Hostname: page-component-78c5997874-4rdpn Total loading time: 0 Render date: 2024-11-10T05:55:39.077Z Has data issue: false hasContentIssue false
  • English
  • Français

Diagnosing functional neurological disorder: seeing the whole picture

Published online by Cambridge University Press:  09 November 2020

Sarah C. Lidstone Open the ORCID record for Sarah C. Lidstone [Opens in a new window] ,
Walid Nassif ,
Jorge Juncos ,
Stewart A. Factor  and
Anthony E. Lang
Sarah C. Lidstone*
Affiliation:
Edmond J. Safra Program in Parkinson’s Disease and the Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital and the University of Toronto, Toronto, Ontario, Canada
Walid Nassif
Affiliation:
Department of Psychiatry, Emory University, and the Veterans Affairs Medical Center, Atlanta, Georgia, USA
Jorge Juncos
Affiliation:
Department of Neurology, Jean and Paul Amos Parkinson’s Disease and Movement Disorders Program, Emory University, Atlanta, Georgia, USA
Stewart A. Factor
Affiliation:
Department of Neurology, Jean and Paul Amos Parkinson’s Disease and Movement Disorders Program, Emory University, Atlanta, Georgia, USA
Anthony E. Lang
Affiliation:
Edmond J. Safra Program in Parkinson’s Disease and the Morton and Gloria Shulman Movement Disorders Clinic, Toronto Western Hospital and the University of Toronto, Toronto, Ontario, Canada
*
*Author for correspondence: Sarah C. Lidstone, Email: sarah.lidstone@uhnresearch.ca
Get access Rights & Permissions [Opens in a new window]

Abstract

Functional neurological disorder (FND) is a complex neuropsychiatric syndrome with many phenotypes that are commonly encountered in clinical practice. Despite the heterogeneity of FND, the rate of misidentification is consistently low. For the more common motor subtypes, there are clear positive clinical, electrophysiological, and rarely imaging criteria that can establish the diagnosis in the traditional sense. For nonmotor subtypes, the characterization may be less clear. Here, we argue that the current diagnostic criteria are not reflective of the current shared neuropsychiatric understanding of FND, and, as a result, provide an incomplete picture of the diagnosis. We propose a three-step diagnostic triad for FND, in which the traditional neurological diagnosis is only the first element. Other steps include psychiatric/psychological formulation, integration, and follow-up. We advocate that this diagnostic approach should be the shared responsibility of neurology and mental health professionals. Finally, a research agenda is proposed to address the missing factors in the field.

Keywords

Diagnosisfunctional movement disorderfunctional neurological disorderpositive signspsychogenic movement disorderpsychogenic nonepileptic seizures
Type
Review
Information
CNS Spectrums , Volume 26 , Issue 6: Special Issue: Functional Neurological Disorder , December 2021 , pp. 593 - 600
Copyright
© The Author(s), 2020. Published by Cambridge University Press

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Kranick, S, Ekanayake, V, Martinez, V, Ameli, R, Hallett, M, Voon, V. Psychopathology and psychogenic movement disorders. Mov Disord. 2011;26(10):1844–1850.CrossRefGoogle ScholarPubMed
Scamvougeras, A, Howard, A. Understanding and Managing Somatoform Disorders: A Guide for Clinicians. Vancouver: AJKS Publishing; 2018.Google Scholar
Stone, J, Carson, A, Duncan, R, Coleman, R, Roberts, R, Warlow, C, et al. Symptoms ‘unexplained by organic disease’ in 1144 new neurology out-patients: how often does the diagnosis change at follow-up? Brain. 2009;132(10):2878–2888.CrossRefGoogle ScholarPubMed
Gupta, A, Lang, AE. Psychogenic movement disorders. Curr Opin Neurol. 2009;22(4):430–436.CrossRefGoogle ScholarPubMed
American Psychiatric Association. DSM-5 Task Force. Diagnostic and statistical manual of mental disorders: DSM-5TM (5th ed.). 5th ed. Arlington, VA, US: American Psychiatric Publishing, Inc.; 2013.Google Scholar
Williams, DT, Ford, B, Fahn, S. Phenomenology and psychopathology related to psychogenic movement disorders. Adv Neurol. 1995;65:231–257.Google ScholarPubMed
LaFrance, WC, Baker, GA, Duncan, R, Goldstein, LH, Reuber, M. Minimum requirements for the diagnosis of psychogenic nonepileptic seizures: a staged approach. Epilepsia. 2013;54(11):2005–2018.CrossRefGoogle Scholar
Fahn, S, Williams, DT. Psychogenic dystonia. Adv Neurol. 1988;50:431–455.Google ScholarPubMed
Lidstone, SC, MacGillivray, L, Lang, AE. Integrated therapy for functional movement disorders: time for a change. Mov Disord Clin Pract. 2020;7(2):169–174.CrossRefGoogle ScholarPubMed
Carson, A, Hallett, M, Stone, J. Chapter 15—assessment of patients with functional neurologic disorders. In: Hallett, M, Stone, J, Carson, A, eds. Handbook of Clinical Neurology. Elsevier; 2016:169–188. Functional Neurologic Disorders; vol 139.Google Scholar
Aybek, S, Lidstone, SC, Nielsen, G, MacGillivray, L, Bassetti, CL, Lang, AE, et al. What Is the role of a specialist assessment clinic for FND? Lessons from three national referral centers. J Neuropsychiatry Clin Neurosci. 2020;32(1):79–84.CrossRefGoogle ScholarPubMed
Stone, J, Smyth, R, Carson, A, Warlow, C. La belle indifférence in conversion symptoms and hysteria: systematic review. Br J Psychiatry. 2006;188(3):204–209.CrossRefGoogle Scholar
Hoeritzauer, I, Pronin, S, Carson, A, Statham, P, Demetriades, AK, Stone, J. The clinical features and outcome of scan-negative and scan-positive cases in suspected cauda equina syndrome: a retrospective study of 276 patients. J Neurol. 2018;265(12):2916–2926.CrossRefGoogle ScholarPubMed
Laub, HN, Dwivedi, AK, Revilla, FJ, Duker, AP, Pecina-Jacob, C, Espay, AJ. Diagnostic performance of the “Huffing and Puffing” sign in psychogenic (functional) movement disorders. Mov Disord Clin Pract. 2015;2(1):29–32.CrossRefGoogle ScholarPubMed
Okun, MS, Rodriguez, RL, Foote, KD, Fernandez, HH. The “chair test” to aid in the diagnosis of psychogenic gait disorders. Neurologist. 2007;13(2):87–91.CrossRefGoogle Scholar
Hoeritzauer, I, Phé, V, Panicker, JN. Chapter 38—urologic symptoms and functional neurologic disorders. In: Hallett, M, Stone, J, Carson, A, eds. Handbook of Clinical Neurology. Elsevier; 2016:469–81. Functional Neurologic Disorders; vol. 139.Google Scholar
Fowler, C, Kirby, RS. Electromyography of urethral sphincter in women with urinary retention. Lancet. 1986;327(8496):1455–1457.CrossRefGoogle Scholar
Daum, C, Gheorghita, F, Spatola, M, Stojanova, V, Medlin, F, Vingerhoets, F, et al. Interobserver agreement and validity of bedside ‘positive signs’ for functional weakness, sensory and gait disorders in conversion disorder: a pilot study. J Neurol Neurosurg Psychiatry. 2015;86(4):425–430.CrossRefGoogle ScholarPubMed
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(2):180–190.CrossRefGoogle ScholarPubMed
Gasca-salas, C, Lang, AE. Chapter 17—neurologic diagnostic criteria for functional neurologic disorders. In: Hallett, M, Stone, J, Carson, A, eds. Handbook of Clinical Neurology. Elsevier; 2016:193–212. Functional Neurologic Disorders; vol 139.Google Scholar
Stone, J. Functional symptoms in neurology: THE BARE ESSENTIALS. Pract Neurol. 2009;9(3):179–189.CrossRefGoogle ScholarPubMed
Stone, J, Carson, A. Functional neurologic disorders. Continuum (Minneap Minn). 2015;21(3 Behavioral Neurology and Neuropsychiatry):818–837.Google ScholarPubMed
LaFaver, K, Espay, AJ. Diagnosis and treatment of functional (psychogenic) parkinsonism. Semin Neurol. 2017;37(2):228–232.Google ScholarPubMed
Stone, J, Edwards, M. Trick or treat? Neurology. 2012;79(3):282.CrossRefGoogle ScholarPubMed
LaFrance, WC, Reuber, M, Goldstein, LH. Management of psychogenic nonepileptic seizures. Epilepsia. 2013;54(s1):53–67.CrossRefGoogle ScholarPubMed
Hall-Patch, L, Brown, R, House A, Howlett, S, Kemp, S, Lawton, G, et al. Acceptability and effectiveness of a strategy for the communication of the diagnosis of psychogenic nonepileptic seizures. Epilepsia. 2010;51(1):70–78.CrossRefGoogle Scholar
Stone, J, Carson, A, Hallett, M. Chapter 44—explanation as treatment for functional neurologic disorders. In: Hallett, M, Stone, J, Carson, A, eds. Handbook of Clinical Neurology. Elsevier; 2016:543–553. Functional Neurologic Disorders; vol. 139.Google Scholar
Voon, V, Cavanna, AE, Coburn, K, Sampson, S, Reeve, A, LaFrance, WC. Functional neuroanatomy and neurophysiology of functional neurological disorders (conversion disorder). J Neuropsychiatry Clin Neurosci. 2016;28(3):168–190.CrossRefGoogle Scholar
Reuber, M, Howlett, S, Khan, A, Grünewald, RA. Non-epileptic seizures and other functional neurological symptoms: predisposing, precipitating, and perpetuating factors. Psychosomatics. 2007;48(3):230–238.CrossRefGoogle ScholarPubMed
Stefánsson, JG, Messina, JA, Meyerowitz, S. Hysterical neurosis, conversion type: clinical and epidemiological considerations. Acta Psychiatr Scand. 1976;53(2):119–138.CrossRefGoogle ScholarPubMed
Carson, A, Lehn, A. Chapter 5—epidemiology. In: Hallett, M, Stone, J, Carson, A, eds. Handbook of Clinical Neurology. Elsevier; 2016:47–60. Functional Neurologic Disorders; vol. 139.Google Scholar
Bodde, NMG, Brooks, JL, Baker, GA, Boon, PAJM, Hendriksen, JGM, Mulder, OG, et al. Psychogenic non-epileptic seizures—definition, etiology, treatment and prognostic issues: a critical review. Seizure. 2009;18(8):543–553.CrossRefGoogle ScholarPubMed
Reuber, M, Pukrop, R, Bauer, J, Derfuss, R, Elger, CE. Multidimensional assessment of personality in patients with psychogenic non-epileptic seizures. J Neurol Neurosurg Psychiatry. 2004;75(5):743–748.CrossRefGoogle ScholarPubMed
Stamelou, M, Cossu, G, Edwards, MJ, Murgia, D, Pareés, I, Melis, M, et al. Familial psychogenic movement disorders. Mov Disord. 2013;28(9):1295–1298.CrossRefGoogle ScholarPubMed
Pellicciari, R, Superbo, M, Gigante, AF, Livrea, P, Defazio, G. Disease modeling in functional movement disorders. Parkinsonism Relat Disord. 2014;20(11):1287–1289.CrossRefGoogle ScholarPubMed
Stone, J, Warlow, C, Sharpe, M. The symptom of functional weakness: a controlled study of 107 patients. Brain. 2010;133(5):1537–1551.CrossRefGoogle ScholarPubMed
Stone, J, Warlow, C, Sharpe, M. Functional weakness: clues to mechanism from the nature of onset. J Neurol Neurosurg Psychiatry. 2012;83(1):67–69.CrossRefGoogle ScholarPubMed
Schrag, A, Trimble, M, Quinn, N, Bhatia, K. The syndrome of fixed dystonia: an evaluation of 103 patients. Brain. 2004;127(10):2360–2372.CrossRefGoogle ScholarPubMed
Pareés, I, Kojovic, M, Pires, C, Rubio-Agusti, I, Saifee, TA, Sadnicka, A, et al. Physical precipitating factors in functional movement disorders. J Neurol Sci. 2014;338(1):174–177.CrossRefGoogle ScholarPubMed
Edwards, MJ, Adams, RA, Brown, H, Parees, I, Friston, KJ. A Bayesian account of “hysteria”. Brain. 2012;135(11):3495–3512.CrossRefGoogle ScholarPubMed
Gilmour, GS, Nielsen, G, Teodoro, T, Yogarajah, M, Coebergh, JA, Dilley, MD, et al. Management of functional neurological disorder. J Neurol. 2020;267:2164–2172.CrossRefGoogle ScholarPubMed