Opinions and clinical practices related to diagnosing and managing functional (psychogenic) movement disorders: changes in the last decade.

BACKGROUND AND PURPOSE: There is large variability in the diagnostic approach and clinical management in functional movement disorders (FMD). This study aimed to examine whether opinions and clinical practices related to FMD have changed over the past decade. METHODS: Adapted from a 2008 version, we repeated the survey to members of the International Parkinson and Movement Disorder Society (MDS). RESULTS: In all, 864/7689 responses (denominator includes non-neurologists) were received from 92 countries. Respondents were more often male (55%), younger than 45 (65%) and from academic practices (85%). Although the likelihood of ordering neurological investigations prior to delivering a diagnosis of FMD was nearly as high as in 2008 (47% vs. 51%), the percentage of respondents communicating the diagnosis without requesting additional tests increased (27% vs. 19%; P = 0.003), with most envisioning their role as providing a diagnosis and coordinating management (57% vs. 40%; P < 0.001). Compared to patients with other disorders, 64% of respondents were more concerned about missing a diagnosis of another neurological disorder. Avoiding iatrogenic harm (58%) and educating patients about the diagnosis (53%) were again rated as the most effective therapeutic options. Frequent treatment barriers included lack of physician knowledge and training (32%), lack of treatment guidelines (39%), limited availability of referral services (48%) and cultural beliefs about psychological illnesses (50%). The preferred term for communication favored 'functional' over 'psychogenic' (P < 0.001). CONCLUSIONS: Attitudes and management of FMDs have changed over the past decade. Important gaps remain in access to treatment and in the education of neurologists about the inclusionary approach to FMD diagnosis.

Neural activity in functional movement disorders after inpatient rehabilitation.

Functional movement disorders (FMD) are a common source of disability in neurology.While treatment of FMD can reduce motor severity and disability, the neural mechanisms implicated in such a response remain unclear. We aimed to investigate neural changes in patients with FMD after a one-week multidisciplinary motor retraining (MoRe) treatment program. Fourteen FMD patients completed an emotional Go/No-Go fMRI task before and after MoRe treatment. Standardized pre- and post-treatment videos were rated for motor severity by a blinded reviewer using the psychogenic movement disorder rating scale (PMDRS). PMDRS scores before and after treatment were used for whole-brain regression. PMDRS scores were significantly reduced after MoRe treatment. Worse severity prior to treatment was associated with greater primary motor cortex (M1) activation at baseline and a larger response to treatment. Globally, increased connectivity between bilateral amygdala and premotor regions was observed following treatment. Lower post-treatment PMDRS scores were associated with increased connectivity between amygdala and ventromedial prefrontal cortex, whereas higher post-treatment PMDRS scores (and poorer treatment response) were associated with increased connectivity between amygdala and M1. Motor retraining in FMD may reorganize activity and connectivity in emotion processing and motor planning networks, with shifts in amygdala connectivity from posterior to frontal/prefrontal regions.

Inpatient treatment for functional neurologic disorders.

Patients with functional neurologic disorders present to clinicians with a variety of symptomatic manifestations, with various levels of severity, chronicity, and comorbidity, as well as with various degrees of past adversity, intrinsic resilience, and available external support. Clearly, treatment must be individualized. For those patients who have been severely or chronically impaired, especially if adequate prior outpatient treatments have failed, inpatient treatment that integrates the various modalities outlined here provides a rational route of rescue from a course otherwise potentially characterized by protracted dependence and disability. Based on the data currently available, we believe this treatment approach is worthy of further study to refine the component treatment strategies and enhance the potentially most effective ingredients. For patients with severe levels of disability, who could be managed in a multimodal day-treatment program, that approach also warrants further consideration.

The "floating door sign" in Parkinson's disease.

Individuals with Parkinson's disease (PD) display micrographia. We report a new method to elicit micrographic drawing in individuals with PD and compare this to drawing in individuals with essential tremor (ET). We asked 81 individuals with PD and 19 individuals with ET to draw a house and write a sentence. We examined house height and whether vertical lines of the door connected to the house floor. If both vertical door lines failed to reach the floor by more than 1mm we designated this a "floating door sign". House height of <5 cm and letter height of <5 mm were considered micrographic drawing and writing. 45 of 81 PD patients displayed a "floating door sign" compared with only 4 of 19 ET patients (p = 0.0103). 24 of 81 PD patients compared with 1 of 19 ET patients had micrographic writing (p = 0.0224). 60 of 81 PD patients compared with 9 of 19 ET patients had micrographic drawing (p = 0.00526). The "floating door sign" correlated with micrographic writing (p = 0.0275) but not micrographic drawing. The "floating door sign" had a positive predictive value for PD but not ET. We believe it correlates with hypometeric hand movements which cause inadequate stroke size, a phenomenon described in PD.