Functional Neurological DisorderSteven Mandel MD
Heidi Mandel PhD DPM LMSWFunctional Neurological Disorder (FND) is the current clinical diagnosis, given by a neurologist, for conditions that were formerly termed, hysteria, conversion or psychogenic disorder. Physicians may determine that individuals can be impaired from performing activities of daily living even in the absence of a defined medical condition. This is classified, according to the American Medical Association (AMA), as “functional limitation and not disability”. It is a complex disorder that may combine features of neurological and psychiatric conditions. Patients initially visit their doctors with a history of multiple diagnoses, with little understanding of their medically unexplained symptoms. Many of these medical and neurological symptoms may not be due to actual structural disease, but rather may be associated with emotional distress and disability. These symptoms may impair an individual’s daily functioning and cause him/her real suffering. Learning about FND will help us understand the interface between physical and emotional health, which is termed the mind-body problem. In the DSM-5, which is the key psychiatric diagnostic manual, FND is called Conversion Disorder, while neurologists will label it Functional Neurological Disorder and/or Dissociative seizures. The neurological symptoms that the patient presents to the doctor are real. They are problems with the normal functioning of the nervous system. It is the second most common reason for visits to neurologists, followed by headaches and migraines. In this group of patients, females outnumber males. Family members with FND may have a history of sexual and physical childhood abuse, which is untreated trauma. This history may play as role in the chronic nature of the illness. The main neurological symptoms fall into two categories: Motor Symptoms include body movements with limb weakness and paralysis, tremors and dystonia and balance disorders. A Non epileptic form of seizures is characterized by preserved awareness, back arching, or pelvic thrusting, weeping, stuttering, and forced eye closures. Sensory symptoms include numbness and tingling, blindness, deafness, somatic cough. altered awareness, chronic pain, fatigue, sleep disturbance, memory changes, anxiety and depression. Clinical clues to help make the correct diagnosis include: Hoovers sign - when flexing the contralateral leg against resistance there is an involuntary extension of the normal leg. In non-organic etiology, the involuntary extension does not occur. Postural testing -There are bizarre or extreme postures when the patient is pulled backwards by the examiner. Patients may have weakness with normal muscle tone and reflexes. La Belle Indifference – a person is unconcerned about symptoms or severity of the disability. The patient may have a combination of organic and non-organic functional weakness. Etiology of FND There can be a history or current presence of physical trauma, mental illness or physiological events. Symptoms can be variable and change, for better or worse, over time. Symptoms may improve with distraction and worsen during the examination. Patients may experience abnormal beliefs and expectations and an inappropriate sense of urgency. They may have impaired ability to cope with stressful situations. Alexithymia – This condition describes a patient’s impaired emotional processing and inability to define his/her emotions. Although there are many risk factors, generally there may have been a physical event in the last 3 months. The symptoms serve to hide the source of the stress and inner conflicts. Four different conditions:
1. Feigning - pretending to be affected, pretending to relieve emotional illness by assuming the role of the sick person.
2. Malingering – purposely exaggerating or feigning illness to escape from working or responsibility.
3. Factitious disorder – a mental disorder where a person acts as if a physical or mental disorder exists, when in fact it doesn’t. No concrete motive or reward.
4. Munchausen syndrome – a factitious disorder characterized by the habitual presentation for hospital treatment of an apparent acute illness, the patient giving a plausible and dramatic history, all of which is false. Treatment and prognosis The sooner the diagnosis the better the prognosis. Treatment may include: physical therapy, psychotherapy (CBT), occupational therapy, gaining confidence in life skills, learning the interaction between emotional unhelpful thoughts and behaviors and psychosocial difficulties. Education to provide clear and supportive explanations to assist in treatment plans, relaxation techniques, acupuncture, pharmacological treatment, stress management, consideration of multicultural and socio-economic factors. Treatment requires an interdisciplinary team-based approach of specialists with expertise in neurology and psychiatry. The time to consult a professional is when it interferes with work, family, social functioning or excessive psychosomatic complaints, both mental and physical. Prognosis is poor when it relates to unprocessed and untreated trauma and the inability to understand the mind-body relationship. Also, a poor prognosis can be associated with secondary gain factors, including eligibility for disability benefits, poor family and social support systems, and passivity in work and family responsibilities Physicians may determine that individuals can be impaired from performing activities of daily living even in the absence of a defined medical condition. This is classified, according to the AMA, as “functional limitation and not disability”. - Strom, Laura, MD. “Functional Neurologic Disorders”. Neurology: Clinical Practice Month 2019 Steven Mandel MD is Professor of Neurology at the Zucker School of Medicine at Hofstra/Northwell. Heidi Mandel PhD, DPM, LMSW. |
