Functional Symptoms in Neurology: Case Studies

Physical examination in functional unresponsiveness

Functional unresponsiveness can present a diagnostic challenge, but there are many positive physical examination findings that may help to confirm this diagnosis. Some of these are associated with pain or potential tissue damage for the patient, and potentially ethical and legal risk for the practitioner, but several lesser-known physical examination techniques do not carry these risks. Such examination techniques include non-damaging irritative stimuli, a modification to the conventional hand drop test and evaluation of eyelid opening.

Functional neurological disorders: effective teaching for health professionals

Objectives

To provide an outline for the delivery of an educational course or lecture about functional neurological disorders (FND) that is directed towards health professionals with varying clinical knowledge and to highlight the educational efficacy that can be derived from a well-designed educational platform.

Method

Through multidisciplinary collaboration, a course designed to develop the skills for diagnosis and management of FND was created. Elements essential to the delivery of education are: (A) knowledge creation; (B) facilitating multidisciplinary cross-pollination; (C) listening to patients’ experiences; (D) communication skills practice; (E) case studies; (F) discipline specific mentoring; (G) establishing and addressing participant learning goals and (H) developing collegial and referral networks. Changes in participants’ knowledge and clinical practice were assessed via anonymous questionnaires before and after the course.

Results

Dramatically improved knowledge and confidence in assessment and management of people with FND has been found both immediately following the course as well as on 6-month follow-up.

Conclusion

It is possible to make real change in the understanding and management of medical and allied health clinicians working with people with FND with a low-cost intervention. Also, the development of educational networks and multidisciplinary collaboration can lead to the creation of therapeutic platforms for the diagnosis, management and advocacy of this patient group.

Moving from stigmatization toward competent interdisciplinary care of patients with functional neurological disorders: focus group interviews

PURPOSE

To explore facilitating and inhibiting factors in the inpatient care of patients with functional neurological disorders as experienced by interdisciplinary teams of healthcare professionals.

METHOD

Qualitative focus group interviews were conducted with 18 healthcare professionals of various professions. Data were analyzed using qualitative content analysis with inductive coding of data.

RESULTS

Two main categories were formulated: (a) Giving the diagnosis to patients - a moment of fragility and opportunities, and (b) Organization of care - ensuring the continuity and protecting patients' self-image. One overarching theme tied the two categories together: Establishing coherence in the inpatient trajectory - moving from stigmatization toward competent care. Coherence and steadiness in care was a prerequisite for transparency in goalsetting and for designating the responsibilities of individual healthcare professionals. Stigma and having clinical experience and knowledge of functional neurological disorders, as two counter-factors, influenced the extent to which this was achieved. Examples of facilitating factors for enhancing competent care were documentation of symptoms, effective ways of passing on clinical information, education, professional dialog, and organizational support.

DISCUSSION

To nurture competent care, guidelines, structured educational initiatives and other supportive actions should be promoted. We provide ideas for the next logical steps for clinical practice and research.IMPLICATIONS FOR REHABILITATIONClose collaboration between interdisciplinary healthcare professionals plays an important role for reaching optimal results in the rehabilitation of inpatients with functional neurological disorder.There is currently limited knowledge regarding the facilitating and inhibiting features encountered by interdisciplinary healthcare professionals in the provision of care for patients with a functional neurological disorder.The findings show that a working environment that endorses a skillful culture of practice and which facilitates actions to reduce problems that hamper effective teamwork needs to be promoted.Solutions that help to solve many obstacles encountered by the team of healthcare professionals in the care provision of patients with functional neurological disorders include open dialog regarding symptoms, diagnosis and treatment, effective ways of documenting and reporting symptoms, and availability of guidelines and supporting educational material.

Functional coma

Functional coma - here defined as a prolonged motionless dissociative attack with absent or reduced response to external stimuli - is a relatively rare presentation. In this chapter we examine a wide range of terms used to describe states of unresponsiveness in which psychologic factors are relevant to etiology, such as depressive stupor, catatonia, nonepileptic "pseudostatus," and factitious disorders, and discuss the place of functional or psychogenic coma among these. Historically, diagnosis of functional coma has sometimes been reached after prolonged investigation and exclusion of other diagnoses. However, as is the case with other functional disorders, diagnosis should preferably be made on the basis of positive findings that provide evidence of inconsistency between an apparent comatose state and normal waking nervous system functioning. In our review of physical signs, we find some evidence for the presence of firm resistance to eye opening as reasonably sensitive and specific for functional coma, as well as the eye gaze sign, in which patients tend to look to the ground when turned on to one side. Noxious stimuli such as Harvey's sign (application of high-frequency vibrating tuning fork to the nasal mucosa) can also be helpful, although patients with this disorder are often remarkably unresponsive to usually painful stimuli, particularly as more commonly applied using sternal or nail bed pressure. The use of repeated painful stimuli is therefore not recommended. We also discuss the role of general anesthesia and other physiologic triggers to functional coma.

Diagnosis and treatment of somatoform disorders

Many patients with somatoform disorders present to the neurology clinic, often after extensive evaluation that has left the patient and multiple other physicians frustrated. Knowledge of the typical characteristics of particular disorders enables the clinician to arrive at a positive diagnosis and facilitate referral to appropriate services. Using a series of representative cases, we review the DSM-IV-TR somatoform disorders most likely to present to the practicing neurologist, highlighting the epidemiologic features, typical presentations, and possible therapeutic approaches to each condition.