Functional Neurologic Disorder Flashcards
other names for functional neurologic disorder
Functional Motor Disease, Functional Neurological Symptoms Disorder, Somatoform Disorder, Psychogenic Movement Disorder, Hysterical Paralysis, or Conversion Disorder
functional neurologic disorder
Neurological symptoms affecting movement that
are caused by a loss of control over movement
rather than a structural disease process in the
neurological system
what are symptoms due to in functional neurotic disorder?
Symptoms are due to an unconscious expression
of a psychological conflict or need (patient may
not be aware of this conflict/need)
what is functional neurologic disorder characterized by?
involuntary but learnt habitual movement patterns driven by abnormal self-directed attention
what is FND triggered by?
physical or psychophysiological events such
as injury, illness, panic and dissociation with panic
what is FND mediated by?
illness beliefs and expectations
motor functional neurologic symptoms include:
weakness, tremor, jerks, dystonia, gait disorder, paralysis of one or more limbs, ataxia, tics, or a combination of symptoms
non-motor functional neurologic symptoms include:
sensory disturbance, memory complaints, pain, fatigue, or dissociative seizures
what happens when symptoms are reinforced by
social support from family and friends or by avoiding the underlying emotional stressors?
high levels of disability and distress, poor
prognosis, high financial burden
types of FND
Motor FND
FND with Sensory Dysfunction
Axial FND
Speech FND
Paroxysmal FND with seizures
Motor FND
- sudden onset of symptoms
- functional weakness
- functional tremor
- functional parkinsonism
- functional dystonia
when do symptoms decrease for Motor FND
with distraction of patient, increase with attention to symptoms, excessive fatigue, or demonstrations of effort
functional weakness of motor FND
- variability in severity over time and discordant performance between assessments
- May be global or limited to parts of the body- just lower extremities mimicking SCI or just on one
side of the body mimicking a stroke
motor FND - functional tremor
variable frequency, characteristic response to externally cued rhythmic movements
motor FND - functional Parkinsonism
excessive slowness without decrement and fatigue
oInconsistent rigidity, normal speed with spontaneous movements
FND with sensory dysfunction
- Midline splitting of vibration sense across a single bone such as forehead or sternum
- Complete hemianopsia with both eyes open during visual field testing
- Persistent perceptual postural dizziness (PPPD)
PPPD in FND with sensory dysfunction
o Provided by upright posture, active/passive motion, exposure to moving visual stimuli or complex visual patterns
o Triggered by an episode of acute dizziness such as vestibular neuritis or panic attack
Axial FND
- Disorders of gait and posture
- Excessive gait slowness, astasia-abasia, knee buckling
- Excessive demonstration of effort during ambulation
- Functional trunk postural abnormalities
what is astasia-abasia
inability to stand or walk despite sparing of
the motor function to do so
functional trunk postural abnormalities in axial FND
Myoclonic jerks affecting the trunk or fixed forward flexion of the thoracolumbar spine
Speech FND
Dysfluency similar to stuttering, articulation deficits, visible demonstration of excessive effort, prosodic
abnormalities (foreign accent)
o Aphonia, dysphonia
Paroxysmal FND with seizures
- Episodic
- Paroxysmal akinesia
- Paroxysmal hyperkinesias
PNES vs epileptic seizures
PNES tends to have a long duration of shaking episodes, fluctuating course of seizures, asynchronous limb movement, pelvic thrusting, side-to-side head movements, closed eyes, ictal crying, and recalling of ictal events
incidence of FND is higher with what population?
patients with 1st degree relatives with psychiatric/medical disorders or history of
sexual/emotion/physical abuse
is FND more common in men or women?
60-70% are women
what do psychodynamic models emphasize?
a symptom may either suppress an emotion
or serve to resolve dilemmas, support important interpersonal relationships, or escape interpersonal conflicts
attentional dysregulation
o Hierarchical information flow in the nervous system is based on the integration
between bottom-up sensory information and top-down predictions about the
nature of the expected sensory information
o Differential weighting of the 2 streams of information leads to abnormal
predictions about sensory data with abnormal perceptions or movements
o Attention is underscored by the suppression of symptoms with distraction
o Practice of deflective attention away from the affected area
integrative cognitive model for PNES
- inherent responses to emotions, ideas about
illness, and illness models contribute to the formation of a symptom which may be
activated by arousal or internal/external stimuli perceived as threatening - Symptoms may be further facilitation by illness awareness, health anxiety, and excessive threat vigilance
once functional symptoms are formed …..
regardless of the initiating mechanism, phobic avoidance, affective disorders, and brain plasticity may be perpetuating features
pathophysiology - neurobiological
Due to the relative disconnection between the
SMA and areas that would usually select or
inhibit movement (prefrontal cortex), movements
occur without a normal feeling or sense of
agency/control
Abnormalities activated via negative emotional
stimuli may be associated with what?
abnormally increased activation in areas involving emotion recognition and self-awareness
(amygdala/cingulate gyrus) and in networks
related to emotion processing
Feigned vs. Functional Weakness on neuroimaging
o Feigned: no activation seen when participants are given command to move
o Functional: Normal activation within areas associated with movement preparation was accompanied by activation within the prefrontal cortex that be unexpected during voluntary movement activation
Physiological studies: Electromyography and Motor Evoked Potentials
o People that have a functional neurologic disorder and were asked to imagine moving the affected limb had smaller motor evoked potentials compared to healthy subjects
o Findings suggest that although structural motor pathways are preserved in motor functional neurological disorders, there is an alteration in the
pathways involved in motor planning
o Conclusion: Normal function of the primary pathways (motor/sensory) and alterations at the level of premotor/sensory association cortex
processing
predisposing vulnerabilities - biological
- Gender- Female; Intellectual disability, Epileptic Seizures, Other nervous system vulnerabilities; Comorbid medically unexplained syndromes (chronic fatigue, pain, or GI complaints)
predisposing vulnerabilities - psychological
Comorbid mood and anxiety disorders, dissociation, alexithymia, insecure attachment, illness perception, Temperament and maladaptive
personality traits
predisposing vulnerabilities - psychosocial
Family functioning, adverse life events, financial status, peer support, attitudes toward health and disease
precipitative factors - biological
- Abnormal physiological events (sleep deprivation, hyperventilation, palpitations), acute physical pain or limb injury, head trauma
(especially mild TBI)
precipitative factors - psychological
- Acute dissociative event, panic attack
- Employment difficulties, marital strain, other relational stress
perpetuating factors - biological
Physiological hyperarousal, Chronic pain, Chronic Fatigue, abnormal motor habit formation, Deconditioning
perpetuating factors - psychological
Negative expectation bias, Negative attentional bias, Illness beliefs including perception of symptom inversibility, fear of falling,
Avoidance of symptom exacerbation preventing treatment participation
perpetuating factors - psychosocial
Provider diagnostic uncertainty, Social benefits of being ill (often without patient awareness), pending litigation/disability, workmen’s compensation, poor care coordination
FND is frequently misdiagnosed as what?
MS, SLE, Guillain Barre, postencephalitic syndrome, brain/spinal tumors
DSM-5 Diagnostic criteria
- symptoms for at least 6 months
o One of more symptoms or deficits affecting voluntary motor/sensory function suggesting neurological or other general medical condition
o Psychological factors are judged to be associated with the symptom or deficit because conflicts or
other stressors precede initiation or exacerbation of the symptom or deficit
o Patient is not feigning or intentionally producing symptoms/deficits
o Symptoms cannot be fully explained by a general medical condition, by the direct effects of a substance, or as a culturally sanctioned behavior/experience
o Symptoms are not limited to pain or a disturbance in sexual functioning and is not better explained by
another mental disorder
FND Diagnosis for PT
- Inconsistencies in repeated testing of sensation and muscle strength
- MMT does not correspond with patient’s functional abilities
- Sensory impairments are present that do not follow anatomical patterns
- Unexplained tremors
- Unexplained or unusual gait patterns
- Simultaneous contraction of agonist/antagonist muscles
what does FND diagnosis rely on
positive examination findings
more diagnosis signs
Distractibility
Fluctuation
- Patients with FND are often polysymptomatic
Type specific signs
entrainment for tremor, Hoover sign for leg weakness
Historical cues
Abrupt onset, rapid escalation, random and unpredictable timing of symptoms, significant changes over time
what is essential for assessment/evaluation?
that all symptoms present are assessed/evaluated for effective neurological consultation and planning future management
While PTs may focus on motor symptoms-
sleep disturbances, fatigue, pain, cognitive symptoms, and psychiatric symptoms have a great impact on motor symptoms, prognosis, and health related quality of life
subjective assessment for FND
- Get detailed understanding of the range of symptoms experienced and their effect on daily function
- Establish patient’s understanding of and level of
confidence in the diagnosis given - Establish patient’s beliefs on if physical therapy can impact symptoms
FND Presentation and potential for normal movement
o Hoover’s or hip abductor sign
o Copying of tremor on uninvolved side (pulls
attention and tremor reduces)
what should be conducted early in the assessment process
Comprehensive screening of psychiatric risk factors to identify predisposing, precipitating, and perpetuating factors that need to be addressed
prognosis is good if…
onset of symptoms is acute and precipitated by a stressful live event, patient had good premorbid health, and absence of other organic or psychiatric disorders
prognosis is poor if….
symptoms persist beyond one year
prognosis is collectively poor with….
disability persisting or worsening over time due to under-recognition or poorly delivered FND diagnosis and lack of availability of knowledgeable therapists
negative prognosis predictors
long duration of symptoms before diagnosis, disability status, and personality disorders
positive prognosis predictors
young age and early diagnosis
critical element for patient care
patient/family clear understanding
symptoms explanation
- adapted medical explanation of their functional
disturbances, but no specific diagnostic label - No exact explanation for symptoms
- Commonly occur after stressful life events
- Rules out serious illness through thorough exam
- Common to see a disconnect between the nervous system and muscles
introduce role of PT as…
retraining the nervous system to help regain control over movement
Therapy is characterized as a treatment process that changes the way the brain process information:
o Create new behaviors that beak the established unconscious pattern that leads to symptoms
o The goal is to change the processing of complex motor programs and to facilitate engagement in more adaptive patterns of movement or gait
o Diary of symptoms and their precipitants
what must a patient leave with?
validation of his/her neurological symptoms and
resultant functional limitations, confidence in the diagnosis, sense of partnership with the clinician, belief that PT can benefit symptoms, and understanding of the rationale for the multidisciplinary management
what do most patients with FND require?
an integrated multi-disciplinary approach
health care professionals should assist…
the individual to move away from the “sick role” and to return to healthy roles in their social, physical, and work life
why must patients families be involved in the rehab process?
to reinforce and carry over behavior modification
outside of therapy
what should treatment options for FND reflect?
the diversity of symptom phenotypes as well as the heterogeneity and comorbidity with the patient population (no one size fits all)
what is cognitive behavioral therapy ?
o Education about functional neurological disorder and the stress response cycle
o Train patient in stress management techniques and new behavioral response
o Help patient identify and change unhelpful thought patterns that reinforce symptoms
goal of CBT
reduce unwanted behaviors and strengthen desired behaviors
CBT creates a mindset that ….
symptoms are learned maladaptive behaviors
how does CBT respond to unwanted behaviors
ignored
not punished
- Stop/ignore behavior- “take a break” “regain control of your body”
in CBT, desired behaviors are…
- rewarded
▪ Positive reinforcement
for FND, when should ADs be removed?
as soon as possible to promote normal/natural
movement patterns
how is patient treated?
as if condition was organic in nature
interventions for FND include:
- endurance training, balance training, postural
stabilization, flexibility, gait and locomotion training, relaxation training, and strengthening with progressive levels of challenge as appropriate if
impairments were organic - Incorporates principles of motor learning to include providing less physical
support, less verbal cueing, and more intrinsic feedback as the patient masters the skill
when going to PT, patient should get simultaneous what?
psychological counseling
develop rapport
▪ Patient involved in selection of awards and positive reinforcement
▪ Consistent clinical staff
▪ Involve patient and family with treatment planning, goals, education
pre-gait activities
▪ Stretching, general strengthening
▪ Sitting/standing balance activities
▪ Coordination, Motor control activities
▪ Transfer training
▪ Weight-shifting activities and stepping activities
supported gait activities
▪ Standing and gait training with parallel bars or walker
▪ Step-to to step through patterns
▪ Side-stepping and backwards walking
general mobility activities
▪ Maneuvering around obstacles
▪ Endurance training; addition of bike/treadmill
training
▪ Multi-task activities
Community gait training
▪ Architectural barriers
▪ Job, work, school tasks
▪ Social activities in the community
emphasis is placed on…
quality and control of movement
what should you focus on in interventions?
the aberrant movements/postures and breaking these down into individual motor components, gradually reconstructing more normal motor patterns
greater emphasis on….
education, movement retraining with focus
on redirecting attention away from undesired movements, greater emphasis on self-management, greater number of sessions, higher intensity/frequency of sessions, addressing co-existing problems
how should you minimize self-focused attention
- by distracting or preventing the patient from
cognitively controlling movement and stimulate automatically generated movement - Thinking about a different part of movement, alter timing, fast, rhythmical movement, unfamiliar/unpredictable movement
- Cognitive distraction
- Meaningful automatic movement and muscle activity can be generated by weightbearing or automatic postural responses
what should you use for movement re-training
visualization, mirrors, videos
non-specific/graded exercise
o Tailored to address reduced exercise tolerance and symptoms of chronic pain/fatigue
o Right intensity to prevent exacerbation of symptoms and promote adherence
what can long term use of ADs lead to
adaptive ways of functioning and behaviors that prevent the return of normal movement and results in secondary changes such as weakness and
pain
what is electrical muscle stimulation used for?
- To demonstrate normal movement and help change illness beliefs and promote motor relearning
- EMG-biofeedback is useful for retraining movement for weakness or muscle relaxation for tremor
- TENS may increase level of sensory awareness for those with sensory deficits
other symptoms of FND
PPPD- Persistent Postural Perceptual Dizziness
Urinary Symptoms
Functional Speech and Voice Disorders
Functional Dysphagia
Comorbid Pain
Fatigue
Cognitive Fog
7 general principles
- diagnosis should be established prior to starting therapy and clearly communicated to family/pt
- encourage transparency, especially with positive diagnostic features
- explore/address unhelpful beliefs/behaviors
- ensure patient understanding of potential for recovery
- foster independence and self-management
- involvement of family and caregivers
- develop self-management and relapse plan
interdisciplinary treatment plan
- core symptoms management
- fatigue
- pain
-cognitive fog - sleep
- beliefs about symptoms
- medication adverse effects
- psychologic factors
- social factors
specialized outpatient program - education
Diagnostic signs, FMD pathophysiology, creation of individual patient symptom formulation- unhelpful reinforcement, triggering events, comorbidity, psychological factors
specialized outpatient program - motor retraining
Sequential motor relearning, redirecting of motor attention
