You’ve made the diagnosis of functional neurological disorder: now what?

Abstract

Patients with functional neurological disorders (FND)/conversion disorder commonly present to outpatient clinics. FND is now a 'rule in' diagnosis based on neurological examination findings and semiological features. While neurologists may be more comfortable diagnosing patients with FND, there is only limited guidance as to how to conduct follow-up outpatient visits. Using clinical vignettes, we provide practical suggestions that may help guide clinical encounters including how to: (1) explore illness beliefs openly; (2) enquire longitudinally about predisposing vulnerabilities, acute precipitants and perpetuating factors that may be further elucidated over time; (3) facilitate psychotherapy engagement by actively listening for potentially unhelpful or maladaptive patterns of thoughts, behaviours, fears or psychosocial stressors that can be reflected back to the patient and (4) enquire about the fidelity of individual treatments and educate other providers who may be less familiar with FND. These suggestions, while important to individualise, provide a blueprint for follow-up FND clinical care.

Twisted in Pain: The Multidisciplinary Treatment Approach to Functional Dystonia

“…[33][34][35] While the above components are core aspects of treatment, the identification of patient-specific predisposing vulnerabilities, acute precipitants, and perpetuating factors should be elucidated to help individualize treatments with these factors in mind. 36 In this case, predisposing vulnerabilities included early-life separation anxiety, dyslexia with academic difficulties, bullying at school, tendency to not verbalize stress and affective symptoms to supports, and the concurrent presence of another functional somatic disorder (irritable bowel syndrome). In the presented case, dystonia and pain symptoms occurred abruptly and spontaneously, though in the literature a minor physical injury has sometimes been described as precipitating onset of some FND presentations.…”

Telling me you don’t know is ok, but not explaining functional neurological disorder is not

“…Two of us (JC, TN) run specialist clinics for functional neurological disorders and one of us (KH) is the chief executive officer of a related charity (FND Action). We agree that a diagnosis of functional neurological disorder is sometimes made but not explained in a way that optimises patient understanding and acceptance of a complex disorder 2…”

<p>Towards an Outpatient Model of Care for Motor Functional Neurological Disorders: A Neuropsychiatric Perspective</p>

“…Lastly, we discuss the physician’s role in longitudinal follow-up. 27 , 28 While recent publications have suggested that specialized FND clinics should be integrated within neurology departments to aid patient care (a sentiment we support), 29 high prevalence rates suggest that both specialized tertiary care centers and community-based care will be needed to meet the needs of this prevalent patient population. As such, clinicians across the clinical neurosciences should develop proficiency in the outpatient assessment and management of mFND.…”

“… 42 , 75 Pictorial illustrations demonstrating useful approaches to the delivery of the diagnosis and follow-up discussions have been published and are helpful educational resources. 28 , 42 …”

“…We would like to highlight that while the neurologist or neuropsychiatrist member of the team may not be performing psychotherapy, follow-up visits are primed to catalyze psychological insights by helping the patient make connections between neurological symptoms, thoughts, behaviors, emotions and life factors. 27 , 28 When such connections are uncovered, this can also be a nice segue into asking the patient to follow-up with their psychotherapist on these themes. To be clear, apart from referrals to physiotherapy for motor retraining and a psychotherapist for CBT, a physician lead must remain actively involved in longitudinal care and collaborating with other members of the treatment team to ensure consistent and coordinated care.…”