Clinicians' implicit and explicit attitudes about the legitimacy of functional neurological disorders correlate with referral decisions

OBJECTIVES

Uncertainty regarding the legitimacy of functional neurological disorder (FND) remains among some health care professionals. Despite treatment guidelines and consensus recommendations, variability in clinical practice referral decisions persists. Evidence from other conditions suggests such clinical decision making is impacted by practitioners' implicit and explicit attitudes. We aimed to identify whether health care professionals hold implicit and/or explicit attitudes about the legitimacy of FND and whether these attitudes are associated with referral decision making.

DESIGN/METHODS

We included 66 health care professionals who work with people with neurological conditions: n = 37 medical doctors, mainly neurologists (n = 18) and psychiatrists (n = 10), and n = 29 doctoral level practitioner psychologists. Participants completed an Implicit Association Test (IAT), Implicit Relational Assessment Procedure (IRAP), a referral decision-making vignette task and self-report measures of explicit attitudes on FND-legitimacy, therapeutic optimism and clinician confidence. Multiple Sclerosis (MS) was used as a comparator condition.

RESULTS

Participants self-reported strong explicit FND-legitimate and MS-legitimate attitudes but demonstrated an implicit FND-illegitimate/MS-legitimate bias. Deeper examination provided by the IRAP data indicated pro-FND-legitimate attitudes, but no bias for or against FND-illegitimate-contrasting the pro-MS-legitimate, anti-MS-illegitimate attitudes for the comparator condition. Attitudes about FND-illegitimacy were negatively associated with likelihood of referral to physical interventions such as physiotherapy. Medical doctors had lower treatment optimism and stronger explicit attitudes that FND is illegitimate than psychologists.

CONCLUSIONS

At an implicit level, clinicians are uncertain about the illegitimacy of FND, and such attitudes are associated with lower likelihood of referral to physiotherapy in particular. Improved education on FND among health care professionals is indicated.

The use of acceptance and commitment therapy in managing psychological symptoms in paediatric functional non-epileptic attacks: A clinical report

Functional non-epileptic attacks (FNEA) are seizure like activities that occur without any organic cause. Although a debilitating and costly disorder, there is much debate within the clinical literature on the causes and prognosis of FNEA, as well as possible effective psychological interventions. This is especially true for FNEA occurring in paediatric populations. Limited evidence to date suggests that acceptance and commitment therapy (ACT) shows promise and has pragmatic benefits in the context of functional disorders for adults. This case study provides information of a brief (8-session) ACT protocol targeting FNEA and associated emotional difficulties in a 12-year child. Treatment aimed to promote psychological flexibility and reduce functional interference of FNEA symptoms using ACT consistent techniques. Post-treatment, the child demonstrated reliable/clinical recovery in psychological flexibility, symptom interference and anxiety, as well as a marked reduction in the frequency of FNEA episodes. The majority of these gains were evidenced at 5-month follow-up. Such promising findings need to be tempered by methodological considerations.

What is it like to live with a functional movement disorder? An interpretative phenomenological analysis of illness experiences from symptom onset to post-diagnosis

OBJECTIVES

With few empirically supported treatments, functional movement disorders (FMD) can be challenging to manage. To enable service providers to better support people with FMD, this study sought to understand the lived experience of FMD: to gain insight into how individuals make sense of their experience from symptom onset through medical evaluation and diagnosis to post-diagnostic adaptation.

DESIGN

An interpretative phenomenological analysis (IPA) of patient accounts of living with FMD.

METHODS

Eight participants were recruited from a UK teaching hospital adult neurology service: seven females, varying in age (20s-70s), FMD symptom type (tremor, dystonia, and tics), and time to diagnosis (10 - 192 months). Semi-structured interviews facilitated participant accounts of key events. Interviews lasted 75-125 minutes and were transcribed verbatim.

RESULTS

Three super-ordinate themes were apparent. The first covered the experiences of onset ('Something is wrong with me'), including loss of control - with the affected body part often described as a separate entity - threats to identity and disturbance in relationships. 'At last! What now?' outlined the bittersweet experience of diagnosis and of treatments. Third, 'Living my life with it' incorporated ongoing experiences of coping with symptoms. While some continued to struggle with the emotional impact of symptoms, others developed a compassionate relationship with their self and maintained satisfying activities.

CONCLUSIONS

FMD has a significant impact on patients' relationships with themselves and others, which in turn affects well-being. These findings suggest some nuanced additions to interventions (diagnosis, psychotherapy, physiotherapy, public education.).

Conversion Disorder (Functional Neurological Symptom Disorder) in Primary Care Mental Health

This case report describes the application of a dialectical behavioral therapy–informed psychotherapy approach to treating conversion disorder (functional neurological symptom disorder) with motor dysfunction in a Veterans Administration Health System Primary Care–Mental Health Integration Clinic. “Jane,” a 30-year-old veteran, was diagnosed with conversion disorder, major depressive disorder (MDD), and posttraumatic stress disorder (PTSD). She completed 25 sessions of treatment focused on improving emotion regulation and interpersonal skills over an 8-month period. At the end of treatment, Jane demonstrated improved motor ability and clinically significant improvements in her reported symptoms of MDD (per the Patient Health Questionnaire–9) and PTSD (per the PTSD Checklist–Civilian Version). This case report supports the conceptualization of conversion disorder as a function of emotion dysregulation and the application of a dialectical behavior therapy–informed treatment approach.

Treating functional non-epileptic attacks - Should we consider acceptance and commitment therapy?

Patients who experience functional non-epileptic attacks (FNEA) are frequently seen in Neurology clinics. Diagnosis alone can result in cessation of attacks for some patients, but many patients require further treatment. There is evidence that certain psychological therapies, like cognitive-behavioral therapy (CBT) and psychodynamic interpersonal therapy (PIT) can be beneficial. Acceptance and commitment therapy (ACT) is a type of CBT that has been found to be effective at treating other somatic disorders, like epilepsy and chronic pain. In this paper, we explain what ACT is, the current evidence-base for its use, and the rationale for why it may be a beneficial treatment for patients who experience FNEA. We conclude that ACT is a potential treatment option for FNEA, and further research is required.