Medically unexplained neurologic symptoms: a primer for physicians who make the initial encounter

Medically unexplained symptoms are common in women in tertiary neurological healthcare center: A survey cohort study of persons investigated for suspected multiple sclerosis

BACKGROUND

A significant proportion of individuals with suspicious onset of multiple sclerosis (MS) does not fulfill the diagnostic criteria. Although some receive other diagnoses, many remain undiagnosed and lack healthcare follow-up. This study aimed to characterize persons with undetermined diagnosis (PwUD) through a questionnaire.

METHODS

Incident cases with suspected MS were consecutively admitted to a tertiary neurological healthcare center in a prospective cohort study. Those who remained undiagnosed after 40 months (mean, range 31-52) were considered PwUD. They completed a modified questionnaire, previously used in a population-based case-control study of incident MS cases. Their responses were compared with two control cohorts, persons with MS (PwMS) and healthy controls, randomly selected from national registries, matched by age, gender, and area of residence.

RESULTS

Out of 271 patients with suspected MS onset, 72 (20.3%) were PwUD with a female majority (79%). The response rate was 83% and 39% reported persisting MS-like symptoms. Compared to controls (n = 548) and PwMS (n = 277), fewer PwUD were currently smoking (p = .4 and p = .03), consumed less alcohol (p = .04 and p = .01), and had children (p = .02 and p = .002). PwUD reported occurrence of other autoimmune disease in 29%, higher compared to PwMS and controls (p < .001 and p < .001).

CONCLUSIONS

UD is common among persons investigated for suspected MS, in particular among female parents. Our data suggest that PwUD can be characterized as nonsmokers with low alcohol consumption and a higher prevalence of autoimmune disease, in particular thyroid disease.

Costs of adult functional neurological disorders at a tertiary hospital in central South Africa

Background

Functional neurological disorders (FND) lead to increased care requirements and costs, negatively impacting healthcare budgets. Healthcare expenditure in FND has escalated beyond other neurologic disorders during the past decade.

Objectives

To assess inpatient costs in adults admitted to the neurology ward at Universitas Academic Hospital (UAH) in central South Africa.

Methods

A retrospective observational study with a comparative component was conducted on patients admitted during 2018 and 2019. All FND cases (n = 29) and a systematic sample of other neurological disorders were included in the comparison group (n = 29). Data were obtained from the Meditech billing system and clinical records.

Results

FND patients accounted for 5.5% of 530 admissions in the neurology ward during the study period. No significant differences regarding daily median cost, age categories, gender or medical comorbidity were observed between FND and the comparison group. However, the length of stay was significantly shorter for the FND patients (median of four versus eight days), translating to approximately half the total costs of patients admitted for other neurological disorders.

Conclusion

The daily median cost was similar for FND and other neurology-related admissions. The lower overall inpatient costs for FND patients were only related to significantly shorter durations of stay, which may reflect new diagnostic approaches resulting from changes in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) diagnostic criteria. The prevalence of FND was similar to those reported in previous studies conducted at neurology clinics.

Contribution

The study contributes towards better understanding the prevalence and cost of FND in local neurology inpatient care settings.

How symptoms of simple acute infections affect the SSS-8 and SSD-12 as screening instruments for somatic symptom disorder in the primary care setting

Objective

Somatic symptom disorder (SSD) is one of the most common reasons for consultations in primary care, in addition to simple acute infections. Questionnaire-based screening instruments to identify patients at high risk of SSD are thus of great clinical relevance. Although screening instruments are frequently used, it is currently unclear to what extent they are influenced by the concurrent presence of simple acute infections. Therefore, this study aimed to investigate how symptoms of simple acute infections affect the two established questionnaires as screening instruments for somatic symptom disorder in the primary care setting.

Methods

In our cross-sectional, multicenter design, a total of 1,000 patients in primary care practices were screened using the two most established SSD screening questionnaires, the 8-item Somatic Symptom Scale (SSS-8) and the 12-item Somatic Symptom Disorder-B Criteria Scale (SSD-12), followed by clinical assessment by the primary care physician.

Results

A total of 140 patients with a simple acute infection (acute infection group, AIG) and 219 patients with chronic somatic symptoms (somatic symptom group, SSG) were included. The patients in the SSG showed higher total SSS-8 and SSD-12 scores than the patients in the AIG; however, the SSS-8 was more susceptible to changes triggered by symptoms of a simple acute infection than the SSD-12.

Conclusion

These results suggest that the SSD-12 is less susceptible to symptoms of a simple acute infection. Its total score and corresponding cutoff value provide a more specific and thus less susceptible screening tool for identifying SSD in primary care.

Functional neurological disorder: Extending the diagnosis to other disorders, and proposing an alternate disease term—Attentionally-modifiable disorder

BACKGROUND: The term “functional neurological disorder,” or “FND,” applies to disorders whose occurrence of neurological symptoms fluctuate with the patient’s attention to them. However, many other disorders that are not called “FND” nonetheless can also follow this pattern. Consequently, guidelines are unclear for diagnosing “FND.” OBJECTIVE: To review the neurological conditions that follow this pattern, but which have not so far been termed “FND,” to understand their overlap with conditions that have been termed “FND,” and to discuss the rationale for why FND has not been diagnosed for them. METHOD: A systematic review of the PubMed literature registry using the terms “fluctuation,” “inconsistency,” or “attention” did not yield much in the way of these candidate disorders. Consequently, this review instead relied on the author’s personal library of peer-reviewed studies of disorders that have resembled FND but which were not termed this way, due to his longstanding interest in this problem. Consequently, this approach was not systematic and was subjective regarding disease inclusion. RESULTS: This review identified numerous, diverse conditions that generally involve fluctuating neurological symptoms that can vary with the person’s attention to them, but which have not been called “FND.” The literature was unclear for reasons for not referring to “FND” in these instances. CONCLUSION: Most likely because of historical biases, the use of the term “FND” has been unnecessarily restricted. Because at its core FND is an attentionally-influenced disorder that can respond well to behavioral treatments, the field of neurological rehabilitation could benefit by extending the range of conditions that could be considered as “FND” and referred for similar behavioral treatments. Because the term “FND” has been viewed unfavorably by some patients and clinical practitioners and whose treatment is not implied, the alternative term attentionally-modifiable disorder is proposed.

Physical symptoms as psychiatric manifestations in medical spaces: A qualitative study

BACKGROUND

Mental health and physical health issues frequently co-occur, but the impact of the psychological wellbeing on the body's physical functioning remains poorly understood within medical spaces. Individuals living with psychiatric diagnoses in particular are at an increased risk for developing chronic health issues and may be especially disadvantaged by healthcare systems which treat the mind and body as separate entities.

METHODS

We used secondary analysis (SA) to analyze 30 semi-structured interviews of individuals living with a serious mental illness or reflecting on a family member living with a serious mental illness. We deliberately sampled participants who reflected on salient experiences with co-occurring physical and mental health symptoms. All participants were associated with the National Alliance on Mental Illness (NAMI), the nation's largest grassroots mental health organization. We coded interviews using qualitative thematic analysis with an interpretative phenomenological framework centered on participants' subjective experiences.

RESULTS

Our analyses uncovered physical health challenges which often occur in individuals living with a psychiatric illness, emphasizing the bidirectionality of mental and physical symptoms. We identified three overarching domains: (i) manifestations, in which participants reflected on how their body responded physically to mental states; (ii) medical management, in which they discussed challenging experiences seeking medical treatment for physical symptoms while living with a mental health condition; and (iii) disjointedness, in which they reflected on challenges in navigating poorly coordinated mental and physical healthcare systems.

DISCUSSION

Participants and their medical providers struggled to incorporate mental wellbeing and its impact on physical health into overall healthcare. Given common experiences with misdiagnoses, difficulties navigating health care, and significantly delayed treatment, medical spaces may be able to improve patient experiences and satisfaction by accounting for psychological influences on health outcomes.

CONCLUSION

Greater integration of physical and mental health care in medical spaces could improve health outcomes and reduce challenges for patients seeking treatment.

Characteristics and economic burden of frequent attenders with medically unexplained symptoms in primary care in Israel

Background

Frequent Attenders with Medically Unexplained Symptoms (FA/MUS) are common in primary care, though challenging to identify and treat.

Objectives

This study sought to compare FA/MUS to FA with organic illnesses (FA/OI) and the general clinic population (Non-FA) to understand their demographic characteristics and healthcare utilisation patterns.

Methods

For this retrospective, observational study, Electronic Medical Records (EMR) were obtained from Clalit Health Services, regarding the population of a sizeable primary care clinic in Be’er-Sheva, Israel. Electronic medical records were screened to identify the top 5% of FA. FA were stratified based on whether they had OI. FA without OI were then corroborated as having MUS by their physicians. Demographics, healthcare utilisation and costs were analysed for FA/OI, FA/MUS and Non-FA.

Results

Out of 594 FA, 305 (53.6%) were FA/OI and 264 (46.4%) were FA/MUS. FA/OI were older (69.1 vs. 56.4 years, p<.001) and costlier (ILS27693 vs. ILS9075, p<.001) than FA/MUS. Average costs for FA/MUS were over four times higher than Non-FA (ILS9075 vs. ILS2035, p<.001). The largest disparities between FA/OI and FA/MUS were in hospitalisations (ILS6998 vs. ILS2033) and surgical procedures (ILS8143 vs. ILS3175). Regarding laboratory tests, differences were smaller between groups of FA but significantly different between FA and Non-FA.

Conclusion

FA/MUS are more costly than Non-FA and exhibit unique healthcare utilisation and costs patterns. FA/OI had more severe illnesses necessitating hospitalisations and surgical interventions, while FA/MUS had more investigations and tests, attempting to find an explanation for their symptoms.

Persons with suspicious onset of multiple sclerosis but with undetermined diagnosis had persistent lower cognition and reduced quality of life

BACKGOUND

Differential diagnosis of multiple sclerosis (MS) includes a variety of disorders and misdiagnosis is common.

OBJECTIVE

To follow-up persons with suspected onset of MS but in whom the diagnostic investigation was negative.

METHODS

In a prospective study including 271 persons with clinical features of suspected MS onset, 136 persons were diagnosed with MS or clinically isolated syndrome (PwMS), 46 had other disorders, and 89 persons had a negative diagnostic work-up, i.e. persons with undetermined diagnosis (PwUD). They underwent diagnostic reassessment, and those who remained without a diagnosis were investigated for signs of pathology including cognitive tests and assessments of quality of life (QoL). Results were compared with those of PwMS and 24 age and sex matched healthy controls (HC).

RESULTS

After reassement 55 (20%) persons still had undetermined diagnosis (PwUD). They had similar age and gender distribution as PwMS. In 76% of PwUD, the suspected clinical onset included sensory symptoms. PwUD and PwMS scored similarly in cognitive tests and QoL but significantly lower than HC. At 3 years follow-up, PwMS and PwUD improved in most test parameters, but PwUD scored lower than PwMS in cognition.

CONCLUSION

PwUD constituted the dominating differential diagnosis in persons with suspected clinical onset of MS. QoL and cognition were comparable with those of PwMS but significantly lower than in HC.

Minimum Electromyographic Burst Duration in Healthy Controls: Implications for Electrodiagnosis in Movement Disorders

Background

Electromyogram (EMG) burst duration can provide additional diagnostic information when investigating hyperkinetic movement disorders, particularly when a functional movement disorder is suspected. It is generally accepted that EMG bursts <50 milliseconds are pathological.

Objective

To reassess minimum physiological EMG burst duration.

Methods

Surface EMG was recorded from face, trunk, and limb muscles in controls (n = 60; ages 19–85). Participants were instructed to generate the briefest possible ballistic movements involving each muscle (40 repetitions) or, in muscles spanning joints, to generate rapid rhythmic alternating movements (20–30 seconds), or both.

Results

We found no effect of age on EMG burst duration. However, EMG burst duration varied significantly between body regions. Rhythmic EMG bursts were shorter than ballistic bursts but only significantly so for lower limbs (P < 0.001). EMG bursts of duration <50 milliseconds were frequently observed, particularly in appendicular muscles.

Conclusion

We present normal reference data for minimum EMG burst duration, which may assist clinical interpretation when investigating hyperkinetic movement disorders.

The first-line management of psychogenic non-epileptic seizures (PNES) in adults in the emergency: a practical approach

Distinguishing non-epileptic events, especially psychogenic non-epileptic seizures (PNES), from epileptic seizures (ES) constitutes a diagnostic challenge. Misdiagnoses are frequent, especially when video-EEG recording, the gold-standard for PNES confirmation, cannot be completed. The issue is further complicated in cases of combined PNES with ES. In emergency units, a misdiagnosis can lead to extreme antiepileptic drug escalade, unnecessary resuscitation measures (intubation, catheterization, etc.), as well as needless biologic and imaging investigations. Outside of the acute window, an incorrect diagnosis can lead to prolonged hospitalization or increase of unhelpful antiepileptic drug therapy. Early recognition is thus desirable to initiate adequate treatment and improve prognosis. Considering experience-based strategies and a thorough review of the literature, we aimed to present the main clinical clues for physicians facing PNES in non-specialized units, before management is transferred to epileptologists and neuropsychiatrists. In such conditions, patient recall or witness-report provide the first orientation for the diagnosis, recognizing that collected information may be inaccurate. Thorough analysis of an event (live or based on home-video) may lead to a clinical diagnosis of PNES with a high confidence level. Indeed, a fluctuating course, crying with gestures of frustration, pelvic thrusting, eye closure during the episode, and the absence of postictal confusion and/or amnesia are highly suggestive of PNES. Moreover, induction and/or inhibition tests of PNES have a good diagnostic value when positive. Prolactinemia may also be a useful biomarker to distinguish PNES from epileptic seizures, especially following bilateral tonic-clonic seizures. Finally, regardless the level of certainty in the diagnosis of the PNES, it is important to subsequently refer the patient for epileptological and neuropsychiatric follow-up.

Functional Somatic Symptoms

BACKGROUND

Approximately 10% of the general population and around one third of adult patients in clinical populations suffer from functional somatic symptoms. These take many forms, are often chronic, impair everyday functioning as well as quality of life, and are cost intensive.

METHODS

The guideline group (32 medical and psychological professional societies, two patients' associations) carried out a systematic survey of the literature and ana- lyzed 3795 original articles and 3345 reviews. The aim was to formulate empirically based recommendations that were practical and user friendly.

RESULTS

Because of the variation in course and symptom severity, three stages of treatment are distinguished. In early contacts, the focus is on basic investigations, reassurance, and advice. For persistent burdensome symptoms, an extended, simultaneous and equitable diagnostic work-up of physical and psychosocial factors is recommended, together with a focus on information and self-help. In the pres- ence of severe and disabling symptoms, multimodal treatment includes further elements such as (body) psychotherapeutic and social medicine measures. Whatever the medical specialty, level of care, or clinical picture, an empathetic professional attitude, reflective communication, information, a cautious, restrained approach to diagnosis, good interdisciplinary cooperation, and above all active interventions for self-efficacy are usually more effective than passive, organ- focused treatments.

CONCLUSION

The cornerstones of diagnosis and treatment are biopsychosocial ex- planatory models, communication, self-efficacy, and interdisciplinary mangagement. This enables safe and efficient patient care from the initial presentation onwards, even in cases where the symptoms cannot yet be traced back to specific causes.

Chronic fatigue syndrome in the emergency department

PURPOSE

Chronic fatigue syndrome (CFS) is a debilitating disease characterized by fatigue, postexertional malaise, cognitive dysfunction, sleep disturbances, and widespread pain. A pilot, online survey was used to determine the common presentations of CFS patients in the emergency department (ED) and attitudes about their encounters.

METHODS

The anonymous survey was created to score the severity of core CFS symptoms, reasons for going to the ED, and Likert scales to grade attitudes and impressions of care. Open text fields were qualitatively categorized to determine common themes about encounters.

RESULTS

Fifty-nine percent of respondents with physician-diagnosed CFS (total n=282) had gone to an ED. One-third of ED presentations were consistent with orthostatic intolerance; 42% of participants were dismissed as having psychosomatic complaints. ED staff were not knowledgeable about CFS. Encounters were unfavorable (3.6 on 10-point scale). The remaining 41% of subjects did not go to ED, stating nothing could be done or they would not be taken seriously. CFS subjects can be identified by a CFS questionnaire and the prolonged presence (>6 months) of unremitting fatigue, cognitive, sleep, and postexertional malaise problems.

CONCLUSION

This is the first investigation of the presentation of CFS in the ED and indicates the importance of orthostatic intolerance as the most frequent acute cause for a visit. The self-report CFS questionnaire may be useful as a screening instrument in the ED. Education of ED staff about modern concepts of CFS is necessary to improve patient and staff satisfaction. Guidance is provided for the diagnosis and treatment of CFS in these challenging encounters.

Quantifying positive communication: Doctor's language and patient anxiety in primary care consultations

OBJECTIVE

Positive communication is advocated for physicians during consultations with patients presenting medically unexplained symptoms (MUS), but studies generally focus on what is said rather than how it is said. This study quantified language use differences of general practitioners (GPs), and assessed their relation to patient anxiety.

METHODS

Language use of 18 Dutch GPs during 82 consultations was compared for patients with MUS versus medically explained symptoms (MES). Message content (positive or negative) was differentiated from its directness (direct or indirect), and related to changes in patient's state anxiety (abbreviated State Trait Anxiety Inventory; STAI).

RESULTS

In total, 2590 clauses were identified. GPs approached patients with MES with relatively more direct (vs. indirect) positive and indirect (vs. direct) negative messages (OR 1.91, 95% CI 1.42-2.59). Anxiety of both patient groups increased when GPs used more direct (vs. indirect) negative messages (b = 0.67, 95% CI 0.07-1.27) CONCLUSIONS: GPs use different language depending on the content of messages for patients with MES, but not MUS. Direct negative messages relate to an increase in patient anxiety.

PRACTICE IMPLICATIONS

GPs could manage patient's state anxiety by expressing negative messages in an indirect rather than direct manner.

[Pathway to diagnosis and real-life experience of patients believing they are affected by "chronic Lyme disease"]

OBJECTIVES

Chronic Lyme disease is a subject of scientific and social controversy in both Europe and the United States. The aim of our study was to analyze the pathway to diagnosis of patients believing they were affected by the disease, and to describe their real-life experience.

METHOD

A qualitative study was performed with 13 patients declaring themselves to be affected by chronic Lyme disease. Interviews were analyzed by 2 general medical practice interns, supervised by a general practitioner with a diploma in socio-anthropology and an infectious diseases specialist.

RESULTS

Internet and other media played a major role in informing the patients or their doctor about the existence and the characteristics of chronic Lyme disease. The diagnosis was confirmed by features considered objective (chronic infection by Borrelia, tick bite, positive serology, beneficial or worsening effects of antibiotics). The long medical diagnosis and treatment process of those interviewed was marked by a conflicted relationship with the medical profession, caused by a feeling of non-recognition and abandonment. They reported their experience as being very painful, both because of the physical pain and also the psychological consequences of their condition.

CONCLUSION

Improving the diagnosis and therapeutic management of patients believing themselves to be affected by chronic Lyme disease appears highly necessary both to limit their search for diagnosis and their experience of pain. It could be based on existing guidelines concerning medically unexplained symptoms to which the chronic Lyme disease issue appears quite similar on several points.

Identifying patterns of communication in patients attending memory clinics: a systematic review of observations and signs with potential diagnostic utility

BACKGROUND

Subjective cognitive complaints are commonly encountered in primary care and often result in memory clinic referral. However, meta-analyses have shown that such concerns do not consistently correspond to objective memory impairment or predict future dementia. Memory clinic referrals are increasing, with greater proportions of patients attending who do not have dementia. Studies of interaction during memory clinic assessments have identified conversational profiles that can differentiate between dementia and functional disorders of memory. To date, studies exploring communication patterns for the purpose of diagnosis have not been reviewed. Such profiles could reduce unnecessary investigations in patients without dementia.

AIM

To identify and collate signs and observable features of communication, which could clinically differentiate between dementia and functional disorders of memory.

DESIGN AND SETTING

This was a systematic review and synthesis of evidence from studies with heterogeneous methodologies.

METHOD

A qualitative, narrative description and typical memory clinic assessment were employed as a framework.

RESULTS

Sixteen studies met the criteria for selection. Two overarching themes emerged: 1) observable clues to incapacity and cognitive impairment during routine assessment and interaction, and 2) strategies and accounts for loss of abilities in people with dementia.

CONCLUSION

Whether the patient attends with a companion, how they participate, give autobiographical history, demonstrate working memory, and make qualitative observations during routine cognitive testing are all useful in building a diagnostic picture. Future studies should explore these phenomena in larger populations, over longer periods, include dementia subtypes, and develop robust definitions of functional memory disorders to facilitate comparison.

Are Patients with Psychogenic Movement Disorders More Likely to be Healthcare Workers?

Background

Reported risk factors for the development of a psychogenic movement disorder (PMD) include young age, female gender, history of abuse, current or past psychiatric disorder, lower levels of education and socioeconomic status, and employment as a healthcare worker. Although employment in healthcare is included in several diagnostic criteria for PMD, as well as in many case series, this association has never been validated.

Methods

Using the University of Maryland Movement Disorder Database (UMMDD), we identified PMD cases, as well as patients with isolated focal dystonia as controls. An experienced movement disorder specialist diagnosed all patients, and all cases met criteria for clinically established PMD. Demographic and occupational histories were obtained from medical records and were supplemented by telephone interviews. PMD cases and controls were compared using t tests/χ² tests.

Results

Controls (n = 148) were older than PMD cases (n = 132), with an average age of 61.4 and 52.1 years, respectively (P < 0.001); there were no significant differences between groups with respect to gender, education level, and ethnicity. The proportion of healthcare workers was not significantly different between PMD cases and controls (25% of PMD cases vs. 20% of controls; P = 0.28).

Conclusions

In contrast to traditional teaching, this investigation demonstrates that in our patient population, patients with a PMD were no more likely to be employed as healthcare workers than patients with isolated focal dystonia. This study calls into question the use of employment in healthcare as a reliable criterion to support the diagnosis of PMD.

Psychogenic nonepileptic seizures and movement disorders: A comparative review

PURPOSE OF REVIEW

Neurologic symptoms due to a psychogenic cause are frequently seen in clinical practice. Psychogenic nonepileptic seizures (PNES) and psychogenic movement disorders (PMD) are among the most common psychogenic neurologic disorders. PNES and PMD are usually investigated and managed separately by different neurology subspecialists. We review the main epidemiologic and clinical features of both PNES and PMD, aiming to highlight their similarities and differences and to see whether a common framework for these disorders exists.

RECENT FINDINGS

Data from the literature show that there is a profound overlap between PNES and PMD, which would argue for a larger unifying pathophysiology with variable phenotypic manifestations.

SUMMARY

Collaborative and integrated research among epileptologists, movement disorders experts, psychiatrists, psychologists, and physiotherapists may increase our collective knowledge about the pathophysiologic mechanisms of PNES and PMD and therefore improve outcomes for these patients.