Functional neurological disorder in the emergency department

Impact of the COVID-19 Pandemic on the Diagnostic Frequency and Medical Therapies Applied to Subjects With Functional Seizures

Background and Purposes

The coronavirus 2019 (COVID-19) pandemic was associated with catastrophic consequences and increased psychological distress. However, it is unknown if the pandemic impacted the frequency of functional seizures (FS), a well known manifestation of psychiatric disease. The study objectives are to evaluate FS diagnostic code frequency before and during the COVID-19 pandemic and the therapies applied. We hypothesized that FS frequency would be higher during the pandemic, but that the therapies applied would be similar between the two time periods.

Methods

This was a retrospective observational cohort study utilizing the TriNetX ® electronic health record (EHR) database. We included subjects aged 8 to 65 years with a diagnostic code of "conversion disorder with seizures or convulsions." After the query, the study population was divided into 2 groups [pre-COVID-19 (3/1/2018 to 2/29/2020) and COVID-19 (3/1/2020 to 2/28/2022). We analyzed subject demographics, diagnostic, procedure, and medication codes.

Results

We included 8680 subjects [5029 (57.9%) pre-COVID-19 and 3651 (42.1%) COVID-19] in this study. There was a higher odds of mental health conditions, anxiolytic prescription, emergency department services, and hospital services, but a lower odds of critical care services during COVID-19. There was no difference in antiepileptic use between the time periods.

Conclusions

During the COVID-19 pandemic, a higher odds of anxiolytic use, need for emergency department services, and hospital services was reported. In addition, there was a decreased odds of critical care services. This may reflect a change in how patients with FS were managed during the pandemic.

Functional neurological disorder mimicking stroke: A case report

Even in the era of technology-guided medicine, the clinician must integrate into his daily practice a careful anamnesis and physical examination to be conducted within a close doctor-patient relationship. All these elements, together with tools such as teleconsultation and digitalized medical records, are able to significantly increase the effectiveness of health care action.

Peripheral nervous system and neuromuscular disorders in the emergency department: A review

INTRODUCTION

Acute presentations and emergencies in neuromuscular disorders (NMDs) often challenge clinical acumen. The objective of this review is to refine the reader's approach to history taking, clinical localization and early diagnosis, as well as emergency management of neuromuscular emergencies.

METHODS

An extensive literature search was performed to identify relevant studies. We prioritized meta-analysis, systematic reviews, and position statements where possible to inform any recommendations.

SUMMARY

The spectrum of clinical presentations and etiologies ranges from neurotoxic envenomation or infection to autoimmune disease such as Guillain-Barré Syndrome (GBS) and myasthenia gravis (MG). Delayed diagnosis is not uncommon when presentations occur "de novo," respiratory failure is dominant or isolated, or in the case of atypical scenarios such as GBS variants, severe autonomic dysfunction, or rhabdomyolysis. Diseases of the central nervous system, systemic and musculoskeletal disorders can mimic presentations in neuromuscular disorders.

CONCLUSIONS

Fortunately, early diagnosis and management can improve prognosis. This article provides a comprehensive review of acute presentations in neuromuscular disorders relevant for the emergency physician.

Functional Neurological Symptom Disorder: A Continuing Conundrum for the Perioperative Physician

Functional neurological symptom disorder (FNSD) or functional neurological disorder (FND) or conversion disorder, is a syndrome of neurological complications unexplained by neuropathology. The term FNSD or FND is now preferred, as conversion disorder is not an etiologically neutral term and is thus falling from use by researchers and clinicians in the field. We report a case of new-onset postoperative neurological deficit in a patient who had undergone uneventful general anesthesia for a urology procedure. Postoperatively, in the post-anesthesia care unit, the patient was found to be unable to move her upper and lower limbs. Organic pathology was excluded and a diagnosis of FNSD was made. Four weeks after the surgery, the patient was only able to ambulate with the help of a mechanical walker device. It is now suggested that procedures involving anesthesia are relatively common triggers for the development of FNSD. The occurrence of FNSD in the postoperative period is increasingly being attributed to the effects of anesthesia, the hypothesis being that it arises from the abreactive or dissociative effects of anesthetic agents. Another theory is the vulnerability of the anesthetized state which may evoke previous traumatic experiences. Psychiatric co-morbidities such as anxiety and depression may be seen in these patients. Preoperative psychological assessment may help identify patients at risk for FNSD. If postoperative neurological deficit occurs, detailed neurological, metabolic, and psychiatric assessments should be done with FNSD being a diagnosis of exclusion. We present this case to increase awareness regarding this uncommon condition which can cause significant distress to the patient and healthcare team. Management should comprise honest disclosure, reassurance of recovery, and reinforcement of alternative coping strategies. The development of preoperative screening tools may help identify patients at risk for this disorder.

Identifying misconceptions and knowledge gaps in functional neurological disorders among emergency care providers

BACKGROUND

Functional Neurologic Disorders (FND) are a common but heterogeneous group of disabling conditions. The Emergency Department (ED) is an important venue for care and referral as it is often the first point of contact when patients with FND are faced with a crisis or exacerbation of symptoms.

METHODS

ED providers (n = 273) practicing in the Cleveland Clinic Foundation Northeast Ohio network were invited to participate through secure web application electronic surveys. Data were collected on practice profiles, knowledge, attitudes, management of FND, and awareness of available resources for FND.

RESULTS

Sixty providers completed the survey (22% response rate; n = 50 ED physicians, 10 advanced care providers) with 95.0% (n = 57) reporting a lack of understanding about FND. The terms Psychogenic Nonepileptic Seizures and stress induced/stress related disease were used by 60.0% (n = 36) and 58.3% (n = 35) respectively. Ninety percent (n = 53) rated their experience with managing FND patients as at least more difficult. Eighty- five percent (n = 51) agreed with "rule out others" and 60% (n = 36) agreed with "caused by psych stress". Eighty six percent (n = 50) believe that there is a difference between FND from malingering. Only one respondent was familiar with any FND resources and 79% (n = 47) reported the need for FND specific educational materials.

CONCLUSION

This survey revealed major gaps in knowledge, inaccurate perceptions, and management that differs from the current standard of care among ED providers caring for patients with FND. Educational opportunities are needed to guide diagnosis and evidence-based treatment to optimize management of patients with FND.

Outcome in Pediatric Functional Tic Disorders Diagnosed During the COVID-19 Pandemic

OBJECTIVES

The incidence of pediatric functional tics has surged during the COVID-19 pandemic with little known about prognosis. To address this knowledge gap, the investigators examined clinical courses of functional tics diagnosed during the pandemic and explored factors predicting prognosis.

METHODS

Study personnel reviewed electronic medical records of 29 pediatric patients diagnosed as having functional tics between March 1, 2020, and December 31, 2021, and estimated Clinical Global Impression-Improvement (CGI-I) scores at follow-up encounters. Twenty patient-guardian dyads completed telephone interviews. Logistic regression models were used to identify possible predictors of clinical trajectories.

RESULTS

Of the 29 patients, 21 (82%) reported at least some improvement since diagnosis at the time of the last follow-up, with a median CGI-I score of 2 (much improved). During the telephone interview, 11 of 20 patients noted ongoing interference from tics, and 16 of 20 agreed with the diagnosis of functional tics. Median time from symptom onset to diagnosis was 197 days, with most patients reporting at least a mild reduction of symptoms (CGI-I score <4) at a median of 21 days after diagnosis. At a median follow-up time of 198 days after diagnosis, patients reported significant but not complete improvement. Greater age and longer time to diagnosis decreased odds of improvement within 1 month of diagnosis.

CONCLUSIONS

Most patients showed improvements in but not the resolution of functional tic symptoms after diagnosis. These data support the importance of early diagnosis for functional tics.

Diagnosis of psychogenic (functional) gait disorders

Psychogenic gait is common in patients with medically unexplained neurological symptoms and provides significant challenges to healthcare providers. Clinicians may arrive at a correct diagnosis earlier if distinctive positive signs are identified and acknowledged. Psychogenic disorders of posture and gait are common and are the major manifestation in 8–10 % of patients with psychogenic movement disorders. Psychogenic movement disorders can present with varied phenomenology that may resemble organic movement disorders. The diagnosis is based on clinical evaluation with a supporting history and classic features on neurologic examination. In functional gait disorders, walking is often bizarre and does not conform to any of the usual patterns observed with neurologic gait disorders. Astasia-abasia, an inability to stand (astasia) or walk (abasia) in the absence of other neurologic abnormalities, was the term applied by investigators in the mid to late 19thcentury to describe certain patients with a frankly functional gait. Other descriptive terms include gaits that resemble walking on ice, walking a sticky surface, walking through water (bringing to mind excessive slowness), tightrope walking, habitual limping, and bizarre, robotic, knock-kneed, trepidant, anxious, and cautious gaits. Ancillary testing, such as imaging and neurophysiologic studies, can provide supplementary information but is not necessary for diagnosis. 

Developing a multidisciplinary pathway for functional neurological disorders in a UK National Health Service: The Exeter model

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.

Diagnostic pitfalls in functional neurological disorders

The diagnosis of functional neurological disorders is a major challenge in neurologist practice. Some clinical strategies can facilitate the recognition of functional disorders, but several pitfalls make their diagnosis difficult. Here we highlight the following points of attention during evaluation of patients with functional disorder: not all bizarre behavior is functional; not every event triggered by an emotional factor is a functional disorder; not every topographic incongruity is a functional disorder; patients may present functional and organic symptoms at the same time; psychiatric comorbid condition is not always evident in the history of a functional disorder; problematic communication at the time of diagnosis can compromise treatment and prognosis. In conclusion, we emphasize that special attention to these possible pitfalls facilitate the correct diagnosis and management of functional neurological disorders.

Diagnosis of Functional Weakness and Functional Gait Disorders in Children and Adolescents

Functional neurological disorder is neurological dysfunction not primarily explained by pathophysiologic or structural abnormalities and can present in children and adolescents with limb weakness, gait abnormality, non-epileptic seizures or sensory changes. In this review article we focus primarily on the diagnosis of functional limb weakness and functional gait disorders, and how to differentiate functional neurological disorders from structural or pathologic neurological presentations of weakness or gait disturbance. Detailed history and attentive observation of a patient outside of the formal neurological examination can be pertinent to identifying inconsistency and incongruency in keeping with functional neurological presentations. Understanding of structural and physiologic neurological pathology is required to identify non-anatomical and non-pathological features consistent with a diagnosis of functional neurological disorder. Diagnosis is made on recognition of positive clinical features of a functional disorder on examination and is not based primarily on exclusion of a pathologic neurological disorder. Specific tests can be performed to elicit pathognomonic findings supportive of a diagnosis of functional limb weakness and gait disorders.

The use of rhythmic auditory stimulation for functional gait disorder: A case report

BACKGROUND: Functional gait disorders (FGD) are a common and disabling condition. Consensus-based rehabilitation techniques for treating FGD and other functional neurological disorder presentations at large utilize a variety of therapeutic strategies, including distraction, novel approaches to movement, entrainment, stress/hypervigilance modulation, and psychotherapy. CASE REPORT: Here we present a case of a 24-year-old woman with a complex history of anxiety, depression, left frontal astrocytoma, postural orthostatic tachycardia syndrome (POTS) and FGD. During a multidisciplinary inpatient rehabilitation stay for FGD, the patient underwent rhythmic auditory stimulation (RAS) delivered by a neurologic music therapist in conjunction with physical therapy, occupational therapy, and psychotherapy. RESULTS: The RAS intervention appeared to play a significant role in symptom resolution for this patient. Improvement in the patient’s truncal displacement, foot dragging, and well as overall gait speed occurred following serial RAS trials performed over a single treatment session. Benefits persisted immediately following the intervention and upon subsequent reassessment. Although at four-year follow-up the patient’s FGD symptoms remained resolved, fatigue continued to limit her ambulatory capacity and overall endurance. CONCLUSION: RAS represents a unique therapeutic approach for treating FGD, complementary to existing consensus-based rehabilitation recommendations, and may warrant further consideration by the field.

Neuropsychiatric Treatment Approaches for Functional Neurological Disorder: A How to Guide

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.