Functional Neurological Syndromes

Question 1

Definition

Answer 1

• CHANGE IN FUNCTION RATHER THAN STRUCTURE OF A SYSTEM

	○ SYMPTOMS W/O CHANGE IN STRUCTURE = NO ORGANIC DISEASE

	○ SYMPTOMS UNEXPLAINED BY DISEASE

Question 2

Examples of functional symptoms

Answer 2

• SEIZURES
  
  • BLACKOUTS
  • PARALYSIS
  • ABNORMAL MOVEMENTS
  • FUNCTIONAL WEAKNESS = as COMMON as MS + has SIMILAR DISABILITY at 12yr follow-up
  • MOVEMENT DISORDERS
  • PRIMARY FUNCTIONAL DISORDER
  • STATUS EPILEPTICUS (prolonged seizures) - 1/2 CAN BE DISSOCIATIVE SEIZURES

pt. has 1/more symptoms of altered voluntary motor/sensory function + clinical findings provide evidence incompatible bwtn symptoms and recognised neurological/medical conditions + symptom/deficit not better explained by another medical/mental disorder + causes sig. distress/impairment in domain/s

Question 3

Investigations

Answer 3

GOOD Hx + EXAMINATION

Hx:

• LIST ALL SYMPTOMS
• ASK ABOUT DISABILITY = WHAT IS A TYPICAL DAY LIKE?
• ONSET & COURSE = TIMELINE, LAST TIME PT. FELT WELL, WHAT HAPPENED w/ PREVIOUS DOCTORS
• DISSOCIATIVE SYMPTOMS = EXPERIENCE DISCONNECTION & LACK of CONTINUITY bwtn THOUGHTS, MEMORIES, SURROUNDINGS, ACTIONS & IDENTITY e.g.
  • AMNESIA
  • DETACHMENT FROM SELF & EMOTIONS
  • LACK of CONTROL over SURROUNDINGS/EVENTS
  • OUT OF BODY EXPERIENCE
  • DISTORTED/UNREAL PERCEPTION of SURROUNDINGS & PEOPLE
  • BLURRED SENSE of IDENTITY
  • SIG. STRESS/PROBLEMS, INABILITY TO COPE WELL w/ EMOTIONAL/PROFESSIONAL STRESS, MENTAL HEALTH PROBLEMS
• ILLNESS BELIEFS = WORK, MONEY, LAW, RELATIONSHIPS, Hx of ABUSE (2ND CONSULTATION = appropriate time & setting)
• SOCIAL
• GET OLD NOTES

ON/E:

• INCONSISTENCY
• +VE FUNCTIONAL SIGNS
  
  • HOOVER’S SIGN = hip extension weak when directly tested; hip extension normal when pt. flexes opposite hip
  • ABDUCTOR SIGN = first get pt. to simultaneously abduct both legs against resistance to check for paresis; then get them to abduct each leg in turn against resistance (when one leg abduct, the other leg should abduct to compensate if normal)○ ORGANIC PARESIS: expected signs; abduct sound leg only = sound leg abducts, paretic leg doesn’t abduct, so examiner resistance force pushes it into adduction; abduct paretic leg = paretic leg pushed into adduction & sound leg remains in midline position○ NON-ORGANIC PARESIS: abduct sound leg = sound leg abducts & paretic leg remains in midline; abduct paretic leg = both legs “become weak” & both adduct due to examiner resistance
  • FUNCTIONAL SENSORY DISTURBANCE (say yes when you feel me touch you & no when you don’t) = could be SPLIT IN MIDLINE - not organic
• ABSENCE of DISEASE SIGNS
• EYE MOVEMENTS = CONVERGENCE SPASM (intermittent sustained convergence, accommodative spasm, miosis)
• TREMOR = DISAPPEARS w. DISTRACTION, ENTRAINMENT (entrainment - pt. focuses on extraneous factor e.g. music rather than normal focus of attention)
• PARALYSIS
  • LEG DRAGGED, HIP INTERNALLY/EXTERNALLY ROTATED
  • “GIVE WAY WEAKNESS”
  • INVERTED PYRAMIDAL WEAKNESS (EXTENSORS vs. FLEXORS)

• “FIXED” DYSTONIA = NOT ORGANIC - NORMAL DYSTONIA TENDS TO COME & GO, COMPLEX REGIONAL PAIN AFTER MINOR INJURY

Question 4

Other investigations

Answer 4

• MRI = MAY FIND INCIDENTAL FINDINGS that may have nothing to do w/ disease
  
  • NEGATIVE VIDEO EEG = non-epileptic seizures, dissociative occurrences
  • FUNCTIONAL MRI

Question 5

Management

Answer 5

Explain condition:

USE METAPHOR (HARDWARE & SOFTWARE)
CONSIDER DISABILTY it may have on pt.
WHAT DO THEY HAVE + WHAT DON’T THEY HAVE
MAKE +VE DIAGNOSIS

Indicate you believe them

Explain it is:

COMMON
POTENTIAL TO GET BETTER
SELF-HELP KEY TO RECOVERY

Depression/anxiety:

ANTIDEPRESSANTS

REFERRALS = PSYCHIATRY, PHYSIO, PSYCHOLOGY (CBT)

If physio, OT don’t work, then refer to psychiatry/psychology or if they have anxiety/depression etc. it's useful to refer onto psychiatry/psychology

Support organisations + info:

PT. FAMILY, FRIENDS, CARERS, CHARITIES

DISABIITY & INCAPACITY BENEFITS
AIDS & APPLIANCES