Trick or treat? Showing patients with functional (psychogenic) motor symptoms their physical signs

Abstract

I read with interest the recent article by Drs. Stone and Edwards.1 Their experience was that if patients with functional motor symptoms were shown their physical signs, they could be persuaded of the accuracy of their diagnosis and the potential reversibility of their symptoms. While this may be true, my personal experience of patients with nonepileptic events has varied. Many patients feel vindicated when shown the nonepileptic event captured on video-EEG. Their complaints finally stand justified in the eyes of their doctor and loved ones. That said, patients rarely if ever completely stop having their typical events after this. In a few patients, the event frequency may exacerbate and new events with previously unreported clinical semiology may be reported.2 These patients are frequently lost to follow-up only to seek medical care in another institution under another physician where invariably diagnostic workup is repeated. This also adds to health care costs to society as a whole. Explicitly telling patients that their events are psychogenic in origin has its own challenges. The discussion is invariably rough for the physician—sometimes heated—and the psychogenic explanation is not readily accepted by most patients. I tell my patients that there is no organic basis to the symptomatology and advise that underlying psychogenic factors need to be aggressively addressed rather than say that the events are real, not imagined, or “all in the mind.”