Functional symptoms in neurology: questions and answers

Diagnosis of psychogenic (functional) gait disorders

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

What psychological interventions are effective for the management of persistent physical symptoms (PPS)? A systematic review and meta-analysis

OBJECTIVES

Presentation of persistent physical symptoms is associated with increased health care utilization, yet clinical outcomes often remain suboptimal. This systematic review aimed to determine whether psychological interventions are effective for the management of PPS and if so, what are the features of the interventions and at what level of care are they delivered. The review also set out to establish which symptoms in those diagnosed with PPS can be effectively managed with psychological intervention.

METHODS

Studies were included if they clearly reported a psychological intervention, specified the study sample as adults with a diagnosis of persistent physical symptoms, included a comparator and as a minimum an outcome measure of somatic symptoms. Risk of bias was assessed using the EPHPP. Meta-analysis was conducted to estimate the overall effect of interventions on somatic symptoms (the primary outcome), anxiety and depression (secondary outcomes).

RESULTS

Seventeen papers of varying quality indicated that psychological interventions can be effective for the management of somatic symptoms reported by individuals with PPS within a primary care setting. Psychological interventions were also found to be effective at reducing depression symptoms in individuals with PPS in twelve of the included studies. However, the meta-analysis results suggest that the psychological interventions utilized within eleven of the included studies did not significantly impact anxiety symptoms.

CONCLUSIONS

Psychological interventions have some success in managing somatic symptoms in PPS patients within primary care settings although their effects on other psychological symptoms is more mixed. The review highlights the importance of establishing a clearer diagnostic classification to inform treatment trajectories and the need for appropriate training and support within a multi-disciplinary team to enable the provision of such therapies.

Functional Neurological Disorders: Clinical Spectrum, Diagnosis, and Treatment

BACKGROUND

Functional neurological disorders (FNDs) are common but often misdiagnosed.

REVIEW SUMMARY

The incidence of FNDs is between 4 and 12 per 100,000, comparable to multiple sclerosis and amyotrophic lateral sclerosis, and it is the second most common diagnosis in neurology clinics. Some clues in the history are sudden onset, intermittent time course, variability of manifestation over time, childhood trauma, and history of other somatic symptoms. Anxiety and depression are common, but not necessarily more than in the general population. Although there are no tests currently capable of demonstrating whether symptoms are willfully produced, there may not be a clear categorical difference between voluntary and involuntary symptoms. The prognosis of an FND is linked to early diagnosis and symptom duration, but unfortunately, the majority of the patients are diagnosed after considerable delays.

CONCLUSIONS

A positive diagnosis of FNDs can be made on the basis of history and neurological signs without reliance on psychological stressors. Past sensitizing events and neurobiological abnormalities contribute to the pathogenesis of FNDs. Physical rehabilitation and psychological interventions alone or in combination are helpful in the treatment.

A Broader Perspective: Functional Symptoms Beyond Neurology

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Functional (psychogenic) symptoms exist in all specialties.

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They are by definition not under voluntary control, unlike factitious disorders and malingering.

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The diagnostic approach to functional symptoms varies among specialties.

Dissociated motor learning and de-adaptation in patients with functional gait disorders

Walking onto a stationary platform that had been previously experienced as moving generates a locomotor after-effect—the so-called ‘broken escalator’ phenomenon. The motor responses that occur during locomotor after-effects have been mapped theoretically using a hierarchal Bayesian model of brain function that takes into account current sensory information that is weighted according to prior contextually-relevant experiences; these in turn inform automatic motor responses. Here, we use the broken escalator phenomenon to explore motor learning in patients with functional gait disorders and probe whether abnormal postural mechanisms override ascending sensory information and conscious intention, leading to maladaptive and disabling gait abnormalities. Fourteen patients with functional gait disorders and 17 healthy control subjects walked onto a stationary sled (‘Before’ condition, five trials), then onto a moving sled (‘Moving’ condition, 10 trials) and then again onto the stationary sled (‘After’ condition, five trials). Subjects were warned of the change in conditions. Kinematic gait measures (trunk displacement, step timing, gait velocity), EMG responses, and subjective measures of state anxiety/instability were recorded per trial. Patients had slower gait velocities in the Before trials (P < 0.05) but were able to increase this to accommodate the moving sled, with similar learning curves to control subjects (P = 0.87). Although trunk and gait velocity locomotor after-effects were present in both groups, there was a persistence of the locomotor after-effect only in patients (P < 0.05). We observed an increase in gait velocity during After trials towards normal values in the patient group. Instability and state anxiety were greater in patients than controls (P < 0.05) only during explicit phases (Before/After) of the task. Mean ‘final’ gait termination EMG activity (right gastrocnemius) was greater in the patient group than controls. Despite a dysfunctional locomotor system, patients show normal adaptive learning. The process of de-adaptation, however, is prolonged in patients indicating a tendency to perpetuate learned motor programmes. The trend to normalization of gait velocity following a period of implicit motor learning has implications for gait rehabilitation potential in patients with functional gait disorders and related disorders (e.g. fear of falling).

Functional stroke symptoms: A prospective observational case series

OBJECTIVE

Functional symptoms are a common mimic of stroke in acute stroke settings, but there are no guidelines on how to manage such patients and scant research on their clinical profile. We explore the presentation of patients with functional stroke symptoms at admission and 2-month follow-up.

METHODS

We conducted a prospective observational study across four SE London acute stroke units, with two-month follow-up. Demographic information, clinical data and GP attendances were recorded. Patients completed self-report measures: Cognitive Behavioural Responses Questionnaire short version, Brief Illness Perception Questionnaire, Hospital Anxiety and Depression Scale, Work and Social Adjustment Scale and Short Form Health Survey.

RESULTS

Fifty-six patients (mean age: 50.9 years) were recruited at baseline; 40 with isolated functional symptoms, the remaining functional symptoms in addition to stroke. Thirty-one completed self-report follow-up measures. Of 56 participants, 63% were female. Patients presented symptoms across modalities, with unilateral and limb weakness the most frequent. There was inconsistent and ambiguous recording of symptoms on medical records. Approximately 40% of patients reported levels of anxiety and depression above the threshold indicating a probable diagnosis. Higher anxiety was associated with greater resting or all-or-nothing behaviours, embarrassment avoidance and symptom focussing on the CBRQ. Only SF-36 physical functioning improved at follow-up. Less than 50% who responded at follow-up were accessing a treatment, though 82% had ongoing symptoms.

CONCLUSION

Patients with functional symptoms in stroke settings report substantial distress, associated with cognitive-behavioural responses to symptoms. Follow-up data suggest recovery can be slow, indicating access to supportive interventions should be improved.

Experiences and Illness Perceptions of Patients with Functional Symptoms Admitted to Hyperacute Stroke Wards: A Mixed-Method Study

INTRODUCTION

A proportion of patients admitted to acute-stroke settings have not had a stroke, but have conditions mimicking a stroke. Approximately 25% of suspected stroke cases are "stroke mimics" and 2% are patients with functional symptoms - "functional stroke mimics". This study aimed to explore experiences and illness perceptions of patients with functional symptoms admitted to hyperacute stroke wards.

METHODS

This study used mixed methods. Patients with functional stroke symptoms participated in semistructured qualitative interviews immediately after admission to one of two acute-stroke units in London and again 2 months after hospital discharge. Qualitative data were assessed using thematic analysis. The Brief Illness Perception Questionnaire (Brief-IPQ) measured illness perceptions at admission and at 2-month follow-up.

RESULTS

A total of 36 participants completed baseline interviews and 25 completed follow-up. Six themes emerged: physical symptom experience, emotional and coping responses, symptom causes, hospital experiences, views on the future, and uncertainty after hospital discharge. Mean Brief-IPQ score at admission was 49.3 (SD: 9.9), indicating a moderate-high level of perceived illness threat. Participants presented with a range of functional symptoms. At baseline, participants were highly concerned about their symptoms, but this had decreased at 2-month follow-up. Two months later, many were confused as to the cause of their admission.

CONCLUSION

This is the first study to examine functional stroke patients' experiences of acute-stroke admission. At admission, patients expressed confusion regarding their diagnosis, experienced high levels of emotional distress, and were concerned they were perceived as time wasting by stroke clinicians. While most participants experienced symptom recovery, there was a significant subgroup for whom symptoms persisted or worsened. A lack of care guidelines on the management of functional stroke patients may perpetuate functional symptoms.

Prevalence of overreporting on symptom validity tests in a large sample of psychosomatic rehabilitation inpatients

Objective: Noncredible symptom claims, regularly expected in forensic contexts, may also occur in clinical and rehabilitation referral contexts. Hidden motives and secondary gain expectations may play a significant role in clinical patients. We studied the prevalence of noncredible symptom report in patients treated for minor mental disorders in an inpatient setting.Method: Five hundred and thirty seven clinical inpatients of a psychosomatic rehabilitation center were studied (mean age: 50.2 years; native speakers of German). They were referred for treatment of depression, anxiety, somatoform disorder, adjustment disorder, and neurasthenia. Results of two symptom validity tests (Structured Inventory of Malingered Symptomatology, SIMS; Self-Report Symptom Inventory, SRSI) and the Beck Depression Inventory-II (BDI-II) were analyzed.Results: At screening level, 34.5% and 29.8% of the patients were found to presumably overreport symptoms on the SIMS and SRSI, respectively. At the standard cut score of the SRSI (maximum false positive rate: 5%), the proportion of diagnosed overreporting was 18.8%. SIMS and SRSI pseudosymptom endorsement correlated at .73. Highly elevated depressive symptom claims with BDI-II scores above 40, found in 9.3% of the patients, were associated with elevated pseudosymptom endorsement. Moreover, extended times of sick leave and higher expectations of disability pension were associated with elevated pseudosymptom endorsement.Conclusions: The prevalence of symptom overreporting in some clinical patient groups is a serious, yet underinvestigated problem. The current estimates yielded a high prevalence of distorted, noncredible symptom claims in psychosomatic rehabilitation patients. The challenges arising to health professionals working in such settings are immense and need more consideration.

Symptom and performance validation in patients with subjective cognitive decline and mild cognitive impairment

Nonauthentic symptom claims (overreporting) and invalid test results (underperformance) can regularly be expected in a forensic context, but may also occur in clinical referrals. While the applicability of symptom and performance validity tests in samples of dementia patients is well studied, the same is not true for patients with subjective cognitive decline (SCD) and mild cognitive impairment (MCI). A sample of 54 memory-clinic outpatients with evidence of SCD or MCI was studied. We evaluated the rate of positive results in three validity measures. A total of 7.4% of the patients showed probable negative response bias in the Word Memory Test. The rate of positive results on the Structured Inventory of Malingered Symptomatology was 14.8% while only one participant (1.9%) scored positive on the Self-Report Symptom Inventory using the standard cutoff. The two questionnaires were moderately correlated at .67. In a combined analysis of all results, five of the patients (9.3%) were judged to show evidence of probable negative response bias (or probably feigned neurocognitive impairment). In the current study, a relatively small but nontrivial rate of probable response distortions was found in a memory-clinic sample. However, it remains a methodological challenge for this kind of research to reliably distinguish between false-positive and correct-positive classifications in clinical patient groups.

From Conversion Disorders to Functional Neurological Disorders. Overcoming the Rule-out Diagnosis?

Functional neurological disorders, formerly referred to as conversion disorders, are a frequent clinical problem in neurology, psychiatry and primary care departments. In the new diagnostic categories, emphasis is placed on the positive characteristics necessary to diagnose this disorder. A narrative review of the scientific medical literature related to the subject was performed in order to determine the differences and advantages that the new classification of functional neurological disorders gives to doctors and patients. Historical, diagnostic, clinical and treatment concepts related to functional neurological disorders are reviewed. The conceptual differences between conversion disorders and functional neurological disorders and the implications of these changes in the clinical approach are identified. The new proposed diagnosis for functional neurological disorders provides the opportunity to transform a diagnosis made by ruling out other pathologies to a diagnosis where the presence of neurological signs suggestive of the disorder are verified and can be taught to the patient, and based on them, treatment strategies posed.

Complaints from patients with functional neurological disorders: a cross-sectional UK survey of why patients complain and the effect on the clinicians who look after them

OBJECTIVE

To evaluate the nature of complaints from patients with functional neurological disorders and understand the reaction of UK neurology consultants to receiving complaints from this patient group.

METHODS

A voluntary online retrospective survey was advertised to UK consultant neurologists. Questions asked about the nature of the complaint, how it was dealt with, how it affected their emotional well-being and attitude to work, and whether it influenced their clinical practice. Responses were anonymised. The frequency of responses and percentage of total responses were analysed. Respondents were also given opportunities to add personal comments.

RESULTS

Responses from 58 clinicians were received. Patient disagreement with the diagnosis was a factor in 90% of complaints received. Only 77% of complaints were resolved within 6 months and 61% of clinicians received no feedback about the outcome. 31% of clinicians reported their most problematic complaint had an adverse effect on their mood. 67% of respondents changed their practice following the complaint with 59% investigating more frequently or due to perceived pressure from patients.

CONCLUSIONS

Complaints from patients with functional neurological disorders appear to be primarily due to disagreement with the diagnosis. They are more difficult to resolve than other complaints, and clinicians who deal with them often become the 'second victim' in the process leading to potentially adverse effects on patient care. Strategies to tackle these issues are discussed.

Characterization of Brain Dysfunction Induced by Bacterial Lipopeptides That Alter Neuronal Activity and Network in Rodent Brains

The immunopathological states of the brain induced by bacterial lipoproteins have been well characterized by using biochemical and histological assays. However, these studies have limitations in determining functional states of damaged brains involving aberrant synaptic activity and network, which makes it difficult to diagnose brain disorders during bacterial infection. To address this, we investigated the effect of Pam₃CSK₄ (PAM), a synthetic bacterial lipopeptide, on synaptic dysfunction of female mice brains and cultured neurons in parallel. Our functional brain imaging using PET with [¹⁸F]fluorodeoxyglucose and [¹⁸F] flumazenil revealed that the brain dysfunction induced by PAM is closely aligned to disruption of neurotransmitter-related neuronal activity and functional correlation in the region of the limbic system rather than to decrease of metabolic activity of neurons in the injection area. This finding was verified by in vivo tissue experiments that analyzed synaptic and dendritic alterations in the regions where PET imaging showed abnormal neuronal activity and network. Recording of synaptic activity also revealed that PAM reorganized synaptic distribution and decreased synaptic plasticity in hippocampus. Further study using in vitro neuron cultures demonstrated that PAM decreased the number of presynapses and the frequency of miniature EPSCs, which suggests PAM disrupts neuronal function by damaging presynapses exclusively. We also showed that PAM caused aggregation of synapses around dendrites, which may have caused no significant change in expression level of synaptic proteins, whereas synaptic number and function were impaired by PAM. Our findings could provide a useful guide for diagnosis and treatment of brain disorders specific to bacterial infection.SIGNIFICANCE STATEMENT It is challenging to diagnose brain disorders caused by bacterial infection because neural damage induced by bacterial products involves nonspecific neurological symptoms, which is rarely detected by laboratory tests with low spatiotemporal resolution. To better understand brain pathology, it is essential to detect functional abnormalities of brain over time. To this end, we investigated characteristic patterns of altered neuronal integrity and functional correlation between various regions in mice brains injected with bacterial lipopeptides using PET with a goal to apply new findings to diagnosis of brain disorder specific to bacterial infection. In addition, we analyzed altered synaptic density and function using both in vivo and in vitro experimental models to understand how bacterial lipopeptides impair brain function and network.

Functional and simulated visual loss

Nonorganic visual loss (NOVL) is the cause of a large number of referrals to neurologists and ophthalmologists and is a frequent area of overlap between neurologists, ophthalmologists, and psychiatrists. NOVL is the presence of visual impairment without an organic cause for disease despite a thorough and comprehensive investigation. A diagnosis of NOVL requires both the absence of any findings on examination and proof of the integrity and functioning of the visual system. Although sometimes a challenging diagnosis to make, there are a number of techniques and maneuvers which can be utilized fairly easily, either at the bedside or in the clinic, to help determine if a patient has NOVL. In some instances specialized testing, such as formal visual field testing, optical coherence tomography, visual evoked responses, electroretinogram, and various imaging modalities (magnetic resonance imaging) are performed to help determine if the cause of visual loss is organic or nonorganic. Once a diagnosis of NOVL is made, treatment centers around reassurance of the patient, close follow-up, and, if necessary, referral to a psychiatrist, as these patients may have underlying psychiatric disorders and a preceding strong emotional event leading to the current symptoms, and may be more likely to develop depression and anxiety.

An International Perspective on Feigned Mental Disabilities: Conceptual Issues and Continuing Controversies

In forensic contexts, an increased prevalence of feigned symptom presentations should be expected, although it will probably vary by the context and specific forensic issue. Forensic experts should examine this possibility proactively while maintaining a balanced perspective that actively considers clinical data for both feigning and genuine responding. Psychological measures and standardized methods developed for feigning and other response styles can facilitate these often complex determinations. The current article provides an international perspective on the issue of feigned mental disabilities. In particular, important conceptual issues are discussed, such as the categorical versus dimensional approaches to feigning, and the advisability of well-defined rather than single-point cut scores for accuracy in clinical decision-making. Salient problems of differential diagnosis include a spectrum from malingering and factitious disorders to somatoform and conversion disorders. In rendering these important diagnostic distinctions, the questions of motivations and intentions remain key. However, the establishment of motivation cannot be facilely assumed from the context. Instead, forensic psychologists and psychiatrists bear the professional burden of carefully evaluating motivation and recognizing the clinical reality that sometimes the motivation in especially challenging cases may not be fully determined. Copyright © 2017 John Wiley & Sons, Ltd.

Validity assessment and the neurological physical examination

BACKGROUND

The assessment of any patient or examinee with neurological impairment, whether acquired or congenital, provides a key set of data points in the context of developing accurate diagnostic impressions and implementing an appropriate neurorehabilitation program. As part of that assessment, the neurological physical exam is an extremely important component of the overall neurological assessment.

PURPOSE

In the aforementioned context, clinicians often are confounded by unusual, atypical or unexplainable physical exam findings that bring into question the organicity, veracity, and/or underlying cause of the observed clinical presentation. The purpose of this review is to provide readers with general directions and specific caveats regarding validity assessment in the context of the neurological physical exam.

CONCLUSIONS

It is of utmost importance for health care practitioners to be aware of assessment methodologies that may assist in determining the validity of the neurological physical exam and differentiating organic from non-organic/functional impairments. Maybe more importantly, the limitations of many commonly used strategies for assessment of non-organicity should be recognized and consider prior to labeling observed physical findings on neurological exam as non-organic or functional.

Effects of music and music therapy on mood in neurological patients

Mood disorder and depressive syndromes represent a common comorbid condition in neurological disorders with a prevalence rate that ranges between 20% and 50% of patients with stroke, epilepsy, multiple sclerosis, and Parkinson’s disease. Notwithstanding, these conditions are often under-diagnosed and under-treated in the clinical practice and negatively affect the functional recovery, the adherence to treatment, the quality of life, and even the mortality risk. In addition, a bidirectional association between depression and neurological disorders may be possible being that depressive syndromes may be considered as a risk factor for certain neurological diseases. Despite the large amount of evidence regarding the effects of music therapy (MT) and other musical interventions on different aspects of neurological disorders, no updated article reviewing outcomes such as mood, emotions, depression, activity of daily living and so on is actually available; for this reason, little is known about the effectiveness of music and MT on these important outcomes in neurological patients. The aim of this article is to provide a narrative review of the current literature on musical interventions and their effects on mood and depression in patients with neurological disorders. Searching on PubMed and PsycInfo databases, 25 studies corresponding to the inclusion criteria have been selected; 11 of them assess the effects of music or MT in Dementia, 9 explore the efficacy on patients with Stroke, and 5 regard other neurological diseases like Multiple Sclerosis, Amyotrophic Lateral Sclerosis/motor neuron disease, Chronic quadriplegia, Parkinson’s Disease, and Acquired Brain dysfunctions. Selected studies are based on relational and rehabilitative music therapy approaches or concern music listening interventions. Most of the studies support the efficacy of MT and other musical interventions on mood, depressive syndromes, and quality of life on neurological patients.

First episode of psychosis in a middle-aged patient with a 14-year history of conversion disorder

We present a case of a middle-aged male patient with a long history of conversion disorder and histrionic personality, who presented with newly onset psychotic symptoms while being engaged to treatment with a community mental health team in a primary care setting. The symptoms could not be attributed to an organic cause. After a short course of olanzapine treatment which caused adverse effects, the symptomatology responded well to low dose amisulpride. Conversion symptoms were stable throughout the psychotic episode. This case illustrates the complex interplay between disorders classified in different categories (somatoform versus psychotic disorders).

Functional relapses in pediatric multiple sclerosis

Multiple sclerosis in children is characterized by more frequent relapses than in adult patients. Diagnosing and treating youth with multiple sclerosis present a number of challenges including differentiating organic relapses from functional symptoms. However, there is no literature describing coexistence of functionality in pediatric multiple sclerosis. Here, we report 2 cases in which inconsistency between clinical history, physical examination, imaging, and atypical disease progression led to suspicion of functional relapses. The purpose of this study is to raise awareness of functional relapses, as prompt recognition can prevent overtreatment and iatrogenic risks in children and adolescents with multiple sclerosis. Underlying psychiatric issues also need to be addressed.

The elbow flex-ex: a new sign to detect unilateral upper extremity non-organic paresis

OBJECTIVE

To examine a new neurological sign that uses synergistic oppositional movements of the arms to evaluate for non-organic upper extremity weakness.

METHODS

Patients with unilateral arm weakness were tested in a standing or sitting position with the elbows flexed at 30°. The examiner held both forearms near the wrists while asking the patient to flex or extend the normal arm at the elbow and simultaneously feeling for flexion or extension of the contralateral (paretic) arm. In patients with organic paresis, there was not a significant detectable force of contralateral opposition of the paretic limb. Patients with non-organic arm weakness had detectable strength of contralateral opposition in the paretic arm when the normal arm was tested.

RESULTS

The test was first performed on 23 patients with no complaint of arm weakness. Then, 31 patients with unilateral arm weakness were tested (10 with non-organic weakness and 21 with organic weakness). The elbow flex-ex sign correctly identified the cause of weakness in all cases.

CONCLUSIONS

The elbow flex-ex sign is useful in differentiating between functional and organic arm paresis.

Are there interactional reasons why doctors may find it hard to tell patients that their physical symptoms may have emotional causes? A conversation analytic study in neurology outpatients

OBJECTIVE

This qualitative study analyses patients' conversational behaviours to explore whether there are interactional factors that could explain why doctors find clinical encounters in which the diagnosis of functional symptoms (physical symptoms with presumed emotional causes) is explained and psychological treatment offered particularly challenging.

METHODS

Twenty out-patient consultations between neurologists and patients with functional symptoms were recorded and analysed using Conversation Analysis. Patients' communication behaviour was characterised by pervasive interactional resistance. Instances of resistance were identified and counted.

RESULTS

Interactional resistance was especially evident when the aetiology of symptoms and treatment recommendations were discussed. Resistance was expressed overtly (through disagreements, challenges, rejections) or more passively (through moves such as lack of engagement with the interaction, silences or the use of minimal responses).

CONCLUSION

This study provides objective evidence that doctors face interactional challenges when they try to explain that symptoms are medically unexplained and suggest psychological treatment.

PRACTICE IMPLICATIONS

Doctors may try to avoid provoking patients' overt resistance because they perceive it as unpleasant. However, the display of overt resistance enables them to deal explicitly with the grounds on which patients reject their explanations and recommendations, and to address patients' particular concerns.

Patients with psychogenic non-epileptic seizures referred to a tertiary epilepsy centre: patient characteristics in relation to diagnostic delay

OBJECTIVE

This clinical study examines patient and seizure characteristics of patients with psychogenic non-epileptic seizures (PNES) in a tertiary epilepsy centre. The main focus was whether a new subgroup of PNES patients emerged with a relatively short referral time and possible specific characteristics.

METHODS

All PNES patients referred to a specialist program in our centre between mid 2007 and mid 2009 were consecutively included. This yielded a study cohort of 90 patients.

RESULTS

The majority of the patients have a patient history with many medical symptoms and they were or had been in treatment by a medical specialist. Furthermore diffuse psychological/psychiatric symptoms and subsequent treatments are also remarkably common, in general without a clear psychological diagnosis. The average time between seizure onset and referral to an epilepsy centre is remarkably low (4.29 years). About 50% of the patients were referred within 2 years of seizure onset. This 'active high speed referral group' had significantly more previous psychological complaints, significantly more previous psychological/psychiatric treatments and a trend towards more previous medical investigations.

CONCLUSION

There seems to be a new subgroup of PNES patients with a short referral time, characterized by a more active attitude towards examination of the symptoms in combination with an active attitude to apply for treatment. However, the PNES cohort as a whole is characterized by having somatoform symptoms based on a process of somatization.

Experts' opinions on the management of medically unexplained symptoms in primary care. A qualitative analysis of narrative reviews and scientific editorials

BACKGROUND

The feasibility as well as the suitability of several therapies for medically unexplained symptoms (MUS) in primary care applied by the family physician (FP) appeared to be low. FPs need effective and acceptable strategies to manage these functionally impaired patients.

OBJECTIVE

To review important and effective elements in the treatment of patients with MUS in primary care according to experts in MUS research.

METHODS

We performed a systematic search of narrative reviews and scientific editorials in Medline and PsycINFO and triangulated our findings by conducting a focus group with MUS experts.

RESULTS

We included 7 scientific editorials and 23 narrative reviews. According to MUS experts, the most important elements in the treatment of MUS are creating a safe therapeutic environment, generic interventions (such as motivational interviewing, giving tangible explanations, reassurance and regularly scheduled appointments) and specific interventions (such as cognitive approaches and pharmacotherapy). Furthermore, MUS experts indicate that a multi-component approach in which these three important elements are combined are most helpful for patients with MUS. In contrast to most specific interventions, opinions of MUS experts regarding generic interventions and creating a safe therapeutic relationship seem to be more based on theory and experience than on quantitative research.

CONCLUSIONS

MUS experts highlight the importance of generic interventions and doctor-patient communication and relationship. However, studies showing the effectiveness of these elements in the management of MUS in primary care is still scarce. Research as well as medical practice should focus more on these non-specific aspects of the medical consultation.

MMPI-II personality profiles of patients with psychogenic nonepileptic seizures

This comparative study explored whether psychogenic nonepileptic seizures (PNES) are a unique disorder with distinctive personality characteristics or (seen from the personality profile) PNES are allied with the domain of a general functional somatic symptom and syndrome (FSSS). We compared the Minnesota Multiphasic Personality Inventory 2 (MMPI-2) results for 41 patients with newly diagnosed PNES and 43 patients with newly diagnosed insomnia. There were no statistically significant quantitative scoring differences on the main clinical scales, indicating that there is no substantial difference in "personality makeup" between the two groups with a FSSS. Additional subscale analysis indicated that patients with PNES reported significantly more somatic complaints (Hysteria 4) and bizarre sensory experiences (Schizophrenia 6). Further profile analysis revealed that the personality pattern of patients with PNES was characterized by a strong tendency toward "conversion V, a lack of control pattern and less excessive worries" as compared with patients with insomnia. Patients with PNES are characterized by a stronger tendency toward somatization and externalization, which has treatment implications.

Psychogenic movement disorders

Psychogenic movement disorders (PMDs) represent a challenging dilemma for the treating neurologist. The terminology to classify this disorder is confusing and making the diagnosis is difficult. Once the diagnosis has been established, treatment options are limited, and the patient generally does not accept the diagnosis.

A guide to disorders causing transient loss of consciousness: focus on syncope

Episodes of transient loss of consciousness (TLOC) events pose diagnostic difficulties, as the causes are diverse, carry vastly different risks, and span various specialties. An inconsistent terminology contributes to the confusion. Here, we present a classification scheme for TLOC, based on ongoing multidisciplinary efforts including those of the Task Force on Syncope of the European Society of Cardiology. We also discuss the pathophysiology of TLOC and the key clinical features that aid diagnosis. TLOC is defined as an apparent loss of consciousness with an abrupt onset, a short duration, and a spontaneous and complete recovery. Syncope is defined as TLOC due to cerebral hypoperfusion, and is divided into reflex syncope (synonymous with neurally mediated syncope), syncope due to orthostatic hypotension, and cardiac syncope (arrhythmic or associated with structural cardiac disease). The other major groups of TLOC are generalized epileptic seizures, functional TLOC (psychogenic TLOC mimicking either epilepsy or syncope), and a further group of miscellaneous disorders. The management of patients who experience TLOC requires the recognition of the defining features of each of the major groups, and cooperation between different clinical specialties.

Psychiatric issues in chronic pain

Chronic pain requires comprehensive care. While interdisciplinary approaches are recommended, the role of psychiatrists is often misunderstood. Psychiatrists should be involved with the care of patients with chronic pain as early as possible to maximize outcome. Psychiatrists offer an expertise that specifically addresses important deficiencies in the care of patients with chronic pain: 1) the lack of a detailed formulation, 2) the lumping of all psychopathology, and 3) the failure to effectively use psychopharmacologic treatments. This review provides a framework for formulating the diagnoses and treatments of patients with chronic pain.

Abduction finger sign: a new sign to detect unilateral functional paralysis of the upper limb

Objective of this study is testing a new sign to differentiate functional from organic paralysis of the arm. Thirty-six healthy subjects, ten patients with acute functional paralysis of one arm and eleven patients with acute organic paralysis of one arm were enrolled. The test consisted of abduction finger movements of one hand against resistance with a maximal sustained contraction to detect synkinetic abduction finger movements of the contralateral hand. For both hands, contralateral hand synkinesias were observed in healthy subjects. The task performed with the unaffected hand evoked synkinesias of the presumed affected hand in functional patients, but did not evoke synkinesias of the affected hand in organic patients. The abduction finger test had 100% sensitivity and specificity in distinguishing functional from organic paralysis of the upper limb in this cohort of patients. The abduction finger sign may be a reliable bedside test to discriminate functional from organic arm paralysis.

Falls, faints, fits and funny turns

In this practically oriented review, we will outline the clinical approach of patients with falls due to an impairment or loss of consciousness. Following a set of definitions, we describe the salient clinical features of disorders leading to such falls. Among falls caused by true loss of consciousness, we separate the clinical characteristics of syncopal falls (due to reflex syncope, hypovolemia, orthostatic hypotension or cardiac syncope) from falls due to other causes of transient unconsciousness, such as seizures. With respect to falls caused by an apparent loss of consciousness, we discuss the presentation of cataplexy, drop attacks, and psychogenic falls. Particular emphasis will be laid upon crucial features obtained by history taking for distinguishing between the various conditions that cause or mimic a transient loss of consciousness.

Psychogenic nonepileptic seizures: answers and questions

Psychogenic nonepileptic seizures (PNES) superficially resemble epileptic seizures, but are not associated with ictal electrical discharges in the brain. PNES constitute one of the most important differential diagnoses of epilepsy. However, despite the fact they have been recognized as a distinctive clinical phenomenon for centuries and that access to video/EEG monitoring has allowed clinicians to make near-certain diagnoses for several decades, our understanding of the etiology, underlying mental processes, and, subsequently, subdifferentiation, nosology, and treatment remains seriously deficient. Emphasizing the clinical picture throughout, the first part of this article is intended to "look and look again" at what we know about the epidemiology, semiology, clinical context, treatment, and prognosis of PNES. The second part is dedicated to the questions that remain to be answered. It argues that the most important reason our understanding of PNES remains limited is the focus on the visible manifestations of PNES or the seizures themselves. In contrast, subjective seizure manifestations and the biographic or clinical context in which they occur have been relatively neglected.

'Noisy patients'--can signal detection theory help?

Signal detection theory tests an observer's ability to discriminate between signal and noise. Deciding whether or not a patient's symptoms warrant further investigation or treatment is an example of this task in the clinical setting. Noise can exist within the observer--for example, in the brain of a tired or inexperienced doctor--or can arise from an external source such as the patient. Patients can produce external noise by giving numerous unrelated presenting complaints, providing overly detailed accounts of their symptoms, or simply talking too quickly. The more noise that is present, the harder the signal (such as a new disease or a notable change in an old condition) is to detect. Patients in the neurology clinic seem to be 'noisier' than average, perhaps owing to the long duration of their condition in many cases and the relatively high proportion of patients with medically unexplained symptoms. The ability to interpret such 'noisy' histories often underpins the neurological diagnosis. This Review aims to promote the relevance of signal detection theory to the overworked neurologist on the ward or in the clinic and explores strategies to reduce the noise generated both within the brain of the doctor and by patients.

Tailored psychotherapy for patients with functional neurological symptoms: a pilot study

OBJECTIVE

The objective of this study was to assess whether individually tailored psychotherapy for patients with functional neurological symptoms is associated with improvements in patient-centered measures of emotional well-being, quality of life, as well as somatic symptoms and whether this treatment modality is likely to be cost-effective.

METHODS

We conducted an uncontrolled prospective pilot study of consecutive patients with functional symptoms referred from neurology outpatient clinics to a single psychotherapist using validated questionnaires [Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM), Short Function (SF)-36 Health Survey, and Patient Health Questionnaire (PHQ)-15]. Patients had a median of 6 treatment sessions (range=1-24). Ninety-one patients completed questionnaires at referral, 63 did at the end of treatment, and 34 did at follow-up after 6 months. Significant improvements were seen on all measures and were maintained at follow-up (CORE-OM, P=.003; SF-36, P<.001; PHQ-15, P=.001). Significance was not lost in an intention-to-treat analysis. Of all the patients, 49.2% improved by at least 1 S.D. in at least one of the measures. The number of patients needed to be treated to see an improvement of at least 1 S.D. in one of the three outcome measures was 2; that in two measures, 3.9; and that in all measures, 7. The mean cost of the intervention was pound231; the cost per quality-adjusted life year was estimated as pound5,328.

RESULTS

Psychotherapy was associated with significant improvements in patient-centered measures, which seemed to be achieved at a comparatively low cost.

CONCLUSIONS

The results indicate that psychotherapy may be a cost-effective intervention for patients presenting with functional neurological symptoms. The findings warrant further assessment of this treatment with a randomized and controlled trial.

Hypomanic mood in a child patient treated with interferon-alpha 2a: case report

We report on a male child born in Rumania, adopted by an Italian family, and who at 10 years of age was submitted to interferon-alpha 2a therapy for chronic hepatitis B. About 30 days after the beginning of the treatment he developed hypomanic mood and psychogenic seizures. Psychological evaluation showed hyperactivity, distractibility, excessive talkativeness, grandiosity and racing thoughts. Temperamental traits were characterized by an elevated emotionality. The patient was successfully administered risperidone and cognitive-behavioral therapy; six months of treatment with interferon led to positive outcome of hepatitis B. Since affective symptoms may occur in children treated with IFN, a careful evaluation of psychiatric disturbances and adequate intervention are needed.

Functional vision loss: A diagnosis of exclusion

BACKGROUND

Most cases of visual acuity or visual field loss can be attributed to ocular pathology or ocular manifestations of systemic pathology. They can also occasionally be attributed to nonpathologic processes or malingering. Functional vision loss is any decrease in vision the origin of which cannot be attributed to a pathologic or structural abnormality.

CASE REPORTS

Two cases of functional vision loss are described. In the first, a 58-year-old man presented for a baseline eye examination for enrollment in a vision rehabilitation program. He reported bilateral blindness since a motor vehicle accident with head trauma 4 years prior. Entering visual acuity was "no light perception" in each eye. Ocular health examination was normal and the patient made frequent eye contact with the examiners. He was referred for neuroimaging and electrophysiologic testing. The second case was a 49-year-old man who presented with a long history of intermittent monocular diplopia. His medical history was significant for psycho-medical evaluations and a diagnosis of factitious disorder. Entering uncorrected visual acuities were 20/20 in each eye, but visual field testing found constriction. No abnormalities were found that could account for the monocular diplopia or visual field deficit. A diagnosis of functional vision loss secondary to factitious disorder was made.

CONCLUSIONS

Functional vision loss is a diagnosis of exclusion. In the event of reduced vision in the context of a normal ocular health examination, all other pathology must be ruled out before making the diagnosis of functional vision loss. Evaluation must include auxiliary ophthalmologic testing, neuroimaging of the visual pathway, review of the medical history and lifestyle, and psychiatric evaluation. Comanagement with a psychiatrist is essential for patients with functional vision loss.

Non-epileptic seizures and other functional neurological symptoms: predisposing, precipitating, and perpetuating factors

This naturalistic study describes potential etiological factors in outpatients with functional neurological symptoms recorded during a screening interview with a single psychotherapist in 59 consecutive patients. The most commonly identified predisposing/precipitating factors were trauma (78.0%), family dysfunction (62.7%), and bereavement (62.7%). Family dysfunction (54.2%) and affective disorder (42%) were the commonest perpetuating factors. Trauma was more common in non-epileptic seizures; health anxiety, in men; family problems, in women. This study demonstrates the heterogeneity of this patient population. Further research is indicated to explore differences in predisposing, precipitating, and perpetuating factors in different patient groups with functional symptoms.