The Inpatient Assessment and Management of Motor Functional Neurological Disorders: An Interdisciplinary Perspective

McKee, Kathleen; Glass, Sean; Adams, Caitlin; Stephen, Christopher D.; King, Franklin; Parlman, Kristin; Perez, David L.; Kontos, Nicholas

doi:10.1016/j.psym.2017.12.006

Cited by 45 publications

(51 citation statements)

References 71 publications

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“…Key points to emphasize in the effective communication about the diagnosis of FND include (1) discussing the suspected diagnosis based on clinical examination; (2) providing a clear name for the condition (e.g., FND); (3) discussing with patients that this condition is common, real, and treatable. 10,36,78 It may be useful to explain to the patient in simple terms the physical exam findings that led to the diagnosis, as is illustrated in our case with Mrs. A. If successful, this communication helps ensure the patients feel validated about their symptoms or functional limitations, rather than feeling unheard by providers.…”

Section: Communicating a "Suspected" Fnd Diagnosismentioning

confidence: 96%

“…Patients with FND may also suffer from other functional medical comorbidities, including irritable bowel syndrome, chronic fatigue, fibromyalgia, and other chronic pain disorders. 10 Neurologic comorbidities may include intellectual disability, history of mild traumatic brain injury (TBI), or epilepsy, among others. Psychiatric comorbidities may include depression, anxiety (generalized anxiety disorder or panic disorder), posttraumatic stress disorder, and personality disorders.…”

Section: Vignette-mrs a (Initial Presentation And Evaluation)mentioning

confidence: 99%

“…As vibration is conducted through bone, if vibration sensation is tested on the forehead or the sternum, in general it should be perceived evenly on both sides. This test is sensitive (73.1- 6 McKee et al, 10 Stone and Carson, 15 and Daum et al 38 99.7%) but not very specific (7.3-23.7%) 39,42,43 and the phenomenon has been identified in other rare neurologic conditions (ischemic or hemorrhagic stroke involving ventroposterior thalamus, 44,45 corona radiata, 46 paramedian dorsolateral pons, 47 lenticulocapsular region, 46,48 and parietal lobe 49 ); therefore, it should be used with caution. 43 Nonanatomical (dermatomal) sensory loss is a heterogeneous phenomenon in which patterns of patient's sensory loss do not fit a known neuroanatomical distribution.…”

Section: Functional Sensory Deficitsmentioning

confidence: 99%

“…However, FND is no longer a "diagnosis of exclusion" due to the emergence of specific physical signs and semiologic features which can be screened for and recorded during routine bedside clinical examinations. [8][9][10] The Diagnostic and Statistical Manual of Mental Disorders was revised for its fifth edition (DSM-5) in 2013 to emphasize identifying positive features, predominantly on neurological examination, that are typical of FND. 9 This revision also dropped the requirement of an acute (proximal) psychological stressor, which may not be consistently identifiable or present.…”

mentioning

confidence: 99%

“…There are many nuances to the neurobiopsychosocial formulation of FND that are beyond the scope of the ED setting (briefly discussed later and elsewhere 10 ). Nevertheless, some FND patients have low adherence rates to appropriate outpatient referrals, raising the need for emergency physicians and allied clinicians to remain informed of the latest clinical understanding of FND and to advance an interdisciplinary approach to the assessment and acute management of FND.…”

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confidence: 99%

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

et al. 2019

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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,

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Section: Communicating a "Suspected" Fnd Diagnosismentioning

confidence: 96%

Section: Vignette-mrs a (Initial Presentation And Evaluation)mentioning

confidence: 99%

Section: Functional Sensory Deficitsmentioning

confidence: 99%

mentioning

confidence: 99%

mentioning

confidence: 99%

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

et al. 2019

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

et al. 2021

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How Is Functional Neurological Disorder Managed in Australian Hospitals? A Multi‐Site Study Conducted on Acute Inpatient and Inpatient Rehabilitation Wards

Petrie

Lehn

Barratt

et al. 2023

Movement Disord Clin Pract

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Background Successful management for functional neurological disorder (FND) requires multidisciplinary involvement starting with providing a definitive diagnosis. Objectives To observe clinical management of patients with FND during hospital admission. Methods A prospective observational study was conducted over six Australian hospitals over a 4‐month period. Data collected included patient demographics, communication of the diagnosis of FND, access to the multidisciplinary team, hospital length of stay (LOS), and emergency department (ED) presentations. Results A total of 113 patients were included. Median LOS was 6 (interquartile range, 3–14) days. Thirty‐five (31%) presented to ED with 9 (8%) re‐presenting two or more times after hospital discharge. Total hospital utilization cost was AUD$3.5million. A new diagnosis was made in 82 (73%) patients. Inpatient referrals were made to neurology (81, 72%), psychology (29, 26%), psychiatry (27, 24%), and physiotherapy (100, 88%). Forty‐four (54%) were not told of the diagnosis. Twenty (24%) did not have their diagnosis documented in their medical record. Of the 19 (23%) not reviewed by neurology on non‐neurosciences wards, 17 (89%) did not have their diagnosis communicated and 11 (58%) did not have it documented. Twenty‐five (42%) referred to neurology were not provided with a diagnosis. Conclusions Current gaps in service provision during inpatient hospital admissions in Australia include low rates of communication of a diagnosis, particularly when patients are not located on a neurosciences ward, and limited and variable access to inpatient multidisciplinary teams. Specialized services are needed to improve education, clinical pathways, communication, and health outcomes while reducing healthcare system costs.

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The Inpatient Assessment and Management of Motor Functional Neurological Disorders: An Interdisciplinary Perspective

Cited by 45 publications

References 71 publications

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

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

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

How Is Functional Neurological Disorder Managed in Australian Hospitals? A Multi‐Site Study Conducted on Acute Inpatient and Inpatient Rehabilitation Wards

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