Functional (Psychogenic) Neurological Disorders: Assessment and Acute Management in the Emergency Department

Abstract

Functional neurological disorders (FND, a.k.a. conversion disorder) are increasingly recognized as highly prevalent neurobehavioral-neuropsychiatric conditions. While patients with FND are frequently seen in outpatient neurology and primary care clinics, 1,2 these conditions are also common in emergency department (ED) settings. 3 While large-scale epidemiologic studies of incidence and prevalence are lacking, 4 there is robust evidence of high utilization of primary care, subspecialty, ED, and acute hospital services by patients with FND, resulting in considerable healthcare and societal costs. 5 Notably, patients with FND show elevated repeat ED visit rates in comparison to other conditions. 3 A variety of FND symptoms may lead to ED presentations, particularly those with paroxysmal or acute onset such as psychogenic nonepileptic seizures (PNES, a.k.a. dissociative seizures) or sensorimotor changes that mimic stroke. 6,7 Other FND symptoms that may lead to ED visits include functional movement disorders (FMDs), including functional tremor, gait disturbance, and/or dystonia. Appropriate triage of FND-related cases in the ED is not yet standardized and is often complex, requiring a time-sensitive, concurrent evaluation of neurological emergencies, as well as elements of shared neurology and neuropsychiatry expertise to provide an appropriate disposition and discharge plan.The assessment of FND has traditionally been a lengthy process utilizing tests that are not routinely performed in EDs Keywords ► conversion disorder ► psychogenic nonepileptic seizures ► functional movement disorders ► functional paralysis Abstract Functional neurological disorders (FND) are complex and prevalent neuropsychiatric conditions. Importantly, some patients with FND develop acute onset symptoms requiring emergency department (ED) evaluations. Historically, FND was a "rule-out" diagnosis, making assessment and management in the ED difficult. While the rapid triage of potential neurological emergencies remains the initial task, advancements have altered the approach to FND. FND is now a "rule-in" diagnosis based on validated neurological examination signs and semiological features. In this perspective article, we review signs and semiological features that can help guide the initial assessment of FND in the acute setting. Thereafter, we outline potential approaches to introduce a suspected diagnosis of FND to patients in the ED, while emphasizing the need for a comprehensive neurological evaluation. Physical and occupational therapy may be useful adjunct assessments in some individuals. Notably, clinicians in the ED setting are important members of the interdisciplinary approach to FND.While the clinical history is nonspecific for a diagnosis of FND, certain clues may help raise one's index of suspicion. 15 With regard to FND overall (including functional weakness,

Assessment of Emergency Department and Inpatient Use and Costs in Adult and Pediatric Functional Neurological Disorders

“…Inpatient admissions for FNDs had shorter hospital stays but often higher workup rates than those of other neurological disorders. The ED 21 and inpatient 22 management of FNDs require multidisciplinary management, including neurological assessment, trained physical therapy, occupational therapy, and speech and language pathology management and, when necessary, psychiatric care. However, data in the present study show a low level of these needed inpatient rehabilitation services and psychiatric management for patients with FNDs despite high levels of psychiatric diagnoses, particularly in children.…”

“…This observation suggests that delivery of the optimum FND care may not be occurring appropriately in the inpatient setting. 21,22 Of concern, approximately 1% of adult patients with FNDs (vs 3% with other neurological disorders) died during their hospitalization. Although the cause of death cannot be ascertained from the data, this finding is surprising and requires further investigation to assess if it may be associated with other medical comorbidities or iatrogenic harm.…”

“…However, data in the present study show a low level of these needed inpatient rehabilitation services and psychiatric management for patients with FNDs despite high levels of psychiatric diagnoses, particularly in children. This observation suggests that delivery of the optimum FND care may not be occurring appropriately in the inpatient setting . Of concern, approximately 1% of adult patients with FNDs (vs 3% with other neurological disorders) died during their hospitalization.…”

Recognising and explaining functional neurological disorder

“…Functional disorders are conditions whose origin arises primarily from a disorder of nervous system functioning rather than clearly identifiable pathophysiological disease—such as irritable bowel syndrome, fibromyalgia, and functional neurological disorder (FND)—they are the second commonest reason for new neurology consultations 1. FND is common in emergency settings,2 stroke,3 and rehabilitation services 4. It causes considerable physical disability and distress, and often places an economic burden both on patients and health services 5.…”

Ätiopathogenese und Behandlung von Funktionellen Neurologischen Störungen mit Fokus auf Funktionelle (Dissoziative) Anfälle

“…Manche Patienten mit leichten und neu aufgetretenen Beschwerden bedürfen lediglich einer versichernden Rückmeldung, dass keine ernsthafte Erkrankung vorliegt und dass die Beschwerden selbstlimitierend sind [90]. Patienten mit ausgeprägten Defiziten werden häufig in Notfallambulanzen vorstellig und/oder stationär diagnostiziert und beginnend behandelt [106,107]. Im initialen stationären Kontext ist die Zusamme-narbeit mit dem psychosomatischen bzw.…”