Functional Neurological Symptoms Research Articles

High Prevalence of Psychological Comorbidities and Functional Neurological Symptoms in Women With Urinary Retention.

Chronic idiopathic urinary retention (CIUR) in young women is poorly understood and a probable etiology is established only in around 40%, most commonly a primary disorder of external urethral sphincter relaxation, sometimes referred to as Fowler's syndrome. A high prevalence of psychological and functional comorbidities is reported, however these have been poorly characterized. Women consecutively referred for the assessment and management of CIUR were evaluated cross-sectionally for 13 psychological/behavioral domains using a structured clinical interview: depression, anxiety, post-traumatic stress disorder (PTSD), other psychiatric history, functional neurological disorder, other functional syndromes, childhood and adult trauma, personality disorder, and self-harm (ever/current). A total of 91 women (mean age [SD]: 34 [11] years) were evaluated. Women with Fowler's syndrome (n = 69) were younger (mean age [SD]: 32 [9] vs 40 [13] years) than women without Fowler's syndrome and reported shorter mean duration of urinary symptoms (mean [SD]: 5 [6] vs 10 [9]). A high prevalence of psychiatric and psychological comorbidities was reported (97%) including current depression (77%), current anxiety (78%), and PTSD (32%). A high prevalence of functional neurological disorder (56%) and other functional symptoms (65%) was also reported. Self-harm was reported in (14%) and personality disorder in 16%. Childhood trauma was reported in 35% of women. Young women with CIUR report a high burden of psychiatric disorders, affective symptoms, trauma, PTSD, self-harm, and functional neurological disorder, particularly in those with Fowler's syndrome. These factors can undermine the engagement with health care professionals and affect management and should therefore be addressed during the urological assessment.

Functional Neurological Disorder Presenting After Concussion: A Retrospective Case Series.

Although a majority of individuals recover from a concussion within weeks of the index injury, a substantial minority of patients report persistent postconcussion symptoms. Some of these symptoms may reflect a diagnosis of functional neurological disorder (FND). The authors evaluated the relationship between persistent postconcussion symptoms and FND symptoms. In this retrospective chart review, the authors characterized demographic and clinical information from 50 patients with a confirmed diagnosis of FND whose functional neurological symptoms started after a concussion. Patients who developed FND after a concussion had high rates of baseline risk factors for both persistent postconcussion symptoms and FND. After the concussive event, functional neurological symptoms presented abruptly or developed insidiously over time. Functional neurological symptoms ranged widely and included gait symptoms, seizures, speech and language symptoms, weakness, sensory symptoms, tremors, and vision and oculomotor symptoms. Functional neurological symptoms can arise after a concussion. FND should be considered in the differential diagnosis of individuals presenting with neurological symptoms beginning after a concussion. By failing to recognize functional symptoms, clinicians may inadvertently reinforce negative health-related beliefs regarding a patient's injured brain.

PREDITORES PARA A PERSISTÊNCIA DE SINTOMAS NEUROLÓGICOS DA COVID-19 UM ANO APÓS O DIAGNÓSTICO: Estudo de coorte

Knowledge about the frequency and predictive variables of persistent neurological manifestations associated with COVID-19 can contribute to directing the best treatment and recovery. The objective of this study was to identify the risk factors for the persistence of neurological symptoms (NSP) one year after the diagnosis of COVID-19. This is prospective research, carried out using a questionnaire sent to participants one month and one year after the diagnosis of COVID-19. To identify PSN risk factors after one year of diagnosis, the frequency of data relating to: sex; age; race/color; education; hospitalization; comorbidities and functional status present after 1 month and neurological symptoms (fatigue, headache, body pain, ageusia, anosmia, discouragement, irritability/mental confusion) present after one month and one year of diagnosis. Bivariate, multivariate and regression analyzes were performed. 379 patients with the following characteristics participated: age: median of 37 (29-49) years; color/race: white (69.1%); gender: female (64.9%); education: higher education (63.1%); hospitalized (9.2%); comorbidities: (33.24%), (13.7% - obesity). Regarding functional status: 55.1% altered; neurological symptoms after one month and after one year, respectively: frequency (57.5%), (38.5%), fatigue (30.3%), (19%) respectively. The predictor variables for PSN one year after diagnosis were comorbidities (P<0.003), changes in functional status and/or neurological symptoms one month after diagnosis: (P<0.001), respectively. One year after diagnosis, 38.5% presented persistent neurological symptoms, with a prevalence of fatigue (19.0%), and the risk factors were the presence of comorbidity, neurological symptoms and changes in functional status one month after diagnosis.

Agreement and disagreement in pediatric functional neurological symptom disorders: Comparing patient reported outcome measures (PROMs) and clinician assessments

Youth with functional neurological symptom disorder (FNSD) often perceive themselves as having limited capabilities, which may not align with clinical evaluations. This study assessed the disparities between clinician evaluations and patient-reported outcome measures (PROMs) regarding pain, motor function, and learning difficulties in youth with FNSD. Sixty-two youths with FNSD participated in this study, all of whom reported experiencing pain, motor problems, and/or learning difficulties. Clinicians also assessed these domains, resulting in a two-by-two categorization matrix: (1) agreement: child and clinician report "problems"; (2) agreement: child and clinician report "no problems"; (3) disagreement: child reports "problems" while the clinician does not; and (4) disagreement: clinician reports "problems" while the child does not. Agreement/disagreement differences were analyzed. No significant differences in prevalence were observed between the evaluators regarding pain (clinician-85%, child-88%), motor (clinician-98%, child-95%), or learning problems (clinician-69%, child-61%). More than 80% of the children and clinicians report pain and motor disorders. Instances in which children and clinicians reported learning problems (40.3%) exceeded cases in which both reported no problems (9.6%) or only the child reported problems (20.9%). Overall, the agreement between pain and motor function assessments was high (>90%), whereas that concerning learning difficulties was moderate (49.9%). Disagreement in pain/motor assessments was minimal (<5%), whereas for learning difficulties, disagreement rates were high (>20%). In conclusion, a significant concordance exists between PROMs and clinician assessments of pain and motor problems. However, the higher frequency of disagreements regarding learning difficulties emphasizes the importance of incorporating patient and clinician evaluations in pediatric FNSD treatment.

Misdiagnosis of functional neurological symptom disorders in paediatrics: Narrative review and relevant case report.

Functional neurological symptom disorders (FNSD) pose a common challenge in clinical practice, particularly in pediatric cases where the clinical phenotypes can be intricate and easily confused with structural disturbances. The frequent coexistence of FNSDs with other medical disorders often results in misdiagnosis. In this review, we highlight the distinctions between FNSD and various psychiatric and neurological conditions. Contrary to the misconception that FNSD is a diagnosis of exclusion, we underscore its nature as a diagnosis of inclusion, contingent upon recognizing specific clinical features. However, our focus is on a critical learning point illustrated by the case of a 14-year-old male initially diagnosed with FNSD, but subsequently found to have a rare primary monogenic movement disorder (paroxysmal kinesigenic dyskinesia, PKD). The crucial takeaway from this case is the importance of avoiding an FNSD diagnosis based solely on psychiatric comorbidity and suppressible symptoms. Instead, clinicians should diligently assess for specific features indicative of FNSD, which were absent in this case. This emphasizes the importance of making a diagnosis of inclusion. Extended follow-up and clinical-oriented genetic testing might help identify comorbidities, prevent misdiagnosis, and guide interventions in complex cases, which cannot be simply classified as "functional" solely because other conditions can be excluded.

Frequent Request of Injectable Biperiden in a Young Patient with Uncommon Neck Deviation and History of Neurodevelopmental Disorder

Introduction: Malingering is a differential diagnosis in the field of medical disorders, especially in the field of forensic medicine. In medicine, malingering is when a person imitates a medical or psychiatric disorder with external motivations to gain financial gain or avoid social or occupational duties. In some cases, diagnosing a medical or psychological condition from malingering can be challenging and difficult. In this case report, a patient with a history of multiple hospitalization, neurodevelopmental disorders, and intellectual disability requested to receive injectable Biperiden due to aggression, irritable mood, and neck deviation, and in order to receive it, he deliberately showed neck dystonia. This report aimed to discuss on a neuropsychiatric symptom, after which the patient requested a drug injection to resolve it, in order to differentiate possible diagnoses such as drug complication, factitious disorder, and functional neurological symptom disorder. On the other hand, during the recent searches of similar texts, conflicting results and suggestions have been presented.

From Software to Hardware: A Case Series of Functional Neurological Symptoms and Cerebrovascular Disease.

Neuroimaging studies have identified alterations in both brain structure and functional connectivity in patients with functional neurological disorder (FND). For many patients, FND emerges from physical precipitating events. Nevertheless, there are a limited number of case series in the literature that describe the clinical presentation and neuroimaging correlates of FND following cerebrovascular disease. The authors collected data from two clinics in the United Kingdom on 14 cases of acute, improving, or delayed functional neurological symptoms following cerebrovascular events. Most patients had functional neurological symptoms that were localized to cerebrovascular lesions, and the lesions mapped onto regions known to be part of functional networks disrupted in FND, including the thalamus, anterior cingulate gyrus, insula, and temporoparietal junction. The findings demonstrate that structural lesions can lead to FND symptoms, possibly explained through changes in relevant mechanistic functional networks.

Abstract WP283: Association of High-Risk Cardioembolic Sources on Cardiac CT With Acute Ischemic Stroke: A Case-Control Study

Background: Cardiac CT is increasingly used to detect a source of cardioembolism in stroke patients. We assessed the association between sources of embolism on cardiac CT, which were predefined as high-risk, and acute ischemic stroke. Methods: We analyzed data from Mind the Heart, a prospective, single-center, observational cohort study, and included consecutive patients with a suspected stroke who underwent ECG-gated cardiac CT during the initial stroke imaging protocol. Cases were patients with a final diagnosis of acute ischemic stroke (AIS), established by an adjudication committee. Controls were patients with stroke mimics (SMi). We excluded patients with a transient ischemic attack. Cardiovascular radiologists diagnosed structural high-risk sources of cardioembolism on cardiac CT according to predefined criteria. High-risk sources on cardiac CT were: cardiac thrombi, signs of endocarditis, recent myocardial infarction, prosthetic valve abnormalities, atrial myxomata and signs of rheumatic valvular disease. We used logistic regression, adjusting for age, sex, history of atrial fibrillation, and history of myocardial infarction. Results: Of 607 included patients, 452 had AIS (74%, median age 72, 59% male) and 155 had a SMi (26%, median age 70, 46% male). Diagnoses in the SMi group were: seizures (45/155, 29%) peripheral vestibulopathy (22/155, 14%), functional neurologic symptoms (16/155, 10%), benign headache disorder (8/155, 5%), intoxication (7/155, 5%), and other diagnoses (57/155, 37%). Cardiac CT detected a structural high-risk cardioembolic source in 52/452 AIS patients (12%) and in 5/155 SMi patients (3%, three patients with seizures, one with peripheral vestibulopathy and one with traumatic brain injury, aOR: 4.1, 95%CI 1.7-12.1). Cardiac thrombi were the most commonly observed high-risk sources of embolism and were detected in 38 (8%) AIS patients and in 2 (1%) SMi patients (aOR 7.0, 95%CI 2.1-43.9). Discussion and conclusion: A high-risk source of cardioembolism was detected on cardiac CT four times more often in patients with acute ischemic stroke than in patients with a stroke mimic. These data substantiate the clinical relevance of using acute CT to search for sources of cardioembolism in ischemic stroke patients.

Transient resting-state salience-limbic co-activation patterns in functional neurological disorders

BackgroundFunctional neurological disorders were historically regarded as the manifestation of a dynamic brain lesion which might be linked to trauma or stress, although this association has not yet been directly tested yet. Analysing large-scale brain network dynamics at rest in relation to stress biomarkers assessed by salivary cortisol and amylase could provide new insights into the pathophysiology of functional neurological symptoms. MethodsCase-control resting-state functional magnetic resonance imaging study of 79 patients with mixed functional neurological disorders (i.e., functional movement disorders, functional seizures, persistent perceptual-postural dizziness) and 74 age- and sex-matched healthy controls. Using a two-step hierarchical data-driven neuroimaging approach, static functional connectivity was first computed between 17 resting-state networks. Second, dynamic alterations in these networks were examined using co-activation pattern analysis. Using a partial least squares correlation analysis, the multivariate pattern of correlation between altered temporal characteristics and stress biomarkers as well as clinical scores were evaluated. ResultsCompared to healthy controls, patients presented with functional aberrancies of the salience-limbic network connectivity. Thus, the insula and amygdala were selected as seed-regions for the subsequent analyses. Insular co-(de)activation patterns related to the salience network, the somatomotor network and the default mode network were detected, which patients entered more frequently than controls. Moreover, an insular co-(de)activation pattern with subcortical regions together with a wide-spread co-(de)activation with diverse cortical networks was detected, which patients entered less frequently than controls. In patients, dynamic alterations conjointly correlated with amylase measures and duration of symptoms. ConclusionThe relationship between alterations in insular co-activation patterns, stress biomarkers and clinical data proposes inter-related mechanisms involved in stress regulation and functional (network) integration. In summary, altered functional brain network dynamics were identified in patients with functional neurological disorder supporting previously raised concepts of impaired attentional and interoceptive processing.

Disorders with functional neurological symptoms, diagnostic and therapeutic difficulties

Disorders with functional neurological symptoms, diagnostic and therapeutic difficulties

Emotional Dysregulation and Temperament-Character Traits in Adolescents With Functional Neurological Symptom Disorder (Conversion Disorder).

The purpose of this study was to evaluate emotion dysregulation and temperament-character traits in adolescents with functional neurological symptom disorder (FNSD). Forty adolescents with FNSD and 40 healthy adolescents were evaluated by a semiconstructed diagnosis interview, Temperament and Character Inventory (TCI), Difficulties in Emotion Regulation Scale (DERS), Regulation of Emotions Questionnaire (REQ), and Children's Somatization Inventory-24 (CSI-24). The external and internal dysfunctional emotion regulation scores of REQ, all subscales of DERS, except the awareness subscale, and CSI-24 scores were significantly higher in FNSD patients compared with healthy controls. There were significant differences between the groups in terms of harm avoidance and reward dependence subscale scores of TCI. Multiple logistic regression analysis showed that the external dysfunctional emotion regulation strategy, somatization, and reward dependence are significant predictors of FNSD. Our results provide evidence that adolescents with FNSD experience emotional dysregulation and that the differential value of some temperament-character traits in the diagnosis of FNSD.

Nocebo Hypothesis Cognitive Behavioural Therapy (NH-CBT) for non-epileptic seizures: a consecutive case series.

Research has demonstrated that implementation of Nocebo Hypothesis Cognitive Behavioural Therapy (NH-CBT) achieved full symptom remission in 93% of people with Functional Neurological Symptoms Disorder (FNSD), most of them exhibiting motor symptoms. The basis for NH-CBT is consistent with a predictive coding aetiological model of FNSD. This idea is transparently shared with people with FNSD in the form of telling them that their symptoms are caused by a nocebo effect, usually followed by some physical activity that aims to change the person's belief about their body. To demonstrate that a version of NH-CBT can also be effective in eliminating or reducing non-epileptic seizures (assumed to be a sub-type of FNSD). A consecutive case series design was employed. Participants were treated with NH-CBT over a 12-week period. The primary outcome measure was seizure frequency. Numerous secondary measures were employed, as well as a brief qualitative interview to explore participants' subjective experience of treatment. Seven out of the 10 participants became seizure free at least 2 weeks before their post-treatment assessment, and all stayed seizure-free for at least 5 months. Six of those seven remained seizure free at 6-month follow-up. There were large positive effect sizes for the majority of secondary measures assessed. This case series provides evidence of feasibility and likely utility of NH-CBT in reducing the frequency of non-epileptic seizures.

Unravelling the influence of affective stimulation on functional neurological symptoms: a pilot experiment examining potential mechanisms

BackgroundDifferences in affective processing have previously been shown in functional neurological disorder (FND); however, the mechanistic relevance is uncertain. We tested the hypotheses that highly arousing affective stimulation would result...

Ayurvedic Management along with Hypnotherapy in Functional Neurological Symptom Disorder (Conversion Disorder)

Functional neurological symptom disorder (FND)/Conversion disorder may be broadly defined as the presence of neurologic symptoms in the absence of a neurologic diagnosis, or when a neurologic diagnosis exists, it does not fully account for all of the patient’s symptoms. The cardinal symptom is limited solely to neurological symptoms. The diagnosis is made on the basis of the positive findings of the examination demonstrating preserved neurological function. Yoshapasmara, described in Madhava nidana, is comparable to FND where gathi / samvedhana (motor or sensory functions) are lost in the absence of underlying neurological conditions.&#x0D; A 29-year female was admitted with C/o Weakness and numbness in the left lower limb for 6 months. She had severe stress factors due to family conflicts. One day after a conflict with her mother-in-law, she felt difficulty walking on her left leg. They consulted a neurologist and done imaging, which was normal. On detailed clinical examination, the diagnosis was FND. She was managed with Internal medications and Udwartana, Abyanga, and Vyathyasa chikitsa (Dry and unctuous therapies alternatively). Hypnotherapy was administered in addition to Ayurvedic management to address stress factors. There were noticeable changes in the Perceived Stress Scale (PSS), muscle strength, and could walk without assistance with some difficulty after treatment. The neuropsychiatric perspective incorporating biopsychosocial aspects at the individual level, including consideration of Psychological and Spiritual aspects wherever relevant, is crucial for better outcomes in such cases.

Group psychotherapy format guided self‐help for patients with FNSD awaiting inpatient multidisciplinary treatment: A pilot study

AbstractBackgroundWe describe our experience of developing Guided Self Help for patients with Functional Neurological Symptom Disorder as group therapy, delivered remotely, via Zoom.AimsThe aims of the current study are (a) to describe how the original Queen Square Guided Self‐Help (QGSH) was adapted for group therapy, and (b) to present a service evaluation of the first 8 months of running QGSH therapy groups remotely.MethodsWe carried out a review after 8 months, from 11 May 2021 until 31 January 2022.ResultsA total of 16 patients were treated in three groups. Assessing our outcomes in terms of Yalom's framework for group psychotherapy, we found that the group provided 10/11 of Yalom's therapeutic factors. Patient satisfaction was high.DiscussionWe outline for plans for further devaluation and development, including the development of a stand‐alone group.ConclusionThe group therapy format is a promising addition to our service.

A - 80 The Role of Adverse Childhood Events and Personality Traits Among Individuals with Functional Neurological Symptom Disorder (FND).

There is an established link between early life trauma and avoidant and anxious attachment in patients with FND.1,2,3 These attachment styles are linked to histrionic (HPD), avoidant (APD), borderline (BPD), and dependent personality disorders (DPD)0.5 The current study seeks to explore the relationship between adverse childhood experiences and personality characteristics among individuals diagnosed with FND. A retrospective analysis of patients diagnosed with FND who completed neuropsychological evaluation was conducted. The outcome measures include the Adverse Childhood Experiences Scale (ACES) and Minnesota Multiphasic Personality Inventory, 3rd Edition (MMPI-3). Composite scores for the ACES and BPD, HPD, APD, and DPD were obtained by calculating equally weighted sum of predetermined component scores on the MMPI-3 based on the DSM-5.6 Spearman correlations were calculated to determine the association between ACES and PD composites. Analysis was conducted with 21 patients, 86% were female, 71% identified as white, and mean sample age was 41.59years (SD = 12.48). 57.14% had elevated ACES score. Mean composite PD scores were BPD - 55.97 (SD = 7.58), HPD - 53.93 (SD = 9.17), APD - 59.26 (SD = 9.71), and DPD - 59.75 (SD = 10.80). The correlations were positive and statistically significant (p < =0.05) across all four PD for ACES Q1 (emotional abuse) and Q4 (unsupportive environment). The results highlight that the ACES can be beneficial in identifying patients with FND who may have, or are at risk, of developing PD. These results also provide targets for treatment including maladaptive attachment styles.

43.4 Functional Neurological Symptom Disorder (FNSD) Education for Families, Primary Care Providers, and School Staff

43.4 Functional Neurological Symptom Disorder (FNSD) Education for Families, Primary Care Providers, and School Staff

Asserting a Functional Neurological Symptom Disorder with a Complementary Diagnostic Approach: A Brief Report.

Functional neurological symptom disorder (FNSD) is a common diagnosis among adolescents. However, we feel it is a difficult diagnosis to assess because of the diversity of its clinical manifestations, the rapid changes in its nosography over the years, and its common imbrication with established somatic diagnoses. We would like to illustrate this hypothesis through a case presentation and the original diagnostic process that emerged from it. We chose to present our diagnosis approach through the case of an 11-year-old boy who showed a progressive loss of motor and sensory function to the point of total dependency, and then suddenly switched between this state and a "normal" physical presentation, while deliriously claiming to be an angel. All possible infectious, autoimmune, metabolic, and toxic disorders were ruled out. After the successive therapeutic failures of antidepressants and neuroleptics, FNSD was diagnosed. The DSM-5-TR classification was insufficient to explain the full clinical picture and a complementary approach (biblical, psychoanalytical, and historical) was used to analyze the cause of this atypical presentation.

Addressing the elephant in the room: understanding functional neurological symptom disorder through the lens of culture and religion.

Owing to the dearth of scholarly works to understand the presence of Functional Neurological Symptom Disorder (FNSD) among mental health patients in Pakistan, this study sought to understand how cultural and religious conflicts are implicated in the aetiology of FNSD. The study recruited 22 participants, comprising five men and 17 women. The participants were recruited from the Department of Psychiatry at Services Hospital, Lahore, Pakistan. Semi-structured interviews were conducted and analyzed through Thematic Analysis. The two main themes identified in this study were cultural and religious values and beliefs about romantic relationships. Within the cultural and religious values theme, subthemes of self-perception, a conviction in religious beliefs, and sexual suppression were identified. Furthermore, the subthemes of beliefs about romantic relationships were family's approval, engagement against wishes, and fear of exposure. The two main themes are interconnected: beliefs about romantic relationships were interpreted and experienced through the perspective of religion and culture. To summarize, this study concluded that stressors related to culture and religion are significant contributing factors in the development of FNSD. This study has important implications for mental health professionals, as awareness around the interplay of cultural as well as religious beliefs and FNSD will enable them to devise effective and holistic therapeutic intervention.

Prospective follow-up study of youth and adults with onset of functional tic-like behaviours during the COVID-19 pandemic.

Very little is known about the long-term prognosis of patients with functional tic-like behaviours (FTLBs). We sought to characterize the trajectory of symptom severity over a 12-month period. Patients with FTLBs were included in our prospective longitudinal child and adult clinical tic disorder registries at the University of Calgary. Patients were prospectively evaluated 6 and 12 months after their first clinical visit. Tic inventories and severity were measured with the Yale Global Tic Severity Scale (YGTSS). Eighty-three youths and adults with FTLBs were evaluated prospectively until April 2023. Mean YGTSS total tic severity scores were high at baseline, with a mean score of 29.8 points (95% confidence interval [CI] = 27.6-32.1). Fifty-eight participants were reevaluated at 6 months, and 32 participants were reevaluated at 12 months. The YGTSS total tic severity score decreased significantly from the first clinical visit to 6 months (raw mean difference = 8.9 points, 95% CI = 5.1-12.7, p < 0.0001), and from 6 to 12 months (raw mean difference = 6.4 points, 95% CI = 0.8-12.0, p = 0.01). Multivariable linear regression demonstrated that tic severity at initial presentation and the presence of other functional neurological symptoms were associated with higher YGTSS total tic scores at 6 months, whereas younger age at baseline, receiving cognitive behavioural therapy for anxiety and/or depression, and prescription of selective serotonin reuptake inhibitors were associated with lower YGTSS total tic scores at 6 months. We observed a meaningful improvement in tic severity scores in youth and adults with FTLBs over a period of 6-12 months.