Functional neurological symptom disorder

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Functional neurological disorder (FND) is a condition in which patients experience neurological symptoms such as weakness, movement disorders, sensory symptoms and blackouts.[1] The brain of a patient with functional neurological symptom disorder is structurally normal, but functions incorrectly.[2] In broad terms, there is a problem with the patient's central nervous system, which is not sending and receiving signals correctly. Other terms for functional neurological disorder represent old ideas and attitudes to these disorders and include functional neurological symptom disorder, conversion disorder, and psychogenic movement disorder/non-epileptic seizures. The cause of functional neurological disorders is considered to be multifactorial, which means many different factors can contribute to the development of the disorder. With greater understanding of the brain most diseases including functional neurological disorders should be thought of as having biological, psychological and social components (the biopsychosocial disease model). Functional neurological disorders are common in neurological services, accounting for up to one third of outpatient neurology clinic attendances, and associated with as much physical disability and distress as other neurological disorders.[1][3] The diagnosis is made based on positive signs and symptoms in the history and examination during consultation of a neurologist (see below). Assessment demonstrates that normal function of the nervous system is possible.[4] The best evidence for treatment for functional neurological disorders from recent studies suggest that physiotherapy and/or psychological therapy can both be helpful depending on the individual patient. Physiotherapy is particularly helpful for patients with motor symptoms (weakness, gait disorders, movement disorders) and tailored cognitive behavioural therapy has the best evidence in patients with dissociative (non-epileptic) attacks.[5]

Signs and symptoms[edit]

There are a great number of symptoms experienced by those with functional neurological disorder. It is important to note that all the symptoms which are experienced by those with FND are real, and often debilitating. The core symptoms are those of motor or sensory function or episodes of altered awareness

  • Limb weakness or paralysis
  • Blackouts (also called dissociative or non-epileptic seizures/attacks) – these may look like epileptic seizures or faints
  • Movement disorders including tremors, dystonia (spasms), myoclonus (jerky movements)
  • Visual symptoms including loss of vision or double vision
  • Speech symptoms including dysphonia (whispering speech), slurred or stuttering speech
  • Sensory disturbance including hemisensory syndrome (altered sensation down one side of the body)

Epidemiology and aetiology[edit]

Epidemiology[edit]

Functional neurological disorders are a common problem, and are the second most common reason for a neurological outpatient visit after headache/migraine. Dissociative (non-epileptic) seizures account for about 1 in 7 referrals to neurologists after an initial seizure, and functional weakness has a similar prevalence to multiple sclerosis.[6]

Aetiology and mechanism[edit]

Epidemiological studies and meta-analysis have shown higher rates of depression and anxiety in patients with FND compared to the general population, but rates are similar to patients with other neurological disorders such as epilepsy or Parkinson's disease.[7][8][9][10]

Diagnostic criteria[edit]

A firm diagnosis of a functional neurological disorder is dependent on positive features from the history and examination.

Patients with functional movement disorders and limb weakness often experience symptom onset triggered by an episode of acute pain, a physical injury or a sudden episode with features of panic or dissociation. Patients with dissociative seizures also may experience symptoms of panic and dissociation as a brief 'warning phase' prior to loss of awareness.

Patients with functional neurological disorders are more likely to have a history of other functional disorders such as irritable bowel syndrome, chronic pelvic pain or fibromyalgia but this cannot be used to make a diagnosis. FND does not show up on blood tests or structural brain imaging such as MRI or CT scanning. However, this is also the case for many other neurological conditions so negative investigations should not be used alone to make the diagnosis. FND can, however, occur alongside other neurological diseases and tests may show non-specific abnormalities which cause confusion for doctors and patients. Published studies show good reliability in diagnosing FND as long as the diagnosis is based on positive signs and symptoms.[11]

ICD-11 diagnostic criteria[edit]

The International Classification of Disease (ICD-11) which is due to be finalised in 2017 will have functional disorders within the neurology section for the first time.[12]

Prevalence[edit]

Functional neurological disorder is a common problem, with estimates suggesting that up to a third of neurology outpatients having functional symptoms.[13] In Scotland, around 5000 new cases of FND are diagnosed annually.[13] Furthermore, non-epileptic seizures account for 1 in 7 referrals to neurologists after an initial seizure, and functional weakness has a similar prevalence to multiple sclerosis.[13]

Misdiagnosis[edit]

Currently, doctors believe that misdiagnosis rates for FND are low, with some research suggesting that only 2% of patients are misdiagnosed after a follow up 12.5 years later.[14]

Treatment[edit]

Treatment requires a firm and transparent diagnosis based on positive features which both health professionals and patients can feel confident about. It is essential that the health professional indicates that this is a common problem which is genuine, not imagined and not a diagnosis of exclusion.

Confidence in the diagnosis does not in itself improve symptoms, but appears to improve the efficacy of treatments such as physiotherapy which require altering established abnormal patterns of movement by allowing the patient different ways of thinking about their symptoms.

A multi-disciplinary approach to treating functional neurological disorder is recommended. Treatment options can include:

  • Physiotherapy and occupational therapy
  • Medication such as sleeping tablets, painkillers, anti-epileptic medications and anti-depressants

Physiotherapy with someone who understands functional disorders may be the initial treatment of choice for patients with motor symptoms such as weakness, gait (walking) disorder and movement disorders. Nielsen et al. have reviewed the medical literature on physiotherapy for functional motor disorders up to 2012 and concluded that the available studies, although limited, mainly report positive results.[15] Since then several studies have shown positive outcomes. In one study, up to 65% of patients were very much or much improved after five days of intensive physiotherapy even though 55% of patients were thought to have poor prognosis.[15] In a randomised controlled trial of physiotherapy there was significant improvement in mobility which was sustained on one year follow up.[16] In multidisciplinary settings 69% of patients markedly improved even with short rehabilitation programmes. Benefit from treatment continued even when patients were contacted up 25months after treatment.[17]

For patients with severe and chronic FND a combination of physiotherapy, occupational therapy and cognitive behavioural therapy may be the best combination with positive studies being published in patients who have had symptoms for up to three years before treatment.

Cognitive behavioural therapy (CBT) alone may be beneficial in treating patients with dissociative (non-epileptic) seizures. A randomised controlled trial of patients who undertook 12 sessions of CBT which taught patients how to interrupt warning signs before seizure onset, challenged unhelpful thoughts and helped patients start activities they had been avoiding found a reduction in the seizure frequency with positive outcomes sustained at six month follow up. A large multicentre trial of CBT for dissociative (non-epileptic) seizures started in 2015 in the UK.[18]

For many patients with FND, accessing treatment can be difficult. Availability of expertise is limited and they may feel that they are being dismissed or told 'it's all in your head' especially if psychological input is part of the treatment plan. Some medical professionals are uncomfortable explaining and treating patients with functional symptoms. Changes in the diagnostic criteria, increasing evidence, literature about how to make the diagnosis and how to explain it and changes in medical training is slowly changing this[19] FND information written for both patients and doctors can also be found online.

After a diagnosis of functional neurological disorder has been made, it is important that the neurologist explains the illness fully to the patient to ensure the patient understands the diagnosis.

Some, but not all patients with FND may experience low moods or anxiety due to their condition. However, they will often not seek treatment due being worried that a doctor will blame their symptoms on their anxiety or depression.[20]

It is recommended that the treatment of functional neurological disorder should be balanced and involve a whole-person approach. This means that it should include professionals from multiple departments, including neurologists, general practitioners (or primary health care providers), physiotherapists, occupational therapists.

Alternative diagnoses[edit]

Functional neurological symptom disorder can mimic many other conditions. However, doctors state that misdiagnosis rates are low.[14] Some alternative diagnoses for FND include:

History[edit]

The first evidence of FND dates back to 1900 BC, where the symptoms were blamed on the uterus moving within the female body. The treatment varied "depending on the position of the uterus, which must be forced to return to its natural position. If the uterus had moved upwards, this could be done by placing malodorous and acrid substances near the woman's mouth and nostrils, while scented ones were placed near her vagina; on the contrary, if the uterus had lowered, the document recommends placing the acrid substances near her vagina and the perfumed ones near her mouth and nostrils."[21]

In Greek mythology, hysteria, the original name for FND, was thought to be caused by a lack of orgasms, uterine melancholy and not procreating. Plato, Aristotle and Hippocrates believed that a lack of sex upset the uterus. The Greeks believed that it could be prevented and cured with wine and orgies. Hippocrates argued that a lack of regular sexual intercourse led to the uterus producing toxic fumes and caused it to move in the body, and that this meant that all women should be married and enjoy a satisfactory sexual life.[21]

Throughout the Middle Ages, melissa, a natural remedy, was used to treat hysteria. Women with the condition were seen as the cause of the condition, which was then referred to as amor heroycus, or the madness of love, unfulfilled sexual desire. Trotula de Ruggerio, the first female doctor in Europe, believed that abstinence caused illness, and advised women to take remedies such as mint or musk oil.[21]

From the 13th century, women with hysteria were exorcised, as it was believed that they were possessed by the devil. They believed that if doctors could not find the cause of a disease or illness, it must be caused by the devil.[21]

In the beginning of the 16th century, women were sexually stimulated by midwives in order to relieve their symptoms. Girolamo Cardano and Giovanni Battista Della Porta believed that polluted water and fumes caused the symptoms of hysteria. Towards the end of the century, however, the role of the uterus was no longer central to the disorder, with Thomas Willis discovering that the brain and central nervous system were the cause of the symptoms. Thomas Sydenham argued that the symptoms of hysteria may have an organic cause. He also proved that the uterus is not the cause of symptoms.[21]

In 1692, in Salem (MA), there was an outbreak of hysteria. This led to the Salem witch trials, where the 'witches' had symptoms such as sudden movements, staring eyes and uncontrollable jumping.[21]

From the 18th century, there is a move from the idea of hysteria being caused by the uterus to it being caused by the nervous system. This led to an understanding that it could affect both sexes. Jean Martin Charcot argued that hysteria was caused by "a hereditary degeneration of the nervous system, namely a neurological disorder."[21]

In the 19th century, hysteria moved from being considered a neurological disorder to being considered a psychological disorder, when Pierre Janet argued that "dissociation appears autonomously for neurotic reasons, and in such a way as to adversely disturb the individual's everyday life."[21] However, as early as 1874, doctors including W. B. Carpenter and J. A. Omerod began to speak out against hysteria due to there being no evidence of its existence.[22]

Freud referred to the condition as both hysteria.However, throughout his career, Freud admitted that "he had not succeeded in curing a single patient, and there was no clinical evidence that his theory had any merit whatsoever."[23] Freud frequently made serious diagnostic errors due to his theory of hysteria. In 1901, a patient died of a sarcoma of the abdominal glands, which had given her abdominal pain. One key feature of hysteria was said to be abdominal pain, and so Freud treated her for this, and claimed her condition had "cleared up". After her death, he then claimed that hysteria had caused her tumour; however, there is no evidence to support his claim.[23]


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Today, there is growing evidence that psychological stress does not cause FND. A recent study by the charity FNDHope found that psychological triggers affected only 30% of patients. Doctors are moving on to look at the role of the central nervous system in FND symptoms.

Research[edit]

Research is ongoing in many aspects of functional neurological disorders but large studies are needed to definitely answer key questions including: What is the best treatment for patients with FND? Even disorders like multiple sclerosis and Parkinson's disease have no definite known cause. The importance of increased awareness in the medical world of what constitutes a positive diagnosis of FND and what the best treatments are may, in the short term, be where research is focused.

Controversy[edit]

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References[edit]

  1. ^ a b Carson, A. et al. Disability, distress and unexployment in neurology outpatients with symptoms 'unexplained by disease'. J.Neurol.Neurosurg.Psychiatry 2011 Jul;82(7):810-3
  2. ^ Stone, J. et al. Who is referred to neurology clinics? - The diagnoses made in 3781 new patients. Clin. Neurol. Neurosurg. 112, 747–751 (2010).
  3. ^ Stone, J. et al. Who is referred to neurology clinics? - The diagnoses made in 3781 new patients. Clin. Neurol. Neurosurg. 112, 747–751 (2010)
  4. ^ Stone, J. & Carson, A. Functional Neurologic Disorders. Contin. (Minneap Minn) 21, 818–837 (2015)
  5. ^ Lehn, A. et al. Functional neurological disorders: mechanisms and treatment. J. Neurol. PMID 2641, (2015).
  6. ^ Stone, J. Functional neurological symptoms. J.R.Coll.Physicians Edinb. 41, 38–41 (2011)
  7. ^ Fiszman, A. & Kanner, A. M. in Gates and Rowan's Nonepileptic Seizures (eds. Schacter, S. & LaFrance Jr, W. C.) 3rd editio, 225–234 (Cambridge University Press, 2010).
  8. ^ Henningsen, P. Medically Unexplained Physical Symptoms, Anxiety, and Depression: A Meta-Analytic Review. Psychosom. Med. 65, 528–533 (2003).
  9. ^ Edwards, M. J., Stone, J. & Lang, A. E. From psychogenic movement disorder to functional movement disorder: It's time to change the name. Mov. Disord. 29, 849–852 (2014)
  10. ^ Kranick, S. et al. Psychopathology and psychogenic movement disorders. Mov. Disord. 26, 1844–1850 (2011)
  11. ^ Stone, J. et al. Systematic review of misdiagnosis of conversion symptoms and 'hysteria'. BMJ 331, 989 (2005).
  12. ^ Stone, J., Hallett, M., Carson, A., Bergen, D. & Shakir, R. Functional disorders in the Neurology section of ICD-11: A landmark opportunity. Neurology 83, 2299–301 (2014).
  13. ^ a b c "Neurological functional symptoms stepped care report". www.healthcareimprovementscotland.org. Retrieved 2015-11-25. 
  14. ^ a b Stone, J.; Sharpe, M.; Rothwell, P. M.; Warlow, C. P. (2003-05-01). "The 12 year prognosis of unilateral functional weakness and sensory disturbance". Journal of Neurology, Neurosurgery & Psychiatry. 74 (5): 591–596. ISSN 1468-330X. PMC 1738446Freely accessible. PMID 12700300. doi:10.1136/jnnp.74.5.591. 
  15. ^ a b Nielsen, G., Stone, J. & Edwards, M. J. Physiotherapy for functional (psychogenic) motor symptoms: a systematic review. J. Psychosom. Res. 75, 93–102 (2013)
  16. ^ Jordbru, A. A., Smedstad, L. M., Klungsoyr, O. & Martinsen, E. W. Psychogenic gait: a randomized controlled trial on effect on rehabilitation. Clin. Rehabil.
  17. ^ McCormack, R. et al. Specialist inpatient treatment for severe motor conversion disorder: a retrospective comparative study. J. Neurol. Neurosurg. Psychiatry 85, 895–900 (2014)
  18. ^ [([1])]
  19. ^ Edwards, M. J. Functional neurological symptoms: welcome to the new normal. Pract. Neurol. 16, 2–3 (2016)
  20. ^ "neurosymptoms.org". www.neurosymptoms.org. Retrieved 2016-02-07. 
  21. ^ a b c d e f g h Tasca, Cecilia; Rapetti, Mariangela; Carta, Mauro Giovanni; Fadda, Bianca (2012-10-19). "Women And Hysteria In The History Of Mental Health". Clinical Practice and Epidemiology in Mental Health : CP & EMH. 8: 110–119. ISSN 1745-0179. PMC 3480686Freely accessible. PMID 23115576. doi:10.2174/1745017901208010110. 
  22. ^ a b c d e Webster, Richard. "Sigmund Freud: hysteria, somatization, medicine and misdiagnosis". www.richardwebster.net. Retrieved 2016-02-21. 
  23. ^ a b Webster, Richard. "The hysteria diagnosis: Freud, Charcot, Breuer and Anna O". www.richardwebster.net. Retrieved 2016-02-21. 
  24. ^ Slater, Eliot (1965). "Diagnosis of "Hysteria"". British Medical Journal. 
  25. ^ a b Wessely, Simon; White, Peter D. (2004-08-01). "There is only one functional somatic syndrome". The British Journal of Psychiatry. 185 (2): 95–96. ISSN 0007-1250. PMID 15286058. doi:10.1192/bjp.185.2.95. 

External links[edit]

Online resources include:

  • Neurosymptoms[1] is written by Dr Jon Stone a Scottish neurologist.
  • FND Hope[2] is registered charity in the United States and non-profit organization in the United Kingdom. They collaborate with Dr. Jon Stone and Dr. Mark Edwards.
  • FND Dimensions is a registered charity in England and Wales who aim "to develop a network of ‘peer support groups’ across the UK either in face to face meetings or online via methods such as Skype."[3]
  • FiNDME is a UK based non profit organisation for patients and carers with FND and ME.
  • #functionalneurologicaldisorder on Instagram has a small community of patients.
  • FND Support is an Instagram profile dedicated to FND.
  • FND Action is a registered charity in England and Wales providing support and information for people with FND.
  • FND Awareness Day is held on April 13th.