Functional Neurological Disorder Lorraine Azam Advanced Clinical Practitioner

Functional Neurological Disorder Lorraine Azam Advanced Clinical Practitioner Salford Royal Stroke Service 4 th March 2020

Another Stroke mimic?

What’s in a name? FND Non-epileptic attack disorder NEAD Functional neurological disorder Psychogenic movement disorder Hysteria Somatisation Functional motor disorder Psychosomatic Malingering Psychogenic disorder Functional neurological symptom disorder Medically unexplained Non-organic Conversion disorder FMD Dissociative symptoms Dissociative disorder

“Functional neurological disorder (FND) is a medical condition in which there is a problem with the functioning of the nervous system and how the brain and body sends and/or receives signals, rather than a structural disease process such as multiple sclerosis or stroke. FND can encompass a wide variety of neurological symptoms, such as limb weakness or seizures. ” (https: //rarediseases. org/rarediseases/fnd/)

How would you diagnose FND?

Diagnosis: the evidence Positive features from the history and examination (Stone, 2015) Hoovers test The history taking and examination requires a skilled clinician (Stone, 2015; Mc. Kee et al. , 2018) Not a diagnosis of exclusion (Healthcare Improvement Scotland, 2012; Rommelfanger et al. , 2017) clear and empathetic way as this alone may be enough to improve symptoms (Saifee et al. , 2012) “Drain the symptoms dry” (Stone, 2015)

How would you describe FND to a patient?

Positives and negatives THE SYMPTOMS ARE GENUINE POSITIVE NATURE OF DIAGNOSIS (NOT EXCLUSION) FND CAN IMPROVE LINK OF THE BRAIN AND MIND PATIENT LED TIME AVOID “ALL RELATED TO STRESS”

How do you treat FND?

Stepped care approach NHS Scotland (2012) Stepped care for functional neurological symptoms: A new approach to improving outcomes for a common neurological problem in Scotland.

The evidence for treatment • MDT essential (Mc. Kee et al. , 2018; Richardson et al. , 2018) • Reinforce normal findings (Stone, 2015) • Inpatient and outpatient • Five days intensive input (Nielsen et al. , 2015) • Brief, intensive, specialist interventions can be more effective (Pleizier et al. , 2017) • Physiotherapy - education component, exploration of the symptoms, retraining movement with redirection of attention and developing a self-management strategy with patients having eight physiotherapy sessions (Nielsen study) • Neuropsychology as required

Patient Resources • • SRFT patient leaflet https: //fndhope. org/ https: //www. neurosymptoms. org/ http: //www. nonepilepticattacks. info/ https: //rarediseases. org/rare-diseases/fnd/ https: //www. fndaction. org. uk/ https: //www. fndsociety. org/

The journey so far…. Psychiatric? Neurology? Stroke? Old idea – it’s all psychological Centralisation Pathway (stroke, neurology, psychiatry, medical, general? )

Training and education • MDT approach [Mc. Cormack et al (2013), Nielsen et al (2017), Richardson et al (2018)] • Stroke and Neurology • Inpatient and Community • Develop ownership of the condition within speciality [Rommelfanger et al (2017)] • Patient led care [Nielsen et al (2017), Richardson et al (2018)]

References • Healthcare Improvement Scotland. (2012). Stepped care for functional neurological symptoms: A new approach to improving outcomes for a common neurological problem in Scotland. Retrieved from www. healthcareimprovementscotland. org • Mc. Cormack, R. , Moriarty, J. , Mellers, J. D. , Shotbolt, P. , Patena, R. , Landes, N. , …. David, A. S. (2013). Specialist inpatient treatment for severe motor conversion disorder: a retrospective comparative study. Journal of Neurology, Neurosurgery & Psychiatry, 85, 893 -98. • Mc. Kee, K. , Glass, S. , Adams, C. , Stephen, C. D. , King, F. , Parlman, K. , … Kontos, N. (2018). The inpatient assessment and management of motor functional neurological disorders: An interdisciplinary perspective. Psychosomatics, 59, 358 -68. • Nielsen, G. , Buszewicz, M. , Stevenson, F. , Hunter, R. , Holt, K. , Dudziec, M. , … Edwards, M. J. (2017). Randomised feasibility study of physiotherapy for patients with functional motor symptoms. Journal of Neurology, Neurosurgery & Psychiatry, 88, 484 -90. • Pleizier, M. , De Haan, R. J. , & Vermeulen, M. (2017). Management of patients with functional neurological symptoms: a single-centre randomised controlled trial. Journal of Neurology, Neurosurgery & Psychiatry, 88, 430 -36. • Richardson, M. , Isbister, G. , & Nicholson, B. (2018). A novel treatment protocol (nocebo hypothesis cognitive behavioural therapy; NH-CBT) for functional neurological symptom disorder/conversion disorder: A retrospective consecutive case series. Behavioural and Cognitive Psychotherapy, 46, 497 -503. • Rommelfanger, K. S. , Factor, S. A. , La. Roche, S. , Rosen, P. , Young, R. , & Rapaport, M. H. (2017). Disentangling stigma from functional neurological disorders: Conference report and roadmap for the future. Frontiers in Neurology, 8, 106, 1 -7. doi: 10. 3389/fneur. 2017. 00106 • Saifee, T. A. , Kassavetis, P. , Parees, I. , Kojovic, M. , Fisher, L. , Morton, L. , … Edwards, M. J. (2012). Inpatient treatment of functional motor symptoms: a long-term follow-up study. Journal of Neurology, 259, 1958 -63.