Anger regulation in patients with functional neurological disorder: A systematic review.

BACKGROUND: Functional neurological disorder (FND) has been associated with predisposing psychological factors, including dysregulation of anger-related processes. This paper provides a systematic review of the literature on anger regulation in FND. We evaluated anger-related research on patient self-report, observational, and laboratory based measures in FND. The review also addresses adverse childhood experiences and their relation with anger regulation, and the effects of therapies targeting anger regulation in FND. METHODS: MEDLINE, EMBASE, and PsycINFO were searched for both quantitative and qualitative research, published in a peer-reviewed journal with a sample size of at least 5 (registered under Prospero protocol CRD42022314340). RESULTS: A total of 2200 articles were identified. After screening, 54 studies were included in this review (k = 20 questionnaire-based studies, k = 12 laboratory studies, k = 21 using other methods, and k = 1 used both questionnaires and other methods) representing data of 2502 patients with FND. Questionnaire-based studies indicated elevated levels of state anger and trait hostility in patients with FND. Laboratory studies showed a higher tendency to avoid social threat cues, attentional bias towards angry faces, difficulties reliving anger, and preoccupation with frustrating barriers among FND patients versus controls. No specific childhood experiences were identified related to anger regulation in FND, and too few small and uncontrolled studies were available (k = 2) to assess the effects of anger-related interventions in FND. The overall quality of the studies was fair (k = 31) to poor (k = 18). Five studies (k = 5) were rated as having a good quality. CONCLUSIONS: This review suggests that patients with FND have maladaptive anger regulation compared to individuals without FND. The findings also highlight the need for further research on the prevalence and consequences of anger-related processes in the development, diagnosis and treatment of FND.

[Conversion disorder, caring for body, mind]. / Le trouble de conversion, prendre soin du corps et de l'esprit.

Conversion disorder is a psychiatric disorder whose clinic and management lie at the crossroads between body and mind. It challenges healthcare professionals in terms of diagnosis, further investigation, referral and care. A number of questions arise, such as how caregivers perceive the relationship between body and mind, the place of the psychiatric hypothesis among the initial diagnostic hypotheses, and the temporality of care.

Papel del servicio de prevención en el diagnóstico de la patología mental para una adecuada integración laboral / Role of the prevention service in the diagnosis of mental pathology for an adequate occupational integration

Las enfermedades mentales tienen especial relevancia tanto por su elevada prevalencia en el momento actual como por sus consecuencias en diferentes ámbitos de la vida. En este artículo se presenta un caso clínico de un trabajador diagnosticado de trastorno conversivo que es evaluado por parte del servicio de prevención con el fin de establecer la aptitud laboral. El conocimiento de la clínica, diagnóstico y abordaje de estos trastornos conjunta y coordinadamente por el servicio de prevención de riesgos labores, mandos directos y otros especialistas es el pilar fundamental para conseguir una adecuada adaptación del puesto de trabajo, así como una integración laboral siempre que se cumplan las restricciones especificadas en el informe de aptitud. (AU)

Mental illnesses are particularly relevant both because of their high prevalence at the present time and because of their consequences in different areas of life. This article presents a clinical case of a worker diagnosed with conversion disorder who is evaluated by the prevention service in order to establish work aptitude. Knowledge of the clinic, diagnosis and approach to these joint and coordinated disorders by the occupational risk prevention service, direct managers and other specialists is the fundamental pillar to achieve an adequate adaptation of the job, as well as labor integration whenever the restrictions specified in the suitability report are met. (AU)

[The historical diagnosis of 'hysterical scoliosis']. / Die historische Differenzialdiagnose der 'hysterischen Skoliose'.

BACKGROUND: Until the beginning of the 20th century, 'hysterical scoliosis' could be considered an established diagnosis in Middle Europe's German-speaking countries. The responsible physicians claimed that certain cases of scoliosis were caused solely by psychological factors, and they did not distinguish between real scoliosis (e.g. with neuromuscular cause) and abnormal posture caused by psychological reasons. Instead, 'hysterical scoliosis' was obviously believed to be a real scoliosis caused by psychologically induced contractures. OBJECTIVE: This study critically discusses the historical diagnosis 'hysterical scoliosis' from today's point of view. MATERIALS AND METHODS: This work is based on historical research (including journals and literature) approximately from the time around 1900. Furthermore, it is also based on recently discovered original material. RESULTS: The original material is a correspondence between H. Schlesinger and G. Muskat, who published an article about 'hysterical scoliosis' in Schlesinger's journal. CONCLUSIONS: Obviously, the underlying medical concepts of 'hysterical scoliosis' were wrong and led to clear diagnostic problems and inaccuracies. 'Hysterical scoliosis' can be considered one of adolescent psychiatry's early fashionable illnesses around the year 1900.

Functional neurological disorder: A common reason for a neurology inpatient referral.

BACKGROUND AND PURPOSE: In 2021, the European Academy of Neurology's training requirements were updated to include functional neurological disorder (FND) as a core topic for the first time. To reinforce these changes, we aimed to understand the proportion of inpatients (in non-neurology settings) who are diagnosed with FND. METHODS: We prospectively collected data on diagnoses made after inpatient ward reviews from neurology trainees at three tertiary neurology centres in Scotland from April to September 2021. We assessed healthcare utilization data for patients with a diagnosis of FND, epilepsy and epileptic seizures, or a neuroinflammatory disorder over the preceding 12 months. RESULTS: There were 437 inpatient reviews for 424 patients by 13 trainees. The largest single diagnosis was FND (n = 80, 18%), followed by epilepsy (n = 64, 14%), primary headache disorder (n = 40, 9%) and neuroinflammatory disorders (n = 28, 6%). There was an uncertain diagnosis for 48 reviews (11%). Compared to patients with epilepsy or neuroinflammatory disorders, patients with FND had a similar number of admissions (2 vs. 2 vs. 1) and brain/spine imaging studies (2 vs. 1 vs. 2). CONCLUSIONS: In Scotland, FND was the most common diagnosis made after a request for an inpatient review by a neurologist from another department in the hospital. Patients with FND have similar health resource needs to those with other common neurological disorders when they present to hospitals with tertiary neurology centres. This data supports the inclusion of FND as a core curriculum topic in neurology training.

Consultation-Liaison Case Conference: A Case of Factitious Disorder Imposed on Self.

We present the case of a young woman with an extensive medical history that most notably includes over 60 emergency-room visits for unfounded respiratory distress that often prompted intubations. Each presentation displays elements of deceitfulness or inappropriate demands that align with factitious disorder imposed on self. Top experts in the Consultation-Liaison field provide guidance for this commonly encountered clinical case based on their experience and review of available literature. Key teaching topics include a review of risk factors for development of deceptive syndromes, distinguishing factitious disorder from malingering and conversion disorder, and the role of a consulting psychiatrist in such cases. Patients with factitious disorder often show signs of pathologic lying, obstinance, and erratic behavior. Such attributes frequently arouse negative countertransference in providers, causing frustration and dread with continuing care, rendering psychiatric involvement. We address the unique challenges in managing factitious disorder and how to effectively collaborate with an interdisciplinary inpatient team with these cases.

[Validated care programs for patients with functional neurological disorders]. / Modèles de soins validés pour les patients souffrant de troubles neurologiques fonctionnels.

Functional neurological disorder (FND) is a common cause of persistent and disabling neurological symptoms. Diagnostic delay may lead to no treatment, inappropriate treatment or even iatrogenic symptoms. Yet, several treatments significantly reduce physical symptoms and improve functioning in FND patients even though not all patients respond to the currently available treatments. This review aims to describe the range of evidence-based rehabilitative and/or psychological therapeutic approaches available for FND patients. The most effective treatments are multidisciplinary and coordinated; using an outpatient or inpatient setting. Building a network of FND-trained healthcare professionals around the patient is an essential aspect of optimal patient management. Indeed, a supportive environment coupled with a collaborative therapeutic relationship improves understanding of FND and appears to help patients engage in appropriate treatments. Patients need to be invested in their own care and have to understand that recovery may depend on their commitment. The conventional treatment combines psychoeducation, physical rehabilitation and psychotherapy (cognitive and behavioral therapy, hypnosis, psychodynamic interpersonal therapy). Early referral of patients to physical therapy is recommended; however, the optimal parameters of treatment, duration and intensity are unknown and seem to vary with the severity and chronicity of symptoms. The goal is to minimize self-awareness by diverting attention or by stimulating automatically generated movements with non-specific and gradual exercises. The use of compensatory technical aids should be avoided as much as possible. Psychotherapeutic management should encourage self-evaluation of cognitive distortions, emotional reactions and maladaptive behaviors while empowering the patient in managing symptoms. Symptom management can use anchoring strategies to fight against dissociation. The aim is to connect to the immediate environment and to enrich one's sensoriality. The psychological interventions should then be adapted to the individual psychopathology, cognitive style and personality functioning of each patient. There is currently no known curative pharmacological treatment for FND. The pharmacological approach rather consists of progressively discontinuing medication that was introduced by default and that could lead to undesirable side effects. Finally, neurostimulation (transcranial magnetic stimulation, transcranial direct current stimulation) can be effective on motor FND.

[Functional neurological disorders and forensic medicine: Clinical and practical characteristics]. / Troubles neurologiques fonctionnels et expertise médico-légale : aspects cliniques et pratiques.

Functional neurological disorders (FND) have long been a challenge for medicine, both on clinical and psychodynamic point of view. The medico-legal issue is often relegated to the background in medicine, and FND patients also suffer from such neglected topic. Nonetheless, despite the difficulty to properly diagnose FND and the numerous associated organic and/or psychiatric comorbidities, FND patients report a significant level of deficiency and a high alteration of quality of life when compared to other well-recognized chronic disorders such as Parkinson's disease or epilepsy. Whether it is for the estimation of a personal injury, a prejudice, after-effects following a medical accident or certain legal contexts requiring the elimination of a factitious disorder or a simulation, the uncertainty and imprecision in the medico-legal assessment can imply notable consequences on the patient. In this article, we propose to define the different medico-legal contexts in which FND can occur that of the legal expert, that of the consulting physician, that of the so-called recourse physician and finally that of the attending physician who can provide detailed medical files to the patient in order to help him/her in his/her procedures. We then explain how to use standardized objective evaluation tools validated by the learned societies and how to encourage multidisciplinary cross-evaluation. Finally, we specify how to differentiate FND from historically FND-associated disorders (factitious and simulated disorders), through the clinical criteria, considering the difficulties linked to the uncertainty in the clinical examination of these disorders in a medico-legal context. In addition to the rigorous completion of expertise missions, we aim to reduce two damaging consequences characterizing FND: diagnostic delay and the patients' suffering through stigma.

[Overview of care management principles in functional neurological disorders]. / Synthèse des principes et schémas de prise en charge dans les troubles neurologiques fonctionnels.

After more than twenty years of academic research on functional neurological disorders (FND) throughout the world, a standardized care management strategy has emerged to allow a more adapted care offer to patients with FND, as close as possible to their experience and their needs. With regard to this special issue on FND in collaboration with L'Encéphale and at the initiative of the Neuropsychiatry section of the AFPBN (French Association of Biological Psychiatry and Neuropsychopharmacology), we would like to suggest a summary of all topics discussed in more detail in each article of this special issue, in order to facilitate its reading. We therefore cover the following themes: the initial contact with a patient with FND, the diagnostic process in favor of a positive diagnosis, the physiological, neural and psychological basis of FND, the diagnostic announcement (and its intangibles), the therapeutic patient education in FND, the general principles of therapeutic management through a personalized and multidisciplinary care program, and the validated therapeutic tools available according to the symptoms identified. This article is designed to be of broad interest on FND, supported by tables and figures showing the key points of all these steps, to keep an educational purpose at most. We hope that through this special issue, each health professional will be able to grasp this knowledge and this framework of care as easily and quickly as possible, in order to participate in the standardization of the care offer.

[Diagnostic criteria, epidemiology and assessment of patients with functional neurological disorders]. / Définitions, épidémiologie et démarche diagnostique clinique dans les troubles neurologiques fonctionnels.

Functional neurological disorders (FND) are symptoms that can affect a variety of functions including motor, sensory and cognitive. These symptoms are genuinely experienced by the patient and are related to a functional disorder rather than a structural one. There is little epidemiological data on these disorders, but their frequency is well established in clinical practice, it is the second most frequent reason for consultation in Neurology. Despite of the frequency of the disorder, general practitioners and specialists are insufficiently trained in the disease, and patients often suffer from stigmatization and/or unnecessary investigations. It is therefore important to be aware of the diagnostic approach to FND, which mostly relies on positive clinical signs. Psychiatric evaluation can help with the characterization of predisposing, precipitating and perpetuating factors of the symptoms (according to the 3P biopsychosocial model related to FND), and guide their management. Finally, diagnosis explanation is a crucial step in the management of the disease, which can in itself have a therapeutic effect, and allow the patient to adhere to the treatments.

Subjective seizure symptom reporting in functional/dissociative seizures and epilepsy: Effects of sampling technique and patient characteristics.

BACKGROUND: Differences in subjectively reportable ictal experiences between epilepsy and functional/dissociative seizures (FDS) have received less attention than visible manifestations. Patients with FDS (pwFDS) tend to report seizure symptoms differently than patients with epilepsy (pwE). The effects of symptom elicitation method and mediation by psychopathological traits have not been examined and may aid in differentiating the disorders. METHOD: Analysis of responses of 24 pwE and 28 pwFDS in interviews exploring ictal experiences through open questioning followed by structured closed questioning using possible symptom prompts (74-item modified Psychosensory-Psychomotor Phenomena Interview, PPPI); self-report of psychological profile (HADS-A, HADS-D, PHQ-15, DES-T, THQ, PCL-C). RESULTS: Symptom prompting with PPPI elicited three times more seizure symptoms than open questions in pwE (median 34 vs. 11.5, p = 0.005) and over four times more in pwFDS (42.5 vs. 11, p = 0.001). Intra-ictal symptoms were reported freely more frequently by pwE (median 6.5 vs. 4, p = 0.005), while pwFDS reported more pre-ictal symptoms after prompts (median 6 vs 14.5, p = 0.004). The difference between freely reported and PPPI-elicited symptoms correlated with different psychopathological traits in pwE and pwFDS. Symptoms of anxiety (HADS-A) correlated more strongly with prompted symptoms among pwE than pwFDS (z = 2.731, p = 0.006). CONCLUSION: Prompting generates more detailed ictal symptom profiles than simply encouraging patients to narrate their subjective seizure experiences. While pwFDS freely reported fewer symptoms related to the intra-ictal period compared to pwE, pwFDS reported more pre-ictal symptoms than pwE when prompted. Differences in the psychopathological traits associated with the number of peri-ictal symptoms captured by symptom prompting in pwE and pwFDS possibly reflect etiological or psychological differences between these patient groups.

Biopsychosocial complexity in functional neurological disorder.

BACKGROUND: Functional Neurological Disorder (FND) is considered a biopsychosocial disorder nowadays, with chronicity in >50% of cases. The INTERMED Self-Assessment Questionnaire (IMSA) assesses the various domains and indicates biopsychosocial complexity. OBJECTIVE: FND patients were compared with a sample of psychosomatic (PSM) patients as well as post-stroke patients. METHODS: The three samples (N = 287 altogether) were largely in inpatient and day clinic psychotherapeutic treatment or inpatient neurological rehabilitation. The IMSA covers all three biopsychosocial domains as well as health care utilisation in the time frame of the past, the present and the future. In addition, affective burden (GAD-7, PHQ-9), somatoform symptoms (PHQ-15), dissociation (FDS) and quality of life (SF-12) were evaluated. RESULTS: FND and PSM patients scored highly in the IMSA, with ≥70% regarded as complex, compared to 15% of post-stroke patients. Affective, somatoform and dissociation scores were high in FND and PSM patients. Mental and somatic quality of life were lower in these groups compared to post-stroke patients. DISCUSSION: FND patients showed high biopsychosocial strain, similar to a typical sample of inpatient and day clinic, i.e. severely affected, PSM patients, and they were more affected than post-stroke patients. These data emphasize that FND should be evaluated with a biopsychosocial perspective. The IMSA likely represents a valuable tool, which has to be assessed by further longitudinal studies.

Functional neurological disorder is common in patients attending chronic pain clinics.

BACKGROUND AND PURPOSE: Chronic pain is a common comorbidity in those with functional neurological disorder (FND); however, the prevalence and characteristics of FND in those with chronic pain is unknown. METHODS: A retrospective electronic records review was made of consecutive new patients attending a chronic pain clinic of a regional service. Clinical features, medication for and outcome of chronic pain, any lifetime diagnoses of functional disorders, FND, and psychiatric disorders, and undiagnosed neurological symptoms were recorded. RESULTS: Of 190 patients attending the chronic pain clinic, 32 (17%) had a lifetime diagnosis of FND and an additional 11 (6%) had undiagnosed neurological symptoms. Pain patients with comorbid FND were more likely to have chronic primary pain (88% with FND, 44% without FND, p < 0.0001), widespread chronic primary pain (53%, 15%, p < 0.00001), and depression (84%, 52%, p < 0.005) and less likely to have a pain-precipitating event (19% vs. 56%, p < 0.001). However, there was no significant difference between these patients in opiate prescription, benzodiazepine prescription, or pain outcome. CONCLUSIONS: This first study of FND in a chronic pain patient population found a remarkably high prevalence of FND (17%) and is possibly an underestimation. The size of the overlap indicates that FND and chronic pain research fields are likely to have a lot to learn from each other.

[Functional Neurological Disorders - A Common but Often Unrecognized Diagnosis]. / Funktionelle neurologische Störungen ­ eine häufige, aber häufig nicht erkannte Diagnose.

Functional Neurological Disorders - A Common but Often Unrecognized Diagnosis Abstract: Functional neurological disorders are frequent and diverse in the clinical presentation. Psychological factors are part of the development and perpetuation of symptoms; psychiatric comorbidities may be present, but are not an obligatory diagnostic criterion. The diagnosis is primarily made on the basis of anamnesis and positive clinical signs. The commonness and reversibility of the symptoms should be emphasised in the clinical consultation, and the positive clinical signs should be demonstrated. Science-based explanations as well as the bio-psycho-social model can help patients to understand their diagnosis, which is relevant for a successful therapeutic outcome. It is recommended to use the neutral and descriptive term "functional neurological disorder". Treatment of the potentially reversible disease will be interdisciplinary and multimodal.

Conversion disorder: An integrated care approach.

Knowing how the diagnosis is made and the condition is managed effectively can help FPs fulfill their role in the multifaceted care of these patients.

How to set up a functional neurological disorder education group.

Functional neurological disorder (FND) can be a difficult diagnosis for patients to understand and for clinicians to explain. The postdiagnostic support that patients with other chronic neurological illnesses normally receive is often not available to patients with FND. Here, we share our experience of how to set up an FND education group, including the content, practical aspects of delivering groups and how to avoid potential pitfalls. A group education session can improve understanding of the diagnosis among patients and caregivers, reduce stigma and provide self-management advice. Such groups should be multidisciplinary and include input from service users.

Does explaining psychogenic nonepileptic seizures using either a biomedical or biopsychosocial framework affect young people's illness representations? An experimental vignette study.

Lay representations of psychogenic nonepileptic seizures (PNES) are important both for understanding public stigma and anticipating patient responses to PNES diagnosis. The current study presents the first evidence of the general public's representations of PNES and the malleability of these understandings to different ways of explaining PNES. An online experimental study exposed participants (n = 193, aged 18-25 years) to a vignette describing a case of PNES in biomedical terms, PNES in biopsychosocial terms, or epilepsy. Subsequent questionnaires assessed participants' illness representations, causal attributions, and stigmatising attitudes regarding the case about which they read. Results suggest that compared with biomedical framings, biopsychosocial explanations increased perceptions of PNES as threatening. While epilepsy was attributed to significantly more biological and less social causes than either of the PNES vignettes, causal attributions did not differ between biomedically- vs. biopsychosocially-framed PNES. Neither were there any differences between the three conditions in stigmatising attitudes towards people who experience seizures. These findings are useful for clinicians delivering a PNES diagnosis and patients disclosing a PNES diagnosis, in helping anticipate responses to these communications. Further research is required to confirm the clinical and societal significance of the study's first insights into the dynamics of lay responses to PNES.

Clinician-rated outcomes of patients with functional neurological disorders treated in an outpatient clinic.

BACKGROUND: Patients with functional neurological (conversion) disorder (FND) have historically been difficult to treat. Outcomes have been studied in research trials, documenting improvements; however, limited information is available from a community-treated FND cohort. OBJECTIVES: We aimed to examine clinical outcomes in outpatients with FND treated with the Neuro-Behavioral Therapy (NBT) approach. These uncontrolled setting treatment data could complement more structured clinical studies results. METHODS: We conducted a retrospective chart review of consecutive patients diagnosed with FND, ages 17 to 75, who were treated with the NBT workbook at the Rhode Island Hospital Behavioral Health clinic between 2014 and 2022. NBT consisted of 45-minute, individual, outpatient sessions, in clinic or via telehealth with one clinician. Global Assessment of Functioning (GAF), and Clinical Global Impression (CGI) -Severity, and -Improvement were scored for every appointment. RESULTS: Baseline characteristics are available for 107 patients. Mean age at FND symptom onset was 37 years. Patients had a mix of FND semiologies, which included Psychogenic Nonepileptic Seizures (71%), Functional Movement Disorder (24.3%), Functional Sensory Disorder (14%), Functional Weakness (6.5%), and Functional Speech Disorder (5.6%). Clinical evaluation scores revealed improvements over time. CONCLUSIONS: We describe a well-characterized sample of patients with various and mixed FND semiologies, who received manualized therapy, NBT, in an outpatient clinic. Patients had similar psychosocial profiles to those in clinical studies and displayed improvement in clinical measures. These results demonstrate the practicability of NBT for motor FND semiologies and for PNES, in a "real-world" outpatient practice, extending care beyond structured clinical trials.

Evidence-Based Mind-Body Interventions for Children and Adolescents with Functional Neurological Disorder.

LEARNING OBJECTIVES: • Develop and implement treatment plans for children and adolescents with functional neurological disorder (FND)• Outline a plan to increase awareness and standardize the care for patients with FND using evidence-based interventions. ABSTRACT: Functional neurological disorder (FND) in children and adolescents involves the biological embedding of lived experience in the body and brain. This embedding culminates in stress-system activation or dysregulation and in aberrant changes in neural network function. In pediatric neurology clinics, FND represents up to one-fifth of patients. Current research shows good outcomes with prompt diagnosis and treatment using a biopsychosocial, stepped-care approach. At present, however-and worldwide-FND services are scarce, the result of long-standing stigma and ingrained belief that patients with FND do not suffer from a real ("organic") disorder and that they therefore do not require, or even deserve, treatment. Since 1994, the Mind-Body Program for children and adolescents with FND at The Children's Hospital at Westmead in Sydney, Australia-run by a consultation-liaison team-has delivered inpatient care to hundreds of patients with FND and outpatient care to hundreds of others. For less-disabled patients, the program enables community-based clinicians to implement biopsychosocial interventions locally by providing a positive diagnosis (by a neurologist or pediatrician), a biopsychosocial assessment and formulation (by clinicians from the consultation-liaison team), a physical therapy assessment, and clinical support (from the consultation-liaison team and the physiotherapist). In this Perspective we describe the elements of a biopsychosocial mind-body program intervention capable of providing, as needed, effective treatment to children and adolescents with FND. Our aim is to communicate to clinicians and institutions around the world what is needed to establish effective community treatment programs, as well as hospital inpatient and outpatient interventions, in their own health care settings.

Neurological Dysfunction in Long COVID Should Not Be Labelled as Functional Neurological Disorder.

There have been suggestions that Long COVID might be purely functional (meaning psychological) in origin. Labelling patients with neurological dysfunction in Long COVID as having functional neurological disorder (FND) in the absence of proper testing may be symptomatic of that line of thought. This practice is problematic for Long COVID patients, as motor and balance symptoms have been reported to occur in Long COVID frequently. FND is characterized by the presentation of symptoms that seem neurological but lack compatibility of the symptom with a neurological substrate. Although diagnostic classification according to the ICD-11 and DSM-5-TR is dependent predominantly on the exclusion of any other medical condition that could account for the symptoms, current neurological practice of FND classification allows for such comorbidity. As a consequence, Long COVID patients with motor and balance symptoms mislabeled as FND have no longer access to Long COVID care, whereas treatment for FND is seldom provided and is ineffective. Research into underlying mechanisms and diagnostic methods should explore how to determine whether motor and balance symptoms currently diagnosed as FND should be considered one part of Long COVID symptoms, in other words, one component of symptomatology, and in which cases they correctly represent FND. Research into rehabilitation models, treatment and integrated care are needed, which should take into account biological underpinnings as well as possible psychological mechanisms and the patient perspective.