1
|
Sireci F, Ragucci F, Menozzi C, Cabboi MP, Picchetto L, Bassi MC, Ghirotto L, Cavallieri F, Pedroni C, Valzania F. Exploring therapeutic interventions for functional neurological disorders: a comprehensive scoping review. J Neurol 2024; 271:3908-3927. [PMID: 38775932 DOI: 10.1007/s00415-024-12441-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 04/24/2024] [Accepted: 04/25/2024] [Indexed: 07/10/2024]
Abstract
Functional Neurological Disorders (FNDs) are characterized by the symptoms experienced by the individuals but also by how they express personal experiences and concerns related to the clinical condition. Access to care programs for functional neurological symptoms appears challenging and may entail circular, self-perpetuating healthcare pathways. Given the challenging and misleading interpretations around FND, in advocating for care pathways beyond medical therapies, we designed a scoping review to map recently suggested practices and interventions. We identified 31 relevant papers published between January 2018 and December 2022. Most of the literature was gathered from the US and UK healthcare experiences, with documented interventions provided by multi-professional teams or stand-alone psychotherapists. We found different care pathways addressing either motor or non-motor manifestations. Persons with Functional Motor Disorder are more likely to be referred to physical therapy first, while Persons suffering from Non-Epileptic Seizures are to mental health services. A narrow focus was given to minor components of multimodal approaches (e.g. social workers, and occupational therapists). High heterogeneity was found between assessment instruments as well, reflecting different perspectives in selecting treatment outcomes (e.g., reduction of non-epileptic events, psychological functioning, motor symptoms). Among healthcare professionals, neurologists and (neuro)psychiatrists are typically engaged in formulating and delivering diagnoses, while treatment is often administered by physiotherapists and/or psychologists. In the context of FNDs, the complex etiopathological nature of the condition, including comorbidities, suggests the recommendation of multidisciplinary treatments adopting a stepped care model progressing from standard to higher level individualized modules may better suit individual complexities.
Collapse
Affiliation(s)
- Francesca Sireci
- Neurology Unit, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
| | - Federica Ragucci
- Neurology Unit, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123, Reggio Emilia, Italy.
| | - Chiara Menozzi
- Primary Care Department, Azienda USL-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
| | - Maria Paola Cabboi
- Neurology Unit, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
| | - Livio Picchetto
- Department of Neuroscience, Neurology Unit, S.Agostino Estense Hospital, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Maria Chiara Bassi
- Medical Library, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Luca Ghirotto
- Qualitative Research Unit, Scientific Directorate, Azienda USL-IRCCS di Reggio Emilia, Viale Umberto I, 50, 42123, Reggio Emilia, Italy
| | - Francesco Cavallieri
- Neurology Unit, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
| | - Cristina Pedroni
- Direzione Delle Professioni Sanitarie, Azienda USL-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
- Laurea Magistrale in Scienze Infermieristiche e Ostetriche, University of Modena and Reggio Emilia, Reggio Emilia, Italy
| | - Franco Valzania
- Neurology Unit, Neuromotor and Rehabilitation Department, Azienda USL-IRCCS di Reggio Emilia, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
| |
Collapse
|
2
|
Kyriazidis I, Demiri E, Mitsaki C, Dionyssiou D. When Nerves Tell a Different Story: Functional Neurological Disorder (FND) After a Minor Hand Injury. Cureus 2024; 16:e61218. [PMID: 38939299 PMCID: PMC11210830 DOI: 10.7759/cureus.61218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/28/2024] [Indexed: 06/29/2024] Open
Abstract
Hand injuries typically present with localized symptoms. However, we report an unusual case of a 32-year-old female who experienced a transient complete loss of sensation and motor function in her entire left nondominant hand after sustaining a minor 1 cm stab wound between the third and fourth metacarpals. Wound exploration under local anesthesia revealed no tendon, vascular, neural, or bony injury. Remarkably, she spontaneously regained full hand sensation and function within 120 minutes of the injury. Extensive neurological evaluation, including magnetic resonance imaging (MRI), electromyography (EMG), nerve conduction studies (NCS), and somatosensory evoked potentials (SSEPs), ruled out organic pathology and supported a diagnosis of functional neurological disorder (FND), specifically functional movement disorder (FMD). Close collaboration between hand surgeons, neurologists, and occupational therapists is essential for accurate diagnosis and appropriate multidisciplinary management. Further research is needed to elucidate the mechanisms underlying FND and optimize evidence-based treatment for FND in the context of hand trauma. The increased awareness of this condition across specialties involved in hand injury management is crucial to facilitate timely diagnosis and avoid unnecessary interventions.
Collapse
Affiliation(s)
- Ioannis Kyriazidis
- Department of Plastic and Reconstructive Surgery, General Hospital Papageorgiou, Thessaloniki, GRC
| | - Efterpi Demiri
- Department of Plastic and Reconstructive Surgery, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, GRC
| | - Charikleia Mitsaki
- Department of Plastic and Reconstructive Surgery, General Hospital Papageorgiou, Thessaloniki, GRC
| | - Dimitrios Dionyssiou
- Department of Plastic and Reconstructive Surgery, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Thessaloniki, GRC
| |
Collapse
|
3
|
Gilmour GS, Langer LK, Bhatt H, MacGillivray L, Lidstone SC. Factors Influencing Triage to Rehabilitation in Functional Movement Disorder. Mov Disord Clin Pract 2024; 11:515-525. [PMID: 38385766 PMCID: PMC11078488 DOI: 10.1002/mdc3.14007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/26/2024] [Accepted: 02/06/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND Treatment of functional movement disorder (FMD) should be individualized, yet factors determining rehabilitation engagement have not been evaluated. Subspecialty FMD clinics are uniquely poised to explore factors influencing treatment suitability and triage. OBJECTIVES To describe our approach and explore factors associated with triage to FMD rehabilitation. METHODS We conducted a retrospective chart review of 158 consecutive patients with FMD seen for integrated assessment by movement disorders neurology and psychiatry, with the purpose of triage to rehabilitation. Demographic and clinical variables were compared between patients triaged to therapy versus no therapy, and logistic regression was used to explore factors predictive of triage outcome. Change in primary outcome scores were analyzed. RESULTS Sixty-six patients (42%) were triaged to FMD therapy from July 2019 to December 2021. Patients triaged to therapy were more likely to have a constant movement disorder, gait disorder and/or tremor, hyperarousal, readiness for change, and people pleasing traits. Patients triaged to no therapy demonstrated persistent diagnostic disagreement, an inability to appreciate motor symptom inconsistency, low self-agency, a propensity to dissociate, and cluster B traits. 90% of patients triaged to rehabilitation had improved outcomes. CONCLUSIONS The ability to "opt-in" to FMD rehabilitation relies on different factors than those relevant to establishing a diagnosis. Unlike many other neurological disorders, a triage and treatment planning step is recommended to identify those likely to meaningfully engage at that time. Holistic assessment through a transdisciplinary lens, and working collaboratively with the patient is essential to prioritize symptoms, determine engagement, and identify treatment targets.
Collapse
Affiliation(s)
- Gabriela S. Gilmour
- Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western HospitalTorontoONCanada
- Division of Neurology, Department of MedicineUniversity of TorontoTorontoONCanada
- Division of Neurology, Department of Clinical NeurosciencesUniversity of CalgaryCalgaryABCanada
| | - Laura K. Langer
- KITE Research Institute, Toronto Rehabilitation Institute, University Health NetworkTorontoONCanada
| | - Haseel Bhatt
- Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western HospitalTorontoONCanada
- KITE Research Institute, Toronto Rehabilitation Institute, University Health NetworkTorontoONCanada
- Integrated Movement Disorders ProgramToronto Rehabilitation Institute, University Health NetworkTorontoONCanada
| | - Lindsey MacGillivray
- Integrated Movement Disorders ProgramToronto Rehabilitation Institute, University Health NetworkTorontoONCanada
- Centre for Mental Health, University Health Network and Department of PsychiatryUniversity of TorontoTorontoONCanada
| | - Sarah C. Lidstone
- Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western HospitalTorontoONCanada
- Division of Neurology, Department of MedicineUniversity of TorontoTorontoONCanada
- KITE Research Institute, Toronto Rehabilitation Institute, University Health NetworkTorontoONCanada
- Integrated Movement Disorders ProgramToronto Rehabilitation Institute, University Health NetworkTorontoONCanada
| |
Collapse
|
4
|
Gilmour GS, Langer LK, Lang AE, MacGillivray L, Lidstone SC. Neuropsychiatric phenotypes in functional movement disorder. CNS Spectr 2023; 28:747-755. [PMID: 37424291 DOI: 10.1017/s1092852923002353] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/11/2023]
Abstract
OBJECTIVE Functional movement disorder (FMD), the motor-dominant subtype of functional neurological disorder, is a complex neuropsychiatric condition. Patients with FMD also manifest non-motor symptoms. Given that patients with FMD are diagnosed based on motor phenotype, the contribution of non-motor features to the neuropsychiatric syndrome is not well characterized. The objective of this hypothesis-generating study was to explore potential novel, neuropsychiatric FMD phenotypes by combining movement disorder presentations with non-motor comorbidities including somatic symptoms, psychiatric diagnoses, and psychological traits. METHODS This retrospective chart review evaluated 158 consecutive patients with a diagnosis of FMD who underwent deep phenotyping across neurological and psychiatric domains. Demographic, clinical, and self-report features were analyzed. A data-driven approach using cluster analysis was performed to detect patterns when combining the movement disorder presentation with somatic symptoms, psychiatric diagnoses, and psychological factors. These new neuropsychiatric FMD phenotypes were then tested using logistic regression models. RESULTS Distinct neuropsychiatric FMD phenotypes emerged when stratifying by episodic vs. constant motor symptoms. Episodic FMD was associated with hyperkinetic movements, hyperarousal, anxiety, and history of trauma. In contrast, constant FMD was associated with weakness, gait disorders, fixed dystonia, activity avoidance, and low self-agency. Pain, fatigue, somatic preoccupation, and health anxiety were common across all phenotypes. CONCLUSION This study found patterns spanning the neurological-psychiatric interface that indicate that FMD is part of a broader neuropsychiatric syndrome. Adopting a transdisciplinary view of illness reveals readily identifiable clinical factors that are relevant for the development and maintenance of FMD.
Collapse
Affiliation(s)
- Gabriela S Gilmour
- Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, Toronto, ON, Canada
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Laura K Langer
- KITE Research Institute, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| | - Anthony E Lang
- Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital, Toronto, ON, Canada
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Lindsey MacGillivray
- Integrated Movement Disorders Program, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Centre for Mental Health, University Health Network, Toronto, ON, Canada
- Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Sarah C Lidstone
- Division of Neurology, Department of Medicine, University of Toronto, Toronto, ON, Canada
- KITE Research Institute, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Integrated Movement Disorders Program, Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
| |
Collapse
|
5
|
Blanco S, Mitra S, Howard C, Sumich A. Psychological trauma, mood and social isolation do not explain elevated dissociation in functional neurological disorder (FND). PERSONALITY AND INDIVIDUAL DIFFERENCES 2023. [DOI: 10.1016/j.paid.2022.111952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
|
6
|
Varley D, Sweetman J, Brabyn S, Lagos D, van der Feltz-Cornelis C. The clinical management of functional neurological disorder: A scoping review of the literature. J Psychosom Res 2023; 165:111121. [PMID: 36549074 DOI: 10.1016/j.jpsychores.2022.111121] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 12/13/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To date, there have been no reviews bringing together evidence on the clinical management of functional neurological disorder (FND) and patients', caregivers', and healthcare workers' experiences. This review provides an overview of the literature focused on the clinical management of FND. METHODS Four databases were searched, and a consultation exercise was conducted to retrieve relevant records dated from September 2010 to September 2020. Articles documenting diagnostic methods, treatments or interventions, or the experiences and perspectives of patients and healthcare workers in the clinical management of FND were included. RESULTS In total, 2756 records were retrieved, with 162 included in this review. The diagnostic methods reported predominantly included positive clinical signs, v-EEG and EEG. Psychological treatments and medication were the most reported treatments. Mixed findings of the effectiveness of CBT were found. Haloperidol, physiotherapy and scripted diagnosis were found to be effective in reducing FND symptoms. Several facilitators and barriers for patients accessing treatment for FND were reported. CONCLUSION The literature describing the clinical management for FND has increased considerably in recent times. A wide variety of diagnostic tools and treatments and interventions were found, with more focus being placed on tests that confirm a diagnosis than 'rule-out' tests. The main treatment type found in this review was medication. This review revealed that there is a lack of high-quality evidence and reflects the need for official clinical guidelines for FND, providing healthcare workers and patients the support needed to navigate the process to diagnose and manage FND.
Collapse
Affiliation(s)
- Danielle Varley
- Department of Health Sciences, University of York, York YO10 5DD, UK.
| | - Jennifer Sweetman
- Department of Health Sciences, University of York, York YO10 5DD, UK
| | - Sally Brabyn
- Department of Health Sciences, University of York, York YO10 5DD, UK
| | - Dimitris Lagos
- Hull York Medical School, University of York, York YO10 5DD, UK
| | - Christina van der Feltz-Cornelis
- Department of Health Sciences, University of York, York YO10 5DD, UK; Hull York Medical School, University of York, York YO10 5DD, UK; York Biomedical Research Institute, University of York, York YO10 5DD, UK; Institute of Health Informatics, University College London, London NW1 2DA, UK
| |
Collapse
|
7
|
Russell L, Butler L, Lovegrove C, Owens C, Roberts L, Yates P, Carrick R, Amoako A, Price C. Developing a multidisciplinary pathway for functional neurological disorders in a UK National Health Service: The Exeter model. ADVANCES IN CLINICAL NEUROSCIENCE & REHABILITATION 2022. [DOI: 10.47795/kazj3546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Functional neurological disorders remain common presentations to both outpatient and inpatient NHS services, but little consensus exists with respect to how such services and clinical pathways for patients should be structured and should function. This article sets out a model for an integrated multidisciplinary approach that takes full account of the number of specialties involved, constraint on resources and time involved, and that has functioned well in the NHS despite a pandemic.
Collapse
|
8
|
Polich G, Zalanowski S, Maney J, Perez DL, Baslet G, Maggio J, O’Neal MA, Dworetzky B, Herman S. Development of an inpatient rehabilitation pathway for motor functional neurological disorders: Initial reflections. NeuroRehabilitation 2022; 50:231-243. [DOI: 10.3233/nre-228006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND: Emerging research supports a primary role for rehabilitation therapy alongside psychoeducation and psychotherapy in the treatment of functional neurological disorder (FND). OBJECTIVE: While consensus recommendations for physical therapists, occupational therapists, and speech and language pathologists treating FND have been published, specific recommendations for multidisciplinary FND care delivered on an inpatient rehabilitation unit are yet to be established. METHODS: This report describes one inpatient rehabilitation facility’s efforts to design and implement a clinical pathway for patients with acute-onset motor FND—patients recently hospitalized for work-up of new neurological symptoms subsequently deemed functional. RESULTS: Detailed descriptions on defining admission criteria and delivering consensus- and evidence-based multidisciplinary inpatient rehabilitation are provided. CONCLUSIONS: In the context of prospective research studies, considerably more work is needed to delineate the optimal duration and intensity of inpatient rehabilitation treatment for the management of patients with motor FND.
Collapse
Affiliation(s)
- Ginger Polich
- Spaulding Rehabilitation Hospital, Charlestown, MA, USA
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| | | | - Julie Maney
- Spaulding Rehabilitation Hospital, Charlestown, MA, USA
| | - David L. Perez
- Departments of Neurology and Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Gaston Baslet
- Department of Psychiatry, Brigham and Women’s Hospital, Boston, MA, USA
| | - Julie Maggio
- Department of Physical Therapy, Massachusetts General Hospital, Boston, MA, USA
| | - Mary A. O’Neal
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Barbara Dworetzky
- Department of Neurology, Brigham and Women’s Hospital, Boston, MA, USA
| | - Seth Herman
- Department of Physical Medicine and Rehabilitation, California Rehabilitation Institute, Los Angeles, CA, USA
| |
Collapse
|
9
|
Mark VW. Functional neurological disorder: Extending the diagnosis to other disorders, and proposing an alternate disease term—Attentionally-modifiable disorder. NeuroRehabilitation 2022; 50:179-207. [DOI: 10.3233/nre-228003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
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.
Collapse
Affiliation(s)
- Victor W. Mark
- Department of Physical Medicine and Rehabilitation, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
| |
Collapse
|
10
|
Finkelstein SA, Adams C, Tuttle M, Saxena A, Perez DL. Neuropsychiatric Treatment Approaches for Functional Neurological Disorder: A How to Guide. Semin Neurol 2022; 42:204-224. [PMID: 35189644 DOI: 10.1055/s-0042-1742773] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
There is a growing body of knowledge regarding management of functional neurological disorder (FND). The aim of this article is to guide the clinician through FND clinical management, from delivery of the diagnosis, to creation of a biopsychosocially-informed treatment plan, to troubleshooting common issues that arise throughout longitudinal care. We review the evidence and core principles of both rehabilitative therapies (physical therapy, occupational therapy, and speech and language therapy) and psychological therapies for the treatment of FND, and discuss the benefits of engaging a multidisciplinary and interdisciplinary team. The optimal timing of specific therapeutic interventions is also discussed, emphasizing a patient-centered perspective. Resources for further reading, for both patients and clinicians, are provided throughout. Additional research is needed to further optimize the therapeutic approach to patients with FND, including the need to develop novel treatments for those that do not positively respond to currently available interventions.
Collapse
Affiliation(s)
- Sara A Finkelstein
- Functional Neurological Disorder Unit, Division of Cognitive Behavioral Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Caitlin Adams
- Functional Neurological Disorder Unit, Division of Cognitive Behavioral Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Inpatient Psychiatry, Department of Psychiatry, Mass General Brigham Salem Hospital, Salem, Massachusetts
| | - Margaret Tuttle
- Functional Neurological Disorder Unit, Division of Cognitive Behavioral Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Primary Care Psychiatry, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Aneeta Saxena
- Functional Neurological Disorder Unit, Division of Cognitive Behavioral Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Epilepsy Division, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - David L Perez
- Functional Neurological Disorder Unit, Division of Cognitive Behavioral Neurology, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.,Division of Neuropsychiatry, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
11
|
Abstract
Functional neurological disorder (FND), previously regarded as a diagnosis of exclusion, is now a rule-in diagnosis with available treatments. This represents a major step toward destigmatizing the disorder, which was often doubted and deemed untreatable. FND is prevalent, generally affecting young and middle aged adults, and can cause severe disability in some individuals. An early diagnosis, with subsequent access to evidence based rehabilitative and/or psychological treatments, can promote recovery-albeit not all patients respond to currently available treatments. This review presents the latest advances in the use of validated rule-in examination signs to guide diagnosis, and the range of therapeutic approaches available to care for patients with FND. The article focuses on the two most frequently identified subtypes of FND: motor (weakness and/or movement disorders) and seizure type symptoms. Twenty two studies on motor and 27 studies on seizure type symptoms report high specificities of clinical signs (64-100%), and individual signs are reviewed. Rehabilitative interventions (physical and occupational therapy) are treatments of choice for functional motor symptoms, while psychotherapy is an emerging evidence based treatment across FND subtypes. The literature to date highlights heterogeneity in responses to treatment, underscoring that more research is needed to individualize treatments and develop novel interventions.
Collapse
Affiliation(s)
- Selma Aybek
- Neurology Department, Psychosomatic Medicine Unit, Inselspital University Hospital, Bern, and Bern University, Bern, Switzerland
| | - David L Perez
- Divisions of Cognitive Behavioral Neurology and Neuropsychiatry, Functional Neurological Disorder Unit, Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
12
|
Management of Functional Neurological Disorders (FND): Experience from a Swiss FND Clinic. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2022. [DOI: 10.3390/ctn6010002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Functional neurological disorder (FND) represent a common disorder with significant socio-economic impact. In this context and alongside recent new neuroscientific insights, FND attracts a growing interest both in clinical practice and academic activities. New international recommendation and expert opinions suggest that therapy of FND should be a tailored multidisciplinary management involving the neurologist, the physiotherapist, and in most cases the psychotherapist/psychiatrist. A first decisive step is the establishment of a definitive diagnosis, based on the presence of clinical positive signs during neurological assessment together with a clear communication and explanation of the diagnosis by the neurologist. A second important step is based on individual therapeutic sessions, involving different disciplines (neurology and psychotherapy or neurology and physiotherapy). Comorbidities, such as pain or fatigue and psychiatric comorbidities (anxiety, depression, dissociation etc.) should be carefully evaluated, as they need an individualized treatment path. New FND clinics have been created worldwide over the last decades to offer such multidisciplinary settings and this article will present the experience of a first Swiss FND clinic created in 2016. The aim is to highlight in the form of a narrative review the current literature supporting the usefulness and importance of FND clinics, by reviewing the latest evidence on multidisciplinary interventions in FND.
Collapse
|
13
|
Cuoco S, Nisticò V, Cappiello A, Scannapieco S, Gambini O, Barone P, Erro R, Demartini B. Attachment styles, identification of feelings and psychiatric symptoms in functional neurological disorders. J Psychosom Res 2021; 147:110539. [PMID: 34091378 DOI: 10.1016/j.jpsychores.2021.110539] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 05/28/2021] [Accepted: 05/28/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The contribution of psychological and psychiatric symptoms in the development of Functional Neurological Disorders (FND) is unclear. We therefore aimed to investigate the role of different attachment styles (AS) and their relationship with psychiatric symptoms in FND patients as compared with both subjects with neurological disorders (ND) and healthy controls (HC); and the possible differences between patients with functional movement disorders (FMD) and with functional seizures. METHODS In this case-control study, forty-six patients with FND were compared to 34 with ND and 30 HC, by means of an extensive battery to investigate the presence of alexithymia, depression, anxiety, dissociation and to explore their AS using the Revised Experiences in Close Relationships instrument (ECR-R). RESULTS Patients with FND had higher depression and alexithymia as well as an avoidant pattern on the ECR-R than patients with ND. In the FND group, ECR-R avoidance was an independent predictor of psychiatric symptoms and, altogether, ECR-R avoidance, the somatic-affective component of depression and difficulty identifying feelings were independent predictors of FND. Gender, anxiety and difficulty identifying feelings predicted the presence of functional seizures. CONCLUSION The avoidant AS may be an important psychological factor influencing the presence of mood disorders and alexithymia. Their co-occurence might drive maladaptive responses underlying the presence of FND. Although we demonstrated a large overlap between FND phenotypes, patients with functional seizures might have higher alexithymia, which in turn could explain a defensive response less anchored to body reactions and physical symptoms.
Collapse
Affiliation(s)
- S Cuoco
- Neuroscience Section, Department of Medicine, Surgery and Dentistry "ScuolaMedicaSalernitana", University of Salerno, Italy.
| | - V Nisticò
- Dipartimento di Scienze della Salute, University of Milan, Italy; Aldo Ravelli' Research Center for Neurotechnology and Experimental Brain Therapeutics, University of Milan, Italy
| | - A Cappiello
- Neuroscience Section, Department of Medicine, Surgery and Dentistry "ScuolaMedicaSalernitana", University of Salerno, Italy
| | - S Scannapieco
- Neuroscience Section, Department of Medicine, Surgery and Dentistry "ScuolaMedicaSalernitana", University of Salerno, Italy
| | - O Gambini
- Dipartimento di Scienze della Salute, University of Milan, Italy; Aldo Ravelli' Research Center for Neurotechnology and Experimental Brain Therapeutics, University of Milan, Italy; Unità di Psichiatria II, Presidio San Paolo, ASST Santi Paolo e Carlo, Milano, Italy
| | - P Barone
- Neuroscience Section, Department of Medicine, Surgery and Dentistry "ScuolaMedicaSalernitana", University of Salerno, Italy
| | - R Erro
- Neuroscience Section, Department of Medicine, Surgery and Dentistry "ScuolaMedicaSalernitana", University of Salerno, Italy
| | - B Demartini
- Dipartimento di Scienze della Salute, University of Milan, Italy; Aldo Ravelli' Research Center for Neurotechnology and Experimental Brain Therapeutics, University of Milan, Italy; Unità di Psichiatria II, Presidio San Paolo, ASST Santi Paolo e Carlo, Milano, Italy
| |
Collapse
|
14
|
Stephen CD, Fung V, Lungu CI, Espay AJ. Assessment of Emergency Department and Inpatient Use and Costs in Adult and Pediatric Functional Neurological Disorders. JAMA Neurol 2021; 78:88-101. [PMID: 33104173 DOI: 10.1001/jamaneurol.2020.3753] [Citation(s) in RCA: 82] [Impact Index Per Article: 27.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Importance There is limited information about health care use and costs in patients with functional neurological disorders (FNDs). Objective To assess US emergency department (ED) and inpatient use and charges for FNDs. Design, Setting, and Participants This economic evaluation used Healthcare Cost and Utilization Project data to assess all-payer (1) adult (age, ≥18 years) hospitalizations (2008-2017), (2) pediatric (age, 5-17 years) hospitalizations (2003, 2006, 2009, 2012, and 2016), and (3) adult and pediatric ED evaluations (2008-2017). International Classification of Diseases, Ninth Revision, Clinical Modification code 300.11 (conversion disorder) or 306.0 (musculoskeletal malfunction arising from mental factors) and International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Clinical Modification codes for conversion disorder/functional neurological symptom disorder (F44.4 to F44.7) were used to conservatively define FNDs and to compare them with other neurological disorders that are associated with high levels of health care use. Analysis was performed between January 2019 and July 2020. Main Outcomes and Measures Admission traits (eg, demographic characteristics of patients, length of stay, and discharge disposition) and hospital charges. Results Compared with other neurological disorders in 2017, emergency FND evaluations of 36 359 adults (25 807 women [71.0%] and 3800 children (2733 girls [71.9%]) more frequently resulted in inpatient admissions (22 895 adult admissions [69.2% female] and 1264 pediatric admissions [73.4% ]). These FND admissions had a shorter mean (SEM) hospital length of stay (5.21 [0.15] days vs 6.03 [0.03] days, P < .001) but higher workup rates than admissions for comparable neurological diagnoses. Admissions for FNDs had low rates of inpatient physical therapy, occupational therapy, speech and language pathology, and psychiatric consultation. The total annual costs (a proxy for total costs in 2017 US dollars) were $1066 million (95% CI, $971-$1160 million) for adult FND inpatient charges in 2017 compared with $1241 million (95% CI, $1132-$1351 million) for anterior horn cell disease; $75 million (95% CI, $57-$92 million) for pediatric FND inpatient charges in 2012 compared with $86 million (95% CI, $63-$108 million) for demyelinating diseases; and $163 million (95% CI, $144-$182 million) for adult and pediatric ED visits in 2017 compared with $135 million (95% CI $111-$159 million) for refractory epilepsy. Total charges per admission for ED care of FNDs were higher than the other comparison groups in adults. Total costs and costs per admission for FNDs increased from 2008 to 2017 at a higher rate than that of other neurological disorders. Conclusions and Relevance This economic evaluation found that the more than $1.2 billion and increasing annual costs for ED and inpatient care of FNDs were similar to other investigation-intensive and pharmacologically demanding neurological disorders. Unnecessary investigations and iatrogenic harm inflate costs at the expense of necessary but neglected psychiatric and rehabilitative treatments.
Collapse
Affiliation(s)
- Christopher D Stephen
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Vicki Fung
- Health Policy Research Center, Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Codrin I Lungu
- Division of Clinical Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Alberto J Espay
- James J. and Joan A. Gardner Center for Parkinson's Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, Ohio
| |
Collapse
|
15
|
Sojka P, Paredes-Echeverri S, Perez DL. Are Functional (Psychogenic Nonepileptic) Seizures the Sole Expression of Psychological Processes? Curr Top Behav Neurosci 2021; 55:329-351. [PMID: 33768494 DOI: 10.1007/7854_2021_225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
Functional [psychogenic nonepileptic/dissociative] seizures (FND-seiz) and related functional neurological disorder subtypes were of immense interest to early founders of modern-day neurology and psychiatry. Unfortunately, the divide that occurred between the both specialties throughout the mid-twentieth century placed FND-seiz at the borderland between the two disciplines. In the process, a false Cartesian dualism emerged that labeled psychiatric conditions as impairments of the mind and neurological conditions as disturbances in structural neuroanatomy. Excitingly, modern-day neuropsychiatric perspectives now consider neurologic and psychiatric conditions as disorders of both brain and mind. In this article, we aim to integrate neurologic and psychiatric perspectives in the conceptual framing of FND-seiz. In doing so, we explore emerging relationships between symptoms, neuropsychological constructs, brain networks, and neuroendocrine/autonomic biomarkers of disease. Evidence suggests that the neuropsychological constructs of emotion processing, attention, interoception, and self-agency are important in the pathophysiology of FND-seiz. Furthermore, FND-seiz is a multi-network brain disorder, with evidence supporting roles for disturbances within and across the salience, limbic, attentional, multimodal integration, and sensorimotor networks. Risk factors, including the magnitude of previously experienced adverse life events, relate to individual differences in network architecture and neuroendocrine profiles. The time has come to use an integrated neuropsychiatric approach that embraces the closely intertwined relationship between physical health and mental health to conceptualize FND-seiz and related functional neurological disorder subtypes.
Collapse
Affiliation(s)
- Petr Sojka
- Department of Psychiatry, University Hospital Brno, Brno, Czech Republic.
| | - Sara Paredes-Echeverri
- Functional Neurological Disorder Research Program, Cognitive Behavioral Neurology Divisions, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - David L Perez
- Functional Neurological Disorder Research Program, Cognitive Behavioral Neurology and Neuropsychiatry Divisions, Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
16
|
Frucht L, Perez DL, Callahan J, MacLean J, Song PC, Sharma N, Stephen CD. Functional Dystonia: Differentiation From Primary Dystonia and Multidisciplinary Treatments. Front Neurol 2021; 11:605262. [PMID: 33613415 PMCID: PMC7894256 DOI: 10.3389/fneur.2020.605262] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 12/31/2020] [Indexed: 12/12/2022] Open
Abstract
Dystonia is a common movement disorder, involving sustained muscle contractions, often resulting in twisting and repetitive movements and abnormal postures. Dystonia may be primary, as the sole feature (isolated) or in combination with other movement disorders (combined dystonia), or as one feature of another neurological process (secondary dystonia). The current hypothesis is that dystonia is a disorder of distributed brain networks, including the basal ganglia, cerebellum, thalamus and the cortex resulting in abnormal neural motor programs. In comparison, functional dystonia (FD) may resemble other forms of dystonia (OD) but has a different pathophysiology, as a subtype of functional movement disorders (FMD). FD is the second most common FMD and amongst the most diagnostically challenging FMD subtypes. Therefore, distinguishing between FD and OD is important, as the management of these disorders is distinct. There are also different pathophysiological underpinnings in FD, with for example evidence of involvement of the right temporoparietal junction in functional movement disorders that is believed to serve as a general comparator of internal predictions/motor intentions with actual motor events resulting in disturbances in self-agency. In this article, we present a comprehensive review across the spectrum of FD, including oromandibular and vocal forms and discuss the history, clinical clues, evidence for adjunctive "laboratory-based" testing, pathophysiological research and prognosis data. We also provide the approach used at the Massachusetts General Hospital Dystonia Center toward the diagnosis, management and treatment of FD. A multidisciplinary approach, including neurology, psychiatry, physical, occupational therapy and speech therapy, and cognitive behavioral psychotherapy approaches are frequently required; pharmacological approaches, including possible targeted use of botulinum toxin injections and inpatient programs are considerations in some patients. Early diagnosis and treatment may help prevent unnecessary investigations and procedures, while facilitating the appropriate management of these highly complex patients, which may help to mitigate frequently poor clinical outcomes.
Collapse
Affiliation(s)
- Lucy Frucht
- Faculty of Arts and Sciences, Harvard University, Boston, MA, United States
| | - David L. Perez
- Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Functional Neurological Disorder Research Program, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Neuropsychiatry Division, Department of Psychiatry, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Janet Callahan
- MGH Institute of Healthcare Professionals, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Julie MacLean
- Occupational Therapy Department, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Phillip C. Song
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, United States
| | - Nutan Sharma
- Functional Neurological Disorder Research Program, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Dystonia Center and Movement Disorders Unit, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Christopher D. Stephen
- Functional Neurological Disorder Research Program, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
- Dystonia Center and Movement Disorders Unit, Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| |
Collapse
|
17
|
Chang C, McDonnell P, Gershwin ME. Complex regional pain syndrome - Autoimmune or functional neurologic syndrome. J Transl Autoimmun 2020; 4:100080. [PMID: 33490941 PMCID: PMC7804982 DOI: 10.1016/j.jtauto.2020.100080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/17/2020] [Accepted: 12/21/2020] [Indexed: 12/23/2022] Open
Abstract
Complex regional pain syndrome (CRPS) purports to explain extremity pain accompanied by a variety of subjective complaints, including sensitivity to touch, fatigue, burning sensations, allodynia and signs consistent with voluntary immobilization, including skin changes, edema and trophic changes. By its own definition, CRPS pain is disproportionate to any inciting event or underlying pathology, which means that the syndrome describes non-anatomic and exaggerated symptoms. Although CRPS was coined in the early 1990s, physicians have described unexplained exaggerated pain for centuries. Before a small group of researchers assigned this historical phenomenon with the name CRPS, other physicians in various subspecialties investigated the existence of a common pathophysiologic mechanism but found none. The literature was searched for evidence of a reproducible pathologic mechanism for CRPS. Although some have suggested that CRPS is an autoimmune disease, there is a paucity of evidence to support this. While cytokines such as IL-1β, IL-6 and TNF-α have been detected during the early phases of CRPS, this cannot lead to the conclusion that CRPS is an autoimmune disease, nor that it is an autoinflammatory disorder. Moreover, intravenous immunoglobulin has showed inconsistent results in the treatment of CRPS. On the other hand, CRPS has been found to meet at least three out of four criteria of malingering, which was previously a DSM-IV diagnosis; and its diagnostic criteria are virtually identical to current DSM-5 Functional Neurological Disorder ("FND"), and proposed ICD-11 classification, which includes FND as a distinct neurological diagnosis apart from any psychiatric condition. Unfortunately, the creation of CPRS is not merely misguided brand marketing. It has serious social and health issues. At least in part, the existence of CRPS has led to the labeling of many patients with a diagnosis that allows the inappropriate use of invasive surgery, addictive opioids, and ketamine. The CRPS hypothesis also ignores the nature and purpose of pain, as a symptom of some organic or psychological process. Physicians have long encountered patients who voice symptoms that cannot be biologically explained. Terminology historically used to describe this phenomenon have been medically unexplained symptoms ("MUS"), hysterical, somatic, non-organic, psychogenic, conversion disorder, or dissociative symptoms. The more recent trend describes disorders where there is a functional, rather than structural cause of the symptoms, as "functional disorders." Physicians report high success treating functional neurological symptoms with reassurance, physiotherapy, and cognitive behavior therapy measured in terms of functional improvement. The CRPS label, however, neither leads to functional improvement in these patients nor resolution of symptoms. Under principles of evidence-based medicine, the CRPS label should be abandoned and the syndrome should simply be considered a subset of FNDs, specifically Functional Pain Disorder; and treated appropriately.
Collapse
Affiliation(s)
- Christopher Chang
- Division of Rheumatology, Allergy and Clinical Immunology, University of California, Davis, 451 Health Sciences Drive, Suite 6510, Davis, CA, 95616, USA.,Division of Immunology, Allergy and Rheumatology, Joe DiMaggio Children's Hospital and Memorial Healthcare System, 1131 N 35th Avenue, Suite 220, Hollywood, FL, 33021, USA
| | | | - M Eric Gershwin
- Division of Rheumatology, Allergy and Clinical Immunology, University of California, Davis, 451 Health Sciences Drive, Suite 6510, Davis, CA, 95616, USA
| |
Collapse
|
18
|
Multidisciplinary inpatient rehabilitation for Functional Movement Disorders: A prospective study with long term follow up. Parkinsonism Relat Disord 2020; 82:50-55. [PMID: 33248393 DOI: 10.1016/j.parkreldis.2020.11.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Revised: 10/24/2020] [Accepted: 11/19/2020] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Functional Movement Disorders (FMDs) are challenging to treat. We assessed the effect of multidisciplinary inpatient rehabilitation, involving motor retraining, psychotherapy and psychotropic medication on FMD patient function and maintenance of improvement after one year. METHODS FMD patients in a movement disorders clinic were referred for inpatient rehabilitation. Baseline, discharge and one year follow-up measures included: Clinical Global Impression (CGI-severity, CGI-change); Depression and Somatic Symptom Scale (DSSS); Generalized Anxiety Disorder-7 (GAD-7); Patient Health Questionnaire-9 (PHQ-9); Post-traumatic stress disorder check-list for DSM-5 (PCL-5). Outcomes were analyzed with non-parametric models. RESULTS Seventeen patients completed rehabilitation. Thirteen completed one-year follow-up. Median CGI-severity was "markedly ill." At discharge, movement disorder improved in 93% (median CGI-change = 2, "much improved") as assessed by neurologist and patient. Psychiatrist ratings showed improvement among 86.7%; physiatrist and psychologist ratings were 66.7% and 53.3%, respectively. Symptoms improved on DSSS (Wilcoxon Z = -2.914, p ≤ 0.004); GAD-7 (Z = -3.045, p ≤ 0.002); PHQ-9 (Z = -3.415, p ≤ 0.01) but not PCL-5 (Z = -1.506, p = 0.132). At 1 year, 54% maintained at least minimal improvement by neurologist rating and 77% by patient rating (median CGI-change = 3, "minimally improved"). Improvement was not maintained for DSSS (Wilcoxon Z = -0.385. p = 0.701), GAD-7 (Z = -0.943, p = 0.357) or PHQ-9 (Z = -0.55, p = 0.582). CONCLUSIONS Multidisciplinary inpatient rehabilitation improved FMD patient function, depression, anxiety and somatic symptoms. One-year follow-up demonstrated minimal sustained improvement and worsening psychopathology, reflecting chronic debility despite initial rehabilitative success.
Collapse
|
19
|
Saxena A, Godena E, Maggio J, Perez DL. Towards an Outpatient Model of Care for Motor Functional Neurological Disorders: A Neuropsychiatric Perspective. Neuropsychiatr Dis Treat 2020; 16:2119-2134. [PMID: 32982250 PMCID: PMC7509337 DOI: 10.2147/ndt.s247119] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 08/26/2020] [Indexed: 12/17/2022] Open
Abstract
Functional neurological disorder (FND), a condition at the intersection of neurology and psychiatry, is a common and disabling outpatient referral to neurology and neuropsychiatry clinics. In this perspective article, we focus on the motor spectrum of FND (mFND), including individuals with functional movement disorders (FND-movt), functional limb weakness/paresis (FND-par) and functional [psychogenic non-epileptic/dissociative] seizures (FND-seiz). Over the past several decades, there have been dedicated efforts within the neurologic and psychiatric communities to create "rule-in" diagnostic criteria, as well as thoughtful approaches to the clinical interview, delivery of the diagnosis and the development of a patient-centered treatment plan. These advances allow the promotion of good clinical practices in the outpatient assessment and management of mFND. Informed by the literature and our prior clinical experiences, we provide suggestions on how to evaluate individuals with suspected functional motor symptoms - including conducting sensitive psychiatric and psychosocial screenings. Additional sections discuss common "rule-in" neurological examination and semiologic signs of motor FND, as well as approaches to deliver the diagnosis and formulate a treatment plan based on individual patient needs. To aid the development of shared (partially overlapping) expertise that catalyzes an interdisciplinary approach to mFND, the use of physiotherapy for therapeutic motor retraining and cognitive behavioral therapy to examine relationships between symptoms, thoughts, behaviors and emotions are also discussed. Additional clinical research is needed to further refine and operationalize the assessment and management of mFND, across clinics, healthcare settings and countries.
Collapse
Affiliation(s)
- Aneeta Saxena
- Functional Neurological Disorder Clinical and Research Program, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Epilepsy Division, Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Ellen Godena
- Functional Neurological Disorder Clinical and Research Program, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Julie Maggio
- Functional Neurological Disorder Clinical and Research Program, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Physical Therapy, Massachusetts General Hospital, Boston, MA, USA
| | - David L Perez
- Functional Neurological Disorder Clinical and Research Program, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Division of Neuropsychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
20
|
Singhal AB, Gonzalez RG, Chwalisz BK, Mukerji SS. Case 26-2020: A 60-Year-Old Woman with Altered Mental Status and Weakness on the Left Side. N Engl J Med 2020; 383:764-773. [PMID: 32813954 PMCID: PMC7449228 DOI: 10.1056/nejmcpc2004976] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Aneesh B Singhal
- From the Departments of Neurology (A.B.S., B.K.C., S.S.M.) and Radiology (R.G.G.), Massachusetts General Hospital, and the Departments of Neurology (A.B.S., B.K.C., S.S.M.) and Radiology (R.G.G.), Harvard Medical School - both in Boston
| | - R Gilberto Gonzalez
- From the Departments of Neurology (A.B.S., B.K.C., S.S.M.) and Radiology (R.G.G.), Massachusetts General Hospital, and the Departments of Neurology (A.B.S., B.K.C., S.S.M.) and Radiology (R.G.G.), Harvard Medical School - both in Boston
| | - Bart K Chwalisz
- From the Departments of Neurology (A.B.S., B.K.C., S.S.M.) and Radiology (R.G.G.), Massachusetts General Hospital, and the Departments of Neurology (A.B.S., B.K.C., S.S.M.) and Radiology (R.G.G.), Harvard Medical School - both in Boston
| | - Shibani S Mukerji
- From the Departments of Neurology (A.B.S., B.K.C., S.S.M.) and Radiology (R.G.G.), Massachusetts General Hospital, and the Departments of Neurology (A.B.S., B.K.C., S.S.M.) and Radiology (R.G.G.), Harvard Medical School - both in Boston
| |
Collapse
|
21
|
Lombardi N, Scévola L, Sarudiansky M, Giagante B, Gargiulo A, Alonso N, Stivala EG, Oddo S, Fernandez-Lima M, Kochen S, Guido Korman, D'Alessio L. Differential Semiology Based on Video Electroencephalography Monitoring Between Psychogenic Nonepileptic Seizures and Temporal Lobe Epileptic Seizures. J Acad Consult Liaison Psychiatry 2020; 62:22-28. [PMID: 32950266 DOI: 10.1016/j.psym.2020.07.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Revised: 07/11/2020] [Accepted: 07/13/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Psychogenic nonepileptic seizures (PNESs) are disruptive changes in behavior without ictal correlate of epileptic activity and high prevalence of psychiatric morbidity. Differential diagnosis is difficult particularly with temporal lobe epilepsy (TLE), which is also associated with high prevalence of psychiatric comorbidity. Although video electroencephalography is the gold standard for differential diagnosis, clinical semiology analysis may help the clinician in general medical practice. OBJECTIVE In this study, the differential semiology, based on video electroencephalography, between PNESs and TLE seizures was analyzed. METHODS The video electroencephalography of patients with diagnosis of PNES and TLE were reviewed and compared between groups. Clinical semiology of all episodes recorded by video electroencephalography in each patient was analyzed and classified in accordance with the presence of behavioral arrest, motor hyperkinetic activity, impaired awareness, aura, and automatisms. Chi square test and binary logistic regression were determined. RESULTS Thirty-two patients with PNES (32 ± 11 y) and 34 with TLE (32 ± 12 y) were included. Female patients were predominant in the PNES group (P < 0.05). Mean time duration of episodes was 6.8 ± 10 minutes in PNES and 1.6 ± 0.8 minutes in TLE (P < 0.05). Impaired awareness (odds ratio = 24.4; 95% confidence interval = 3.79 -157.3, P < 0.01), automatisms (odds ratio = 13.9; 95% confidence interval = 2.1- 90.5, P < 0.01), and shorter duration of the events (odds ratio = 2.261, 95% confidence interval = 1.149 - 4.449, P = 0.018) were found as independent factors for detecting TLE seizures comparing PNESs. CONCLUSION Clinical semiology analysis may orientate the differential diagnosis in general medical practice, between PNESs and TLE seizures. Further studies comparing PNES semiology with other subtypes of epilepsies may complete these preliminary findings.
Collapse
Affiliation(s)
- Nicolás Lombardi
- Universidad de Buenos Aires, Hospital Ramos Mejía, Centro de Epilepsia, Buenos Aires, Argentina
| | - Laura Scévola
- Universidad de Buenos Aires, Hospital Ramos Mejía, Centro de Epilepsia, Buenos Aires, Argentina
| | - Mercedes Sarudiansky
- Universidad de Buenos Aires, Hospital Ramos Mejía, Centro de Epilepsia, Buenos Aires, Argentina; Universidad de Buenos Aires, CAEA-CONICET, Buenos Aires, Argentina
| | - Brenda Giagante
- Universidad de Buenos Aires, Hospital Ramos Mejía, Centro de Epilepsia, Buenos Aires, Argentina; Hospital El Cruce, Centro de Epilepsia, ENyS-CONICET, Buenos Aires, Argentina
| | - Angel Gargiulo
- Universidad de Buenos Aires, Hospital Ramos Mejía, Centro de Epilepsia, Buenos Aires, Argentina
| | - Nicolás Alonso
- Universidad de Buenos Aires, Hospital Ramos Mejía, Centro de Epilepsia, Buenos Aires, Argentina
| | - Ernesto Gonzalez Stivala
- Universidad de Buenos Aires, Hospital Ramos Mejía, Centro de Epilepsia, Buenos Aires, Argentina; Universidad de Buenos Aires, IBCN-CONICET, Buenos Aires, Argentina
| | - Silvia Oddo
- Universidad de Buenos Aires, Hospital Ramos Mejía, Centro de Epilepsia, Buenos Aires, Argentina; Hospital El Cruce, Centro de Epilepsia, ENyS-CONICET, Buenos Aires, Argentina
| | - Mónica Fernandez-Lima
- Universidad de Buenos Aires, Hospital Ramos Mejía, Centro de Epilepsia, Buenos Aires, Argentina; Hospital El Cruce, Centro de Epilepsia, ENyS-CONICET, Buenos Aires, Argentina
| | - Silvia Kochen
- Universidad de Buenos Aires, Hospital Ramos Mejía, Centro de Epilepsia, Buenos Aires, Argentina; Hospital El Cruce, Centro de Epilepsia, ENyS-CONICET, Buenos Aires, Argentina
| | - Guido Korman
- Universidad de Buenos Aires, Hospital Ramos Mejía, Centro de Epilepsia, Buenos Aires, Argentina; Universidad de Buenos Aires, CAEA-CONICET, Buenos Aires, Argentina
| | - Luciana D'Alessio
- Universidad de Buenos Aires, Hospital Ramos Mejía, Centro de Epilepsia, Buenos Aires, Argentina; Universidad de Buenos Aires, IBCN-CONICET, Buenos Aires, Argentina.
| |
Collapse
|
22
|
Cognitive Complaints in Motor Functional Neurological (Conversion) Disorders: A Focused Review and Clinical Perspective. Cogn Behav Neurol 2020; 33:77-89. [DOI: 10.1097/wnn.0000000000000218] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
23
|
Gallucci-Neto J, Brunoni AR, Ono CR, Fiore LA, Martins Castro LH, Marchetti RL. Ictal SPECT in Psychogenic Nonepileptic and Epileptic Seizures. J Acad Consult Liaison Psychiatry 2020; 62:29-37. [PMID: 32641235 DOI: 10.1016/j.psym.2020.05.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/02/2020] [Accepted: 05/04/2020] [Indexed: 01/04/2023]
Abstract
BACKGROUND Psychogenic nonepileptic seizures (PNES) are a common and debilitating problem in patients with epilepsy. They can be virtually indistinguishable from epileptic seizures, demanding video-electroencaphalogram monitoring, which is costly and not widely available, for differential diagnosis. Specific functional brain correlates of PNES have not been demonstrated so far. We hypothesized that PNES and epileptic seizures have distinct brain activation patterns, assessed by functional neuroimaging during ictal events of both conditions. OBJECTIVE Compare ictal brain activation patterns of PNES and epileptic seizures using single-photon emission computerized tomography. METHODS We prospectively assessed brain functional activation using single-photon emission computerized tomography 99mTc-ethyl cysteinate dimer in 26 patients with PNES, confirmed by trained psychiatrists in epileptology, who had their seizures induced by provocative tests compared with 22 age- and sex-matched subjects with temporal lobe epilepsy who underwent prolonged intensive video-electroencaphalogram monitoring. RESULTS In PNES patients compared with temporal lobe epilepsy group, we found a consistent increase in regional cerebral blood flow in the right precuneus (Brodmann area 7; P = 0.003) and right posterior cingulate cortex (Brodmann area 31; P = 0.001), as well as a decrease in regional cerebral blood flow in the right amygdala (P = 0.027). CONCLUSIONS Activation of default mode network brain areas and temporoparietal junction may be a distinct feature of ictal PNES and could be explained by a disruption between movement prediction input and sensory outcome. Such information mismatch might be the neurobiological underpinning of dissociative episodes.
Collapse
Affiliation(s)
- Jose Gallucci-Neto
- Neuropsychiatry Program, Department and Instidtute of Psychiatry, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
| | - Andre Russowsky Brunoni
- Department of Internal Medicine, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Laboratory of Neurosciences (LIM-27), Department and Institute of Psychiatry, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Carla Rachel Ono
- Department of Nuclear Medicine, University of Sao Paulo, São Paulo, Brazil
| | - Lia Arno Fiore
- Neuropsychiatry Program, Department and Instidtute of Psychiatry, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Renato Luiz Marchetti
- Neuropsychiatry Program, Department and Instidtute of Psychiatry, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| |
Collapse
|
24
|
|
25
|
Ben-Naim S, Dienstag A, Freedman SA, Ekstein D, Foul YA, Gilad M, Peled O, Waldman A, Oster S, Azoulay M, Blondheim S, Arzy S, Eitan R. A Novel Integrative Psychotherapy for Psychogenic Nonepileptic Seizures Based on the Biopsychosocial Model: A Retrospective Pilot Outcome Study. PSYCHOSOMATICS 2020; 61:353-362. [PMID: 32284248 DOI: 10.1016/j.psym.2020.02.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 02/16/2020] [Accepted: 02/17/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Psychogenic nonepileptic seizures (PNES) represent one of the most sizable treatment challenges in neuropsychiatry. Although the underlying mechanism is far from being understood, several interventions have been suggested. However, patients with comorbid psychiatric diagnoses and epilepsy are excluded from most intervention studies. OBJECTIVE To To present a within-group posttreatment vs pretreatment study representing the retrospective clinical results of an integrative psychotherapy model. METHODS We present the clinical results of 22 patients with PNES diagnosed in an epilepsy center and treated in our neuropsychiatry clinic using an integrative rehabilitative psychotherapy. Therapy included presenting the diagnosis, psychoeducation, seizure reduction behavioral techniques, and coping with past and present stressors. Insomuch as integrative biopsychosocial psychotherapy is based on an individualized treatment protocol for each patient, treatment was individualized and case specific. RESULTS By the end of treatment, 36% of patients had become seizure free and a further 54% achieved a major seizure reduction (reduction of more than 70%). Seventy-two percent of patients kept at least 70% seizure reduction at follow-up. Global Assessment of Functioning scores improved from a mean of 43.09 to a mean of 72.81 at the end of treatment and 69.72 at follow-up. In addition, we present 3 case descriptions that emphasize the individualized nature of psychotherapeutic decisions. CONCLUSIONS Our results support the feasibility and effectiveness of biopsychosocial based integrative psychotherapy for PNES and set principles for future treatment and prospective clinical trials in the field of individualized psychotherapy.
Collapse
Affiliation(s)
- Shiri Ben-Naim
- Neuropsychiatry Clinic, Hadassah Hebrew University Medical Center, Jerusalem, Israel; Department of Social Sciences, Academic College Tel-Aviv-Jaffa, Tel-Aviv, Israel.
| | - Aryeh Dienstag
- Neuropsychiatry Clinic, Hadassah Hebrew University Medical Center, Jerusalem, Israel; Department of Psychiatry, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Sara A Freedman
- School of Social Work, Bar Ilan University, Ramat Gan, Israel
| | - Dana Ekstein
- Department of Neurology, Agnes Ginges Center for Neurogenesis, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Yasmin Abo Foul
- Neuropsychiatry Clinic, Hadassah Hebrew University Medical Center, Jerusalem, Israel; Department of Psychology, Hebrew University, Jerusalem, Israel
| | - Moran Gilad
- Neuropsychiatry Clinic, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Or Peled
- Neuropsychiatry Clinic, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Avigail Waldman
- Neuropsychiatry Clinic, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Sivan Oster
- Neuropsychiatry Clinic, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - Moriya Azoulay
- Neuropsychiatry Clinic, Hadassah Hebrew University Medical Center, Jerusalem, Israel; Department of Psychology, Hebrew University, Jerusalem, Israel
| | - Shir Blondheim
- Neuropsychiatry Clinic, Hadassah Hebrew University Medical Center, Jerusalem, Israel; Department of Psychology, Hebrew University, Jerusalem, Israel
| | - Shahar Arzy
- Neuropsychiatry Clinic, Hadassah Hebrew University Medical Center, Jerusalem, Israel; Department of Neurology, Agnes Ginges Center for Neurogenesis, Hadassah Hebrew University Medical Center, Jerusalem, Israel; Department of Medical Neurobiology, Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Renana Eitan
- Neuropsychiatry Clinic, Hadassah Hebrew University Medical Center, Jerusalem, Israel; Department of Medical Neurobiology, Faculty of Medicine, Hebrew University of Jerusalem, Israel; Jerusalem Mental Health Center, Hebrew University Medical School, Jerusalem, Israel; Department of Psychiatry, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| |
Collapse
|
26
|
Ranford J, MacLean J, Alluri PR, Comeau O, Godena E, LaFrance WC, Hunt A, Stephen CD, Perez DL. Sensory Processing Difficulties in Functional Neurological Disorder: A Possible Predisposing Vulnerability? PSYCHOSOMATICS 2020; 61:343-352. [PMID: 32284249 DOI: 10.1016/j.psym.2020.02.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 02/07/2020] [Accepted: 02/10/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Functional neurological disorder (FND) is a prevalent neuropsychiatric condition characterized by sensorimotor difficulties. Patients with FND at times report that sensory experiences trigger and/or exacerbate their symptoms. Sensory processing difficulties are also commonly reported in other psychiatric disorders frequently comorbid in FND, suggesting that contextualizing sensory profiles in FND within a biopsychosocial model may be clinically relevant. OBJECTIVE To address this literature gap, we conducted a retrospective cohort study to examine sensory processing patterns and their relationship to other neuropsychiatric characteristics in patients with FND. METHODS A retrospective chart review design was used to investigate sensory processing patterns, established with the Adolescent/Adult Sensory Profile self-report questionnaire, in 44 patients with FND. Univariate analyses of cross-sectional screening tests followed by multivariate linear regression analyses were performed to identify clinical factors associated with sensory processing scores in the FND cohort. RESULTS Compared to normative data, most patients with FND reported sensory processing tendencies toward low registration, sensory sensitivity, and sensation avoiding. In multivariate regression analyses, the presence of a lifetime anxiety disorder independently predicted elevated low registration scores, while female gender and number of current medications independently predicted increased sensory sensitivity scores. In uncorrected univariate analyses only, individuals with psychogenic nonepileptic seizures were more likely to report increased sensory sensitivity and elevated low registration. CONCLUSION These preliminary findings support sensory processing difficulties in some patients with FND. Prospective and large sample size studies are needed to investigate relationships between sensory processing profiles and neuropsychiatric comorbidities, FND subtypes, and treatment outcomes.
Collapse
Affiliation(s)
- Jessica Ranford
- Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Occupational Therapy, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Julie MacLean
- Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Department of Occupational Therapy, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Priyanka R Alluri
- Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Olivia Comeau
- Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Ellen Godena
- Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - W Curt LaFrance
- Neuropsychiatry and Behavioral Neurology Division, Departments of Psychiatry and Neurology, Rhode Island Hospital, Alpert Medical School, Brown University, Providence, RI
| | - Ann Hunt
- Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Movement Disorders Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Christopher D Stephen
- Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Movement Disorders Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - David L Perez
- Functional Neurology Research Group, Cognitive Behavioral Neurology Unit, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA; Neuropsychiatry Unit, Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| |
Collapse
|
27
|
Klinke ME, Hjartardóttir TE, Hauksdóttir A, Jónsdóttir H, Hjaltason H, Andrésdóttir GT. Moving from stigmatization toward competent interdisciplinary care of patients with functional neurological disorders: focus group interviews. Disabil Rehabil 2019; 43:1237-1246. [PMID: 31526059 DOI: 10.1080/09638288.2019.1661037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
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.
Collapse
Affiliation(s)
- Marianne E Klinke
- Faculty of Nursing, School of Health Sciences, University of Iceland, Reykjavik, Iceland.,The National University Hospital of Iceland, Reykjavik, Iceland
| | | | | | - Helga Jónsdóttir
- Faculty of Nursing, School of Health Sciences, University of Iceland, Reykjavik, Iceland.,The National University Hospital of Iceland, Reykjavik, Iceland
| | - Haukur Hjaltason
- The National University Hospital of Iceland, Reykjavik, Iceland.,Faculty of Medicine, School of Health Sciences, University of Iceland, Reykjavik, Iceland
| | | |
Collapse
|
28
|
Personality and Psychopathology in Patients With Mixed Sensory-Motor Functional Neurological Disorder (Conversion Disorder): A Pilot Study. J Nerv Ment Dis 2019; 207:546-554. [PMID: 31206424 DOI: 10.1097/nmd.0000000000001015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
The purpose of this pilot study was to explore differences in the level of personality functioning, symptom severity, and personality pathology in patients with mixed sensory-motor functional neurological disorder (conversion disorder). Individuals with psychogenic nonepileptic seizures were not included. We recruited 15 patients, mean age of 33.5 years (SD, 11.4 years), 13 females and 2 males, from an outpatient clinic for psychotherapeutic treatment. We assessed the patients using the Structured Clinical Interview for DSM-4 Axis II Personality Disorders, the SCL-90-R, the Karolinska Psychodynamic Profile, and the Defense Style Questionnaire. We were able to distinguish two levels of difficulty in relation to personality functioning as distinct subgroups: 1) "neurotic" with less severe or moderate personality psychopathology and 2) "borderline" with severe personality psychopathology. Furthermore, we concluded that all patients showed severe deficits in personality functioning. The study points out the clinical relevance of identifying personality functioning as part of an assessment in the preparation of a treatment strategy.
Collapse
|
29
|
Ryznar E, Wilcox D. Functional Coma: Two Case Reports and a Review of the Literature. PSYCHOSOMATICS 2019; 60:343-351. [DOI: 10.1016/j.psym.2019.03.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Revised: 03/17/2019] [Accepted: 03/18/2019] [Indexed: 11/26/2022]
|
30
|
Burke MJ, Lizano P, Jacobs C, Stern TA. Post-traumatic Stress Disorder Symptom Substitution as a Cause of Functional Neurological Disorder. PSYCHOSOMATICS 2019; 61:81-85. [PMID: 31005267 DOI: 10.1016/j.psym.2019.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 03/03/2019] [Accepted: 03/05/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Matthew J Burke
- Division of Cognitive Neurology, Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
| | - Paulo Lizano
- Division of Cognitive Neurology, Department of Psychiatry, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Claire Jacobs
- Division of Epilepsy, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Theodore A Stern
- Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| |
Collapse
|
31
|
|
32
|
Ospina JP, Jalilianhasanpour R, Perez DL. The role of the anterior and midcingulate cortex in the neurobiology of functional neurologic disorder. HANDBOOK OF CLINICAL NEUROLOGY 2019; 166:267-279. [PMID: 31731915 DOI: 10.1016/b978-0-444-64196-0.00014-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Functional neurologic disorder (FND)/conversion disorder is a prevalent and disabling condition at the intersection of neurology and psychiatry. Clinicians often report feeling ill-equipped treating patients with FND, perpetuated by a historically limited understanding of neurobiologic disease mechanisms. In this review, we summarize the neuroimaging literature across the spectrum of sensorimotor FND, including functional imaging studies during rest, sensorimotor performance, and emotional-processing tasks as well as structural magnetic resonance imaging findings. Particular attention is given to studies implicating the anterior and middle cingulate cortex and related salience network structures (insula, amygdala, and periaqueductal gray) in the neurobiology of FND. Neuroimaging studies identify cingulo-insular functional alterations during rest, motor performance, and emotion processing in FND populations. The literature also supports that patients with FND exhibit heightened amygdalar and periaqueductal gray reactivity to emotionally valenced stimuli, enhanced coupling between amygdalar and motor control areas, and increased amygdalar volumes. The structural neuroimaging literature also implicates cingulo-insular areas in the pathophysiology of FND, though these findings require replication and clarification. While more research is needed to fully elucidate the pathophysiology of FND, salience network alterations appear present in some FND populations and can be contextualized using biopsychosocial models for FND.
Collapse
Affiliation(s)
- Juan Pablo Ospina
- Department of Neurology, Cognitive Behavioral Neurology Unit, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Rozita Jalilianhasanpour
- Department of Neurology, Cognitive Behavioral Neurology Unit, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - David L Perez
- Departments of Neurology and Psychiatry, Cognitive Behavioral Neurology and Neuropsychiatry Units, Functional Neurology Research Group, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.
| |
Collapse
|