Functional neurological disorders: acute presentations and management

Treatment outcomes in the inpatient management of severe functional neurological disorder: a retrospective cohort study

Background

Functional neurological disorder (FND) is a heterogeneous condition; severe forms can be disabling. Multidisciplinary treatment and rehabilitation are recommended for severe FND, but there remains a lack of evidence for its efficacy and lack of understanding of the predictors and components of recovery.

Methods

We report clinical outcome data for an inpatient cohort with severe FND. Clinical Global Impression Improvement with treatment is the primary outcome measure. Admission and discharge measures (Euroqol quality of life measures, Beck Depression Inventory, Spielberger Trait Anxiety Inventory, Cambridge Depersonalisation Scale, Illness Perception Questionnaire (Revised) and Functional Mobility Scale) are reported as secondary outcomes.

Results

We describe an FND cohort (n=52) with chronic illness (mean symptom duration 9.7 years). At admission, there were clinically relevant levels of depression, anxiety and depersonalisation derealisation. At the time of discharge, most (43/52) patients' global condition had improved. Measures of mobility, depression and quality of life also significantly improved while at discharge, symptoms were experienced as more understandable and less distressing than at admission. An admission measure of patient confidence in treatment was predictive of eventual clinical outcome.

Conclusions

The most frequent outcome of inpatient rehabilitation is global improvement, even when symptoms are chronic and severe, reflected in measurable changes in both physical and psychological functioning. Significant levels of depersonalisation derealisation seen in this patient group suggest that routine enquiry into such experiences could help personalise FND treatment approaches. Patient confidence in treatment is key in determining clinical outcomes.

A global neuronal workspace model of functional neurological disorders

We introduce here a general model of Functional Neurological Disorders based on the following hypothesis: a Functional Neurological Disorder could correspond to a consciously initiated voluntary top-down process causing involuntary lasting consequences that are consciously experienced and subjectively interpreted by the patient as involuntary. We develop this central hypothesis according to Global Neuronal Workspace theory of consciousness, that is particularly suited to describe interactions between conscious and non-conscious cognitive processes. We then present a list of predictions defining a research program aimed at empirically testing their validity. Finally, this general model leads us to reinterpret the long-debated links between hypnotic suggestion and functional neurological disorders. Driven by both scientific and therapeutic goals, this theoretical paper aims at bringing closer the psychiatric and neurological worlds of functional neurological disorders with the latest developments of cognitive neuroscience of consciousness.

Functional neurological disorder: A common reason for a neurology inpatient referral

BACKGROUND AND PURPOSE

In 2021, the European Academy of Neurology's training requirements were updated to include functional neurological disorder (FND) as a core topic for the first time. To reinforce these changes, we aimed to understand the proportion of inpatients (in non-neurology settings) who are diagnosed with FND.

METHODS

We prospectively collected data on diagnoses made after inpatient ward reviews from neurology trainees at three tertiary neurology centres in Scotland from April to September 2021. We assessed healthcare utilization data for patients with a diagnosis of FND, epilepsy and epileptic seizures, or a neuroinflammatory disorder over the preceding 12 months.

RESULTS

There were 437 inpatient reviews for 424 patients by 13 trainees. The largest single diagnosis was FND (n = 80, 18%), followed by epilepsy (n = 64, 14%), primary headache disorder (n = 40, 9%) and neuroinflammatory disorders (n = 28, 6%). There was an uncertain diagnosis for 48 reviews (11%). Compared to patients with epilepsy or neuroinflammatory disorders, patients with FND had a similar number of admissions (2 vs. 2 vs. 1) and brain/spine imaging studies (2 vs. 1 vs. 2).

CONCLUSIONS

In Scotland, FND was the most common diagnosis made after a request for an inpatient review by a neurologist from another department in the hospital. Patients with FND have similar health resource needs to those with other common neurological disorders when they present to hospitals with tertiary neurology centres. This data supports the inclusion of FND as a core curriculum topic in neurology training.

"Somewhere Between an Actual Disease and a Disease": A Grounded Theory Study on Diagnosing Functional Neurological Disorders From a Multi-Informant Perspective

Functional Neurological Disorders are characterized by sensory-motor or cognitive symptoms. Recent research has revealed their complex nature involving biological, psychological, and social factors. Care requires a multidisciplinary approach, which, to date, has yet to be considered. A Constructivist Grounded Theory study was conducted to understand the reasons behind this, exploring Functional Neurological Disorders diagnosis, communication, and understanding from multiple perspectives (patients and healthcare professionals). The core category was "negotiating Functional Neurological Disorders meanings and care amid a dissatisfying dichotomy," with sub-categories: i) seeking to "word" the disease, ii) exposing reductionism, and iii) a pluralist vision emerging. Diagnosing and communicating Functional Neurological Disorders is a process of negotiating meanings and care that hinges on participants' diverse ontological perspectives regarding the condition. Results highlight the difficulty in finding common ground and achieving mutual understanding among the various viewpoints, creating a challenge in establishing a unified approach to Functional Neurological Disorders care. In this context, only a few healthcare professionals emphasized the potential benefits of increased integration. A shift is required from a reductionist to an integrated biopsychosocial perspective to develop a more cohesive approach. Defining a medical paradigm through dialogue with teams and patients is essential in addressing Functional Neurological Disorders effectively. Furthermore, the required interdisciplinary approach holds the potential to mitigate the dissatisfaction arising from fragmented and compartmentalized care (the "dissatisfying dichotomy") experienced by our participants. It signifies a comprehensive strategy that could address the concerns of all involved parties and enhance the overall quality of care provided.

White matter microstructure and serum biomarkers of inflammation in psychogenic non-epileptic seizures

BACKGROUND

Neuroinflammation may contribute to the pathophysiology of psychogenic non-epileptic seizures (PNES). However, it is unclear whether and to what degree comorbid psychiatric symptoms explain this association. In this study, we investigated the neuroinflammatory signature of PNES and how it compares to that of people with psychiatric conditions (PwPCs).

METHODS

We prospectively assessed differences in neurite density (NDI), orientation dispersion (ODI), and isotropic diffusion (F-ISO) in 23 participants with PNES and 27 PwPCs, and their relationships to serum levels of tumor necrosis factor (TNF)-α, TNF receptor 1 (TNF-R1), TNF-related apoptosis-inducing ligand (TRAIL), interleukin (IL)-6, intercellular adhesion molecule (ICAM)-1, and monocyte chemoattractant protein (MCP)-1 using voxelwise multiple linear regressions. Pearson correlations between serum biomarkers and clinical symptoms were also obtained.

RESULTS

There were no white matter (WM) microstructural differences between groups. In PNES, TNF-R1 was negatively associated with NDI in the right uncinate fasciculus (UF) and positively associated with F-ISO in the left UF. IL-6 was positively associated with NDI and negatively with F-ISO in the left UF. ICAM-1 was positively associated with ODI in the left UF. TNF-α was negatively associated with ODI in the left cingulum bundle. The opposite relationships were observed in PwPCs. Higher TNF-R1 was associated with higher depression, anxiety, lower emotional quality of life, and higher levels of disability in PNES.

CONCLUSIONS

For the first time, we report relationships between peripheral inflammatory biomarkers and WM integrity in PNES, including abnormalities in the UF and cingulum bundle. Our results suggest that serum biomarkers of inflammation may, with additional studies, become a useful aid to PNES diagnosis, especially in settings where video-EEG is not available. The lack of group differences in WM microstructure suggests that previously identified WM abnormalities in PNES versus healthy controls may be related to psychological comorbidities of PNES.

Identifying misconceptions and knowledge gaps in functional neurological disorders among emergency care providers

BACKGROUND

Functional Neurologic Disorders (FND) are a common but heterogeneous group of disabling conditions. The Emergency Department (ED) is an important venue for care and referral as it is often the first point of contact when patients with FND are faced with a crisis or exacerbation of symptoms.

METHODS

ED providers (n = 273) practicing in the Cleveland Clinic Foundation Northeast Ohio network were invited to participate through secure web application electronic surveys. Data were collected on practice profiles, knowledge, attitudes, management of FND, and awareness of available resources for FND.

RESULTS

Sixty providers completed the survey (22% response rate; n = 50 ED physicians, 10 advanced care providers) with 95.0% (n = 57) reporting a lack of understanding about FND. The terms Psychogenic Nonepileptic Seizures and stress induced/stress related disease were used by 60.0% (n = 36) and 58.3% (n = 35) respectively. Ninety percent (n = 53) rated their experience with managing FND patients as at least more difficult. Eighty- five percent (n = 51) agreed with "rule out others" and 60% (n = 36) agreed with "caused by psych stress". Eighty six percent (n = 50) believe that there is a difference between FND from malingering. Only one respondent was familiar with any FND resources and 79% (n = 47) reported the need for FND specific educational materials.

CONCLUSION

This survey revealed major gaps in knowledge, inaccurate perceptions, and management that differs from the current standard of care among ED providers caring for patients with FND. Educational opportunities are needed to guide diagnosis and evidence-based treatment to optimize management of patients with FND.

CSF neopterin, quinolinic acid and kynurenine/tryptophan ratio are biomarkers of active neuroinflammation

BACKGROUND

Defining the presence of acute and chronic brain inflammation remains a challenge to clinicians due to the heterogeneity of clinical presentations and aetiologies. However, defining the presence of neuroinflammation, and monitoring the effects of therapy is important given its reversible and potentially damaging nature. We investigated the utility of CSF metabolites in the diagnosis of primary neuroinflammatory disorders such as encephalitis and explored the potential pathogenic role of inflammation in epilepsy.

METHODS

Cerebrospinal fluid (CSF) collected from 341 paediatric patients (169 males, median age 5.8 years, range 0.1-17.1) were examined. The patients were separated into a primary inflammatory disorder group (n = 90) and epilepsy group (n = 80), who were compared with three control groups including neurogenetic and structural (n = 76), neurodevelopmental disorders, psychiatric and functional neurological disorders (n = 63), and headache (n = 32).

FINDINGS

There were statistically significant increases of CSF neopterin, kynurenine, quinolinic acid and kynurenine/tryptophan ratio (KYN/TRP) in the inflammation group compared to all control groups (all p < 0.0003). As biomarkers, at thresholds with 95% specificity, CSF neopterin had the best sensitivity for defining neuroinflammation (82%, CI 73-89), then quinolinic acid (57%, CI 47-67), KYN/TRP ratio (47%, CI 36-56) and kynurenine (37%, CI 28-48). CSF pleocytosis had sensitivity of 53%, CI 42-64). The area under the receiver operating characteristic curve (ROC AUC) of CSF neopterin (94.4% CI 91.0-97.7%) was superior to that of CSF pleocytosis (84.9% CI 79.5-90.4%) (p = 0.005). CSF kynurenic acid/kynurenine ratio (KYNA/KYN) was statistically decreased in the epilepsy group compared to all control groups (all p ≤ 0.0003), which was evident in most epilepsy subgroups.

INTERPRETATION

Here we show that CSF neopterin, kynurenine, quinolinic acid and KYN/TRP are useful diagnostic and monitoring biomarkers of neuroinflammation. These findings provide biological insights into the role of inflammatory metabolism in neurological disorders and provide diagnostic and therapeutic opportunities for improved management of neurological diseases.

FUNDING

Financial support for the study was granted by Dale NHMRC Investigator grant APP1193648, University of Sydney, Petre Foundation, Cerebral Palsy Alliance and Department of Biochemistry at the Children's Hospital at Westmead. Prof Guillemin is funded by NHMRC Investigator grant APP 1176660 and Macquarie University.

Hazard Perception Skill and Driver Behavior in Patients With Functional Neurologic Disorders

BACKGROUND AND OBJECTIVES

Driving in patients with functional neurologic disorders (FND) is a major concern, but current guidelines (where they exist) are based on expert consensus only due to a lack of relevant empirical evidence. This study aimed to provide such evidence by comparing drivers with FND with healthy controls on aspects of driving performance and behavior important to crash risk, including hazard perception skill.

METHODS

Participants completed validated self-report questionnaires of driving behaviors (assessing lapses, errors, violations, and attentional issues) and 2 computer-based measures of hazard perception skill (both known to be associated with crash risk).

RESULTS

We compared 43 patients who experience dissociative attacks or functional motor symptoms and 43 healthy controls. Patients with FND self-reported significantly more driving lapses and driving errors compared with healthy controls. However, there were no significant between-group differences in self-reports of ordinary violations, aggressive violations, or attention-related errors. Participants in the FND group and healthy controls exhibited a similar performance on a response time hazard perception test (6.27 vs 5.51 seconds, p = 0.245). However, participants with FND remarkably outperformed the controls in the number of plausible predictions they made in a verbal response hazard prediction test (1.55 vs 1.18 predictions per clip, p = 0.006).

DISCUSSION

Our findings suggest that the ability of drivers with FND to predict traffic hazards in between attacks or flares is not worse than that of healthy individuals, with the possibility that it might even be better under some circumstances. Further studies with various populations are needed to replicate our findings.

Health Care Utilization in Functional Neurologic Disorders: Impact of Explaining the Diagnosis of Functional Seizures on Health Care Costs

Background and Objective

The objectives of this study were to investigate health care utilization costs of patients with video-electroencephalography (VEEG)-confirmed functional seizures (FS), determine whether patients who received a satisfactory functional neurologic disorder (FND) diagnosis explanation had reduced health care utilization compared with those with a poor explanation; and to quantify the overall health care costs 2 years prediagnosis and postdiagnosis for those receiving a different explanation.

Methods

Patients with VEEG-confirmed pure FS (pFS) or mixed (functional seizure plus epileptic seizures) diagnosis between July 1, 2017, and July 1, 2019, were evaluated. Explanation of the diagnosis was determined "unsatisfactory" or "satisfactory" using self-developed criteria, and health care utilization data were collected using an itemized list. The subsequent costs 2 years post-FND diagnosis were compared with those 2 years before, and cost outcomes were compared between both groups.

Results

In patients who received a satisfactory explanation (n = 18), total health care costs were reduced from $169,803 to $117,133 USD (-31%). An increase in costs was found ($73,430 to $186,553 USD = +154%) in patients with pPNES after an unsatisfactory explanation (n = 7). On an individual level, 78% with a satisfactory explanation saw a reduction in total health care costs per year (mean $5,111 USD to $1,728 USD), and in 57%, an unsatisfactory explanation led to an increase (mean $4,425 to $20,524 USD). A similar effect was seen from explanation on patients with a dual diagnosis.

Discussion

The method of communicating an FND diagnosis has a significant impact on subsequent health care utilization. Those receiving satisfactory explanations demonstrated reduced health care utilization, whereas an unsatisfactory explanation resulted in additional expenses.

Classification of Functional Movement Disorders with Resting-State Functional Magnetic Resonance Imaging

Introduction: Functional movement disorder (FMD) is a type of functional neurological disorder characterized by abnormal movements that patients do not perceive as self-generated. Prior imaging studies show a complex pattern of altered activity, linking regions of the brain involved in emotional responses, motor control, and agency. This study aimed to better characterize these relationships by building a classifier using a support vector machine to accurately distinguish between 61 FMD patients and 59 healthy controls using features derived from resting-state functional magnetic resonance imaging. Materials and Methods: First, we selected 66 seed regions based on prior related studies, then we calculated the full correlation matrix between them before performing recursive feature elimination to winnow the feature set to the most predictive features and building the classifier. Results: We identified 29 features of interest that were highly predictive of the FMD condition, classifying patients and controls with 80% accuracy. Several key features included regions in the right sensorimotor cortex, left dorsolateral prefrontal cortex, left cerebellum, and left posterior insula. Conclusions: The features selected by the model highlight the importance of the interconnected relationship between areas associated with emotion, reward, and sensorimotor integration, potentially mediating communication between regions associated with motor function, attention, and executive function. Exploratory machine learning was able to identify this distinctive abnormal pattern, suggesting that alterations in functional linkages between these regions may be a consistent feature of the condition in many FMD patients. Clinical-Trials.gov ID: NCT00500994 Impact statement Our research presents novel results that further elucidate the pathophysiology of functional movement disorder (FMD) with a machine learning model that classifies FMD and healthy controls correctly 80% of the time. Herein, we demonstrate how known differences in resting-state functional magnetic resonance imaging connectivity in FMD patients can be leveraged to better understand the complex pattern of neural changes in these patients. Knowing that there are measurable predictable differences in brain activity in patients with FMD may help both clinicians and patients conceptualize and better understand the illness at the point of diagnosis and during treatment. Our methods demonstrate how an effective combination of machine learning and qualitative approaches to analyzing functional brain connectivity can enhance our understanding of abnormal patterns of brain activity in FMD patients.

Psychogenic non-epileptic seizures (PNES) in the COVID-19 pandemic era: A systematic review with individual patients' analysis

OBJECTIVE

Psychogenic non-epileptic seizures (PNES) resemble epileptic seizures but are not due to underlying epileptic activity and in some cases coexist alongside epilepsy. We described the clinical characteristics of patients with PNES as reported in the literature from the outbreak of the COVID-19 pandemic. We evaluated differences between patients with a diagnosis made immediately before the pandemic (pPNES) and those newly diagnosed during it (nPNES).

METHODS

A systematic search with individual patient analysis of PNES cases published since the COVID-19 pandemic outbreak was performed. Differences between pPNES and nPNES were analyzed using Chi-square or Fisher exact test.

RESULTS

Eleven articles were included, with 133 patients (106 pPNES and 27 nPNES). In the pPNES group, PNES frequency increased during the pandemic in 20/106 patients, whereas in 78/106, the frequency remained stable or decreased. nPNES was associated with higher risks of SARS-CoV-2 infection and epilepsy diagnosis, whereas psychiatric comorbidities were less frequent.

CONCLUSIONS

During the pandemic, most patients with pPNES remained stable or improved, whereas nPNES was associated with a lower burden of psychiatric comorbidities. These intriguing findings suggest that, at least in some patients, the COVID-19 pandemic may not necessarily lead to worsening in the frequency of PNES and quality of life.

Case report on psychogenic nonepileptic seizures: A series of unfortunate events

Psychogenic nonepileptic seizures, also called Functional Seizures, are a highly disabling form of Functional Neurological Disorder. The diagnosis of PNES could be missed in clinical scenarios where patients exhibit concurrent musculoskeletal/neurological findings. Characterization of convulsions and judicious use of diagnostics are equally valuable in establishing the diagnosis.

Functional neurologic disorder (FND) in pediatrics: A clinical review with discussion of FND in the era of COVID-19

ABSTRACT

Functional neurologic disorder is a complex disorder of truly experienced neurologic symptoms without evidence of underlying neurologic disease. This clinical review focuses on the pediatric population and includes the impacts of the COVID-19 pandemic. Clinician knowledge and early identification can substantially improve patient outcomes.

Functional Neurological Disorders: Clinical Spectrum, Diagnosis, and Treatment

BACKGROUND

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

REVIEW SUMMARY

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

CONCLUSIONS

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

The use of rhythmic auditory stimulation for functional gait disorder: A case report

BACKGROUND: Functional gait disorders (FGD) are a common and disabling condition. Consensus-based rehabilitation techniques for treating FGD and other functional neurological disorder presentations at large utilize a variety of therapeutic strategies, including distraction, novel approaches to movement, entrainment, stress/hypervigilance modulation, and psychotherapy. CASE REPORT: Here we present a case of a 24-year-old woman with a complex history of anxiety, depression, left frontal astrocytoma, postural orthostatic tachycardia syndrome (POTS) and FGD. During a multidisciplinary inpatient rehabilitation stay for FGD, the patient underwent rhythmic auditory stimulation (RAS) delivered by a neurologic music therapist in conjunction with physical therapy, occupational therapy, and psychotherapy. RESULTS: The RAS intervention appeared to play a significant role in symptom resolution for this patient. Improvement in the patient’s truncal displacement, foot dragging, and well as overall gait speed occurred following serial RAS trials performed over a single treatment session. Benefits persisted immediately following the intervention and upon subsequent reassessment. Although at four-year follow-up the patient’s FGD symptoms remained resolved, fatigue continued to limit her ambulatory capacity and overall endurance. CONCLUSION: RAS represents a unique therapeutic approach for treating FGD, complementary to existing consensus-based rehabilitation recommendations, and may warrant further consideration by the field.

Neurostimulation for the treatment of functional neurological disorder: A systematic review

Functional Neurological Disorder (FND), also known as conversion disorder, is characterized by neurological symptoms that are incompatible with any known structural disorder and best explained by a biopsychosocial model. Evidence-based treatments for FND are limited, with cognitive behavioral therapy (CBT) and physiotherapy being the most effective interventions [1]. In recent years, functional neuroimaging studies have provided robust evidence of alterations in activity and connectivity in multiple brain networks in FND. This body of evidence suggests that neurocircuitry-based interventions, such as non-invasive brain stimulation techniques (NIBS), may also represent an effective therapeutic option for patients with FND. In this systematic review, we outline the current state of knowledge of NIBS in FND, and discuss limitations and future directions that may help establish the efficacy of NIBS as a therapeutic option for FND.

History of abuse and psychogenic nonepileptic seizures: A systematic review

Psychogenic nonepileptic seizures resemble epileptic seizures but lack the physiological basis of epileptic seizures. We conducted a systematic review to explore whether childhood abuse is a risk factor for subsequent development of PNES. We reviewed only papers with an epilepsy control group, which employed strict criteria for diagnosis of epilepsy and well-validated tools for assessing abuse history. Odds ratios (ORs) for the different categories of childhood abuse and for childhood abuse as a whole were calculated where not previously available, and pooled ORs were calculated where suitable. In papers where OR could not be calculated data are presented as p values. Most Odds Ratios fell between 1.8 and 5.2 with relatively narrow confidence intervals. In 14 out of 18 calculations, 95% confidence intervals did not cross 1. This suggests that the chance of reporting abuse is higher in people with PNES than those with epilepsy and may be a causative factor in developing PNES. Several limitations of the data and directions for future study are discussed.

When neurologists diagnose functional neurological disorder, why don't they code for it?

Objective:

Clinicians who recognize functional neurological disorders (FND) may not share that diagnosis with patients. Poor communication delays treatment and contributes to substantial disability in FND. Diagnostic (ICD-10) coding, one form of medical communication, offers an insight into clinicians’ face-to-face communication. Therefore, quantifying the phenomenon of non-coding, and identifying beliefs and practice habits that reduce coding, may suggest routes to improve medical communication in FND.

Methods:

We reviewed all pediatric neurology consultations in our hospital from 2017–2020, selecting those in which neurologists explicitly stated an FND-related diagnosis (N=57). We identified the neurological symptoms and ICD-10 codes assigned for each consultation. In parallel, we reviewed all encounters that utilized FND-related codes to determine whether insurers paid for this care. Finally, we assessed beliefs and practices that influence FND-related coding through a nationwide survey of pediatric neurologists (N=460).

Results:

After diagnosing FND, neurologists selected FND-related ICD-10 codes in only 22.8% of consultations. 96.2% of neurologists estimated that they would code for non-epileptic seizure (NES) when substantiated by EEG; in practice, they coded for 36.7% of such consultations. For other FND manifestations, neurologists coded in only 13.3% of cases. When presented with FND and non-FND scenarios with equal levels of information, neurologists coded for FND 41% less often. The strongest predictor of non-coding was the outdated belief that FND is a diagnosis of exclusion. Coding for FND never resulted in insurance non-payment.

Conclusion:

Non-coding for FND is common. Most factors that amplify non-coding also hinder face-to-face communication. Research based on ICD-10 coding (e.g., prevalence, cost) may underestimate the impact of FND by >4-fold.

'It's both challenging and probably the most rewarding work' - A qualitative study of psychological therapy provider's experiences of working with people with dissociative seizures

Limited research exists exploring the experiences of psychological therapy providers (PTPs) working with people with dissociative seizures (DS). PTPs play a key role in the treatment of DS, yet sit at the end of a long, often ineffective process of diagnosis and waiting before treatment can commence. This qualitative study was undertaken involving 12 PTPs from specialist DS services throughout England and Scotland. Semi-structured interviews were carried out, using thematic analysis to evaluate the data. Four key themes were identified, "neurological to psychological", "putting the person with DS at the center", "treatment process", and "issues and impact of therapy with patients with DS". The findings showed that an unclear and uncomprehended diagnosis, together with waiting times had a detrimental impact on patients at the starting point of therapy. People with DS were perceived as a heterogeneous group whose treatment needed to be individualized, using the PTPs' full 'toolkit' of modalities and techniques, with a focus on improving quality of life, rather than reducing seizures. The study highlighted the complexity for PTPs of working with major but also accumulated minor traumas, compounded by the impact of DS on both PTPs and treatment. The desire of PTPs to be totally patient-focused meant that individualized treatment was considered essential and meant that participants were doubtful about the possibility of compiling an effective manual for the psychological treatment for DS.

Medically unexplained symptoms: assessment and management

Medically unexplained symptoms or persistent physical symptoms are common, real and are associated with significant distress, loss of functioning and high healthcare costs. History, examination and appropriate investigations are essential to make a diagnosis. Once the diagnosis has been made, exploring the impact of the symptoms helps us to tailor our advice to patients. This paper sets out a practical approach to taking a history, assessment and stepwise management principles.

Inpatient Treatment of Functional Neurological Disorder: A Scoping Review

BACKGROUND

The aim of this scoping review is to describe the characteristics of patients requiring admission to hospital for functional neurological disorder (FND), assess interventions provided, and evaluate outcomes in the context of acute hospital presentation or elective admission with chronic symptoms (>3 months).

METHODS

A scoping review was performed. Included articles described adult patients admitted with FND to an inpatient care setting. Articles focusing on psychogenic non-epileptic attacks (PNEA) were excluded.

RESULTS

The search strategy identified 1963 citations. A total of 34 articles met inclusion criteria, with 458 patients (66% female) described. The pooled mean age of patients in all studies was 40.6 years. Eleven studies described patients with acute presentation, and 16 studies described patients with chronic FND symptoms admitted to the hospital. Motor symptoms were most common. Interventions were most commonly physiotherapy and psychotherapy. Most studies reported partial or complete resolution of symptoms.

CONCLUSIONS

This scoping review summarizes the literature on the characteristics of patients admitted to the hospital, both with acute and chronic symptoms, for inpatient treatment of FND. When comparing patients with acute to those with chronic symptoms, we found that acute presentations were older (46.9 vs. 43.7 years) and had a higher representation of men (33% vs. 30%). Those presenting with chronic symptoms were more likely to not improve or relapse. We postulate that early diagnosis and inpatient rehabilitation could have a positive impact on outcomes for patients with FND.

Functional stroke symptoms: A prospective observational case series

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Medical management of status epilepticus: Emergency room to intensive care unit

In convulsive status epilepticus (SE), achieving seizure control within the first 1-2 hours after onset is a significant determinant of outcome. Treatment is also more likely to work and be cost effective the earlier it is given. Initial first aid measures should be accompanied by establishing intravenous access if possible and administering thiamine and glucose if required. Calling for help will support efficient management, and also the potential for video-recording the events. This can be done as a best interests investigation to inform later management, provided adequate steps to protect data are taken. There is high quality evidence supporting the use of benzodiazepines for initial treatment. Midazolam (buccal, intranasal or intramuscular) has the most evidence where there is no intravenous access, with the practical advantages of administration outweighing the slightly slower onset of action. Either lorazepam or diazepam are suitable IV agents. Speed of administration and adequate initial dosing are probably more important than choice of drug. Although only phenytoin (and its prodrug fosphenytoin) and phenobarbitone are licensed for established SE, a now considerable body of evidence and international consensus supports the utility of both levetiracetam and valproate as options in established status. Both also have the advantage of being well tolerated as maintenance treatment, and possibly a lower risk of serious adverse events. Two adequately powered randomized open studies in children have recently reported, supporting the use of levetiracetam as an alterantive to phenytoin. The results of a large double blind study also including valproate are also imminent, and together likely to change practice in benzodiazepine-resistant SE.