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Functional Neurological Disorders: Forging a Path forward for Patients with Disabling Symptoms

Kathrin LaFaver
Kathrin LaFaver

Kathrin LaFaver, MD
Associate Professor of Neurology
Northwestern University Feinberg School of Medicine

If you have never heard of Functional Neurological Disorders (FND), you are not alone. Despite being one of the most common reasons for patients to see a neurologist1, FND have largely stayed out of the spotlight. Triggered by emotional or physical stress factors, FND can cause tremor, weakness, seizure-like attacks, speech problems, abnormal balance and walking; essentially mimicking any other disorder of the neurologic system. Affected patients also often complain of difficulties with concentration and thinking, fatigue, chronic pain and mood symptoms. FND can start at any age and affect males and females, but is most common in females during early adulthood and midlife. Symptoms are often sudden in onset and interfere with daily activities, school, work and family life. Although spontaneous remissions can occur, many patients remain chronically affected without appropriate treatment. Despite the recognition of the scope of the problem and negative impacts for affected patients, families and healthcare systems, public awareness of the disorder and access to treatment services are lacking throughout the US and elsewhere2.

Terminology in FND can be confusing. While previously seen as purely psychologic problem, reflected by the older terms of “conversion disorder” and “psychogenic neurologic disorder”, the presence of a psychological stress factor is no longer required as part of the diagnostic criteria per DSM-5 guidelines. Informed by our understanding of functional neurological differences in emotional and motor pathways in the brain, the term “functional neurological disorders” is now preferred by most experts in the field3. Although comorbid anxiety, depression and a history of traumatic life experiences are common, the current biopsychosocial disease model considers those as risk factors, but not sufficient to explain abnormal neurologic symptoms.

The diagnosis of FND is generally made by a neurologist after a detailed history and neurologic exam based on typical clinical findings4. Motor symptoms such as weakness show inconsistent and variable features during the exam. For tremor, bedside testing and electrophysiology can confirm changing tremor frequencies and amplitude not congruent with other tremor types. For patients with non-epileptic spells, video-EEG monitoring during an event can confirm the absence of seizure activity. Additional diagnostic studies may be helpful to rule out other causes of neurologic disease. Research has shown that brain circuits in functional movement disorders, a subset of FND, function differently compared to healthy controls, and may overstimulate the motor system, leading to abnormal movements5.

The most important step in treatment of FND is a timely diagnosis and an individualized treatment plan. Depending on the severity of affected movements and associated health problems, patients can benefit from specialized physical, occupational and speech therapy to retrain the motor system, delivered in an outpatient or inpatient setting6,7. For patients with non-epileptic spells, cognitive behavioral therapy has been shown to be effective in reducing spell frequency, and is thought to be helpful for patients with other forms of FND as well8. Furthermore, patients often present with depression, anxiety, and report a history of trauma, although they may have difficulties recognizing clinically significant mood symptoms. Depending on psychiatric comorbidities, appropriate psychotropic medication may be indicated. Given the complexity of many patients with FND and the stigma associated with the diagnosis, improved efforts towards multidisciplinary care by neurologists, psychiatrists, psychologists and rehabilitation experts is urgently needed.  There is a paucity of mental health professionals with knowledge and treatment expertise in FND, especially outside of larger urban areas in the US. Health psychologists could fill an important role in the care of patients with FND, providing disease education and treatment interventions. In particular, motivational interviewing has been shown to increase treatment adherence and patient commitment which led to improved treatment outcomes for non-epileptic spells9. Working with FND patients can be extremely rewarding, as many can learn to overcome their disabling symptoms and take back control over their lives.

Additional information about FND can be found at www.neurosymptoms.org, a website by Dr. Jon Stone, and www.fndhope.org, a patient-led non-profit organization. You are also invited to attend the upcoming meeting of the new FND Society in Boston from June 14-16, 2020, which will bring together clinicians and researchers interested in FND from throughout the world (www.fndsociety.org)!

 

References

  1. 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(9):747-751.
  2. Hallett M. Psychogenic movement disorders: a crisis for neurology. Curr Neurol Neurosci Rep. 2006;6(4):269-271.
  3. Edwards MJ, Stone J, Lang AE. From psychogenic movement disorder to functional movement disorder: it’s time to change the name. Movement disorders : official journal of the Movement Disorder Society. 2014;29(7):849-852.
  4. Espay AJ, Aybek S, Carson A, et al. Current Concepts in Diagnosis and Treatment of Functional Neurological Disorders. JAMA neurology. 2018;75(9):1132-1141.
  5. Voon V. Functional neurological disorders: imaging. Neurophysiol Clin. 2014;44(4):339-342.
  6. Nielsen G, Buszewicz M, Stevenson F, et al. Randomised feasibility study of physiotherapy for patients with functional motor symptoms. Journal of neurology, neurosurgery, and psychiatry. 2017;88(6):484-490.
  7. Jacob AE, Kaelin DL, Roach AR, Ziegler CH, LaFaver K. Motor Retraining (MoRe) for Functional Movement Disorders: Outcomes From a 1-Week Multidisciplinary Rehabilitation Program. PM R. 2018;10(11):1164-1172.
  8. LaFrance WC, Jr., Miller IW, Ryan CE, et al. Cognitive behavioral therapy for psychogenic nonepileptic seizures. Epilepsy Behav. 2009;14(4):591-596.
  9. Tolchin B, Baslet G, Martino S, et al. Motivational Interviewing Techniques to Improve Psychotherapy Adherence and Outcomes for Patients With Psychogenic Nonepileptic Seizures. The Journal of neuropsychiatry and clinical neurosciences. 2019:appineuropsych19020045.