Functional Neurological Symptoms

Question 1

What is a functional neurological disorder?

Answer 1

change in function rather than structure of a system (blackouts, paralysis, abnormal movements). Symptoms not explained by a neurological disease

Question 2

Explain the numbers of functional symptoms in neurology?

Answer 2

1/10 Outpatients have a functional symptom¹

In Scotland 5000 new diagnoses per year

1/7 of “First seizure” is Non-epileptic

Functional weakness is as common as MS

^{• Similar disability at 12 year follow up}

5-10% Movement disorder clinic referrals

1-10% Primary functional disorder

50% “Status epilepticus” are dissociative seizures

Economic impact

^{• 27% with symptoms unexplained by disease were not working for health reasons}

^{• £1.3 million per year outpatients}

^{• £6.01 million inpatients (13887 bed days)}

^{• £4.01 million for primary care}

Question 3

What is the approach for a history when dealing with functional symptoms in neurology?

Answer 3

• List all symptoms
• Ask about disability - “ What is a typical day like?”
• Onset and Course - Timeline, “When last did you fell well?”, “What happened with previous doctors?”
• Dissociative symptoms
• Illness beliefs
• Social

^{- Work, money, the law, relationships}

^{- History of abuse- second consultation}

• GET THE OLD NOTES

Question 4

What is the approach for an examination when dealing with functional symptoms in neurology?

Answer 4

• Inconsistency
• Positive functional signs
• Absence of signs of disease
• Eye movements: convergence spasm
• Tremor: disappears with distraction, entrainment
• Paralysis:

^{- Leg dragged, hip internally/ externally rotated}

^{- “Give way weakness”}

^{- Inverted pyramidal weakness (Extensors vs Flexors)}

• “Fixed” dystonia, complex regional pain after minor injury

Question 5

What is the approach for investigations when dealing with functional symptoms in neurology?

Answer 5

MRI brain scan - 10-15% incidental findings

Negative Video EEG

Functional MRI

Question 6

What is the approach for management when dealing with functional symptoms in neurology?

Answer 6

Explain what they do and don’t have - Make a positive diagnosis

Indicate you believe them

Explain that it is - common, potential to get better, self-help is key to recovery

Metaphors - Hardware and software

The role of depression/anxiety - Antidepressants

Referral:

^{• Psychiatry}

^{• Physical Rehabilitation}

^{• Psychology : cognitive behavioural therapy}

Support organisations and information - Patient, Family, Friends, Carers, Charities

Question 7

What is the prognosis of patients with functional symptoms in neurology?

Answer 7

Regular A&E attendance dropped (50-18%) in 260 patients with non-epileptic attacks in Glasgow

6 months after diagnosis in non-epileptic attacks cost dropped by 84%¹⁰

Question 8

WHat is the misdiagnosis rate of apratients with functional symptoms in neurology?

Answer 8

Same as other Neurological conditions 5%

Question 9

Apart from the prognosis and misdiagnosis, what other outcomes are there for patients with functional symptoms in neurology?

Answer 9

Litigation

Disability and incapacity benefits

Aids and appliances

Complaints