vignette of a patient with motor FND is presented followed by a discussion of general assessment principles. Thereafter, a detailed description of the neurologic and psychiatric assessments is outlined. Delivery of a "rule-in" diagnosis is emphasized and specific guidance for what can be accomplished postdiagnosis in the hospital is suggested. DISCUSSION We encourage an interdisciplinary approach beginning at the early stages of the diagnostic assessment once an individual is suspected of having motor FND. CONCLUSIONS Practical suggestions for the inpatient assessment of motor FND are presented. It is also important to individualize the diagnostic assessment. Future research should be conducted to test best practices for motor FND management in the acute inpatient hospital setting.
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164
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Edwards M. Functional (psychogenic) gait disorder: diagnosis and management. HANDBOOK OF CLINICAL NEUROLOGY 2018; 159:417-423. [PMID: 30482331 DOI: 10.1016/b978-0-444-63916-5.00027-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Functional (psychogenic) gait disorders are a common presentation of functional neurological disorder - one of the commonest diagnoses made in neurology practice. People with functional neurological disorder are as disabled and experience as poor a quality of life as patients with multiple sclerosis and Parkinson's disease. People with functional neurological disorder, including gait disorder, are often perceived as being challenging to diagnose and manage, and as a result attitudes of health professionals towards them are often negative. However, a rapid positive diagnosis of functional gait disorder can often be made, and with a specific approach to diagnostic explanation and treatment, many patients experience improvement in symptoms and disability, with such improvements sustained in the long term. Here I review current evidence regarding the diagnosis, pathophysiology and management of functional gait disturbance with an emphasis on how to make a positive diagnosis and how to select the most appropriate treatment approach. Rehabilitative treatments, with an emphasis on specific physiotherapy interventions, have increasing evidence for benefit, particularly if carried out following a comprehensive explanation of the diagnosis.
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Affiliation(s)
- Mark Edwards
- Department of Neurology, St. George's, University of London, London, United Kingdom.
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165
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Biological and perceived stress in motor functional neurological disorders. Psychoneuroendocrinology 2017; 85:142-150. [PMID: 28863348 DOI: 10.1016/j.psyneuen.2017.08.023] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 08/21/2017] [Accepted: 08/21/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Current models explaining motor functional neurological disorders (FND) integrate both the neurobiological mechanisms underlying symptoms production and the role of psychosocial stressors. Imaging studies have suggested abnormal motor control linked to impaired emotional and stress regulation. However, little is known on the biological stress regulation in FND. Our aim was to study the biological and perceived response to stress in patients with motor FND. METHODS Sixteen patients with motor FND (DSM-5 criteria) and fifteen healthy controls underwent the Trier Social Stress Test. Hypothalamo-pituitary-adrenal axis (HPA) response was evaluated with salivary cortisol and autonomous sympathetic response with salivary alpha-amylase. Area under the curve was computed to reflect background levels (AUCg) and change over time (AUCi). Life adversities and perceived subjective stress on a visual analog scale (VAS) were correlated with biological responses. RESULTS FND patients had significantly higher background levels (AUCg) of both stress markers (cortisol and amylase) than controls. The biological response (AUCi) to stress did not differ between groups for both markers but the subjective response showed an interaction effect with patients reporting higher levels of stress than controls. After stress, controls showed a strong correlation between subjective and objective sympathetic values (amylase) but not patients. The number and subjective impact of adverse life events correlated with cortisol AUCg in patients only. CONCLUSION This study confirms a baseline HPA-axis and sympathetic hyperarousal state in motor FND related to life adversities. During a social stress, dissociation between perceived stress and biological markers was observed in patients only, reflecting a dysregulation of interoception capacity, which might represent an endophenotype of this disorder.
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166
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Wegrzyk J, Kebets V, Richiardi J, Galli S, de Ville DV, Aybek S. Identifying motor functional neurological disorder using resting-state functional connectivity. NEUROIMAGE-CLINICAL 2017; 17:163-168. [PMID: 29071210 PMCID: PMC5651543 DOI: 10.1016/j.nicl.2017.10.012] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2017] [Revised: 10/07/2017] [Accepted: 10/10/2017] [Indexed: 12/02/2022]
Abstract
Background Motor functional neurological disorder (mFND) is a clinical diagnosis with reliable features; however, patients are reluctant to accept the diagnosis and physicians themselves bear doubts on potential misdiagnoses. The identification of a positive biomarker could help limiting unnecessary costs of multiple referrals and investigations, thus promoting early diagnosis and allowing early engagement in appropriate therapy. Objectives To test whether resting-state (RS) functional magnetic resonance imaging could discriminate patients suffering from mFND from healthy controls. Methods We classified 23 mFND patients and 25 age- and gender-matched healthy controls based on whole-brain RS functional connectivity (FC) data, using a support vector machine classifier and the standard Automated Anatomic Labeling (AAL) atlas, as well as two additional atlases for validation. Results Accuracy, specificity and sensitivity were over 68% (p = 0.004) to discriminate between mFND patients and controls, with consistent findings between the three tested atlases. The most discriminative connections comprised the right caudate, amygdala, prefrontal and sensorimotor regions. Post-hoc seed connectivity analyses showed that these regions were hyperconnected in patients compared to controls. Conclusions The good accuracy to discriminate patients from controls suggests that RS FC could be used as a biomarker with high diagnostic value in future clinical practice to identify mFND patients at the individual level. We classified FND patients from controls with 68% accuracy using resting-state fMRI. Right caudate-amygdala connectivity best discriminated patients with FND from controls. Future additional steps are needed before translation to clinical use. This could be used in complement of clinical signs for the diagnosis of FND.
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Affiliation(s)
- Jennifer Wegrzyk
- Department of Clinical Neuroscience, Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva, Switzerland
| | - Valeria Kebets
- Department of Neuroscience, University of Geneva, Campus Biotech, Chemin des Mines 9, 1202 Geneva, Switzerland
| | - Jonas Richiardi
- Department of Neuroscience, University of Geneva, Campus Biotech, Chemin des Mines 9, 1202 Geneva, Switzerland
| | - Silvio Galli
- Department of Clinical Neuroscience, Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva, Switzerland
| | - Dimitri Van de Ville
- Institute of Bioengineering, Ecole Polytechnique Fédérale de Lausanne, Campus Biotech, Chemin des Mines 9, 1202 Geneva, Switzerland; Department of Radiology and Medical Informatics, University of Geneva, Campus Biotech, Chemin des Mines 9, 1202 Geneva, Switzerland
| | - Selma Aybek
- Department of Clinical Neuroscience, Geneva University Hospital, Rue Gabrielle-Perret-Gentil 4, 1211 Geneva, Switzerland; Department of Neuroscience, University of Geneva, Campus Biotech, Chemin des Mines 9, 1202 Geneva, Switzerland; Neurology University Clinic, InselSpital, Department of Clinical Neuroscience, 3010 Bern, Switzerland.
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167
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Karaahmet OZ, Gurcay E, Sancioglu H, Unlu E, Cakci A. Beneficial effect of faradic stimulation treatment on the rehabilitation of hysterical paraplegia. J Back Musculoskelet Rehabil 2017; 30:1117-1119. [PMID: 28582839 DOI: 10.3233/bmr-169764] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Hysterical paralysis, a type of conversion disorder, presents with the loss of motor or sensory function. Although this disorder is nonorganic, it resembles the symptoms of a structural disease of the nervous system. It is generally associated with a traumatic or social event. The patients often require excessive testing and comprehensive assessment in exposing this psychogenic ailment. We reported the most dramatic type of conversion disorder, hysterical paralysis, in which full recovery was obtained with early recognition and rehabilitation approach including faradic stimulation.
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169
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Garcin B, Mesrati F, Hubsch C, Mauras T, Iliescu I, Naccache L, Vidailhet M, Roze E, Degos B. Impact of Transcranial Magnetic Stimulation on Functional Movement Disorders: Cortical Modulation or a Behavioral Effect? Front Neurol 2017; 8:338. [PMID: 28769869 PMCID: PMC5515822 DOI: 10.3389/fneur.2017.00338] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 06/28/2017] [Indexed: 11/30/2022] Open
Abstract
Introduction Recent studies suggest that repeated transcranial magnetic stimulation (TMS) improves functional movement disorders (FMDs), but the underlying mechanisms are unclear. The objective was to determine whether the beneficial action of TMS in patients with FMDs is due to cortical neuromodulation or rather to a cognitive-behavioral effect. Method Consecutive patients with FMDs underwent repeated low-frequency (0.25 Hz) magnetic stimulation over the cortex contralateral to the symptoms or over the spinal roots [root magnetic stimulation (RMS)] homolateral to the symptoms. The patients were randomized into two groups: group 1 received RMS on day 1 and TMS on day 2, while group 2 received the same treatments in reverse order. We blindly assessed the severity of movement disorders before and after each stimulation session. Results We studied 33 patients with FMDs (dystonia, tremor, myoclonus, Parkinsonism, or stereotypies). The median symptom duration was 2.9 years. The magnetic stimulation sessions led to a significant improvement (>50%) in 22 patients (66%). We found no difference between TMS and RMS. Conclusion We suggest that the therapeutic benefit of TMS in patients with FMDs is due more to a cognitive-behavioral effect than to cortical neuromodulation.
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Affiliation(s)
- Béatrice Garcin
- Neurology Department, Parkinson's Disease Expert Centre, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,Institut du Cerveau et de la Moelle épinière (ICM), UPMC UMRS 1127, INSERM U 1127, CNRS UMR 7225, Paris, France
| | - Francine Mesrati
- Neurophysiology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Cécile Hubsch
- Neurology Department, Parkinson's Disease Expert Centre, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Thomas Mauras
- Neurology Department, Parkinson's Disease Expert Centre, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,Psychiatry Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Iulia Iliescu
- Neurophysiology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Lionel Naccache
- Institut du Cerveau et de la Moelle épinière (ICM), UPMC UMRS 1127, INSERM U 1127, CNRS UMR 7225, Paris, France.,Neurophysiology Department, Pitié-Salpêtrière Hospital, AP-HP, Paris, France
| | - Marie Vidailhet
- Neurology Department, Parkinson's Disease Expert Centre, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,Institut du Cerveau et de la Moelle épinière (ICM), UPMC UMRS 1127, INSERM U 1127, CNRS UMR 7225, Paris, France
| | - Emmanuel Roze
- Neurology Department, Parkinson's Disease Expert Centre, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,Institut du Cerveau et de la Moelle épinière (ICM), UPMC UMRS 1127, INSERM U 1127, CNRS UMR 7225, Paris, France
| | - Bertrand Degos
- Neurology Department, Parkinson's Disease Expert Centre, Pitié-Salpêtrière Hospital, AP-HP, Paris, France.,CNRS-UMR 7241/INSERM U1050, CIRB, Collège de France, UPMC, Paris, France
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170
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Perez DL, Matin N, Barsky A, Costumero-Ramos V, Makaretz SJ, Young SS, Sepulcre J, LaFrance WC, Keshavan MS, Dickerson BC. Cingulo-insular structural alterations associated with psychogenic symptoms, childhood abuse and PTSD in functional neurological disorders. J Neurol Neurosurg Psychiatry 2017; 88:491-497. [PMID: 28416565 PMCID: PMC5497745 DOI: 10.1136/jnnp-2016-314998] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 01/24/2017] [Accepted: 02/01/2017] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Adverse early-life events are predisposing factors for functional neurological disorder (FND) and post-traumatic stress disorder (PTSD). Cingulo-insular regions are implicated in the biology of both conditions and are sites of stress-mediated neuroplasticity. We hypothesised that functional neurological symptoms and the magnitude of childhood abuse would be associated with overlapping anterior cingulate cortex (ACC) and insular volumetric reductions, and that FND and PTSD symptoms would map onto distinct cingulo-insular areas. METHODS This within-group voxel-based morphometry study probes volumetric associations with self-report measures of functional neurological symptoms, adverse life events and PTSD symptoms in 23 mixed-gender FND patients. Separate secondary analyses were also performed in the subset of 18 women with FND to account for gender-specific effects. RESULTS Across the entire cohort, there were no statistically significant volumetric associations with self-report measures of functional neurological symptom severity or childhood abuse. In women with FND, however, parallel inverse associations were observed between left anterior insular volume and functional neurological symptoms as measured by the Patient Health Questionnaire-15 and the Screening for Somatoform Symptoms Conversion Disorder subscale. Similar inverse relationships were also appreciated between childhood abuse burden and left anterior insular volume. Across all subjects, PTSD symptom severity was inversely associated with dorsal ACC volume, and the magnitude of lifetime adverse events was inversely associated with left hippocampal volume. CONCLUSIONS This study reveals distinct cingulo-insular alterations for FND and PTSD symptoms and may advance our understanding of FND. Potential biological convergence between stress-related neuroplasticity, functional neurological symptoms and reduced insular volume was identified.
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Affiliation(s)
- David L. Perez
- Massachusetts General Hospital, Department of Neurology, Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital, Department of Psychiatry, Neuropsychiatry Unit, Harvard Medical School, Boston, MA, USA
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - Nassim Matin
- Massachusetts General Hospital, Department of Neurology, Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Harvard Medical School, Boston, MA, USA
| | - Arthur Barsky
- Brigham and Women’s Hospital, Department of Psychiatry, Harvard Medical School, Boston, MA, USA
| | | | - Sara J Makaretz
- Massachusetts General Hospital, Department of Neurology, Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Harvard Medical School, Boston, MA, USA
- Massachusetts General Hospital, Department of Neurology, Frontotemporal Disorders Unit, Harvard Medical School, Boston, MA, USA
| | - Sigrid S. Young
- Massachusetts General Hospital, Department of Neurology, Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Harvard Medical School, Boston, MA, USA
| | - Jorge Sepulcre
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
| | - W. Curt LaFrance
- Neuropsychiatry and Behavioral Neurology Division, Rhode Island Hospital, Departments of Psychiatry and Neurology, Brown University, Alpert Medical School, Providence, Rhode Island, USA
| | | | - Bradford C Dickerson
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Harvard Medical School, Charlestown, MA, USA
- Massachusetts General Hospital, Department of Neurology, Frontotemporal Disorders Unit, Harvard Medical School, Boston, MA, USA
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171
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Nielsen G, Buszewicz M, Stevenson F, Hunter R, Holt K, Dudziec M, Ricciardi L, Marsden J, Joyce E, Edwards MJ. Randomised feasibility study of physiotherapy for patients with functional motor symptoms. J Neurol Neurosurg Psychiatry 2017; 88:484-490. [PMID: 27694498 DOI: 10.1136/jnnp-2016-314408] [Citation(s) in RCA: 149] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 08/30/2016] [Accepted: 09/06/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine the feasibility of conducting a randomised controlled trial of a specialist physiotherapy intervention for functional motor symptoms (FMS). METHODS A randomised feasibility study was conducted recruiting patients with a clinically established diagnosis of FMS from a tertiary neurology clinic in London, UK. Participants were randomised to the intervention or a treatment as usual control. Measures of feasibility and clinical outcome were collected and assessed at 6 months. RESULTS 60 individuals were recruited over a 9-month period. Three withdrew, leaving 29 intervention and 28 controls participants in the final analysis. 32% of patients with FMS met the inclusion criteria, of which 90% enrolled. Acceptability of the intervention was high and there were no adverse events. At 6 months, 72% of the intervention group rated their symptoms as improved, compared to 18% in the control group. There was a moderate to large treatment effect across a range of outcomes, including three of eight Short Form 36 (SF36) domains (d=0.46-0.79). The SF36 Physical function was found to be a suitable primary outcome measure for a future trial; adjusted mean difference 19.8 (95% CI 10.2 to 29.5). The additional quality adjusted life years (QALY) with intervention was 0.08 (95% CI 0.03 to 0.13), the mean incremental cost per QALY gained was £12 087. CONCLUSIONS This feasibility study demonstrated high rates of recruitment, retention and acceptability. Clinical effect size was moderate to large with high probability of being cost-effective. A randomised controlled trial is needed. TRIAL REGISTRATION NUMBER NCT02275000; Results.
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Affiliation(s)
- G Nielsen
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London, UK.,Therapy Services Department, National Hospital for Neurology and Neurosurgery, London, UK
| | - M Buszewicz
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - F Stevenson
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - R Hunter
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - K Holt
- Therapy Services Department, National Hospital for Neurology and Neurosurgery, London, UK.,Institute of Cardiovascular and Cell Sciences, St Georges University of London, London, UK
| | - M Dudziec
- Therapy Services Department, National Hospital for Neurology and Neurosurgery, London, UK
| | - L Ricciardi
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London, UK
| | - J Marsden
- School of Health Professions, Peninsula Allied Health Centre, University of Plymouth, Plymouth, UK
| | - E Joyce
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London, UK
| | - M J Edwards
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London, UK.,Institute of Cardiovascular and Cell Sciences, St Georges University of London, London, UK
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172
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Graham CD, Kyle SD. A preliminary investigation of sleep quality in functional neurological disorders: Poor sleep appears common, and is associated with functional impairment. J Neurol Sci 2017; 378:163-166. [PMID: 28566156 DOI: 10.1016/j.jns.2017.05.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 04/20/2017] [Accepted: 05/10/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE Functional neurological disorders (FND) are disabling conditions for which there are few empirically-supported treatments. Disturbed sleep appears to be part of the FND context; however, the clinical importance of sleep disturbance (extent, characteristics and impact) remains largely unknown. We described sleep quality in two samples, and investigated the relationship between sleep and FND-related functional impairment. METHODS We included a sample recruited online via patient charities (N=205) and a consecutive clinical sample (N=20). Participants completed validated measures of sleep quality and sleep characteristics (e.g. total sleep time, sleep efficiency), mood, and FND-related functional impairment. RESULTS Poor sleep was common in both samples (89% in the clinical range), which was characterised by low sleep efficiency (M=65.40%) and low total sleep time (M=6.05h). In regression analysis, sleep quality was negatively associated with FND-related functional impairment, accounting for 16% of the variance and remaining significant after the introduction of mood variables. CONCLUSIONS These preliminary analyses suggest that subjective sleep disturbance (low efficiency, short sleep) is common in FND. Sleep quality was negatively associated with the functional impairment attributed to FND, independent of depression. Therefore, sleep disturbance may be a clinically important feature of FND.
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173
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Graham CD, Stuart SR, O’Hara DJ, Kemp S. Using Acceptance and Commitment Therapy to Improve Outcomes in Functional Movement Disorders: A Case Study. Clin Case Stud 2017. [DOI: 10.1177/1534650117706544] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although there are many theories of functional movement disorders (FMD), the causes and prognosis remain unclear, and there are no treatments with high-quality empirical support. Acceptance and commitment therapy (ACT) is an acceptance-based behavior therapy which, via altering a process called psychological flexibility, aims to support behaviors that are consistent with a person’s overarching values—even in difficult, uncertain, or immutable contexts. It may, therefore, have pragmatic benefits in the context of FMD. We outline the theoretical basis for ACT and detail a case study of a brief (six session) intervention for increasing personally meaningful activity with FMD. The participant was in her early 20s and had been diagnosed with functional propriospinal myoclonus. ACT techniques including relational framing, defusion, and mindfulness exercises were used to increase psychological flexibility, with the goal of enabling effective functioning within the difficult context created by FMD. Following treatment, the participant showed a reliable change/clinical recovery in psychological flexibility (Acceptance and Action Questionnaire II [AAQ-II]), FMD symptom interference (Work and Social Adjustment Scale [WSAS]; primary outcome), and mood (Clinical Outcomes in Routine Evaluation 10-item scale [CORE-10]; secondary outcome). This case study demonstrates an approach that focuses first on improving functioning with FMD, as opposed to eliminating or controlling symptoms.
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Affiliation(s)
- Christopher D. Graham
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
- Leeds Teaching Hospitals NHS Trust, St. James University Hospital, Leeds, UK
| | | | - Daniel J. O’Hara
- Leeds Teaching Hospitals NHS Trust, St. James University Hospital, Leeds, UK
| | - Steven Kemp
- Leeds Teaching Hospitals NHS Trust, St. James University Hospital, Leeds, UK
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174
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Pringsheim T, Edwards M. Functional movement disorders: Five new things. Neurol Clin Pract 2017; 7:141-147. [PMID: 29185540 PMCID: PMC5669411 DOI: 10.1212/cpj.0000000000000350] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 01/23/2017] [Indexed: 11/15/2022]
Abstract
PURPOSE OF REVIEW Functional movement disorders (FMD) are commonly seen in neurologic practice, but are associated with poor outcomes. Recent years have seen a resurgence of interest in this area, with new developments in pathophysiologic understanding and therapeutic management. RECENT FINDINGS Individuals with FMD are a psychologically heterogeneous group, with many individuals having no detectable psychopathology on symptom screening measures, and possibly significant etiologically relevant life events only revealed through in-depth interviews. A randomized trial of specialist intensive physical rehabilitation compared to community-based neurophysiotherapy in FMD has demonstrated moderate to large effect sizes for both physical and social functioning outcomes. Experimental evidence suggests an impairment in the neural systems conferring a sense of agency over movement in individuals with FMD, and may explain why movements that appear voluntary are not experienced as such. SUMMARY The prognosis of individuals with FMD may be improved with greater access to appropriately organized care and treatment.
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Affiliation(s)
- Tamara Pringsheim
- Department of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences (TP), University of Calgary, Canada; and St George's University of London (ME), UK
| | - Mark Edwards
- Department of Clinical Neurosciences, Psychiatry, Pediatrics, and Community Health Sciences (TP), University of Calgary, Canada; and St George's University of London (ME), UK
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Bryson A, Carter O, Norman T, Kanaan R. 5-HT2A Agonists: A Novel Therapy for Functional Neurological Disorders? Int J Neuropsychopharmacol 2017; 20:422-427. [PMID: 28177082 PMCID: PMC5417053 DOI: 10.1093/ijnp/pyx011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 02/06/2017] [Indexed: 11/13/2022] Open
Abstract
Functional neurological disorders are frequently encountered in clinical practice. They have a poor prognosis and treatment options are limited. Their etiology is unknown, but leading theories propose a disturbance of somatic self-representation: the mind perceives dysfunction of a body region despite intact motor and sensory pathways. Central to this model is the concept of an abnormal top-down cognitive influence upon sensorimotor function. There is growing interest in the use of 5-HT2A agonists in the management of neuropsychiatric conditions. Recent studies have shown that these agents induce changes in neural activity that disrupt hierarchical brain dynamics and modulate networks subserving self-related processing. Converging evidence suggests they may hold unique therapeutic potential in functional neurological disorders. This is of importance given the considerable personal and societal burden of this condition and we argue a clinical trial to test this hypothesis is warranted.
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Affiliation(s)
- Alexander Bryson
- Howard Florey Institute of Neuroscience & Mental Health, University of Melbourne, Australia (Dr Bryson); Department of Neurology, Austin Hospital, Melbourne, Australia (Dr Bryson); Melbourne School of Psychological Sciences, University of Melbourne, Australia (Dr Carter); Department of Psychiatry, Austin Hospital, Melbourne, Australia (Drs Norman and Kanaan); Department of Psychiatry, University of Melbourne, Australia (Drs Norman and Kanaan)
| | - Olivia Carter
- Howard Florey Institute of Neuroscience & Mental Health, University of Melbourne, Australia (Dr Bryson); Department of Neurology, Austin Hospital, Melbourne, Australia (Dr Bryson); Melbourne School of Psychological Sciences, University of Melbourne, Australia (Dr Carter); Department of Psychiatry, Austin Hospital, Melbourne, Australia (Drs Norman and Kanaan); Department of Psychiatry, University of Melbourne, Australia (Drs Norman and Kanaan)
| | - Trevor Norman
- Howard Florey Institute of Neuroscience & Mental Health, University of Melbourne, Australia (Dr Bryson); Department of Neurology, Austin Hospital, Melbourne, Australia (Dr Bryson); Melbourne School of Psychological Sciences, University of Melbourne, Australia (Dr Carter); Department of Psychiatry, Austin Hospital, Melbourne, Australia (Drs Norman and Kanaan); Department of Psychiatry, University of Melbourne, Australia (Drs Norman and Kanaan)
| | - Richard Kanaan
- Howard Florey Institute of Neuroscience & Mental Health, University of Melbourne, Australia (Dr Bryson); Department of Neurology, Austin Hospital, Melbourne, Australia (Dr Bryson); Melbourne School of Psychological Sciences, University of Melbourne, Australia (Dr Carter); Department of Psychiatry, Austin Hospital, Melbourne, Australia (Drs Norman and Kanaan); Department of Psychiatry, University of Melbourne, Australia (Drs Norman and Kanaan)
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Preliminary Predictors of Initial Attendance, Symptom Burden, and Motor Subtype in a US Functional Neurological Disorders Clinic Population. Cogn Behav Neurol 2017; 29:197-205. [PMID: 27984257 DOI: 10.1097/wnn.0000000000000106] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND OBJECTIVE Although many patients present with functional neurological symptoms (FNS), few US clinics offer specialized FNS care, and data on clinic attendees remain limited. We determined predictors of initial attendance, symptom burden, and FNS subtype in the first patients referred to our Functional Neurological Disorders Clinic for suspected FNS. METHODS We reviewed the charts of 62 consecutive patients (46 women, 16 men). Regression analyses investigated predictors of keeping the first scheduled clinic appointment. For the 49 patients who did keep that appointment, regression analyses examined neuropsychiatric factors associated with symptom burden and motor FNS subtypes. RESULTS The odds of not keeping the first appointment were 10.4 times greater for patients referred from the emergency department than from other sources. The patients who kept their appointment reported a symptom burden that was significantly associated with a past FNS-related emergency department visit and a diagnosis of another medically unexplained somatic syndrome. The number of FNS findings on neurological examination also correlated with a history of an FNS-related emergency department visit. Patients with psychogenic non-epileptic seizures reported cognitive complaints and prior psychiatric hospitalizations significantly more often than did patients with other FNS. One fourth of all patients had two or more motor FNS. CONCLUSIONS In our FNS cohort, patients were less likely to keep an initial clinic appointment if they were referred from the emergency department than from other sources. Patients with psychogenic non-epileptic seizures were more likely to report cognitive symptoms and past psychiatric hospitalizations than patients with other FNS.
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Abstract
Functional neurological symptom disorder (FNSD) is characterized by motor or sensory impairments inconsistent with recognized neurologic conditions. Usually emerging in adolescence, somatic symptoms remain challenging for the physician to assess and treat. Also termed "conversion disorder," FNSD has been recently reconceptualized with greater diagnostic emphasis on positive neurologic findings while eliminating the requirement for a precipitating stressor. This has broadened the initial treatment emphasis from mandating psychotherapeutic engagement to a more collaborative model that requires open communication of neurologic findings and strives to align with families' perspectives. Severe disorders necessitate a unified treatment approach from several clinical specialties, including behavioral approaches, and pediatricians may play a central role in the management of youth with FNSD as well as their families. Treatment engagement can be facilitated by validating the distress of the patient, providing resources to address diagnostic questions and parental concerns, and implementing shared goals toward rapid return to self-efficacy. [Pediatr Ann. 2016;45(10):e356-e361.].
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178
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Wilshire CE, Ward T. Psychogenic Explanations of Physical Illness. PERSPECTIVES ON PSYCHOLOGICAL SCIENCE 2016; 11:606-631. [DOI: 10.1177/1745691616645540] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
In some patients with chronic physical complaints, detailed examination fails to reveal a well-recognized underlying disease process. In this situation, the physician may suspect a psychological cause. In this review, we critically evaluated the evidence for this causal claim, focusing on complaints presenting as neurological disorders. There were four main conclusions. First, patients with these complaints frequently exhibit psychopathology but not consistently more often than patients with a comparable “organic” diagnosis, so a causal role cannot be inferred. Second, these patients report a high incidence of adverse life experiences, but again, there is insufficient evidence to indicate a causal role for any particular type of experience. Third, although psychogenic illnesses are believed to be more responsive to psychological interventions than comparable “organic” illnesses, there is currently no evidence to support this claim. Finally, recent evidence suggests that biological and physical factors play a much greater causal role in these illnesses than previously believed. We conclude that there is currently little evidential support for psychogenic theories of illness in the neurological domain. In future research, researchers need to take a wider view concerning the etiology of these illnesses.
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180
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Can motor imagery and hypnotic susceptibility explain Conversion Disorder with motor symptoms? Neuropsychologia 2016; 89:287-298. [PMID: 27346334 DOI: 10.1016/j.neuropsychologia.2016.06.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Revised: 06/08/2016] [Accepted: 06/22/2016] [Indexed: 11/24/2022]
Abstract
Marked distortions in sense of agency can be induced by hypnosis in susceptible individuals, including alterations in subjective awareness of movement initiation and control. These distortions, with associated disability, are similar to those experienced with Conversion Disorder (CD), an observation that has led to the hypothesis that hypnosis and CD share causal mechanisms. The purpose of this review is to explore the relationships among motor imagery (MI), hypnotic susceptibility, and CD, then to propose how MI ability may contribute to hypnotic responding and CD. Studies employing subjective assessments of mental imagery have found little association between imagery abilities and hypnotic susceptibility. A positive association between imagery abilities and hypnotic susceptibility becomes apparent when objective measures of imagery ability are employed. A candidate mechanism to explain motor responses during hypnosis is kinaesthetic MI, which engages a strategy that involves proprioception or the "feel" of movement when no movement occurs. Motor suppression imagery (MSI), a strategy involving inhibition of movement, may provide an alternate objective measurable phenomenon that underlies both hypnotic susceptibility and CD. Evidence to date supports the idea that there may be a positive association between kinaesthetic MI ability and hypnotic susceptibility. Additional evidence supports a positive association between hypnotic susceptibility and CD. Disturbances in kinaesthetic MI performance in CD patients indicate that MI mechanisms may also underlie CD symptoms. Further investigation of the above relationships is warranted to explain these phenomena, and establish theoretical explanations underlying sense of agency.
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181
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Functional neurological disorders in outpatient practice: An Australian cohort. J Clin Neurosci 2016; 28:93-6. [DOI: 10.1016/j.jocn.2015.11.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 10/19/2015] [Accepted: 11/29/2015] [Indexed: 11/23/2022]
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182
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Merkler AE, Parikh NS, Chaudhry S, Chait A, Allen NC, Navi BB, Kamel H. Hospital revisit rate after a diagnosis of conversion disorder. J Neurol Neurosurg Psychiatry 2016; 87:363-6. [PMID: 25855400 DOI: 10.1136/jnnp-2014-310181] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Accepted: 03/19/2015] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To estimate the hospital revisit rate of patients diagnosed with conversion disorder (CD). METHODS Using administrative data, we identified all patients discharged from California, Florida and New York emergency departments (EDs) and acute care hospitals between 2005 and 2011 with a primary discharge diagnosis of CD. Patients discharged with a primary diagnosis of seizure or transient global amnesia (TGA) served as control groups. Our primary outcome was the rate of repeat ED visits and hospital admissions after initial presentation. Poisson regression was used to compare rates between diagnosis groups while adjusting for demographic characteristics. RESULTS We identified 7946 patients discharged with a primary diagnosis of CD. During a mean follow-up of 3.0 (±1.6) years, patients with CD had a median of three (IQR, 1-9) ED or inpatient revisits, compared with 0 (IQR, 0-2) in patients with TGA and 3 (IQR, 1-7) in those with seizures. Revisit rates were 18.25 (95% CI, 18.10 to 18.40) visits per 100 patients per month in those with CD, 3.90 (95% CI, 3.84 to 3.95) in those with TGA and 17.78 (95% CI, 17.75 to 17.81) in those with seizures. As compared to CD, the incidence rate ratio for repeat ED visits or hospitalisations was 0.89 (95% CI, 0.86 to 0.93) for seizure disorder and 0.32 (95% CI 0.31 to 0.34) for TGA. CONCLUSIONS CD is associated with a substantial hospital revisit rate. Our findings suggest that CD is not an acute, time-limited response to stress, but rather that CD is a manifestation of a broader pattern of chronic neuropsychiatric disease.
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Affiliation(s)
- Alexander E Merkler
- Department of Neurology, Weill Cornell Medical College, New York, New York, USA
| | - Neal S Parikh
- Department of Neurology, Weill Cornell Medical College, New York, New York, USA
| | - Simriti Chaudhry
- Department of Psychiatry, Weill Cornell Medical College, New York, New York, USA
| | - Alanna Chait
- Department of Psychiatry, Weill Cornell Medical College, New York, New York, USA
| | - Nicole C Allen
- Department of Psychiatry, Montefiore Medical Center, Bronx, New York, USA
| | - Babak B Navi
- Department of Neurology, Weill Cornell Medical College, New York, New York, USA Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, New York, USA
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medical College, New York, New York, USA Feil Family Brain and Mind Research Institute, Weill Cornell Medical College, New York, New York, USA
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183
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Schwingenschuh P, Saifee TA, Katschnig-Winter P, Macerollo A, Koegl-Wallner M, Culea V, Ghadery C, Hofer E, Pendl T, Seiler S, Werner U, Franthal S, Maurits NM, Tijssen MA, Schmidt R, Rothwell JC, Bhatia KP, Edwards MJ. Validation of "laboratory-supported" criteria for functional (psychogenic) tremor. Mov Disord 2016; 31:555-62. [PMID: 26879346 DOI: 10.1002/mds.26525] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 11/24/2015] [Accepted: 12/06/2015] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND In a small group of patients, we have previously shown that a combination of electrophysiological tests was able to distinguish functional (psychogenic) tremor and organic tremor with excellent sensitivity and specificity. OBJECTIVES This study aims to validate an electrophysiological test battery as a tool to diagnose patients with functional tremor with a "laboratory-supported" level of certainty. METHODS For this prospective data collection study, we recruited 38 new patients with functional tremor (mean age 37.9 ± 24.5 years; mean disease duration 5.9 ± 9.0 years) and 73 new patients with organic tremor (mean age 55.4 ± 25.4 years; mean disease duration 15.8 ± 17.7 years). Tremor was recorded at rest, posture (with and without loading), action, while performing tapping tasks (1, 3, and 5 Hz), and while performing ballistic movements with the less-affected hand. Electrophysiological tests were performed by raters blinded to the clinical diagnosis. We calculated a sum score for all performed tests (maximum of 10 points) and used a previously suggested cut-off score of 3 points for a diagnosis of laboratory-supported functional tremor. RESULTS We demonstrated good interrater reliability and test-retest reliability. Patients with functional tremor had a higher average score on the test battery when compared with patients with organic tremor (3.6 ± 1.4 points vs 1.0 ± 0.8 points; P < .001), and the predefined cut-off score for laboratory-supported functional tremor yielded a test sensitivity of 89.5% and a specificity of 95.9%. CONCLUSION We now propose this test battery as the basis of laboratory-supported criteria for the diagnosis of functional tremor, and we encourage its use in clinical and research practice.
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Affiliation(s)
- Petra Schwingenschuh
- Department of Neurology, Medical University of Graz, Graz, Austria.,Division of Neuroradiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Tabish A Saifee
- Sobell Department, UCL Institute of Neurology, London, United Kingdom
| | | | | | | | - Valeriu Culea
- Department of Neurology, Medical University of Graz, Graz, Austria
| | | | - Edith Hofer
- Department of Neurology, Medical University of Graz, Graz, Austria.,Institute for Medical Informatics, Statistics and Documentation, Medical University of Graz, Graz, Austria
| | - Tamara Pendl
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Stephan Seiler
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Ulrike Werner
- Department of Neurology, Medical University of Graz, Graz, Austria
| | | | - Natasha M Maurits
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Marina A Tijssen
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Reinhold Schmidt
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - John C Rothwell
- Sobell Department, UCL Institute of Neurology, London, United Kingdom
| | - Kailash P Bhatia
- Sobell Department, UCL Institute of Neurology, London, United Kingdom
| | - Mark J Edwards
- Sobell Department, UCL Institute of Neurology, London, United Kingdom.,Department for Cardiovascular and Cell Sciences, St. George's University of London, London, United Kingdom
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184
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Matthews A, Brown M, Stone J. Inpatient Physiotherapy for Functional (Psychogenic) Gait Disorder: A Case Series of 35 Patients. Mov Disord Clin Pract 2016; 3:603-606. [PMID: 30838253 DOI: 10.1002/mdc3.12325] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 12/09/2015] [Accepted: 12/19/2015] [Indexed: 11/05/2022] Open
Abstract
Patients with functional gait disorder (FGD) are often referred for physiotherapy, but data on their outcome is limited. The authors present a case series of 35 patients who received targeted physiotherapy for FGD at a regional neuroscience center (mean number of sessions, 11). Significant improvements in the Modified Rivermead Mobility Index (score range, 0-40) were recorded between pretreatment and posttreatment (mean pretreatment vs. posttreatment score, 20 vs. 37, respectively). Improvements also were seen in patients who had chronic symptoms, including those with symptom duration over 6 months (mean pretreatment vs. posttreatment score, 21 vs. 33, respectively) and in patients who had no psychological intervention. These data support the hypothesis that specific physiotherapy for FGD can be surprisingly effective and further encourage the development of larger randomized trials to test efficacy.
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Affiliation(s)
- Audrey Matthews
- Physiotherapy Department Institute of Neurological Sciences Queen Elizabeth University Hospital Glasgow UK
| | - Melanie Brown
- Physiotherapy Department Institute of Neurological Sciences Queen Elizabeth University Hospital Glasgow UK
| | - Jon Stone
- Department of Clinical Neurosciences University of Edinburgh Western General Hospital Edinburgh UK
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185
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Abstract
Physical interventions are widely considered an important part of treatment of functional neurologic disorders (FNDs). The evidence base for physical interventions has been limited to a collection of case series, but the recent publication of several large cohort studies and a randomized controlled trial have provided stronger evidence to support its use. While the evidence for efficacy appears to be promising, details on how this should be delivered remain limited, perhaps due to the dominance of psychologically focused etiologic models. A move towards understanding how the symptoms of FND are generated on a neurobiologic level has resulted in an expansion of pathophysiologic models providing a clearer rationale for physical treatment. In this context, the motor symptoms of FND can be considered as learnt patterns of movement, driven by attention and belief. Physical treatment aims to retrain movement by redirecting attention and addressing unhelpful illness beliefs and behaviors. The patient's problems should be considered in a broad biopsychosocial framework where symptom-predisposing, precipitating, and perpetuating factors can be addressed within a multidisciplinary environment as a gold standard. Further research is required to refine interventions and create evidence-based treatment guidelines.
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Affiliation(s)
- G Nielsen
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology and Therapy Services, National Hospital for Neurology and Neurosurgery, Queen Square, London, UK.
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186
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Abstract
The prognosis of functional (psychogenic) neurologic disorders is important in being able to help answer patients' and carers' questions, determine whether treatment is worthwhile, and to find out which factors predict outcome. We reviewed data on prognosis of functional neurologic disorders from two systematic reviews on functional motor disorders and dissociative (nonepileptic) seizures as well as additional studies on functional visual and sensory symptoms. Methodologic problems include heterogeneity in studied samples and outcome measures, diagnostic suspicion and referral bias, small size and retrospective design of available studies, possible treatments during follow-up, and literature review bias. With these caveats, the prognosis of functional neurologic disorders does appear to be generally unfavorable. In most studies, functional motor symptoms and psychogenic nonepileptic attacks remain the same or are worse in the majority of patients at follow-up. Measures of quality of life and working status were often poor at follow-up. Frequency of misdiagnosis at follow-up was as low as other neurologic and psychiatric disorders. Long duration of symptoms was the most distinct negative predictor. Early diagnosis and young age seem to predict good outcome. Emotional disorders and personality disorders were inconsistent predictors. Litigation and state benefits were found to be negative predictors in some studies, but others found they did not influence outcome.
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Affiliation(s)
- J Gelauff
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - J Stone
- Department of Clinical Neurosciences, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
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187
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Nicholson TRJ, Voon V. Transcranial magnetic stimulation and sedation as treatment for functional neurologic disorders. HANDBOOK OF CLINICAL NEUROLOGY 2016; 139:619-629. [PMID: 27719877 DOI: 10.1016/b978-0-12-801772-2.00050-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Functional neurologic disorder (FND), also known as conversion disorder, is common and often associated with a poor prognosis. It has been relatively neglected by research and as such there is a conspicuous lack of evidence-based treatments. Physical and psychologic therapies are the main treatment modalities, over and above reassurance and sensitive explanation of the diagnosis. However there are two other historic treatments that have seen a recent resurgence of interest and use. The first is electric stimulation, which was initially pioneered with direct stimulation of nerves but now used indirectly (and therefore noninvasively) in the form of transcranial magnetic stimulation (TMS). The second is (therapeutic) sedation, previously known as "abreaction," where it was mostly used in the context of psychologic investigation and treatment, but now increasingly advocated during rehabilitation as a way to therapeutically demonstrate reversibility of symptoms. This chapter introduces the background of these treatment modalities, their evolution into their current applications before critically evaluating their current evidence base and exploring possible mechanisms of action. It also tentatively suggests when they should be considered in current practice and briefly considers their future potential. In summary there is encouraging preliminary evidence to suggest that both TMS and sedation may be effective treatments for FNDs.
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Affiliation(s)
- T R J Nicholson
- Section of Cognitive Neuropsychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.
| | - V Voon
- Department of Psychiatry, Behavioural and Clinical Neurosciences Institute, University of Cambridge, Cambridge, UK
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188
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Bass C, Halligan P. Factitious disorders and malingering in relation to functional neurologic disorders. HANDBOOK OF CLINICAL NEUROLOGY 2016; 139:509-520. [PMID: 27719868 DOI: 10.1016/b978-0-12-801772-2.00042-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Interest in malingering has grown in recent years, and is reflected in the exponential increase in academic publications since 1990. Although malingering is more commonly detected in medicolegal practice, it is not an all-or-nothing presentation and moreover can vary in the extent of presentation. As a nonmedical disorder, the challenge for clinical practice remains that malingering by definition is intentional and deliberate. As such, clinical skills alone are often insufficient to detect it and we describe psychometric tests such as symptom validity tests and relevant nonmedical investigations. Finally, we describe those areas of neurologic practice where symptom exaggeration and deception are more likely to occur, e.g., postconcussional syndrome, psychogenic nonepileptic seizures, motor weakness and movement disorders, and chronic pain. Factitious disorders are rare in clinical practice and their detection depends largely on the level of clinical suspicion supported by the systematic collection of relevant information from a variety of sources. In this chapter we challenge the accepted DSM-5 definition of factitious disorder and suggest that the traditional glossaries have neglected the extent to which a person's reported symptoms can be considered a product of intentional choice or selective psychopathology largely beyond the subject's voluntary control, or more likely, both. We present evidence to suggest that neurologists preferentially diagnose factitious presentations in healthcare workers as "hysterical," possibly to avoid the stigma of simulated illness.
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Affiliation(s)
- C Bass
- Department of Psychological Medicine, John Radcliffe Hospital, Oxford, UK.
| | - P Halligan
- School of Psychology, Cardiff University, Cardiff, UK
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189
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Rommelfanger KS. The role of placebo in the diagnosis and treatment of functional neurologic disorders. HANDBOOK OF CLINICAL NEUROLOGY 2016; 139:607-617. [PMID: 27719875 DOI: 10.1016/b978-0-12-801772-2.00049-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Placebo therapy can produce meaningful, clinical relief for a variety of conditions. While placebos are not without their ethically fraught history, they continue to be used, largely covertly, even today. Because the prognosis for psychogenic disorders is often poor and recovery may be highly dependent on the patient's belief in the diagnosis and treatment regimen, some physicians find placebo therapy for psychogenic disorders compelling, but also particularly contentious. Yet placebos also have a long tradition of being used for provocative diagnosis (wherein placebo is used to elicit and/or terminate the symptoms as a way of diagnosing symptoms as "psychogenic"). In this chapter we discuss cases describing placebo as therapy for psychogenic disorders and the challenges related to embedded Cartesian beliefs in Western medicine. The legitimate ethical reservations against placebo therapy, in general, have been related to assumptions about their "inertness" and a requirement for deception, both which are being refuted by emerging data. In this chapter, we also re-evaluate the concerns associated with placebo therapy for psychogenic disorders by asking, "Are we harming patients by withholding placebo treatment?"
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Affiliation(s)
- K S Rommelfanger
- Department of Neurology, Department of Psychiatry and Neuroethics Program, Center for Ethics, Emory University, Atlanta, GA, USA.
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190
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Dreissen YEM, Cath DC, Tijssen MAJ. Functional jerks, tics, and paroxysmal movement disorders. HANDBOOK OF CLINICAL NEUROLOGY 2016; 139:247-258. [PMID: 27719843 DOI: 10.1016/b978-0-12-801772-2.00021-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Functional jerks are among the most common functional movement disorders. The diagnosis of functional jerks is mainly based on neurologic examination revealing specific positive clinical signs. Differentiation from other jerky movements, such as tics, organic myoclonus, and primary paroxysmal dyskinesias, can be difficult. In support of a functional jerk are: acute onset in adulthood, precipitation by a physical event, variable, complex, and inconsistent phenomenology, suggestibility, distractibility, entrainment and a Bereitschaftspotential preceding the movement. Although functional jerks and tics share many similarities, characteristics differentiating tics from functional jerks are: urge preceding the tic, childhood onset, rostrocaudal development of the symptoms, a positive family history of tics, attention-deficit hyperactivity disorder or obsessive-compulsive symptoms, and response to dopamine antagonist medication. To differentiate functional jerks from organic myoclonus, localization of the movements can give direction. Further features in support of organic myoclonus include: insidious onset, simple and consistent phenomenology, and response to benzodiazepines or antiepileptic medication. Primary paroxysmal dyskinesias and functional jerks share a paroxysmal nature. Leading in the differentiation between the two are: a positive family history, in combination with video recordings revealing a consistent symptom pattern in primary paroxysmal dyskinesias. In this chapter functional jerks and their differential diagnoses will be discussed in terms of epidemiology, symptom characteristics, disease course, psychopathology, and supportive neurophysiologic tests.
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Affiliation(s)
- Y E M Dreissen
- Department of Neurology, University Medical Centre Groningen, Groningen, The Netherlands
| | - D C Cath
- Department of Clinical and Health Psychology, Utrecht University/Altrecht, Utrecht, The Netherlands
| | - M A J Tijssen
- Department of Neurology, University Medical Centre Groningen, Groningen, The Netherlands.
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191
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Abstract
Although currently lacking a sensitive and specific electrophysiologic battery test, functional (psychogenic) dystonia can sometimes be diagnosed with clinically definite certainty using available criteria. Certain regional phenotypes have been recognized as distinctive, such as unilateral lip and jaw deviation, laterocollis with ipsilateral shoulder elevation and contralateral shoulder depression, fixed wrist and finger flexion with relative sparing of the thumb and index fingers, and fixed foot plantar flexion and inversion. The pathophysiologic abnormalities in functional dystonia overlap substantially with those of organic dystonia, with similar impairments in cortical and spinal inhibition and somatosensory processing, but with emerging data suggesting abnormalities in regional blood flow and activation patterns on positron emission tomography and functional magnetic resonance imaging, respectively. Management of functional dystonia begins with compassionate and assertive debriefing of the diagnosis to ensure full acceptance by the patient, a critical step in enhancing the likelihood of success with physical rehabilitation, and psychodynamic or cognitive therapy. Physical therapy, with or without cognitive behavioral therapy, appears to be of benefit but has not yet been examined in a controlled fashion. While the prognosis remains grim for a substantial majority of patients, partly stemming from restricted mobility, delayed diagnosis, and inappropriate pharmacotherapy, early recognition and initiation of therapy stand to minimize iatrogenic harm and unnecessary laboratory investigations, and potentially reduce the long-term neurologic disability.
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192
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Stone J. Functional neurological disorders: the neurological assessment as treatment. Pract Neurol 2015; 16:7-17. [DOI: 10.1136/practneurol-2015-001241] [Citation(s) in RCA: 82] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2015] [Indexed: 11/03/2022]
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193
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Ricciardi L, Demartini B, Crucianelli L, Krahé C, Edwards MJ, Fotopoulou A. Interoceptive awareness in patients with functional neurological symptoms. Biol Psychol 2015; 113:68-74. [PMID: 26528552 DOI: 10.1016/j.biopsycho.2015.10.009] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Revised: 10/13/2015] [Accepted: 10/25/2015] [Indexed: 10/22/2022]
Abstract
Historically, emotional factors, such as trauma or psychological conflict, have been suggested as causal factors of functional motor disorders (FMD). More recent approaches have instead stressed potential neural and cognitive abnormalities in the allocation and maintenance of attention. Yet these studies have mostly focused on how attention is allocated to exteroceptive signals about the state of the body. Given the proposed important role of interoception for emotion, the study of FMD patients' ability to monitor their interoceptive signals may serve as a useful, mechanistic link between studies that aim to identify key emotional factors in FMD, and those that examine specific sensorimotor or cognitive abnormalities. In the current study, we compared the interoceptive awareness of a group of individuals with FMD (N=16) with a group of healthy controls (N=17). We employed a commonly used heartbeat detection task which tracks the level of concordance between one's heart rate and its subjective perception, as a proxy for interoceptive awareness more generally. We found that FMD patients have lower interoceptive accuracy than healthy subjects, and such reduced interoceptive accuracy was predictive of their depressive symptoms, as well as their tendency to focus on the external features of their body (self-objectification). Contary to our predictions, interoceptive accuracy was not predictive of alexithymia. These results suggest a potental trade-off between the allocation of attention to internal versus external aspects of the body in FMD. More generally, they warrant further investigation of interoceptive awareness in this population, as a means to understand their emotional abnormalities at a more mechanistic level than studies concentrating on traumatic life events and related risk factors.
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Affiliation(s)
- Lucia Ricciardi
- Sobell Department, UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK
| | - Benedetta Demartini
- Sobell Department, UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK; Cattedra di Psichiatria - Dipartimento di Scienze della Salute, Universita` degli Studi di Milano, Italy
| | | | - Charlotte Krahé
- Department of Neuroimaging, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Mark J Edwards
- Sobell Department, UCL Institute of Neurology, Queen Square, London WC1N 3BG, UK
| | - Aikaterini Fotopoulou
- Division of Psychology and Language Sciences, CEHP Research Department, University College London, London, UK.
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194
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Nielsen G, Stone J, Matthews A, Brown M, Sparkes C, Farmer R, Masterton L, Duncan L, Winters A, Daniell L, Lumsden C, Carson A, David AS, Edwards M. Physiotherapy for functional motor disorders: a consensus recommendation. J Neurol Neurosurg Psychiatry 2015; 86:1113-9. [PMID: 25433033 PMCID: PMC4602268 DOI: 10.1136/jnnp-2014-309255] [Citation(s) in RCA: 210] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 11/13/2014] [Indexed: 11/06/2022]
Abstract
BACKGROUND Patients with functional motor disorder (FMD) including weakness and paralysis are commonly referred to physiotherapists. There is growing evidence that physiotherapy is an effective treatment, but the existing literature has limited explanations of what physiotherapy should consist of and there are insufficient data to produce evidence-based guidelines. We aim to address this issue by presenting recommendations for physiotherapy treatment. METHODS A meeting was held between physiotherapists, neurologists and neuropsychiatrists, all with extensive experience in treating FMD. A set of consensus recommendations were produced based on existing evidence and experience. RESULTS We recommend that physiotherapy treatment is based on a biopsychosocial aetiological framework. Treatment should address illness beliefs, self-directed attention and abnormal habitual movement patterns through a process of education, movement retraining and self-management strategies within a positive and non-judgemental context. We provide specific examples of these strategies for different symptoms. CONCLUSIONS Physiotherapy has a key role in the multidisciplinary management of patients with FMD. There appear to be specific physiotherapy techniques which are useful in FMD and which are amenable to and require prospective evaluation. The processes involved in referral, treatment and discharge from physiotherapy should be considered carefully as a part of a treatment package.
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Affiliation(s)
- Glenn Nielsen
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London, UK Therapy Services, The National Hospital for Neurology and Neurosurgery, London, UK
| | - Jon Stone
- Department Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - Audrey Matthews
- Institute of Neurological Sciences, Southern General Hospital, Glasgow, UK
| | - Melanie Brown
- Institute of Neurological Sciences, Southern General Hospital, Glasgow, UK
| | - Chris Sparkes
- Therapy Services, The Ipswich Hospital NHS Trust, Ipswich, UK
| | - Ross Farmer
- South London & Maudsley NHS Foundation Trust, London, UK
| | | | - Linsey Duncan
- Community Rehabilitation and Brain Injury Service, West Lothian, UK
| | - Alisa Winters
- Department Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - Laura Daniell
- Department Clinical Neurosciences, Western General Hospital, Edinburgh, UK
| | - Carrie Lumsden
- Community Rehabilitation and Brain Injury Service, West Lothian, UK
| | - Alan Carson
- Department of Clinical Neurosciences, University of Edinburgh, Edinburgh, UK
| | - Anthony S David
- Institute of Psychiatry, King's College London, London, UK National Institute of Health Research Biomedical Research Centre at the South London & Maudsley NHS Foundation Trust and Institute of Psychiatry KCL, London, UK
| | - Mark Edwards
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London, UK
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195
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Lehn A, Gelauff J, Hoeritzauer I, Ludwig L, McWhirter L, Williams S, Gardiner P, Carson A, Stone J. Functional neurological disorders: mechanisms and treatment. J Neurol 2015; 263:611-20. [DOI: 10.1007/s00415-015-7893-2] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 08/28/2015] [Accepted: 08/28/2015] [Indexed: 12/01/2022]
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196
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Hubschmid M, Aybek S, Maccaferri GE, Chocron O, Gholamrezaee MM, Rossetti AO, Vingerhoets F, Berney A. Efficacy of brief interdisciplinary psychotherapeutic intervention for motor conversion disorder and nonepileptic attacks. Gen Hosp Psychiatry 2015; 37:448-55. [PMID: 26099544 DOI: 10.1016/j.genhosppsych.2015.05.007] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2014] [Revised: 05/21/2015] [Accepted: 05/22/2015] [Indexed: 12/22/2022]
Abstract
OBJECTIVE The objective was to compare a brief interdisciplinary psychotherapeutic intervention to standard care as treatments for patients recently diagnosed with severe motor conversion disorder or nonepileptic attacks. METHODS This randomized controlled trial of 23 consecutive patients compared (a) an interdisciplinary psychotherapeutic intervention group receiving four to six sessions by a consultation liaison psychiatrist, the first and last sessions adding a neurological consultation and a joint psychiatric and neurological consultation, and (b) a standard care group. After intervention, patients were assessed at 2, 6 and 12 months with the Somatoform Dissociation Questionnaire (SDQ-20), Clinical Global Impression scale, Rankin scale, use of medical care, global mental health [Montgomery and Asberg Depression Rating Scale, Beck Depression Inventory, mental health component of Short Form (SF)-36] and quality of life (SF-36). We calculated linear mixed models. RESULTS Our intervention brought a statistically significant improvement of physical symptoms [as measured by the SDQ-20 (P<.02) and the Clinical Global Impression scale (P=.02)] and psychological symptoms [better scores on the mental health component of the SF-36 (P<.05) and on the Beck Depression Inventory (P<.05)] and a reduction in new hospital stays after intervention (P<.05). CONCLUSION A brief psychotherapeutic intervention taking advantage of a close collaboration with neurology consultants in the setting of consultation liaison psychiatry appears effective.
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Affiliation(s)
- M Hubschmid
- Psychiatric Liaison Service, Department of Psychiatry, Lausanne University Hospital (CHUV), Rue du Bugnon 44, 1011 Lausanne, Switzerland.
| | - S Aybek
- Department of Clinical Neurosciences, Lausanne University Hospital (CHUV), Rue du Bugnon 44, 1011 Lausanne, Switzerland.
| | - G E Maccaferri
- Psychiatric Liaison Service, Department of Psychiatry, Lausanne University Hospital (CHUV), Rue du Bugnon 44, 1011 Lausanne, Switzerland.
| | - O Chocron
- Psychiatric Liaison Service, Department of Psychiatry, Lausanne University Hospital (CHUV), Rue du Bugnon 44, 1011 Lausanne, Switzerland.
| | - M M Gholamrezaee
- Department of Psychiatry, Lausanne University Hospital (CHUV), Rue du Bugnon 44, 1011 Lausanne, Switzerland.
| | - A O Rossetti
- Department of Clinical Neurosciences, Lausanne University Hospital (CHUV), Rue du Bugnon 44, 1011 Lausanne, Switzerland.
| | - F Vingerhoets
- Department of Clinical Neurosciences, Lausanne University Hospital (CHUV), Rue du Bugnon 44, 1011 Lausanne, Switzerland.
| | - A Berney
- Psychiatric Liaison Service, Department of Psychiatry, Lausanne University Hospital (CHUV), Rue du Bugnon 44, 1011 Lausanne, Switzerland.
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Bharadwaj S, Lee M, Moffat AC. Functional movement disorder: a long journey to diagnosis. BMJ Case Rep 2015; 2015:bcr-2015-211455. [PMID: 26318375 DOI: 10.1136/bcr-2015-211455] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 61-year-old man presented to a country clinic with involuntary orofacial movements and progressive cognitive decline, causing significant disability and psychosocial distress. Review of records uncovered a 7-year history of presentations to several specialties, including memory clinics, neurology, internal medicine and emergency departments, with varied symptoms, extensive complex work up and inconclusive diagnosis. Comprehensive review at our hospital highlighted inconsistent neurological signs, fluctuating cognition and psychosocial stressors, which preceded symptom onset, leading to the diagnosis of a functional movement disorder (FMD), which subsequently improved with relaxation therapy, cognitive-behavioural therapy and physiotherapy. We illustrate a variety of somatic symptoms, diagnostic clues and management outcomes for FMDs, and the importance of diagnostic criteria to minimise costly, time-consuming and ultimately unnecessary tests of exclusion.
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Affiliation(s)
- Sneha Bharadwaj
- Department of Geriatric Medicine, Fremantle Hospital, Perth, Western Australia, Australia
| | - Melissa Lee
- Fiona Stanley Hospital, Perth, Western Australia, Australia
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198
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Koegl-Wallner M, Schwingenschuh P. An update on functional (psychogenic) tremor. FUTURE NEUROLOGY 2015. [DOI: 10.2217/fnl.15.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Functional tremor accounts for at least 50% of patients with functional movement disorders. The diagnostic work-up of these patients can be challenging. It is a multistep process based on patients’ history and clinical criteria finally providing a ‘positive’ diagnosis. Variability of the tremor over the disease course and during clinical examination is characteristic. Patients often show increased attention toward the tremulous body part and distractability of the tremor once attention is drawn away. Sometimes distractability becomes obvious during history taking or neurological examination, in others certain distraction tasks are needed. If uncertainty remains, ancillary investigations such as electrophysiological tests may be helpful. Recent studies suggested that a loss of sense of control of ones actions may help to explain why patients with functional tremor report that they do not experience the abnormal movement as voluntary. Treatment has to be placed in a multidisciplinary team involving neurologists, psychiatrists, physiotherapists and psychologists.
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Affiliation(s)
- Mariella Koegl-Wallner
- Department of Neurology, Medical University of Graz, Auenbruggerplatz 22, 8036 Graz, Austria
| | - Petra Schwingenschuh
- Department of Neurology, Medical University of Graz, Auenbruggerplatz 22, 8036 Graz, Austria
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Hoeritzauer I, Stone J, Fowler C, Elneil-Coker S, Carson A, Panicker J. Fowler's syndrome of urinary retention: A retrospective study of co-morbidity. Neurourol Urodyn 2015; 35:601-3. [PMID: 25865606 DOI: 10.1002/nau.22758] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Accepted: 02/02/2015] [Indexed: 12/30/2022]
Abstract
AIMS To study the frequency of pain, psychological, or functional disorders in patients with Fowler's syndrome. METHODS We carried out a retrospective chart review of patients with a diagnosis of Fowler's syndrome attending the Uro-Neurology centre at the National Hospital for Neurology and Neurosurgery between 2009 and 2013 looking at triggering events, physical and psychological comorbidities. RESULTS Of 62 patients with clinical and electromyographic diagnosis of Fowler's syndrome, 31 (50%) had unexplained chronic pain syndromes, 12 (19%) of these were taking opiates. Fifteen (24%) had "functional" neurological symptoms. Abdominopelvic surgery with general anesthesia was the leading trigger (n = 21, 35%). CONCLUSIONS We found high levels of co-morbidity with patients having some form of pain (50%), a probable functional disorder (24%), or psychological symptoms (31%). There are several potential explanations for this association including the effect of developing an apparently unexplained distressing condition, confounding effect of opiate use or referral bias. The findings suggest a need for prospective systematic study of comorbidity for this disabling condition. Neurourol. Urodynam. 35:601-603, 2016. © 2015 Wiley Periodicals, Inc.
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Affiliation(s)
- Ingrid Hoeritzauer
- Department of Neurosciences, Royal Victoria Hospital, Belfast, United Kingdom
| | - Jon Stone
- Department of Clinical Neurosciences, University of Edinburgh, Western General Hospital, Crewe Rd, Edinburgh, United Kingdom
| | - Clare Fowler
- Department of Uro-Neurology, The National Hospital for Neurology and Neurosurgery and UCL Institute of Neurology, Queen Square, London, United Kingdom
| | - Suzy Elneil-Coker
- Department of Uro-Neurology, The National Hospital for Neurology and Neurosurgery and UCL Institute of Neurology, Queen Square, London, United Kingdom
| | - Alan Carson
- Department of Clinical Neurosciences, University of Edinburgh, Western General Hospital, Crewe Rd, Edinburgh, United Kingdom
| | - Jalesh Panicker
- Department of Uro-Neurology, The National Hospital for Neurology and Neurosurgery and UCL Institute of Neurology, Queen Square, London, United Kingdom
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