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Van Patten R, Bellone JA. The neuropsychology of functional neurological disorders. J Clin Exp Neuropsychol 2023; 45:957-969. [PMID: 38441076 DOI: 10.1080/13803395.2024.2322798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2024]
Affiliation(s)
- Ryan Van Patten
- VA Providence Healthcare System, Center for Neurorestoration & Neurotechnology, Providence, RI, USA
- Department of Psychiatry and Human Behavior, Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - John A Bellone
- Department of Behavioral Health, Kaiser Permanente, San Bernardino, CA, USA
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Al-Sibahee EM, Hashim A, Al-Badri S, Al-Fatlawi N. Myths and facts about functional neurological disorders: a cross-sectional study of knowledge and awareness among medical students and healthcare professionals in Iraq. BMJ Neurol Open 2023; 5:e000470. [PMID: 37794883 PMCID: PMC10546105 DOI: 10.1136/bmjno-2023-000470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 09/14/2023] [Indexed: 10/06/2023] Open
Abstract
Background Functional neurological disorder (FND) is a complex condition with neurological symptoms but no clear structural or biochemical explanation. Myths and misconceptions about FND can lead to misdiagnosis and inappropriate treatment. This study aimed to assess knowledge and common myths about FND among medical students and practitioners. Methods Data were collected from 324 participants using a structured questionnaire. The questionnaire included demographics, general information about FND and myths about FND. Data were analysed using non-parametric tests and Spearman's r for correlations. Results The majority of participants were clinical-years medical students (65.1%) and female (59.6%). Overall, knowledge about FND was limited, with a mean score of 42.3% of correct answers. Common myths included the belief that FND is a psychological disorder and that patients feign symptoms. Knowledge scores differed significantly among different grades/experience levels, with postgraduate practitioners having the highest scores. There was a positive correlation between knowledge scores and confidence in managing FND. Conclusion This study highlights the prevalence of myths and misconceptions about FND among medical students and practitioners, emphasising the need for accurate education to improve diagnosis and management. Healthcare professionals should take a biopsychosocial approach to FND, considering the complex interplay between biological, psychological and social factors. Efforts to increase awareness and reduce stigma associated with FND are crucial for promoting better care. Targeted educational interventions may be beneficial to improve the understanding and management of FND among medical professionals.
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Affiliation(s)
- Essam M Al-Sibahee
- Department of Medicine, Neurology, University of Baghdad Bab al-Moadham Campus College of Medicine, Baghdad, Iraq
| | - Ahmed Hashim
- Department of Medicine, University of Baghdad Bab al-Moadham Campus College of Medicine, Baghdad, Iraq
| | - Sajjad Al-Badri
- Department of Medicine, University of Baghdad Bab al-Moadham Campus College of Medicine, Baghdad, Iraq
| | - Nabeel Al-Fatlawi
- Department of Medicine, University of Baghdad Bab al-Moadham Campus College of Medicine, Baghdad, Iraq
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3
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Gilmour GS, Lidstone SC. Moving Beyond Movement: Diagnosing Functional Movement Disorder. Semin Neurol 2023; 43:106-122. [PMID: 36893796 DOI: 10.1055/s-0043-1763505] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
Functional movement disorder (FMD) is a complex neuropsychiatric syndrome, encompassing abnormal movements and weakness, and is a common cause of potentially disabling neurological symptoms. It is vital to recognize that FMD is a syndrome, with nonmotor manifestations negatively affecting a patient's quality of life. This review highlights a diagnostic algorithm, where a history suggestive of FMD is combined with the presence of positive signs on examination and appropriate investigations to make the diagnosis. Positive signs indicate internal inconsistency such as variability and distractibility, and clinical findings that are incongruent with other known neurological disease. Importantly, the clinical assessment acts as the first opportunity to allow patients to understand FMD as the cause for their symptoms. Accurate and early diagnosis of FMD is necessary given that it is a treatable and potentially reversible cause of disability, with significant risk of iatrogenic harm associated with misdiagnosis.
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Affiliation(s)
- Gabriela S Gilmour
- Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic, University Health Network, Toronto, Ontario, Canada
| | - Sarah C Lidstone
- Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic, University Health Network, Toronto, Ontario, Canada.,Integrated Movement Disorders Program, Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada.,KITE Research Institute, Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
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4
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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.
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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
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5
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Piliavska K, Dantlgraber M, Dettmers C, Jöbges M, Liepert J, Schmidt R. Functional neurological symptoms are a frequent and relevant comorbidity in patients with multiple sclerosis. Front Neurol 2023; 14:1077838. [PMID: 37114221 PMCID: PMC10126263 DOI: 10.3389/fneur.2023.1077838] [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] [Received: 10/23/2022] [Accepted: 03/20/2023] [Indexed: 04/29/2023] Open
Abstract
Introduction Functional neurological symptoms (FNS) in multiple sclerosis (MS) have shown to be underinvestigated even though neurological diseases such as MS represent a risk factor for developing FNS. Comorbidity of FNS and MS can produce high personal and social costs since FNS patients have high healthcare utilization costs and a quality of life at least as impaired as in patients with disorders with underlying structural pathology. This study aims to assess comorbid FNS in patients with MS (pwMS) and investigate whether FNS in pwMS are associated with poorer health-related quality of life and work ability. Methods Newly admitted patients (234) with MS were studied during their stay at Kliniken Schmieder, a neurological rehabilitation clinic in Konstanz, Germany. The degree to which the overall clinical picture was explained by MS pathology was rated by neurologists and allied health practitioners on a five-point Likert scale. Additionally, neurologists rated each symptom reported by the patients. Health-related quality of life was assessed using a self-report questionnaire and work ability was assessed using the mean number of hours worked per day and information regarding disability pension as reported by patients. Results In 55.1% of cases, the clinical picture was completely explained by structural pathology due to MS. 17.1% of pwMS presented an overall clinical picture half or less of which could be explained by underlying structural pathology. PwMS with a higher comorbid FNS burden had a lower health-related quality of life and reported fewer working hours per day than pwMS with symptoms explained by structural pathology. Furthermore, pwMS with a full disability pension had a higher comorbid FNS burden than pwMS with no or partial disability pension. Discussion These results show that FNS should be addressed diagnostically and therapeutically since such symptoms are an important comorbidity in MS that is related to poorer health-related quality of life and lower work ability.
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Affiliation(s)
- Katya Piliavska
- Lurija Institute for Rehabilitation Sciences and Health Research, Allensbach, Germany
- *Correspondence: Katya Piliavska,
| | | | - Christian Dettmers
- Lurija Institute for Rehabilitation Sciences and Health Research, Allensbach, Germany
- Kliniken Schmieder Konstanz, Konstanz, Germany
| | - Michael Jöbges
- Lurija Institute for Rehabilitation Sciences and Health Research, Allensbach, Germany
- Kliniken Schmieder Konstanz, Konstanz, Germany
| | - Joachim Liepert
- Lurija Institute for Rehabilitation Sciences and Health Research, Allensbach, Germany
- Kliniken Schmieder Allensbach, Allensbach, Germany
| | - Roger Schmidt
- Lurija Institute for Rehabilitation Sciences and Health Research, Allensbach, Germany
- Klinik für Psychosomatik und Konsiliarpsychiatrie, Kantonsspital, St. Gallen, Switzerland
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Sensory Processing Difficulties in Patients with Functional Neurological Disorder: Occupational Therapy Management Strategies and Two Cases. Semin Pediatr Neurol 2022; 41:100951. [PMID: 35450672 DOI: 10.1016/j.spen.2022.100951] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 12/22/2021] [Accepted: 01/05/2022] [Indexed: 10/19/2022]
Abstract
Functional neurological disorder (FND) is a condition at the intersection of neurology and psychiatry, with some patients experiencing sensory hypersensitivities and other sensory processing difficulties. It has been postulated that poor integration and modulation of sensory information with cognitive, affective and behavioral processes may play a role in the pathophysiology of FND. In this article, we first succinctly review the role for occupational therapy (OT) in the multidisciplinary therapeutic approach to managing patients with FND. After highlighting previously published data identifying sensory processing difficulties in patients with FND, we subsequently outline the components of the sensory-based outpatient OT program for FND at the Massachusetts General Hospital. Here, we detail how occupational therapists assess and treat sensory modulation difficulties with the aid of resources like the Adolescent/Adult Sensory Profile (AASP), The Canadian Occupational Performance Measure (COPM), and the Sensory-Motor Preference Checklist. We then report on 2 clinical cases representative of the sensory modulation difficulties endorsed by some patients with FND, illustrating how developing an individualized, sensory-based treatment plan can help improve functional neurological symptoms and overall participation in activities of daily living. Prospective, controlled research is needed to further operationalize OT-based sensory modulation interventions, as well as define the tolerability and efficacy of this intervention for pediatric and adult populations with FND.
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Martindale JM, Mink JW. The Rise of Functional Tic-Like Behaviors: What Do the COVID-19 Pandemic and Social Media Have to Do With It? A Narrative Review. Front Pediatr 2022; 10:863919. [PMID: 35899132 PMCID: PMC9309505 DOI: 10.3389/fped.2022.863919] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 06/24/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND There has been a rise in explosive onset of tic-like behaviors during the COVID-19 pandemic. Historically, this is an uncommon phenomenology of functional movement disorders across all ages. Both the psychological burden of the pandemic and social media usage have been implicated in the rise of these tic-like behaviors. METHODS This paper provides a narrative review of the literature on chronic tic disorders, functional tics, and mass functional illness with particular focus on the key distinguishing features, role of social media, and the role of COVID-19. RESULTS The COVID-19 pandemic has profoundly affected the mental health of many individuals, including children, adolescents, and their caregivers. Implementation of lockdowns, lifestyle disruptions, school closures, and social distancing have driven a surge in social media and digital technology use. The combination of predisposing factors, the psychological burden of the COVID-19 pandemic, and social media are implicated in the rise and spread of tic-like behaviors; which may represent a modern-day form of mass functional illness. While many of the features overlap with functional tics, there are emerging distinctive features that are important to recognize. A more encompassing term, Functional Tic-Like Behaviors, is used to better reflect multiple contributing factors. CONCLUSION Knowledge of these differences is essential to mitigate downstream health effects and poor outcomes.
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Affiliation(s)
- Jaclyn M Martindale
- Department of Neurology, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, NC, United States
| | - Jonathan W Mink
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, United States
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Butler M, Shipston-Sharman O, Seynaeve M, Bao J, Pick S, Bradley-Westguard A, Ilola E, Mildon B, Golder D, Rucker J, Stone J, Nicholson T. International online survey of 1048 individuals with functional neurological disorder. Eur J Neurol 2021; 28:3591-3602. [PMID: 34245646 DOI: 10.1111/ene.15018] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 07/07/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE Functional neurological disorder (FND) is common, and symptoms can be severe. There have been no international large-scale studies of patient experiences of FND. METHODS A patient questionnaire was created to assess FND patient characteristics, symptom comorbidities and illness perceptions. Respondents were recruited internationally through an open access questionnaire via social media and patient groups over a month-long period. RESULTS In total, 1048 respondents from 16 countries participated. Mean age was 42 years (86% female). Median FND symptom duration was 5 years, and median time from first symptom to diagnosis was 2 years. Mean number of current symptoms (core FND and associated) was 9.9. Many respondents had associated symptoms, for example fatigue (93%), memory difficulties (80%) and headache (70%). Self-reported psychiatric comorbidities were relatively common (depression, 43%; anxiety, 51%; panic, 20%; and post-traumatic stress disorder, 22%). Most respondents reported that FND had multiple causes, including physical and psychological. CONCLUSIONS This large survey adds further evidence that people with FND typically have high levels of multiple symptom comorbidity with resultant distress. It also supports the notion that associated physical symptoms are of particular clinical significance in FND patients. Dualistic ideas of FND were not supported by respondents, who generally preferred to conceptualize the disorder as one at the interface of mind and brain. The need for a broad approach to this poorly served patient group is highlighted. Potential selection and response biases due to distribution of the survey online, mostly via FND patient groups, are a key limitation.
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Affiliation(s)
- Matthew Butler
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | | | - Mathieu Seynaeve
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Jianan Bao
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Susannah Pick
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | | | - Eveliina Ilola
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | | | | | - James Rucker
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Jon Stone
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Timothy Nicholson
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Posttraumatic functional movement disorders and litigation. Acta Neurol Belg 2021; 121:643-647. [PMID: 33772740 DOI: 10.1007/s13760-021-01660-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 03/19/2021] [Indexed: 10/21/2022]
Abstract
The concept of functional movement disorders has evolved considerably over the past few decades. More specifically, the views on the relation with psychological stressors or personality disorders have substantially changed, emphasizing a shift from the previously dominant dualistic scheme. This evolution is reflected in adaptations to diagnostic criteria and management approaches. Functional movement disorders which arise in a close temporal relationship with a peripheral trauma are specifically challenging with respect to diagnosis and treatment, but similar considerations seem to apply. The relationship of functional disorders with trauma appears to be much closer than is often thought. Clinical and pathophysiological research has identified shared factors underlying functional posttraumatic as well as primary movement disorders. These evolving insights impact on discussions in terms of litigation for compensation after trauma. The literature is reviewed and the consequences for argumentation in litigation are outlined, including ethical and legal considerations. Finally, we formulate a number of recommendations.
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Bennett K, Diamond C, Hoeritzauer I, Gardiner P, McWhirter L, Carson A, Stone J. A practical review of functional neurological disorder (FND) for the general physician. Clin Med (Lond) 2021; 21:28-36. [PMID: 33479065 PMCID: PMC7850207 DOI: 10.7861/clinmed.2020-0987] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We present a practical overview of functional neurological disorder (FND), its epidemiology, assessment and diagnosis, diagnostic pitfalls, treatment, aetiology and mechanism. We present an update on functional limb weakness, tremor, dystonia and other abnormal movements, dissociative seizures, functional cognitive symptoms and urinary retention, and 'scan-negative' cauda equina syndrome. The diagnosis of FND should rest on clear positive evidence, typically from a combination of physical signs on examination or the nature of seizures. In treatment of FND, clear communication of the diagnosis and the involvement of the multidisciplinary team is beneficial. We recommend that patients with FND are referred to specialists with expertise in neurological diagnosis. FND is a common presentation in emergency and acute medical settings and there are many practical elements to making a positive diagnosis and communication which are useful for all physicians to be familiar with.
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Affiliation(s)
| | | | | | | | | | - Alan Carson
- Centre for Clinical Brain Services, Edinburgh, UK
| | - Jon Stone
- Centre for Clinical Brain Services, Edinburgh, UK
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A South African review of routinely-collected health data of psychogenic nonepileptic seizure patients referred to psychiatrists in Johannesburg. Epilepsy Behav 2021; 114:107578. [PMID: 33268018 DOI: 10.1016/j.yebeh.2020.107578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/08/2020] [Accepted: 10/20/2020] [Indexed: 11/24/2022]
Abstract
Patients with psychogenic nonepileptic seizures (PNES) are often referred to psychiatrists for treatment of functional neurological symptom disorder (FNSD). However, not all patients with FNSD have an identified psychiatric comorbidity [1]. The aim of this observational study was to characterize the clinical and psychiatric features of patients with PNES from Johannesburg, South Africa, where a high frequency of PNES has been reported [2], and compare these findings to other reports. We hypothesized that patient outcomes regarding treatment adherence and episode frequency would improve when treated within a closed multidisciplinary team. The data included a retrospective record review of patients diagnosed with PNES from an epilepsy monitoring unit and referred for psychiatric assessment and treatment between November 2013 and July 2017. Fifty-nine cases met the criteria for the study. There were 7 male and 52 female participants, aged between 14 and 72 years (M = 33.76, SD = 13.88). The most frequently reported comorbid symptoms were anxiety (90%); dissociative symptoms (51%); headaches (76%) and gastrointestinal symptoms (36%). Important patient characteristics included past substance abuse (76%); impaired attachment (86%); past trauma (69%) and sexual trauma (29%). Generalized anxiety disorder (76%), major depressive disorder (64%) and PTSD (22%) were the most prevalent psychiatric diagnoses. After receiving psychiatric treatment, 47% of patients experienced a decrease in the frequency of episodes, while 86% became aware of the precipitants of their episodes. Psychiatric data can valuably inform current theories of PNES management. This study contributes to the understanding of comorbid, aetiological, and prognostic factors that are crucial to refining coherent models that will guide practice.
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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.
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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
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