The care of patients with functional neurological disorders overlaps both the neurology and psychiatry specialties. It is often the case that neither provider thinks that he or she should be the treating clinician, and as a result, this patient group can suffer a substantial gap in care. Here, we illustrate a practical approach toward integration of care to appropriately treat patients with functional neurological disorders.
DEFINITIONSThe chapter on somatic symptoms and related disorders in DSM-5 encompasses several psychiatric disorders for which the primary feature is a symptom related to a physical or health-related complaint. The diagnostic criteria for somatic symptom disorder require that the patient have one or more Which of the following reflects a DSM-5 criterion for conversion disorder (functional neurologic symptom disorder)?A. Symptoms of altered voluntary motor, cognitive, or sensory function. B. Clinical findings compatible with a recognized neurologic condition. C. Symptom onset following an identified stressor. D. Evidence of intentional production of neurologic symptoms. "Ms. A," a 29-year-old woman, was referred for a second neurologic opinion. Several months earlier, she woke with a pins-and-needles sensation involving both legs from the knees to the toes. The following day, she could not move her legs without help from her fiancé. Several hours later, she developed transient numbness of the left arm. Alarmed by her increasing symptoms, she presented to the emergency department. A brain and cervical MRI with gadolinium contrast showed no abnormalities. The patient was discharged with neurologic follow-up. Results of an electromyogram and nerve conduction study of the upper and lower extremities were normal. Later, because of increasing back and diffuse leg pain, the patient underwent a lumbar MRI, which also showed no abnormalities. She continued to experience lower extremity weakness and paresthesias as well as back and leg pain. No diagnosis was made. The patient had been unable to work since her symptoms began.Ms. A had a history of posttraumatic stress disorder related to a rape in college. She still endorsed presence of frequent nightmares and flashbacks related to the experience. She denied hypervigilance or avoidance related to her trauma. She denied any history of depression or other anxiety symptoms.On examination the patient had diffuse lower extremity weakness with variability of effort (the strength of her lower extremities did not consistently show the same response, as would be expected in a physiological motor deficit). Her reflexes were normal and there were no pathological reflexes. Sensation to pinprick was decreased in both legs without a sensory level or a dermatomal pattern (if a patient has a spinal cord abnormality, a sensory level would be an expected finding, or if there were cauda equina involvement, the sensory loss should conform to that of multiple sensory dermatomes). The patient's vibratory sense was diminished over the thoracic but not the lumbar vertebrae or in...