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CASE
John D,* a 25-year-old patient with an otherwise unremarkable medical history, describes 2 months of daily headache, lower-extremity weakness, and unsteady gait that began fairly suddenly during his first deployment in the US Army. He explains that these symptoms affected his ability to perform his duties and necessitated an early return stateside for evaluation and treatment.
Mr. D denies precipitating trauma or unusual environmental exposures. He reports that, stateside now, symptoms continue to affect his ability to work and attend to personal and family responsibilities.
Asked about stressors, Mr. D notes the birth of his first child approximately 3 months ago, while he was deployed, and marital stressors. He denies suicidal or homicidal ideation.
* The patient’s name has been changed to protect his identity.
The challenge of identifying and managing FND
A functional neurological disorder (FND) is a constellation of psychological, physiological, and neurological symptoms, without an identifiable organic etiology, a conscious decision, or secondary gain for the patient,1 that adversely impacts functioning in 1 or more significant life domains.
Given the high throughput of patients in primary care practices, family physicians can expect to encounter suspected cases of FND in their practices. Regrettably, however, a lack of familiarity with the disorder and its related problems (eg, nonorganic paralysis, sensory loss, nonepileptic seizures, and abnormal movements) can add as much as $20,000 in excess direct and indirect costs of care for every such patient.1 In this article, we synthesize the recent literature on FND so that family physicians can expand their acumen in understanding, identifying, and evaluating patients whose presentation suggests FND.
An underrecognized entity
A precise estimate of the prevalence of FND is difficult to determine because the disorder is underrecognized and misdiagnosed and because it is often accompanied by the confounding of psychological and physiological comorbidities. A 2012 study estimated the annual incidence of FND to be 4 to 12 cases for every 100,000 people2; in primary care and outpatient neurology settings, prevalence is 6% to 22% of all patients.3,4 Stone and colleagues identified functional neurological symptoms as the second most common reason for outpatient neurology consultation,5 with 1 nonepileptic seizure patient seen for every 6 epileptic patients, and functional weakness presenting at the same rate as multiple sclerosis.6
Continue to: Demographics of patients with FND...
Demographics of patients with FND vary, depending on presenting neurological symptoms and disorder subtype. Existing data indicate a correlation between FND and younger age, female sex, physical disability,7 and a history of abuse or trauma.3,8 A challenge in concretely ascertaining the prevalence of FND is that conditions such as fibromyalgia, chronic pelvic pain, globus hystericus, and nonepileptic seizures can also be characterized as medically unexplained functional disorders, even within the network of neurology care.4
Misdiagnosis and bias are not uncommon
Ambiguity in classifying and evaluating FND can affect physicians’ perceptions, assessment, and care of patients with suggestive presenting symptoms. A major early challenge in diagnosing FND is the inconsistency of characterizing terminology (pseudoneurological, somatic, dissociative, conversion, psychogenic, hysterical, factitious, functional, medically unexplained9,10) and definitions in the literature. Neurological symptoms of unidentifiable organic cause can greatly diminish quality of life4; FND is a scientifically and clinically useful diagnosis for many combinations of nonrandomly co-occurring symptoms and clinical signs.
The pitfall of misdiagnosis. Remain cautious about making a diagnosis of FND by exclusion, which might yield an incorrect or false-negative finding because of an atypical presentation. It is important to avoid misdiagnosis by prematurely closing the differential diagnosis; instead, keep in mind that a medically unexplained diagnosis might be better explained by conducting a robust social and medical history and obtaining additional or collateral data, or both, along with appropriate consultation.4,9
Misdiagnosis can lead to a circuitous and costly work-up, with the potential to increase the patient’s distress. You can reduce this burden with early recognition of FND and centralized management of multidisciplinary care, which are more likely to lead to an accurate and timely diagnosis—paramount to empowering patients with access to the correct information and meaningful support needed to enhance treatment and self-care.9
Bias, haste, and dismissal are unproductive. Even with a clear definition of FND, it is not uncommon for a physician to rapidly assess a patient’s clinical signs, make a diagnosis of “unknown etiology,” or openly question the veracity of complaints. Furthermore, be aware of inadvertently characterizing FND using the prefix “pseudo” or the term “hysterical,” which can be psychologically discomforting for many patients, who legitimately experience inexplicable symptoms. Such pejoratives can lead to stigmatizing and misleading assessments and treatment paths4—courses of action that can cause early and, possibly, irreparable harm to the patient–physician relationship and increase the patient’s inclination to go “doctor-shopping,” with associated loss of continuity of care.
Why is it difficult to diagnose FND?
The latest (5th) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) describes conversion, somatoform disorder, and FND synonymously.DSM-5 diagnostic criteria for conversion disorderare11:
- a specified type of symptom or deficit of altered voluntary motor or sensory function (eg, weakness, difficulty swallowing, slurred speech, seizures)
- clinical evidence of the incompatibility of the symptom or deficit and any recognized neurological or medical disorder
- incapability of better explaining the symptom or deficit as another medical or mental disorder.
- The symptom or deficit causes distress or impairment that (1) is clinically significant in occupational, social, or other important areas of function or (2) warrants medical evaluation.
The overarching feature of these criteria is the inconsistency of symptoms with recognized neurological, physiological, or psychiatric conditions. Although identification of psychological factors can help clarify and provide a treatment direction, such identification is not essential for making a diagnosis of FND. Malingering does not need to be refuted as part of establishing the diagnosis.12
Continue to: In contrast...
In contrast, the World Health Organization’s ICD-10 Classification of Mental and Behavioural Disorders groups diagnostic criteria for FND among the dissociative disorders13:
- Clinical features are specified for the individual dissociative disorder (motor, sensory, convulsions, mixed).
- Evidence is absent of a physical disorder that might explain symptoms.
- Evidence of psychological causation is present in clear temporal association with stressful events and problems or disturbed relationships, even if the patient denies such association.
Note the emphasis on psychological causation and exclusion of purposeful simulation of symptoms, as opposed to a primarily unconscious disconnection from the patient’s body or environment.
ICD-10 guidelines acknowledge the difficulty of finding definitive evidence of a psychological cause and recommend provisional diagnosis of FND if psychological factors are not readily apparent.14 Of note, many patients with FND are affected psychologically by their condition, with an impact on mood, behaviors, and interpersonal interactions, although not necessarily to a clinically diagnostic degree. Therefore, a psychiatric diagnosis alone is not a necessary precursor for the diagnosis of an FND.
CASE
History. Mr. D’s history is positive for light alcohol consumption (“2 or 3 cans of beer on weekends”) and chewing tobacco (he reports stopping 6 months earlier) and negative for substance abuse. The family history is positive for maternal hypertension and paternal suicide when the patient was 10 years old (no other known paternal history).
Physical findings. The review of systems is positive for intermittent palpitations, lower-extremity weakness causing unsteady gait, and generalized headache.
Vital signs are within normal limits, including blood pressure (120/82 mm Hg) and heart rate (110 beats/min). The patient is not in acute distress; he is awake, alert, and oriented × 3. No murmurs are heard; lungs are clear bilaterally to auscultation. There is no tenderness on abdominal palpation, and no hepatomegaly or splenomegaly; bowel sounds are normal. No significant bruising or lacerations are noted.
Neurology exam. Cranial nerves II-XII are intact. Pupils are equal and reactive to light. Reflexes are 2+ bilaterally. Muscle strength and tone are normal; no tremors are noted. Babinski signs are normal. A Romberg test is positive (swaying).
Continue to: Mr. D has an antalgic gait...
Mr. D has an antalgic gait with significant swaying (without falling); bent posture; and unsteadiness that requires a cane. However, he is able to get up and off the exam table without assistance, and to propel himself, by rolling a chair forward and backward, without difficulty.
Conducting a diagnostic examination
Taking the history. Certain clues can aid in the diagnosis of FND (TABLE 1).15 For example, the patient might have been seen in multiple specialty practices for a multitude of vague symptoms indicative of potentially related conditions (eg, chronic fatigue, allergies and sensitivities, fibromyalgia, and other chronic pain). The history might include repeated surgeries to investigate those symptoms (eg, laparoscopy, or hysterectomy at an early age). Taking time and care to explore all clinical clues, patient reports, and collateral data are therefore key to making an accurate diagnosis.
Note any discrepancies between the severity of reported symptoms and functional ability. A technique that can help elucidate a complex or ambiguous medical presentation is to ask the patient to list all their symptoms at the beginning of the interview. This has threefold benefit: You get a broad picture of the problem; the patient is unburdened of their concerns and experiences your validation; and a long list of symptoms can be an early clue to a diagnosis of FND.
Other helpful questions to determine the impact of symptoms on the patient’s well-being include inquiries about16:
- functional impairment
- onset and course of symptoms
- potential causal or correlating events
- dissociative episodes
- previous diagnoses and treatments
- the patient’s perceptions of, and emotional response to, their illness
- a history of abuse.
The physical examination to determine the presence of FND varies, depending on the functional area of impact (eg, motor, neurological, sensory, speech and swallowing). Pay particular attention to presenting signs and clues, and balance them with the patient’s report (or lack of report). Endeavor to demonstrate positive functional signs, such as a positive Hoover test, which relies on the principle of synergistic muscle contraction. You might see evidence of inconsistency, such as weakness or a change in gait, under observation, that seemingly resolves when the patient is getting on and off the exam table.16Table 215-24 describes areas affected by FND, characteristics of the disorder, and related diagnostic examinations.
Table 315,18,19 reviews validated special exams that can aid in making the diagnosis. Additional special tests are discussed in the literature.15-24 These tests can be helpful in narrowing the differential diagnosis but have not been validated and should be used with caution.
Some clinical signs associated with FND might be affected by other factors, including socioeconomic status, limited access to health care, low health literacy, poor communication skills, and physician bias. Keep these factors in mind during the visit, to avoid contributing further to health disparities among groups of patients affected by these problems.
Continue to: CASE
CASE
The work-up over the next month for Mr. D includes numerous studies, all yielding results that are negative or within normal limits: visual acuity; electrocardiography and an event monitor; laboratory testing (including a complete blood count, comprehensive metabolic panel, thyroid-stimulating hormone, creatine kinase, erythrocyte sedimentation rate, C-reactive protein, vitamin B12, folate, and vitamin D); magnetic resonance imaging of the brain and lumbar spine; lumbar puncture; and electromyography.
The score on the 9-item Patient Health Questionnaire for depression is 4 (severity: “none or minimal”); on the 7-item Generalized Anxiety Disorder scale, 0 (“no anxiety disorder”).
Referral. A neurology work-up of headache, lower extremity weakness, and unsteady gait to address several diagnostic possibilities, including migraine and multiple sclerosis, is within normal limits. A cardiology work-up of palpitations is negative for arrhythmias and other concerning findings.
Mr. D declines psychiatric and psychological evaluations.
Building a differential diagnosisis a formidable task
The differential diagnosis of FND is vast. It includes neurological, physiological, and psychiatric symptoms and disorders; somatization; and malingering (Table 4).6 Any disorder or condition in these areas that is in the differential diagnosis can be precipitated or exacerbated by stress; most, however, do not involve loss of physical function.12 In addition, the diagnosis of an FND does not necessarily exclude an organic disorder.
A patient’s presentation becomes complicated—and more difficult to treat—when functional symptoms and an unrelated underlying or early-stage neurological condition coexist. For example, a patient with epilepsy might also have dissociative seizures atop their organic disorder. Neurological disease is considered a risk factor for an overlying FND—just as the risk of depression or anxiety runs concurrently with other chronic diseases.14
Focus on clinical signs to narrow the differential. A thorough social and medical history and physical examination, as discussed earlier, help narrow the differential diagnosis of organic and medically unexplained disorders. Well-defined imaging or laboratory protocols do not exist to guide physicians to a definitive diagnosis, however.
Continue to: Psychiatric conditions
Psychiatric conditions can coexist with the diagnosis of FND, but might be unrelated. A systematic review of the literature showed that 17% to 42% of patients with FND had a concurrent anxiety disorder. Depression disorders were co-diagnosed in 19% to 71% of patients with FND; dissociative and personality disorders were noted, as well.25 However, coexisting psychiatric diagnosis might more likely be associated with distress from the presenting functional neurological symptoms, not linked to the FND diagnosis itself.12 This shift in understanding is reflected in the description of FND in the DSM-5.11
CASE
Mr. D reports debilitating headaches at return office visits. Trials of abortive triptans provide no relief; neither do control medications (beta-blockers, coenzyme Q10, magnesium, onabotulinumtoxinA [Botox], topiramate, and valproate). Lower-extremity weakness and unsteadiness are managed with supportive devices, including a cane, and physical therapy.
Importance of establishing a multidisciplinary approach
The complexity of FND lends itself to a multidisciplinary approach during evaluation and, eventually, for treatment. The assessment and diagnostic intervention that you provide, along with the contributions of consulted specialists (including neurology, physical and occupational therapy, psychiatry, psychology, and other mental health professionals) establishes a team-based approach that can increase the patient’s sense of support and reduce excessive testing and unnecessary medications, surgeries, and other treatments.26
Family physicians are in the ideal position to recognize the patient’s functional capacity and the quality of symptoms and to provide timely referral (eg, to Neurology and Psychiatry) for confirmation of the diagnosis and then treatment.
Evidence-based treatment options include:
- psychotherapy, with an emphasis on cognitive behavioral therapy
- physical therapy
- psychopharmacology
- promising combinations of physical and psychological treatment to improve long-term functionality.27
A promising diagnostic tool
The most significant update in the FND literature is on functional neuroimaging for assessing the disorder. Early findings suggest an intricate relationship between mind and body regarding the pathological distortion in FND. And, there is clear evidence that neuroimaging—specifically, functional magnetic resonance imaging—shows changes in brain activity that correspond to the patient’s symptom report. That said, imaging is not the recommended standard of care in the initial work-up of FND because of its cost and the fact that the diagnosis is principally a clinical undertaking.17,28
Call to action
Offer a generous ear. Begin the diagnostic pursuit by listening carefully and fully to the patient’s complaints, without arriving at a diagnosis with unwarranted bias or haste. This endeavor might require support from other clinical staff (eg, nurses, social workers, case managers) because the diagnostic process can be arduous and lengthy.
Continue to: Convey the diagnosis with sensitivity
Convey the diagnosis with sensitivity. Inquire about the patient’s perceptions and impairments to best personalize your diagnostic explanations. Delivery of the diagnosis might affect the patient’s acceptance and compliance with further testing and treatment of what is generally a persistent and treatment-resistant disorder; poor delivery of diagnostic information can impair the patient–physician relationship and increase the risk of disjointed care. Many patients find that improved patient–physician communication is therapeutic.29
Let the patient know that you’re taking her seriously. Validate patient concerns with a nonstigmatizing diagnostic label; discuss the diagnostic parameters and cause of symptoms in layman’s terms; and emphasize the potential for reversibility.30 Some patients are not satisfied with having a diagnosis of FND until they are reassured with normal results of testing and provided with referral; even then, some seek further reassurance.
Key tenets of managing care for patients who have been given a diagnosis of FND include:
- nonjudgmental, positive regard
- meaningful expression of empathy
- multidisciplinary coordination
- avoidance of unnecessary testing and harmful treatments
- descriptive and contextual explanations of the diagnosis.
Last, keep in mind that the course of treatment for FND is potentially prolonged and multilayered.
CASE
After many visits with his family physician and the neurology and cardiology specialists, as well as an extensive work-up, the physician approaches Mr. D with the possibility of a diagnosis of FND and proposes a multidisciplinary plan that includes:
- a course of physical and occupational therapy
- development of individualized cognitive behavioral tools
- weekly personal and marital counseling
- initiation of a selective serotonin reuptake inhibitor for anxiety
- monthly visits with his family physician.
Months after his return from deployment for evaluation and treatment, Mr. D is able to return to military duty. He reports that his quality of life has improved.
CORRESPONDENCE
Roselyn W. Clemente Fuentes, MD, FAAFP, Eglin Family Medicine Residency, 307 Boatner Road, Eglin AFB, FL 32547; [email protected].
1. Konnopka A, Schaefert R, Heinrich S, et al. Economics of medically unexplained symptoms: a systematic review of the literature. Psychother Psychosom. 2012;81:265-275.
2. Carson AJ, Brown R, David AS, et al; on behalf of UK-FNS. Functional (conversion) neurological symptoms: research since the millennium. J Neurol Neurosurg Psychiatry. 2012;83:842-850.
3. Stone J, Carson A, Duncan R, et al. Who is referred to neurology clinics?—the diagnoses made in 3781 new patients. Clin Neurol Neurosurg. 2010;112:747-751.
4. Evens A, Vendetta L, Krebs K, et al. Medically unexplained neurologic symptoms: a primer for physicians who make the initial encounter. Am J Med. 2015;128:1059-1064.
5. Stone J, Reuber M, Carson A. Functional symptoms in neurology: mimics and chameleons. Pract Neurol. 2013;13:104-113.
6. Stone J, Warlow C, Sharpe M. The symptom of functional weakness: a controlled study of 107 patients. Brain. 2010;133:1537-1551.
7. Carson A, Stone J, Hibberd C, et al. Disability, distress and unemployment in neurology outpatients with symptoms ‘unexplained by organic disease’. J Neurol Neurosurg Psychiatry. 2011;82:810-813.
8. Fink P, Hansen MS, Oxhøj M-L. The prevalence of somatoform disorders among internal medical inpatients. J Psychosom Res. 2004;56:413-418.
9. Thomas LE. Are your patient’s medically unexplained symptoms really “all in her head”? Med Hypotheses. 2012;78:542-547.
10. Ding JM, Kanaan RAA. What should we say to patients with unexplained neurological symptoms? How explanation affects offence. J Psychosom Res. 2016;91:55-60.
11. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. American Psychiatric Association; 2013.
12. Stone J, LaFrance WC Jr, Levenson JL, et al. Issues for DSM-5: Conversion disorder. Am J Psychiatry. 2010;167:626-627.
13. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. World Health Organization; 1994. Accessed January 21, 2021. www.who.int/classifications/icd/en/bluebook.pdf
14. Stone J, Carson A, Duncan R, et al. Which neurological diseases are most likely to be associated with “symptoms unexplained by organic disease.” J Neurol. 2012;259:33-38.
15. Shaibani A, Sabbagh M. Pseudoneurologic syndromes: recognition and diagnosis. Am Fam Physician. 1998;57:2485-2494.
16. Stone J, Carson A, Sharpe M. Functional symptoms and signs in neurology: assessment and diagnosis. J Neurol Neurosurg Psychiatry. 2005;76(suppl 1):i2-i12.
17. Vuilleumier P. Brain circuits implicated in psychogenic paralysis in conversion disorders and hypnosis. Neurophysiol Clin. 2014;44:323-337.
18. McKee K, Glass S, Adams C, et al. The inpatient assessment and management of motor functional neurological disorders: an interdisciplinary perspective. Psychosomatics. 2018;59:358-368.
19. Daum C, Hubschmid M, Aybek S. The value of ‘positive’ clinical signs for weakness, sensory and gait disorders in conversion disorder: a systematic and narrative review. J Neurol Neurosurg Psychiatry. 2014;85:180-190.
20. Brown P, Thompson PD. Electrophysiological aids to the diagnosis of psychogenic jerks, spasms, and tremor. Mov Disord. 2001;16:595-599.
21. Ludwig L, McWhirter L, Williams S, et al. Functional coma. In: Hallett M, Stone J, Carson A, eds. Handbook of Clinical Neurology: Volume 139: Functional Neurologic Disorders. 1st ed. Academic Press; 2016:313.
22. Miller NR, Subramanian PS, Patel VR. Walsh and Hoyt’s Clinical Neuro-ophthalmology. 3rd ed. Wolters Kluwer; 2016:512-513.
23. Takazaki K, Stransky AD, Miller G. Psychogenic nonepileptic seizures: diagnosis, management, and bioethics. Pediatr Neurol. 2016;62:3-8.
24. Sahaya K, Dholakia SA, Sahota PK. Psychogenic non-epileptic seizures: a challenging entity. J Clin Neurosci. 2011;18:1602-1607.
25. Gelauff J, Stone J, Edwards M, et al. The prognosis of functional (psychogenic) motor symptoms: a systematic review. J Neurol Neurosurg Psychiatry. 2014;85:220-226.
26. Kranick SM, Gorrindo T, Hallett M. Psychogenic movement disorders and motor conversion: a roadmap for collaboration between neurology and psychiatry. Psychosomatics. 2011;52:109-116.
27. Edwards MJ, Bhatia KP. Functional (psychogenic) movement disorders: merging mind and brain. Lancet Neurol. 2012;11:250-260.
28. Burgmer M, Kugel H, Pfleiderer B, et al. The mirror neuron system under hypnosis—brain substrates of voluntary and involuntary motor activation in hypnotic paralysis. Cortex. 2013;49:437-445.
29. van Bokhoven MA, Koch H, van der Weijden T, et al. Influence of watchful waiting on satisfaction and anxiety among patients seeking care for unexplained complaints, Ann Fam Med. 2009;7:112-120.
30. Stone J, Carson A, Hallet M. Explanation as treatment for functional neurologic disorders. Handb Clin Neurol. 2016;139:543-553.
CASE
John D,* a 25-year-old patient with an otherwise unremarkable medical history, describes 2 months of daily headache, lower-extremity weakness, and unsteady gait that began fairly suddenly during his first deployment in the US Army. He explains that these symptoms affected his ability to perform his duties and necessitated an early return stateside for evaluation and treatment.
Mr. D denies precipitating trauma or unusual environmental exposures. He reports that, stateside now, symptoms continue to affect his ability to work and attend to personal and family responsibilities.
Asked about stressors, Mr. D notes the birth of his first child approximately 3 months ago, while he was deployed, and marital stressors. He denies suicidal or homicidal ideation.
* The patient’s name has been changed to protect his identity.
The challenge of identifying and managing FND
A functional neurological disorder (FND) is a constellation of psychological, physiological, and neurological symptoms, without an identifiable organic etiology, a conscious decision, or secondary gain for the patient,1 that adversely impacts functioning in 1 or more significant life domains.
Given the high throughput of patients in primary care practices, family physicians can expect to encounter suspected cases of FND in their practices. Regrettably, however, a lack of familiarity with the disorder and its related problems (eg, nonorganic paralysis, sensory loss, nonepileptic seizures, and abnormal movements) can add as much as $20,000 in excess direct and indirect costs of care for every such patient.1 In this article, we synthesize the recent literature on FND so that family physicians can expand their acumen in understanding, identifying, and evaluating patients whose presentation suggests FND.
An underrecognized entity
A precise estimate of the prevalence of FND is difficult to determine because the disorder is underrecognized and misdiagnosed and because it is often accompanied by the confounding of psychological and physiological comorbidities. A 2012 study estimated the annual incidence of FND to be 4 to 12 cases for every 100,000 people2; in primary care and outpatient neurology settings, prevalence is 6% to 22% of all patients.3,4 Stone and colleagues identified functional neurological symptoms as the second most common reason for outpatient neurology consultation,5 with 1 nonepileptic seizure patient seen for every 6 epileptic patients, and functional weakness presenting at the same rate as multiple sclerosis.6
Continue to: Demographics of patients with FND...
Demographics of patients with FND vary, depending on presenting neurological symptoms and disorder subtype. Existing data indicate a correlation between FND and younger age, female sex, physical disability,7 and a history of abuse or trauma.3,8 A challenge in concretely ascertaining the prevalence of FND is that conditions such as fibromyalgia, chronic pelvic pain, globus hystericus, and nonepileptic seizures can also be characterized as medically unexplained functional disorders, even within the network of neurology care.4
Misdiagnosis and bias are not uncommon
Ambiguity in classifying and evaluating FND can affect physicians’ perceptions, assessment, and care of patients with suggestive presenting symptoms. A major early challenge in diagnosing FND is the inconsistency of characterizing terminology (pseudoneurological, somatic, dissociative, conversion, psychogenic, hysterical, factitious, functional, medically unexplained9,10) and definitions in the literature. Neurological symptoms of unidentifiable organic cause can greatly diminish quality of life4; FND is a scientifically and clinically useful diagnosis for many combinations of nonrandomly co-occurring symptoms and clinical signs.
The pitfall of misdiagnosis. Remain cautious about making a diagnosis of FND by exclusion, which might yield an incorrect or false-negative finding because of an atypical presentation. It is important to avoid misdiagnosis by prematurely closing the differential diagnosis; instead, keep in mind that a medically unexplained diagnosis might be better explained by conducting a robust social and medical history and obtaining additional or collateral data, or both, along with appropriate consultation.4,9
Misdiagnosis can lead to a circuitous and costly work-up, with the potential to increase the patient’s distress. You can reduce this burden with early recognition of FND and centralized management of multidisciplinary care, which are more likely to lead to an accurate and timely diagnosis—paramount to empowering patients with access to the correct information and meaningful support needed to enhance treatment and self-care.9
Bias, haste, and dismissal are unproductive. Even with a clear definition of FND, it is not uncommon for a physician to rapidly assess a patient’s clinical signs, make a diagnosis of “unknown etiology,” or openly question the veracity of complaints. Furthermore, be aware of inadvertently characterizing FND using the prefix “pseudo” or the term “hysterical,” which can be psychologically discomforting for many patients, who legitimately experience inexplicable symptoms. Such pejoratives can lead to stigmatizing and misleading assessments and treatment paths4—courses of action that can cause early and, possibly, irreparable harm to the patient–physician relationship and increase the patient’s inclination to go “doctor-shopping,” with associated loss of continuity of care.
Why is it difficult to diagnose FND?
The latest (5th) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) describes conversion, somatoform disorder, and FND synonymously.DSM-5 diagnostic criteria for conversion disorderare11:
- a specified type of symptom or deficit of altered voluntary motor or sensory function (eg, weakness, difficulty swallowing, slurred speech, seizures)
- clinical evidence of the incompatibility of the symptom or deficit and any recognized neurological or medical disorder
- incapability of better explaining the symptom or deficit as another medical or mental disorder.
- The symptom or deficit causes distress or impairment that (1) is clinically significant in occupational, social, or other important areas of function or (2) warrants medical evaluation.
The overarching feature of these criteria is the inconsistency of symptoms with recognized neurological, physiological, or psychiatric conditions. Although identification of psychological factors can help clarify and provide a treatment direction, such identification is not essential for making a diagnosis of FND. Malingering does not need to be refuted as part of establishing the diagnosis.12
Continue to: In contrast...
In contrast, the World Health Organization’s ICD-10 Classification of Mental and Behavioural Disorders groups diagnostic criteria for FND among the dissociative disorders13:
- Clinical features are specified for the individual dissociative disorder (motor, sensory, convulsions, mixed).
- Evidence is absent of a physical disorder that might explain symptoms.
- Evidence of psychological causation is present in clear temporal association with stressful events and problems or disturbed relationships, even if the patient denies such association.
Note the emphasis on psychological causation and exclusion of purposeful simulation of symptoms, as opposed to a primarily unconscious disconnection from the patient’s body or environment.
ICD-10 guidelines acknowledge the difficulty of finding definitive evidence of a psychological cause and recommend provisional diagnosis of FND if psychological factors are not readily apparent.14 Of note, many patients with FND are affected psychologically by their condition, with an impact on mood, behaviors, and interpersonal interactions, although not necessarily to a clinically diagnostic degree. Therefore, a psychiatric diagnosis alone is not a necessary precursor for the diagnosis of an FND.
CASE
History. Mr. D’s history is positive for light alcohol consumption (“2 or 3 cans of beer on weekends”) and chewing tobacco (he reports stopping 6 months earlier) and negative for substance abuse. The family history is positive for maternal hypertension and paternal suicide when the patient was 10 years old (no other known paternal history).
Physical findings. The review of systems is positive for intermittent palpitations, lower-extremity weakness causing unsteady gait, and generalized headache.
Vital signs are within normal limits, including blood pressure (120/82 mm Hg) and heart rate (110 beats/min). The patient is not in acute distress; he is awake, alert, and oriented × 3. No murmurs are heard; lungs are clear bilaterally to auscultation. There is no tenderness on abdominal palpation, and no hepatomegaly or splenomegaly; bowel sounds are normal. No significant bruising or lacerations are noted.
Neurology exam. Cranial nerves II-XII are intact. Pupils are equal and reactive to light. Reflexes are 2+ bilaterally. Muscle strength and tone are normal; no tremors are noted. Babinski signs are normal. A Romberg test is positive (swaying).
Continue to: Mr. D has an antalgic gait...
Mr. D has an antalgic gait with significant swaying (without falling); bent posture; and unsteadiness that requires a cane. However, he is able to get up and off the exam table without assistance, and to propel himself, by rolling a chair forward and backward, without difficulty.
Conducting a diagnostic examination
Taking the history. Certain clues can aid in the diagnosis of FND (TABLE 1).15 For example, the patient might have been seen in multiple specialty practices for a multitude of vague symptoms indicative of potentially related conditions (eg, chronic fatigue, allergies and sensitivities, fibromyalgia, and other chronic pain). The history might include repeated surgeries to investigate those symptoms (eg, laparoscopy, or hysterectomy at an early age). Taking time and care to explore all clinical clues, patient reports, and collateral data are therefore key to making an accurate diagnosis.
Note any discrepancies between the severity of reported symptoms and functional ability. A technique that can help elucidate a complex or ambiguous medical presentation is to ask the patient to list all their symptoms at the beginning of the interview. This has threefold benefit: You get a broad picture of the problem; the patient is unburdened of their concerns and experiences your validation; and a long list of symptoms can be an early clue to a diagnosis of FND.
Other helpful questions to determine the impact of symptoms on the patient’s well-being include inquiries about16:
- functional impairment
- onset and course of symptoms
- potential causal or correlating events
- dissociative episodes
- previous diagnoses and treatments
- the patient’s perceptions of, and emotional response to, their illness
- a history of abuse.
The physical examination to determine the presence of FND varies, depending on the functional area of impact (eg, motor, neurological, sensory, speech and swallowing). Pay particular attention to presenting signs and clues, and balance them with the patient’s report (or lack of report). Endeavor to demonstrate positive functional signs, such as a positive Hoover test, which relies on the principle of synergistic muscle contraction. You might see evidence of inconsistency, such as weakness or a change in gait, under observation, that seemingly resolves when the patient is getting on and off the exam table.16Table 215-24 describes areas affected by FND, characteristics of the disorder, and related diagnostic examinations.
Table 315,18,19 reviews validated special exams that can aid in making the diagnosis. Additional special tests are discussed in the literature.15-24 These tests can be helpful in narrowing the differential diagnosis but have not been validated and should be used with caution.
Some clinical signs associated with FND might be affected by other factors, including socioeconomic status, limited access to health care, low health literacy, poor communication skills, and physician bias. Keep these factors in mind during the visit, to avoid contributing further to health disparities among groups of patients affected by these problems.
Continue to: CASE
CASE
The work-up over the next month for Mr. D includes numerous studies, all yielding results that are negative or within normal limits: visual acuity; electrocardiography and an event monitor; laboratory testing (including a complete blood count, comprehensive metabolic panel, thyroid-stimulating hormone, creatine kinase, erythrocyte sedimentation rate, C-reactive protein, vitamin B12, folate, and vitamin D); magnetic resonance imaging of the brain and lumbar spine; lumbar puncture; and electromyography.
The score on the 9-item Patient Health Questionnaire for depression is 4 (severity: “none or minimal”); on the 7-item Generalized Anxiety Disorder scale, 0 (“no anxiety disorder”).
Referral. A neurology work-up of headache, lower extremity weakness, and unsteady gait to address several diagnostic possibilities, including migraine and multiple sclerosis, is within normal limits. A cardiology work-up of palpitations is negative for arrhythmias and other concerning findings.
Mr. D declines psychiatric and psychological evaluations.
Building a differential diagnosisis a formidable task
The differential diagnosis of FND is vast. It includes neurological, physiological, and psychiatric symptoms and disorders; somatization; and malingering (Table 4).6 Any disorder or condition in these areas that is in the differential diagnosis can be precipitated or exacerbated by stress; most, however, do not involve loss of physical function.12 In addition, the diagnosis of an FND does not necessarily exclude an organic disorder.
A patient’s presentation becomes complicated—and more difficult to treat—when functional symptoms and an unrelated underlying or early-stage neurological condition coexist. For example, a patient with epilepsy might also have dissociative seizures atop their organic disorder. Neurological disease is considered a risk factor for an overlying FND—just as the risk of depression or anxiety runs concurrently with other chronic diseases.14
Focus on clinical signs to narrow the differential. A thorough social and medical history and physical examination, as discussed earlier, help narrow the differential diagnosis of organic and medically unexplained disorders. Well-defined imaging or laboratory protocols do not exist to guide physicians to a definitive diagnosis, however.
Continue to: Psychiatric conditions
Psychiatric conditions can coexist with the diagnosis of FND, but might be unrelated. A systematic review of the literature showed that 17% to 42% of patients with FND had a concurrent anxiety disorder. Depression disorders were co-diagnosed in 19% to 71% of patients with FND; dissociative and personality disorders were noted, as well.25 However, coexisting psychiatric diagnosis might more likely be associated with distress from the presenting functional neurological symptoms, not linked to the FND diagnosis itself.12 This shift in understanding is reflected in the description of FND in the DSM-5.11
CASE
Mr. D reports debilitating headaches at return office visits. Trials of abortive triptans provide no relief; neither do control medications (beta-blockers, coenzyme Q10, magnesium, onabotulinumtoxinA [Botox], topiramate, and valproate). Lower-extremity weakness and unsteadiness are managed with supportive devices, including a cane, and physical therapy.
Importance of establishing a multidisciplinary approach
The complexity of FND lends itself to a multidisciplinary approach during evaluation and, eventually, for treatment. The assessment and diagnostic intervention that you provide, along with the contributions of consulted specialists (including neurology, physical and occupational therapy, psychiatry, psychology, and other mental health professionals) establishes a team-based approach that can increase the patient’s sense of support and reduce excessive testing and unnecessary medications, surgeries, and other treatments.26
Family physicians are in the ideal position to recognize the patient’s functional capacity and the quality of symptoms and to provide timely referral (eg, to Neurology and Psychiatry) for confirmation of the diagnosis and then treatment.
Evidence-based treatment options include:
- psychotherapy, with an emphasis on cognitive behavioral therapy
- physical therapy
- psychopharmacology
- promising combinations of physical and psychological treatment to improve long-term functionality.27
A promising diagnostic tool
The most significant update in the FND literature is on functional neuroimaging for assessing the disorder. Early findings suggest an intricate relationship between mind and body regarding the pathological distortion in FND. And, there is clear evidence that neuroimaging—specifically, functional magnetic resonance imaging—shows changes in brain activity that correspond to the patient’s symptom report. That said, imaging is not the recommended standard of care in the initial work-up of FND because of its cost and the fact that the diagnosis is principally a clinical undertaking.17,28
Call to action
Offer a generous ear. Begin the diagnostic pursuit by listening carefully and fully to the patient’s complaints, without arriving at a diagnosis with unwarranted bias or haste. This endeavor might require support from other clinical staff (eg, nurses, social workers, case managers) because the diagnostic process can be arduous and lengthy.
Continue to: Convey the diagnosis with sensitivity
Convey the diagnosis with sensitivity. Inquire about the patient’s perceptions and impairments to best personalize your diagnostic explanations. Delivery of the diagnosis might affect the patient’s acceptance and compliance with further testing and treatment of what is generally a persistent and treatment-resistant disorder; poor delivery of diagnostic information can impair the patient–physician relationship and increase the risk of disjointed care. Many patients find that improved patient–physician communication is therapeutic.29
Let the patient know that you’re taking her seriously. Validate patient concerns with a nonstigmatizing diagnostic label; discuss the diagnostic parameters and cause of symptoms in layman’s terms; and emphasize the potential for reversibility.30 Some patients are not satisfied with having a diagnosis of FND until they are reassured with normal results of testing and provided with referral; even then, some seek further reassurance.
Key tenets of managing care for patients who have been given a diagnosis of FND include:
- nonjudgmental, positive regard
- meaningful expression of empathy
- multidisciplinary coordination
- avoidance of unnecessary testing and harmful treatments
- descriptive and contextual explanations of the diagnosis.
Last, keep in mind that the course of treatment for FND is potentially prolonged and multilayered.
CASE
After many visits with his family physician and the neurology and cardiology specialists, as well as an extensive work-up, the physician approaches Mr. D with the possibility of a diagnosis of FND and proposes a multidisciplinary plan that includes:
- a course of physical and occupational therapy
- development of individualized cognitive behavioral tools
- weekly personal and marital counseling
- initiation of a selective serotonin reuptake inhibitor for anxiety
- monthly visits with his family physician.
Months after his return from deployment for evaluation and treatment, Mr. D is able to return to military duty. He reports that his quality of life has improved.
CORRESPONDENCE
Roselyn W. Clemente Fuentes, MD, FAAFP, Eglin Family Medicine Residency, 307 Boatner Road, Eglin AFB, FL 32547; [email protected].
CASE
John D,* a 25-year-old patient with an otherwise unremarkable medical history, describes 2 months of daily headache, lower-extremity weakness, and unsteady gait that began fairly suddenly during his first deployment in the US Army. He explains that these symptoms affected his ability to perform his duties and necessitated an early return stateside for evaluation and treatment.
Mr. D denies precipitating trauma or unusual environmental exposures. He reports that, stateside now, symptoms continue to affect his ability to work and attend to personal and family responsibilities.
Asked about stressors, Mr. D notes the birth of his first child approximately 3 months ago, while he was deployed, and marital stressors. He denies suicidal or homicidal ideation.
* The patient’s name has been changed to protect his identity.
The challenge of identifying and managing FND
A functional neurological disorder (FND) is a constellation of psychological, physiological, and neurological symptoms, without an identifiable organic etiology, a conscious decision, or secondary gain for the patient,1 that adversely impacts functioning in 1 or more significant life domains.
Given the high throughput of patients in primary care practices, family physicians can expect to encounter suspected cases of FND in their practices. Regrettably, however, a lack of familiarity with the disorder and its related problems (eg, nonorganic paralysis, sensory loss, nonepileptic seizures, and abnormal movements) can add as much as $20,000 in excess direct and indirect costs of care for every such patient.1 In this article, we synthesize the recent literature on FND so that family physicians can expand their acumen in understanding, identifying, and evaluating patients whose presentation suggests FND.
An underrecognized entity
A precise estimate of the prevalence of FND is difficult to determine because the disorder is underrecognized and misdiagnosed and because it is often accompanied by the confounding of psychological and physiological comorbidities. A 2012 study estimated the annual incidence of FND to be 4 to 12 cases for every 100,000 people2; in primary care and outpatient neurology settings, prevalence is 6% to 22% of all patients.3,4 Stone and colleagues identified functional neurological symptoms as the second most common reason for outpatient neurology consultation,5 with 1 nonepileptic seizure patient seen for every 6 epileptic patients, and functional weakness presenting at the same rate as multiple sclerosis.6
Continue to: Demographics of patients with FND...
Demographics of patients with FND vary, depending on presenting neurological symptoms and disorder subtype. Existing data indicate a correlation between FND and younger age, female sex, physical disability,7 and a history of abuse or trauma.3,8 A challenge in concretely ascertaining the prevalence of FND is that conditions such as fibromyalgia, chronic pelvic pain, globus hystericus, and nonepileptic seizures can also be characterized as medically unexplained functional disorders, even within the network of neurology care.4
Misdiagnosis and bias are not uncommon
Ambiguity in classifying and evaluating FND can affect physicians’ perceptions, assessment, and care of patients with suggestive presenting symptoms. A major early challenge in diagnosing FND is the inconsistency of characterizing terminology (pseudoneurological, somatic, dissociative, conversion, psychogenic, hysterical, factitious, functional, medically unexplained9,10) and definitions in the literature. Neurological symptoms of unidentifiable organic cause can greatly diminish quality of life4; FND is a scientifically and clinically useful diagnosis for many combinations of nonrandomly co-occurring symptoms and clinical signs.
The pitfall of misdiagnosis. Remain cautious about making a diagnosis of FND by exclusion, which might yield an incorrect or false-negative finding because of an atypical presentation. It is important to avoid misdiagnosis by prematurely closing the differential diagnosis; instead, keep in mind that a medically unexplained diagnosis might be better explained by conducting a robust social and medical history and obtaining additional or collateral data, or both, along with appropriate consultation.4,9
Misdiagnosis can lead to a circuitous and costly work-up, with the potential to increase the patient’s distress. You can reduce this burden with early recognition of FND and centralized management of multidisciplinary care, which are more likely to lead to an accurate and timely diagnosis—paramount to empowering patients with access to the correct information and meaningful support needed to enhance treatment and self-care.9
Bias, haste, and dismissal are unproductive. Even with a clear definition of FND, it is not uncommon for a physician to rapidly assess a patient’s clinical signs, make a diagnosis of “unknown etiology,” or openly question the veracity of complaints. Furthermore, be aware of inadvertently characterizing FND using the prefix “pseudo” or the term “hysterical,” which can be psychologically discomforting for many patients, who legitimately experience inexplicable symptoms. Such pejoratives can lead to stigmatizing and misleading assessments and treatment paths4—courses of action that can cause early and, possibly, irreparable harm to the patient–physician relationship and increase the patient’s inclination to go “doctor-shopping,” with associated loss of continuity of care.
Why is it difficult to diagnose FND?
The latest (5th) edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) describes conversion, somatoform disorder, and FND synonymously.DSM-5 diagnostic criteria for conversion disorderare11:
- a specified type of symptom or deficit of altered voluntary motor or sensory function (eg, weakness, difficulty swallowing, slurred speech, seizures)
- clinical evidence of the incompatibility of the symptom or deficit and any recognized neurological or medical disorder
- incapability of better explaining the symptom or deficit as another medical or mental disorder.
- The symptom or deficit causes distress or impairment that (1) is clinically significant in occupational, social, or other important areas of function or (2) warrants medical evaluation.
The overarching feature of these criteria is the inconsistency of symptoms with recognized neurological, physiological, or psychiatric conditions. Although identification of psychological factors can help clarify and provide a treatment direction, such identification is not essential for making a diagnosis of FND. Malingering does not need to be refuted as part of establishing the diagnosis.12
Continue to: In contrast...
In contrast, the World Health Organization’s ICD-10 Classification of Mental and Behavioural Disorders groups diagnostic criteria for FND among the dissociative disorders13:
- Clinical features are specified for the individual dissociative disorder (motor, sensory, convulsions, mixed).
- Evidence is absent of a physical disorder that might explain symptoms.
- Evidence of psychological causation is present in clear temporal association with stressful events and problems or disturbed relationships, even if the patient denies such association.
Note the emphasis on psychological causation and exclusion of purposeful simulation of symptoms, as opposed to a primarily unconscious disconnection from the patient’s body or environment.
ICD-10 guidelines acknowledge the difficulty of finding definitive evidence of a psychological cause and recommend provisional diagnosis of FND if psychological factors are not readily apparent.14 Of note, many patients with FND are affected psychologically by their condition, with an impact on mood, behaviors, and interpersonal interactions, although not necessarily to a clinically diagnostic degree. Therefore, a psychiatric diagnosis alone is not a necessary precursor for the diagnosis of an FND.
CASE
History. Mr. D’s history is positive for light alcohol consumption (“2 or 3 cans of beer on weekends”) and chewing tobacco (he reports stopping 6 months earlier) and negative for substance abuse. The family history is positive for maternal hypertension and paternal suicide when the patient was 10 years old (no other known paternal history).
Physical findings. The review of systems is positive for intermittent palpitations, lower-extremity weakness causing unsteady gait, and generalized headache.
Vital signs are within normal limits, including blood pressure (120/82 mm Hg) and heart rate (110 beats/min). The patient is not in acute distress; he is awake, alert, and oriented × 3. No murmurs are heard; lungs are clear bilaterally to auscultation. There is no tenderness on abdominal palpation, and no hepatomegaly or splenomegaly; bowel sounds are normal. No significant bruising or lacerations are noted.
Neurology exam. Cranial nerves II-XII are intact. Pupils are equal and reactive to light. Reflexes are 2+ bilaterally. Muscle strength and tone are normal; no tremors are noted. Babinski signs are normal. A Romberg test is positive (swaying).
Continue to: Mr. D has an antalgic gait...
Mr. D has an antalgic gait with significant swaying (without falling); bent posture; and unsteadiness that requires a cane. However, he is able to get up and off the exam table without assistance, and to propel himself, by rolling a chair forward and backward, without difficulty.
Conducting a diagnostic examination
Taking the history. Certain clues can aid in the diagnosis of FND (TABLE 1).15 For example, the patient might have been seen in multiple specialty practices for a multitude of vague symptoms indicative of potentially related conditions (eg, chronic fatigue, allergies and sensitivities, fibromyalgia, and other chronic pain). The history might include repeated surgeries to investigate those symptoms (eg, laparoscopy, or hysterectomy at an early age). Taking time and care to explore all clinical clues, patient reports, and collateral data are therefore key to making an accurate diagnosis.
Note any discrepancies between the severity of reported symptoms and functional ability. A technique that can help elucidate a complex or ambiguous medical presentation is to ask the patient to list all their symptoms at the beginning of the interview. This has threefold benefit: You get a broad picture of the problem; the patient is unburdened of their concerns and experiences your validation; and a long list of symptoms can be an early clue to a diagnosis of FND.
Other helpful questions to determine the impact of symptoms on the patient’s well-being include inquiries about16:
- functional impairment
- onset and course of symptoms
- potential causal or correlating events
- dissociative episodes
- previous diagnoses and treatments
- the patient’s perceptions of, and emotional response to, their illness
- a history of abuse.
The physical examination to determine the presence of FND varies, depending on the functional area of impact (eg, motor, neurological, sensory, speech and swallowing). Pay particular attention to presenting signs and clues, and balance them with the patient’s report (or lack of report). Endeavor to demonstrate positive functional signs, such as a positive Hoover test, which relies on the principle of synergistic muscle contraction. You might see evidence of inconsistency, such as weakness or a change in gait, under observation, that seemingly resolves when the patient is getting on and off the exam table.16Table 215-24 describes areas affected by FND, characteristics of the disorder, and related diagnostic examinations.
Table 315,18,19 reviews validated special exams that can aid in making the diagnosis. Additional special tests are discussed in the literature.15-24 These tests can be helpful in narrowing the differential diagnosis but have not been validated and should be used with caution.
Some clinical signs associated with FND might be affected by other factors, including socioeconomic status, limited access to health care, low health literacy, poor communication skills, and physician bias. Keep these factors in mind during the visit, to avoid contributing further to health disparities among groups of patients affected by these problems.
Continue to: CASE
CASE
The work-up over the next month for Mr. D includes numerous studies, all yielding results that are negative or within normal limits: visual acuity; electrocardiography and an event monitor; laboratory testing (including a complete blood count, comprehensive metabolic panel, thyroid-stimulating hormone, creatine kinase, erythrocyte sedimentation rate, C-reactive protein, vitamin B12, folate, and vitamin D); magnetic resonance imaging of the brain and lumbar spine; lumbar puncture; and electromyography.
The score on the 9-item Patient Health Questionnaire for depression is 4 (severity: “none or minimal”); on the 7-item Generalized Anxiety Disorder scale, 0 (“no anxiety disorder”).
Referral. A neurology work-up of headache, lower extremity weakness, and unsteady gait to address several diagnostic possibilities, including migraine and multiple sclerosis, is within normal limits. A cardiology work-up of palpitations is negative for arrhythmias and other concerning findings.
Mr. D declines psychiatric and psychological evaluations.
Building a differential diagnosisis a formidable task
The differential diagnosis of FND is vast. It includes neurological, physiological, and psychiatric symptoms and disorders; somatization; and malingering (Table 4).6 Any disorder or condition in these areas that is in the differential diagnosis can be precipitated or exacerbated by stress; most, however, do not involve loss of physical function.12 In addition, the diagnosis of an FND does not necessarily exclude an organic disorder.
A patient’s presentation becomes complicated—and more difficult to treat—when functional symptoms and an unrelated underlying or early-stage neurological condition coexist. For example, a patient with epilepsy might also have dissociative seizures atop their organic disorder. Neurological disease is considered a risk factor for an overlying FND—just as the risk of depression or anxiety runs concurrently with other chronic diseases.14
Focus on clinical signs to narrow the differential. A thorough social and medical history and physical examination, as discussed earlier, help narrow the differential diagnosis of organic and medically unexplained disorders. Well-defined imaging or laboratory protocols do not exist to guide physicians to a definitive diagnosis, however.
Continue to: Psychiatric conditions
Psychiatric conditions can coexist with the diagnosis of FND, but might be unrelated. A systematic review of the literature showed that 17% to 42% of patients with FND had a concurrent anxiety disorder. Depression disorders were co-diagnosed in 19% to 71% of patients with FND; dissociative and personality disorders were noted, as well.25 However, coexisting psychiatric diagnosis might more likely be associated with distress from the presenting functional neurological symptoms, not linked to the FND diagnosis itself.12 This shift in understanding is reflected in the description of FND in the DSM-5.11
CASE
Mr. D reports debilitating headaches at return office visits. Trials of abortive triptans provide no relief; neither do control medications (beta-blockers, coenzyme Q10, magnesium, onabotulinumtoxinA [Botox], topiramate, and valproate). Lower-extremity weakness and unsteadiness are managed with supportive devices, including a cane, and physical therapy.
Importance of establishing a multidisciplinary approach
The complexity of FND lends itself to a multidisciplinary approach during evaluation and, eventually, for treatment. The assessment and diagnostic intervention that you provide, along with the contributions of consulted specialists (including neurology, physical and occupational therapy, psychiatry, psychology, and other mental health professionals) establishes a team-based approach that can increase the patient’s sense of support and reduce excessive testing and unnecessary medications, surgeries, and other treatments.26
Family physicians are in the ideal position to recognize the patient’s functional capacity and the quality of symptoms and to provide timely referral (eg, to Neurology and Psychiatry) for confirmation of the diagnosis and then treatment.
Evidence-based treatment options include:
- psychotherapy, with an emphasis on cognitive behavioral therapy
- physical therapy
- psychopharmacology
- promising combinations of physical and psychological treatment to improve long-term functionality.27
A promising diagnostic tool
The most significant update in the FND literature is on functional neuroimaging for assessing the disorder. Early findings suggest an intricate relationship between mind and body regarding the pathological distortion in FND. And, there is clear evidence that neuroimaging—specifically, functional magnetic resonance imaging—shows changes in brain activity that correspond to the patient’s symptom report. That said, imaging is not the recommended standard of care in the initial work-up of FND because of its cost and the fact that the diagnosis is principally a clinical undertaking.17,28
Call to action
Offer a generous ear. Begin the diagnostic pursuit by listening carefully and fully to the patient’s complaints, without arriving at a diagnosis with unwarranted bias or haste. This endeavor might require support from other clinical staff (eg, nurses, social workers, case managers) because the diagnostic process can be arduous and lengthy.
Continue to: Convey the diagnosis with sensitivity
Convey the diagnosis with sensitivity. Inquire about the patient’s perceptions and impairments to best personalize your diagnostic explanations. Delivery of the diagnosis might affect the patient’s acceptance and compliance with further testing and treatment of what is generally a persistent and treatment-resistant disorder; poor delivery of diagnostic information can impair the patient–physician relationship and increase the risk of disjointed care. Many patients find that improved patient–physician communication is therapeutic.29
Let the patient know that you’re taking her seriously. Validate patient concerns with a nonstigmatizing diagnostic label; discuss the diagnostic parameters and cause of symptoms in layman’s terms; and emphasize the potential for reversibility.30 Some patients are not satisfied with having a diagnosis of FND until they are reassured with normal results of testing and provided with referral; even then, some seek further reassurance.
Key tenets of managing care for patients who have been given a diagnosis of FND include:
- nonjudgmental, positive regard
- meaningful expression of empathy
- multidisciplinary coordination
- avoidance of unnecessary testing and harmful treatments
- descriptive and contextual explanations of the diagnosis.
Last, keep in mind that the course of treatment for FND is potentially prolonged and multilayered.
CASE
After many visits with his family physician and the neurology and cardiology specialists, as well as an extensive work-up, the physician approaches Mr. D with the possibility of a diagnosis of FND and proposes a multidisciplinary plan that includes:
- a course of physical and occupational therapy
- development of individualized cognitive behavioral tools
- weekly personal and marital counseling
- initiation of a selective serotonin reuptake inhibitor for anxiety
- monthly visits with his family physician.
Months after his return from deployment for evaluation and treatment, Mr. D is able to return to military duty. He reports that his quality of life has improved.
CORRESPONDENCE
Roselyn W. Clemente Fuentes, MD, FAAFP, Eglin Family Medicine Residency, 307 Boatner Road, Eglin AFB, FL 32547; [email protected].
1. Konnopka A, Schaefert R, Heinrich S, et al. Economics of medically unexplained symptoms: a systematic review of the literature. Psychother Psychosom. 2012;81:265-275.
2. Carson AJ, Brown R, David AS, et al; on behalf of UK-FNS. Functional (conversion) neurological symptoms: research since the millennium. J Neurol Neurosurg Psychiatry. 2012;83:842-850.
3. Stone J, Carson A, Duncan R, et al. Who is referred to neurology clinics?—the diagnoses made in 3781 new patients. Clin Neurol Neurosurg. 2010;112:747-751.
4. Evens A, Vendetta L, Krebs K, et al. Medically unexplained neurologic symptoms: a primer for physicians who make the initial encounter. Am J Med. 2015;128:1059-1064.
5. Stone J, Reuber M, Carson A. Functional symptoms in neurology: mimics and chameleons. Pract Neurol. 2013;13:104-113.
6. Stone J, Warlow C, Sharpe M. The symptom of functional weakness: a controlled study of 107 patients. Brain. 2010;133:1537-1551.
7. Carson A, Stone J, Hibberd C, et al. Disability, distress and unemployment in neurology outpatients with symptoms ‘unexplained by organic disease’. J Neurol Neurosurg Psychiatry. 2011;82:810-813.
8. Fink P, Hansen MS, Oxhøj M-L. The prevalence of somatoform disorders among internal medical inpatients. J Psychosom Res. 2004;56:413-418.
9. Thomas LE. Are your patient’s medically unexplained symptoms really “all in her head”? Med Hypotheses. 2012;78:542-547.
10. Ding JM, Kanaan RAA. What should we say to patients with unexplained neurological symptoms? How explanation affects offence. J Psychosom Res. 2016;91:55-60.
11. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. American Psychiatric Association; 2013.
12. Stone J, LaFrance WC Jr, Levenson JL, et al. Issues for DSM-5: Conversion disorder. Am J Psychiatry. 2010;167:626-627.
13. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. World Health Organization; 1994. Accessed January 21, 2021. www.who.int/classifications/icd/en/bluebook.pdf
14. Stone J, Carson A, Duncan R, et al. Which neurological diseases are most likely to be associated with “symptoms unexplained by organic disease.” J Neurol. 2012;259:33-38.
15. Shaibani A, Sabbagh M. Pseudoneurologic syndromes: recognition and diagnosis. Am Fam Physician. 1998;57:2485-2494.
16. Stone J, Carson A, Sharpe M. Functional symptoms and signs in neurology: assessment and diagnosis. J Neurol Neurosurg Psychiatry. 2005;76(suppl 1):i2-i12.
17. Vuilleumier P. Brain circuits implicated in psychogenic paralysis in conversion disorders and hypnosis. Neurophysiol Clin. 2014;44:323-337.
18. McKee K, Glass S, Adams C, et al. The inpatient assessment and management of motor functional neurological disorders: an interdisciplinary perspective. Psychosomatics. 2018;59:358-368.
19. Daum C, Hubschmid M, Aybek S. The value of ‘positive’ clinical signs for weakness, sensory and gait disorders in conversion disorder: a systematic and narrative review. J Neurol Neurosurg Psychiatry. 2014;85:180-190.
20. Brown P, Thompson PD. Electrophysiological aids to the diagnosis of psychogenic jerks, spasms, and tremor. Mov Disord. 2001;16:595-599.
21. Ludwig L, McWhirter L, Williams S, et al. Functional coma. In: Hallett M, Stone J, Carson A, eds. Handbook of Clinical Neurology: Volume 139: Functional Neurologic Disorders. 1st ed. Academic Press; 2016:313.
22. Miller NR, Subramanian PS, Patel VR. Walsh and Hoyt’s Clinical Neuro-ophthalmology. 3rd ed. Wolters Kluwer; 2016:512-513.
23. Takazaki K, Stransky AD, Miller G. Psychogenic nonepileptic seizures: diagnosis, management, and bioethics. Pediatr Neurol. 2016;62:3-8.
24. Sahaya K, Dholakia SA, Sahota PK. Psychogenic non-epileptic seizures: a challenging entity. J Clin Neurosci. 2011;18:1602-1607.
25. Gelauff J, Stone J, Edwards M, et al. The prognosis of functional (psychogenic) motor symptoms: a systematic review. J Neurol Neurosurg Psychiatry. 2014;85:220-226.
26. Kranick SM, Gorrindo T, Hallett M. Psychogenic movement disorders and motor conversion: a roadmap for collaboration between neurology and psychiatry. Psychosomatics. 2011;52:109-116.
27. Edwards MJ, Bhatia KP. Functional (psychogenic) movement disorders: merging mind and brain. Lancet Neurol. 2012;11:250-260.
28. Burgmer M, Kugel H, Pfleiderer B, et al. The mirror neuron system under hypnosis—brain substrates of voluntary and involuntary motor activation in hypnotic paralysis. Cortex. 2013;49:437-445.
29. van Bokhoven MA, Koch H, van der Weijden T, et al. Influence of watchful waiting on satisfaction and anxiety among patients seeking care for unexplained complaints, Ann Fam Med. 2009;7:112-120.
30. Stone J, Carson A, Hallet M. Explanation as treatment for functional neurologic disorders. Handb Clin Neurol. 2016;139:543-553.
1. Konnopka A, Schaefert R, Heinrich S, et al. Economics of medically unexplained symptoms: a systematic review of the literature. Psychother Psychosom. 2012;81:265-275.
2. Carson AJ, Brown R, David AS, et al; on behalf of UK-FNS. Functional (conversion) neurological symptoms: research since the millennium. J Neurol Neurosurg Psychiatry. 2012;83:842-850.
3. Stone J, Carson A, Duncan R, et al. Who is referred to neurology clinics?—the diagnoses made in 3781 new patients. Clin Neurol Neurosurg. 2010;112:747-751.
4. Evens A, Vendetta L, Krebs K, et al. Medically unexplained neurologic symptoms: a primer for physicians who make the initial encounter. Am J Med. 2015;128:1059-1064.
5. Stone J, Reuber M, Carson A. Functional symptoms in neurology: mimics and chameleons. Pract Neurol. 2013;13:104-113.
6. Stone J, Warlow C, Sharpe M. The symptom of functional weakness: a controlled study of 107 patients. Brain. 2010;133:1537-1551.
7. Carson A, Stone J, Hibberd C, et al. Disability, distress and unemployment in neurology outpatients with symptoms ‘unexplained by organic disease’. J Neurol Neurosurg Psychiatry. 2011;82:810-813.
8. Fink P, Hansen MS, Oxhøj M-L. The prevalence of somatoform disorders among internal medical inpatients. J Psychosom Res. 2004;56:413-418.
9. Thomas LE. Are your patient’s medically unexplained symptoms really “all in her head”? Med Hypotheses. 2012;78:542-547.
10. Ding JM, Kanaan RAA. What should we say to patients with unexplained neurological symptoms? How explanation affects offence. J Psychosom Res. 2016;91:55-60.
11. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. American Psychiatric Association; 2013.
12. Stone J, LaFrance WC Jr, Levenson JL, et al. Issues for DSM-5: Conversion disorder. Am J Psychiatry. 2010;167:626-627.
13. The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines. World Health Organization; 1994. Accessed January 21, 2021. www.who.int/classifications/icd/en/bluebook.pdf
14. Stone J, Carson A, Duncan R, et al. Which neurological diseases are most likely to be associated with “symptoms unexplained by organic disease.” J Neurol. 2012;259:33-38.
15. Shaibani A, Sabbagh M. Pseudoneurologic syndromes: recognition and diagnosis. Am Fam Physician. 1998;57:2485-2494.
16. Stone J, Carson A, Sharpe M. Functional symptoms and signs in neurology: assessment and diagnosis. J Neurol Neurosurg Psychiatry. 2005;76(suppl 1):i2-i12.
17. Vuilleumier P. Brain circuits implicated in psychogenic paralysis in conversion disorders and hypnosis. Neurophysiol Clin. 2014;44:323-337.
18. McKee K, Glass S, Adams C, et al. The inpatient assessment and management of motor functional neurological disorders: an interdisciplinary perspective. Psychosomatics. 2018;59:358-368.
19. Daum C, Hubschmid M, Aybek S. The value of ‘positive’ clinical signs for weakness, sensory and gait disorders in conversion disorder: a systematic and narrative review. J Neurol Neurosurg Psychiatry. 2014;85:180-190.
20. Brown P, Thompson PD. Electrophysiological aids to the diagnosis of psychogenic jerks, spasms, and tremor. Mov Disord. 2001;16:595-599.
21. Ludwig L, McWhirter L, Williams S, et al. Functional coma. In: Hallett M, Stone J, Carson A, eds. Handbook of Clinical Neurology: Volume 139: Functional Neurologic Disorders. 1st ed. Academic Press; 2016:313.
22. Miller NR, Subramanian PS, Patel VR. Walsh and Hoyt’s Clinical Neuro-ophthalmology. 3rd ed. Wolters Kluwer; 2016:512-513.
23. Takazaki K, Stransky AD, Miller G. Psychogenic nonepileptic seizures: diagnosis, management, and bioethics. Pediatr Neurol. 2016;62:3-8.
24. Sahaya K, Dholakia SA, Sahota PK. Psychogenic non-epileptic seizures: a challenging entity. J Clin Neurosci. 2011;18:1602-1607.
25. Gelauff J, Stone J, Edwards M, et al. The prognosis of functional (psychogenic) motor symptoms: a systematic review. J Neurol Neurosurg Psychiatry. 2014;85:220-226.
26. Kranick SM, Gorrindo T, Hallett M. Psychogenic movement disorders and motor conversion: a roadmap for collaboration between neurology and psychiatry. Psychosomatics. 2011;52:109-116.
27. Edwards MJ, Bhatia KP. Functional (psychogenic) movement disorders: merging mind and brain. Lancet Neurol. 2012;11:250-260.
28. Burgmer M, Kugel H, Pfleiderer B, et al. The mirror neuron system under hypnosis—brain substrates of voluntary and involuntary motor activation in hypnotic paralysis. Cortex. 2013;49:437-445.
29. van Bokhoven MA, Koch H, van der Weijden T, et al. Influence of watchful waiting on satisfaction and anxiety among patients seeking care for unexplained complaints, Ann Fam Med. 2009;7:112-120.
30. Stone J, Carson A, Hallet M. Explanation as treatment for functional neurologic disorders. Handb Clin Neurol. 2016;139:543-553.
PRACTICE RECOMMENDATIONS
› Avoid using stigmatizing terminology (eg, adding the prefix “pseudo” or the adjective “hysterical”) to characterize a suspected functional neurological disorder (FND) or a medically unexplained disorder. C
› Refrain from ordering functional magnetic resonance imaging as part of the routine evaluation of suspected FND. C
› Validate the patient‘s concerns with an appropriate diagnostic label; use layman’s terms to discuss the diagnostic parameters of FND and the cause of symptoms; and emphasize treatment possibilities and plans. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
