Functional movement disorder: a long journey to diagnosis

Abstract

SUMMARYA 61-year-old man presented to a country clinic with involuntary orofacial movements and progressive cognitive decline, causing significant disability and psychosocial distress. Review of records uncovered a 7-year history of presentations to several specialties, including memory clinics, neurology, internal medicine and emergency departments, with varied symptoms, extensive complex work up and inconclusive diagnosis. Comprehensive review at our hospital highlighted inconsistent neurological signs, fluctuating cognition and psychosocial stressors, which preceded symptom onset, leading to the diagnosis of a functional movement disorder (FMD), which subsequently improved with relaxation therapy, cognitive-behavioural therapy and physiotherapy. We illustrate a variety of somatic symptoms, diagnostic clues and management outcomes for FMDs, and the importance of diagnostic criteria to minimise costly, time-consuming and ultimately unnecessary tests of exclusion. BACKGROUND

Inpatient Treatment of Functional Neurological Disorder: A Scoping Review

“…Only 10 studies captured health domains, such as degree of disability, cognitive, emotional, and quality of life with specific tools. 11,14,16,19,[32][33][34][41][42][43] Degree of disability was most commonly captured with the Functional Independence Measure (FIM) (n = 3) 14,32,34 and Modified Rankin Scale (mRS) (n = 2). 16,33 Impact on quality of life was assessed using the health-related quality of life scale in two studies.…”

“…Follow-up symptoms were described in a total of 78 chronic patients (follow-up pooled mean 12.7 months), 14 acute patients (follow-up mean 18.0 months, median 8 months), and 60 unspecified patients (follow-up pooled mean 13.2 months). 11,16,19,[22][23][24][25]28,[32][33][34][35][36][37][38][39][40][41][42]44 A total of 16 chronic patients (18% of patients with reported follow-up) had a recurrence of symptoms in the follow-up period ranging from 1 month to 2.5 years. 34,37,38,40,44 Jacob et al (2018) reported eight patients that either had no change in symptoms or worsening symptoms at 6 months, but did not distinguish how many of these patients were relapses or nonresponders.…”

“…Only nine studies specifically described psychiatric comorbidity, beyond a diagnosis of conversion disorder or somatization disorder. 20,23,27,32,33,39,[42][43][44] Comorbid psychiatric diseases included depression (30 patients), PTSD (30 patients), anxiety (23 patients), ADHD (1 patient), and specific phobia (1 patient). In many larger trials, patients with comorbid psychiatric disease were excluded.…”

“…Eleven studies reported the duration of symptoms of specific patients prior to admission, with a mean duration of 5.8 ± 6.4 years and a median of 3 years. 32,[35][36][37][38][39][40]42,[44][45][46] Larger elective admission studies presented the duration of symptoms using alternative intervals. Thirty-two patients with a mean duration of symptoms of 7.4 years were described in a retrospective chart review by Jacob et al (2018).…”

“…Seven studies specifically described patients with psychiatric comorbidities, which included: major depressive disorder (n = 5), post-traumatic stress disorder (n = 3), generalized anxiety disorder (n = 2), attention-deficit/hyperactivity disorder (n = 1), and a specific phobia (n = 1). 32,33,[42][43][44][45][46] Interventions Thirty-three studies broadly discussed the types of interventions given to patients while admitted to the hospital (Tables 1-3). The most common types of intervention included physiotherapy (n = 29) and psychotherapeutic strategies (n = 27).…”