Functional neurological disorder is a feminist issue

Functional neurological disorder (FND) is a common and disabling disorder, often misunderstood by clinicians. Although viewed sceptically by some, FND is a diagnosis that can be made accurately, based on positive clinical signs, with clinical features that have remained stable for over 100 years. Despite some progress in the last decade, people with FND continue to suffer subtle and overt forms of discrimination by clinicians, researchers and the public. There is abundant evidence that disorders perceived as primarily affecting women are neglected in healthcare and medical research, and the course of FND mirrors this neglect. We outline the reasons why FND is a feminist issue, incorporating historical and contemporary clinical, research and social perspectives. We call for parity for FND in medical education, research and clinical service development so that people affected by FND can receive the care they need.

Prevalence of autistic traits in functional neurological disorder and relationship to alexithymia and psychiatric comorbidity

INTRODUCTION

In a cohort of adults with Functional Neurological Disorder (FND), we aim to: METHODS: 91 patients participating in a FND 5-week outpatient program completed baseline self-report questionnaires for total phobia, somatic symptom severity, attention deficit hyperactivity disorder (ADHD) and dyslexia. Patients were grouped by Autism Spectrum Quotient (AQ-10) score of <6 or ≥ 6 and compared for significant differences in tested variables. This analysis was repeated with patients grouped by alexithymia status. Simple effects were tested using pairwise comparisons. Multistep regression models tested direct relationships between autistic traits and psychiatric comorbidity scores, and mediation by alexithymia.

RESULTS

36 patients (40%) were AQ-10 positive (scoring ≥6 on AQ-10). A further 36 patients (across AQ-10 positive and AQ-10 negative groups) (40%) screened positive for alexithymia. AQ-10 positive patients scored significantly higher for alexithymia, depression, generalised anxiety, social phobia, ADHD, and dyslexia. Alexithymia positive patients scored significantly higher for generalised anxiety, depression, somatic symptoms severity, social phobia, and dyslexia. Alexithymia score was found to mediate the relationship between autistic trait and depression scores.

CONCLUSION

We demonstrate a high proportion of autistic and alexithymic traits, in adults with FND. A higher prevalence of autistic traits may highlight a need for specialised communication approaches in FND management. Mechanistic conclusions are limited. Future research could explore links with interoceptive data.

006 A novel approach in the management of functional neurological disorder in the hyper-acute setting

Introduction

Functional Neurological Disorder (FND) is common and can lead to multiple emergency department (ED) presentations and unnecessary investigation. Early identification and intervention have been shown to reduce health care costs and re-presentation to acute services by more than 50%1.

We created a pilot model to provide early access to a multi-disciplinary FND team for patients assessed by the ED-embedded neurology team (Stroke or Neurology SDEC pathway) to have a new diagnosis of FND. The MDT provided patients with individualised information about FND, pathway navigation, and shown self-management tools.

Methods

We reviewed data for all patients seen to date by the pilot service.

Results

Since commencement in November 2021, nine patients have been seen by the MDT. All patients were seen within two weeks by a neurophysiotherapist and neuropsychiatrist with neurology support.

6 were female and median age was 41 years. All presented with limb weakness and/or sensory distur- bance. 7 reported prior anxiety or depression. 6 had psychiatric factors, including Emotionally Unstable Personality Disorder and health anxiety. Follow up, 2 of the 9 patients so far demonstrated reduced health anxiety and increased confidence.

Conclusion

An acute FND pathway can provide timely intervention and reduce symptoms for new presentations with FND.

1. Stepped care for functional neurological disorder, A new approach to improving outcomes for a common neurological problem in Scotland. Report and Recommendations, NHS Improvement, February 2012

16 Outcomes of a novel 5-week individualized multidisciplinary outpatient (day-patient) treatment programme for functional (psychogenic) neurological symptoms

Aim

We report the results of a novel 5-week treatment programme, delivered by a multi-disciplinary team, with individualised sessions to treat functional neurological symptoms in a neuropsychiatric outpatient setting. The primary aims of this MDT programme were to (a) reduce symptoms (b) improve health and social functioning (c) improve functional performance (d) improve health status.

Method

Treatment involved individual sessions of neuropsychiatry, cognitive behavioural therapy, physiotherapy, occupational therapy, education and family meetings. Outcome measures were collected at the beginning and end of treatment and at a 6 month face to face follow-up. These were both patient and clinician reported. The aims were assessed by the following measures: symptom reduction (PHQ15, PHQ9, GAD7, SPIN, Rosenberg, CGI); health and social functioning (HONOS, WSAS); functional performance (COPM); and improvements in health status (EQ5DL). Results: Analyses were conducted on 78 patients who started and completed the programme and attended a 6 month face to face review. There were high baseline levels of disability compared to EQ5DL population norms and high rates of disability and psychopathology as indicated by the WSAS and mental health indices (PHQ9, GAD7, SPIN, Rosenberg’s self-esteem). At baseline, 92.3% met the IAPT caseness threshold for depression (PHQ9 >10) and 71% met the IAPT caseness threshold for anxiety (GAD7 >8). A repeated measures Freidman’s ANOVA over 3 timepoints (admission, discharge and 6 month follow-up) followed by Dunn-Bonferroni post hoc tests indicated statistically significant improvements from admission to discharge and admission to 6 months follow up. These improvements were seen in in somatic symptoms (PHQ15), depression (PHQ9) and anxiety (GAD7) symptoms, health and social functioning (HONOS), functional performance (COPM), health status (EQ5D-5L and EQ5D-EL VAS) and patient ratings of clinical global improvement (CGI). There was a high acceptance of this neuropsychiatry led MDT programme indicated by the patient reported visual analogue scale for benefit of programme averaging at 90%.

Conclusion

An MDT can effectively deliver an outpatient programme for FNS which can serve as an alternative to an inpatient programme for patients with fewer or no nursing needs, for those whose preference is an outpatient setting or for those seeking to minimise disruption to work or family life. There may be potential cost reductions for institutions compared to inpatient treatment depending on local calculations. In the future, earlier identification and treatment of co-morbidities may modify some predisposing and perpetuating factors.

Outcomes of a 5-week individualised MDT outpatient (day-patient) treatment programme for functional neurological symptom disorder (FNSD)

Aim

We report results from a 5-week MDT treatment programme, with individualised sessions, for a selected group of patients with FNSD, delivered in a neuropsychiatric outpatient setting. Primary aims were to (1) reduce symptoms, (2) improve functional performance and (3) improve health status.

Methods

Treatment involved individual sessions of neuropsychiatry, cognitive behavioural therapy, physiotherapy, occupational-therapy, education and family meetings. Outcome measures collected at the beginning and end of treatment and at 6 months, were patient and clinician reported. Aims were assessed by the following: symptom reduction (PHQ15, PHQ9, GAD7, SPIN, Rosenberg); health and social functioning (HONOS, WSAS); functional performance (COPM); health status (EQ-5D-5L) and patient-rated perception of improvement (CGI).

Results

Analyses of 78 patients completing the programme and attending a 6-month review revealed high-baseline levels of disability compared to EQ-5DL population norms and high rates of disability and psychopathology as indicated by the WSAS and mental health indices (PHQ9, GAD7, SPIN, Rosenberg’s self-esteem). At baseline, 92.3% met the IAPT caseness threshold for depression and 71% met the IAPT caseness threshold for anxiety. A Friedman ANOVA over the three time points and Dunn-Bonferroni post hoc tests indicated statistically significant improvements from admission to discharge and admission to 6-month follow-up. Sustained improvements were seen in somatic symptoms (PHQ15), depression (PHQ9), anxiety (GAD7), health and social functioning (HONOS), functionality (COPM), health status (EQ-5D-5L) and patient-rated clinical global improvement (CGI).

Conclusion

An MDT can effectively deliver an outpatient programme for FNSD which can serve as an alternative to costlier inpatient programmes. Early identification and treatment of co-morbidities is advised.

Electronic supplementary material

The online version of this article (10.1007/s00415-020-09874-5) contains supplementary material, which is available to authorized users.

Multidisciplinary treatment for functional neurological symptoms: a prospective study

Although functional neurological symptoms are often very disabling there is limited information on outcome after treatment. Here we prospectively assessed the short- and long-term efficacy of an inpatient multidisciplinary programme for patients with FNS. We also sought to determine predictors of good outcome by assessing the responsiveness of different scales administered at admission, discharge and follow-up. Sixty-six consecutive patients were included. Assessments at admission, discharge and at 1 year follow-up (55%) included: the Health of the Nation Outcome Scale, the Hospital Anxiety and Depression Scale, the Patient Health Questionnaire-15, the Revised Illness Perception Questionnaire, the Common Neurological Symptom Questionnaire, the Fear Questionnaire and the Canadian Occupational Performance Measure. At discharge and at 1 year follow-up patients were also asked to complete five-point self-rated scales of improvement. There were significant improvements in clinician-rated mental health and functional ability. In addition, patients reported that their levels of mood and anxiety had improved and that they were less bothered by somatic symptoms in general and neurological symptoms in particular. Two-thirds of patients rated their general health such as "better" or "much better" at discharge and this improvement was maintained over the following year. Change in HoNOS score was the only measure that successfully predicted patient-rated improvement. Our data suggest that a specialized multidisciplinary inpatient programme for FNS can provide long-lasting benefits in the majority of patients. Good outcome at discharge was exclusively predicted by improvement in the HoNOS which continued to improve over the 1 year following discharge.

The role of alexithymia in the development of functional motor symptoms (conversion disorder)

BACKGROUND

The mechanisms leading to the development of functional motor symptoms (FMS) are of pathophysiological and clinical relevance, yet are poorly understood.

AIM

The aim of the present study was to evaluate whether impaired emotional processing at the cognitive level (alexithymia) is present in patients affected by FMS. We conducted a cross-sectional study in a population of patients with FMS and in two control groups (patients with organic movement disorders (OMD) and healthy volunteers).

METHODS

55 patients with FMS, 33 patients affected by OMD and 34 healthy volunteers were recruited. The assessment included the 20-item Toronto Alexithymia Scale (TAS-20), the Montgomery-Asberg Depression Rating Scale, the Reading the Mind in the Eyes' Test and the Structured Clinical Interview for Personality Disorders.

RESULTS

Alexithymia was present in 34.5% of patients with FMS, 9.1% with OMD and 5.9% of the healthy volunteers, which was significantly higher in the FMS group (χ(2) (2)=14.129, p<0.001), even after controlling for the severity of symptoms of depression. Group differences in mean scores were observed on both the difficulty identifying feelings and difficulty describing feelings dimensions of the TAS-20, whereas the externally orientated thinking subscale score was similar across the three groups. Regarding personality disorder, χ(2) analysis showed a significantly higher prominence of obsessive-compulsive personality disorder (OCPD) in the FMS group (χ(2) (2)=16.217, p<0.001) and 71.4% of those with OCPD also reached threshold criteria for alexithymia.

CONCLUSIONS

Because alexithymia is a mental state denoting the inability to identify emotions at a cognitive level, one hypothesis is that some patients misattribute autonomic symptoms of anxiety, for example, tremor, paraesthesiae, paralysis, to that of a physical illness. Further work is required to understand the contribution of OCPD to the development of FMS.