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

Trust, belief and transitions: people's experiences of multidisciplinary inpatient treatment for persistent physical symptoms. A qualitative study

PURPOSE

People with Persistent Physical Symptoms experience physical symptoms that are not wholly explained by a medical disorder or disease. Multidisciplinary treatment is recommended for people with severe difficulties and is provided in a small number of specialist centres in the UK. Only brief descriptions of this treatment are available, and the experiences of people receiving this treatment as an inpatient have not been explored. This study aimed to explore how people with persistent physical symptoms experience inpatient treatment from a specialist multidisciplinary team, and to identify which factors facilitated their engagement in the rehabilitation.

MATERIALS AND METHODS

18 people who had received inpatient multidisciplinary treatment for persistent physical symptoms participated in semi-structured interviews. The transcripts were analysed using reflexive thematic analysis.

RESULTS

Participants' experiences were influenced by whether they felt believed by the healthcare team, and whether they could place their own trust and belief in the staff team and the treatment approach. Their experiences involved a series of transitions; both in environment and understanding.

CONCLUSIONS

Improvements are possible for people receiving inpatient multidisciplinary treatment for severe PPS. Trusting relationships between patients and staff members take time to develop but play a major role in patients' experiences of treatment.

Nurses' Descriptions of Interdisciplinary Interactions in Stroke and Geriatric Rehabilitation Units: A Case Example of the Registered Practical Nurse

AIM

To analyse how nurses describe their interactions with other interdisciplinary team members within stroke and geriatric rehabilitation.

DESIGN

A secondary analysis of cross-sectional ethnographic interview data was conducted using Elo and Kyngäs' (2008) deductive content analysis.

METHODS

Between April 12 and July 25, 2022, semi-structured interviews were conducted with 31 registered practical nurses recruited through convenience sampling from three tertiary hospital sites in Southwestern Ontario. Interview transcripts were reviewed to identify described interactions between nurses and interdisciplinary team members and were coded for: who were the interdisciplinary team member(s) involved; what content was addressed; and where, when, and why the interaction occurred.

RESULTS

Categories representing how nurses describe their interactions with interdisciplinary team members were as follows: (1) arising from the unique roles owned by either the nurse or interdisciplinary team member(s); (2) requiring open communication to achieve patient goals and improve patient care; (3) occurring within what is perceived to be either the therapists' or nurses' physical space; and (4) contributing to supportive team environments that are mutually beneficial.

CONCLUSIONS

While nurses view other interdisciplinary team members as 'owning' certain roles and physical spaces within rehabilitation, they also recognised their 'owned' spaces and roles. Unique contributions of all team members were valued as necessary to provide holistic, person-centred patient care and positive team-based support.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Nurses' descriptions of their interactions with interdisciplinary team members demonstrated their essential contributions to team-based patient care and acknowledged nurse contributions to the rehabilitation process for patients.

IMPACT

Findings elucidate the nature of interprofessional interactions and 'ownership' within the rehabilitation process. Results are beneficial for policymakers, educators, and healthcare organisations aiming to optimise the nursing role within rehabilitation spaces.

REPORTING METHOD

The Consolidated Criteria for Reporting Qualitative Research Checklist (COREQ).

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Physiotherapy management of functional movement disorders: the patient perspective

PURPOSE

People with functional movement disorders (FMD) are commonly seen in neurology clinics. Despite a recent increase in research, no standardised treatment pathway across the UK exists. Currently only a few qualitative studies in FMD with a focus on psychological aspects and diagnosis have been published. This study aimed to understand people with FMD perceptions of their physiotherapy treatment.

METHOD

Qualitative web-based interviews were conducted with seven participants and an interpretive phenomenological approach was used to identify themes from the data.

RESULTS

Four themes were identified; 1) my brain, mind and body are all me, 2) physiotherapy; what helps and what doesn't, 3) what recovery is to me, and 4) barriers to treatment. Participants desired a combination of psychological and physical approaches, which were holistic, individualised, and delivered by experienced physiotherapists. Limited availability and funding of specialist treatments were barriers to recovery.

CONCLUSION

Holistic management combining psychological and physiological systems seems to be crucial for effective management of FMD. Large variations in physiotherapy treatment exist across the UK. It is hoped that increasing the understanding, amongst healthcare professionals will lead to the development of timely and appropriate pathways for patients that otherwise find themselves lost between medical specialities.IMPLICATIONS FOR REHABILITATIONPatients report more positive experiences when a combined and detailed psychological and physiological explanation to their symptoms is given.An individualised approach working with the patient on activities they find challenging is more preferable than group exercise or impairment based (e.g., strengthening/stretching) treatments.Having a physiotherapist who is experienced in treating functional movement disorders or prepared to learn and understand them helped with adherence to treatment.

Stigma in functional neurological disorder (FND) - A systematic review

OBJECTIVE

The purpose of this systematic review was to evaluate stigma and Functional Neurological Disorder (FND) regarding: 1) prevalence and associated factors, 2) the nature and context of stigma in FND, and 3) stigma-reduction interventions.

METHODS

We searched four relevant databases from inception to December 2023, using search terms relevant to FND and stigma themes. We employed the method of synthesis by "aggregation and configuration" to synthesise and analyse the data into emergent themes.

RESULTS

We found 127 studies, spanning 148 countries, involving 18,886 participants. Of these, 4889 were patients, 13,123 were healthcare professionals, and 526 were caregivers. Quantitatively, stigma has been mainly studied in patients with functional seizures, and was higher than patients with epilepsy in three studies. Stigma experienced by patients is associated with poorer quality of life and caregiver burden. We found 10 themes and 29 subthemes revealing stigma as a systemic process, with intrapersonal, interpersonal and structural aspects. Few studies examined the perspective of caregivers, the public or online community. We identified six anti-stigma interventions.

CONCLUSION

Stigma in FND is a layered process, and affects patient quality of life and provision of care. Stigma needs to be addressed from the top structures, at governmental level, so that appropriate care pathways can be created, giving patients with FND parity of esteem with other medical conditions.

The role of neuropsychology in the care of patients with functional neurological symptom disorder

OBJECTIVE

Functional neurological symptom disorder (FNSD) is a neuropsychiatric condition characterized by signs/symptoms associated with brain network dysfunction. FNSDs are common and are associated with high healthcare costs. FNSDs are relevant to neuropsychologists, as they frequently present with chronic neuropsychiatric symptoms, subjective cognitive concerns, and/or low neuropsychological test scores, with associated disability and reduced quality of life. However, neuropsychologists in some settings are not involved in care of patients with FNSDs. This review summarizes relevant FNSD literature with a focus on the role of neuropsychologists.

METHODS

A brief review of the literature is provided with respect to epidemiology, public health impact, symptomatology, pathophysiology, and treatment.

RESULTS

Two primary areas of focus for this review are the following: (1) increasing neuropsychologists' training in FNSDs, and (2) increasing neuropsychologists' role in assessment and treatment of FNSD patients.

CONCLUSIONS

Patients with FNSD would benefit from increased involvement of neuropsychologists in their care.

Developing a Curriculum for Functional Neurological Disorder in Neurology Training: Questions and Answers

Functional neurologic disorder (FND) is a common condition for which neurology residents often receive little to no formal teaching. Using a question-and-answer format, this article puts forward a case for why an FND curriculum is needed and aims to provide guidance on possible curricular content including medical knowledge, clinical skills, communication, and team-based collaboration. The authors also discuss methods for teaching and evaluating this knowledge and associated clinical skills, linking this to current Accreditation Council for Graduate Medical Education neurology milestones. Finally, the authors consider how to better engage and energize neurology trainees around this underserved yet challenging patient population.

Non-Motor Symptoms and Quality of Life in Patients with PRRT2-Related Paroxysmal Kinesigenic Dyskinesia

Background

Monoallelic pathogenic variants of PRRT2 often result in paroxysmal kinesigenic dyskinesia (PKD). Little is known about health-related quality of life (HrQoL), non-motor manifestations, self-esteem, and stigma in patients with PKD.

Objectives

We investigated non-motor symptoms and how they related to HrQoL in a genetically homogeneous group of PRRT2-PKD patients. We paid special attention to perceived stigmatization and self-esteem.

Methods

We prospectively enrolled 21 consecutive PKD patients with a pathogenic variant of PRRT2, and 21 healthy controls matched for age and sex. They were evaluated with dedicated standardized tests for non-motor symptoms, HrQoL, anxiety, depression, stigma, self-esteem, sleep, fatigue, pain, and psychological well-being.

Results

Patients reported an alteration of the physical aspects of HrQoL, regardless of the presence of residual paroxysmal episodes. Non-motor manifestations were frequent, and were an important determinant of the alteration of HrQoL. In addition, patients perceived a higher level of stigmatization which positively correlated with a delay in diagnosis (ρ = 0.615, P = 0.003) and the fear of being judged (ρ = 0.452, P = 0.04), but not with the presence of paroxysmal episodes (ρ = 0.203, P = 0.379).

Conclusions

Our findings have important implications for care givers concerning patient management and medical education about paroxysmal dyskinesia. PRRT2-PKD patients should be screened for non-motor disorders in routine care. A long history of misdiagnosis may play a role in the high level of perceived stigmatization. Improving knowledge about diagnostic clues suggestive of PKD is mandatory.

The clinical management of functional neurological disorder: A scoping review of the literature

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.

When neurologists diagnose functional neurological disorder, why don't they code for it?

Objective:

Clinicians who recognize functional neurological disorders (FND) may not share that diagnosis with patients. Poor communication delays treatment and contributes to substantial disability in FND. Diagnostic (ICD-10) coding, one form of medical communication, offers an insight into clinicians’ face-to-face communication. Therefore, quantifying the phenomenon of non-coding, and identifying beliefs and practice habits that reduce coding, may suggest routes to improve medical communication in FND.

Methods:

We reviewed all pediatric neurology consultations in our hospital from 2017–2020, selecting those in which neurologists explicitly stated an FND-related diagnosis (N=57). We identified the neurological symptoms and ICD-10 codes assigned for each consultation. In parallel, we reviewed all encounters that utilized FND-related codes to determine whether insurers paid for this care. Finally, we assessed beliefs and practices that influence FND-related coding through a nationwide survey of pediatric neurologists (N=460).

Results:

After diagnosing FND, neurologists selected FND-related ICD-10 codes in only 22.8% of consultations. 96.2% of neurologists estimated that they would code for non-epileptic seizure (NES) when substantiated by EEG; in practice, they coded for 36.7% of such consultations. For other FND manifestations, neurologists coded in only 13.3% of cases. When presented with FND and non-FND scenarios with equal levels of information, neurologists coded for FND 41% less often. The strongest predictor of non-coding was the outdated belief that FND is a diagnosis of exclusion. Coding for FND never resulted in insurance non-payment.

Conclusion:

Non-coding for FND is common. Most factors that amplify non-coding also hinder face-to-face communication. Research based on ICD-10 coding (e.g., prevalence, cost) may underestimate the impact of FND by >4-fold.

Stigma and functional neurological disorder: a research agenda targeting the clinical encounter

Stigma against patients with functional neurological disorder (FND) presents obstacles to diagnosis, treatment, and research. The lack of biomarkers and the potential for symptoms to be misunderstood, invalidated, or dismissed can leave patients, families, and healthcare professionals at a loss. Stigma exacerbates suffering and unmet needs of patients and families, and can result in poor clinical management and prolonged, repetitive use of healthcare resources. Our current understanding of stigma in FND comes from surveys documenting frustration experienced by providers and distressing healthcare interactions experienced by patients. However, little is known about the origins of FND stigma, its prevalence across different healthcare contexts, its impact on patient health outcomes, and optimal methods for reduction. In this paper, we set forth a research agenda directed at better understanding the prevalence and context of stigma, clarifying its impact on patients and providers, and promoting best practices for stigma reduction.