Functional NeurologyWhat’s it all about?

Dr Naomi Warren

Content Background Clinical presentations Investigations Management Future aims

Background

Historically: hysteria (the “wandering womb”) conversion disorders dissociative disorders psychogenic medically unexplained non-organic psychosomatic functional

Functional symptomsCommon… 15% new outpatient neurology 1-10% of inpatient neurology admissions 50% of “status epilepticus” 10% of “first fits” 5% of movement disorders

Patients are just as distressed as patients with disease

Not specific to Neurology...Speciality SymptomCardiology non-cardiac CP

Gastroenterology IBS

Respiratory chronic cough

Renal/gynae recurrent loin/pelvic pain

Surgery chronic abdominal pain

Rheumatology fibromyalgia chronic fatigue syndrome

Case 1 16 yr old girl – sporty Ankle injury 2/52 previous 4/52 right weakness leg 3/7 jerking body movements – intermittent o/e – dragging R leg behind her On bed – no movement R leg +ve Hoover’s sign Reflexes normal Episode jerking body – 2 mins

Hoover’s sign

Case cont…. Explained

Functional Not seizure

Denied stresses initially Parents – due to leave UK stress

Treatment Physio Snowboarding!! www.neurosymptoms.org

Good outcome

Functional weakness Half sudden onset Often with pain Examination

Look for inconsistencies bed/day to day

Hoovers sign Odd pattern Giving way Dragging leg Ass hemi sensory loss

Functional gait disorders gait disorders

dragging leg crouching gait tightrope gait without falling

Rhombergs Wibble and wobble but don’t fall down

Case 2 34 yr old R handed woman FT administrator Sudden onset tremor right hand 4 days

previous Present constantly No previous history

video

Functional movement disorders

Can be more difficult to identify

Mostly sudden onset Eg after injury

Tremor Disappears with distraction, entrainment,

variable

Other mvmt disorders - rarer Dystonia

Fixed, often painful Beware - often organic disease looks unusual

Myoclonus often axial

Tics

Non-epileptic attacks

Aura Not stereotyped Variable time

Attack Violent Long/multiple Violent No “tonic” phase Fast resp

Post ictal Crying No true confusion

• Not helpfulIncontinenceInjuries

• Some helpTongue biting - lateral

Other functional presentations Cognitive decline

subjective cognitive problems although can usually give a very clear account of themselves

Visual loss tunnel vision or blindness with preserved pupil reflexes and

optico-kinetic nystagmus Globus Dysphonia

Investigations? Minimal tests Often need MRI in weakness

Reassure pt/docs ?functional overlay

Explain You think the tests will be normal Incidental findings

Video EEG in seizures

Management Explanation

Key Psychiatry/ology

To help manage symps CBT

Antidepressants Physio Pain team www.neurosymptoms.

org

Give diagnosis Tell what don’t have Mechanism Understanding Emphasise common Reversible “stress/mood makes it

worse” Self help Consistency

PrognosisGood Bad

Acceptance Strong belief permanent

Young age Long history

Short history Delayed diagnosis

Lack other symps Anger at diagnosis

Change in marital status after diagnosis

Multiple other symps

Anx/depression Pampering carer

Helpful family Personality disorder

Financial benefit

Primary + secondary care aims To understand/believe the condition To provide swift diagnosis To give a consistent message

(limit 2nd opinions) To give appropriate psychological and

physical therapies

Unless self limiting and clearly functional – refer to neurology

Conclusion Very common problem in neurology Huge cause disability Needs swift investigation and mgmt Careful explanation Appropriate psychological help

Questions?