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Saunders C, Bawa H, Aslanyan D, Coleman F, Jinadu H, Sigala N, Medford N. Treatment outcomes in the inpatient management of severe functional neurological disorder: a retrospective cohort study. BMJ Neurol Open 2024; 6:e000675. [PMID: 38979396 PMCID: PMC11227748 DOI: 10.1136/bmjno-2024-000675] [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: 02/07/2024] [Accepted: 06/10/2024] [Indexed: 07/10/2024] Open
Abstract
Background Functional neurological disorder (FND) is a heterogeneous condition; severe forms can be disabling. Multidisciplinary treatment and rehabilitation are recommended for severe FND, but there remains a lack of evidence for its efficacy and lack of understanding of the predictors and components of recovery. Methods We report clinical outcome data for an inpatient cohort with severe FND. Clinical Global Impression Improvement with treatment is the primary outcome measure. Admission and discharge measures (Euroqol quality of life measures, Beck Depression Inventory, Spielberger Trait Anxiety Inventory, Cambridge Depersonalisation Scale, Illness Perception Questionnaire (Revised) and Functional Mobility Scale) are reported as secondary outcomes. Results We describe an FND cohort (n=52) with chronic illness (mean symptom duration 9.7 years). At admission, there were clinically relevant levels of depression, anxiety and depersonalisation derealisation. At the time of discharge, most (43/52) patients' global condition had improved. Measures of mobility, depression and quality of life also significantly improved while at discharge, symptoms were experienced as more understandable and less distressing than at admission. An admission measure of patient confidence in treatment was predictive of eventual clinical outcome. Conclusions The most frequent outcome of inpatient rehabilitation is global improvement, even when symptoms are chronic and severe, reflected in measurable changes in both physical and psychological functioning. Significant levels of depersonalisation derealisation seen in this patient group suggest that routine enquiry into such experiences could help personalise FND treatment approaches. Patient confidence in treatment is key in determining clinical outcomes.
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Affiliation(s)
- Chloe Saunders
- Department of Neuropsychiatry, South London and Maudsley NHS Foundation Trust, London, UK
- Aarhus University Hospital, Aarhus, Denmark
| | - Hetashi Bawa
- Department of Neuropsychiatry, South London and Maudsley NHS Foundation Trust, London, UK
- Canterbury Christ Church University, Canterbury, UK
| | - Daron Aslanyan
- Department of Neuropsychiatry, South London and Maudsley NHS Foundation Trust, London, UK
| | - Frances Coleman
- Department of Neuropsychiatry, South London and Maudsley NHS Foundation Trust, London, UK
| | - Helen Jinadu
- Department of Neuropsychiatry, South London and Maudsley NHS Foundation Trust, London, UK
| | - Natasha Sigala
- Department of Clinical Neuroscience, Brighton and Sussex Medical School, Brighton, UK
| | - Nick Medford
- Department of Neuropsychiatry, South London and Maudsley NHS Foundation Trust, London, UK
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2
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Molero-Mateo P, Molina-Rueda F. Physiotherapy for patients with functional movement disorder: a systematic review. Neurologia 2024; 39:505-514. [PMID: 37116691 DOI: 10.1016/j.nrleng.2022.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 01/15/2022] [Indexed: 04/30/2023] Open
Abstract
INTRODUCTION Functional movement disorder (FMD), a type of functional neurological disorder, is a common reason for consultation with the neurology department. The efficacy of physiotherapy for motor rehabilitation of these patients has been widely studied. The aim of this review is to analyse the available evidence on the effects of physiotherapy on motor symptoms, activity (gait, mobility, balance), perceived health, quality of life, and the cognitive/emotional state of patients with FMD. METHODS This review follows the PRISMA recommendations. Four electronic databases were searched for relevant articles. Our review included randomised controlled trials investigating the effects of a specialised physiotherapy intervention alone or in combination with other therapies as part of a multidisciplinary approach, with results compared against standard physiotherapy. RESULTS We reviewed 4 studies, including a total of 188 patients. We gathered data on the study population, outcome measures, protocols, and results. According to the Oxford quality scoring system, 3 studies had moderate methodological quality (3-4/5) and the remaining study presented poor methodological quality (< 3). CONCLUSIONS Physiotherapy improves motor symptoms, activity, perceived health, and quality of life in patients with FMD.
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Affiliation(s)
- P Molero-Mateo
- Escuela Internacional de Doctorado, Universidad Rey Juan Carlos, Móstoles, Madrid, Spain; Centro Lescer (rehabilitación neurológica), Madrid, Spain
| | - F Molina-Rueda
- Departamento de Fisioterapia, Terapia Ocupacional, Rehabilitación y Medicina Física, Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Alcorcón, Madrid, Spain.
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3
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Guy L, Caceres GA, Jackson T, Gorman S, Wilson J, Hsieh Y, Petty D, Harrison S, Pick S. Routine outcomes and evaluation of an 8-week outpatient multidisciplinary rehabilitative therapy program for functional neurological disorder. J Neurol 2024; 271:1873-1884. [PMID: 38091087 PMCID: PMC10973040 DOI: 10.1007/s00415-023-12111-4] [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: 08/29/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 03/28/2024]
Abstract
OBJECTIVES We report routinely collected outcome data from an 8-week outpatient rehabilitative therapy program. The aims of the intervention were to (1) reduce symptom severity and (2) improve functional mobility in adults with functional neurological disorder (FND). METHODS The program delivered individual physiotherapy, cognitive behavioral therapy (CBT) and self-management sessions, group physiotherapy, and psychoeducation. Outcome measures included the Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI-II), Work and Social Adjustment Scale (WSAS), 10-Meter Walk Test (10MWT), Timed Up and Go (TUG), and Berg Balance Scale (BBS). Data were analyzed retrospectively in accordance with routine service evaluation. Wilcoxon signed-rank tests assessed changes in outcomes between weeks 1 and 8 for all patients completing treatment (n = 45). For patients who attended the 3-month follow-up (n = 31), Friedman's ANOVA assessed overall change in outcomes over time. Post hoc Wilcoxon signed-rank tests compared pairs of time-points (Weeks 1, 8, and 3-month follow-up). RESULTS Analyses of patients completing the program revealed significant improvements in scores between week 1 and week 8. Excluding the BBS, there were statistically significant improvements in all outcomes between weeks 1 and 8 and between weeks 1 and 3-month follow-up. DISCUSSION This outpatient therapy program provided effective treatment for FND. Patients reported reduced anxiety, depression, and functional impairment, as well as improved performance on most physiotherapy measures.
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Affiliation(s)
- Lisette Guy
- FiND Programme, Bethlem Royal Hospital, South London and Maudsley NHS Foundation Trust, London, UK
| | - Gabriella A Caceres
- FiND Programme, Bethlem Royal Hospital, South London and Maudsley NHS Foundation Trust, London, UK
| | - Temeika Jackson
- FiND Programme, Bethlem Royal Hospital, South London and Maudsley NHS Foundation Trust, London, UK
| | - Sean Gorman
- FiND Programme, Bethlem Royal Hospital, South London and Maudsley NHS Foundation Trust, London, UK
| | - Jennifer Wilson
- FiND Programme, Bethlem Royal Hospital, South London and Maudsley NHS Foundation Trust, London, UK
| | - Yvonne Hsieh
- FiND Programme, Bethlem Royal Hospital, South London and Maudsley NHS Foundation Trust, London, UK
| | - Demelza Petty
- FiND Programme, Bethlem Royal Hospital, South London and Maudsley NHS Foundation Trust, London, UK
| | - Simon Harrison
- FiND Programme, Bethlem Royal Hospital, South London and Maudsley NHS Foundation Trust, London, UK
| | - Susannah Pick
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 De Crespigny Park, London, SE5 8AB, UK.
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4
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Scheurich JA, Klaas KM, Sim LA, Weiss KE, Case HF, Harbeck-Weber C. Characteristics and outcomes of youth with functional seizures attending intensive interdisciplinary pain treatment. Epilepsy Behav 2024; 153:109689. [PMID: 38447301 DOI: 10.1016/j.yebeh.2024.109689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Revised: 02/05/2024] [Accepted: 02/10/2024] [Indexed: 03/08/2024]
Abstract
Functional seizures (FS) can be debilitating and negatively impact quality of life. Yet intervention research for FS is limited, especially for youth. This study examined clinical characteristics and outcomes of youth with FS (13-23 years) presenting to a pediatric intensive interdisciplinary pain treatment (IIPT) program in the midwestern United States. Sixty youth (mean age = 16.5 years; 83.3 % female) met inclusion criteria. At intake, comorbid chronic pain, somatic symptoms, autonomic dysfunction, eating and weight disturbances, and mental health concerns were common. Despite this high symptom burden, youth with FS reported significant improvements in functioning measured with the Functional Disability Inventory, t(53) = 9.80, p <.001, d = 1.32; depression measured with the Center for Epidemiological Studies - Depression Scale for Children, t(53) = 6.76, p <.001, d = 0.91; anxiety measured with the Spence Children's Anxiety Scale, t(53) = 3.97, p < .001, d = 0.53; and catastrophizing measured with the Pain Catastrophizing Scale for Children, t(53) = 6.44, p <.001, d = 0.86, following completion of the program, suggesting that IIPT may be an effective treatment option for highly disabled and emotionally distressed youth with FS. Future research is needed to continue to refine best practices for youth with FS to reduce suffering and improve outcomes.
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Affiliation(s)
- Jennifer A Scheurich
- Department of Psychiatry & Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA; Department of Pediatrics, Children's Mercy Kansas City, 2401 Gillham Road, Kansas City, MO 64108, USA; University of Missouri-Kansas City School of Medicine, 2411 Holmes St, Kansas City, MO 64108, USA.
| | - Kelsey M Klaas
- Department of Pediatric & Adolescent Medicine, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - Leslie A Sim
- Department of Psychiatry & Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - Karen E Weiss
- Department of Psychiatry & Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
| | - Hannah F Case
- Department of Otolaryngology, Texas Tech University Health Sciences Center, 3601 4th Street STOP 8315, Lubbock, TX 79430, USA.
| | - Cynthia Harbeck-Weber
- Department of Psychiatry & Psychology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
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5
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Vanini G, Bühler J, Weber S, Steinauer M, Aybek S. Healthcare employment as a risk factor for functional neurological disorder: A case-control study. Eur J Neurol 2024; 31:e16056. [PMID: 37697728 PMCID: PMC11235703 DOI: 10.1111/ene.16056] [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: 06/14/2023] [Revised: 08/21/2023] [Accepted: 08/24/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND AND PURPOSE Female gender, younger age and stressful life events are known predisposing factors for functional neurological disorders (FNDs). Employment in a healthcare profession has also been suggested to be a predisposing factor. We set out to conduct a large-scale case-control study to estimate the rate employment in a healthcare profession among people with FND. METHODS We included 200 consecutive patients with a confirmed diagnosis of FND, referred to our clinic at University Hospital Bern Switzerland between October 1, 2016, and August 1, 2019. In addition, we included a control group of 200 patients with a confirmed neurological disorder, matched for age and gender, seen during the same period. The primary endpoint was to compare the prevalence of healthcare professionals between the groups. We also describe the clinical manifestations and concomitant psychiatric diagnoses in the FND cohort. RESULTS Female gender was predominant (70%), and the participants' mean age was 37 years. The proportion of healthcare professionals in the FND patients was 18% (33/186), which was significantly higher than in the control group, in which it was 10.6% (17/189; p = 0.019, 95% confidence interval odds ratio 1.168-4.074). Most healthcare professionals in both cohorts were nurses (21/33 among FND patients, 10/17 among controls). Among FND patients, 140 (70%) had motor symptoms and 65 (32.5%) had a concomitant psychiatric diagnosis. CONCLUSION This case-control study confirmed a higher rate of employment in healthcare professions in patients with FND, suggesting two potential mechanisms of FND: exposure to models/specific knowledge about neurological symptoms or stress-related professional factors. This warrants further studies on underlying mechanisms and prevention.
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Affiliation(s)
- Giorgio Vanini
- Department of Neurology, Psychosomatic Medicine Unit, Inselspital Bern University HospitalUniversity of BernBernSwitzerland
| | - Janine Bühler
- Department of Neurology, Psychosomatic Medicine Unit, Inselspital Bern University HospitalUniversity of BernBernSwitzerland
- Graduate School for Health Sciences (GHS)University of BernBernSwitzerland
| | - Samantha Weber
- Department of Neurology, Psychosomatic Medicine Unit, Inselspital Bern University HospitalUniversity of BernBernSwitzerland
| | - Manuela Steinauer
- Department of Neurology, Psychosomatic Medicine Unit, Inselspital Bern University HospitalUniversity of BernBernSwitzerland
| | - Selma Aybek
- Department of Neurology, Psychosomatic Medicine Unit, Inselspital Bern University HospitalUniversity of BernBernSwitzerland
- Neurology, Faculty of Science and MedicineUniversity of FribourgFribourgSwitzerland
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6
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Ranford J, MacLean J. Outpatient Approach to Occupational Therapy for Paroxysmal Functional Neurologic Symptoms: Sensory Modulation Training as an Emerging Treatment. Neurol Clin 2023; 41:695-709. [PMID: 37775199 DOI: 10.1016/j.ncl.2023.02.008] [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: 10/01/2023]
Abstract
Occupational therapy (OT) is an important treatment modality for patients with paroxysmal functional neurologic disorder (FND) symptoms. In our clinical experience, an outpatient, OT-based sensory modulation treatment can address sensory processing difficulties often endorsed by patients with paroxysmal motor FND and functional seizures. This article aims to describe in detail the goals and treatment strategies for occupational therapists to replicate this approach. This article is also an important first step in aiding the development and execution of clinical trials to further evaluate the effectiveness of sensory-based treatment in patients with FND.
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Affiliation(s)
- Jessica Ranford
- Functional Neurological Disorder Unit and Research Group, Department of Neurology, Massachusetts General Hospital, Wang Ambulatory Care Center 8th Floor, Suite 835, 15 Parkman Street, Boston, MA, USA; Department of Occupational Therapy, Massachusetts General Hospital, Wang Ambulatory Care Center 1st Floor, Suite 127, 15 Parkman Street, Boston, MA 02114, USA.
| | - Julie MacLean
- Functional Neurological Disorder Unit and Research Group, Department of Neurology, Massachusetts General Hospital, Wang Ambulatory Care Center 8th Floor, Suite 835, 15 Parkman Street, Boston, MA, USA; Department of Occupational Therapy, Massachusetts General Hospital, Wang Ambulatory Care Center 1st Floor, Suite 127, 15 Parkman Street, Boston, MA 02114, USA
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7
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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.
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8
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Molero-Mateo P, Molina-Rueda F. Tratamiento fisioterápico del paciente con trastorno del movimiento funcional: una revisión sistemática. Neurologia 2022. [DOI: 10.1016/j.nrl.2022.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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9
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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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10
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Diagnosis and Initial Treatment of Functional Movement Disorders in Children. Semin Pediatr Neurol 2022; 41:100953. [PMID: 35450668 DOI: 10.1016/j.spen.2022.100953] [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: 01/07/2022] [Accepted: 01/12/2022] [Indexed: 11/20/2022]
Abstract
Functional movement disorders (FMD) are complex neurobehavioral disorders that can be a significant source of disability for both children and their caregivers. While FMD in the adult population is better characterized, the aim of this paper is to review the pertinent clinical and historical features, diagnostic criteria, and multi-disciplinary management of FMD in the pediatric population. We highlight recent trends in pediatric FMD, including the increase in functional tic-like behaviors that has been observed during the COVID-19 pandemic.
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11
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Polich G, Thompson J, Molton I, Herman S, LaFaver K. Intensive rehabilitation for functional motor disorders (FMD) in the United States: A review. NeuroRehabilitation 2022; 50:245-254. [DOI: 10.3233/nre-228007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: Higher levels of care in the form of intensive rehabilitation may be appropriate for select patients with a diagnosis of functional motor disorder (FMD). Intensive rehabilitation, as delivered through an outpatient day program or through admission to an inpatient rehabilitation facility, can offer a greater frequency and variety of integrated clinical services than most lower levels of care. OBJECTIVE: Higher levels of rehabilitation for FMD have not yet been well characterized in the literature. In this article, we will focus on the population of FMD patients who begin receiving care in the outpatient setting. METHOD: In this review, we describe a range of options for higher levels of FMD care, evaluate the supporting literature, and weigh the pros and cons of each approach. Several specific examples of intensive rehabilitation programs in the United States will be described. Finally, we will consider existing health systems barriers to each of these outpatient and inpatient higher levels of care. RESULTS: Within a stepped model of care, intensive outpatient day-programs and inpatient rehabilitation may be considered for individuals who present with complex, refractory motor deficits from FMD. For appropriately selected patients, a growing body of literature suggests that time-limited, goal-oriented intensive rehabilitation may provide an effective treatment avenue. CONCLUSION: It remains to be determined whether treatment in intensive care settings, while more costly in the short term, could lead to greater cost savings in the long term. The prospect of telemedicine rehabilitation for FND in terms of efficacy and cost also remains to be determined.
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Affiliation(s)
- Ginger Polich
- Spaulding Rehabilitation Hospital, Charlestown, MA, USA
| | - Jeffrey Thompson
- Department of Physical Medicine and Rehabilitation, Mayo Medical School, Rochester, MN, USA
| | - Ivan Molton
- Department of Rehabilitation Medicine, University of Washington Medical Center, Seattle, WA, USA
| | - Seth Herman
- Department of Physical Medicine and Rehabilitation, California Rehabilitation Institute, Los Angeles, CA, USA
| | - Kathrin LaFaver
- Department of Neurology, Northwestern Feinberg School of Medicine, Chicago, IL, USA
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12
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Psychological interventions for treating functional motor symptoms: Scoping review of the literature. Clin Psychol Rev 2022; 94:102146. [DOI: 10.1016/j.cpr.2022.102146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 01/31/2022] [Accepted: 03/16/2022] [Indexed: 11/21/2022]
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13
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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.
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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
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14
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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.
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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
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15
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Tinazzi M, Fiorio M, Berardelli A, Bonetti B, Bonifati DM, Burlina A, Cagnin A, Calabria F, Corbetta M, Cortelli P, Giometto B, Guidoni SV, Lopiano L, Mancardi G, Marchioretto F, Pellegrini M, Teatini F, Tedeschi G, Tesolin L, Turinese E, Zappia M, Marotta A. Opinion, knowledge, and clinical experience with functional neurological disorders among Italian neurologists: results from an online survey. J Neurol 2021; 269:2549-2559. [PMID: 34665330 PMCID: PMC9021063 DOI: 10.1007/s00415-021-10840-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 10/05/2021] [Accepted: 10/06/2021] [Indexed: 01/07/2023]
Abstract
BACKGROUND Functional neurological disorders (FND) are disabling medical conditions commonly seen in neurological practice. Neurologists play an essential role in managing FND, from establishing a diagnosis to coordination of multidisciplinary team-based treatment for patients. With this study, we investigated the knowledge and the clinical experience of Italian neurologists in managing patients with FND. METHODS Members of the Italian Society of Neurology were invited via e-mail to participate in this ad hoc online survey; 492 questionnaires were returned completed. RESULTS The term "Functional neurological disorders" in reference to FND was used more frequently than other psychological (e.g., psychogenic or conversion), or descriptive terms (e.g., non-organic or stress-related). When speaking with patients, the respondents stated that they preferred explaining symptoms based on abnormal functioning of the nervous system than discussing mental illness and that they would refer their patient to a psychologist rather than to a psychiatrist. Few considered that physiotherapy and psychiatric interventions are useful approaches to treating FND. Some believed that patients simulate their symptoms. CONCLUSIONS Overall, the responses suggest that knowledge about scientific advances in FND is somewhat sparse. A psychiatric-centered view of FND opens the way to an approach in which neurobiological and psychological aspects constitute essential factors of the condition. In this context, professional education could improve understanding of FND and optimize patient management.
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Affiliation(s)
- Michele Tinazzi
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Mirta Fiorio
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy
| | - Alfredo Berardelli
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy.,IRCSS Neuromed, Pozzilli, Isernia, Italy
| | - Bruno Bonetti
- Neurology Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | | | | | - Annachiara Cagnin
- Department of Neuroscience, University of Padua, Padua, Italy.,Padova Neuroscience Center, University of Padua, Padua, Italy
| | - Francesca Calabria
- Neurology Unit, Azienda Ospedaliera Universitaria Integrata Verona, Verona, Italy
| | - Maurizio Corbetta
- Department of Neuroscience, University of Padua, Padua, Italy.,Venetian Institute of Molecular Medicine, VIMM Fondazione Biomedica Padova, Padua, Italy
| | - Pietro Cortelli
- IRCCS, Istituto di Scienze Neurologiche di Bologna, Bologna, Italy.,DIBINEM, Alma Mater Studiorum, Università di Bologna, Bologna, Italy
| | - Bruno Giometto
- Department of Neurology, Santa Chiara Hospital, Trento, Italy
| | | | - Leonardo Lopiano
- Department of Neurosciences Rita Levi Montalcini, University of Torino, Turin, Italy.,AOU Città della Salute e della Scienza, Torino, Italy
| | - Gianluigi Mancardi
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Child, University of Genova, Genoa, Italy.,IRCCS ICS Maugeri, Pavia, Italy
| | - Fabio Marchioretto
- Neurology Unit, IRCCS Sacro Cuore Don Calabria Hospital, Negrar di Valpolicella, Verona, Italy
| | | | - Francesco Teatini
- Functional Movement Disorders Outpatient Clinic, Clinical Neurology and Stroke Unit Department, Central Country Hospital, Bolzano, Italy
| | - Gioacchino Tedeschi
- Department of Advanced Medical and Surgical Sciences, University of Campania, Naples, Italy
| | - Lucia Tesolin
- Functional Movement Disorders Outpatient Clinic, Clinical Neurology and Stroke Unit Department, Central Country Hospital, Bolzano, Italy
| | | | - Mario Zappia
- Department of Medical and Surgical Sciences and Advanced Technologies "G.F. Ingrassia", Neuroscience Section, University of Catania, Catania, Italy
| | - Angela Marotta
- Department of Neurosciences, Biomedicine and Movement Sciences, University of Verona, Verona, Italy.
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16
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Schmidt T, Ebersbach G, Oelsner H, Sprock A, König IR, Bäumer T, Münchau A, Weissbach A. Evaluation of Individualized Multi-Disciplinary Inpatient Treatment for Functional Movement Disorders. Mov Disord Clin Pract 2021; 8:911-918. [PMID: 34401405 PMCID: PMC8354066 DOI: 10.1002/mdc3.13268] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 05/21/2021] [Accepted: 06/03/2021] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Functional movement disorders (FMD) are associated with considerable morbidity and impairment of quality of life. Specialized treatment is scarce and data on efficacy of different therapies are limited. OBJECTIVE To evaluate a multi-modal inpatient treatment program for patients with FMD. METHODS Thirty-one patients with FMD were analyzed before (t1) and after multi-modal inpatient treatment (t2) by a blinded video rating using the Psychogenic Movement Disorder Rating Scale (PMDRS), the simplified Functional Movement Disorder Rating Scale (S-FMDRS), and the Clinical Global Impression Scale of Severity (CGI-S), as well as patients' self-rating. In 23 out of 31 patients a 5 months follow-up investigation was performed (t3). Wilcoxon signed-rank test and Friedman test were used for rating scale and self-rating comparisons over time. Spearman correlation was used for correlation of symptom improvement and clinical characteristics. RESULTS Video rating revealed significant reduction of scores after therapy (median PMDRS t1 = 24, t2 = 8, P = 0.0006; S-FMDRS t1 = 11, t2 = 4, P = 0.008; CGI-S t1 = 4, t2 = 3, P = 0.000136) with sustained score decrease in follow-up evaluations (PMDRS t1 = 31, t2 = 8, t3 = 7, P = 0.000032; S-FMDRS t1 = 12, t2 = 4, t3 = 3, P = 0.000888; CGI-S t1 = 4, t2 = 3, t3 = 3, P = 0.000032). Patients reported a stable reduction of symptoms in the self-rating (CGI-S t1 = 5, t2 = 4, t3 = 4, P = 0.016). Age correlated with treatment response with older patients showing better improvement, but disease duration did not correlate with outcome. Patients who suffered from physical trauma, sexual or physical abuse had smaller score reductions. CONCLUSION Blinded video and self-rating assessment showed significant score reduction in patients with FMD after an individualized interdisciplinary inpatient intervention.
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Affiliation(s)
- Tamara Schmidt
- Movement Disorders ClinicKliniken Beelitz GmbHBeelitz‐HeilstättenGermany
| | - Georg Ebersbach
- Movement Disorders ClinicKliniken Beelitz GmbHBeelitz‐HeilstättenGermany
| | - Henriette Oelsner
- Movement Disorders ClinicKliniken Beelitz GmbHBeelitz‐HeilstättenGermany
| | - Anette Sprock
- Movement Disorders ClinicKliniken Beelitz GmbHBeelitz‐HeilstättenGermany
| | - Inke R. König
- Institute of Medical Biometry and StatisticsUniversity of LübeckLübeckGermany
| | - Tobias Bäumer
- Institute of Systems Motor ScienceUniversity of LübeckLübeckGermany
| | | | - Anne Weissbach
- Institute of Systems Motor ScienceUniversity of LübeckLübeckGermany
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17
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Finkelstein SA, Cortel‐LeBlanc MA, Cortel‐LeBlanc A, Stone J. Functional neurological disorder in the emergency department. Acad Emerg Med 2021; 28:685-696. [PMID: 33866653 DOI: 10.1111/acem.14263] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 04/08/2021] [Accepted: 04/12/2021] [Indexed: 12/27/2022]
Abstract
We provide a narrative review of functional neurological disorder (FND, or conversion disorder) for the emergency department (ED). Diagnosis of FND has shifted from a "rule-out" disorder to one now based on the recognition of positive clinical signs, allowing the ED physician to make a suspected or likely diagnosis of FND. PubMed, Google Scholar, academic books, and a hand search through review article references were used to conduct a literature review. We review clinical features and diagnostic pitfalls for the most common functional neurologic presentations to the ED, including functional limb weakness, functional (nonepileptic) seizures, and functional movement disorders. We provide practical advice for discussing FND as a possible diagnosis and suggestions for initial steps in workup and management plans.
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Affiliation(s)
| | - Miguel A. Cortel‐LeBlanc
- Faculty of Medicine University of Ottawa Ottawa Ontario Canada
- The Ottawa Hospital Ottawa Ontario Canada
- Queensway Carleton Hospital Ottawa Ontario Canada
| | - Achelle Cortel‐LeBlanc
- Faculty of Medicine University of Ottawa Ottawa Ontario Canada
- Queensway Carleton Hospital Ottawa Ontario Canada
| | - Jon Stone
- Centre for Clinical Brain Sciences University of Edinburgh Edinburgh UK
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18
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O'Keeffe S, Chowdhury I, Sinanaj A, Ewang I, Blain C, Teodoro T, Edwards M, Yogarajah M. A Service Evaluation of the Experiences of Patients With Functional Neurological Disorders Within the NHS. Front Neurol 2021; 12:656466. [PMID: 34135848 PMCID: PMC8200476 DOI: 10.3389/fneur.2021.656466] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 05/07/2021] [Indexed: 11/29/2022] Open
Abstract
Previous research into Functional Neurological Disorder (FND) has shown that there are significant barriers in providing patient-centred care. However, there has been no specific research into whether patient experiences of care for FND meet the current standards of care. This study aimed to investigate the types of problems experienced by FND patients, and whether these differed to patients with multiple sclerosis (MS). FND (n = 40) and MS patients (n = 37) were recruited from NHS tertiary neurology clinics and completed questionnaires on their experiences of health care services. Significant differences in experiences of care between the two patient groups were found, with FND patients reporting significantly more problems in their diagnosis and treatment (p = 0.003), patient-centred care (p < 0.001), relationships with healthcare professionals (p < 0.001), and in accessing community care (p = 0.001). Limitations include a small sample size, specificity to a single centre, and cross-sectional design. The results suggest that current care for FND patients is not meeting expected standards for long-term neurological conditions, highlighting the need for structured care pathways and patient-centred care.
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Affiliation(s)
- Shauna O'Keeffe
- Atkinson Morley Regional Neuroscience Centre, St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom
| | - Ibrahim Chowdhury
- Neuroscience Research Centre, Institute of Molecular and Clinical Sciences, St. George's University of London, Cranmer Terrace, London, United Kingdom
| | - Anila Sinanaj
- Atkinson Morley Regional Neuroscience Centre, St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom
| | - Iberedem Ewang
- Atkinson Morley Regional Neuroscience Centre, St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom
| | - Camilla Blain
- Atkinson Morley Regional Neuroscience Centre, St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom
| | - Tiago Teodoro
- Atkinson Morley Regional Neuroscience Centre, St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom
| | - Mark Edwards
- Atkinson Morley Regional Neuroscience Centre, St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom.,Neuroscience Research Centre, Institute of Molecular and Clinical Sciences, St. George's University of London, Cranmer Terrace, London, United Kingdom
| | - Mahinda Yogarajah
- Atkinson Morley Regional Neuroscience Centre, St. George's University Hospitals National Health Service Foundation Trust, London, United Kingdom.,Neuroscience Research Centre, Institute of Molecular and Clinical Sciences, St. George's University of London, Cranmer Terrace, London, United Kingdom.,National Hospital for Neurology and Neurosurgery, London, United Kingdom.,Department of Experimental and Clinical Epilepsy, University College London Institute of Neurology, London, United Kingdom
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19
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Nicholson C, Francis J, Nielsen G, Lorencatto F. Barriers and enablers to providing community-based occupational therapy to people with functional neurological disorder: An interview study with occupational therapists in the United Kingdom. Br J Occup Ther 2021. [DOI: 10.1177/03080226211020658] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction Occupational therapists have an integral role in the treatment of people with functional neurological disorder, yet there is evidence of variable implementation of occupational therapy in community settings. This study explored the barriers and enablers to delivering community-based occupational therapy to people with functional neurological disorder in the United Kingdom. Methods Community-based neurological occupational therapists ( n = 10) with experience in functional neurological disorder were invited to complete semi-structured qualitative interviews. The interview schedule and analysis were based on the Theoretical Domains Framework, a behavioural science tool for investigating barriers and enablers to clinical practice. Data were analysed using a combined content and framework analysis approach. Findings Important barriers to treatment included limited published information to guide practice, lack of professional role clarity and restricted multidisciplinary team working. Enablers included occupational therapists’ dual training in physical and mental health and focus on activity engagement. Service provision, quality and access varied across geographical locations. Conclusion Occupational therapists are uniquely placed to help people with functional neurological disorder; however, findings suggest that existing community service structures in many regions in the United Kingdom are inadequate and limit the quality of treatment that can be provided. Additional resources are required to support occupational therapy service provision in community settings.
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Affiliation(s)
- Clare Nicholson
- Department of Therapy Services, National Hospital for Neurology & Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK
| | - Jill Francis
- Faculty of Medicine Dentistry and Health Science, Clinical Epidemiology Program, University of Melbourne, Ottawa Hospital Research Institute, Melbourne, Australia
| | - Glenn Nielsen
- Neurosciences Research Centre, St George’s, University of London, London, UK
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20
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Naidoo L, Bhigjee AI. The spectrum of functional neurological disorders: A retrospective analysis at a tertiary hospital in South Africa. S Afr J Psychiatr 2021; 27:1607. [PMID: 33936802 PMCID: PMC8063761 DOI: 10.4102/sajpsychiatry.v27i0.1607] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 11/01/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Functional neurological disorders (FNDs) are commonly encountered in practice; however, there is a paucity of data in Africa. AIM To identify and describe the clinical profile of patients presenting with FNDs, underlying medical and psychiatric diagnoses and review the investigation and management of these patients. SETTING Inkosi Albert Luthuli Central Hospital (IALCH), a tertiary-level hospital in Durban, South Africa. METHODS A retrospective chart review and descriptive analysis were performed over a 14-year period (2003-2017) on cases meeting the study criteria. RESULTS Of 158 subjects, the majority were female (72.8%), had a mean age of 32.8 years, were single (63.3%), unemployed (56.3%) and of black African ethnicity (64.6%). The most common clinical presentation was sensory impairment (57%) followed by weakness (53.2%) and seizures (38.6%). Inconsistency was the most frequent examination finding (16.5%). Medical conditions were identified in half of the study population (51.3%), with hypertension (22.2%) and human immunodeficiency virus (HIV) (17.2%) being most common. Of patients with a psychiatric diagnosis (55.1%), 25.3% had depression. Magnetic resonance imaging (MRI) was the most frequently performed investigation (36.1%). The majority of patients received psychotherapy (72%) and most had not shown improvement (55.3%) at a median follow-up of 2 months, whilst 17% had deteriorated. CONCLUSION Functional neurological disorders were most frequently diagnosed in young unmarried females, of black African ethnicity. Family history, personal exposure to a neurological illness and certain socioeconomic factors may be potential risk factors. Sensory impairment was the most common clinical phenotype. Further studies are needed to better understand and manage FNDs in the South African context.
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Affiliation(s)
- Lavanya Naidoo
- Department of Neurology, Nelson R Mandela School of Medicine, University of Kwazulu-Natal, Durban, South Africa
| | - Ahmed I. Bhigjee
- Department of Neurology, Nelson R Mandela School of Medicine, University of Kwazulu-Natal, Durban, South Africa
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21
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Marotta A, Fiorio M, Fracasso I, Franchini CA, Defazio G, Tinazzi M. Functional Neurological Disorders as Seen by a Cohort of General Practitioners in Northern Italy: Evidence From an Online Survey. Front Neurol 2021; 12:583672. [PMID: 33569039 PMCID: PMC7868405 DOI: 10.3389/fneur.2021.583672] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 01/04/2021] [Indexed: 11/13/2022] Open
Abstract
General practitioners (GPs) provide primary care and advise their patients on which diagnostic and therapeutic pathways they judge most appropriate. For patients with functional neurological disorders (FND), receiving a proper explanation of diagnosis by their GP from the very beginning may drastically improve prognosis. Novel approaches to the diagnosis and treatment of FND have important implications for effective management. The aim of this study was to investigate Italian GP opinion and knowledge about FND in light of new approaches to the illness. To do this, we evaluated the responses to a 13-item web-based survey completed by 133 GPs practicing in northern Italy. Psychological terms to describe FND were more frequently used than functional neurological disorder and mental illness was considered an important predictor of diagnosis. Referral to a neurologist rather than to a psychiatrist was largely preferred, while physiotherapy consultation was seldom recognized as a valuable approach to treating FND. Overall, the survey findings suggest that knowledge about novel approaches to FND is somewhat lacking. Currently, GPs appear to be transitioning from a classical psychological view of the disorder toward a more modern conceptualization, in which neurobiological, psychological, and social factors all play an important role. Professional education during this transition would be an advantageous way to optimize physician management of FND and to enhance diagnosis, explanation, and management across primary and secondary care pathways.
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Affiliation(s)
- Angela Marotta
- Department of Neurosciences, Biomedicine and Movement Sciences, Università di Verona, Verona, Italy
| | - Mirta Fiorio
- Department of Neurosciences, Biomedicine and Movement Sciences, Università di Verona, Verona, Italy
| | - Isabella Fracasso
- Italian Society of General Practice and Primary Care (SIMG)-Section of Verona, Verona, Italy
| | - Carlo Andrea Franchini
- Italian Society of General Practice and Primary Care (SIMG)-Section of Verona, Verona, Italy
| | - Giovanni Defazio
- Neurology Unit, Department of Medical Sciences and Public Health, University of Cagliari and AOU Cagliari, Cagliari, Italy
| | - Michele Tinazzi
- Department of Neurosciences, Biomedicine and Movement Sciences, Università di Verona, Verona, Italy
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22
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Richardson M, Kleinstäuber M, Wong D. Nocebo-Hypothesis Cognitive Behavioral Therapy (NH-CBT) for Persons With Functional Neurological Symptoms (Motor Type): Design and Implementation of a Randomized Active-Controlled Trial. Front Neurol 2021; 11:586359. [PMID: 33424742 PMCID: PMC7793953 DOI: 10.3389/fneur.2020.586359] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 10/30/2020] [Indexed: 11/23/2022] Open
Abstract
Introduction: Functional Neurological Symptom Disorders (FNSD) are associated with high levels of disability and immense direct and indirect health costs. An innovative interdisciplinary rehabilitation approach for individuals with functional neurological symptoms of motor type–Nocebo-Hypothesis Cognitive Behavioral Therapy (NH-CBT)—combines CBT and movement retraining with video feedback embedded in a comprehensive explanatory model of the etiology of FNSD. Methods: This protocol describes the development and implementation of a phase II, parallel group, randomized controlled trial with blinded outcome assessors to compare the efficacy of NH-CBT with an active control condition (supportive counseling and movement retraining). Individuals meeting diagnostic criteria of an FNSD or psychogenic movement disorder will be randomly assigned to one of the 8-week interventions. Self-report scales of motor and other physical symptoms, symptom-related psychological variables, and assessor ratings of participants' mobility will be administered at baseline, and at 8- and 16-week follow-up. Adverse events will be monitored across all sessions and therapeutic alliance will be measured at the end of therapy. The primary statistical analysis will test the hypothesis that NH-CBT is more effective than the control intervention at the 8-week follow-up. Discussion: The therapeutic strategies of NH-CBT are theory-driven by assumptions of the predictive coding model of the etiology of FNSD. Strengths and limitations of this trial will be discussed. Trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR; identifier: ACTRN12620000550909).
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Affiliation(s)
- Matt Richardson
- Department of Psychological Medicine, Otago Medical School - Dunedin Campus, University of Otago, Dunedin, New Zealand
| | - Maria Kleinstäuber
- Department of Psychological Medicine, Otago Medical School - Dunedin Campus, University of Otago, Dunedin, New Zealand
| | - Dana Wong
- Department of Psychology and Counselling, School of Psychology and Public Health, La Trobe University, Bundoora, VIC, Australia
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23
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LaFaver K, LaFrance WC, Price ME, Rosen PB, Rapaport M. Treatment of functional neurological disorder: current state, future directions, and a research agenda. CNS Spectr 2020; 26:1-7. [PMID: 33280634 DOI: 10.1017/s1092852920002138] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Functional neurological disorder (FND) encompasses a complex and heterogeneous group of neuropsychiatric syndromes commonly encountered in clinical practice. Patients with FND may present with a myriad of neurological symptoms and frequently have comorbid medical, neurological, and psychiatric disorders. Over the past decade, important advances have been made in understanding the pathophysiology of FND within a biopsychosocial framework. Many challenges remain in addressing the stigma associated with this diagnosis, refining diagnostic criteria, and providing access to evidence-based treatments. This paper outlines FND treatment approaches, emphasizing the importance of respectful communication and comprehensive explanation of the diagnosis to patients, as critical first step to enhance engagement, adherence, self-agency, and treatment outcomes. We then focus on a brief review of evidence-based treatments for psychogenic non-epileptic seizures and functional movement disorder, a guide for designing future treatment trials for FND, and a proposal for a treatment research agenda, in order to aid in advancing the field to develop and implement treatments for patients with FND.
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Affiliation(s)
- Kathrin LaFaver
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - William Curt LaFrance
- Departments of Psychiatry and Neurology, Rhode Island Hospital, Brown University, Providence, Rhode Island, USA
| | - Michele E Price
- Department of Neurology, Emory School of Medicine, Atlanta, Georgia, USA
| | - Phyllis B Rosen
- Department of Psychiatry and Behavioral Sciences, Emory School of Medicine, Atlanta, Georgia, USA
| | - Mark Rapaport
- Department of Psychiatry and Behavioral Sciences, Emory School of Medicine, Atlanta, Georgia, USA
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24
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Thomsen BLC, Teodoro T, Edwards MJ. Biomarkers in functional movement disorders: a systematic review. J Neurol Neurosurg Psychiatry 2020; 91:1261-1269. [PMID: 33087421 DOI: 10.1136/jnnp-2020-323141] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 08/11/2020] [Accepted: 09/23/2020] [Indexed: 11/04/2022]
Abstract
Functional movement disorders (FMD) are proposed to reflect a specific problem with voluntary control of movement, despite normal intent to move and an intact neural capacity for movement. In many cases, a positive diagnosis of FMD can be established on clinical grounds. However, the diagnosis remains challenging in certain scenarios, and there is a need for predictors of treatment response and long-term prognosis.In this context, we performed a systematic review of biomarkers in FMD. Eighty-six studies met our predefined criteria and were included.We found fairly reliable electroencephalography and electromyography-based diagnostic biomarkers for functional myoclonus and tremor. Promising biomarkers have also been described for functional paresis, gait and balance disorders. In contrast, there is still a lack of diagnostic biomarkers of functional dystonia and tics, where clinical diagnosis is often also more challenging. Importantly, many promising findings focus on pathophysiology and reflect group-level comparisons, but cannot differentiate on an individual basis. Some biomarkers also require access to time-consuming and resource-consuming techniques such as functional MRI.In conclusion, there are important gaps in diagnostic biomarkers in FMD in the areas of most clinical uncertainty. There is also is a lack of treatment response and prognostic biomarkers to aid in the selection of patients who would benefit from rehabilitation and other forms of treatment.
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Affiliation(s)
- Birgitte Liang Chen Thomsen
- Neurology, Bispebjerg Hospital, Copenhagen, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Tiago Teodoro
- Neurosciences Research Centre, St George's University of London, London, UK.,Instituto de Medicina Molecular, University of Lisbon, Lisboa, Portugal
| | - Mark J Edwards
- Neurosciences Research Centre, St George's University of London, London, UK
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25
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O'Connell N, Watson G, Grey C, Pastena R, McKeown K, David AS. Outpatient CBT for Motor Functional Neurological Disorder and Other Neuropsychiatric Conditions: A Retrospective Case Comparison. J Neuropsychiatry Clin Neurosci 2020; 32:58-66. [PMID: 31466518 DOI: 10.1176/appi.neuropsych.19030067] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE No gold-standard treatment exists for motor functional neurological disorder (mFND), and limited evidence has been found for the effectiveness of cognitive-behavioral therapy (CBT) in treating the disorder. This study examined sociodemographic and clinical characteristics, treatment outcomes, and treatment dropout among patients with and without mFND who received CBT in a neuropsychiatric outpatient clinic in the United Kingdom. METHODS Data from a large anonymized psychiatric register were used to identify patients who received outpatient CBT in a neuropsychiatry clinic between 2006 and 2016 and who had either mFND (N=98) or other neuropsychiatric conditions (ONP) (N=76, control group). The study examined sociodemographic characteristics, physical symptom improvement, and changes in clinical outcome and scores on three instruments measuring psychological distress, psychiatric sequelae of brain injury, and depression. RESULTS The most common mFND symptoms were weakness, pain, and tremors. A logistic regression analysis found no sociodemographic differences between patients with mFND who dropped out early and those who completed CBT. Pre- and post-CBT scores on the three instruments were available for only a small subset of patients; both mFND and ONP patients showed significant improvements in overall scores. A logistic regression analysis found only a single predictor of symptom improvement in the mFND group: acceptance of a psychological explanation of symptoms prior to treatment. CONCLUSIONS Improvements in physical and psychological functioning were similar for patients with mFND and patients with ONP who were treated in a specialist CBT clinic. This study provides evidence that CBT is feasible and effective for some patients with mFND.
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Affiliation(s)
- Nicola O'Connell
- Section of Cognitive Neuropsychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London (O'Connell, David); and South London and Maudsley National Health Service (NHS) Foundation Trust, London (Watson, Grey, Pastena [deceased], McKeown)
| | - Gillian Watson
- Section of Cognitive Neuropsychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London (O'Connell, David); and South London and Maudsley National Health Service (NHS) Foundation Trust, London (Watson, Grey, Pastena [deceased], McKeown)
| | - Clare Grey
- Section of Cognitive Neuropsychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London (O'Connell, David); and South London and Maudsley National Health Service (NHS) Foundation Trust, London (Watson, Grey, Pastena [deceased], McKeown)
| | - Rosa Pastena
- Section of Cognitive Neuropsychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London (O'Connell, David); and South London and Maudsley National Health Service (NHS) Foundation Trust, London (Watson, Grey, Pastena [deceased], McKeown)
| | - Kenneth McKeown
- Section of Cognitive Neuropsychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London (O'Connell, David); and South London and Maudsley National Health Service (NHS) Foundation Trust, London (Watson, Grey, Pastena [deceased], McKeown)
| | - Anthony S David
- Section of Cognitive Neuropsychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London (O'Connell, David); and South London and Maudsley National Health Service (NHS) Foundation Trust, London (Watson, Grey, Pastena [deceased], McKeown)
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26
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Nicholson C, Edwards MJ, Carson AJ, Gardiner P, Golder D, Hayward K, Humblestone S, Jinadu H, Lumsden C, MacLean J, Main L, Macgregor L, Nielsen G, Oakley L, Price J, Ranford J, Ranu J, Sum E, Stone J. Occupational therapy consensus recommendations for functional neurological disorder. J Neurol Neurosurg Psychiatry 2020; 91:1037-1045. [PMID: 32732388 DOI: 10.1136/jnnp-2019-322281] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Revised: 03/12/2020] [Accepted: 04/01/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND People with functional neurological disorder (FND) are commonly seen by occupational therapists; however, there are limited descriptions in the literature about the type of interventions that are likely to be helpful. This document aims to address this issue by providing consensus recommendations for occupational therapy assessment and intervention. METHODS The recommendations were developed in four stages. Stage 1: an invitation was sent to occupational therapists with expertise in FND in different countries to complete two surveys exploring their opinions regarding best practice for assessment and interventions for FND. Stage 2: a face-to-face meeting of multidisciplinary clinical experts in FND discussed and debated the data from stage 1, aiming to achieve consensus on each issue. Stage 3: recommendations based on the meeting were drafted. Stage 4: successive drafts of recommendations were circulated among the multidisciplinary group until consensus was achieved. RESULTS We recommend that occupational therapy treatment for FND is based on a biopsychosocial aetiological framework. Education, rehabilitation within functional activity and the use of taught self-management strategies are central to occupational therapy intervention for FND. Several aspects of occupational therapy for FND are distinct from therapy for other neurological conditions. Examples to illustrate the recommendations are included within this document. CONCLUSIONS Occupational therapists have an integral role in the multidisciplinary management of people with FND. This document forms a starting point for research aiming to develop evidence-based occupational therapy interventions for people with FND.
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Affiliation(s)
- Clare Nicholson
- Department of Therapy Services, University College London Hospitals NHS Foundation Trust National Hospital for Neurology and Neurosurgery, London, UK
| | - Mark J Edwards
- Neurosciences Research Centre, University of London St George's Molecular and Clinical Sciences Research Institute, London, UK
| | - Alan J Carson
- Centre for Clinical Brain Sciences, University of Edinburgh, Western General Hospital, Edinburgh, UK
| | - Paula Gardiner
- Centre for Clinical Brain Services, University of Edinburgh, NHS Lothian, Edinburgh, UK
| | | | - Kate Hayward
- Department of Therapy Services, University College London Hospitals NHS Foundation Trust National Hospital for Neurology and Neurosurgery, London, UK
| | - Susan Humblestone
- Department of Neuropsychiatry, University College London Hospitals NHS Foundation Trust, National Hospital for Neurology & Neurosurgery, London, United Kingdom
| | - Helen Jinadu
- The Lishman Unit, South London and Maudsley NHS Foundation Trust, London, United Kingdom
| | - Carrie Lumsden
- Community Rehabilitation and Brain Injury Service, West Lothian Community Health and Care Partnership, Livingston, West Lothian, United Kingdom
| | - Julie MacLean
- Occupational Therapy Department, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Lynne Main
- Neurological rehabilitation out-patient services, Astley Ainslie Hospital, NHS Lothian, Edinburgh, Scotland, United Kingdom
| | - Lindsey Macgregor
- Falkirk Community Mental Health Service for Adults, NHS Forth Valley, Falkirk, Scotland, United Kingdom
| | - Glenn Nielsen
- Neurosciences Research Centre, University of London St George's Molecular and Clinical Sciences Research Institute, London, UK
| | - Louise Oakley
- National Centre for Mental Health, Birmingham and Solihull Mental Health NHS Foundation Trust, Birmingham, United Kingdom
| | - Jason Price
- Department of Neuropsychology, James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, United Kingdom
| | - Jessica Ranford
- Occupational Therapy Department, Massachusetts General Hospital, Boston, Massachusetts, United States
| | - Jasbir Ranu
- Department of Therapy Services, University College London Hospitals NHS Foundation Trust National Hospital for Neurology and Neurosurgery, London, UK
| | - Ed Sum
- Integrated Community Neurology Team, East Coast Community Healthcare CIC, Lowestoft, United Kingdom
| | - Jon Stone
- Centre for Clinical Brain Sciences, University of Edinburgh, Western General Hospital, Edinburgh, UK
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Faul L, Knight LK, Espay AJ, Depue BE, LaFaver K. Neural activity in functional movement disorders after inpatient rehabilitation. Psychiatry Res Neuroimaging 2020; 303:111125. [PMID: 32585576 DOI: 10.1016/j.pscychresns.2020.111125] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Revised: 05/29/2020] [Accepted: 06/11/2020] [Indexed: 11/18/2022]
Abstract
Functional movement disorders (FMD) are a common source of disability in neurology.While treatment of FMD can reduce motor severity and disability, the neural mechanisms implicated in such a response remain unclear. We aimed to investigate neural changes in patients with FMD after a one-week multidisciplinary motor retraining (MoRe) treatment program. Fourteen FMD patients completed an emotional Go/No-Go fMRI task before and after MoRe treatment. Standardized pre- and post-treatment videos were rated for motor severity by a blinded reviewer using the psychogenic movement disorder rating scale (PMDRS). PMDRS scores before and after treatment were used for whole-brain regression. PMDRS scores were significantly reduced after MoRe treatment. Worse severity prior to treatment was associated with greater primary motor cortex (M1) activation at baseline and a larger response to treatment. Globally, increased connectivity between bilateral amygdala and premotor regions was observed following treatment. Lower post-treatment PMDRS scores were associated with increased connectivity between amygdala and ventromedial prefrontal cortex, whereas higher post-treatment PMDRS scores (and poorer treatment response) were associated with increased connectivity between amygdala and M1. Motor retraining in FMD may reorganize activity and connectivity in emotion processing and motor planning networks, with shifts in amygdala connectivity from posterior to frontal/prefrontal regions.
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Affiliation(s)
- L Faul
- Center for Cognitive Neuroscience, Duke University, DurhamNC, United States
| | - L K Knight
- Interdisciplinary Program in Translational Neuroscience, University of Louisville, LouisvilleKY, United States; Department of Psychological and Brain Sciences, University of Louisville, LouisvilleKY, United States
| | - A J Espay
- Department of Neurology, University of Cincinnati, Cincinnati, OH, United States
| | - B E Depue
- Department of Psychological and Brain Sciences, University of Louisville, LouisvilleKY, United States; Department of Anatomical Sciences and Neurobiology, University of Louisville, LouisvilleKY, United States.
| | - K LaFaver
- Department of Neurology, University of Louisville, Louisville, KY, United States; Northwestern University, Feinberg School of Medicine, Chicago, IL, United States
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Naro A, Pignolo L, Billeri L, Porcari B, Portaro S, Tonin P, Calabrò RS. A Case of Psychogenic Myoclonus Responding to a Novel Transcranial Magnetic Stimulation Approach: Rationale, Feasibility, and Possible Neurophysiological Basis. Front Hum Neurosci 2020; 14:292. [PMID: 32848667 PMCID: PMC7396578 DOI: 10.3389/fnhum.2020.00292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/29/2020] [Indexed: 01/11/2023] Open
Abstract
Repetitive transcranial magnetic stimulation (rTMS) can relieve motor symptoms related to psychogenic movement disorders (PMDs), but the subtending neurophysiological basis is unclear. We report on a 50-year-old woman with a diagnosis of psychogenic myoclonus in the right lower limb, who was treated with a daily session (in the late morning/early afternoon) of 1 Hz rTMS over the left premotor cortex (PMC), five times a week for 6 weeks. Clinical data and EEG at rest were collected before and immediately and 2-month after the rTMS protocol completion. The patient reported a significant reduction of involuntary movement frequency and intensity and the related disability burden up to the follow-up. In parallel, any abnormality in terms of source current density within and connectivity between the frontal and parietal areas was reset. The short follow–up period, the lack of extensive neurophysiological measures, and the lack of control treatment represent the main limitation of the study. However, low-frequency rTMS over PMC seems a safe and promising approach for the management of psychogenic myoclonus owing to the combination of cortical neuromodulation and non-specific mechanisms suggesting cognitive-behavioral effects.
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Affiliation(s)
- Antonino Naro
- IRCCS Centro Neurolesi Bonino Pulejo, Messina, Italy
| | - Loris Pignolo
- Sant'Anna Institute, Research in Advanced Neurorehabilitation (RAN), Crotone, Italy
| | - Luana Billeri
- IRCCS Centro Neurolesi Bonino Pulejo, Messina, Italy
| | - Bruno Porcari
- IRCCS Centro Neurolesi Bonino Pulejo, Messina, Italy
| | | | - Paolo Tonin
- Sant'Anna Institute, Research in Advanced Neurorehabilitation (RAN), Crotone, Italy
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Abstract
BACKGROUND The aim of this scoping review is to describe the characteristics of patients requiring admission to hospital for functional neurological disorder (FND), assess interventions provided, and evaluate outcomes in the context of acute hospital presentation or elective admission with chronic symptoms (>3 months). METHODS A scoping review was performed. Included articles described adult patients admitted with FND to an inpatient care setting. Articles focusing on psychogenic non-epileptic attacks (PNEA) were excluded. RESULTS The search strategy identified 1963 citations. A total of 34 articles met inclusion criteria, with 458 patients (66% female) described. The pooled mean age of patients in all studies was 40.6 years. Eleven studies described patients with acute presentation, and 16 studies described patients with chronic FND symptoms admitted to the hospital. Motor symptoms were most common. Interventions were most commonly physiotherapy and psychotherapy. Most studies reported partial or complete resolution of symptoms. CONCLUSIONS This scoping review summarizes the literature on the characteristics of patients admitted to the hospital, both with acute and chronic symptoms, for inpatient treatment of FND. When comparing patients with acute to those with chronic symptoms, we found that acute presentations were older (46.9 vs. 43.7 years) and had a higher representation of men (33% vs. 30%). Those presenting with chronic symptoms were more likely to not improve or relapse. We postulate that early diagnosis and inpatient rehabilitation could have a positive impact on outcomes for patients with FND.
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Gelauff JM, Rosmalen JGM, Carson A, Dijk JM, Ekkel M, Nielsen G, Stone J, Tijssen MAJ. Internet-based self-help randomized trial for motor functional neurologic disorder (SHIFT). Neurology 2020; 95:e1883-e1896. [PMID: 32690783 DOI: 10.1212/wnl.0000000000010381] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 04/07/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine whether self-rated health of patients with motor functional neurologic disorder (FND) can be improved by unguided Internet-based self-help and education. METHODS In this nonblinded randomized controlled trial, patients were allocated 1:1 unbiased to an unguided education and self-help website in addition to usual care or usual care only. Patients over 17 years of age with a functional motor symptom that caused distress or disability were included. The primary outcome was self-rated health on the Clinical Global Improvement scale at 3 and 6 months. Secondary outcomes were severity of motor symptoms, other physical and psychiatric symptoms, physical functioning, quality of life, work and social adjustment, illness beliefs, and satisfaction with care. RESULTS A total of 186 patients were randomized, with a follow-up rate of 87% at 6 months. There was no difference in improvement of self-rated health at 3 months (44% vs 40%, p = 0.899) or 6 months (42% vs 43%, p = 0.435). Secondary outcomes did not differ between groups, with a threshold of p < 0.01. Satisfaction was high, with 86% of patients recommending the website to other patients. CONCLUSION We found no significant effect of the intervention added to usual care on self-rated health or secondary outcome measures, despite high patient satisfaction with the intervention. These results suggest that online education and nonguided self-help could be valuable additions to stepped care for motor FND, but are not effective treatments as interventions in their own right. CLINICALTRIALSGOV IDENTIFIER NCT02589886. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that for patients with motor FND, online education and self-help intervention does not significantly improve self-rated health.
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Affiliation(s)
- Jeannette M Gelauff
- From the Departments of Neurology (J.M.G., M.E., M.A.J.T.), Psychiatry (J.G.M.R.), and Internal Medicine (J.G.M.R.), University Medical Center Groningen, University of Groningen, the Netherlands; Centre for Clinical Brain Sciences (A.C., J.S.), University of Edinburgh, UK; Department of Neurology (J.M.D.), University of Amsterdam, Amsterdam University Medical Center, the Netherlands; and Neurosciences Research Centre (G.N.), Molecular and Clinical Sciences Research Institute, St George's University of London, UK
| | - Judith G M Rosmalen
- From the Departments of Neurology (J.M.G., M.E., M.A.J.T.), Psychiatry (J.G.M.R.), and Internal Medicine (J.G.M.R.), University Medical Center Groningen, University of Groningen, the Netherlands; Centre for Clinical Brain Sciences (A.C., J.S.), University of Edinburgh, UK; Department of Neurology (J.M.D.), University of Amsterdam, Amsterdam University Medical Center, the Netherlands; and Neurosciences Research Centre (G.N.), Molecular and Clinical Sciences Research Institute, St George's University of London, UK
| | - Alan Carson
- From the Departments of Neurology (J.M.G., M.E., M.A.J.T.), Psychiatry (J.G.M.R.), and Internal Medicine (J.G.M.R.), University Medical Center Groningen, University of Groningen, the Netherlands; Centre for Clinical Brain Sciences (A.C., J.S.), University of Edinburgh, UK; Department of Neurology (J.M.D.), University of Amsterdam, Amsterdam University Medical Center, the Netherlands; and Neurosciences Research Centre (G.N.), Molecular and Clinical Sciences Research Institute, St George's University of London, UK
| | - Joke M Dijk
- From the Departments of Neurology (J.M.G., M.E., M.A.J.T.), Psychiatry (J.G.M.R.), and Internal Medicine (J.G.M.R.), University Medical Center Groningen, University of Groningen, the Netherlands; Centre for Clinical Brain Sciences (A.C., J.S.), University of Edinburgh, UK; Department of Neurology (J.M.D.), University of Amsterdam, Amsterdam University Medical Center, the Netherlands; and Neurosciences Research Centre (G.N.), Molecular and Clinical Sciences Research Institute, St George's University of London, UK
| | - Martijn Ekkel
- From the Departments of Neurology (J.M.G., M.E., M.A.J.T.), Psychiatry (J.G.M.R.), and Internal Medicine (J.G.M.R.), University Medical Center Groningen, University of Groningen, the Netherlands; Centre for Clinical Brain Sciences (A.C., J.S.), University of Edinburgh, UK; Department of Neurology (J.M.D.), University of Amsterdam, Amsterdam University Medical Center, the Netherlands; and Neurosciences Research Centre (G.N.), Molecular and Clinical Sciences Research Institute, St George's University of London, UK
| | - Glenn Nielsen
- From the Departments of Neurology (J.M.G., M.E., M.A.J.T.), Psychiatry (J.G.M.R.), and Internal Medicine (J.G.M.R.), University Medical Center Groningen, University of Groningen, the Netherlands; Centre for Clinical Brain Sciences (A.C., J.S.), University of Edinburgh, UK; Department of Neurology (J.M.D.), University of Amsterdam, Amsterdam University Medical Center, the Netherlands; and Neurosciences Research Centre (G.N.), Molecular and Clinical Sciences Research Institute, St George's University of London, UK
| | - Jon Stone
- From the Departments of Neurology (J.M.G., M.E., M.A.J.T.), Psychiatry (J.G.M.R.), and Internal Medicine (J.G.M.R.), University Medical Center Groningen, University of Groningen, the Netherlands; Centre for Clinical Brain Sciences (A.C., J.S.), University of Edinburgh, UK; Department of Neurology (J.M.D.), University of Amsterdam, Amsterdam University Medical Center, the Netherlands; and Neurosciences Research Centre (G.N.), Molecular and Clinical Sciences Research Institute, St George's University of London, UK
| | - Marina A J Tijssen
- From the Departments of Neurology (J.M.G., M.E., M.A.J.T.), Psychiatry (J.G.M.R.), and Internal Medicine (J.G.M.R.), University Medical Center Groningen, University of Groningen, the Netherlands; Centre for Clinical Brain Sciences (A.C., J.S.), University of Edinburgh, UK; Department of Neurology (J.M.D.), University of Amsterdam, Amsterdam University Medical Center, the Netherlands; and Neurosciences Research Centre (G.N.), Molecular and Clinical Sciences Research Institute, St George's University of London, UK.
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Ganslev CA, Storebø OJ, Callesen HE, Ruddy R, Søgaard U. Psychosocial interventions for conversion and dissociative disorders in adults. Cochrane Database Syst Rev 2020; 7:CD005331. [PMID: 32681745 PMCID: PMC7388313 DOI: 10.1002/14651858.cd005331.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Conversion and dissociative disorders are conditions where people experience unusual neurological symptoms or changes in awareness or identity. However, symptoms and clinical signs cannot be explained by a neurological disease or other medical condition. Instead, a psychological stressor or trauma is often present. The symptoms are real and can cause significant distress or problems with functioning in everyday life for the people experiencing them. OBJECTIVES To assess the beneficial and harmful effects of psychosocial interventions of conversion and dissociative disorders in adults. SEARCH METHODS We conducted database searches between 16 July and 16 August 2019. We searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and eight other databases, together with reference checking, citation searching and contact with study authors to identify additional studies. SELECTION CRITERIA: We included all randomised controlled trials that compared psychosocial interventions for conversion and dissociative disorders with standard care, wait list or other interventions (pharmaceutical, somatic or psychosocial). DATA COLLECTION AND ANALYSIS: We selected, quality assessed and extracted data from the identified studies. Two review authors independently performed all tasks. We used standard Cochrane methodology. For continuous data, we calculated mean differences (MD) and standardised mean differences (SMD) with 95% confidence interval (CI). For dichotomous outcomes, we calculated risk ratio (RR) with 95% CI. We assessed and downgraded the evidence according to the GRADE system for risk of bias, imprecision, indirectness, inconsistency and publication bias. MAIN RESULTS We included 17 studies (16 with parallel-group designs and one with a cross-over design), with 894 participants aged 18 to 80 years (female:male ratio 3:1). The data were separated into 12 comparisons based on the different interventions and comparators. Studies were pooled into the same comparison when identical interventions and comparisons were evaluated. The certainty of the evidence was downgraded as a consequence of potential risk of bias, as many of the studies had unclear or inadequate allocation concealment. Further downgrading was performed due to imprecision, few participants and inconsistency. There were 12 comparisons for the primary outcome of reduction in physical signs. Inpatient paradoxical intention therapy compared with outpatient diazepam: inpatient paradoxical intention therapy did not reduce conversive symptoms compared with outpatient diazepam at the end of treatment (RR 1.44, 95% CI 0.91 to 2.28; 1 study, 30 participants; P = 0.12; very low-quality evidence). Inpatient treatment programme plus hypnosis compared with inpatient treatment programme: inpatient treatment programme plus hypnosis did not reduce severity of impairment compared with inpatient treatment programme at the end of treatment (MD -0.49 (negative value better), 95% CI -1.28 to 0.30; 1 study, 45 participants; P = 0.23; very low-quality evidence). Outpatient hypnosis compared with wait list: outpatient hypnosis might reduce severity of impairment compared with wait list at the end of treatment (MD 2.10 (higher value better), 95% CI 1.34 to 2.86; 1 study, 49 participants; P < 0.00001; low-quality evidence). Behavioural therapy plus routine clinical care compared with routine clinical care: behavioural therapy plus routine clinical care might reduce the number of weekly seizures compared with routine clinical care alone at the end of treatment (MD -21.40 (negative value better), 95% CI -27.88 to -14.92; 1 study, 18 participants; P < 0.00001; very low-quality evidence). Cognitive behavioural therapy (CBT) compared with standard medical care: CBT did not reduce monthly seizure frequency compared to standard medical care at end of treatment (RR 1.56, 95% CI 0.39 to 6.19; 1 study, 16 participants; P = 0.53; very low-quality evidence). CBT did not reduce physical signs compared to standard medical care at the end of treatment (MD -4.75 (negative value better), 95% CI -18.73 to 9.23; 1 study, 61 participants; P = 0.51; low-quality evidence). CBT did not reduce seizure freedom compared to standard medical care at end of treatment (RR 2.33, 95% CI 0.30 to 17.88; 1 trial, 16 participants; P = 0.41; very low-quality evidence). Psychoeducational follow-up programmes compared with treatment as usual (TAU): no study measured reduction in physical signs at end of treatment. Specialised CBT-based physiotherapy inpatient programme compared with wait list: no study measured reduction in physical signs at end of treatment. Specialised CBT-based physiotherapy outpatient intervention compared with TAU: no study measured reduction in physical signs at end of treatment. Brief psychotherapeutic intervention (psychodynamic interpersonal treatment approach) compared with standard care: brief psychotherapeutic interventions did not reduce conversion symptoms compared to standard care at end of treatment (RR 0.12, 95% CI 0.01 to 2.00; 1 study, 19 participants; P = 0.14; very low-quality evidence). CBT plus adjunctive physical activity (APA) compared with CBT alone: CBT plus APA did not reduce overall physical impacts compared to CBT alone at end of treatment (MD 5.60 (negative value better), 95% CI -15.48 to 26.68; 1 study, 21 participants; P = 0.60; very low-quality evidence). Hypnosis compared to diazepam: hypnosis did not reduce symptoms compared to diazepam at end of treatment (RR 0.69, 95% CI 0.39 to 1.24; 1 study, 40 participants; P = 0.22; very low-quality evidence). Outpatient motivational interviewing (MI) and mindfulness-based psychotherapy compared with psychotherapy alone: psychotherapy preceded by MI might decrease seizure frequency compared with psychotherapy alone at end of treatment (MD 41.40 (negative value better), 95% CI 4.92 to 77.88; 1 study, 54 participants; P = 0.03; very low-quality evidence). The effect on the secondary outcomes was reported in 16/17 studies. None of the studies reported results on adverse effects. In the studies reporting on level of functioning and quality of life at end of treatment the effects ranged from small to no effect. AUTHORS' CONCLUSIONS The results of the meta-analysis and reporting of single studies suggest there is lack of evidence regarding the effects of any psychosocial intervention on conversion and dissociative disorders in adults. It is not possible to draw any conclusions about potential benefits or harms from the included studies.
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Affiliation(s)
- Christina A Ganslev
- Clinic of Liaison Psychiatry, Region Zealand, Denmark
- Psychiatric Research Unit, Psychiatry of Region Zealand, Slagelse, Denmark
| | - Ole Jakob Storebø
- Psychiatric Research Unit, Psychiatry of Region Zealand, Slagelse, Denmark
- Child and Adolescent Psychiatric Department, Region Zealand, Roskilde, Denmark
- Department of Psychology, University of Southern Denmark, Odense, Denmark
| | | | | | - Ulf Søgaard
- Clinic of Liaison Psychiatry, Region Zealand, Denmark
- Psychiatric Research Unit, Psychiatry of Region Zealand, Slagelse, Denmark
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Gilmour GS, Nielsen G, Teodoro T, Yogarajah M, Coebergh JA, Dilley MD, Martino D, Edwards MJ. Management of functional neurological disorder. J Neurol 2020; 267:2164-2172. [PMID: 32193596 PMCID: PMC7320922 DOI: 10.1007/s00415-020-09772-w] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 02/19/2020] [Accepted: 02/20/2020] [Indexed: 01/24/2023]
Abstract
Functional neurological disorder (FND) is a common cause of persistent and disabling neurological symptoms. These symptoms are varied and include abnormal control of movement, episodes of altered awareness resembling epileptic seizures and abnormal sensation and are often comorbid with chronic pain, fatigue and cognitive symptoms. There is increasing evidence for the role of neurologists in both the assessment and management of FND. The aim of this review is to discuss strategies for the management of FND by focusing on the diagnostic discussion and general principles, as well as specific treatment strategies for various FND symptoms, highlighting the role of the neurologist and proposing a structure for an interdisciplinary FND service.
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Affiliation(s)
- Gabriela S Gilmour
- Department of Clinical Neurosciences, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Glenn Nielsen
- Neuroscience Research Centre, Institute of Molecular and Clinical Sciences, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Tiago Teodoro
- Neuroscience Research Centre, Institute of Molecular and Clinical Sciences, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
- Faculdade de Medicina, Instituto de Medicina Molecular, Universidade de Lisboa, Hospital de Santa Maria, Lisbon, Portugal
- Atkinson Morley Regional Neuroscience Centre, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Mahinda Yogarajah
- Neuroscience Research Centre, Institute of Molecular and Clinical Sciences, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Jan Adriaan Coebergh
- Atkinson Morley Regional Neuroscience Centre, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Michael D Dilley
- Atkinson Morley Regional Neuroscience Centre, St. George's University Hospitals NHS Foundation Trust, London, UK
| | - Davide Martino
- Department of Clinical Neurosciences, Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | - Mark J Edwards
- Neuroscience Research Centre, Institute of Molecular and Clinical Sciences, St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK.
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Petrochilos P, Elmalem MS, Patel D, Louissaint H, Hayward K, Ranu J, Selai C. Outcomes of a 5-week individualised MDT outpatient (day-patient) treatment programme for functional neurological symptom disorder (FNSD). J Neurol 2020; 267:2655-2666. [PMID: 32410018 PMCID: PMC7419475 DOI: 10.1007/s00415-020-09874-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/27/2020] [Accepted: 04/29/2020] [Indexed: 11/29/2022]
Abstract
Aim We report results from a 5-week MDT treatment programme, with individualised sessions, for a selected group of patients with FNSD, delivered in a neuropsychiatric outpatient setting. Primary aims were to (1) reduce symptoms, (2) improve functional performance and (3) improve health status. Methods Treatment involved individual sessions of neuropsychiatry, cognitive behavioural therapy, physiotherapy, occupational-therapy, education and family meetings. Outcome measures collected at the beginning and end of treatment and at 6 months, were patient and clinician reported. Aims were assessed by the following: symptom reduction (PHQ15, PHQ9, GAD7, SPIN, Rosenberg); health and social functioning (HONOS, WSAS); functional performance (COPM); health status (EQ-5D-5L) and patient-rated perception of improvement (CGI). Results Analyses of 78 patients completing the programme and attending a 6-month review revealed high-baseline levels of disability compared to EQ-5DL population norms and high rates of disability and psychopathology as indicated by the WSAS and mental health indices (PHQ9, GAD7, SPIN, Rosenberg’s self-esteem). At baseline, 92.3% met the IAPT caseness threshold for depression and 71% met the IAPT caseness threshold for anxiety. A Friedman ANOVA over the three time points and Dunn-Bonferroni post hoc tests indicated statistically significant improvements from admission to discharge and admission to 6-month follow-up. Sustained improvements were seen in somatic symptoms (PHQ15), depression (PHQ9), anxiety (GAD7), health and social functioning (HONOS), functionality (COPM), health status (EQ-5D-5L) and patient-rated clinical global improvement (CGI). Conclusion An MDT can effectively deliver an outpatient programme for FNSD which can serve as an alternative to costlier inpatient programmes. Early identification and treatment of co-morbidities is advised. Electronic supplementary material The online version of this article (10.1007/s00415-020-09874-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Panayiota Petrochilos
- Department of Neuropsychiatry, National Hospital for Neurology and Neurosurgery, Queen Square, Box 19, London, WC1N 3BG, UK.
| | - M S Elmalem
- Department of Clinical and Movement Neurosciences, National Hospital for Neurology and Neurosurgery, UCL Queen Square Institute of Neurology, Queen Square, Box 95, London, WC1N 3BG, UK
| | - D Patel
- Department of Neuropsychiatry, National Hospital for Neurology and Neurosurgery, Queen Square, Box 19, London, WC1N 3BG, UK
| | - H Louissaint
- Therapies Services Department, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
| | - K Hayward
- Therapies Services Department, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
| | - J Ranu
- Therapies Services Department, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
| | - C Selai
- Department of Clinical and Movement Neurosciences, National Hospital for Neurology and Neurosurgery, UCL Queen Square Institute of Neurology, Queen Square, Box 95, London, WC1N 3BG, UK
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Lidstone SC, MacGillivray L, Lang AE. Integrated Therapy for Functional Movement Disorders: Time for a Change. Mov Disord Clin Pract 2020; 7:169-174. [PMID: 32071934 PMCID: PMC7011811 DOI: 10.1002/mdc3.12888] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/22/2019] [Accepted: 12/07/2019] [Indexed: 11/11/2022] Open
Abstract
View Supplementary Video 1View Supplementary Video 2
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Affiliation(s)
- Sarah C. Lidstone
- Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital and the University of TorontoTorontoOntarioCanada
| | - Lindsey MacGillivray
- Division of PsychiatryUniversity Health Network and the University of TorontoTorontoOntarioCanada
| | - Anthony E. Lang
- Edmond J. Safra Program in Parkinson's Disease and the Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital and the University of TorontoTorontoOntarioCanada
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O'Connell N, Nicholson TR, Wessely S, David AS. Characteristics of patients with motor functional neurological disorder in a large UK mental health service: a case-control study. Psychol Med 2020; 50:446-455. [PMID: 30773149 DOI: 10.1017/s0033291719000266] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Functional neurological disorder (FND), previously known as conversion disorder, is common and often results in substantial distress and disability. Previous research lacks large sample sizes and clinical surveys are most commonly derived from neurological settings, limiting our understanding of the disorder and its associations in other contexts. We sought to address this by analysing a large anonymised electronic psychiatric health record dataset. METHODS Data were obtained from 322 patients in the South London and Maudsley NHS Foundation Trust (SLaM) who had an ICD-10 diagnosis of motor FND (mFND) (limb weakness or disorders of movement or gait) between 1 January 2006 and 31 December 2016. Data were collected on a range of socio-demographic and clinical factors and compared to 644 psychiatric control patients from the same register. RESULTS Weakness was the most commonly occurring functional symptom. mFND patients were more likely to be female, British, married, employed pre-morbidly, to have a carer and a physical health condition, but less likely to have had an inpatient psychiatric admission or to receive benefits. No differences in self-reported sexual or physical abuse rates were observed between groups, although mFND patients were more likely to experience life events linked to inter-personal difficulties. CONCLUSIONS mFND patients have distinct demographic characteristics compared with psychiatric controls. Experiences of abuse appear to be equally prevalent across psychiatric patient groups. This study establishes the socio-demographic and life experience profile of this understudied patient group and may be used to guide future therapeutic interventions designed specifically for mFND.
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Affiliation(s)
- N O'Connell
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - T R Nicholson
- Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - S Wessely
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - A S David
- UCL Institute of Mental Health Studies, University College London, London, UK
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Mesaroli G, Munns C, DeSouza C. Evidence-Based Practice: Physiotherapy for Children and Adolescents with Motor Symptoms of Conversion Disorder. Physiother Can 2019; 71:400-402. [PMID: 31762550 DOI: 10.3138/ptc-2018-68] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Clinical Case: A boy aged 14 years with conversion disorder who presented with an ataxic gait pattern experienced complete symptom resolution after engaging in physiotherapy (PT) as part of interdisciplinary treatment. Clinical Question: Is there evidence to support the use of PT in children and adolescents with motor symptoms of conversion disorder? Evidence: All the extant paediatric literature consists of case studies and case series. Some exciting research has been published in the adult literature that suggests the potential positive benefits of PT. Limitation of the Evidence and Future Research: The paediatric literature is limited in quantity and quality. In the adult literature, most studies are limited in that they do not control for the type of motor symptoms and do not evaluate PT independent of interdisciplinary treatment. In future research, it would be pertinent to (1) evaluate PT independent of interdisciplinary treatment, (2) control for the type of motor symptoms, and (3) describe theoretical models. Recommendation for Clinical Question: Expert consensus and emerging evidence suggest that PT may be beneficial in adults with conversion disorder, but the evidence in the paediatric population is insufficient.
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Affiliation(s)
- Giulia Mesaroli
- Department of Rehabilitation Services.,Department of Anesthesia and Pain Medicine.,Department of Physical Therapy
| | - Catherine Munns
- Department of Anesthesia and Pain Medicine.,Department of Psychology
| | - Claire DeSouza
- Department of Psychiatry, Consultation-Liaison Psychiatry Program, Hospital for Sick Children.,Department of Psychiatry, University of Toronto, Toronto
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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.
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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
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Survey of the perceptions of health practitioners regarding Functional Neurological Disorders in Australia. J Clin Neurosci 2019; 67:114-123. [DOI: 10.1016/j.jocn.2019.06.008] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 05/25/2019] [Accepted: 06/09/2019] [Indexed: 11/20/2022]
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Taib S, Ory‐Magne F, Brefel‐Courbon C, Moreau Y, Thalamas C, Arbus C, Simonetta‐Moreau M. Repetitive transcranial magnetic stimulation for functional tremor: A randomized, double‐blind, controlled study. Mov Disord 2019; 34:1210-1219. [DOI: 10.1002/mds.27727] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/04/2019] [Accepted: 05/08/2019] [Indexed: 12/20/2022] Open
Affiliation(s)
- Simon Taib
- Psychiatry and Medical Psychology DepartmentToulouse University Hospital Toulouse France
- Toulouse NeuroImaging CenterToulouse University‐Institut National de la Santé et de la Recherche Médicale (INSERM)‐University of Toulouse Toulouse France
| | - Fabienne Ory‐Magne
- Toulouse NeuroImaging CenterToulouse University‐Institut National de la Santé et de la Recherche Médicale (INSERM)‐University of Toulouse Toulouse France
- Neuroscience CenterToulouse University Hospital Toulouse France
| | - Christine Brefel‐Courbon
- Toulouse NeuroImaging CenterToulouse University‐Institut National de la Santé et de la Recherche Médicale (INSERM)‐University of Toulouse Toulouse France
- Neuroscience CenterToulouse University Hospital Toulouse France
| | - Ysé Moreau
- Toulouse NeuroImaging CenterToulouse University‐Institut National de la Santé et de la Recherche Médicale (INSERM)‐University of Toulouse Toulouse France
| | - Claire Thalamas
- Clinical Investigation CenterToulouse University Hospital, INSERM Toulouse France
| | - Christophe Arbus
- Psychiatry and Medical Psychology DepartmentToulouse University Hospital Toulouse France
- Toulouse NeuroImaging CenterToulouse University‐Institut National de la Santé et de la Recherche Médicale (INSERM)‐University of Toulouse Toulouse France
| | - Marion Simonetta‐Moreau
- Toulouse NeuroImaging CenterToulouse University‐Institut National de la Santé et de la Recherche Médicale (INSERM)‐University of Toulouse Toulouse France
- Neuroscience CenterToulouse University Hospital Toulouse France
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Barnett C, Armes J, Smith C. Speech, language and swallowing impairments in functional neurological disorder: a scoping review. INTERNATIONAL JOURNAL OF LANGUAGE & COMMUNICATION DISORDERS 2019; 54:309-320. [PMID: 30592118 DOI: 10.1111/1460-6984.12448] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 11/27/2018] [Accepted: 12/04/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND Functional neurological disorder (FND) is common across healthcare settings. The Diagnostic and Statistical Manual of Mental Disorders states that speech and swallowing symptoms can be present in FND. Despite this, there is a dearth of guidelines for speech and language therapists (SLTs) for this client group. AIMS To address the following question in order to identify gaps for further research: What is known about speech, language and swallowing symptoms in patients with FND? METHODS & PROCEDURES A scoping review was conducted. Six healthcare databases were searched for relevant literature: CINAHL PLUS, MEDLINE, ProQuest Nursing and Allied Health Professionals, Science Citation Index, Scopus, and PsychINFO. The following symptoms were excluded from the review: dysphonia, globus pharyngeus, dysfluency, foreign accent syndrome and oesophageal dysphagia. MAIN CONTRIBUTION A total of 63 papers were included in the final review; they ranged in date from 1953 to 2018. Case studies were the most frequent research method (n = 23, 37%). 'Psychogenic' was the term used most frequently (n = 24, 38%), followed by 'functional' (n = 21, 33%). Speech symptoms were reported most frequently (n = 41, 65%), followed by language impairments (n = 35, 56%) and dysphagia (n = 13, 21%). Only 11 publications comment on the involvement of SLTs. Eight papers report direct speech and language therapy input; however, none studied the effectiveness of speech and language therapy. CONCLUSIONS & IMPLICATIONS Speech, language and swallowing symptoms do occur in patients with FND, yet it is a highly under-researched area. Further research is required to create a set of positive diagnostic criteria, gather accurate data on numbers of patients with FND and speech, language or swallowing symptoms, and to evaluate the effectiveness of direct speech and language therapy involvement.
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Affiliation(s)
- Caroline Barnett
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Jean Armes
- Birmingham Community Healthcare NHS Trust, Birmingham, UK
| | - Christina Smith
- Department of Language and Cognition, University College London, London, UK
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Abstract
Although children with dissociative disorders (DD) are referred to mental health inpatient units, no research exists to endorse this. We studied the outcomes of patients with DD over a 5-year period on a national inpatient unit for children up to 12 years of age. Demographic, clinical, and satisfaction data were collected and compared with the data of other inpatients not having DD. Eight patients were identified, of whom six were female. All had several comorbidities. Mean Children's Global Assessment Scale scores improved from admission to discharge (from 31 to 61, respectively). Admissions in DD were longer by 53 days (p = 0.059), and parents were statistically less satisfied about professionals' ability to listen to worries they may have about their child (p = 0.049). Referrers should expect children with DD to respond as well to inpatient interventions as those with other diagnoses but potentially with marginally longer admissions and lower parental satisfaction.
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O'Connell N, Nicholson T, Blackman G, Tavener J, David AS. Medication prescriptions in 322 motor functional neurological disorder patients in a large UK mental health service: A case control study. Gen Hosp Psychiatry 2019; 58:94-102. [PMID: 31031213 DOI: 10.1016/j.genhosppsych.2019.04.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/01/2019] [Accepted: 04/02/2019] [Indexed: 01/26/2023]
Abstract
OBJECTIVE This study describes medication prescribing patterns in patients with motor functional neurological disorder (mFND) treated in South London and Maudsley NHS Foundation Trust (SLaM), comparing outcomes to a control group of psychiatric patients from the same hospital trust. METHOD This is a retrospective case-control study using a psychiatric case register. Cross-sectional data were obtained from 322 mFND patients and 644 psychiatry controls who had had contact with SLaM between 1st January 2006 and 31st December 2016. RESULTS A slightly lower proportion of mFND patients received medication compared to controls (76.6% v. 83.4%, OR: 0.59, CI: 0.39-0.89, p < 0.05). Of medication recipients, mFND patients were prescribed a higher number of agents (mean: 4.7 v 2.9, p = 0.001) and had higher prescription rates of antidepressants, anti-epileptics, analgesics, and certain non-psychotropic medications. Higher numbers of prescriptions were associated with co-morbid physical conditions, and previous psychiatric admissions. CONCLUSIONS This is the first study to describe medication prescriptions in a large cohort of mFND patients. Patients were prescribed a wide range of psychiatric and physical health medications, with higher rates of polypharmacy than controls. Psychotropic medication prescription is not necessarily the first line treatment for mFND, where physiotherapy and psychotherapy may be offered initially. There is limited, early-phase evidence for pharmacological therapies for mFND, and as such, the benefit-to-risk ratio of prescribing in this complex and poorly understood disorder should be carefully assessed.
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Affiliation(s)
- Nicola O'Connell
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 DeCrespigny Park, London SE5 8AF, United Kingdom. nicola.k.o'
| | - Timothy Nicholson
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 DeCrespigny Park, London SE5 8AF, United Kingdom.
| | - Graham Blackman
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 DeCrespigny Park, London SE5 8AF, United Kingdom.
| | - Jennifer Tavener
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, 16 DeCrespigny Park, London SE5 8AF, United Kingdom.
| | - Anthony S David
- Institute of Mental Health, UCL Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London W1T 7BN, United Kingdom.
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Popkirov S, Hoeritzauer I, Colvin L, Carson AJ, Stone J. Complex regional pain syndrome and functional neurological disorders - time for reconciliation. J Neurol Neurosurg Psychiatry 2019; 90:608-614. [PMID: 30355604 DOI: 10.1136/jnnp-2018-318298] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Revised: 09/27/2018] [Accepted: 09/28/2018] [Indexed: 12/17/2022]
Abstract
There have been many articles highlighting differences and similarities between complex regional pain syndrome (CRPS) and functional neurological disorders (FND) but until now the discussions have often been adversarial with an erroneous focus on malingering and a view of FND as 'all in the mind'. However, understanding of the nature, frequency and treatment of FND has changed dramatically in the last 10-15 years. FND is no longer assumed to be only the result of 'conversion' of psychological conflict but is understood as a complex interplay between physiological stimulus, expectation, learning and attention mediated through a Bayesian framework, with biopsychosocial predisposing, triggering and perpetuating inputs. Building on this new 'whole brain' perspective of FND, we reframe the debate about the 'psychological versus physical' basis of CRPS. We recognise how CRPS research may inform mechanistic understanding of FND and conversely, how advances in FND, especially treatment, have implications for improving understanding and management of CRPS.
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Affiliation(s)
- Stoyan Popkirov
- Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Bochum, Germany
| | - Ingrid Hoeritzauer
- Centre for Clinical Brain Sciences, Western General Hospital, NHS Lothian and University of Edinburgh, Edinburgh, UK
| | - Lesley Colvin
- Division of Population Health Sciences and Genomics, University of Dundee, Ninewells Hospital and Medical School, Dundee, UK
| | - Alan J Carson
- Centre for Clinical Brain Sciences, Western General Hospital, NHS Lothian and University of Edinburgh, Edinburgh, UK
| | - Jon Stone
- Centre for Clinical Brain Sciences, Western General Hospital, NHS Lothian and University of Edinburgh, Edinburgh, UK
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Abstract
Functional neurological disorders (FND) are common and associated with significant morbidity and healthcare costs. Patients with FND often present acutely, particularly with dissociative seizures (resembling epilepsy) or persistent weakness resembling a stroke. History and careful observation and examination are critical to diagnosis, as investigations will often be normal or non-contributory. The nature of convulsive movements in dissociative seizures often differs from that in epilepsy, and long duration of individual events, waxing and waning, closed eyes and high reported frequency in an apparently well individual are all suggestive. In those with stroke-like episodes, demonstration of normal power even briefly (eg Hoover's sign, 'give way' weakness) together with distractability are positive physical features indicating a functional disorder. A positive diagnosis and clear non-judgemental explanation, backed up by reliable information sources associated with prompt onward referral to a neurologist can greatly reduce distress and ultimately improve outcomes.
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Affiliation(s)
- Hannah R Cock
- Institute of Medical and Biomedical Education, St George's University of London, London, UK
- Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Trust, London, UK
| | - Mark J Edwards
- Institute of Molecular and Clinical Sciences, St George's University of London, London, UK
- Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Trust, London, UK
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46
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Abstract
Functional neurological disorders (FND)-also called psychogenic, nonorganic, conversion, and dissociative disorders-constitute one of the commonest problems in neurological practice. An occupational therapist (OT) is commonly involved in management, but there is no specific literature or guidance for these professionals. Classification now emphasizes the importance of positive diagnosis of FND based on physical signs, more than psychological features. Studies of mechanism have produced new clinical and neurobiological ways of thinking about these disorders. Evidence has emerged to support the use of physiotherapy and occupational therapy as part of a multidisciplinary team for functional movement disorders (FMD) and psychotherapy for dissociative (nonepileptic) attacks. The diagnosis and management of FND has entered a new evidence-based era and deserves a standard place in the OT neurological curriculum. We discuss specific management areas relevant to occupational therapy and propose a research agenda.
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47
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Jacob AE, Kaelin DL, Roach AR, Ziegler CH, LaFaver K. Motor Retraining (MoRe) for Functional Movement Disorders: Outcomes From a 1-Week Multidisciplinary Rehabilitation Program. PM R 2018; 10:1164-1172. [PMID: 29783067 DOI: 10.1016/j.pmrj.2018.05.011] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 05/04/2018] [Accepted: 05/08/2018] [Indexed: 11/16/2022]
Abstract
BACKGROUND Functional movement disorders (FMDs) are conditions of abnormal motor control thought to be caused by psychological factors. These disorders are commonly seen in neurologic practice, and prognosis is often poor. No consensus treatment guidelines have been established; however, the role of physical therapy in addition to psychotherapy has increasingly been recognized. This study reports patient outcomes from a multidisciplinary FMD treatment program using motor retraining (MoRe) strategies. OBJECTIVE To assess outcomes of FMD patients undergoing a multidisciplinary treatment program and determine factors predictive of treatment success. DESIGN Retrospective chart review. SETTING University-affiliated rehabilitation institute. PATIENTS Thirty-two consecutive FMD patients admitted to the MoRe program from July 2014-July 2016. INTERVENTION Patients participated in a 1-week, multidisciplinary inpatient treatment program with daily physical, occupational, speech therapy, and psychotherapy interventions. MAIN OUTCOME MEASUREMENTS Primary outcome measures were changes in the patient-rated Clinical Global Impression Scale (CGI) and the physician-rated Psychogenic Movement Disorder Rating Scale (PMDRS) based on review of standardized patient videos. Measurements were taken as part of the clinical evaluation of the program. RESULTS Twenty-four of the 32 patients were female with a mean age of 49.1 (±14.2) years and mean symptom duration of 7.4 (±10.8) years. Most common movement phenomenologies were abnormal gait (31.2%), hyperkinetic movements (31.2%), and dystonia (31.2%). At discharge, 86.7% of patients reported symptom improvement on the CGI, and self-reported improvement was maintained in 69.2% at the 6-month follow-up. PMDRS scores improved by 59.1% from baseline to discharge. Longer duration of symptoms, history of abuse, and comorbid psychiatric disorders were not significant predictors of treatment outcomes. CONCLUSIONS The majority of FMD patients experienced improvement from a 1-week multidisciplinary inpatient rehabilitation program. Treatment outcomes were not negatively correlated with longer disease duration or psychiatric comorbidities. The results from our study are encouraging, although further long-term prospective randomized studies are needed. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Alexandra E Jacob
- Department of Neurology, University of Louisville, Louisville, KY(∗)
| | - Darryl L Kaelin
- Division of Physical Medicine and Rehabilitation, University of Louisville, Louisville, KY(†)
| | - Abbey R Roach
- Division of Psychology and Neuropsychology, Frazier Rehab Institute, Louisville, KY(‡)
| | - Craig H Ziegler
- School of Medicine, University of Louisville, Louisville, KY(§)
| | - Kathrin LaFaver
- Department of Neurology, University of Louisville, 220 Abraham Flexner Way, Suite 606, Louisville, KY, 40202(¶).
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48
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Garcin B. Motor functional neurological disorders: An update. Rev Neurol (Paris) 2018; 174:203-211. [DOI: 10.1016/j.neurol.2017.11.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 11/28/2017] [Accepted: 11/29/2017] [Indexed: 11/26/2022]
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Tsui P, Deptula A, Yuan DY. Conversion Disorder, Functional Neurological Symptom Disorder, and Chronic Pain: Comorbidity, Assessment, and Treatment. Curr Pain Headache Rep 2018; 21:29. [PMID: 28434123 DOI: 10.1007/s11916-017-0627-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE OF REVIEW This paper examines the overlap of conversion disorder with chronic pain conditions, describes ways to assess for conversion disorder, and provides an overview of evidence-based treatments for conversion disorder and chronic pain, with a focus on conversion symptoms. RECENT FINDINGS Conversion disorder is a significant problem that warrants further study, given that there are not many well-established guidelines. Accurate and timely assessment should help move treatment in a more fruitful direction and avoid unnecessary medical interventions. Advances in neuroimaging may also help further our understanding of conversion disorder. Creating a supportive environment and a collaborative treatment relationship and improving understanding of conversion symptoms appear to help individuals diagnosed with conversion disorder engage in appropriate treatments. Novel uses of earlier treatments, such as hypnosis and psychodynamic approaches, could potentially be beneficial and require a more vigorous and systematic study. There are treatments that produce significant improvements in functioning and reduction of physical symptoms from conversion disorder even for very severe cases. Hypnotherapy, cognitive behavioral therapy, and inpatient multidisciplinary treatment with intensive physiotherapy for severe cases have the most evidence to support reduction of symptoms. Components of treatment for conversion disorder overlap with treatments for chronic pain and can be used together to produce therapeutic effects for both conditions. Treatment needs to be tailored for each individual's specific symptoms.
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Affiliation(s)
- Patricia Tsui
- Department of Anesthesiology, Chronic Pain Division Stony Brook Medicine, 3 Edmund Pellegrino Rd, Stony Brook, NY, 11794, USA.
| | - Andrew Deptula
- Department of Psychiatry, Stony Brook University, 101 Nicolls Rd, Stony Brook, NY, 11794, USA
| | - Derek Y Yuan
- Department of Neurology, Health Sciences Center T-12, 020, Stony Brook Medical Center, Stony Brook, NY, 11794, USA
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Kienle J, Rockstroh B, Fiess J, Schmidt R, Popov T, Steffen-Klatt A. Variation of Functional Neurological Symptoms and Emotion Regulation with Time. Front Psychiatry 2018; 9:35. [PMID: 29487543 PMCID: PMC5816796 DOI: 10.3389/fpsyt.2018.00035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2017] [Accepted: 01/29/2018] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION The present study addressed the variation of emotion regulation in the context of functional neurological symptom disorder (FNSD) by examining changes of functional neurological symptoms (FNS), general psychological strain, alexithymia, emotion regulation strategies, and cortical correlates of emotion regulation in the context of a standard inpatient treatment program. METHODS AND MATERIALS Self-report data on FNS, general psychological strain, alexithymia, emotion regulation strategies, and cortical correlates of an experimentally induced emotion regulation task (participants either passively watched unpleasant and neutral pictures or regulated their emotional response to unpleasant pictures using pre-trained reappraisal, while an electroencephalogram was recorded) were compared between 19 patients with FNSD and 19 healthy comparison participants (HC) before and after a 4-week standard treatment protocol that included a combination of (individual and group) psychotherapies and functional treatments (such as physiotherapy) or a 4-week interval in HC, respectively. RESULTS General psychological strain did not decrease significantly in FNSD patients. Changes in emotion regulation in FNSD patients were constrained to an increase in self-reported use of cognitive reappraisal strategies. Subjective symptom intensity in FNSD patients varied with alexithymia pretreatment, but did not decrease significantly. Cortical activity in the time and frequency-domain distinguished passive watching of neutral and unpleasant pictures and regulating emotional responses upon unpleasant pictures from passively watching them without difference between groups and/or time. DISCUSSION Over the investigated time interval, augmented habitual cognitive emotion regulation suggests an alleviation of emotion processing deficits, but no significant symptom decrease. More controlled and prolonged treatment studies would be needed to determine whether and how a specific contribution of treatment-related changes of emotion regulation and FNS might be inferred.
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Affiliation(s)
- Johanna Kienle
- Department of Psychology, University of Konstanz, Konstanz, Germany
| | | | - Johanna Fiess
- Department of Psychology, University of Konstanz, Konstanz, Germany
| | | | - Tzvetan Popov
- Department of Psychology, University of Konstanz, Konstanz, Germany
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