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Neuropsychiatric Factors Linked to Adherence and Short-Term Outcome in a U.S. Functional Neurological Disorders Clinic: A Retrospective Cohort Study
Abstract
Despite advancements in the assessment and management of functional neurological disorder (FND), the feasibility of implementing a new standard of care remains unclear. Chart reviews were performed for 100 patients with motor FND to investigate factors related to treatment adherence and clinical improvement over an average follow-up of 7 months. Of 81 patients who returned for follow-up, a history of chronic pain disorder inversely correlated with improvement. Of the 50 individuals newly referred for treatment, adherence correlated with improvement, while having abnormal neuroimaging inversely correlated with improvement. This study supports the feasibility of applying a new standard of care for FND.
... 12,[16][17][18] The Massachusetts General Hospital FND Unit focuses on an outpatient multidisciplinary and interdisciplinary (nonintensive) care model informed by PT consensus recommendations. 3,15,19 Across health care settings, access to outpatient care is generally more available. ...
... Such factors can include unhelpful behavioral patterns, prominent pain, and illness beliefs among other considerations. 6,19,31 These themes are discussed further later. ...
... 36 The presence of other bodily symptoms such as pain has been linked to poor outcomes. 6,19 Given the frequent co-occurrence of core sensorimotor mFND symptoms and other bodily complaints, there have been recent calls to think holistically about mFND with prominent somatic symptoms, potentially akin to a FND plus syndrome. 31 Physical therapists should get a sense of the balance of motor versus pain/other somatic symptoms in each patient. ...
Background and purpose:
Motor functional neurological disorder is a prevalent and costly condition at the intersection of neurology and psychiatry that is diagnosed using positive "rule-in" signs. Physical therapy is a first-line treatment and consensus recommendations exist to guide clinical care. Nonetheless, optimal outpatient treatment of adults with functional motor symptoms requires an expanded physical therapy tool kit to effectively guide care.
Summary of key points:
In this article, lessons learned from a physical therapist practicing in a multidisciplinary and interdisciplinary outpatient functional neurological disorder clinic are highlighted. In doing so, we discuss how use of the biopsychosocial model and neuroscience constructs can inform physical therapy interventions. The importance of team-based care and the delivery of physical therapy through video telehealth services are also outlined.
Recommendations for clinical practice:
Use of the biopsychosocial formulation to triage clinical challenges and guide longitudinal care, coupled with application of neuroscience to aid intervention selection, allows for patient-centered physical therapy treatment across the spectrum of functional motor symptoms.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A400).
... As the diagnosis can sometimes be misunderstood as a process of elimination, it is not surprising that clinicians, from many disciplines, have difficulty sharing the diagnosis with their patients (Glass et al., 2018), often due to lack of confidence (Lehn, Bullock-Saxton, Newcombe, Carson, & Stone, 2019;Monzoni, Duncan, Grünewald, & Reuber, 2011). This is perhaps why so many patients presenting with these symptoms are left feeling misunderstood, misdiagnosed and powerless . ...
... In some cases, individuals presenting with functional symptoms have a history of adverse life events and trauma (Glass et al., 2018), but this is not the case in all presentations, and has been removed as a requirement for diagnosis in the DSM (American Psychiatric Association, 2013). However, if this is present, there is a need to focus on the treatment of the existing trauma and its integration into the formulation for treatment (Roelofs & Pasman, 2016). ...
... However, if this is present, there is a need to focus on the treatment of the existing trauma and its integration into the formulation for treatment (Roelofs & Pasman, 2016). Furthermore, research has shown that there is a high comorbidity of functional symptoms with chronic pain, and that there is an inverse correlation with improvement if there is a history of chronic pain present (Glass et al., 2018). Therefore, this too should be formulated and integrated into treatment on a case-by-case basis. ...
Functional Movement Disorders (FMD) can be identified by limb weakness, gait disorders, or involuntary movements which are inconsistent with a neurological diagnosis. Despite the prevalence of such symptoms, there has been little consensus on models for treatment. This scoping review set out to identify the literature exploring the efficacy of psychological interventions for the treatment of FMD, either as a stand-alone intervention or as part of a multi-disciplinary team approach. Studies set in an adult inpatient and outpatient setting were considered for inclusion. The final review consisted of 33 papers; 13 reviewing psychological treatments only, and 20 reviewing multidisciplinary approaches that included a psychological intervention. This review of the literature reaffirms the inconsistency across treatment for FMD, although identifies a trend towards an MDT approach in recent years. The review also identifies areas where consistency in methodology may be beneficial in future research, in order to improve the validity of results for greater comparison of treatments. There are promising outcomes that support the continued investigation focused on an interdisciplinary, collaborative approach to care, for the reduction of symptoms
... 25 This intervention is a part of an individualized, multidisciplinary treatment approach based on the clinical phenotype and the biopsychosocial formulation, which can also include physical therapy, speech and language pathology, and skill-based psychotherapy (all patients are provided education on FND). [26][27][28] This individualized treatment approach has demonstrated utility and feasibility as a transdiagnostic approach to management of patients with FND. 26,27 However, to date, the sensory-based OT program has not been systematically researched itself, including in prospective clinical trials. ...
... [26][27][28] This individualized treatment approach has demonstrated utility and feasibility as a transdiagnostic approach to management of patients with FND. 26,27 However, to date, the sensory-based OT program has not been systematically researched itself, including in prospective clinical trials. This article aims to operationalize the modules for this intervention to catalyze prospective clinical trial research aimed at further understanding the potential benefits and pitfalls of this treatment approach. ...
... Alongside the core neurological symptoms, associated physical symptoms (e.g., pain, fatigue, sleep disturbance, poor concentration, bladder and bowel dysfunction) as well as psychological symptoms (e.g., low mood, anxiety, panic, dissociative phenomena, and posttraumatic stress symptoms) are of particular clinical significance in FND patients [13][14][15][16][17]. These frequently co-occurring symptoms have been shown to negatively affect clinical outcomes [7,18], and are often at least as severe and disabling as the core features [13]. ...
... Our results support the notion that associated physical symptoms are of particular clinical significance in FND patients [13]; as has been shown previously, these symptoms negatively affect quality of life [19,20], as well as clinical outcomes [7,18], and are often as severe and disabling as the core features of FND [13]. Although pain F I G U R E 2 Network of current symptom co-occurrence. ...
Background:
Functional neurological disorder (FND) is common, and symptoms can be severe. There have been no international large-scale studies of patient experiences of FND.
Methods:
We created a patient questionnaire to assess FND patient characteristics, symptom comorbidities, and illness perceptions. Respondents were recruited internationally through an open access questionnaire via social media and patient groups over a month-long period.
Results:
In total, 1048 respondents from sixteen countries participated. Mean age was 42 years (86% female). Median FND symptom duration was five years, and median time from first symptom to diagnosis was two years. Mean number of current symptoms (core FND and associated) was 9.9. Many respondents had associated symptoms, for example fatigue (93%), memory difficulties (80%), and headache (70%). Self-reported psychiatric comorbidities were relatively common (depression (43%), anxiety (51%), panic (20%), and post-traumatic stress disorder (22%)). Most respondents reported that FND had multiple causes, including physical and psychological.
Conclusions:
This large survey adds further evidence that people with FND typically have high levels of multiple symptom comorbidity with resultant distress. It also supports the notion that associated physical symptoms are of particular clinical significance in FND patients. Dualistic ideas of FND were not supported by respondents, who generally preferred to conceptualise the disorder as one at the interface of mind and brain. We highlight the need for a broad approach to this poorly served patient group. Potential selection and response biases due to distribution of the survey online, mostly via FND patient groups, is a key limitation.
... In FND, pain is common and clinically-relevant (Glass et al., 2018). For example, in a large cohort (n=107) of patients with functional limb weakness, pain beyond the affected limb (64%), headache (40%) and back pain (38%) were frequently present and https://mc.manuscriptcentral.com/braincom ...
... The above overlapping characteristics between DSM-IV-SD and FND have relevant clinical and research implications in FND based on 3 additional observations: 1) pain is a common comorbid symptom in FND (including particularly high rates in pediatric FND (Kozlowska et al., 2007)) that can limit treatment engagement and incur a poor prognosis (Glass et al., 2018); 2) a subset of FND patients meet criteria for comorbid DSMhttps://mc.manuscriptcentral.com/braincom IV-SD (Interian et al., 2004;Schrag et al., 2004;Marchetti et al., 2008;Stone et al., 2010b;Epstein et al., 2016); 3) comorbid DSM-IV-SD in FND is associated with a poor prognosis (Gelauff et al., 2019). ...
With the creation of the Somatic Symptom and Related Disorders category of the Diagnostic and Statistical Manual of Mental Disorders–Fifth Edition (DSM-5) in 2013, the functional neurological (symptom) disorder diagnostic criteria underwent transformative changes. These included an emphasis on “rule-in” physical examination signs/semiological features guiding diagnosis and the removal of a required proximal psychological stressor to be linked to symptoms. Additionally, the DSM–Fourth Edition (DSM-IV) somatization disorder, somatoform pain disorder and undifferentiated somatoform disorder conditions were eliminated and collapsed into the DSM-5 somatic symptom disorder diagnosis. With somatic symptom disorder, emphasis was placed on a cognitive-behavioral (psychological) formulation as the basis for diagnosis in individuals reporting distressing bodily symptoms such as pain and fatigue; the need for bodily symptoms to be “medically unexplained” was removed, and the overall utility of this diagnostic criteria remains debated. A consequence of the DSM-5 restructuring is that the diagnosis of somatization disorder that encompassed individuals with functional neurological (sensorimotor) symptoms and prominent other bodily symptoms, including pain, was eliminated. This change negatively impacts clinical and research efforts because many patients with functional neurological disorder experience pain, supporting that the DSM-5 would benefit from an integrated diagnosis at this intersection. We seek to revisit this with modifications, particularly since pain (and a DSM-IV somatization disorder comorbidity, more specifically) is associated with poor clinical prognosis in functional neurological disorder. As a first step, we systematically reviewed the DSM-IV somatization disorder literature to detail epidemiologic, healthcare utilization, demographic, diagnostic, medical and psychiatric comorbidity, psychosocial, neurobiological and treatment data. Thereafter, we propose a preliminary revision to DSM-5 allowing for the specifier functional neurological disorder “with prominent pain”. To meet this criteria, core functional neurological symptoms (e.g., limb weakness, gait difficulties, seizures, non-dermatomal sensory loss, and/or blindness) would have “rule-in” signs and pain (> 6 months) impairing social and/or occupational functioning would also be present. Two optional secondary specifiers assist in characterizing individuals with cognitive-behavioral (psychological) features recognized to amplify or perpetuate pain and documenting if there is a pain-related comorbidity. The specifier of “with prominent pain” is etiologically neutral, while secondary specifiers provide additional clarification. We advocate for a similar approach to contextualize fatigue and mixed somatic symptoms in functional neurological disorder. While this preliminary proposal requires prospective data and additional discussion, these revisions offer the potential benefit to readily identify important functional neurological disorder subgroups - resulting in diagnostic, treatment and pathophysiology implications.
... 21,22 Here, we provide a framework for the initial assessment and management of mFND modeled in part after the example of the Massachusetts General Hospital FND Clinic. 6,[23][24][25][26] Using the approach detailed below, Glass et al previously reported in 81 consecutive patients with at least one follow-up that 42% noted some degree of clinical improvement at 7 months. 23 While emphasis on neurological examination and semiological features aids the neurologist's role in diagnosis, a comprehensive assessment guiding the development of a patientcentered treatment plan benefits from interdisciplinary neurologic, psychiatric, allied mental health and rehabilitation perspectives. ...
... 6,[23][24][25][26] Using the approach detailed below, Glass et al previously reported in 81 consecutive patients with at least one follow-up that 42% noted some degree of clinical improvement at 7 months. 23 While emphasis on neurological examination and semiological features aids the neurologist's role in diagnosis, a comprehensive assessment guiding the development of a patientcentered treatment plan benefits from interdisciplinary neurologic, psychiatric, allied mental health and rehabilitation perspectives. 14 Sections of this article outline the neuropsychiatric history, physical examination, delivery of the diagnosis, treatment planning, physical rehabilitation, and psychological treatments. ...
Functional neurological disorder (FND), a condition at the intersection of neurology and psychiatry, is a common and disabling outpatient referral to neurology and neuropsychiatry clinics. In this perspective article, we focus on the motor spectrum of FND (mFND), including individuals with functional movement disorders (FND-movt), functional limb weakness/paresis (FND-par) and functional [psychogenic non-epileptic/dissociative] seizures (FND-seiz). Over the past several decades, there have been dedicated efforts within the neurologic and psychiatric communities to create “rule-in” diagnostic criteria, as well as thoughtful approaches to the clinical interview, delivery of the diagnosis and the development of a patient-centered treatment plan. These advances allow the promotion of good clinical practices in the outpatient assessment and management of mFND. Informed by the literature and our prior clinical experiences, we provide suggestions on how to evaluate individuals with suspected functional motor symptoms - including conducting sensitive psychiatric and psychosocial screenings. Additional sections discuss common “rule-in” neurological examination and semiologic signs of motor FND, as well as approaches to deliver the diagnosis and formulate a treatment plan based on individual patient needs. To aid the development of shared (partially overlapping) expertise that catalyzes an interdisciplinary approach to mFND, the use of physiotherapy for therapeutic motor retraining and cognitive behavioral therapy to examine relationships between symptoms, thoughts, behaviors and emotions are also discussed. Additional clinical research is needed to further refine and operationalize the assessment and management of mFND, across clinics, healthcare settings and countries.
... female predominance, high rates of depressionanxiety and adverse life event burden (Guz et al., 2004;Paras et al., 2009;Taylor, 2003)) further raising the possibility of a partially overlapping biology. Comorbid somatic symptoms in patients with FND also negatively impact healthcare utilization and prognosis (Ettinger et al., 1999;Glass et al., 2018;Ibrahim et al., 2009;Salinsky et al., 2016). ...
... Given the frequent co-occurrence of FND with other functional somatic disorders (i.e. fibromyalgia, irritable bowel syndrome) and chronic pain disorders, as well as their negative impact on clinical outcomes (Glass et al., 2018), it is notable that individuals with chronic back pain, chronic tension headache, and fibromyalgia exhibit neurocircuit alterations within the central pain matrix which strikingly overlap with many of the regions identified in the FND and SSD literature (Denk et al., 2014;Kuchinad et al., 2007;Schmidt-Wilcke et al., 2006;Schmidt-Wilcke et al., 2005;Yuan et al., 2017). Furthermore, prefrontal-striatal-thalamic-limbic structural alterations have also been described in fibromyalgia, irritable bowel syndrome and/or chronic fatigue syndrome (Cagnie et al., 2014;Finkelmeyer et al., 2018;Labus et al., 2014;Seminowicz et al., 2010;Shi et al., 2016). ...
Functional neurological (conversion) disorder (FND) is a condition at the interface of neurology and psychiatry. A “software” vs. “hardware” analogy describes abnormal neurobiological mechanisms occurring in the context of intact macroscopic brain structure. While useful for explanatory and treatment models, this framework may require more nuanced considerations in the context of quantitative structural neuroimaging findings in FND. Moreover, high co-occurrence of FND and somatic symptom disorders (SSD) as defined in DSM-IV (somatization disorder, somatoform pain disorder, and undifferentiated somatoform disorder; referred to as SSD for brevity in this article) raises the possibility of a partially overlapping pathophysiology. In this systematic review, we use a transdiagnostic approach to review and appraise the structural neuroimaging literature in FND and SSD. While larger sample size studies are needed for definitive characterization, this article highlights that individuals with FND and SSD may exhibit sensorimotor, prefrontal, striatal-thalamic, paralimbic, and limbic structural alterations. The structural neuroimaging literature is contextualized within the neurobiology of stress-related neuroplasticity, gender differences, psychiatric comorbidities, and the greater spectrum of functional somatic disorders. Future directions that could accelerate the characterization of the pathophysiology of FND and DSM-5 SSD are outlined, including “disease staging” discussions to contextualize subgroups with or without structural changes. Emerging neuroimaging evidence suggests that some individuals with FND and SSD may have a “software” and “hardware” problem, although if structural alterations are present the neural mechanisms of functional disorders remain distinct from lesional neurological conditions. Furthermore, it remains unclear whether structural alterations relate to predisposing vulnerabilities or consequences of the disorder.
... Forty-six patients with a diagnosis of motor FND were recruited from the Massachusetts General Hospital FND Clinic. 19 Thirty-four of 46 initially enrolled patients successfully completed 6-month follow-up questionnaires (mean age = 41.3 § 11.6; 28 women, 6 men; illness duration = 3.6 § 4.0 years) and 12 were lost to follow-up due to failed attempts to reach patients via phone. The average interval between baseline and follow-up visits was 6.3 § 1.0 months (range = 4.6À9.4 ...
... 13,94 In clinical practice, many patients participate in several evidence-based treatments concurrently, highlighting the importance of patientcentered, and multidisciplinary approaches. 19 Limitations of this study include lack of objective symptom severity measurements, relatively short follow-up interval, small sample size, mixed cohorts, 26% loss to follow-up, and that treatment was not limited to 1 institution. However, outcome measures for FND have yet to be standardized, and more objective measures of symptom severity are difficult to apply across motor FND subtypes. ...
Background:
The relationships between baseline neuropsychiatric factors and clinical outcome in patients with functional neurological disorder (FND)/conversion disorder remain poorly understood.
Objective:
This prospective, naturalistic pilot study investigated links between predisposing vulnerabilities (risk factors) and clinical outcome in patients with motor FND engaged in usual care within a subspecialty FND clinic.
Methods:
Thirty-four patients with motor FND were enrolled and completed baseline and 6-month follow-up psychometric questionnaires. Univariate screening tests followed by multivariate linear regression analyses were used to investigate neuropsychiatric predictors of 6-month clinical outcome in patients with motor FND.
Results:
In univariate analyses, baseline secure attachment traits and depression as measured by the Relationship Scales Questionnaire and Beck Depression Inventory-II positively correlated with improved Patient Health Questionnaire-15 scores. In a multivariate linear regression analysis adjusting for the interval time between baseline and follow-up data collection, baseline secure attachment and depression scores independently predicted improvements in Patient Health Questionnaire-15 scores. In additional analyses, patients with a diagnosis of psychogenic nonepileptic seizures compared to individuals with other motor FND subtypes showed a trend toward worse 6-month physical health outcomes as measured by the Short Form Health Survey-36.
Conclusion:
Future large-scale, multi-site longitudinal studies are needed to comprehensively investigate neuropsychiatric predictors of clinical outcome in patients with motor FND, including functional weakness, functional movement disorders, and psychogenic nonepileptic seizures.
... 23 In a study of 81 patients with FND, those with a chronic pain disorder were less likely to show overall clinical improvement at 7-month follow-up (12% improved compared with 34% without a pain diagnosis). 25 A cluster analysis of 48 patients with functional dystonia found that patients who were more likely to experience progressive deterioration also more often had a CRPS diagnosis or described prominent pain. 20 ...
Background
Functional neurological disorder (FND) is characterised by neurological symptoms, such as seizures and abnormal movements. Despite its significance to patients, the clinical features of chronic pain in people with FND, and of FND in people with chronic pain, have not been comprehensively studied.
Methods
We systematically reviewed PubMed, Embase and PsycINFO for studies of chronic pain in adults with FND and FND in patients with chronic pain. We described the proportions of patients reporting pain, pain rating and timing, pain-related diagnoses and responsiveness to treatment. We performed random effects meta-analyses of the proportions of patients with FND who reported pain or were diagnosed with pain-related disorders.
Results
Seven hundred and fifteen articles were screened and 64 were included in the analysis. Eight case–control studies of 3476 patients described pain symptoms in a higher proportion of patients with FND than controls with other neurological disorders. A random effects model of 30 cohorts found that an estimated 55% (95% CI 46% to 64%) of 4272 patients with FND reported pain. Random effects models estimated diagnoses of complex regional pain syndrome in 22% (95% CI 6% to 39%) of patients, irritable bowel syndrome in 16% (95% CI 9% to 24%) and fibromyalgia in 10% (95% CI 8% to 13%). Five studies of FND diagnoses among 361 patients with chronic pain were identified. Most interventions for FND did not ameliorate pain, even when other symptoms improved.
Conclusions
Pain symptoms and pain-related diagnoses are common in FND. Classification systems and treatments should routinely consider pain as a comorbidity in patients with FND.
... A notable observation is that a subset of patients in the asymptomatic and improved categories were "on or applying for disability" and/or endorsed other bodily symptoms such as pain, fatigue, and cognitive complaints. These factors in other FND populations have been associated with poor clinical outcomes and reduced quality of life (Gelauff & Stone, 2016;Glass et al., 2018;Maggio et al., 2020;Věchetová et al., 2018). For example, a concurrent diagnosis of somatization disorder (indicative of prominent bodily complaints including pain) correlated with poor prognosis in a 14-year prospective study of clinical outcomes in patients with functional weakness (Gelauff et al., 2019). ...
Background:
While expert consensus recommendations support the use of speech and language therapy (SLT) for patients with functional speech disorder (FND-speech), there is limited published data on clinical outcomes.
Objective:
To retrospectively report the treatment outcomes and clinical characteristics of patients with FND-speech that attended outpatient SLT as part of a multidisciplinary program for functional neurological disorder (FND).
Methods:
In this case series, we included adult patients with FND-speech that consecutively participated in outpatient SLT at our institution between October 2014 and September 2021. Baseline demographic and neuropsychiatric characteristics were extracted from the medical records, along with data on FND-speech phenotypes, number of treatment sessions received, and clinician-determined outcomes. Only descriptive statistics were used to report findings.
Results:
Twenty patients met inclusion criteria; ages ranged from 21-77, with a mean of 51.6±16.2 years. 85% of the cohort presented with mixed FND-speech symptoms. Patients attended a range of 2-37 visits, with an average of 9.2±8.0 visits over 4.4±3.5 months. At the last treatment session, 3 patients were asymptomatic, 15 had improved, and 2 had not improved; 8 individuals that improved received video telehealth interventions.
Conclusion:
This case series lends additional support for outpatient SLT in the assessment and management of individuals with FND-speech, and may help clarify patient and provider treatment expectations. Additional prospective research is needed to investigate baseline predictors of treatment response and further define the optimal frequency, intensity, duration, and clinical setting for SLT delivery in this population.
... The Alfred functional seizure clinic in its first year of operations, is an early example of public outpatient services for FS and is feasible and potentially effective. Standalone clinics have been established elsewhere for FS and FND more broadly, and provide helpful models [31,33,[37][38][39]. This clinic provides further evidence towards a model for establishing a dedicated service for functional seizure patients adjacent to epilepsy services with well-established infrastructure and resources, and in doing so, improving the care and services for a highly under-served and disabled patient population. ...
Objectives:
We performed an audit of the first 12 months of clinical operations to assess the feasibility of a newly established public outpatient clinic for the assessment and treatment of functional (psychogenic nonepileptic) seizures (FS).
Method:
Clinical notes for the first 12 months of the FSclinic weresystematicallyreviewed with data compiled onreferral pathways, clinic attendance, clinical features, treatments, and outcomes.
Results:
Of eighty-two new FS patients referred to the clinic, over 90% attended. Patients were diagnosed with FS after comprehensive epileptological and neuropsychiatric review, mostly with typical seizure-like episodes captured during video-EEG monitoring, and most accepted the diagnosis. Most had FS at least weekly, with little sense of control and significant impairment. The majority of individuals had significant psychiatric and medical comorbidity. Predisposing, precipitating, and perpetuating factors were readily identified in >90% of cases. Of 52 patients with follow-up data within12 months, 88% were either stable or improved in terms of the control of their FS.
Conclusion:
The Alfred functional seizure clinic model, the first dedicated public outpatient clinic for FS in Australia, provides a feasible and potentially effective treatment pathway for this underserved and disabled patient group.
... There was a tendency for fatigue and pain symptoms to be present. These symptoms are frequently found in FND (16,19,20) and have been deemed to negatively influence long-term prognosis (21). Again, this may have been due to the relatively small sample size. ...
Objective:
Functional neurological disorder (FND) is frequently encountered in clinical practice but commonly misdiagnosed, which might lead to higher direct costs for the health care system. The investigators analyzed the direct costs associated with the diagnosis of FND compared with costs associated with other neurological conditions and explored possible cost trends related to the clinical and demographic features of FND.
Methods:
Consecutive patients attending a general neurology clinic were recruited and underwent a structured assessment aimed to collect information pertaining to their demographic and clinical characteristics, as well as data regarding their prior diagnostic processes (e.g., the number of consulted specialists, number and type of investigations, emergency department visits, etc.). The costs were hence calculated and compared between the study groups.
Results:
A total of 155 consecutive patients were recruited; of these, 18.6% had FND, 55.84% had one or more other neurological disorder (OND), and 27.10% presented with comorbid FND and OND. The total prediagnostic costs (in euros [€]) were higher in the FND group compared with the OND group (median=€289, interquartile range [IQR] €385 vs. median=€98, IQR €216; Mann-Whitney U=879.5, p=0.04). There was a higher diagnostic delay in the FND group compared with the OND group (median=48 months, IQR 60 months vs. median=12 months, IQR 6 months; Mann-Whitney U=162.00, p<0.01). Diagnostic delay significantly correlated with the total costs in the entire study sample (Spearman's ρ=0.25, p=0.003) but more strongly in the FND group (Spearman's ρ=0.81, p<0.001). In the FND group, higher numbers of investigations and costs were associated with the presence of a physiological or psychological trigger and multiple symptoms.
Conclusions:
Delayed diagnosis of FND significantly affects health care system costs, and raising awareness about FND to improve the diagnostic process and outcomes is necessary.
... When considering use of medications to treat concurrent symptoms (insomnia, pain, depression, anxiety, and PTSD), it is important to recognize that patients with FND who are at times hyperattuned to their body may have greater tendencies toward medication intolerances or sensitivities. 112,113 As such, prescribers should educate patients on this possibility upfront and note that if FND symptoms initially flare up, this does not necessarily imply a clear medication side effect but that upward titration schedules will "start low and go slow." Additionally, use of antiseizure medications requires explicit mentioning. ...
There is a growing body of knowledge regarding management of functional neurological disorder (FND). The aim of this article is to guide the clinician through FND clinical management, from delivery of the diagnosis, to creation of a biopsychosocially-informed treatment plan, to troubleshooting common issues that arise throughout longitudinal care. We review the evidence and core principles of both rehabilitative therapies (physical therapy, occupational therapy, and speech and language therapy) and psychological therapies for the treatment of FND, and discuss the benefits of engaging a multidisciplinary and interdisciplinary team. The optimal timing of specific therapeutic interventions is also discussed, emphasizing a patient-centered perspective. Resources for further reading, for both patients and clinicians, are provided throughout. Additional research is needed to further optimize the therapeutic approach to patients with FND, including the need to develop novel treatments for those that do not positively respond to currently available interventions.
... The LC-NE system can activate amygdala, which responds by sending signals to the hypothalamus, which in turn stimulates the PNS NE activity. "Core" FND symptoms include weakness, seizures or paralysis, other movement disorders (such as tremor, dystonia, abnormal gait, and myoclonus), and sensory disorders (including vision, physical sensation, and auditory impairment) (Jones et al., 2016), as well as symptoms including pain, fatigue, sleep disturbance, inattention, and memory cognitive impairment (Glass et al., 2018;Nicholson et al., 2020). It is not difficult to find that most of the core symptoms of FND and other related physical and psychological symptoms are consistent with the deficits of NE, because NE has been known to have the function of arousal, and antiepileptic effects. ...
Functional neurologic disorders (FNDs), also called conversion disorder (previously called hysteria), can show almost all the symptoms of other neurological diseases, including both physical (for example, seizure, weakness, fatigue) and psychological (for instance, depression, anxiety) symptoms. In spite of our general knowledge about emotional processes and developmental defects in the formation of these somatic symptoms, there is still no systemic and comprehensive research on the effects of emotional developmental variables in FND. Recently, both experimental and theoretical emotion studies have been greatly increased, such as prediction error, conceptual act model, basic emotional theory, and monoamine neuromodulator based three primary emotions. In addition, a large amount of evidence has confirmed the role of psychosocial adversity (such as stressful life events, interpersonal difficulties) as an important risk factor for FND. Here, we review recent advances about emotional stress on FND, and pay special attention to the effects of monoamine neuromodulators, such as how norepinephrine and serotonin affect behaviors. Then, we discuss the significance of these changes for FND, which may contribute to clarifying the pathogenesis of FND, and thus provide potential therapeutic drug targets or psychological intervention methods in the future.
... Beyond these core symptoms, many other physical and psychological symptoms are commonly reported in FND that have been shown to negatively affect health-related quality of life (39,40) and clinical outcomes (41,42). These symptoms include pain, fatigue, sleep disturbance, poor concentration, bladder and bowel dysfunction, and psychological symptoms, such as depression, anxiety, panic, dissociative phenomena (e.g., depersonalization), and posttraumatic stress symptoms (43,44). ...
The development and selection of optimal outcome measures is increasingly recognized as a key component of evidence-based medicine, particularly the need for the development of a standardized set of measures for use in clinical trials. This process is particularly complex for functional neurological disorder (FND) for several reasons. FND can present with a wide range of symptoms that resemble the full spectrum of other neurological disorders. Additional physical (e.g., pain, fatigue) and psychological (e.g., depression, anxiety) symptoms are commonly associated with FND, which also can be highly disabling with implications for prognosis, and warrant concurrent assessment, despite an unclear etiological relationship with FND. Furthermore, several unique clinical aspects of FND make it likely that the usual prioritization of "objective" (or clinician-rated) over "subjective" (or patient-rated) measures might not be appropriate. Self-report measures may be more clinically meaningful in this patient population. Despite being a common and disabling disorder, there has been little research into outcome measures in FND, and to date trials have largely used measures designed for the assessment of other disorders. An international FND Core Outcome Measure group (FND-COM) has been established to develop a consensus battery of outcomes for FND: a "core outcome set." In this perspective article, the authors reviewed the process of outcome measure development and selection before considering the specific features of FND affecting the development of a core outcome set, as well as a research agenda to optimize outcome measurement in this complex neuropsychiatric disorder.
... Once a patient and the immediate family are receptive to the diagnosis, the core components of treatment for functional dystonia and related functional motor symptoms include physical interventions (e.g., physical therapy, occupational therapy), [28][29][30] psychological interventions (including a component of cognitive-behavioral therapy [CBT] to explore the interactions between functional neurological symptoms, thoughts, behaviors, emotions, and psychosocial factors), 31,32 and management of comorbid psychiatric and somatic (e.g., pain, fatigue) symptoms that may have prognostic implications. [33][34][35] While the above components are core aspects of treatment, the identification of patient-specific predisposing vulnerabilities, acute precipitants, and perpetuating factors should be elucidated to help individualize treatments with these factors in mind. 36 In this case, predisposing vulnerabilities included early-life separation anxiety, dyslexia with academic difficulties, bullying at school, tendency to not verbalize stress and affective symptoms to supports, and the concurrent presence of another functional somatic disorder (irritable bowel syndrome). ...
... FND clinics can also provide time and expertise to triage patients into appropriate treatment, paying specific attention to individuals with comorbidities such as fatigue and pain, which have a worse prognosis (17). ...
Objective:
A growing interest in functional neurological disorders (FND) has led to the development of specialized clinics. This study aimed to better understand the structure and role of such clinics.
Methods:
Data were retrospectively collected from clinical records at three national referral centers, two specifically for motor FND and one for FND in general. Data were for 492 consecutive patients referred over a 9- to 15-month period: 100 from the United Kingdom clinic, 302 from the Swiss clinic, and 90 from the Canadian clinic. Data included symptom subtype and duration, comorbid pain and fatigue, disability, and treatment recommendations.
Results:
The mean age of the 492 patients was 44 years, and most (73%) were female. Most had a prolonged motor FND (mean symptom duration of 6 years); 35% were not working because of ill health, 26% received disability benefits, and up to 38% required a care giver for personal care. In the Swiss cohort, 39% were given a diagnosis of another somatic symptom disorder rather than an FND diagnosis. Pain was common in the United Kingdom (79%) and Canada (56%), as was fatigue (48% and 47%, respectively). Most patients (61%) were offered physiotherapy; referral to neuropsychiatry or psychology differed across centers (32%-100%).
Conclusions:
FND specialty clinics have an important role in ensuring correct diagnosis and appropriate treatment. Most patients with motor FND require specialized neurophysiotherapy. Patients readily accepted an integrated neuropsychiatric approach. Close collaboration between FND clinics and acute neurology facilities might improve early detection of FND and could improve outcomes.
... Individual informed consent was not required for this study. We reviewed the medical charts of 50 consecutive outpatients (female, N=40; male, N=10) who were referred for physical therapy from a subspecialty FND clinical program at Massachusetts General Hospital between May 2016 and October 2018 (16,17). Referred patients were diagnosed with motor FND using established DSM-5 diagnostic criteria supportive of a clinically established functional movement disorder (N=42; gait disorder, N=15, tremor, N=12, dystonia, N=4, mixed, N=11) and/or functional limb weakness (N=21) (18). ...
Objective:
Despite promising research and consensus recommendations on the important therapeutic role of physical therapy for motor functional neurological disorder (FND), little is known about the feasibility and potential efficacy of implementing physical therapy for this population in a U.S.-based outpatient program. Given health care system differences internationally, this is an important gap in the literature.
Methods:
In this retrospective cohort study, the authors investigated the relationship between treatment adherence and clinical outcome in a hospital-based outpatient physical therapy clinical program. Medical records of 50 consecutive patients with motor FND referred from an FND clinical program were reviewed. The physical therapy intervention included a 1-hour initial assessment and the development of individualized treatment plans guided by published consensus recommendations. Statistical analyses included nonparametric, univariate screening tests followed by multivariate regression analyses.
Results:
In univariate analyses, there was a statistically significant positive correlation between the number of sessions attended and clinical improvement. This relationship held when adjusting for demographic variables, concurrent psychogenic nonepileptic seizures, and other major neurological comorbidities. In a post hoc analysis of the subset of individuals with available gait speed data, posttreatment 10-meter gait speed times improved compared with baseline measurements. Baseline neuropsychiatric factors did not correlate with clinical improvement.
Conclusions:
This preliminary, retrospective cohort study demonstrated that treatment adherence to a U.S.-based outpatient physical therapy program was associated with clinical improvement. Prospective observational and randomized controlled trials are needed to further optimize physical therapy for patients with functional motor symptoms in the outpatient setting.
... 13 Although pain is not a critical diagnostic feature of FND according to DSM and other diagnostic models, chronic pain comorbidity has been long-demonstrated in great numbers among patients with FND 14 ; in fact, the presence of comorbid chronic pain has been inversely correlated with clinical outcomes in FND. 15 These shared clinical observations and treatment response patterns-particularly interdisciplinary and rehabilitation methods-suggest potential iCPRP benefit to patients with FND. FND-specific programs are rare and early in development, [16][17][18] whereas iCPRPs and other pain-focused rehabilitation programs are more commonly available and established. ...
Background:
Functional neurological disorder (FND) is difficult to treat and costly. Interdisciplinary chronic pain rehabilitation programs (iCPRPs) are multidimensional functional restoration interventions for pain; their impact on FND specifically has not been assessed.
Objective:
The purpose of this study was to assess iCPRP's impact on functioning in FND.
Methods:
Data were examined retrospectively from an Institutional Review Board-approved registry capturing admission and discharge data from patients participating in an outpatient iCPRP. Subjective measures included pain-related disability, depression, anxiety, and stress scores, whereas objective measures included physical functioning measures (timed up and go, stair climbing test, and 6-min walk test). Pre-iCPRP and post-iCPRP measures were compared using a paired t-test approach.
Results:
Forty-nine FND patients completed care and showed pre-measures and postmeasures. Statistically significant reductions in subjective measures of pain-related disability (46.40-20.91; P < 0.001, d = 1.92), depression (20.38-4.81; P < 0.001, d = 1.53), anxiety (15.09-6.29; P < 0.001, d = 1.18), and stress (21.96-9.70; P < 0.001, d = 1.21) scores were observed. Statistically significant changes in objective measures of mean timed up and go scores (decreased from 15.96 to 8.87 s), stair climbing test scores (increased from 40.98 to 71.93 steps), and mean 6-minute walk test scores (increased from 0.21 to 0.30 miles) were also observed across the group.
Conclusions:
While preliminary and based on a small patient sample, these findings support the use of interdisciplinary care models for FND treatment. Clinical and investigational implications are explored.
... 13 Despite the increased understanding of the neurobiology of PNES and related motor FNDs, 11,13 there are few effective treatments, and many patients remain symptomatic despite treatment adherence. 14,15 The neuroimaging literature has identified broadly distributed neural circuit alterations in FND, including involvement of right-lateralized temporoparietal regions. 12 Several studies have connected the right TPJ to the pathophysiology of FND, including, for example, an fMRI study which showed right TPJ hypoactivation and diminished right TPJsensorimotor functional connectivity in 8 patients with functional tremor. ...
Background
Psychogenic non-epileptic seizures (PNES) may involve hypoactivity in the right temporoparietal junction (TPJ), suggesting a promising target for therapeutic neuromodulation. In this proof-of-concept case series, we aimed to investigate the tolerability and potential efficacy of high frequency repetitive Transcranial Magnetic Stimulation (rTMS) over the right TPJ to decrease non-epileptic seizure rates.
Methods
Seven subjects with video-EEG documented PNES without comorbid epileptic seizures were recruited. The rTMS protocol involved thirty stimulation sessions administered twice per day over three weeks. Each session consisted of three thousand pulses of high frequency (10 Hz) rTMS applied over the right TPJ. Tolerability was monitored throughout treatment. Weekly PNES counts were recorded at baseline, during treatment, and at post treatment intervals as the primary outcome measure. Additional psychometric scales assessing dissociation and functional neurological symptoms were collected at baseline and within 1-week post treatment as secondary outcome measures.
Results
Treatment with rTMS was well tolerated by all participants. Participants reported a decrease in weekly seizure rates post vs. pre-treatment, which was sustained at 3-month follow-up. Improvement was also reported on the Dissociative Experiences Scale and the Conversion Disorder Subscale of the Screening for Somatoform Symptoms-7 Scale.
Conclusion
High-frequency rTMS over the right TPJ represents a promising treatment for PNES that warrants additional research.
... For example, mindfulness-based relaxation response and stress-management training programs are linked to improved coping and a heightened sense of selfefficacy, along with reduced depression and anxiety [78]. Given that a subset of patients with FND remain symptomatic despite receiving an updated standard of care [79], future studies should investigate the utility of adjunctive mind-body interventions in the management of FND. ...
Objective:
Reduced resilience, a construct associated with maladaptive stress coping and a predisposing vulnerability for Functional Neurological Disorders (FND), has been under-studied compared to other neuropsychiatric factors in FND. This prospective case-control study investigated self-reported resilience in patients with FND compared to controls and examined relationships between resilience and affective symptoms, personality traits, alexithymia, health status and adverse life event burden.
Methods:
50 individuals with motor FND and 47 healthy controls participated. A univariate test followed by a logistic regression analysis investigated group-level differences in Connor-Davidson Resilience Scale (CD-RISC) scores. For within-group analyses performed separately in patients with FND and controls, univariate screening tests followed by multivariate linear regression analyses examined factors associated with self-reported resilience.
Results:
Adjusting for age, gender, education status, ethnicity and lifetime adverse event burden, patients with FND reported reduced resilience compared to controls. Within-group analyses in patients with FND showed that individual-differences in mental health, extraversion, conscientiousness, and openness positively correlated with CD-RISC scores; post-traumatic stress disorder symptom severity, depression, anxiety, alexithymia and neuroticism scores negatively correlated with CD-RISC scores. Extraversion independently predicted resilience scores in patients with FND. In control subjects, univariate associations were appreciated between CD-RISC scores and gender, personality traits, anxiety, alexithymia and physical health; conscientiousness independently predicted resilience in controls.
Conclusion:
Patients with FND reported reduced resilience, and CD-RISC scores covaried with other important predisposing vulnerabilities for the development of FND. Future research should investigate if the CD-RISC is predictive of clinical outcomes in patients with FND.
... Asimismo, factores como el proceso de neurorrehabilitación funcional, la frecuencia de las terapias [17,18], la percepción del cumplimiento por parte del profesional de la salud [5,6], la percepción de mejoría por parte del usuario [19][20][21] y las complicaciones o los efectos secundarios resultado de los procesos terapéuticos [18,22,23] muestran un impacto directo sobre el cumplimiento y la adherencia a dichos procesos. Igualmente, en el factor que tiene que ver con la discapacidad, se han descrito relaciones de la adherencia terapéutica con la condición funcional [24], la progresión de la enfermedad [22], la severidad de la enfermedad [15,22,25] y las comorbilidades [22,26,27]. Por último, respecto a los factores asociados al paciente, el nivel de motivación en el proceso de rehabilitación [12,21], la importancia dada en el proceso de recuperación [11,28], la comprensión del proceso [21,29] y la esperanza [15,30] son considerados elementos importantes para la adherencia a procesos de neurorrehabilitación funcional. ...
OBJECTIVE: to design an assessment instrument for the adherence of adult patients to long-term functional Neurorehabilitation processes, based on the dimensions of the who, and evaluate its internal characteristics and content validity. METHODOLOGY: 100 patients diagnosed with neurological injury participated in the internal consistency tests, and a non-probability sampling was carried out on the subjects. Health professionals whose area of expertise is Functional Neurorehabilitation participated in the content validation tests. Internal consistency tests were applied in order to validate the tool using Cronbachs alpha coefficient. RESULTS: taking into account all factors and each of the sman instruments items, the Cronbach Alpha coefficient was 0.835, demonstrating good internal consistency and longitudinal validity. CONCLUSSION: the factorial structure of the sman resulting from this research and the items which comprise it, show satisfactory reliability, demonstrated through the internal consistency test which showed the tools homogeneity. This demonstrated the degree with which the elements that make up the scale measure the same concept.
Purpose:
To describe the therapy approaches and clinical outcomes of an integrated care model for patients with functional movement disorder (FMD).
Materials and methods:
A retrospective chart review was conducted for all treated individuals with a primary diagnosis of FMD between January 2020 and July 2022. Patients received time-limited integrated therapy (n = 21) (i.e., simultaneous therapy delivered by psychiatry, neurology and physiotherapy), physiotherapy (n = 18) or virtual physiotherapy alone (n = 9). Primary outcomes included the Simplified-Functional Movement Disorders Rating Scale (S-FMDRS) and Clinical Global Impression-Improvement scale (CGI-I) collected at baseline and post-intervention.
Results:
Forty-eight patients completed treatment (42% male; mean age, 48.5 ± 16.6 years, median symptom duration 30 months). The most common presentations were gait disorder, tremor and mixed hyperkinetic FMD. Common comorbidities included pain and fatigue. Three-quarters of patients had a comorbid psychiatric diagnosis. There was a significant reduction in S-FMDRS score following therapy (71%, p < 0.0001) and 69% had "much" or "very much" improved on the CGI-I. There was no difference between therapy groups. Attendance rates were high for both in-person (94%) and virtual (97%) visits.
Conclusions:
These findings support that a time-limited integrated model of care is feasible and effective in treating patients with FMD.
This chapter gives an overview and update on functional neurological disorder (FND), also known as dissociative neurological symptom disorder and previously known as conversion disorder. FND is the presence of neurological symptoms that are not explained or explainable by a neurological disorder. FND has been assumed to be a purely stress-related psychiatric disorder, but over the recent decades, this simplistic conception has been supplanted by more nuanced models of symptom generation. FND is no longer a diagnosis of exclusion. Instead, wherever possible, it is ruled-in by distinct features of history and examination, the latter known as positive clinical signs. There have been concurrent advances in the biological understanding of FND, exemplified by functional neuroimaging studies that have indicated that FND can be distinguished from, for example, feigned symptoms mimicking the disorder. FND encompasses multiple subtypes, from seizures to motor disorders to sensory abnormalities. Symptoms often co-occur, sometimes in a striking fashion.
Current treatment options for FND are limited, and many patients have severe long-term symptoms despite best-available treatment including psychological therapies and medication. Nevertheless, there are simple, and sometimes effective, steps that clinicians can take to manage and treat patients.
Objectives
We report routinely collected outcome data from an 8-week outpatient rehabilitative therapy program. The aims of the intervention were to (1) reduce symptom severity and (2) improve functional mobility in adults with functional neurological disorder (FND).
Methods
The program delivered individual physiotherapy, cognitive behavioral therapy (CBT) and self-management sessions, group physiotherapy, and psychoeducation. Outcome measures included the Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI-II), Work and Social Adjustment Scale (WSAS), 10-Meter Walk Test (10MWT), Timed Up and Go (TUG), and Berg Balance Scale (BBS). Data were analyzed retrospectively in accordance with routine service evaluation. Wilcoxon signed-rank tests assessed changes in outcomes between weeks 1 and 8 for all patients completing treatment (n = 45). For patients who attended the 3-month follow-up (n = 31), Friedman’s ANOVA assessed overall change in outcomes over time. Post hoc Wilcoxon signed-rank tests compared pairs of time-points (Weeks 1, 8, and 3-month follow-up).
Results
Analyses of patients completing the program revealed significant improvements in scores between week 1 and week 8. Excluding the BBS, there were statistically significant improvements in all outcomes between weeks 1 and 8 and between weeks 1 and 3-month follow-up.
Discussion
This outpatient therapy program provided effective treatment for FND. Patients reported reduced anxiety, depression, and functional impairment, as well as improved performance on most physiotherapy measures.
Background:
Chronic pain is a common comorbidity in those with functional neurological disorder (FND), however the prevalence and characteristics of FND in those with chronic pain is unknown.
Methods:
A retrospective electronic records review of consecutive new patients attending a chronic pain clinic of a regional service. Clinical features, medication and outcome of chronic pain, any lifetime diagnoses of functional, FND and psychiatric disorders and undiagnosed neurological symptoms were recorded.
Results:
Of 190 patients attending the chronic pain clinic, 32 (17%) had a lifetime diagnosis of FND and an additional 11 (6%) had undiagnosed neurological symptoms. Pain patients with comorbid FND were more likely to have chronic primary pain (88% with FND, 44% without FND, p < 0.0001), widespread chronic primary pain (53%, 15%, p < 0.00001) and depression (84%, 52%, p < 0.005) and less likely to have a pain-precipitating event (19% vs 56%, p < 0.001). However, there was no significant difference between these patients in opiate prescription, benzodiazepine prescription or pain outcome.
Conclusions:
This first study of FND in a chronic pain patient population found a remarkably high prevalence of FND (17%) and is possibly an underestimate. The size of the overlap indicates that FND and chronic pain research fields are likely to have a lot to learn from each other.
Functional Neurological Disorder (FND) is common and is often accompanied by multiple comorbid symptoms and conditions. There have been no large-scale studies exploring the change of its clinical manifestations and comorbidities. We used an online survey to assess FND patient characteristics, changes to fatigue, sleep and pain and comorbid symptoms and diagnoses, as well as treatment strategies. The survey was shared via the charities FND Action and FND Hope. 527 participants were included in the analysis. Most (97.3%) reported experiencing more than one core FND symptom. Many respondents reported associated pain (78.1%), fatigue (78.0%) and sleep disturbances (46.7%) before FND diagnosis which often increased thereafter. Rates of obesity were higher (36.9%) than in the general population. Obesity was associated with increased pain, fatigue and sleep difficulties. There was frequent weight gain after diagnosis. 50.0% of participants reported having other diagnoses prior to FND, while in 43.3% new comorbidities arise after FND diagnosis. Many respondents reported being dissatisfied with their care, expressing a wish for further follow-up from mental health (32.7%) and/or neurological services (44.3%). This large online survey further supports the phenotypic complexity of FND. High rates of pain, fatigue and sleep disturbance exist before diagnosis but monitoring for change is worthwhile. Our study identified major gaps in service provision; we highlight the importance of an open mind regarding change in symptoms; this could aid the early identification and management of co-morbidities, including obesity and migraine, which possibly have a negative impact on FND.
Functional Movement Disorders (FMD) can be identified by limb weakness, gait disorders, or involuntary movements which are inconsistent with a neurological diagnosis. Despite the prevalence of such symptoms, there has been little consensus on models for treatment. This scoping review set out to identify the literature exploring the efficacy of psychological interventions for the treatment of FMD, either as a stand-alone intervention or as part of a multi-disciplinary team approach. Studies set in an adult inpatient and outpatient setting were considered for inclusion. The final review consisted of 33 papers; 13 reviewing psychological treatments only, and 20 reviewing multidisciplinary approaches that included a psychological intervention. This review of the literature reaffirms the inconsistency across treatment for FMD, although identifies a trend towards an MDT approach in recent years. The review also identifies areas where consistency in methodology may be beneficial in future research, in order to improve the validity of results for greater comparison of treatments. There are promising outcomes that support the continued investigation focused on an interdisciplinary, collaborative approach to care, for the reduction of symptoms.
This book is a practical manual for clinical practitioners seeking to take an interdisciplinary and multidisciplinary approach to the diagnosis and management of functional movement disorder (FMD). It discusses case vignettes, reviews the diagnostic approach, provides an update on available treatments, highlights clinical pearls and details references for further reading.
Organized into three parts, the book begins with a framework for conceptualizing FMD - including its historical context, the biopsychosocial model and an integrated neurologic-psychiatric perspective towards overcoming mind-body dualism. Part II then provides a comprehensive overview of different FMD presentations including tremor, dystonia, gait disorders, and limb weakness, as well as common non-motor issues such as pain and cognitive symptoms. The book concludes with chapters on updated practices in delivering the diagnosis, working with patients and care partners to achieve shared understanding of a complex condition, as well as an overview of evidence-based and evolving treatments.
Supplemented with high-quality patient videos, Functional Movement Disorder is written for practicing neurologists, psychiatrists, psychologists, allied mental health professionals, and rehabilitation experts with an interest in learning more about diagnosis and management of FMD.
Functional movement disorder and related functional neurological disorder subtypes are an exciting and rapidly growing area of clinical neuroscience. Great progress has been made over the past several decades, yet challenges remain – including continuing to recruit the best and brightest across the wide range of relevant specialties to care for and conduct research in this underserved yet highly prevalent patient population. In this chapter, the four co-editors of this case-based textbook in functional movement disorder reflect on their own personal journeys in the field. The steadfast hope is that the perspectives shared will energize clinicians and scientists alike to join us and other likeminded colleagues in working to address unmet clinical and research needs in functional movement disorder and related conditions.KeywordsFunctional movement disorderFunctional neurological disorderCareerClinicalResearch
Objetivo: Determinar la validez de constructo de la escala
para evaluar la adherencia a procesos de neurorrehabilitación
funcional (sman) en personas adultas. Metodología: Estudio
instrumental, con un diseño transversal, en el que se hace uso
del método de análisis factorial confirmatorio para un modelo
inicial de 5 factores y 20 ítems. Se utilizó el método de máxima
verosimilitud y se realizaron pruebas de normalidad univariada
y multivariada. El modelo hipotetizado se valoró con medidas
de ajuste absoluto, ajuste incremental y ajuste de la parsimonia.
Para el modelo definitivo, se calcularon estadísticos de
fiabilidad, y validez convergente y discriminante, a través
de matriz de correlaciones. Resultados: Para el modelo
inicial (M0), los índices de modificación mostraron cargas
cruzadas, pertenecientes a los constructos de “discapacidad”
y “paciente”; por tanto, se hizo una revisión teórica de los
ítems del instrumento y se eliminaron dos ítems redundantes,
uno en cada factor. Posterior a la reespecificación del modelo
(M2), la sman quedo conformada por 5 factores y 18 ítems.
Conclusión: la sman posee propiedades psicométricas
destacables y confiables para la medición de la adherencia
en poblaciones con déficit funcional asociado a condición
neurológica.
There is a growing interest in functional movement disorders (FMD). However, epidemiological data from large cohorts of patients with FMD are scarce and come mainly from General Neurology and Movement Disorders Clinics. Recently, specialized FMD clinics have been developed and epidemiological data from such clinics may provide useful information. We aimed to describe the clinical and sociodemographic features of patients diagnosed with FMD at our specialized FMD clinic. A standardized form was used to extract data from electronic records from the first-100 consecutive patients who were evaluated and diagnosed with FMD at our clinic from 2017 to 2019. Mean age was 40.88 ± (14.02) years, 63% females. Most patients were within working-age range, but only 16% were working at the time of consultation. Mean disease duration was 3.74 ± 5.73 years and was longer among men. The most common FMD were gait disturbance (42%), tremor (22%) and dystonia (15%). A precipitating event (mainly physical) was reported by 74%. The onset was mostly acute (83%) and the clinical course fluctuating (62%). Pain (64%) and fatigue (44%) were common comorbidities. Potential joint-hypermobility was present in 21%, mostly women (90%) and related to the presence of dystonia. FMD affects men and women mostly in working-age. Gait disturbance was the most common diagnosis, possibly because it causes a higher level of disability that may lead to consultation in a specialized clinic. Non-motor symptoms (pain and fatigue) were frequent in this cohort. Further data from specialized units may contribute to both understanding and management of FMD.
Functional movement disorders (FMD) are commonly seen in neurologic practice and frequent sources of disability. Patients may present with tremor, weakness, dystonia, jerking movements, abnormal gait and speech, often combining several movement phenomenologies. Associated symptoms include chronic pain, depression, and anxiety. Treatment of FMD begins with an explanation of the diagnosis and needs to be tailored to patients' symptoms and comorbidities. There may be benefit from multidisciplinary treatment, including physical, occupational, and speech therapy, as well as psychotherapeutic interventions, especially cognitive behavior therapy. The role for neuromodulation such as transmagnetic stimulation in FMD treatment requires further research.
Purpose of review:
This paper examines the overlap of conversion disorder with chronic pain conditions, describes ways to assess for conversion disorder, and provides an overview of evidence-based treatments for conversion disorder and chronic pain, with a focus on conversion symptoms.
Recent findings:
Conversion disorder is a significant problem that warrants further study, given that there are not many well-established guidelines. Accurate and timely assessment should help move treatment in a more fruitful direction and avoid unnecessary medical interventions. Advances in neuroimaging may also help further our understanding of conversion disorder. Creating a supportive environment and a collaborative treatment relationship and improving understanding of conversion symptoms appear to help individuals diagnosed with conversion disorder engage in appropriate treatments. Novel uses of earlier treatments, such as hypnosis and psychodynamic approaches, could potentially be beneficial and require a more vigorous and systematic study. There are treatments that produce significant improvements in functioning and reduction of physical symptoms from conversion disorder even for very severe cases. Hypnotherapy, cognitive behavioral therapy, and inpatient multidisciplinary treatment with intensive physiotherapy for severe cases have the most evidence to support reduction of symptoms. Components of treatment for conversion disorder overlap with treatments for chronic pain and can be used together to produce therapeutic effects for both conditions. Treatment needs to be tailored for each individual's specific symptoms.
Patients with functional motor disorder (FMD) including weakness and paralysis are commonly referred to physiotherapists. There is growing evidence that physiotherapy is an effective treatment, but the existing literature has limited explanations of what physiotherapy should consist of and there are insufficient data to produce evidence-based guidelines. We aim to address this issue by presenting recommendations for physiotherapy treatment.
A meeting was held between physiotherapists, neurologists and neuropsychiatrists, all with extensive experience in treating FMD. A set of consensus recommendations were produced based on existing evidence and experience.
We recommend that physiotherapy treatment is based on a biopsychosocial aetiological framework. Treatment should address illness beliefs, self-directed attention and abnormal habitual movement patterns through a process of education, movement retraining and self-management strategies within a positive and non-judgemental context. We provide specific examples of these strategies for different symptoms.
Physiotherapy has a key role in the multidisciplinary management of patients with FMD. There appear to be specific physiotherapy techniques which are useful in FMD and which are amenable to and require prospective evaluation. The processes involved in referral, treatment and discharge from physiotherapy should be considered carefully as a part of a treatment package.
Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
Recent diagnostic and treatment advances in psychogenic nonepileptic seizures (PNES) have the potential to improve care for patients, but little is known about the current state of PNES care delivery in the Veterans Health Administration (VA). We conducted semistructured interviews with 74 health-care clinicians and workers in the VA, eliciting provider perceptions of PNES care. Data were analyzed according to principles of Grounded Theory. The results revealed variation in care and two emergent domain themes of frustration and hope. Frustration was manifest in subthemes including Complexity, Patient Acceptance, Uncertainty About Treatment, Need for Evidence-based Treatment, and Failure of Cross-Disciplinary Collaboration between neurologists and mental health providers. Hope encompassed subthemes of Positive Attitudes, Developing Cross-Disciplinary Treatment, and Specific PNES Care. Increased resources for diagnosing, treating, and researching PNES have improved awareness of the disorder. More research is needed to understand patients' and caregivers' perceptions of PNES care.
The mechanisms leading to the development of functional motor symptoms (FMS) are of pathophysiological and clinical relevance, yet are poorly understood.
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).
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.
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.
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.
Over the past three decades, cognitive-behavioral therapy (CBT) has become a first-line psychosocial treatment for individuals with chronic pain. Evidence for efficacy in improving pain and pain-related problems across a wide spectrum of chronic pain syndromes has come from multiple randomized controlled trials. CBT has been tailored to, and found beneficial for, special populations with chronic pain, including children and older adults. Innovations in CBT delivery formats (e.g., Web-based, telephone-delivered) and treatments based on CBT principles that are delivered by health professionals other than psychologists show promise for chronic pain problems. This article reviews (a) the evidence base for CBT as applied to chronic pain, (b) recent innovations in target populations and delivery methods that expand the application of CBT to underserved populations, (c) current limitations and knowledge gaps, and (d) promising directions for improving CBT efficacy and access for people living with chronic pain. (PsycINFO Database Record (c) 2014 APA, all rights reserved).
Background
The effectiveness of multidisciplinary treatment in chronic widespread pain (CWP) is limited. The considerable heterogeneity among patients is a likely explanation. Knowledge on predictors of the outcome of multidisciplinary treatment can help to optimize treatment effectiveness. The purpose of this study was to identify predictors of multidisciplinary treatment outcome in patients with CWP.
Methods
Data were used from baseline and 6 months follow-up measurements of a prospective cohort study of 120 CWP. Regression models were used to assess whether baseline variables predicted treatment outcome. Outcome domains included: pain, pain interference, depression, and global perceived effect (GPE). Potential predictors included: psychological distress, illness and self-efficacy beliefs, fear-avoidance beliefs and behaviour, symptoms, disability, and socio-demographic factors.
Results
Greater improvement in pain was predicted by more pain at baseline and male gender. Greater improvement in interference of pain in daily life was predicted by more interference of pain in daily life at baseline, lower levels of anxiety, a stronger belief in personal control, less belief in consequences, male gender, and a higher level of education. Greater improvement in depression was predicted by higher baseline values of depression, stronger beliefs in personal control, and a higher level of education. Better outcome on GPE was predicted by less pain, less fatigue, and a higher level of education.
Conclusion
Less anxiety, stronger beliefs in personal control, less belief in consequences, less pain, less fatigue, higher level of education, and male gender are predictors of better outcome of multidisciplinary treatment in CWP. Tailoring treatment to these specific patient characteristics or selecting eligible patients for multidisciplinary treatment may further improve treatment outcome.
Experts in the field of conversion disorder have suggested for the upcoming DSM-V edition to put less weight on the associated psychological factors and to emphasise the role of clinical findings. Indeed, a critical step in reaching a diagnosis of conversion disorder is careful bedside neurological examination, aimed at excluding organic signs and identifying 'positive' signs suggestive of a functional disorder. These positive signs are well known to all trained neurologists but their validity is still not established. The aim of this study is to provide current evidence regarding their sensitivity and specificity. We conducted a systematic search on motor, sensory and gait functional signs in Embase, Medline, PsycINfo from 1965 to June 2012. Studies in English, German or French reporting objective data on more than 10 participants in a controlled design were included in a systematic review. Other relevant signs are discussed in a narrative review. Eleven controlled studies (out of 147 eligible articles) describing 14 signs (7 motor, 5 sensory, 2 gait) reported low sensitivity of 8-100% but high specificity of 92-100%. Studies were evidence class III, only two had a blinded design and none reported on inter-rater reliability of the signs. Clinical signs for functional neurological symptoms are numerous but only 14 have been validated; overall they have low sensitivity but high specificity and their use should thus be recommended, especially with the introduction of the new DSM-V criteria.
Conversion disorder is largely managed by neurologists, for whom it presents great challenges to understanding and management. This study aimed to quantify these challenges, examining how neurologists understand conversion disorder, and what they tell their patients.
A postal survey of all consultant neurologists in the UK registered with the Association of British Neurologists.
349 of 591 practising consultant neurologists completed the survey. They saw conversion disorder commonly. While they endorsed psychological models for conversion, they diagnosed it according to features of the clinical presentation, most importantly inconsistency and abnormal illness behaviour. Most of the respondents saw feigning as entangled with conversion disorder, with a minority seeing one as a variant of the other. They were quite willing to discuss psychological factors as long as the patient was receptive but were generally unwilling to discuss feigning even though they saw it as their responsibility. Those who favoured models in terms of feigning were older, while younger, female neurologists preferred psychological models, believed conversion would one day be understood neurologically and found communicating with their conversion patients easier than it had been in the past.
Neurologists accept psychological models for conversion disorder but do not employ them in their diagnosis; they do not see conversion as clearly different from feigning. This may be changing as younger, female neurologists endorse psychological views more clearly and find it easier to discuss with their patients.
Communicating the diagnosis of psychogenic nonepileptic seizures (PNES) is a challenging task. This study was carried out to assess the acceptability and effectiveness of a new communication procedure consisting of a patient information leaflet and a communication strategy for neurologists.
In a multicenter prospective study, 50 patients newly diagnosed with PNES were informed about the diagnosis by 10 different neurologists using the communication procedure. Follow-up data were gathered by telephone interview and completion of a questionnaire about symptom attributions (psychological/physical) and illness cognitions (Illness Perception Questionnaire-Revised, IPQ-R).
Ninety-four percent of patients found the leaflet easy to understand. Ninety-four percent stated their questions were answered by the doctor; 70% got what they wanted from the consultation; only 4% reported feeling angry during the consultation. Eighty-six percent of patients acknowledged that psychological factors were at least contributing to their seizures. On the IPQ-R, "emotional" causes for the seizures were endorsed more commonly than "nonemotional" causes (p < 0.001). After 3 months, 14% of patients were seizure-free and 63% reported a >50% reduction in seizure frequency.
We conclude that our procedure is acceptable and effectively communicates a psychological etiologic model for PNES.
To systematically review the efficacy of multicomponent treatment of fibromyalgia syndrome (FMS).
We screened Medline, PsychINFO, Scopus, and the Cochrane Library (through December 2007), as well as reference sections of original studies, reviews, and evidence-based guidelines. Randomized controlled trials (RCTs) on the multicomponent treatment (at least 1 educational or other psychological therapy with at least 1 exercise therapy) of FMS were analyzed.
We included 9 (of 14) RCTs with 1,119 subjects (median treatment time 24 hours) in the meta-analysis. Effects were summarized using standardized mean differences (SMDs) or weighted mean differences (WMDs). There was strong evidence that multicomponent treatment reduces pain (SMD -0.37; 95% confidence interval [95% CI] -0.62, -0.13), fatigue (WMD -0.85; 95% CI -1.50, -0.20), depressive symptoms (SMD -0.67; 95% CI -1.08, -0.26), and limitations to health-related quality of life (HRQOL) (SMD -0.59; 95% CI -0.90, -0.27) and improves self-efficacy pain (SMD 0.54; 95% CI 0.26, 0.82) and physical fitness (SMD 0.30; 95% CI 0.02, 0.57) at posttreatment. There was no evidence of its efficacy on pain, fatigue, sleep disturbances, depressive symptoms, HRQOL, or self-efficacy pain in the long term. There was strong evidence that positive effects on physical fitness (SMD 0.30; 95% CI 0.09, 0.51) can be maintained in the long term (median followup 7 months).
There is strong evidence that multicomponent treatment has beneficial short-term effects on the key symptoms of FMS. Strategies to maintain the benefits of multicomponent treatment in the long term need to be developed.
To investigate psychiatric and neurological morbidity, diagnostic stability, and indicators of prognosis in patients previously identified as having medically unexplained motor symptoms.
Follow up study.
National Hospital for Neurology and Neurosurgery, London--a secondary and tertiary referral hospital for neurological disorders.
73 patients with medically unexplained motor symptoms admitted consecutively in 1989-91. 35 (48%) patients had absence of motor function (for example, hemiplegia) and 38 (52%) had abnormal motor activity (for example, tremor, dystonia, or ataxia).
Neurological clinical diagnosis at face to face reassessment by a neurologist and a psychiatric diagnosis after a standardised assessment interview--the schedule for affective disorders and schizophrenia--conducted by a psychiatrist.
Good follow up data were available for 64 subjects (88%). Only three subjects had new organic neurological disorders at follow up that fully or partly explained their previous symptoms. 44/59 (75%) subjects had had psychiatric disorders; in 33 (75%) patients, the psychiatric diagnosis coincided with their unexplained motor symptoms. 31/59 (45%) patients had a personality disorder. Three subjects had developed new psychiatric illnesses at follow up, but in only one did the diagnosis account for the previous motor symptoms. Resolution of physical symptoms was associated with short length of symptoms, comorbid psychiatric disorder, and a change in marital status during follow up.
Unlike Slater's study of 1965, a low incidence of physical or psychiatric diagnoses which explained these patients' symptoms or disability was found. However, a high level of psychiatric comorbidity existed.
Treating Nonepileptic Seizures: Therapist Guide offers therapists, physicians, and other healthcare professionals a comprehensive approach to improving seizure control and enhancing the quality of lives of their patients diagnosed with epileptic and nonepileptic seizures (NES). The book is intended to be used by therapists, in conjunction with Taking Control of Your Seizures: Workbook. The Therapist Guide provides guidance to the healthcare professional and seizure counselor for helping patients who, using the Workbook, seek to take an active role in their treatment. The Therapist Guide provides the therapist with step-by-step instructions about how to help their patients identify physical, interpersonal, and emotional factors that can trigger seizures, and how to help them take proactive action before or when negative emotions lead to seizures. Each chapter provides the therapist with information on seizures, including epilepsy, drug therapy, relaxation, pre-seizure aura and how to help their patients to stay safe and potentially stop seizures from progressing. Gleaned from direct supervision notes, the Therapist Guide provides insight into helping therapists guide their patients to identify negative emotions, external stressors, and inner issues and conflicts that affect seizure control and well-being. The Therapist Guide details ways to help patients reduce tension and manage life stresses, and examines “other symptoms” of seizures, ranging from déjà vu and scattered thinking to odd sensations. Therapists who used the Therapist Guide noted the benefits as their patients progressed through treatment. Therapists who used the principles in the Guide saw a decrease in seizure frequency and improvement in associated symptoms in their patients.
The assessment of functional neurological disorders (FND) requires an interdisciplinary approach. The authors retrospectively reviewed charts for 100 outpatients with FND and used univariate and regression analyses to investigate neuropsychiatric associations with gender, illness duration, and work disability; secondary analyses evaluated for differences across motor FND subtypes. Men reported higher rates of cognitive complaints and functional weakness, whereas women endorsed increased past physical/sexual trauma. Number of self-reported medication allergies/sensitivities positively correlated with illness duration. Individuals with functional weakness compared with other motor FND subtypes exhibited lower rates of past psychiatric hospitalization and head trauma. This study supports the feasibility of integrating FND research.
Objective:
Adverse early-life events are predisposing factors for functional neurological disorder (FND) and post-traumatic stress disorder (PTSD). Cingulo-insular regions are implicated in the biology of both conditions and are sites of stress-mediated neuroplasticity. We hypothesised that functional neurological symptoms and the magnitude of childhood abuse would be associated with overlapping anterior cingulate cortex (ACC) and insular volumetric reductions, and that FND and PTSD symptoms would map onto distinct cingulo-insular areas.
Methods:
This within-group voxel-based morphometry study probes volumetric associations with self-report measures of functional neurological symptoms, adverse life events and PTSD symptoms in 23 mixed-gender FND patients. Separate secondary analyses were also performed in the subset of 18 women with FND to account for gender-specific effects.
Results:
Across the entire cohort, there were no statistically significant volumetric associations with self-report measures of functional neurological symptom severity or childhood abuse. In women with FND, however, parallel inverse associations were observed between left anterior insular volume and functional neurological symptoms as measured by the Patient Health Questionnaire-15 and the Screening for Somatoform Symptoms Conversion Disorder subscale. Similar inverse relationships were also appreciated between childhood abuse burden and left anterior insular volume. Across all subjects, PTSD symptom severity was inversely associated with dorsal ACC volume, and the magnitude of lifetime adverse events was inversely associated with left hippocampal volume.
Conclusions:
This study reveals distinct cingulo-insular alterations for FND and PTSD symptoms and may advance our understanding of FND. Potential biological convergence between stress-related neuroplasticity, functional neurological symptoms and reduced insular volume was identified.
Objective:
Psychogenic movement disorder (PMD) and psychogenic nonepileptic seizures (PNES) are two subtypes of conversion disorder (CD). In this case-control study, we asked whether these subtypes varied as a function of personality and history of childhood abuse.
Methods:
Fifty-nine patients with PMD from the Human Motor Control Section Clinic at the National Institutes of Health, 43 patients with PNES from the Rhode Island Hospital Neuropsychiatry and Behavioral Neurology Division, and 26 healthy volunteers (HC) received a battery of neurological, psychiatric and psychological assessments, including the NEO Personality Inventory Revised (NEO PI-R), the Childhood Trauma Questionnaire (CTQ), and the Traumatic Life Events Questionnaire (TLEQ).
Results:
One-way ANOVA between the three groups indicated significant differences in overall domains of Neuroticism (p=0.001) and Conscientiousness (p=0.009): Patients with PNES reported significantly greater levels of Neuroticism (p=0.002) and lower levels of Conscientiousness (p=0.023) than patients with PMD. Levels of Neuroticism remained significantly higher in both PMD and PNES than HC following correction for multiple comparisons. Patients with PNES reported greater levels of depressive and anxiety symptoms, overall psychopathology, greater history of sexual abuse, greater levels of alexithymia, higher levels of dissociative symptoms, and an earlier age at which they experienced their most distressing traumatic event than patients with PMD.
Conclusions:
These findings suggest that personality traits, type of abuse and age of onset of trauma varies as a function of CD subtype. Patients with PNES rated greater Neuroticism and lower Conscientiousness than patients with PMD. These differing psychological profiles may inform differing treatment approaches such as psychological therapies for PNES and physiotherapy (with/without psychotherapy) for PMD.
Background and objective:
Although many patients present with functional neurological symptoms (FNS), few US clinics offer specialized FNS care, and data on clinic attendees remain limited. We determined predictors of initial attendance, symptom burden, and FNS subtype in the first patients referred to our Functional Neurological Disorders Clinic for suspected FNS.
Methods:
We reviewed the charts of 62 consecutive patients (46 women, 16 men). Regression analyses investigated predictors of keeping the first scheduled clinic appointment. For the 49 patients who did keep that appointment, regression analyses examined neuropsychiatric factors associated with symptom burden and motor FNS subtypes.
Results:
The odds of not keeping the first appointment were 10.4 times greater for patients referred from the emergency department than from other sources. The patients who kept their appointment reported a symptom burden that was significantly associated with a past FNS-related emergency department visit and a diagnosis of another medically unexplained somatic syndrome. The number of FNS findings on neurological examination also correlated with a history of an FNS-related emergency department visit. Patients with psychogenic non-epileptic seizures reported cognitive complaints and prior psychiatric hospitalizations significantly more often than did patients with other FNS. One fourth of all patients had two or more motor FNS.
Conclusions:
In our FNS cohort, patients were less likely to keep an initial clinic appointment if they were referred from the emergency department than from other sources. Patients with psychogenic non-epileptic seizures were more likely to report cognitive symptoms and past psychiatric hospitalizations than patients with other FNS.
Objective
To determine the feasibility of conducting a randomised controlled trial of a specialist physiotherapy intervention for functional motor symptoms (FMS).
Methods
A randomised feasibility study was conducted recruiting patients with a clinically established diagnosis of FMS from a tertiary neurology clinic in London, UK. Participants were randomised to the intervention or a treatment as usual control. Measures of feasibility and clinical outcome were collected and assessed at 6 months.
Results
60 individuals were recruited over a 9-month period. Three withdrew, leaving 29 intervention and 28 controls participants in the final analysis. 32% of patients with FMS met the inclusion criteria, of which 90% enrolled. Acceptability of the intervention was high and there were no adverse events. At 6 months, 72% of the intervention group rated their symptoms as improved, compared to 18% in the control group. There was a moderate to large treatment effect across a range of outcomes, including three of eight Short Form 36 (SF36) domains (d=0.46–0.79). The SF36 Physical function was found to be a suitable primary outcome measure for a future trial; adjusted mean difference 19.8 (95% CI 10.2 to 29.5). The additional quality adjusted life years (QALY) with intervention was 0.08 (95% CI 0.03 to 0.13), the mean incremental cost per QALY gained was £12 087.
Conclusions
This feasibility study demonstrated high rates of recruitment, retention and acceptability. Clinical effect size was moderate to large with high probability of being cost-effective. A randomised controlled trial is needed.
Trial registration number
NCT02275000; Results.
Psychogenic nonepileptic seizures (PNES) are a functional neurological disorder/conversion disorder subtype, which are neurobehavioral conditions at the interface of neurology and psychiatry. Significant advancements over the past decade have been made in the diagnosis, management, and neurobiological understanding of PNES. This article reviews published PNES research focusing on semiologic features that distinguish PNES from epileptic seizures, consensus diagnostic criteria, the intersection of PNES and other comorbidities, neurobiological studies, evidence-based treatment interventions, and outcome studies. Epidemiology and healthcare utilization studies highlight a continued unmet medical need in the comprehensive care of PNES. Consensus guidelines for diagnostic certainty are based on clinical history, semiology of witnessed typical event(s), and EEG findings. While certain semiologic features may aid in the diagnosis of PNES, the gold standard remains capturing a typical event on video electroencephalography (EEG) showing the absence of epileptiform activity with history and semiology consistent with PNES. Medical-neurologic and psychiatric comorbidities are prevalent in PNES; these should be assessed in diagnostic evaluations and integrated into treatment interventions and prognostic considerations. Several studies, including a pilot, multicenter, randomized clinical trial, have now demonstrated that a cognitive behavioral therapy-informed psychotherapy is an efficacious treatment for PNES, and additional efforts are necessary to evaluate the utility of pharmacologic and other psychotherapy treatments. Neuroimaging studies, while requiring replication, suggest that PNES may occur in the context of alterations within and across sensorimotor, emotion regulation/processing, cognitive control, and multimodal integration brain systems. Future research could investigate similarities and differences between PNES and other somatic symptom disorders.
Purpose:
Clinical observations suggest that psychogenic non-epileptic seizure (PNES) patients often have severe migraine, more severe than epilepsy patients. Investigations into migraine characteristics in patients with PNES are lacking. In this study we tested the hypothesis that, compared to epilepsy patients, PNES patients have more severe migraine, with more frequent and longer duration attacks that cause greater disability.
Method:
In this observational study, 633 patients with video-EEG proven epilepsy or PNES were identified from the Mayo Clinic Epilepsy Monitoring Unit database. Contacted patients were screened for migraine via a validated questionnaire, and when present, data regarding migraine characteristics were collected. Two-sample t-tests, chi square analyses, and Mann-Whitney U tests were used to compare migraine characteristics in PNES patients to those of epilepsy patients.
Results:
Data from 43 PNES patients with migraine and 29 epilepsy patients with migraine were available. Compared to epilepsy patients, PNES patients reported having more frequent headaches (mean 15.1±9.8 vs. 8.1±6.6 headache days/month, p<.001), more frequent migraine attacks (mean 6.5±6.3 vs. 3.8.±4.1 migraines/month, p=.028), longer duration migraines (mean 39.5±28.3 vs. 27.3±20.1h, p=.035), and more frequently had non-visual migraine auras (78.6% vs. 46.7% of patients with migraine auras, p=.033). Migraine-related disability scores were not different between PNES and epilepsy patients (median 39, interquartile range 89 vs. 25, interquartile range 60.6, p=.15).
Conclusion:
Compared to epilepsy patients with migraine, PNES patients with migraine report having a more severe form of migraine with more frequent and longer duration attacks that are more commonly associated with non-visual migraine auras.
Importance
There is a paucity of controlled treatment trials for the treatment of conversion disorder, seizures type, also known as psychogenic nonepileptic seizures (PNES). Psychogenic nonepileptic seizures, the most common conversion disorder, are as disabling as epilepsy and are not adequately addressed or treated by mental health clinicians.Objective
To evaluate different PNES treatments compared with standard medical care (treatment as usual).Design, Setting, and Participants
Pilot randomized clinical trial at 3 academic medical centers with mental health clinicians trained to administer psychotherapy or psychopharmacology to outpatients with PNES. Thirty-eight participants were randomized in a blocked schedule among 3 sites to 1 of 4 treatment arms and were followed up for 16 weeks between September 2008 and February 2012; 34 were included in the analysis.Interventions
Medication (flexible-dose sertraline hydrochloride) only, cognitive behavioral therapy informed psychotherapy (CBT-ip) only, CBT-ip with medication (sertraline), or treatment as usual.Main Outcomes and Measures
Seizure frequency was the primary outcome; psychosocial and functioning measures, including psychiatric symptoms, social interactions, quality of life, and global functioning, were secondary outcomes. Data were collected prospectively, weekly, and with baseline, week 2, midpoint (week 8), and exit (week 16) batteries. Within-group analyses for each arm were performed on primary (seizure frequency) and secondary outcomes from treatment-blinded raters using an intention-to-treat analysis.Results
The psychotherapy (CBT-ip) arm showed a 51.4% seizure reduction (P = .01) and significant improvement from baseline in secondary measures including depression, anxiety, quality of life, and global functioning (P < .001). The combined arm (CBT-ip with sertraline) showed 59.3% seizure reduction (P = .008) and significant improvements in some secondary measures, including global functioning (P = .007). The sertraline-only arm did not show a reduction in seizures (P = .08). The treatment as usual group showed no significant seizure reduction or improvement in secondary outcome measures (P = .19).Conclusions and Relevance
This pilot randomized clinical trial for PNES revealed significant seizure reduction and improved comorbid symptoms and global functioning with CBT-ip for PNES without and with sertraline. There were no improvements in the sertraline-only or treatment-as-usual arms. This study supports the use of manualized psychotherapy for PNES and successful training of mental health clinicians in the treatment. Future studies could assess larger-scale intervention dissemination.Trial Registration
clinicaltrials.gov Identifier: NCT00835627
Despite the high prevalence and disabling nature of nonepileptic attacks (NEAs) and other types of functional neurological symptoms (FNSs), treatment trials are few. Preliminary evidence supports the efficacy of cognitive behavioral therapy (CBT) approaches, and CBT-based group therapies have the potential to improve cost-effectiveness and deliverability of treatment. This pilot study was undertaken to evaluate whether CBT-based group therapy would offer a feasible treatment option for patients with NEAs and other FNSs. We evaluated the outcomes of an information and management intervention within a neuropsychiatry service, which included weekly CBT-based group therapy sessions for patients with NEAs and other FNSs. Outcomes pertaining to quality of life and physical and emotional well-being were measured using the 36-item Short-Form Health Survey (SF-36), the Hospital Anxiety and Depression Scale (HADS), and the Clinical Global Impression (CGI) scale. Data were collected from 16 patients, of whom 10 presented with NEAs. Significant improvements were selectively reported in the 'emotional well-being' (p=0.04) and 'role limitation due to emotional well-being' (p=0.04) subscores of the SF-36. Improvements in overall quality-of-life scores (p=0.22), as well as in HADS anxiety (p=0.34) and depression (p=0.46) scores, did not reach statistical significance. These trends were supported by a positive mean CGI improvement scale score of 2.4, indicating minimal-to-considerable improvement. Group therapy intervention with a CBT-based approach is a feasible treatment option in the management of NEAs and other FNSs, as shown by significant improvements in emotional domains of quality of life in this low power pilot study.
The International League Against Epilepsy (ILAE) Neuropsychobiology Commission gave the charge to provide practical guidance for health professionals for the pharmacologic and nonpharmacologic treatment of patients with psychogenic nonepileptic seizures (PNES). Using a consensus review of the literature, an international group of clinician-researchers in epilepsy, neurology, neuropsychology, and neuropsychiatry evaluated key management approaches for PNES. These included the following: presentation of the diagnosis, early phase treatment, psychological and pharmacologic interventions, and maintenance management. The aim of this report is to provide greater clarity about the range and current evidence base for treatment for patients with PNES, with the intention of improving the care of patients with PNES and patients who develop PNES as a comorbidity of epilepsy.
An international consensus group of clinician-researchers in epilepsy, neurology, neuropsychology, and neuropsychiatry collaborated with the aim of developing clear guidance on standards for the diagnosis of psychogenic nonepileptic seizures (PNES). Because the gold standard of video electroencephalography (vEEG) is not available worldwide, or for every patient, the group delineated a staged approach to PNES diagnosis. Using a consensus review of the literature, this group evaluated key diagnostic approaches. These included: history, EEG, ambulatory EEG, vEEG/monitoring, neurophysiologic, neurohumoral, neuroimaging, neuropsychological testing, hypnosis, and conversation analysis. Levels of diagnostic certainty were developed including possible, probable, clinically established, and documented diagnosis, based on the availability of history, witnessed event, and investigations, including vEEG. The aim and hope of this report is to provide greater clarity about the process and certainty of the diagnosis of PNES, with the intent to improve the care for people with epilepsy and nonepileptic seizures.
The prognosis of functional (or psychogenic) motor symptoms (weakness and movement disorder) has not been systematically reviewed.
We systematically reviewed PubMed for all studies of eight or more patients with functional motor symptoms reporting follow-up data longer than 6 months (excluding studies reporting specific treatments). We recorded symptom duration, physical and psychiatric comorbidity, disability, occupational functioning at follow-up and prognostic factors.
24 studies were included. There was heterogeneity regarding study size (number of patients (n)=10 491), follow-up duration clinical setting and data availability. Most studies (n=15) were retrospective. Reported symptom outcome was highly variable. Mean weighted follow-up duration was 7.4 years (in 13 studies where data was extractable). The mean percentage of patients same or worse at follow-up for all studies was 39%, range 10% to 90%, n=1134. Levels of physical disability and psychological comorbidity at follow-up were high. Short duration of symptoms, early diagnosis and high satisfaction with care predicted positive outcome in two studies. Gender had no effect. Delayed diagnosis and personality disorder were negatively correlated with outcome. Prognostic factors that varied between studies included age, comorbid anxiety and depression, IQ, educational status, marital status and pending litigation.
Existing follow-up studies of functional motor symptoms give us some insights regarding outcome and prognostic factors but are limited by their largely retrospective and selective nature. Overall, prognosis appears unfavourable. The severity and chronicity of functional motor symptoms argues for larger prospective studies including multiple prognostic factors at baseline in order to better understand their natural history.
Differentiating between psychogenic nonepileptic spells (PNES) and epileptic seizures without video-EEG monitoring is difficult. The presence of specific medical comorbidities may discriminate the two, helping physicians suspect PNES over epilepsy earlier. A retrospective analysis comparing the medical comorbidities of patients with PNES with those of patients with epilepsy was performed in 280 patients diagnosed with either PNES (N=158, 74.7% females) or epilepsy (N=122, 46.7% females) in the Epilepsy Monitoring Unit (EMU) of the University of Pittsburgh Medical Center over a two-year period. Patients with PNES, compared to those with epilepsy, were mostly female, significantly more likely to have a history of abuse, had more functional somatic syndromes (fibromyalgia, chronic fatigue syndrome, chronic pain syndrome, tension headaches, and irritable bowel syndrome), and had more medical illnesses that are chronic with intermittent attacks (migraines, asthma, and GERD). The presence of at least of one these disorders may lead physicians to suspect PNES over epilepsy and expedite appropriate referral for video-EEG monitoring for diagnosis.
This study investigated whether initial adherence to treatment in psychogenic epileptic seizures differed on the basis of mental health treatment modality and which subject characteristics were predictive of adherence. Initial adherence rates were 54% for combined treatment conducted in the same institution (integrated intervention) and 31% for psychotherapy and psychiatric management offered in different settings (divided intervention). Cognitive complaints and current exposure to antiepileptic drugs (AEDs) were more common among nonadherent patients, and being married (or having a live-in partner) was more common among adherent patients. A predictive model using the mentioned variables (intervention type, marital status, cognitive complaints, and concurrent use of AEDs) showed that this set of variables was predictive of adherence. Marital status and cognitive complaints were the significant contributors to prediction of adherence in the model.
Background:
Psychogenic non-epileptic seizures (PNES) pose a substantial burden to patients and the health care system, due to long diagnostic and treatment delays.
Methods:
This study used medical chart notes from 103 patients to shed light on the diagnostic process. Electronic medical records and cost data from a US health system were also used to investigate costs and utilization for the 12-months before and after PNES diagnosis.
Results:
The results show that accurate diagnosis was typically achieved via the use of multiple medical tests, including vEEG, magnetic resonance imaging (MRI), and computed tomography (CT) scans, as well as historical diagnostic and clinical information. In the year following PNES diagnosis, a decline in average visits (-1.45) and costs (-$1784) were observed. The largest cost savings were seen in neurology care and inpatient stays.
Conclusions:
This study has implications for timely and accurate diagnosis of PNES, which may decrease the overall health care burden for individuals and the health care system.
Psychogenic nonepileptic seizures (PNES) and psychogenic movement disorders (PMD) are common and disabling problems with abnormal psychological profiles, and they may have common features that could aid in better understanding and management. Since PNES and PMD are investigated and reported separately, comparisons are lacking. Psychogenic nonepileptic seizure and psychogenic movement disorder patients completed demographic, clinical, and psychological inventories including the Short Form (SF)-12 Health Status Survey (Physical and Mental Health Summary Scores), the Brief Symptom Inventory (BSI)-18 (somatization, depression, and anxiety subscales), and the Lorig Self-Efficacy Scale. Psychogenic nonepileptic seizure and psychogenic movement disorder patients had similar psychological profiles with reduced SF-12 Physical Health and Mental Health Summary Scores and increased BSI somatization, depression, and anxiety ratings. They varied slightly in age and gender, but their main distinguishing features were the presenting signs. These similar profiles suggest that PNES and PMD may not be distinct or separate entities and that collaborative investigative efforts and management are warranted.
Purpose:
Psychogenic nonepileptic seizures (PNES) can be challenging to diagnose, but certain clinical features can help to distinguish PNES from epileptic seizures. The purpose of this study is to assess chronic pain and prescribed pain medication use in PNES patients.
Methods:
A case-controlled, retrospective analysis was performed examining pain medication use in 85 PNES patients versus an active control group of 85 patients with idiopathic generalized epilepsy (IGE).
Results:
Chronic pain was more frequent among PNES patients (N=40) than active controls (N=10) (p<0.0001). Reported use of prescription pain medication was higher among PNES patients (N=20) versus active controls (N=6) (p=0.0048). The Positive Predictive Value of prescription pain medications for PNES patients was 76.9%. Opioid use in the PNES population was higher compared with active controls (p=0.0096). When excluding patients with a dual diagnosis of PNES and epilepsy from the latter two analyses and comparing these results to those that included this patient population, no statistically significant difference in results was found.
Conclusions:
Patients with PNES are more likely than those with IGE to report chronic pain disorders. A history of chronic pain and opioid use among patients with seizures raises the possibility of PNES. Among patients with PNES and chronic pain, a psychogenic etiology for pain and non-opiate pain management strategies should be considered.
Psychogenic movement disorder is defined as abnormal movements unrelated to a medical cause and presumed related to underlying psychological factors. Although psychological factors are of both clinical and pathophysiological relevance, very few studies to date have systematically assessed their role in psychogenic movement disorder. We sought to assess the role of previous life stress using validated quantitative measures in patients with psychogenic movement disorder compared with age- and sex-matched healthy volunteers as well as a convenience sample of patients with focal hand dystonia. Sixty-four patients with psychogenic movement disorder (72% female; mean age, 45.2 years [standard deviation, 15.2 years]), 38 healthy volunteers (74% female; mean age, 49 years [standard deviation, 13.7 years]), and 39 patients with focal hand dystonia (37% female; mean age, 48.7 years [standard deviation, 11.7 years]) were evaluated using a standardized psychological interview as well as validated quantitative scales to assess trauma and previous stressors, depression, anxiety, and personality traits. Patients with psychogenic movement disorder reported higher rates of childhood trauma, specifically greater emotional abuse and physical neglect, greater fear associated with traumatic events, and a greater number of traumatic episodes compared with healthy volunteers and patients with focal hand dystonia controlled for depressive symptoms and sex (Bonferroni corrected P < .005). There were no differences in categorical psychiatric diagnoses or scores on childhood physical or sexual abuse subscales, personality traits, or the dissociative experience scale. Our findings highlight a biopsychosocial approach toward the pathophysiology of psychogenic movement disorder, although the association with psychological issues is much less prominent than expected compared with the nonepileptic seizure population. A careful psychological assessment is indicated to optimize therapeutic modalities. © 2011 Movement Disorder Society
Functional (psychogenic) motor symptoms are diagnosed on the basis of positive signs of inconsistency or incongruity with known neurologic disease. These signs, such as Hoover sign or tremor entrainment, are often regarded by neurologists as 'tricks of the trade,' to 'catch the patient out, ' and certainly not to be shared with them. In this reflective article, the authors suggest that showing the patient with functional motor symptoms their physical signs, if done in the right way, is actually one of the most useful things a neurologist can do for these patients in persuading them of the accuracy of their diagnosis and the potential reversibility of their symptoms.
Conversion disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) describes neurological symptoms, including weakness, numbness and events resembling epilepsy or syncope, which can be positively identified as not being due to recognised neurological disease. This review combines perspectives from psychiatry, psychology and neurology to identify and discuss key problems with the current diagnostic DSM-IV criteria for conversion disorder and to make the following proposals for DSM-5: (a) abandoning the label "conversion disorder" and replacing it with an alternative term that is both theoretically neutral and potentially more acceptable to patients and practitioners; (b) relegating the requirements for "association of psychological factors" and the "exclusion of feigning" to the accompanying text; (c) adding a criterion requiring clinical findings of internal inconsistency or incongruity with recognised neurological or medical disease and altering the current 'disease exclusion' criteria to one in which the symptom must not be 'better explained' by a disease if present, (d) adding a 'cognitive symptoms' subtype. We also discuss whether conversion symptoms are better classified with other somatic symptom disorders or with dissociative disorders and how we might address the potential heterogeneity of conversion symptoms in classification.
Functional ("psychogenic") gait and other movement disorders have proven very difficult to treat.
Describe the Mayo Clinic functional movement disorder motor-reprogramming protocol conducted in the Department of Physical Medicine and Rehabilitation (PMR), and assess short-term and long-term outcomes.
Historical-cohort-study assessing non-randomized PMR intervention.
Tertiary care center.
Interventional group: 60 consecutive patients with a chronic functional movement disorder that underwent the PMR protocol between January 2005 and December 2008. Control group: age- and sex-matched patients with treatment-as-usual (n = 60).
An outpatient, one-week intensive rehabilitation program based on the concept of motor-reprogramming following a comprehensive diagnostic neurological evaluation, including psychiatric/psychological assessment.
Improvement of the movement disorder by the end of the week-long program (patient- and physician-rated), plus the long-term outcome (patient-rated).
Patient demographics: median symptom duration, 17 months (range, 1-276); female predominance (76.7%); mean age 45 years (range, 17-79). Physician-rated outcomes after the one-week treatment program documented 73.5% were markedly improved, nearly normal or in remission, similar to the patient-ratings (68.8%). Long-term treatment outcomes (patient-rated; median follow-up, 25 months) revealed 60.4% were markedly improved or almost completely normal/in remission, compared to 21.9% of controls (p < 0.001).
Short-term and long-term successful outcomes were documented in the treatment of patients with functional movement disorders by a rehabilitative, goal-oriented program with intense physical and occupational therapy. The rapid benefit, which was sustained in most patients, suggests substantial efficacy that should be further assessed in a prospective, controlled, clinical trial.
Functional (psychogenic or somatoform) symptoms are common in neurology clinics. Cognitive-behavioral therapy (CBT) can be an effective treatment, but there are major obstacles to its provision in practice. We tested the hypothesis that adding CBT-based guided self-help (GSH) to the usual care (UC) received by patients improves outcomes.
We conducted a randomized trial in 2 neurology services in the United Kingdom. Outpatients with functional symptoms (rated by the neurologist as "not at all" or only "somewhat" explained by organic disease) were randomly allocated to UC or UC plus GSH. GSH comprised a self-help manual and 4 half-hour guidance sessions. The primary outcome was self-rated health on a 5-point clinical global improvement scale (CGI) at 3 months. Secondary outcomes were measured at 3 and 6 months.
In this trial, 127 participants were enrolled, and primary outcome data were collected for 125. Participants allocated to GSH reported greater improvement on the primary outcome (adjusted common odds ratio on the CGI 2.36 [95% confidence interval 1.17-4.74; p = 0.016]). The absolute difference in proportion "better" or "much better" was 13% (number needed to treat was 8). At 6 months the treatment effect was no longer statistically significant on the CGI but was apparent in symptom improvement and in physical functioning.
CBT-based GSH is feasible to implement and efficacious. Further evaluation is indicated.
This study provides Class III evidence that CBT-based GSH therapy improves self-reported general health, as measured by the CGI, in patients with functional neurologic symptoms.
Psychogenic non-epileptic seizures (PNES) and psychogenic movement disorders (PMDs) are common in neurology practice, yet it is not established whether clinically relevant differences between these two groups exist.
In this retrospective chart review 172 patients were identified (PNES n = 116, PMD n = 56).
The whole group was characterized by female gender (82%), abuse history (45%), chronic pain (70%), depression (42%), subjective fatigue (47%), subjective cognitive complaints (55%), and referral for psychiatric evaluation (54%). Statistically significant differences (P <. 01) were found for age, education, frequency of symptoms, altered consciousness, developmental abuse, and coexisting anxiety. Clinical practice also differed for the two groups in history-taking and referrals for neuropsychological testing and/or psychiatric evaluation.
This retrospective study revealed more similarities than differences suggesting these are manifestations of the same psychopathology, with age and co-morbid anxiety potentially being important factors in predicting the symptomatic presentation. Prospective studies are needed to confirm our results. Future studies focusing more globally on somatoform disorders, rather than each phenotypic presentation, are likely needed to improve clinical care and outcomes.
In clinical practice, it is sometimes observed that patients in whom psychogenic non-epileptic seizures (PNES) cease, develop another medically unexplained symptom (MUS).
In order to determine how many patients develop new MUS post diagnosis and whether patients whose attacks cease are more likely to do so, new MUS were recorded 6-12 months after the diagnosis of PNES in 187 consecutive patients.
Compared with baseline, the overall proportion of patients with MUS increased slightly, from 70.1% to 76.5%, with 44/187 patients (23.5%) developing new MUS. There were no significant differences between attack free and non-attack free patients. Binary logistic regression analysis showed that predictors of new MUS diverged between attack free and non-attack free patients. Among patients continuing to have attacks, those with previous health related psychological trauma were 18.00 times more likely to develop new MUS (p<0.0005). In patients who became attack free, patients drawing disability benefits were 5.04 times more likely to have new MUS (p = 0.011).
The results suggest that almost 25% of patients develop new MUS following a diagnosis of PNES, although most of those have MUS pre-diagnosis. Patients with a history of health related psychological trauma whose attacks continue after diagnosis are at particularly high risk of developing new MUS. The data do not support the hypothesis that PNES that resolve are likely to be 'replaced' by other MUS.
To compare cognitive-behavioral therapy (CBT) and standard medical care (SMC) as treatments for psychogenic nonepileptic seizures (PNES).
Our randomized controlled trial (RCT) compared CBT with SMC in an outpatient neuropsychiatric setting. Sixty-six PNES patients were randomized to either CBT (plus SMC) or SMC alone, scheduled to occur over 4 months. PNES diagnosis was established by video-EEG telemetry for most patients. Exclusion criteria included comorbid history of epilepsy, <2 PNES/month, and IQ <70. The primary outcome was seizure frequency at end of treatment and at 6-month follow-up. Secondary outcomes included 3 months of seizure freedom at 6-month follow-up, measures of psychosocial functioning, health service use, and employment.
In an intention-to-treat analysis, seizure reduction following CBT was superior at treatment end (group x time interaction p < 0.0001; large to medium effect sizes). At follow-up, the CBT group tended to be more likely to have experienced 3 months of seizure freedom (odds ratio 3.125, p = 0.086). Both groups improved in some health service use measures and on the Work and Social Adjustment Scale. Mood and employment status showed no change.
Our findings suggest that cognitive-behavioral therapy is more effective than standard medical care alone in reducing seizure frequency in PNES patients. Classification of evidence: This study provides Class III evidence that CBT in addition to SMC, as compared to SMC alone, significantly reduces seizure frequency in patients with PNES (change in median monthly seizure frequency: baseline to 6 months follow-up, CBT group, 12 to 1.5; SMC alone group, 8 to 5).
Functional weakness describes weakness which is both internally inconsistent and incongruent with any recognizable neurological disease. It may be diagnosed as a manifestation of conversion disorder or dissociative motor disorder. Other names include psychogenic or 'non-organic' paralysis. We aimed to describe the incidence, demographic and clinical characteristics of cases with functional weakness of less than 2 years duration, and to compare these with controls with weakness attributable to neurological disease. Both cases and controls were recruited from consultant neurologists in South East Scotland. Participating patients underwent detailed assessments which included: physical examination, structured psychiatric interview (Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders), measures of symptoms, disability and distress [Short Form (36) Health Survey, Hospital and Anxiety Depression Scale], and assessment of their illness beliefs using an augmented version of the Illness Perception Questionnaire. In total, 107 cases (79% female, mean age 39 years, median duration of illness 9 months) were recruited. This number suggests a minimum annual incidence of 3.9/100 000. Forty-six controls (83% female, median age 39 years, duration 11 months) were also recruited. Compared to controls, cases had similar levels of disability but more physical symptoms, especially pain. They had a higher frequency of psychiatric disorders, especially current major depression (32 versus 7%, P < 0.0001), generalized anxiety disorder (21 versus 2%, P < 0.005), panic disorder (36 versus 13%, P < 0.001) and somatization disorder (27 versus 0%, P < 0001). There was no difference in median self-rated anxiety and depression scores. Paradoxically, they were less likely than controls to agree that stress was a possible cause of their illness (24 versus 56%, P < 0.001). Cases were twice as likely as controls to report that they were not working because of their symptoms (65 versus 33%, P < 0.0005). Functional weakness is a commonly encountered clinical problem. Patients with this symptom are as disabled as patients with weakness of similar duration due to neurological disease. There is a paradox between the frequency of depression and anxiety diagnoses and the patient's willingness to accept these as potentially relevant to their symptoms. We discuss the theoretical and practical implications of these findings for the concept of conversion disorder.
Psychogenic movement disorders (PMD) are a diagnostic fascinating challenge in both neurologic and psychiatric setting. Many factors influence response to treatment, but few treatment strategies are available. Physical activity proves to be effective in the treatment of depression, anxiety, and other psychiatric disorders, but the effects of regular walking exercise on patients with PMD have never been investigated in a single-blind study. Sixteen outpatients [13 women; mean age 33.0 years (range 22-51)] with primarily mild-to-moderate PMD completed a thrice-weekly, 12-weeks mild walking program. Assessments included DSM-IV interview, the Psychogenic Movement Disorder Rating Scale (PMDRS), Beck Anxiety Inventory (BAI), Hamilton Depression Scale (HDS), V02 Max, and body mass index (BMI). Changes in total score on the PMDRS were the primary endpoint. A comparison of all measures taken at study onset and after completing the exercise program indicates statistically significant improvements. We observed a relevant improvement in 10 of 16 patients (62%). The mean difference for the primary outcome (PMDRS total) corresponded to about 70%. Compliance was good, and there were no adverse effects. This study provides preliminary evidence for regular low-medium intensity exercise as a safe, adequate, and pleasing intervention for PMD. Furthermore, well-designed studies appear justified to confirm these findings.
To determine short-term outcome and its predictors in patients with psychogenic nonepileptic attacks (PNEA).
Retrospective cohort study of outcomes relating to attendance at follow-up, spells, use of emergency services, employment, and social security payments recorded at 6 and 12 months post diagnosis in 260 consecutive patients.
A total of 187 patients (71.9%) attended at least 1 follow-up visit, and 105 patients (40.4%) attended 2. A total of 71/187 patients (38.0%) were spell-free at last follow-up. In contrast, 35/187 patients (18.7%) had marked increase in spell frequency postdiagnosis. Delay to diagnosis had no relationship to outcome. Patients with anxiety or depression were 2.32 times less likely to become spell-free (p = 0.012), and patients drawing social security payments at baseline were 2.34 times less likely to become spell-free (p = 0.014), than patients without those factors. Men were 2.46 times more likely to become spell-free than women (p = 0.016). While 93/187 patients (49.7%) were using emergency medical services at baseline, only 29/187 (15.5%) were using them at follow-up (p < 0.001). This was independent of whether or not the patient became spell-free.
A substantial minority of our patients became spell-free with communication of the diagnosis the only intervention. Previous psychiatric diagnoses, social security payments, and gender were important predictors of outcome. Most patients stopped using emergency services, irrespective of whether or not spells continued. Outcomes other than spell frequency may be important in patients with psychogenic nonepileptic attacks.
It has been previously reported that a substantial proportion of newly referred neurology out-patients have symptoms that are considered by the assessing neurologist as unexplained by 'organic disease'. There has however been much controversy about how often such patients subsequently develop a disease diagnosis that, with hindsight, would have explained the symptoms. We aimed to determine in a large sample of new neurology out-patients: (i) what proportion are assessed as having symptoms unexplained by disease and the diagnoses given to them; and (ii) how often a neurological disorder emerged which, with hindsight, explained the original symptoms. We carried out a prospective cohort study of patients referred from primary care to National Health Service neurology clinics in Scotland, UK. Measures were: (i) the proportion of patients with symptoms rated by the assessing neurologist as 'not at all' or only 'somewhat explained' by 'organic disease' and the neurological diagnoses recorded at initial assessment; and (ii) the frequency of unexpected new diagnoses made over the following 18 months (according to the primary-care physician). One thousand four hundred and forty-four patients (30% of all new patients) were rated as having symptoms 'not at all' or only 'somewhat explained' by 'organic disease'. The most common categories of diagnosis were: (i) organic neurological disease but with symptoms unexplained by it (26%); (ii) headache disorders (26%); and (iii) conversion symptoms (motor, sensory or non-epileptic attacks) (18%). At follow-up only 4 out of 1030 patients (0.4%) had acquired an organic disease diagnosis that was unexpected at initial assessment and plausibly the cause of the patients' original symptoms. Eight patients had died at follow-up; five of whom had initial diagnoses of non-epileptic attacks. Seven other types of diagnostic change with very different implications to a 'missed diagnosis' were found and a new classification of diagnostic revision is presented. One-third of new neurology out-patients are assessed as having symptoms 'unexplained by organic disease'. A new diagnosis, which with hindsight explained the original symptoms, rarely became apparent to the patient's primary care doctor in the 18 months following the initial hospital consultation.
To investigate the patterns of occurrence of psychogenic pseudoseizures (PPS) of 45 consecutive patients during a 6-month period after diagnosis, and to determine whether psychiatric and neurologic variables identified previously in PPS patient series can predict their recurrence after diagnosis, and whether any of these variables are associated with a particular outcome pattern.
Postdiagnosis PPS recurrence was assessed twice: during the first month and during a period ranging from the second to the sixth month. Outcome was categorized as follows: class I, complete cessation of PPS; class II, PPS only during one of the two observation periods; and class III, persistent PPS during the two observation periods. The authors used a logistic regression model to identify predictors of PPS recurrence (versus no PPS) among four neurologic and nine psychiatric variables, and compared their frequency among the three outcome classes.
Class I, n = 13 (29%); class II, n = 12 (27%); and class III, n = 20 (44%). The presence of an abnormal MR image predicted PPS recurrence during the second observation period with a 75% accuracy. The presence of all nine psychiatric variables predicted PPS recurrence during both the first and second observation periods with a 93% and an 89% accuracy respectively. Patients with a class III outcome had a markedly higher frequency of recurrent major depression, dissociative and personality disorders, and a history of chronic abuse. Patients with a class II outcome displayed a notably higher frequency of denial of stressors and psychosocial problems, refusal of treatment recommendations, and new somatic symptoms after disclosure of diagnosis. Conversely, one episode of major depression was the one common diagnosis in patients with a class I outcome.
PPS outcome after disclosure of diagnosis can be predicted by the presence of certain psychiatric characteristics. More than one psychopathogenic mechanism appears to operate in PPS.