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Functional Neurological Disorder

Research Articles

FUNCTIONAL NEUROLOGICAL DISORDER RESEARCH ARTICLES

Current Concepts in Diagnosis and Treatment of Functional Neurological Disorders -September 2018

Espay, Aybek, Carson, Edwards, Goldstein, Hallett, LaFaver, LaFrance, Lang, Nicholson, Nielsen, Reuber, Voon, Stone, Morgante

Abstract

Functional neurological disorders (FND) are common sources of disability in medicine. Patients have often been misdiagnosed, correctly diagnosed after lengthy delays, and/or subjected to poorly delivered diagnoses that prevent diagnostic understanding and lead to inappropriate treatments, iatrogenic harm, unnecessary and costly evaluations, and poor outcomes.

Conclusions

Functional neurological disorders are a neglected but potentially reversible source of disability. Further research is needed to determine the dose and duration of various interventions, the value of combination treatments and multidisciplinary therapy, and the therapeutic modality best suited for each patient.


 

UROLOGIC SYMPTOMS AND FUNCTIONAL NEUROLOGICAL DISORDERS (extract from Handbook of Clinical Neurology, Edited by Mark Hallett; Jon Stone; Alan Carson, Elsevier 2016. Used with kind permission of the editors)

I Hoeritzauer, V Phe, J N Panicker

Abstract

The term functional urologic disorders covers a wide range of conditions related broadly to altered function rather than structure of the lower urinary tract, mainly of impaired urine voiding or storage. Confusingly, for a neurologic readership, these disorders of function may often be due to a urologic, gynecologic, or neurologic cause. However, there is a subset of functional urologic disorders where the cause remains uncertain and, in this chapter, we describe the clinical features of these disorders in turn: psychogenic urinary retention; Fowler’s syndrome; paruresis (shy-bladder syndrome); dysfunctional voiding; idiopathic overactive bladder, and interstitial cystitis/bladder pain syndrome.

Some of these overlap in terms of symptoms, but have become historically separated. Psychogenic urinary retention in particular has now largely been abandoned as a concept, in part because of the finding of specific urethral electromyogram findings in patients with this symptom now described as having Fowler’s syndrome, and their successful treatment with sacral neurostimulation.

In this chapter we review the poorly researched interface between these “idiopathic” functional urologic disorders and other functional disorders (e.g., irritable-bowel syndrome, fibromyalgia) as well as specifically functional neurologic disorders. We conclude that there may be a relationship and overlap between them and that this requires further research, especially in those idiopathic functional urologic disorders which involve disorders of the urethral sphincter (i.e., voluntary muscle).


 

FUNCTIONAL SYMPTOMS IN NEUROLOGY: MANAGEMENT– October 29 2015 

J Stone, A Carson, M Sharpe

In this article we offer an approach to management of functional symptoms based on our own experience and on the evidence from other specialities (because the evidence from neurology is so slim). We also tackle some of the most difficult questions in this area. What causes functional symptoms? Does treatment really work? What about malingering?

We give two example cases adapted from real patients to illustrate our approach.

WHAT CAUSES FUNCTIONAL SYMPTOMS?

EXPLAINING THE DIAGNOSIS

TREATMENT

PROGNOSIS

Conclusions​​​​​​​

Early management of functional symptoms involves demonstrating to the patient that you believe them and that you recognise their symptoms as being common and potentially reversible. A lot more research is needed in to the optimum approach but our experience is that using the ‘‘functional model’’ of symptom generation allows a transparent explanation and interaction with the patient that can facilitate later physical and psychological treatments. Much of the core of a cognitive behavioural approach to treatment is in fact simple advice about exercise, sleep, and ways about thinking about symptoms that can be given effectively by a neurologist. While it is unreasonable to expect everyone to get better, it is also a mistake to think that a neurologist cannot make a difference, even in a limited time.


 

Functional Neurologic Disorders– June 2015

(This publication does not have free public access.)

Abstract​​​​​​​

Purpose of Review: Functional neurologic disorders, also called psychogenic, nonorganic, conversion, and dissociative disorders, are among the most common problems in neurologic practice. This article presents a practical guide to clinical assessment and treatment, incorporating emerging research evidence. This article places an emphasis on encouraging neurologists to use the assessment as treatment, take an active role in educating and treating the patient, and work in a multidisciplinary way with psychiatry, psychology, and physical therapy.

Recent Findings

Classification of functional neurologic disorders now emphasizes the importance of positive diagnosis based on physical signs, not psychological features. Studies of mechanism have produced new clinical and neurobiological ways of thinking about these disorders. Evidence has emerged to support the use of physical therapy for functional movement disorders and psychotherapy for dissociative (nonepileptic) attacks.

Summary

The diagnosis and management of functional neurologic disorders has entered a new evidence-based era and deserves a standard place in the neurologic curriculum.


 

Physiotherapy For Functional (Psychogenic) Motor Symptoms:  A Systematic Review – June 13 2013

Objective

“Functional (psychogenic) motor symptoms (FMS), also called motor conversion disorder or non-organic motor symptoms are a common cause of disability and distress among patients attending neurology and neurorehabilitation services. Patients with FMS are often referred for physiotherapy but it is not clear whether this is effective. Here we aim to systematically review the literature regarding physiotherapy interventions for patients with functional motor symptoms.”

Methods

“Systematic review of databases with reference search for period 1950 to September 2012.”

Results

“There was only one controlled intervention study with a historical control group and 28 case series or reports describing interventions. The total number of patients in all studies was 373. Physiotherapy most commonly occurred in the context of multidisciplinary treatment and involved a motor learning approach. Novel approaches included the use of distraction techniques and transcutaneous electrical nerve stimulation (TENS) machine. Deceptive behavioural techniques have also been described. Most studies reported benefit from physical treatment, including some studies with long-term follow up.”

Conclusions

“Patients with FMS are commonly encountered in neurological practice and are often referred for physiotherapy. The existing data to guide physiotherapy treatment for FMS is of low quality and limited in scope. However, it suggests potential positive effects and provides a useful resource for developing and testing physiotherapy interventions in future studies.”


 

Functional Symptoms In Neurology: Mimics And Chameleons – 2013

Abstract

“The mimics and chameleons of functional symptoms in neurology could be a whole textbook of neurology.  Nevertheless, there are some recurring themes when things go wrong, notably diagnostic bias introduced by the presence or absence of psychiatric comorbidity or life events, neurological diseases that look ‘weird’ and lack of appreciation of the more unusual features of functional symptoms themselves.”

Introduction

“When the request came to write this review article on mimics and chameleons of functional neurological symptoms, we had to do a double take.  You want us to help neurologists to avoid accidentally diagnosing functional symptoms as a disease?  Are you sure you don’t just mean the other way round?  Functional/psychogenic/non-organic symptoms are customarily diagnoses that figure on the differential diagnosis of other conditions.  There are plenty of cautionary tales in the literature about patients with a neurological disease misdiagnosed as ‘hysterical’ and ‘non-organic’.  However, we are not aware of any previous review article that has tackled the issue of differential diagnosis from the perspective of functional symptoms.  It is gratifying, therefore, that the field has come sufficiently far to warrant a discussion of diagnostic pitfalls in the same terms as that for epilepsy and Alzheimer’s disease, the ultimate aim being that neurologists might all one day say to themselves, ‘It would be really embarrassing (or maybe I will get sued) if I miss the diagnosis of functional symptoms in this patient’.  Functional symptoms are, as any general neurologist knows, very common, and are the second commonest reason for a neurological outpatient consultation (in Scotland, anyway).1 Non-epileptic attacks account for around one in seven patients in a ‘first fit’ clinic, and functional limb weakness is as common as multiple sclerosis.  They also account for a group of patients who, by self-report at least, are as physically impaired and more distressed than equivalent patients seen in neurology outpatients with disease.  Most neurological symptoms can have a functional explanation.  In this article, we will discuss general pitfalls in assessing and approaching patients with functional symptoms, and then discuss separately individual pitfalls of dissociative (non-epileptic) attacks, functional motor symptoms and speech/visual/cognitive symptoms. The guiding principle of diagnosis of most functional symptoms is that there should be inconsistency during the physical examination (so-called internal inconsistency) or incongruity with recognized neurological disease.  Sticking to this principle will avoid many of the pit-falls listed below.  This article does not recapitulate all the positive clinical signs of inconsistency and incongruity (such as Hoover’s sign for functional weakness, motor distraction tasks for functional tremor and features such as eyes closed during a generalized shaking attack), but they are available elsewhere.  As in much of neurology, there are patients where there is diagnostic uncertainty; as a clinician you should always be prepared to say ‘not sure’.”



‘A Leg To Stand On’ By Oliver Sacks: A Unique Autobiographical Account Of Functional Paralysis – September 12 2012

Abstract

“Oliver Sacks, the well known neurologist and writer, published his fourth book, ‘A Leg to Stand On’, in 1984 following an earlier essay ‘The Leg’ in 1982.  The book described his recovery after a fall in a remote region of Norway in which he injured his leg.  Following surgery to reattach his quadriceps muscle, he experienced an emotional period in which his leg no longer felt a part of his body, and he struggled to regain his ability to walk.  Sacks attributed the experience to a neurologically determined disorder of body-image and body ego induced by peripheral injury.  In the first edition of his book Sacks explicitly rejected the diagnosis of ‘hysterical paralysis’ as it was then understood, although he approached this diagnosis more closely in subsequent revisions.  In this article we propose that, in the light of better understanding of functional neurological symptoms, Sacks’ experiences deserve to be reappraised as a unique insight in to a genuinely experienced functional/ psychogenic leg paralysis following injury.”

A Traumatic Injury

“Ten years before he wrote his book, A Leg to Stand On, Sacks was hiking in Norway when he sustained a severe leg injury.  On an isolated mountain path he stumbled upon a bull and as he fled from the animal he fell and found himself “lying at the bottom of a short sharp cliff of rock, with my left leg twisted grotesquely beneath me, and my knee in such pain as I had never, ever known.”  Finding himself “terrifyingly and seriously alone”, he formed a make- shift splint for his “utterly useless”’ injured leg from his umbrella and anorak and partially descended down the mountain.  Sacks described a sense of being near to death and talks about the leg as an object which was “stupid, senseless. out of control”.  He was eventually rescued by reindeer hunters, put in a temporary cast and reached a hospital in London, where his leg was successfully operated on to repair an avulsed quadriceps tendon.  Post- operatively he spent two days “feverish, shocked and toxic, and there was intense pain in my knee.I had periods of delirium. I felt horribly sick.” He described “the systematic depersonalization which goes with becoming a patient.”  It was clearly a painful, fearful and distressing experience.”


 

Functional (Psychogenic) Movement Disorder – August 25 2012

Purpose of Review

“This review provides an overview of recent developments in diagnosis, pathophysiology, neuroimaging and management of functional (psychogenic) movement disorders (FMD).”

Recent Findings

“There has been increasing interest to study the underlying pathophysiology of FMD, which has resulted in a broadened disease model, taking neurobiologic and psychosocial factors equally into account. In this context, the term ‘psychogenic’ has been replaced by ‘functional’ movement disorders by many authors in the field to express the changing focus toward a multifactorial disease model. The need for establishing a positive diagnosis of FMD as opposed to providing a diagnosis of exclusion is increasingly recognized and reflected by the introduction of ‘laboratory-supported’ diagnostic criteria of FMD. Important advances have been made through behavioral, electrophysiological and neuroimaging studies, although the fundamental cause of FMD remains poorly understood. Of particular interest have been several reports on abnormal sensorimotor features and cortical inhibition in both organic and functional dystonia, highlighting possible shared traits of both conditions. In terms of treatment, recent studies have reported benefit from both psychiatric and physical therapy-based interventions.”

Summary

“Increasing efforts have been made toward better understanding of FMD, and the disease model has been broadened to include neurobiologic and psychosocial factors. Laboratory-based diagnostic criteria have been established for many FMD to support the clinical diagnosis. To determine the most effective management strategies for FMD, a closer collaboration between neurologists and psychiatrists and intensified research efforts with prospective treatment trials are needed.”


 

Neuroinflammation, Neuroautoimmunity, And The Co-Morbidities Of Complex Regional Pain Syndrome – August 25 2012

Abstract

“Complex Regional Pain Syndrome (CRPS) is associated with non-dermatomal patterns of pain, unusual movement disorders, and somatovisceral dysfunctions.  These symptoms are viewed by some neurologists and psychiatrists as being psychogenic in origin. Recent evidence, however, suggests that an autoimmune attack on selfantigens found in the peripheral and central nervous system may underlie a number of CRPS symptoms.  From both animal and human studies, evidence is accumulating that neuroinflammation can spread, either anterograde or retrograde, via axonal projections in the CNS, thereby establishing neuroinflammatory tracks and secondary neuroinflammatory foci within the neuraxis.  These findings suggest that neuroinflammatory lesions, as well as their associated functional consequences, should be evaluated during the differential diagnosis of non-dermatomal pain presentations, atypical movement disorders, as well as other “medically unexplained symptoms”, which are often attributed to psychogenic illness.”

Conclusion

“In clinical practice, when an organic explanation cannot be found for functional disorders, psychogenic etiologies are often asserted. However, as the understanding of functional disorders improves, it appears that neuroim- mune and neuroinflammatory disorders are much more common than previously thought. Neuroautoimmunity combined with neuroinflammation together provide a via- ble etiology for the relapsing-remitting chronicity, atypical presentation and intensity of neurological and psychiatric symptoms.”


 

Simple Mathematical Computations Underlie Brain Circuits – August 9 2012

“The brain has billions of neurons, arranged in complex circuits that allow us to perceive the world, control our movements and make decisions. Deciphering those circuits is critical to understanding how the brain works and what goes wrong in neurological disorders.”

“MIT neuroscientists have now taken a major step toward that goal. In a new paper appearing in the Aug. 9 issue of Nature, they report that two major classes of brain cells repress neural activity in specific mathematical ways: One type subtracts from overall activation, while the other divides it.”

“These are very simple but profound computations,” says Mriganka Sur, the Paul E. Newton Professor of Neuroscience and senior author of the Nature paper. “The major challenge for neuroscience is to conceptualize massive amounts of data into a framework that can be put into the language of computation. It had been a mystery how these different cell types achieve that.”

“The findings could help scientists learn more about diseases thought to be caused by imbalances in brain inhibition and excitation, including autism, schizophrenia and bipolar disorder.”

“Lead authors of the paper are grad student Caroline Runyan and postdoc Nathan Wilson. Forea Wang ’11, who contributed to the work as an MIT undergraduate, is also an author of the paper.”


 

(Psychogenic) Motor Symptoms: A Survey Of Attitudes And Interest – April 11 2012

Abstract

“Background Functional (psychogenic) motor symptoms are commonly encountered in clinical neurology.  Physiotherapy has face validity as a treatment for such symptoms and, anecdotally, referral of patients with functional motor symptoms (FMS) to physiotherapy services is common practice by neurologists.  Here the authors sought to explore exposure to and attitudes towards patients with FMS among neurophysiotherapists.”

Method

“The authors used an internet survey to gather information on the knowledge and attitudes of patients with FMS among 1402 members of a UK neurophysiotherapy organization.”

Results

“The response rate was 61%.  Most physiotherapists saw patients with FMS, and for 25% of respondents these patients made up over 10% of their workload.  Respondents were moderately interested in treating these patients (ranking them sixth out of 10 neurological conditions), but had low self-judged knowledge.  Most respondents felt physiotherapy had more to offer patients with FMS, but felt poorly supported by referring neurologists and by inadequate service structures.”

Conclusions

“Neurologists frequently refer patients with FMS to neurophysiotherapy services. Physiotherapists in general are interested in treating such patients and feel physiotherapy to be an appropriate treatment.  However, inadequate service structures, knowledge and support from non-physiotherapy colleagues are judged to be barriers to provision of care.”


 

Functional (Psychogenic) Movement Disorders: Merging Mind And Brain – March 11 2012

Abstract

“Functional (psychogenic) movement disorders (FMD) are part of the wide spectrum of functional neurological disorders, which together account for over 16% of patients referred to neurology clinics. FMD have been described as a “crisis for neurology” and cause major challenges in terms of diagnosis and treatment. As with other functional disorders, a key issue is the absence of pathophysiological understanding. There has been an influential historical emphasis on causation by emotional trauma, which is not supported by epidemiological studies. The similarity between physical signs in functional disorders and those that occur in feigned illness has also raised important challenges for pathophysiological understanding and has challenged health professionals’ attitudes toward patients with these disorders. However, physical signs and selected investigations can help clinicians to reach a positive diagnosis, and modern pathophysiological research is showing an appreciation of the importance of both physical and psychological factors in FMD.”


 

The Function Of ‘Functional’: A Mixed Methods Investigation -March 2012

Objective

“The term ‘functional’ has a distinguished history, embodying a number of physiological concepts, but has increasingly come to mean ‘hysterical’. The DSM-V working group proposes to use ‘functional’ as the official diagnostic term for medically unexplained neurological symptoms (currently known as ‘conversion disorder’). This study aimed to explore the current neurological meanings of the term and to understand its resilience.”

Design

“Mixed methods were used, first interviewing the neurologists in a large UK region and then surveying all neurologists in the UK on their use of the term.”

Results

“The interviews revealed four dominant uses—‘not organic’, a physical disability, a brain disorder and a psychiatric problem—as well as considerable ambiguity. Although there was much dissatisfaction with the term, the ambiguity was also seen as useful when engaging with patients. The survey confirmed these findings, with a majority adhering to a strict interpretation of ‘functional’ to mean only ‘not organic’, but a minority employing it to mean different things in different contexts – and endorsing the view that ‘functional’ would one day be a neurological construct again.”

Conclusions

“‘Functional’ embodies real divisions in neurologists’ conceptualisation of unexplained symptoms and, perhaps, between those of patients and neurologists: its diversity of meanings allows it to be a common term while meaning different things to different people, or at different times, and thus conceal some of the conflict in a particularly contentious area. This flexibility may help explain the term’s longevity.”


 

Trick Or Treat Showing Patients With Functional (Psychogenic) Motor Symptoms Their Physical Signs – 2012

Abstract

“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.”

“Functional (psychogenic) motor symptoms such as paralysis, tremor, and gait disorder should be diagnosed primarily on the basis of positive evidence of internal inconsistency.  For example, in Hoover’s sign of functional paralysis, weakness of hip extension returns to normal with contralateral hip flexion against resistance.  In functional tremor, the patient’s tremor is distractible and may stop or entrain in frequency during rapid cued rhythmical movements of the unaffected hand.  As neurology trainees in the United Kingdom in the 1990s, we learned these techniques from our seniors as parts of neurologic lore; “tricks of the trade” which could be used to “catch the patient out” and show that there was indeed nothing wrong with them.  You certainly would not dream of sharing such signs with a patient.  An eminent professor of neurology, not unsympathetic to these patients, speaking in 2000, put it thus: “We shouldn’t let these signs become widely known.  The patients will stop having them.”  This probably reflects considerable ambivalence among many neurologists regarding whether patients with these symptoms may be feigning or partially feigning their symptoms.  However, independently of one another, we have come to the conclusion that neurologists’ traditional approach to these signs is a mistake.  Our experience is that patients do not lose their “psychogenic” signs once they are shown them.  More importantly, we have found that sharing these signs with patients is often a powerful way of persuading them that we, as their clinical neurologists, know what is wrong with them and that their problem cannot be due to anything else.  In this article, we suggest that sharing the basis for the diagnosis of functional motor symptoms using physical signs is the natural territory of the neurologist and can exert a powerful therapeutic effect.”


 

P15 A Structural MRI Study Of Motor Conversion Disorder: Evidence Of Bilateral Reduction In Thalamic Volume – 2012

Abstract

“Objective Conversion disorder is the presence of neurological symptoms that are not due to neurological disease and are thought to be psychological in origin. It is assumed that patients have normal brain anatomy; structural brain abnormalities of potential aetiological relevance generally preclude the diagnosis. However, it remains possible there are subtle neuroanatomical differences that are only discernable at the group, rather than at the patient level. We aimed to test this hypothesis by comparing high-resolution MRI scans of patients with motor conversion disorder with healthy controls using a Region Of Interest (ROI) approach.”

Method

“15 patients with ICD-10 diagnoses of motor conversion disorder with symptom onset within 2 years and 31 age- and sex-matched healthy controls had high resolution Spoiled Gradient Recalled sequence scanning on a 3 T MRI scanner. ROIs, chosen on the basis of previous reports or on theoretical grounds, were placed on the bilateral amygdala, thalamus, caudate and lentiform nuclei. Freesurfer V.5.0 software was used to identify, label and measure the anatomical structure volumes.”

Results

“There were uncorrected reductions in bilateral thalamic volume in patients compared to controls (left thalamus p=0.001, right thalamus p=0.002). Intracranial volume was also reduced in patients, however (p=0.012), and when corrected for this the thalamic reductions remained significant (left thalamus p=0.02, right thalamus p=0.05) and there was a significant (p=0.05) reduction in the volume of the left, but not the right, lentiform nucleus. There were no other ROI differences.”

Conclusion

“We have found evidence for reduced volume of the thalamus in conversion disorder. These changes could be secondary to chronic limb immobility as there is some evidence of similar thalamic volume losses after limb amputation. Longitudinal studies of conversion disorder patients, particularly re-scanning post recovery, would be needed to address this question. If thalamic volume changes are found to correlate to level of limb disuse such changes would be a strong indicator of the severity of this disorder in terms of the amount of actual, as well as reported, immobility. However, a functional imaging study (Vuilleumier et al, 2001) has found evidence of reduced activation of the thalamus (and basal ganglia) in symptomatic conversion disorder patients and it therefore remains possible these changes could be of aetiological or mechanistic significance.”


 

Spectacular Brain Images Reveal Surprisingly Simple Structure – March 29 2012

“Stunning new visuals of the brain reveal a deceptively simple pattern of organization in the wiring of this complex organ.”

“Instead of nerve fibers travelling willy-nilly through the brain like spaghetti, as some imaging has suggested, the new portraits reveal two-dimensional sheets of parallel fibers crisscrossing other sheets at right angles in a gridlike structure that folds and contorts with the convolutions of the brain.”

“This same pattern appeared in the brains of humans, rhesus monkeys, owl monkeys, marmosets and galagos, researchers report Thursday in the journal Science.”

“The upshot is the fibers of the brain form a 3-D grid and are organized in this exceptionally simple way,” study leader Van Wedeen, a neuroscientist at Harvard Medical School and Massachusetts General Hospital, told LiveScience. “This motif of crossing in three axes is the basic motif of brain tissue.”

The surface of the brain contains about 40 billion nerve cells, each making about 1,000 connections in a pattern that brain researchers have yet to decipher, said Marsel Mesulam, the director of the Cognitive Neurology and Alzheimer’s Disease Center at Northwestern University. Mesulam, who was not involved in the study, called Wedeen’s work “very exciting.”

“There can be no more fundamental question in philosophy, in psychology,” Mesulam told LiveScience. “The human brain is the single most complex device in the known universe, and it works by nerve cells talking to each other. If we can’t figure out how they decide who to talk to and what they tell each other, we just don’t understand how the brain functions.”

“Using a technique he developed called diffusion spectrum magnetic resonance imaging (MRI), Wedeen traced the movement of water molecules along the intersections of brain fibers (the cellular projections that form the brain’s communication network), tracking the orientation of each fiber at each crossing.”


 

Functional Weakness: Clues To  Mechanism From The Nature Of Onset – August 11 2011

Background

“Functional weakness describes weakness which is inconsistent and incongruent with disease.  It is also referred to as motor conversion disorder (DSM-IV), dissociative motor disorder (ICD-10) and ‘psychogenic’ paralysis.  Studies of aetiology have focused on risk factors such as childhood adversity and life events; information on the nature and circumstance of symptom onset may shed light on the mechanism of symptom formation.  Aim To describe the mode of onset, associated symptoms and circumstances at the onset of functional weakness.”

Methods

“Retrospective interviews administered to 107 adults with functional weakness of <2 years’ duration.”

Results

“The sample was 79% female, mean age 39 years and median duration of weakness 9 months.  Three distinct modes of onset were discerned.  These were: sudden (n¼49, 46%), present on waking (or from general anaesthesia) (n¼16, 13%) or gradual (n¼42, 39%).  In ‘sudden onset’ cases, panic (n¼29, 59%), dissociative symptoms (n¼19, 39%) and injury to the relevant limb (n¼10, 20%) were commonly associated with onset.  Other associated symptoms were non-epileptic attacks, migraine, fatigue and sleep paralysis. In six patients the weakness was noticed first by a health professional. In 16% of all patients, no potentially relevant factors could be discerned.”

Conclusions

“The onset of functional weakness is commonly sudden. Examining symptoms and circumstances associated closely with the onset suggests hypotheses for the mechanism of onset of weakness in vulnerable individuals.”


 

How “Psychogenic” Are Psychogenic Movement Disorders? – July 14 2011

Stone, J. and Edwards, M. J. (2011), How “psychogenic” are psychogenic movement disorders?. Mov. Disord., 26: 1787–1788. doi: 10.1002/mds.23882

‘….Just because an abnormal movement might be distractible, variable, or responsive to cognitive behavioral therapy or placebo, does that mean that the only possible mecha- nism for its production is psychological difficulty and distress? This seems an inappropriately narrow formulation, and yet use of the word psychogenic continues….’

‘….The picture emerging is that patients with PMDs and paralysis tend to be older, less female-biased, and with symptoms less dependent on childhood adversity and life events than patients with nonepileptic attacks. Other factors such as physical injury or pain,9,10 the presence of a comorbid ‘‘organic’’ condition,….’

‘….Studies such as this are helpful in chal- lenging stereotypes, and may push us away from a narrow dogmatic approach and toward a broader view of the etiologies and mechanisms of these common and disabling disorders….’


 

Psychogenic Movement Disorders And Motor Conversion: A Roadmap For Collaboration Between Neurology And Psychiatry – March 2011

Introduction

“Psychogenic movement disorders are characterized by the presence of abnormal movements or absence of normal movement not attributable to an organic neurologic disorder and considered to be psychologically mediated.  A large movement disorder clinic estimated the prevalence of psychogenic movement disorders to be 5.3%, a rate higher than both the prevalence of Huntington disease and restless leg syndrome in the same clinic.  While recent imaging research has pointed to an abnormal network of neuronal activation, the mainstay of treatment for these patients remains psychotherapy.”

“Psychogenic movement disorders have been called a “crisis for neurology” as patients are often unaccepting of the diagnosis, few treatments exist, and few patients have been shown to improve in the published case series.   Worsening this already grim picture is lack of discourse between neurology and psychiatry regarding these patients; while this is an ideal disease model for partnership between psychiatry and neurology, there are significant differences between the two fields’ perspectives towards this disorder that make collaboration difficult. Differences in terminology alone begin to illustrate this divide: the term “psychogenic movement disorder” has gained popularity among many neurologists and is presented as a separate chapter in movement disorder textbooks, but this phrase has little diagnostic specificity for psychiatrists and is not found in the current Diagnostic and Statistical Manual of Psychiatry (DSM-IV-TR) or textbooks of psychiatry. The differences between neurology and psychiatry go beyond terminology and extend into nosology, as not all patients with psychogenic movement disorders meet criteria for its closest approximation in the DSM-IV-TR, conversion disorder with motor symptom or deficit.”


 

Pro- and Anti-Inflammatory Effects of Stress in the Brain: Mechanisms and Implications – August 23 2010

“Some stress protocols show a pro-inflammatory response in the brain and other systems characterized by a complex release of several inflammatory mediators such as cytokines, transcription factors, prostanoids and free radicals.”

“Such response might contribute to cell damage during several neuropsychiatric diseases related with stress (post-traumatic stress disorder, major depressive disorder, anxiety disorders, and schizophrenia). In particular, data from the clinical arena associate an increase in proinflammatory mediators with major depression.  This review considers the current status of knowledge of stress-induced inflammation in the brain.  Interestingly, anti-inflammatory pathways are also activated in response to stress, constituting a possible endogenous mechanism of defense against excessive inflammation.  Both in brain and digestive tract, stress exposure switch on a compensatory anti-inflammatory mechanism, the synthesis of deoxyprostaglandins.  Pharmacological stimulation of its nuclear receptor, the peroxisome proliferator activated receptor (PPAR) gamma, prevents stress-induced inflammatory and functional damage both in the brain and in the digestive tract.  This dual response deserves further attention in order to understand pathophysiological changes and possible new therapeutic approaches of stress-related neuropsychopathologies.”

Introduction

“The physiologist Hans Selye first defined the physiological responses to stressors and adapted the term stress from physics and engineering to introduce it in the medical vocabulary.  He was the first to use the terms stress and “stress response” in a medical context.  This response, consisting of a three-phase mechanism, is the result of an adaptation necessary to allow the overcoming of situations in which an organism has to “fight or flight” to survive (e.g. higher blood pressure, faster cardiac rhythm, suppression of the digestive processes, or re-direction of blood to muscles).  Nowadays, the stress response is considered a characteristic set of physiological, affective, cognitive and behavioral changes that can have costs for well being whether or not successful adaptation is achieved.”

“Stress is a dual phenomenon, since while this fast and reversible response is essential for survival, it may cause adverse effects when secretion of the stress hormones are sustained.  In this way, the “stress hormones” production during stress response is very similar to the inflammatory process, generated in an organism when is invaded by certain micro-organisms or after trauma or tissue damage. Both responses are closely related and are preserved during evolution.”


 

Who Is Referred To Neurology Clinics? – The diagnoses Made In 3781 New Patients – 2010

Abstract

“Information on the nature and relative frequency of diagnoses made in referrals to neurology outpatient clinics is an important guide to priorities in services, teaching and research.  Previous studies of this topic have been limited by being of only single centres or lacking in detail.  We aimed to describe the neurological diagnoses made in a large series of referrals to neurology outpatient clinics.”

Method

“Newly referred outpatients attending neurology clinics in all the NHS neurological centres in Scotland, UK were recruited over a period of 15 months.  The assessing neurologists recorded the initial diagnosis they made.  An additional rating of the degree to which the neurologist considered the patient’s symptoms to be explained by disease was used to categorise those diagnoses that simply described a symptom such as ‘fatigue’.”

Results

“Three thousand seven hundred and eighty-one patients participated (91% of those eligible). The commonest categories of diagnosis made were: headache (19%), functional and psychological symptoms (16%), epilepsy (14%), peripheral nerve disorders (11%), miscellaneous neurological disorders (10%), demyelination (7%), spinal disorders (6%), Parkinson’s Disease/movement disorders (6%), and syncope (4%).  Detailed breakdowns of each category are provided.”

Conclusions

“Headache, functional/psychological disorders and epilepsy are the most common diagnoses in new patient referral to neurological services.  This information should be used to shape priorities for services, teaching and research.”


 

The Role Of Injury In Motor And Sensory Conversion Symptoms: A Systematic And Narrative Review – July 22 2008

Objectives

“Conversion symptoms are currently conceptualized as physical symptoms induced by psychological trauma, conflict or stress.  Historical accounts also included physical injury as an important precipitant.
We aimed to determine (a) the frequency of reported physical injury prior to onset in published studies
of patients with motor or sensory conversion symptoms and (b) the clinical characteristics of patients
in whom onset was associated with physical injury.”

Methods

“Firstly, we employed a systematic review of all reports of adults with motor or sensory conversion
symptoms published between 1965 and 2005. Secondly, we used a narrative review of the literature on
this topic, especially possible mechanisms.”

Results

“A total of 133  eligible studies, which recorded 869 patients, were found.  Physical injury prior to symptom onset was reported in 324 patients (37%).   Clinical features associated with physical injury included younger age, weakness (vs. movement disorder), paraparesis (vs. hemiparesis) and neurological vs. psychiatric study settings.”

Conclusions

“Despite the current dominance of a psychological view of conversion symptoms, physical injury prior to  onset has been frequently reported in papers published since 1965.  While the data are of low quality, they nevertheless suggest that physical trauma has a role in the onset of motor and sensory conversion symptoms.”


 

Neurological Syndromes Which Can Be Mistaken For Psychiatric Conditions -2005

“All illness has both psychological and physical dimensions. This may seem a startling claim, but on reflection it is uncontroversial.   Diseases don’t come to doctors, patients do—and the processes by which patients detect, describe, and ponder their symptoms are all eminently psychological. This theoretical point has practical implications. If we adopt a “bio-psycho-social” approach to illness generally, one which recognises the biological, psychological, and social aspects of our lives, we become less likely to neglect the treatable psychological origins of many physical complaints (from globus hystericus to full blown conversion disorder) and the treatable psychological consequences (such as depression and anxiety) of much physical disease.”


 

Neurology, Psychology And Psychiatry

“Neurology has an especially close relationship with psychology and psychiatry, as all three disciplines focus on the functions and disorders of a single organ, the brain. The main targets of the traditional British “neurological examination” may be elementary motor and sensory processes, but any adequate assessment of “brain function” must take account of cognition and behaviour. The notion many of us bring to neurology—that only a minority of neurological disorders has a significant psychological or psychiatric dimension—is almost certainly wrong. Cognitive and behavioural involvement is the rule, not the exception, among patients with disorders of the central nervous system (CNS). The physical and psychological symptoms of disease can therefore be related in the following ways: (1) physical symptoms come to light by way of complex psychological processes; (2) psychological upset can manifest itself in physical symptoms; (3) physical diseases commonly cause a secondary psychological reaction; (4) one category of physical disease, affecting the brain, can give rise, more or less directly, to psychological manifestations.”

“The importance of a wide ranging approach to assessment is well illustrated by the example of dementia, a primarily cognitive and behavioural disorder: the clue to diagnosis may come from general medical examination (revealing, for example, the testicular tumour causing limbic encephalitis or the bradycardia of hypothyroidism), from traditional neurological examination (subtle chorea in early Huntington’s disease), from cognitive assessment (isolated anterograde memory impairment in early Alzheimer’s disease), or from observation of behaviour (the patient with a frontal lobe dementia who leans over your desk and takes apart your pen). Moreover, this type of assessment is essential if one is to do justice to the symptoms of dementia which most bother patients: these are more often “psychiatric” than “neurological”.”


 

Functional Neuroanatomical Correlates Of Hysterical Sensorimotor Loss – January 31 2001

“Hysterical conversion disorders refer to functional neurological deficits such as paralysis, anaesthesia or blindness not caused by organic damage but associated with emotional `psychogenic’ disturbances. Symptoms are not intentionally feigned by the patients whose handicap often outweighs possible short-term gains. Neural concomitants of their altered experience of sensation and volition are still not known. We assessed brain functional activation in seven patients with unilateral hysterical sensorimotor loss during passive vibratory stimulation of both hands, when their deficit was present and 2–4 months later when they had recovered. Single photon emission computerized tomography using 99mTc-ECD revealed a consistent decrease of regional cerebral blood flow in the thalamus and basal ganglia contralateral to the deficit. Independent parametric mapping and principal component statistical analyses converged to show that such subcortical asymmetries were present in each subject. Importantly, contralateral basal ganglia and thalamic hypoactivation resolved after recovery. Furthermore, lower activation in contralateral caudate during hysterical conversion symptoms predicted poor recovery at follow-up. These results suggest that hysterical conversion deficits may entail a functional disorder in striatothalamocortical circuits controlling sensorimotor function and voluntary motor behaviour. Basal ganglia, especially the caudate nucleus, might be particularly well situated to modulate motor processes based on emotional and situational cues from the limbic system.   Remarkably, the same subcortical premotor circuits are also involved in unilateral motor neglect after organic neurological damage, where voluntary limb use may fail despite a lack of true paralysis and intact primary sensorimotor pathways. These findings provide novel constraints for a modern psychobiological theory of hysteria.”


 

Neurologists’ Understanding And Manangement Of Conversion Disorder – February 16 2011

“Neurologists’ understanding and management of conversion disorder.  This is a research study looking at neurologists in the UK.  Study was questioner based, and it examines how neurologist understand conversion disorder, and what they tell their patients.  The one thing that is not completely clear is if most neurologists included in the study saw FND separate as Conversion Disorder or see them as the same.  A common source of ambiguity as doctors are finding almost half of Conversion patients do not show signs of psychological manifestations nor have a history of psychological illness.”

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