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Ramsay N, McKee J, Al-Ani G, Stone J. How do I manage functional visual loss. Eye (Lond) 2024; 38:2257-2266. [PMID: 38778139 PMCID: PMC11306732 DOI: 10.1038/s41433-024-03126-w] [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] [Received: 02/21/2024] [Revised: 04/25/2024] [Accepted: 05/02/2024] [Indexed: 05/25/2024] Open
Abstract
Functional visual loss is a subtype of functional neurological disorder (FND) and is a common cause of visual impairment seen in both general and neuro-ophthalmological practice. Ophthalmologists can generally diagnose functional visual loss reasonably confidently but often find it harder to know what to say to the patient, how to approach, or even whether to attempt, treatment. There is little evidence-based treatment despite studies showing up to 60% of adults having impactful symptoms on long-term follow-up. The last 20 years has seen large changes in how we understand, approach, and manage FND more widely. In this article, we set out our practical approach to managing functional visual loss which includes : 1) Make a positive diagnosis based on investigations that demonstrate normal vision in the presence of subjectively impaired vision, not just because tests or ocular exam is normal; 2) Explain and label the condition with an emphasis on these positive diagnostic features, not reassurance; 3) Consider eye or brain comorbidities such as migraine, idiopathic intracranial hypertension or amblyopia; 4) Consider working with an orthoptist using diagnostic tests in a positive way to highlight the possibility of better vision; 5) Develop simple treatment strategies for photophobia; 6) Consider psychological factors and comorbidity as part of assessment and therapy, but keep a broader view of aetiology and don't use this to make a diagnosis; 7) Other treatment modalities including hypnotherapy, transcranial magnetic stimulation and more advanced forms of visual feedback are promising candidates for functional visual loss treatment in the future.
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Affiliation(s)
- Neil Ramsay
- Institute of Neurological Sciences, Queen Elizabeth University Hospital, Glasgow, UK
| | - Justin McKee
- Dept Ophthalmology, Royal Infirmary of Edinburgh and Princess Alexandra Eye Pavilion, Edinburgh, UK
| | - Gillian Al-Ani
- Dept Ophthalmology, Royal Infirmary of Edinburgh and Princess Alexandra Eye Pavilion, Edinburgh, UK
| | - Jon Stone
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
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2
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Davenport TE, Blitshteyn S, Clague-Baker N, Davies-Payne D, Treisman GJ, Tyson SF. Long COVID Is Not a Functional Neurologic Disorder. J Pers Med 2024; 14:799. [PMID: 39201991 PMCID: PMC11355889 DOI: 10.3390/jpm14080799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2024] [Revised: 07/22/2024] [Accepted: 07/23/2024] [Indexed: 09/03/2024] Open
Abstract
Long COVID is a common sequela of SARS-CoV-2 infection. Data from numerous scientific studies indicate that long COVID involves a complex interaction between pathophysiological processes. Long COVID may involve the development of new diagnosable health conditions and exacerbation of pre-existing health conditions. However, despite this rapidly accumulating body of evidence regarding the pathobiology of long COVID, psychogenic and functional interpretations of the illness presentation continue to be endorsed by some healthcare professionals, creating confusion and inappropriate diagnostic and therapeutic pathways for people living with long COVID. The purpose of this perspective is to present a clinical and scientific rationale for why long COVID should not be considered as a functional neurologic disorder. It will begin by discussing the parallel historical development of pathobiological and psychosomatic/sociogenic diagnostic constructs arising from a common root in neurasthenia, which has resulted in the collective understandings of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) and functional neurologic disorder (FND), respectively. We will also review the case definition criteria for FND and the distinguishing clinical and neuroimaging findings in FND vs. long COVID. We conclude that considering long COVID as FND is inappropriate based on differentiating pathophysiologic mechanisms and distinguishing clinical findings.
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Affiliation(s)
- Todd E. Davenport
- Department of Physical Therapy, University of the Pacific, Stockton, CA 95211, USA
- Workwell Foundation, Santa Rosa, CA 95403, USA
| | - Svetlana Blitshteyn
- Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University of Buffalo, Buffalo, NY 14203, USA
- Dysautonomia Clinic, Williamsville, NY 14221, USA
| | - Nicola Clague-Baker
- School of Allied Health Professions and Nursing, Institute of Population Health, University of Liverpool, Liverpool L69 7ZX, UK
| | - David Davies-Payne
- Department of Radiology, Starship Children’s Hospital, Auckland 1023, New Zealand
| | - Glenn J. Treisman
- Department of Psychiatry, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA;
| | - Sarah F. Tyson
- School of Health Sciences, University of Manchester, Manchester M14 4PX, UK;
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3
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Verme F, Fontana JM, Piterà P, Alito A, Saffioti S, Baccalaro G, Zebellin G, Capodaglio P. Whole-Body Cryostimulation in Functional Neurological Disorders: A Case Report. Healthcare (Basel) 2023; 12:71. [PMID: 38200977 PMCID: PMC10778987 DOI: 10.3390/healthcare12010071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Revised: 11/27/2023] [Accepted: 12/22/2023] [Indexed: 01/12/2024] Open
Abstract
Functional neurological disorders (FNDs) are complex disabling conditions requiring a multiple rehabilitation intervention. Here, we propose a new use of whole-body cryostimulation (WBC) that was implemented in a multidisciplinary rehabilitation programme in a wheelchair-ridden woman diagnosed with FND and other comorbidities. WBC is a promising adjuvant treatment in various conditions of rehabilitation interest, mainly because of its wide range of rapid effects, from anti-inflammatory to pain and autonomic modulating effects. The 4-week program included physiotherapy, nutritional intervention, psychological support, and WBC (-110 °C for 2 min). Questionnaires to assess disease impact, pain level, fatigue and sleep quality were administered. At discharge, improvements in body composition, haematological biomarkers, physical performance, and questionnaire scores were observed. The patient was able to walk independently with a walker for medium distances and reported unprecedented improvements, particularly in functional parameters and questionnaire scores. Although the extent to which WBC per se contributed to the measured improvements cannot be ascertained, subjective reports and our clinical observations indicate that WBC, the only intervention not previously experienced by the patient, acted as a booster for the rehabilitation interventions. Further research will be necessary to rule out any possible placebo effect and to confirm the effects of WBC on FND.
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Affiliation(s)
- Federica Verme
- Research Laboratory in Biomechanics, Rehabilitation and Ergonomics, Istituto Auxologico Italiano, IRCCS, San Giuseppe Hospital, Piancavallo, 28824 Verbania, Italy; (J.M.F.); (P.P.); (S.S.); (G.B.); (G.Z.); (P.C.)
| | - Jacopo Maria Fontana
- Research Laboratory in Biomechanics, Rehabilitation and Ergonomics, Istituto Auxologico Italiano, IRCCS, San Giuseppe Hospital, Piancavallo, 28824 Verbania, Italy; (J.M.F.); (P.P.); (S.S.); (G.B.); (G.Z.); (P.C.)
| | - Paolo Piterà
- Research Laboratory in Biomechanics, Rehabilitation and Ergonomics, Istituto Auxologico Italiano, IRCCS, San Giuseppe Hospital, Piancavallo, 28824 Verbania, Italy; (J.M.F.); (P.P.); (S.S.); (G.B.); (G.Z.); (P.C.)
| | - Angelo Alito
- Department of Biomedical, Dental Sciences and Morphological and Functional Images, University of Messina, 98125 Messina, Italy;
| | - Silvia Saffioti
- Research Laboratory in Biomechanics, Rehabilitation and Ergonomics, Istituto Auxologico Italiano, IRCCS, San Giuseppe Hospital, Piancavallo, 28824 Verbania, Italy; (J.M.F.); (P.P.); (S.S.); (G.B.); (G.Z.); (P.C.)
| | - Gabriele Baccalaro
- Research Laboratory in Biomechanics, Rehabilitation and Ergonomics, Istituto Auxologico Italiano, IRCCS, San Giuseppe Hospital, Piancavallo, 28824 Verbania, Italy; (J.M.F.); (P.P.); (S.S.); (G.B.); (G.Z.); (P.C.)
| | - Giuliano Zebellin
- Research Laboratory in Biomechanics, Rehabilitation and Ergonomics, Istituto Auxologico Italiano, IRCCS, San Giuseppe Hospital, Piancavallo, 28824 Verbania, Italy; (J.M.F.); (P.P.); (S.S.); (G.B.); (G.Z.); (P.C.)
| | - Paolo Capodaglio
- Research Laboratory in Biomechanics, Rehabilitation and Ergonomics, Istituto Auxologico Italiano, IRCCS, San Giuseppe Hospital, Piancavallo, 28824 Verbania, Italy; (J.M.F.); (P.P.); (S.S.); (G.B.); (G.Z.); (P.C.)
- Department of Surgical Sciences, Physical Medicine and Rehabilitation, University of Torino, 10126 Torino, Italy
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4
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Lee JS, Son HK. Evaluation of a Virtual Reality Simulation to Improve Problem-Based Learning for Neurologic Examination in Nursing Students. IRANIAN JOURNAL OF PUBLIC HEALTH 2023; 52:2128-2137. [PMID: 37899922 PMCID: PMC10612552 DOI: 10.18502/ijph.v52i10.13851] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 11/14/2022] [Indexed: 10/31/2023]
Abstract
Background In the era of the fourth industrial revolution, there is a requirement of innovative strategies to enhance nursing students' learning transfer. Virtual Reality Simulation Problem-Based Learning (VRS-PBL) has been validated to be an advantageous strategy that can improve knowledge, clinical performance, and self-efficacy. We aimed to identify the effectiveness of VRS-PBL for improving nursing students' neurologic examination. Methods Data were collected in 2021. Seventy-six participants were recruited via the convenience sampling. Students in the control group underwent conventional lecture and demonstration of neurological assessment prior to practicum, whereas students in the experimental group underwent VRS-PBL once a week for 2 weeks (60 minutes per session). Results Compared with the control group, the academic self-efficacy (t = -2.80, P = .007) and neurological examination performance (t = -11.62, P < .001) of the nursing students increased significantly in the experimental group. On the other hand, there was no significant difference between the two groups of the transfer motivation (t = -1.76, P = .082). Conclusion The nursing students integrated the knowledge and skills learned through VRS-PBL, and improved the effectiveness and efficiency of their learning. VRS-PBL that reflects various clinical situations can be used as a foundation for establishing effective teaching strategies to improve nursing competency from novice to expert nurses.
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Affiliation(s)
- Ji Sun Lee
- Department of Nursing, Daejeon University, Daejeon City 34520, Republic of Korea
| | - Hae Kyoung Son
- Department of Nursing, Eulji University, Seongnam City 13135, Republic of Korea
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Anurag S, Singh BK, Krishna D, Prasanna K, Deepeshwar S. Heart-brain Rhythmic Synchronization during Meditation: A Nonlinear Signal Analysis. Int J Yoga 2023; 16:132-139. [PMID: 38204769 PMCID: PMC10775837 DOI: 10.4103/ijoy.ijoy_161_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 10/04/2023] [Accepted: 10/05/2023] [Indexed: 01/12/2024] Open
Abstract
Background Heart-brain synchronization is the integration of mind, body, and spirit. It occurs when the electrical activity of the heart and brain is synchronized. In recent years, there has been mounting curiosity to investigate the effects of meditation on heart-brain synchronization with respect to mental and emotional health and well-being. The current investigation aims to explore the rhythmic synchronicity between the brain and the heart during heartfulness meditation (HM) practice. Materials and Methods The study was performed on 45 healthy volunteers who were categorized into three equal groups: long-term meditators (LTMs), short-term meditators (STMs), and nonmeditators (NMs). The electroencephalogram (EEG) signals were recorded to measure the prefrontal activity, and electrocardiogram (ECG) signals were recorded to measure the cardiac activity. The data were recorded in four states: baseline, meditation, transmission, and posttransmission. The detrended fluctuation analysis (DFA) method was used for the analysis of EEG and ECG signals. Results The result indicates that DFA values of EEG and ECG declined during meditation and transmission states as compared to pre- and postmeditation states. Significant results were obtained for the LTM group in all the states. A positive correlation was also observed between DFA of the heart and brain for the LTM group and no significant correlations were observed for the STM and NM groups. Conclusion The shreds of evidence suggest that heart-brain synchronization facilitates mental and emotional stability. HM practice has the potential to regulate the fluctuation of the mind. Regular meditation practice may result in physiological synchrony between cardiac and neural behavior, which can be considered a quality index for meditation practice.
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Affiliation(s)
- Shrivastava Anurag
- Department of Biomedical Engineering, National Institute of Technology, Raipur, Chhattisgarh, India
| | - Bikesh Kumar Singh
- Department of Biomedical Engineering, National Institute of Technology, Raipur, Chhattisgarh, India
| | - Dwivedi Krishna
- Department of Yoga Life Sciences, Swami Vivekananda Yoga AnusandhanaSamsthana, Bengaluru, Karnataka, India
| | | | - Singh Deepeshwar
- Department of Yoga, School of Yoga, Naturopathy and Cognitive Studies, Babasaheb Bhimrao Ambedkar University, Lucknow, Uttar Pradesh, India
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Onofrj M, Ajdinaj P, Digiovanni A, Malek N, Martinotti G, Ferro FM, Russo M, Thomas A, Sensi SL. Functional Neurologic Disorders, disorders to be managed by neurologists, or are neurologists wandering in a dangerous field with inadequate resources? Front Psychiatry 2023; 14:1120981. [PMID: 37009111 PMCID: PMC10064068 DOI: 10.3389/fpsyt.2023.1120981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 02/24/2023] [Indexed: 03/19/2023] Open
Abstract
In recent years, some neurologists reconsidered their approach to Medically Unexplained Symptoms and proposed Functional Neurologic Disorders (FND) as a new entity, claiming that neurology could offer alternative treatment options to the psychotherapies provided in psychiatry settings. FNDs, for this purpose, should include only the disorders listed as Conversion from the Somatic Symptom and Related Disorders (SSRD) group. The present review analyzes the rationale of this position and challenges the arguments provided for its support. The review also discusses the systematization of these disorders as provided by public health systems. It outlines risks stemming from economic support and public funding uncertainty, given their negligible epidemiological dimensions resulting from the parcellation of SSRD. The review underlines the unresolved issue of Factitious Disorders, which are in the same SSRD category of the international classification but are, nonetheless, overlooked by the theoretical proponents of the FND entity. Comorbidity with other psychiatric disorders is also analyzed. We propose a model that supports the continuum between different SSRD conditions, including Factitious Disorders. The model is based on the emergence of feigned death reflex and deception from frontal lobe dysfunction. Finally, the paper summarizes the wealth of historical psychiatric and psychodynamic approaches and critical reviews. The study also puts in context the categorization and interpretation efforts provided by the most eminent researchers of the past century.
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Affiliation(s)
- Marco Onofrj
- Department of Neuroscience, Imaging, and Clinical Sciences, “G. D'Annunzio University” of Chieti-Pescara, Chieti, Italy
- Center for Advanced Studies and Technology (CAST), “G. D'Annunzio University” of Chieti-Pescara, Chieti, Italy
- *Correspondence: Marco Onofrj,
| | - Paola Ajdinaj
- Department of Neuroscience, Imaging, and Clinical Sciences, “G. D'Annunzio University” of Chieti-Pescara, Chieti, Italy
- Center for Advanced Studies and Technology (CAST), “G. D'Annunzio University” of Chieti-Pescara, Chieti, Italy
| | - Anna Digiovanni
- Department of Neuroscience, Imaging, and Clinical Sciences, “G. D'Annunzio University” of Chieti-Pescara, Chieti, Italy
- Center for Advanced Studies and Technology (CAST), “G. D'Annunzio University” of Chieti-Pescara, Chieti, Italy
| | - Naveed Malek
- Barking, Havering, and Redbridge University Hospitals NHS Trust, London, United Kingdom
| | - Giovanni Martinotti
- Department of Neuroscience, Imaging, and Clinical Sciences, “G. D'Annunzio University” of Chieti-Pescara, Chieti, Italy
- Department of Clinical, Pharmaceutical and Biological Sciences, University of Hertfordshire, Hertfordshire, United Kingdom
| | - Filippo Maria Ferro
- Department of Neuroscience, Imaging, and Clinical Sciences, “G. D'Annunzio University” of Chieti-Pescara, Chieti, Italy
| | - Mirella Russo
- Department of Neuroscience, Imaging, and Clinical Sciences, “G. D'Annunzio University” of Chieti-Pescara, Chieti, Italy
- Center for Advanced Studies and Technology (CAST), “G. D'Annunzio University” of Chieti-Pescara, Chieti, Italy
| | - Astrid Thomas
- Department of Neuroscience, Imaging, and Clinical Sciences, “G. D'Annunzio University” of Chieti-Pescara, Chieti, Italy
- Center for Advanced Studies and Technology (CAST), “G. D'Annunzio University” of Chieti-Pescara, Chieti, Italy
| | - Stefano Luca Sensi
- Department of Neuroscience, Imaging, and Clinical Sciences, “G. D'Annunzio University” of Chieti-Pescara, Chieti, Italy
- Center for Advanced Studies and Technology (CAST), “G. D'Annunzio University” of Chieti-Pescara, Chieti, Italy
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7
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Hagey DW, El Andaloussi S. The promise and challenges of extracellular vesicles in the diagnosis of neurodegenerative diseases. HANDBOOK OF CLINICAL NEUROLOGY 2023; 193:227-241. [PMID: 36803813 DOI: 10.1016/b978-0-323-85555-6.00014-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
Extracellular vesicles (EVs) have emerged as essential means of intercommunication for all cell types, and their role in CNS physiology is increasingly appreciated. Accumulating evidence has demonstrated that EVs play important roles in neural cell maintenance, plasticity, and growth. However, EVs have also been demonstrated to spread amyloids and inflammation characteristic of neurodegenerative disease. Such dual roles suggest that EVs may be prime candidates for neurodegenerative disease biomarker analysis. This is supported by several intrinsic properties of EVs: Populations can be enriched by capturing surface proteins from their cell of origin, their diverse cargo represent the complex intracellular states of the cells they derive from, and they can pass the blood-brain barrier. Despite this promise, there are important questions outstanding in this young field that will need to be answered before it can fulfill its potential. Namely, overcoming the technical challenges of isolating rare EV populations, the difficulties inherent in detecting neurodegeneration, and the ethical considerations of diagnosing asymptomatic individuals. Although daunting, succeeding to answer these questions has the potential to provide unprecedented insight and improved treatment of neurodegenerative disease in the future.
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Affiliation(s)
- Daniel W Hagey
- Department of Laboratory Medicine, Karolinska Institutet, Stockholm, Sweden.
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8
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Piliavska K, Dantlgraber M, Dettmers C, Jöbges M, Liepert J, Schmidt R. Functional neurological symptoms are a frequent and relevant comorbidity in patients with multiple sclerosis. Front Neurol 2023; 14:1077838. [PMID: 37114221 PMCID: PMC10126263 DOI: 10.3389/fneur.2023.1077838] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Accepted: 03/20/2023] [Indexed: 04/29/2023] Open
Abstract
Introduction Functional neurological symptoms (FNS) in multiple sclerosis (MS) have shown to be underinvestigated even though neurological diseases such as MS represent a risk factor for developing FNS. Comorbidity of FNS and MS can produce high personal and social costs since FNS patients have high healthcare utilization costs and a quality of life at least as impaired as in patients with disorders with underlying structural pathology. This study aims to assess comorbid FNS in patients with MS (pwMS) and investigate whether FNS in pwMS are associated with poorer health-related quality of life and work ability. Methods Newly admitted patients (234) with MS were studied during their stay at Kliniken Schmieder, a neurological rehabilitation clinic in Konstanz, Germany. The degree to which the overall clinical picture was explained by MS pathology was rated by neurologists and allied health practitioners on a five-point Likert scale. Additionally, neurologists rated each symptom reported by the patients. Health-related quality of life was assessed using a self-report questionnaire and work ability was assessed using the mean number of hours worked per day and information regarding disability pension as reported by patients. Results In 55.1% of cases, the clinical picture was completely explained by structural pathology due to MS. 17.1% of pwMS presented an overall clinical picture half or less of which could be explained by underlying structural pathology. PwMS with a higher comorbid FNS burden had a lower health-related quality of life and reported fewer working hours per day than pwMS with symptoms explained by structural pathology. Furthermore, pwMS with a full disability pension had a higher comorbid FNS burden than pwMS with no or partial disability pension. Discussion These results show that FNS should be addressed diagnostically and therapeutically since such symptoms are an important comorbidity in MS that is related to poorer health-related quality of life and lower work ability.
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Affiliation(s)
- Katya Piliavska
- Lurija Institute for Rehabilitation Sciences and Health Research, Allensbach, Germany
- *Correspondence: Katya Piliavska,
| | | | - Christian Dettmers
- Lurija Institute for Rehabilitation Sciences and Health Research, Allensbach, Germany
- Kliniken Schmieder Konstanz, Konstanz, Germany
| | - Michael Jöbges
- Lurija Institute for Rehabilitation Sciences and Health Research, Allensbach, Germany
- Kliniken Schmieder Konstanz, Konstanz, Germany
| | - Joachim Liepert
- Lurija Institute for Rehabilitation Sciences and Health Research, Allensbach, Germany
- Kliniken Schmieder Allensbach, Allensbach, Germany
| | - Roger Schmidt
- Lurija Institute for Rehabilitation Sciences and Health Research, Allensbach, Germany
- Klinik für Psychosomatik und Konsiliarpsychiatrie, Kantonsspital, St. Gallen, Switzerland
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9
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Xu L, Liss J, Berisha V. Dysarthria detection based on a deep learning model with a clinically-interpretable layer. JASA EXPRESS LETTERS 2023; 3:015201. [PMID: 36725533 PMCID: PMC9835557 DOI: 10.1121/10.0016833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 12/20/2022] [Indexed: 06/18/2023]
Abstract
Studies have shown deep neural networks (DNN) as a potential tool for classifying dysarthric speakers and controls. However, representations used to train DNNs are largely not clinically interpretable, which limits clinical value. Here, a model with a bottleneck layer is trained to jointly learn a classification label and four clinically-interpretable features. Evaluation of two dysarthria subtypes shows that the proposed method can flexibly trade-off between improved classification accuracy and discovery of clinically-interpretable deficit patterns. The analysis using Shapley additive explanation shows the model learns a representation consistent with the disturbances that define the two dysarthria subtypes considered in this work.
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Affiliation(s)
- Lingfeng Xu
- School of Computing and Augmented Intelligence, Arizona State University, Tempe, Arizona 85281, USA
| | - Julie Liss
- College of Health Solutions, Arizona State University, Tempe, Arizona 85281, USA ; ;
| | - Visar Berisha
- College of Health Solutions, Arizona State University, Tempe, Arizona 85281, USA ; ;
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10
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Mishra A, Pandey S. Functional Neurological Disorders: Clinical Spectrum, Diagnosis, and Treatment. Neurologist 2022; 27:276-289. [PMID: 35858632 DOI: 10.1097/nrl.0000000000000453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Anumeha Mishra
- Department of Neurology, Govind Ballabh Pant Postgraduate institute of medical education and research; New Delhi, India
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11
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Singh D. Functional dystonia: A pitfall for the foot and ankle surgeon. Foot Ankle Surg 2022; 28:691-696. [PMID: 34649761 DOI: 10.1016/j.fas.2021.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 09/23/2021] [Accepted: 10/05/2021] [Indexed: 02/04/2023]
Abstract
Functional dystonia represents a condition where psychological distress is being expressed as involuntary muscle contractions. In the foot and ankle, it most commonly presents as a sudden onset of a painful fixed ankle/hindfoot deformity in a female patient with a history of trivial trauma or surgery. The "fixed deformity" found on clinical examination is usually correctable under general anesthesia. Less commonly, it can present in the toes or may present as paroxysmal muscle movements rather than a fixed deformity. CRPS may occur concurrently with the dystonia. Failure to consider the diagnosis leads to a long delay in appropriate diagnosis, patient distress and unnecessary or even harmful surgery. A better approach to this clinical syndrome is to define it as fixed abnormal posturing that is most commonly psychogenic. Early referral to a movement disorder clinic is recommended. The prognosis is generally poor as less than a quarter of patients report subjective long-term improvement even when managed in a movement disorder clinic. Foot and ankle surgeons should, whenever possible, avoid operating on patients with functional dystonia in order to avoid symptomatic deterioration.
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Affiliation(s)
- Dishan Singh
- Royal National Orthopaedic Hospital, Stanmore, Middlesex HA7 4LP, United Kingdom.
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12
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Clark CN, Edwards MJ, Ong BE, Goodliffe L, Ahmad H, Dilley MD, Betteridge S, Griffin C, Jenkins PO. Reframing postconcussional syndrome as an interface disorder of neurology, psychiatry and psychology. Brain 2022; 145:1906-1915. [PMID: 35472071 PMCID: PMC9246708 DOI: 10.1093/brain/awac149] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 03/30/2022] [Accepted: 03/31/2022] [Indexed: 11/13/2022] Open
Abstract
Persistent symptoms following a minor head injury can cause significant morbidity, yet the underlying mechanisms for this are poorly understood. The shortcomings of the current terminology that refer to non-specific symptom clusters is discussed. This update considers the need for a multi-dimensional approach for the heterogenous mechanisms driving persistent symptoms after mild traumatic brain injury. Relevant pathophysiology is discussed to make the case for mild traumatic brain injury to be conceptualized as an interface disorder spanning neurology, psychiatry and psychology. The relevance of pre-injury factors, psychological co-morbidities and their interaction with the injury to produce persistent symptoms are reviewed. The interplay with psychiatric diagnoses, functional and somatic symptom disorder presentations and the influence of the medicolegal process is considered. The judicious use and interpretation of investigations given the above complexity is discussed, with suggestions of how the explanation of the diagnostic formulation to the patient can be tailored, including insight into the above processes, to aid recovery. Moving beyond the one-dimensional concept of 'postconcussional syndrome' and reframing the cause of persistent symptoms following mild traumatic brain injury in a bio-psycho-socio-ecological model will hopefully improve understanding of the underlying contributory mechanistic interactions and facilitate treatment.
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Affiliation(s)
- Camilla N Clark
- Institute of Molecular & Clinical Sciences, St George's University of London, SW17 0RE London, UK
- UK DRI Care Research and Technology Centre, Imperial College London, W12 0BZ London, UK
- Neurology department, Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust, SW17 0QT London, UK
| | - Mark J Edwards
- Institute of Molecular & Clinical Sciences, St George's University of London, SW17 0RE London, UK
- Neurology department, Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust, SW17 0QT London, UK
| | - Bee Eng Ong
- Neurology department, Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust, SW17 0QT London, UK
| | - Luke Goodliffe
- Neurology department, Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust, SW17 0QT London, UK
| | - Hena Ahmad
- Neurology department, Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust, SW17 0QT London, UK
| | - Michael D Dilley
- Neurology department, Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust, SW17 0QT London, UK
| | - Shai Betteridge
- Neurology department, Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust, SW17 0QT London, UK
| | - Colette Griffin
- Neurology department, Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust, SW17 0QT London, UK
| | - Peter O Jenkins
- UK DRI Care Research and Technology Centre, Imperial College London, W12 0BZ London, UK
- Neurology department, Atkinson Morley Regional Neuroscience Centre, St George's University Hospitals NHS Foundation Trust, SW17 0QT London, UK
- Neurology Department, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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13
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Mark VW. Functional neurological disorder: Extending the diagnosis to other disorders, and proposing an alternate disease term—Attentionally-modifiable disorder. NeuroRehabilitation 2022; 50:179-207. [DOI: 10.3233/nre-228003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: The term “functional neurological disorder,” or “FND,” applies to disorders whose occurrence of neurological symptoms fluctuate with the patient’s attention to them. However, many other disorders that are not called “FND” nonetheless can also follow this pattern. Consequently, guidelines are unclear for diagnosing “FND.” OBJECTIVE: To review the neurological conditions that follow this pattern, but which have not so far been termed “FND,” to understand their overlap with conditions that have been termed “FND,” and to discuss the rationale for why FND has not been diagnosed for them. METHOD: A systematic review of the PubMed literature registry using the terms “fluctuation,” “inconsistency,” or “attention” did not yield much in the way of these candidate disorders. Consequently, this review instead relied on the author’s personal library of peer-reviewed studies of disorders that have resembled FND but which were not termed this way, due to his longstanding interest in this problem. Consequently, this approach was not systematic and was subjective regarding disease inclusion. RESULTS: This review identified numerous, diverse conditions that generally involve fluctuating neurological symptoms that can vary with the person’s attention to them, but which have not been called “FND.” The literature was unclear for reasons for not referring to “FND” in these instances. CONCLUSION: Most likely because of historical biases, the use of the term “FND” has been unnecessarily restricted. Because at its core FND is an attentionally-influenced disorder that can respond well to behavioral treatments, the field of neurological rehabilitation could benefit by extending the range of conditions that could be considered as “FND” and referred for similar behavioral treatments. Because the term “FND” has been viewed unfavorably by some patients and clinical practitioners and whose treatment is not implied, the alternative term attentionally-modifiable disorder is proposed.
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Affiliation(s)
- Victor W. Mark
- Department of Physical Medicine and Rehabilitation, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
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14
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Kirkwood B, Mark VW. Consistency of inclusion criteria for functional movement disorder clinical research studies: A systematic review. NeuroRehabilitation 2022; 50:169-178. [DOI: 10.3233/nre-228002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: Functional movement disorders (FMDs) are a common cause of disability. With an increasing research interest in FMD, including the emergence of intervention trials, it is crucial that research methodology be examined, and standardized protocols be developed. OBJECTIVE: To characterize the current inclusion criteria used to select patients for FMD research studies and review the consistency and appropriateness of these criteria. METHODS: We identified studies of potential biomarkers for FMD that were published over the last two decades and performed a qualitative analysis on the finally included studies. RESULTS: We identified 79 articles and found inconsistent inclusion criteria. The Fahn-Williams and DSM-IV criteria were the most commonly applied, but neither accounted for the majority (Fahn-Williams 46%, DSM-IV 32% of the total). The selection of the inclusion criteria depended in part on the phenotype of FMD under investigation. We also identified inclusion methodologies that were not appropriate, such as the inclusion of low-certainty diagnoses and diagnosing by excluding specific biomarkers rather than including patients based on clinical characteristics that commonly are thought to suggest FMD. CONCLUSIONS: Significant variability exists with the inclusion criteria for FMD research studies. This variability could limit reproducibility and the appropriate aggregation of data for meta-analysis. Advancing FMD rehabilitation research will need standardized inclusion criteria. We make some suggestions.
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Affiliation(s)
- Brian Kirkwood
- Department of Physical Medicine and Rehabilitation, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Victor W. Mark
- Department of Physical Medicine and Rehabilitation, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Psychology, University of Alabama at Birmingham, Birmingham, AL, USA
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15
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Guzman NA, Guzman DE. Immunoaffinity Capillary Electrophoresis in the Era of Proteoforms, Liquid Biopsy and Preventive Medicine: A Potential Impact in the Diagnosis and Monitoring of Disease Progression. Biomolecules 2021; 11:1443. [PMID: 34680076 PMCID: PMC8533156 DOI: 10.3390/biom11101443] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 09/22/2021] [Accepted: 09/29/2021] [Indexed: 01/08/2023] Open
Abstract
Over the years, multiple biomarkers have been used to aid in disease screening, diagnosis, prognosis, and response to therapy. As of late, protein biomarkers are gaining strength in their role for early disease diagnosis and prognosis in part due to the advancements in identification and characterization of a distinct functional pool of proteins known as proteoforms. Proteoforms are defined as all of the different molecular forms of a protein derived from a single gene caused by genetic variations, alternative spliced RNA transcripts and post-translational modifications. Monitoring the structural changes of each proteoform of a particular protein is essential to elucidate the complex molecular mechanisms that guide the course of disease. Clinical proteomics therefore holds the potential to offer further insight into disease pathology, progression, and prevention. Nevertheless, more technologically advanced diagnostic methods are needed to improve the reliability and clinical applicability of proteomics in preventive medicine. In this manuscript, we review the use of immunoaffinity capillary electrophoresis (IACE) as an emerging powerful diagnostic tool to isolate, separate, detect and characterize proteoform biomarkers obtained from liquid biopsy. IACE is an affinity capture-separation technology capable of isolating, concentrating and analyzing a wide range of biomarkers present in biological fluids. Isolation and concentration of target analytes is accomplished through binding to one or more biorecognition affinity ligands immobilized to a solid support, while separation and analysis are achieved by high-resolution capillary electrophoresis (CE) coupled to one or more detectors. IACE has the potential to generate rapid results with significant accuracy, leading to reliability and reproducibility in diagnosing and monitoring disease. Additionally, IACE has the capability of monitoring the efficacy of therapeutic agents by quantifying companion and complementary protein biomarkers. With advancements in telemedicine and artificial intelligence, the implementation of proteoform biomarker detection and analysis may significantly improve our capacity to identify medical conditions early and intervene in ways that improve health outcomes for individuals and populations.
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Affiliation(s)
| | - Daniel E. Guzman
- Princeton Biochemicals, Inc., Princeton, NJ 08543, USA;
- Division of Hospital Medicine, Department of Medicine, University of California at San Francisco, San Francisco, CA 94143, USA
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16
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Abstract
This article offers a framework in history taking for functional gastrointestinal disorders (FGIDs). Clinicians rely on history taking and knowledge of the latest 'Rome IV criteria' rather than biomarkers to make a positive diagnosis of FGIDs. Improving one's history-taking skills is imperative, as early diagnosis can improve patient outcomes by avoiding over investigation and/or chronicity.Our suggested structure for history taking adopts the bio-psycho-social model of disease. We describe the assessment of gastrointestinal symptoms with open and closed questions, the importance of ruling out 'alarm' signs or symptoms, the use of a multi-system approach to identify coexisting functional disorders and eliciting patients' nutritional history. We explore the increased psychological comorbidity present in FGIDs and the significance of the social history in identify predisposing, precipitating, perpetuating and protective factors, which will ultimately guide treatment recommendations.We believe history taking should be used to build rapport with patients while, at the same time, validating their problems and reducing stigma. Reattribution of symptoms is then achieved through education of the gut-brain axis and can be used to provide reassurance to patients at the first encounter. Success of treatment depends on engagement and acceptance of such explanations.
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17
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Onofrj M, Digiovanni A, Ajdinaj P, Russo M, Carrarini C, Di Giannantonio M, Martinotti G, Sensi SL. The factitious/malingering continuum and its burden on public health costs: a review and experience in an Italian neurology setting. Neurol Sci 2021; 42:4073-4083. [PMID: 34346017 PMCID: PMC8443469 DOI: 10.1007/s10072-021-05422-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 06/17/2021] [Indexed: 11/26/2022]
Abstract
Factitious disorder is classified as one of the five aspects of somatic symptom disorders. The fundamental element of factitious disorder is deception, i.e., pretending to have a medical or psychiatric disorder, but the enactment of deception is considered unconscious. Indeed, volition, i.e., the perception of deliberate deception, is blurred in patients presenting with factitious disorder. In the USA and the UK, factitious disorder has received constant media attention because of its forensic implications and outrageous costs for the National Health Systems. Unfortunately, a comparable level of attention is not present in Italian National Health System or the Italian mass media. The review analyzes the classifications, disorder mechanisms, costs, and medico-legal implications in the hope of raising awareness on this disturbing issue. Moreover, the review depicts 13 exemplification cases, anonymized and fictionalized by expert writers. Finally, our paper also evaluates the National Health System's expenditures for each patient, outlandish costs in the range between 50,000 and 1 million euros.
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Affiliation(s)
- Marco Onofrj
- Department of Neuroscience, Imaging, and Clinical Sciences, "G. D'Annunzio University" of Chieti-Pescara 66100, Chieti, Italy.
- Center for Advanced Studies and Technology (CAST) "G. D', Annunzio University" of Chieti-Pescara 66100, Chieti, Italy.
- YDA Foundation, Institute of Immune Therapy and Advanced biological treatment, Pescara, Italy.
| | - Anna Digiovanni
- Department of Neuroscience, Imaging, and Clinical Sciences, "G. D'Annunzio University" of Chieti-Pescara 66100, Chieti, Italy
| | - Paola Ajdinaj
- Department of Neuroscience, Imaging, and Clinical Sciences, "G. D'Annunzio University" of Chieti-Pescara 66100, Chieti, Italy
| | - Mirella Russo
- Department of Neuroscience, Imaging, and Clinical Sciences, "G. D'Annunzio University" of Chieti-Pescara 66100, Chieti, Italy
- Center for Advanced Studies and Technology (CAST) "G. D', Annunzio University" of Chieti-Pescara 66100, Chieti, Italy
| | - Claudia Carrarini
- Department of Neuroscience, Imaging, and Clinical Sciences, "G. D'Annunzio University" of Chieti-Pescara 66100, Chieti, Italy
| | - Massimo Di Giannantonio
- Department of Neuroscience, Imaging, and Clinical Sciences, "G. D'Annunzio University" of Chieti-Pescara 66100, Chieti, Italy
| | - Giovanni Martinotti
- Department of Neuroscience, Imaging, and Clinical Sciences, "G. D'Annunzio University" of Chieti-Pescara 66100, Chieti, Italy
- Department of Clinical, Pharmaceutical and Biological Sciences, University of Hertfordshire, Herts, UK
| | - Stefano L Sensi
- Department of Neuroscience, Imaging, and Clinical Sciences, "G. D'Annunzio University" of Chieti-Pescara 66100, Chieti, Italy
- Center for Advanced Studies and Technology (CAST) "G. D', Annunzio University" of Chieti-Pescara 66100, Chieti, Italy
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18
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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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19
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Koh PX, Ti J, Saffari SE, Lim ZYIC, Tu T. Hemisensory syndrome: Hyperacute symptom onset and age differentiates ischemic stroke from other aetiologies. BMC Neurol 2021; 21:179. [PMID: 33906637 PMCID: PMC8077773 DOI: 10.1186/s12883-021-02206-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 04/20/2021] [Indexed: 11/13/2022] Open
Abstract
Background An important cause of hemisensory syndrome is ischemic stroke. However, the diagnostic yield of neuroradiological imaging on hemisensory syndrome is low. Therefore, we aim to describe patients hospitalized with isolated hemisensory syndrome, and to identify clinical features associated with an aetiology of ischemic stroke. Methods We performed a single centre retrospective observation study, identifying patients who were hospitalised with hemisensory syndrome from October 2015 to March 2016, and whom underwent a magnetic resonance imaging (MRI) brain during the admission. Ischemic stroke was defined as the presence of restricted diffusion-weighted image on the MRI brain. Clinical information was analysed and compared between patients with and without stroke seen on MRI brain. Results 79 patients, 36 (45.6%) males and 43 (54.4%) females, aged between 30 to 87 years (mean 54), were included in the final analysis. 18 (22.8%) patients were identified to have an acute ischemic stroke. Clinical features associated with ischemic stroke in hospitalised patients with hemisensory syndrome include symptom onset of ≤24 h at presentation (odds ratio 31.4, 95% CI 3.89–254.4), advanced age (odds ratio 1.14, CI 1.05–1.25) and smoking (odds ratio 7.35, 95% CI 1.20–45). Conclusion Older patients, with a history of smoking, and who present with an acute onset of symptoms, are more likely to have ischemic stroke as the cause of their hemisensory syndrome. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-021-02206-8.
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Affiliation(s)
- Pei Xuan Koh
- National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.
| | - Joanna Ti
- National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore
| | - Seyed Ehsan Saffari
- Duke-National University of Singapore (NUS) Medical School, Singapore, Singapore
| | | | - Tianming Tu
- National Neuroscience Institute, 11 Jalan Tan Tock Seng, Singapore, 308433, Singapore.,Duke-National University of Singapore (NUS) Medical School, Singapore, Singapore
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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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Barnett C, Mitchell C, Tyson S. The management of patients with functional stroke: speech and language therapists’ views and experiences. Disabil Rehabil 2021; 44:3547-3558. [DOI: 10.1080/09638288.2020.1867910] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Caroline Barnett
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Claire Mitchell
- Division of Human Communication, Development & Hearing, University of Manchester, Manchester, UK
| | - Sarah Tyson
- Division of Nursing, Midwifery & Social Work, University of Manchester, Manchester, UK
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22
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Hassa T, Spiteri S, Schmidt R, Merkel C, Schoenfeld MA. Increased Amygdala Activity Associated With Cognitive Reappraisal Strategy in Functional Neurologic Disorder. Front Psychiatry 2021; 12:613156. [PMID: 33841199 PMCID: PMC8032865 DOI: 10.3389/fpsyt.2021.613156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 02/18/2021] [Indexed: 01/12/2023] Open
Abstract
Cognitive reappraisal is an emotion regulation strategy to reduce the impact of affective stimuli. This regulation could be incomplete in patients with functional neurologic disorder (FND) resulting in an overflowing emotional stimulation perpetuating symptoms in FND patients. Here we employed functional MRI to study cognitive reappraisal in FND. A total of 24 FND patients and 24 healthy controls employed cognitive reappraisal while seeing emotional visual stimuli in the scanner. The Symptom Checklist-90-R (SCL-90-R) was used to evaluate concomitant psychopathologies of the patients. During cognitive reappraisal of negative IAPS images FND patients show an increased activation of the right amygdala compared to normal controls. We found no evidence of downregulation in the amygdala during reappraisal neither in the patients nor in the control group. The valence and arousal ratings of the IAPS images were similar across groups. However, a subgroup of patients showed a significant higher account of extreme low ratings for arousal for negative images. These low ratings correlated inversely with the item "anxiety" of the SCL-90-R. The increased activation of the amygdala during cognitive reappraisal suggests altered processing of emotional stimuli in this region in FND patients.
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Affiliation(s)
- Thomas Hassa
- Lurija Institute for Rehabilitation and Health Sciences, University of Konstanz, Konstanz, Germany.,Neurological Rehabilitation Center Kliniken Schmieder, Allensbach, Germany
| | - Stefan Spiteri
- Lurija Institute for Rehabilitation and Health Sciences, University of Konstanz, Konstanz, Germany.,Neurological Rehabilitation Center Kliniken Schmieder, Allensbach, Germany
| | - Roger Schmidt
- Department of Psychology, University of Konstanz, Konstanz, Germany.,Department of Psychotherapeutic Neurology, Neurological Rehabilitation Center Kliniken Schmieder, Konstanz, Germany
| | - Christian Merkel
- Department of Neurology, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Mircea Ariel Schoenfeld
- Department of Neurology, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany.,Leibniz-Institute for Neurobiology, Magdeburg, Germany.,Neurological Rehabilitation Center Kliniken Schmieder, Heidelberg, Germany
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23
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Jones A, O'Connell N, David AS, Chalder T. Functional Stroke Symptoms: A Narrative Review and Conceptual Model. J Neuropsychiatry Clin Neurosci 2020; 32:14-23. [PMID: 31726918 DOI: 10.1176/appi.neuropsych.19030075] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Stroke services have been reconfigured in recent years to facilitate early intervention. Throughout stroke settings, some patients present with functional symptoms that cannot be attributed to a structural cause. Emphasis on fast diagnosis and treatment means that a proportion of patients entering the care pathway present with functional symptoms that mimic stroke or have functional symptoms in addition to vascular stroke. There is limited understanding of mechanisms underlying functional stroke symptoms, how the treatment of such patients should be managed, and no referral pathway or treatment. Predisposing factors vary between individuals, and symptoms are heterogeneous: onset can be acute or insidious, and duration can be short-lived or chronic in the context of new or recurrent illness cognitions and behaviors. This article proposes a conceptual model of functional symptoms identified in stroke services and some hypotheses based on a narrative review of the functional neurological disorder literature. Predisposing factors may include illness experiences, stressors, and chronic autonomic nervous system arousal. Following the onset of distressing symptoms, perpetuating factors may include implicit cognitive processes, classical and operant conditioning, illness beliefs, and behavioral responses, which could form the basis of treatment targets. The proposed model will inform the development of theory-based interventions as well as a functional stroke care pathway.
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Affiliation(s)
- Abbeygail Jones
- The Department of Psychological Medicine, King's College London (Jones, Chalder); the Institute of Population Health, Trinity College Dublin (O'Connell); and the Institute of Mental Health, University College London (David)
| | - Nicola O'Connell
- The Department of Psychological Medicine, King's College London (Jones, Chalder); the Institute of Population Health, Trinity College Dublin (O'Connell); and the Institute of Mental Health, University College London (David)
| | - Anthony S David
- The Department of Psychological Medicine, King's College London (Jones, Chalder); the Institute of Population Health, Trinity College Dublin (O'Connell); and the Institute of Mental Health, University College London (David)
| | - Trudie Chalder
- The Department of Psychological Medicine, King's College London (Jones, Chalder); the Institute of Population Health, Trinity College Dublin (O'Connell); and the Institute of Mental Health, University College London (David)
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24
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Functional neurological disorders miming a stroke: management in the acute phase. Clin Neurol Neurosurg 2020; 196:105840. [DOI: 10.1016/j.clineuro.2020.105840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 03/31/2020] [Accepted: 04/06/2020] [Indexed: 11/18/2022]
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25
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Functional Neurological Symptom Disorder in Children and Adolescents within Medical Settings. J Clin Psychol Med Settings 2020; 28:90-101. [DOI: 10.1007/s10880-020-09736-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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26
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O'Connell N, Jones A, Chalder T, David AS. Experiences and Illness Perceptions of Patients with Functional Symptoms Admitted to Hyperacute Stroke Wards: A Mixed-Method Study. Neuropsychiatr Dis Treat 2020; 16:1795-1805. [PMID: 32801714 PMCID: PMC7399446 DOI: 10.2147/ndt.s251328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 07/07/2020] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Nicola O'Connell
- Department of Public Health and Primary Care, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Abbeygail Jones
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Trudie Chalder
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Anthony S David
- UCL Institute of Mental Health, University College London, London, UK
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27
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Chin J, Kviatkovsky B, Lomiguen C. Osteopathic Considerations for Peripheral Neuropathy Due to Concomitant Diffuse Idiopathic Skeletal Hyperostosis Syndrome and Lumbar Epidural Lipomatosis: Case Report. Interact J Med Res 2019; 8:e14607. [PMID: 31746769 PMCID: PMC6914272 DOI: 10.2196/14607] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 06/16/2019] [Accepted: 08/30/2019] [Indexed: 12/12/2022] Open
Abstract
Background Diffuse idiopathic skeletal hyperostosis (DISH) syndrome and lumbar epidural lipomatosis are relatively asymptomatic neurological conditions, with findings often seen incidentally on radiological studies. Objective The aim of this paper is to present unique findings of concomitant, symptomatic DISH syndrome and lumbar epidural lipomatosis and to discuss the osteopathic diagnosis and treatment implications. Methods Concomitant, symptomatic variants are rare and present challenges to treatment and management, as seen with a 60-year-old African American woman who presented with worsening disequilibrium and new-onset bilateral fingertip numbness. Past medical history was significant for alcohol abuse disorder, hypertension, hyperlipidemia, and multiple episodes of self-resolving vertigo and lower extremity neuropathy. Results The patient was referred to the neurology department for stroke workup, which was negative. Osteopathic structural exam revealed thoracolumbar and sacral dysfunctions. Magnetic resonance imaging revealed findings consistent with thoracic DISH syndrome and lumbar epidural lipomatosis in the areas of somatic dysfunctions. Conclusions Due to minimal information on osteopathic manipulative treatment in rare neurological diseases, only gentle techniques of myofascial release, balanced ligamentous tension, and muscle energy were performed with resultant minimal improvement, thus highlighting the necessity for better guidelines and further research.
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Affiliation(s)
- Justin Chin
- Touro College of Osteopathic Medicine, New York, NY, United States
| | - Bina Kviatkovsky
- Staten Island University Hospital, Northwell Health, Staten Island, NY, United States
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Diagnosis of Conversion Disorder Using Diffusion Tensor Tractography and Transcranial Magnetic Stimulation in a Patient with Mild Traumatic Brain Injury. Diagnostics (Basel) 2019; 9:diagnostics9040155. [PMID: 31652549 PMCID: PMC6963761 DOI: 10.3390/diagnostics9040155] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2019] [Revised: 10/16/2019] [Accepted: 10/17/2019] [Indexed: 11/17/2022] Open
Abstract
We report on a patient with mild traumatic brain injury (TBI) who was diagnosed with conversion disorder for severe weakness of an arm, which was demonstrated using diffusion tensor tractography (DTT) and transcranial magnetic stimulation (TMS). A 23-year-old right-handed female suffered from head trauma resulting from a pedestrian car accident. She underwent rehabilitative management for memory impairment and central pain. At 14 months after onset, she complained of severe weakness of her right arm, which was detected in the morning after sleeping (right shoulder abductor: 3/5, elbow flexor: 3/5, wrist extensor: 1/5, finger flexor: 1/5, and finger extensor: 1/5). Electromyography study for peripheral neuropathy performed at 2 weeks after onset of weakness showed no abnormality. On a 14-month DTT configuration, the integrities of the left corticospinal tract (CST), supplementary motor area-corticofugal tract (SMA-CFT), and dorsal premotor cortex (dPMC)-CFT were well-preserved. Significant differences were not observed for the fractional anisotropy (FA), mean diffusivity (MD), and tract volume (TV) values of the CST, SMA-CFT, and dPMC-CFT in both hemispheres between the patient and ten right-handed age- and sex-matched normal subjects (p > 0.05). On a 14-month TMS study, MEPs obtained at the right abductor pollicis brevis muscle showed no abnormality. Using DTT and TMS, conversion disorder was demonstrated in a patient with mild TBI, who showed severe weakness of an arm. Our results suggest the usefulness of an evaluation of the CST and CFTs from the secondary motor areas using DTT, and the CST using TMS for patients who complain of motor weakness due to conversion disorder.
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Jones AT, O'Connell NK, David AS. Epidemiology of functional stroke mimic patients: a systematic review and meta‐analysis. Eur J Neurol 2019; 27:18-26. [DOI: 10.1111/ene.14069] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 08/21/2019] [Indexed: 11/30/2022]
Affiliation(s)
- A. T. Jones
- Institute of Psychiatry, Psychology and Neuroscience King's College London London UK
| | - N. K. O'Connell
- Department of Public Health and Primary Care Institute of Population Health Trinity College Dublin Dublin Ireland
| | - A. S. David
- Institute of Mental Health University College London London UK
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Sojka P, Lošák J, Lamoš M, Bareš M, Kašpárek T, Brázdil M, Baláž M, Světlák M, Kočvarová J, Fialová J. Processing of Emotions in Functional Movement Disorder: An Exploratory fMRI Study. Front Neurol 2019; 10:861. [PMID: 31474926 PMCID: PMC6703143 DOI: 10.3389/fneur.2019.00861] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 07/25/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Affective dysregulation and impaired cognitive control are implicated in the pathology of functional neurological disorders (FNDs). However, voluntary regulation of emotions has seldom been researched in this group of patients. We hypothesized that patients with FNDs use inefficient voluntary emotion regulation strategies and regulate emotional reactions via increased motor activation. Methods: Fifteen patients with functional movement disorder (FMD) and fifteen healthy subjects matched by age, sex, and education underwent an emotion regulation task in fMRI. For stimuli, we used neutral and negative pictures from the International Affective Picture System. There was no restriction on their emotion regulation strategy. Both patients and healthy subjects were asked about the strategies they had used in a post-scanning interview. Participant levels of depression, trait anxiety, and alexithymia were assessed. Results: There were no significant differences in the emotion regulation strategies used by patients and healthy subjects, nor in levels of reported alexithymia and depression. However, patients showed increased activation in several brain areas when observing negative pictures, notably in the post-central gyrus, precuneus, posterior cingulate cortex (PCC) and cerebellar vermis, and also in their emotion regulation condition, particularly in the precuneus and post-central gyrus. Alexithymia was negatively associated with left insular activation during the observation of unpleasant stimuli only in the patient group. Conclusions: Our findings may implicate areas associated with self-referential processing in voluntary emotional regulation and lower emotional awareness as having a role in patients with functional movement disorders. However, our findings must be replicated with larger sample.
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Affiliation(s)
- Petr Sojka
- Department of Neurology, Faculty of Medicine, Masaryk University and St. Anne's University Hospital Brno, Brno, Czechia.,Department of Psychology and Psychosomatics, Faculty of Medicine, Masaryk University and University Hospital Brno, Brno, Czechia
| | - Jan Lošák
- Department of Psychology and Psychosomatics, Faculty of Medicine, Masaryk University and University Hospital Brno, Brno, Czechia.,Department of Psychiatry, Faculty of Medicine, Masaryk University and University Hospital Brno, Brno, Czechia
| | - Martin Lamoš
- Multimodal and Functional Neuroimaging, CEITEC, Masaryk University, Brno, Czechia
| | - Martin Bareš
- Department of Neurology, Faculty of Medicine, Masaryk University and St. Anne's University Hospital Brno, Brno, Czechia.,Department of Psychiatry, Faculty of Medicine, Masaryk University and University Hospital Brno, Brno, Czechia
| | - Tomáš Kašpárek
- Department of Psychiatry, Faculty of Medicine, Masaryk University and University Hospital Brno, Brno, Czechia
| | - M Brázdil
- Department of Neurology, Faculty of Medicine, Masaryk University and St. Anne's University Hospital Brno, Brno, Czechia
| | - M Baláž
- Department of Neurology, Faculty of Medicine, Masaryk University and St. Anne's University Hospital Brno, Brno, Czechia
| | - Miroslav Světlák
- Department of Psychology and Psychosomatics, Faculty of Medicine, Masaryk University and University Hospital Brno, Brno, Czechia
| | - J Kočvarová
- Department of Neurology, Faculty of Medicine, Masaryk University and St. Anne's University Hospital Brno, Brno, Czechia
| | - J Fialová
- Department of Public Health, Faculty of Medicine, Masaryk University, Brno, Czechia
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Araújo R, van de Warrenburg B, Lang A, Lees A, Bloem B. The Waiting Room: neurological observations made outside the movement disorder specialist's consulting office. Pract Neurol 2019; 19:295-301. [PMID: 30872358 DOI: 10.1136/practneurol-2018-002110] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 01/07/2019] [Accepted: 01/28/2019] [Indexed: 11/04/2022]
Abstract
The neurological examination should always begin before the patient enters the doctor's office. Movement disorders in particular lend themselves to a spot diagnosis. In today's busy buzzing world, it seems wasteful not to make use of the various diagnostic clues that can be picked up readily while the patient is still in the waiting room. We present several illustrative examples, drawn from the literature and from our own experience. These are divided according to the different waiting room 'stages': the patient sitting in the waiting room, the response on being summoned to enter the consulting room-including rising from the chair, exchanging initial pleasantries and the way of walking. We also discuss the importance of paying attention to the patient's behaviour, clothing, posture, breathing patterns, facial expression and major gait abnormalities.
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Affiliation(s)
- Rui Araújo
- Neurology, Centro Hospitalar e Universitario de Coimbra EPE, Coimbra, Portugal
| | | | - Anthony Lang
- Morton and Gloria Shulman Movement Disorders Clinic and the Edmond J Safra Program in Parkinson's Disease, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Andrew Lees
- Reta Lila Weston Institute of Neurological Studies, University College London, London, UK
| | - Bastiaan Bloem
- Neurology, Radboud University Medical Centre, Nijmegen, The Netherlands
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Bezerra DM, Bezerra EM, Junior AJS, Amorim MAS, Miranda DBD. Postoperative visual loss due to conversion disorder after spine surgery: a case report. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2018. [PMID: 26804714 PMCID: PMC9391679 DOI: 10.1016/j.bjane.2015.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Background and objective Case report Conclusions
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First episode of consciousness loss: setting new standards in acute care management. ROMANIAN NEUROSURGERY 2017. [DOI: 10.1515/romneu-2017-0073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
There is a high prevalence of patients addressed to the emergency department presenting a first episode of consciousness loss. The high prevalence of patients admitted to the emergency departments (ED) with a first episode of consciousness loss (ECL) is well established. Although there are studies assessing acute management in these patients, there is still need for more data on clinical and paraclinical characteristics which may prompt early etiological diagnosis, especially in countries where integrated medical procedures are lacking and access to specialized medical care is still limited. Sudden death syndrome, early cerebral morphological changes emerging in chronic epilepsy is the main motivation for an early diagnosis of epilepsy. The aim of our study was to evaluate demographic, clinical and paraclinical data in adult patients referred to our emergency hospital presenting a first episode of consciousness loss, in order to avoid misdiagnosis (with personal and social high impact) and unnecessary anti-epileptic treatment versus underestimation of epilepsy diagnosis. Conclusion: There is a clear need to improve multidisciplinary circuits in patients with a first episode of consciousness loss at a local level, in order to promote accurate and prompt diagnosis. We consider necessary to build a unitary online platform in order to establish an early and complete diagnosis.
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Abstract
Functional somatic syndrome (FSS) occurs in as many as 30% of patients in general medical practice, but it is infrequently a topic of formal instruction. Many physicians feel uncomfortable with medically unexplained symptoms and are unfamiliar with how to assess or manage them. Traditional medical approaches can be ineffective and can contribute to iatrogenic or adverse physiologic effects in patients. Physicians treating patients with FSS should not only consider standard medical tests, but they should also try to gain a deeper behavioral understanding of the mind-body connections that underlie the presenting symptoms. Osteopathic physicians, with their emphasis on holistic patient care, are in a key position to treat patients with FSS. This review provides a brief recapitulation of the literature and illustrates key factors in the assessment and management of FSS.
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Bryson A, Carter O, Norman T, Kanaan R. 5-HT2A Agonists: A Novel Therapy for Functional Neurological Disorders? Int J Neuropsychopharmacol 2017; 20:422-427. [PMID: 28177082 PMCID: PMC5417053 DOI: 10.1093/ijnp/pyx011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 02/06/2017] [Indexed: 11/13/2022] Open
Abstract
Functional neurological disorders are frequently encountered in clinical practice. They have a poor prognosis and treatment options are limited. Their etiology is unknown, but leading theories propose a disturbance of somatic self-representation: the mind perceives dysfunction of a body region despite intact motor and sensory pathways. Central to this model is the concept of an abnormal top-down cognitive influence upon sensorimotor function. There is growing interest in the use of 5-HT2A agonists in the management of neuropsychiatric conditions. Recent studies have shown that these agents induce changes in neural activity that disrupt hierarchical brain dynamics and modulate networks subserving self-related processing. Converging evidence suggests they may hold unique therapeutic potential in functional neurological disorders. This is of importance given the considerable personal and societal burden of this condition and we argue a clinical trial to test this hypothesis is warranted.
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Affiliation(s)
- Alexander Bryson
- Howard Florey Institute of Neuroscience & Mental Health, University of Melbourne, Australia (Dr Bryson); Department of Neurology, Austin Hospital, Melbourne, Australia (Dr Bryson); Melbourne School of Psychological Sciences, University of Melbourne, Australia (Dr Carter); Department of Psychiatry, Austin Hospital, Melbourne, Australia (Drs Norman and Kanaan); Department of Psychiatry, University of Melbourne, Australia (Drs Norman and Kanaan)
| | - Olivia Carter
- Howard Florey Institute of Neuroscience & Mental Health, University of Melbourne, Australia (Dr Bryson); Department of Neurology, Austin Hospital, Melbourne, Australia (Dr Bryson); Melbourne School of Psychological Sciences, University of Melbourne, Australia (Dr Carter); Department of Psychiatry, Austin Hospital, Melbourne, Australia (Drs Norman and Kanaan); Department of Psychiatry, University of Melbourne, Australia (Drs Norman and Kanaan)
| | - Trevor Norman
- Howard Florey Institute of Neuroscience & Mental Health, University of Melbourne, Australia (Dr Bryson); Department of Neurology, Austin Hospital, Melbourne, Australia (Dr Bryson); Melbourne School of Psychological Sciences, University of Melbourne, Australia (Dr Carter); Department of Psychiatry, Austin Hospital, Melbourne, Australia (Drs Norman and Kanaan); Department of Psychiatry, University of Melbourne, Australia (Drs Norman and Kanaan)
| | - Richard Kanaan
- Howard Florey Institute of Neuroscience & Mental Health, University of Melbourne, Australia (Dr Bryson); Department of Neurology, Austin Hospital, Melbourne, Australia (Dr Bryson); Melbourne School of Psychological Sciences, University of Melbourne, Australia (Dr Carter); Department of Psychiatry, Austin Hospital, Melbourne, Australia (Drs Norman and Kanaan); Department of Psychiatry, University of Melbourne, Australia (Drs Norman and Kanaan)
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Yate ZM. A Qualitative Study on Negative Emotions Triggered by Breastfeeding; Describing the Phenomenon of Breastfeeding/Nursing Aversion and Agitation in Breastfeeding Mothers. IRANIAN JOURNAL OF NURSING AND MIDWIFERY RESEARCH 2017; 22:449-454. [PMID: 29184583 PMCID: PMC5684792 DOI: 10.4103/ijnmr.ijnmr_235_16] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background: Breastfeeding aversion and agitation (BAA) while breastfeeding is anecdotally known to occur in some women who breastfeed while pregnant or those who tandem feed a newborn and a toddler. However, it is a little-researched area and the paucity of published literature around BAA reveals a significant gap in the literature. Materials and Methods: This study presents the findings and responses of 694 women who filled in an anonymous survey questionnaire that collected data on their basic demographics and their experiences with breastfeeding. It uses thematic and inductive content analysis, with qualitative interpretive description to present the findings. Results: The findings of this study shed light on an experienced phenomenon of aversion and agitation whilst breastfeeding, which varies in form, severity, and duration. It is characterised by feelings of anger or rage, a skin crawling sensation and an urge to remove the suckling infant, but can also be feelings of agitation and irritability whilst the infant is latched. A number of mothers who experience aversion still continue to breastfeed, but have feelings of guilt and shame while also experiencing confusion around those feelings. Conclusions: BAA is a phenomenon that occurs in some women who breastfeed, whereby breastfeeding triggers negative emotions. The reason women experience it is not clearly known. Research is needed to understand its cause, triggers, and strategies to minimise the experience in breastfeeding mothers.
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Affiliation(s)
- Zainab M Yate
- Independent Researcher and Vice Chair of the London-Brent Health Research Authority Research Ethics Committee, London, UK
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37
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Demonstration of Injury of the Corticospinal Tract in a Patient with Suspected Motor Conversion Disorder. Am J Phys Med Rehabil 2016; 96:e53-e54. [PMID: 27386816 DOI: 10.1097/phm.0000000000000576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Hassa T, de Jel E, Tuescher O, Schmidt R, Schoenfeld MA. Functional networks of motor inhibition in conversion disorder patients and feigning subjects. NEUROIMAGE-CLINICAL 2016; 11:719-727. [PMID: 27330971 PMCID: PMC4900693 DOI: 10.1016/j.nicl.2016.05.009] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Revised: 04/24/2016] [Accepted: 05/16/2016] [Indexed: 11/24/2022]
Abstract
The neural correlates of motor inhibition leading to paresis in conversion disorder are not well known. The key question is whether they are different of those of normal subjects feigning the symptoms. Thirteen conversion disorder patients with hemiparesis and twelve healthy controls were investigated using functional magnetic resonance tomography under conditions of passive motor stimulation of the paretic/feigned paretic and the non-paretic hand. Healthy controls were also investigated in a non-feigning condition. During passive movement of the affected right hand conversion disorder patients exhibited activations in the bilateral triangular part of the inferior frontal gyri (IFG), with a left side dominance compared to controls in non-feigning condition. Feigning controls revealed for the same condition a weak unilateral activation in the right triangular part of IFG and an activity decrease in frontal midline areas, which couldn't be observed in patients. The results suggest that motor inhibition in conversion disorder patients is mediated by the IFG that was also involved in inhibition processes in normal subjects. The activity pattern in feigning controls resembled that of conversion disorder patients but with a clear difference in the medial prefrontal cortex. Healthy controls showed decreased activity in this region during feigning compared to non-feigning conditions suggesting a reduced sense of self-agency during feigning. Remarkably, no activity differences could be observed in medial prefrontal cortex for patients vs healthy controls in feigning or non-feigning conditions suggesting self-agency related activity in patients to be in between those of non-feigning and feigning healthy subjects.
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Affiliation(s)
- Thomas Hassa
- Lurija Institute for Rehabilitation and Health Sciences, Allensbach, Germany; Neurological Rehabilitation Center Kliniken Schmieder, Allensbach, Germany.
| | - Esther de Jel
- Department of Psychology, University of Konstanz, Germany
| | - Oliver Tuescher
- Department of Psychiatry and Psychotherapy, University Medical Center of the Johannes Gutenberg University Mainz, Germany
| | - Roger Schmidt
- Department of Psychology, University of Konstanz, Germany; Department of Psychotherapeutic Neurology, Neurological Rehabilitation Center Kliniken Schmieder, Konstanz and Gailingen, Germany
| | - Mircea Ariel Schoenfeld
- Neurological Rehabilitation Center Kliniken Schmieder, Allensbach, Germany; Department of Neurology, Otto-von-Guericke-University Magdeburg, Germany; Leibniz-Institute for Neurobiology, Magdeburg, Germany
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Régny P, Cathébras P. [Conversion disorder in an internal medicine department: A series of 37 cases]. Encephale 2016; 42:150-5. [PMID: 26827119 DOI: 10.1016/j.encep.2014.11.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 11/24/2014] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To describe the clinical characteristics of a series of patients presenting conversion disorder in a general internal medicine ward and outpatient clinic, the arguments retained by the physicians in favour of the diagnosis, the somatic and psychiatric co-morbidities, the management and the outcome of the disorder. METHODS We report the study of 37 patients diagnosed with conversion disorder in an internal medicine department of a French university hospital over a period of 14 years. We retrospectively reviewed the charts of the patients and contacted their primary care physicians to obtain follow-up data. No structured instrument was used for the diagnosis of conversion disorder or for the assessment of psychiatric comorbidities. RESULTS As expected, patients were mostly young females, although a great variety of age, gender, and socio-cultural background was observed. Motor symptoms predominated (62%). A relevant psychogenic factor was explicitly mentioned in only 43% of the cases. In many cases, organic disease was also present, and an organic cause for the symptom initially considered as conversion was suspected in 3 cases. Depressive and anxious disorders were present respectively in 38% and 35% of cases. A pain complaint was associated in half of the cases. Among patients for whom follow-up data is available, conversion symptoms persisted or recurred in 70% of cases and were associated with a poor quality of life. CONCLUSION This case series confirms that the DSM-IV-TR criterion of "psychogenicity" (later abandoned in DSM-5) is highly problematic in clinical practice. It suggests a close relationship between conversion disorder and unexplained chronic pain.
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Affiliation(s)
- P Régny
- Service de médecine interne, hôpital Nord, CHU de Saint-Étienne, 42055 Saint-Étienne cedex 2, France
| | - P Cathébras
- Service de médecine interne, hôpital Nord, CHU de Saint-Étienne, 42055 Saint-Étienne cedex 2, France.
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Bezerra DM, Bezerra EM, Silva Junior AJ, Amorim MAS, Miranda DBD. [Postoperative visual loss due to conversion disorder after spine surgery: a case report]. Rev Bras Anestesiol 2016; 68:91-95. [PMID: 26804714 DOI: 10.1016/j.bjan.2015.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Accepted: 03/03/2015] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Patients undergoing spinal surgeries may develop postoperative visual loss. We present a case of total bilateral visual loss in a patient who, despite having clinical and surgical risk factors for organic lesion, evolved with visual disturbance due to conversion disorder. CASE REPORT A male patient, 39 years old, 71kg, 1.72 m, ASA I, admitted to undergo fusion and discectomy at L4-L5 and L5-S1. Venoclysis, cardioscopy, oximetry, NIBP; induction with remifentanil, propofol and rocuronium; intubation with ETT (8.0mm) followed by capnography and urinary catheterization for diuresis. Maintenance with full target-controlled intravenous anesthesia. During fixation and laminectomy, the patient developed severe bleeding and hypovolemic shock. After 30minutes, hemostasis and hemodynamic stability was achieved with infusion of norepinephrine, volume expansion, and blood products. In the ICU, the patient developed mental confusion, weakness in the limbs, and bilateral visual loss. It was not possible to identify clinical, laboratory or image findings of organic lesion. He evolved with episodes of anxiety, emotional lability, and language impairment; the hypothesis of conversion syndrome with visual component was raised after psychiatric evaluation. The patient had complete resolution of symptoms after visual education and introduction of low doses of antipsychotic, antidepressant, and benzodiazepine. Other symptoms also regressed, and the patient was discharged 12 days after surgery. After 60 days, the patient had no more symptoms. CONCLUSIONS Conversion disorders may have different signs and symptoms of non-organic origin, including visual component. It is noteworthy that the occurrence of this type of visual dysfunction in the postoperative period of spinal surgery is a rare event and should be remembered as a differential diagnosis.
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Affiliation(s)
- Dailson Mamede Bezerra
- Centro de Ensino e Treinamento Dr. José Quinan, Goiânia, GO, Brasil; Defesa Profissional da Sociedade de Anestesiologia do Estado de Goiás (2015/2016), Goiânia, GO, Brasil; Universidade Estadual Paulista Júlio de Mesquita Filho (FMB/Unesp), Faculdade de Medicina, Botucatu, SP, Brasil.
| | | | | | | | - Denismar Borges de Miranda
- Pontifícia Universidade Católica de Goiás (PUC/GO), Goiânia, GO, Brasil; Universidade Federal de Goiás (UFG), Goiânia, GO, Brasil
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Carson A, Ludwig L, Welch K. Psychologic theories in functional neurologic disorders. HANDBOOK OF CLINICAL NEUROLOGY 2016; 139:105-120. [PMID: 27719831 DOI: 10.1016/b978-0-12-801772-2.00010-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
In this chapter we review key psychologic theories that have been mooted as possible explanations for the etiology of functional neurologic symptoms, conversion disorder, and hysteria. We cover Freudian psychoanalysis and later object relations and attachment theories, social theories, illness behavior, classic and operant conditioning, social learning theory, self-regulation theory, cognitive-behavioral theories, and mindfulness. Dissociation and modern cognitive neuroscience theories are covered in other chapters in this series and, although of central importance, are omitted from this chapter. Our aim is an overview with the emphasis on breadth of coverage rather than depth.
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Affiliation(s)
- A Carson
- Departments of Clinical Neurosciences and of Rehabilitation Medicine, NHS Lothian and Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK.
| | - L Ludwig
- Departments of Clinical Neurosciences and of Rehabilitation Medicine, NHS Lothian and Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - K Welch
- Departments of Clinical Neurosciences and of Rehabilitation Medicine, NHS Lothian and Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
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Emotion regulation and functional neurological symptoms: Does emotion processing convert into sensorimotor activity? J Psychosom Res 2015; 79:477-83. [PMID: 26652591 DOI: 10.1016/j.jpsychores.2015.10.009] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Revised: 10/12/2015] [Accepted: 10/25/2015] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Functional neurological symptoms (FNS) are hypothetically explained as a shift of emotion processing to sensorimotor deficits, but psychophysiological evidence supporting this hypothesis is scarce. The present study measured neuromagnetic and somatic sensation during emotion regulation to examine frontocortical and sensorimotor activity as signals of altered emotion processing. METHODS Magnetoencephalographic (MEG) activity was mapped during an emotion regulation task in 20 patients with FNS and 20 healthy comparison participants (HC). Participants were instructed to (A) passively watch unpleasant or neutral pictures or (B) down-regulate their emotional response to unpleasant pictures utilizing cognitive reappraisal strategies. Group- and task-specific cortical activity was evaluated via 8-12 Hz (alpha) power modulation, while modulation of somatic sensation was measured via perception and discomfort thresholds of transcutaneous electrical nerve stimulation. RESULTS Implementing emotion regulation strategies induced frontocortical alpha power modulation in HC but not in patients, who showed prominent activity modulation in sensorimotor regions. Compared to HC, discomfort threshold for transcutaneous stimulation decreased after the task in patients, who also expressed increased symptom intensity. CONCLUSIONS Reduced frontocortical, but enhanced sensorimotor involvement in emotion regulation efforts offers a trace to modeling a conversion of (aversive) feelings into (aversive) somatic sensations in FNS.
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Gana K, Saada Y, Broc G, Quintard B, Amieva H, Dartigues JF. As long as you've got your health: Longitudinal relationships between positive affect and functional health in old age. Soc Sci Med 2015; 150:231-8. [PMID: 26774710 DOI: 10.1016/j.socscimed.2015.11.038] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Revised: 11/23/2015] [Accepted: 11/24/2015] [Indexed: 01/07/2023]
Abstract
OBJECTIVE Reciprocal relationships between positive affect (PA) and health are now subject of a heuristic debate in psychology and behavioral medicine. Two radically opposed approaches address the link between subjective well being (SWB) and physical health: top-down (i.e., psychosomatic hypothesis) and bottom-up (i.e., disability/ability hypothesis) approaches. The aim of the present study was to test these two approaches by investigating thirteen-year longitudinal relationships between PA, as an affective dimension of SWB, and functional health in older people. METHODS The study included 3754 participants aged 62-101 years assessed 6 times over a thirteen-year period. PA was measured by the mean of the positive affect subscale of the CES-D scale. Functional health was assessed by four composite items: a single-item self-rating of hearing impairment, a single-item self-rating of vision impairment, the number of medically prescribed drugs, and a single-item self-rating of dyspnoea. We used cross-lagged modeling with latent variables, which is appropriate for testing specific theories. Mean arterial pressure, diabetes mellitus and hypercholesterolemia status, sequelae of stroke, gender, level of education, and age at baseline were use as control variables in the models. RESULTS Results indicated that good health significantly predicted subsequent levels of PA (average β = -0.58, p < 0.001), but PA did not predict subsequent levels of good health (β = 0.01, ns). CONCLUSION This finding, obtained from a sample of older people, is in keeping with the bottom-up approach, and supports the popular adage "As long as you've got your health". Limitations of this finding are reviewed and discussed. Models including longitudinal mediators, such as biomarkers and life style patterns, are needed to clarify the nature of the link between these constructs.
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Al Saif A, Al Senany S. The clinical and demographic features of dizziness related to general health among the Saudi population. J Phys Ther Sci 2015; 27:3195-8. [PMID: 26644673 PMCID: PMC4668164 DOI: 10.1589/jpts.27.3195] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 07/16/2015] [Indexed: 01/30/2023] Open
Abstract
[Purpose] The purpose of this study was to determine the validity, demographic features
of the newly developed Amer Dizziness Diagnostic Scale (ADDS), provide differential
diagnosis of the vestibular disorders, assist in the clinical research and practice
activities of health workers as well as to understand the probability of the utilization
of the ADDS as a first-line evaluation tool in general clinical practice. [Subjects and
Methods] Two hundred subjects of various ages including both male and female patients with
a history of vertigo and/or dizziness were included in the study and evaluated once using
the ADDS. [Results] There were more female (59.5%) than male (49.5) patients in this
study. Additionally, we found that most patients (64.4%) had a central mediated problem.
In addition, the Amer Dizziness Diagnostic Scale has been found to have both a sensitivity
and specificity of 96% that can adequately determine the possible diagnosis of vestibular
disorders. [Conclusion] This study has demonstrated the validity of the ADDS scale, the
predominance of female involvement related to supplementary medication, vitamin D
deficiency, general lifestyle factors, and fluid retention, high sensitivity and
specificity, provide differential diagnosis of vestibular disorders that could be used as
a first-line evaluation tool in general clinics.
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Affiliation(s)
- Amer Al Saif
- Department of Physical Therapy, Faculty of Applied Medical Sciences, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Samira Al Senany
- Department of Public Health, Faculty of Nursing, King Abdulaziz University: P.O. Box 22246, Jeddah 4929, Saudi Arabia
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Abstract
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.
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Affiliation(s)
- Nathan D Zasler
- Concussion Care Centre of Virginia, Ltd, Richmond, VA, USA.,Tree of Life Services, Inc, Richmond, VA, USA.,VCU Department of Physical Medicine and Rehabilitation, Richmond, VA, USA.,Department of Physical Medicine and Rehabilitation, University of Virginia, Charlottesville, VA, USA.,University of Virginia Brain Injury and Sports Concussion Institute, Charlottesville, VA, USA.,Distinguished Clinical Professor of Health Sciences, School of Health Sciences, Touro College, NY, USA
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Reneker JC, Cheruvu V, Yang J, Cook CE, James MA, Moughiman MC, Congeni JA. Differential diagnosis of dizziness after a sports-related concussion based on descriptors and triggers: an observational study. Inj Epidemiol 2015; 2:22. [PMID: 27747755 PMCID: PMC5005635 DOI: 10.1186/s40621-015-0055-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2015] [Accepted: 09/03/2015] [Indexed: 11/10/2022] Open
Abstract
Background Dizziness is often reported after a sports-related concussion. Forces experienced at the time of the concussion can cause an injury to multiple anatomical areas, including the central nervous system, the vestibular system, and the cervical spine, each of which is sufficient to cause dizziness. Medical professionals routinely use the subjective history to develop hypotheses about what may be causing a patient’s dizziness. No previous studies have attempted to differentiate the source of the dizziness through precise patient descriptors or the triggers of dizziness. Methods A structured symptom questionnaire was developed through purposive exploration of relevant literature for common dizziness quality descriptors and triggers. This questionnaire was used to interview a sample of 86 adolescent athletes (12–19 years of age) with a sports-related concussion between August 2013 and April 2014. Exploratory Latent Class Analysis was used to uncover latent constructs within the 15 dizziness descriptors and 11 dizziness triggers. The covariates sex, attention deficit hyperactivity disorder, and number of days between the concussion and the assessment were added to the model to estimate if these variables influenced class membership probabilities. Results Thirty-two (36 %) of the patients interviewed did not report a complaint of dizziness but did affirm one or more of the other descriptors. Three classes of dizziness based on dizziness quality descriptors and three classes based on dizziness triggers were identified by the analysis. Neither the classes of descriptors nor the classes of triggers enabled differentiation based on anatomical etiology of the dizziness. Conclusions Patient description of dizziness is limited in its ability to assist in differential diagnosis based on anatomical location for athletes with concussion. This may be because more than one area is contributing to the dizziness or because concussed adolescents have difficulty describing the way that they feel. In this case, solely relying on the patient to provide a description of dizziness to develop the formation of hypotheses and lead the direction of objective tests is inappropriate. If the scope of the objective assessment is limited by the patient description of dizziness, it is likely that areas of dysfunction may be overlooked.
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Affiliation(s)
- Jennifer C Reneker
- Department of Biostatistics, Environmental Health Sciences, and Epidemiology, College of Public Health, Kent State University, Kent, OH, USA. .,Physical Therapy Program, Division of Health Sciences, Walsh University, North Canton, OH, USA.
| | - Vinay Cheruvu
- Department of Biostatistics, Environmental Health Sciences, and Epidemiology, College of Public Health, Kent State University, Kent, OH, USA
| | - Jingzhen Yang
- Center for Injury Research and Policy, The Research Institute at Nationwide Children's Hospital, Department Of Pediatrics, College of Medicine, The Ohio State University, Columbus, OH, USA
| | - Chad E Cook
- Division of Physical Therapy, Department of Orthopaedics, Duke University, Durham, NC, USA
| | - Mark A James
- Department of Biostatistics, Environmental Health Sciences, and Epidemiology, College of Public Health, Kent State University, Kent, OH, USA
| | - M Clay Moughiman
- Physical Therapy Service, Community Based Outpatient Services, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
| | - Joseph A Congeni
- Center for Orthopedics and Sports Medicine, Akron Children's Hospital, Considine Professional Building, Akron, OH, USA
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Steffen A, Fiess J, Schmidt R, Rockstroh B. "That pulled the rug out from under my feet!" - adverse experiences and altered emotion processing in patients with functional neurological symptoms compared to healthy comparison subjects. BMC Psychiatry 2015; 15:133. [PMID: 26103961 PMCID: PMC4477601 DOI: 10.1186/s12888-015-0514-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 06/02/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Medically unexplained movement or sensibility disorders, recently defined in DSM-5 as functional neurological symptoms (FNS), are still insufficiently understood. Stress and trauma have been addressed as relevant factors in FNS genesis. Altered emotion processing has been discussed. The present study screened different types and times of adverse experiences in childhood and adulthood in patients with FNS as well as in healthy individuals. The relationship between stress profile, aspects of emotion processing and symptom severity was examined, with the hypothesis that particularly emotional childhood adversities would have an impact on dysfunctional emotion processing as a mediator of FNS. METHODS Adverse childhood experiences (ACE), recent negative life events (LE), alexithymia, and emotion regulation style were assessed in 45 inpatients diagnosed with dissociative disorder expressing FNS, and in 45 healthy comparison subjects (HC). RESULTS Patients reported more severe FNS, more (particularly emotional) ACE, and more LE than HC. FNS severity varied with emotional ACE and negative LE, and LE partially mediated the relation between ACE and FNS. Alexithymia and suppressive emotion regulation style were stronger in patients than HC, and alexithymia varied with FNS severity. Structural equation modeling verified partial mediation of the relationship between emotional ACE and FNS by alexithymia. CONCLUSIONS Early, emotional and accumulating stress show a substantial impact on FNS-associated emotion processing, influencing FNS. Understanding this complex interplay of stress, emotion processing and the severity of FNS is relevant not only for theoretical models, but, as a consequence also inform diagnostic and therapeutic adjustments.
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Affiliation(s)
- Astrid Steffen
- Department of Psychology, University of Konstanz, P.O.Box 905, Konstanz, 78457, Germany.
| | - Johanna Fiess
- Department of Psychology, University of Konstanz, P.O.Box 905, Konstanz, 78457, Germany.
| | - Roger Schmidt
- Neurological Rehabilitation Center Kliniken Schmieder, Eichhornstraße 68, Konstanz, 78464, Germany.
| | - Brigitte Rockstroh
- Department of Psychology, University of Konstanz, P.O.Box 905, Konstanz, 78457, Germany.
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Affiliation(s)
- Sirous Mobini
- Institute of Cognitive Neuroscience, University College London, London WC1N 3AR, UK
- Regional Neurological Rehabilitation Unit, Homerton University Hospital NHS Foundation Trust, London E9 6SR, UK
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