Functional Neurologic Disorders

Review Article

Address correspondence to Dr Jon Stone, Department of Clinical Neuroscience, Functional Neurologic Western General Hospital, Edinburgh, UK EH4 2XU, [email protected]. Disorders Relationship Disclosure: Dr Stone receives personal Jon Stone, MB, ChB, FRCP, PhD; compensation for expert testimony related to personal Alan Carson, MD, MPhil, MRCPsych, FRCP injury and negligence cases from multiple UK law firms and receives royalties from UpToDate, Inc. Dr Stone has ABSTRACT received honoraria for lectures PurposeofReview:Functional neurologic disorders, also called psychogenic, nonorganic, from the British Medical conversion, and dissociative disorders, are among the most common problems in Association and Novartis AG and travel compensation from neurologic practice. This article presents a practical guide to clinical assessment and the European Neurological treatment, incorporating emerging research evidence. This article places an emphasis Society, Movement Disorders on encouraging neurologists to use the assessment as treatment, take an active role in Society, Royal College of Psychiatrists, and from neurology educating and treating the patient, and work in a multidisciplinary way with psychiatry, departments in Amsterdam, psychology, and physical therapy. Cork, Leuven, Oxford, Recent Findings: Classification of functional neurologic disorders now emphasizes Reykjavı´k, and St Louis. Dr Carson receives personal the importance of positive diagnosis based on physical signs, not psychological features. compensation for expert Studies of mechanism have produced new clinical and neurobiological ways of thinking testimony related to personal about these disorders. Evidence has emerged to support the use of physical therapy for injury and negligence cases and has received honoraria for functional movement disorders and psychotherapy for dissociative (nonepileptic) attacks. lectures from Novartis AG and Summary: The diagnosis and management of functional neurologic disorders has entered UCB, Inc. Dr Carson serves as a new evidence-based era and deserves a standard place in the neurologic curriculum. associate editor of the Journal of Neurology, Neurosurgery, and Psychiatry,servesas Continuum (Minneap Minn) 2015;21(3):818–837. president of the executive committee of The British NeuroPsychiatry Association, and receives book royalties INTRODUCTION ache disorders. In other studies, func- from BMJ Books. Studies in many settings have demon- tional symptoms account for between Unlabeled Use of Products/Investigational strated that functional disorders are one in ten to one in three presentations to Use Disclosure: common in neurology services. Func- neurology outpatient services, depending Drs Stone and Carson discuss the unlabeled/investigational tional disorders, in this context, refer to how they are defined. use of antidepressant bodily symptoms and disorders, such Studies in movement disorder, epi- medication and transcranial as functional movement disorders or lepsy, and dizziness clinics show that magnetic stimulation for treating functional disorders. nonepileptic seizures, which are genu- whenever there is a symptom-based clinic, * 2015, American Academy ine but not related to a defined disease functional disorders will be highly prev- of Neurology. process. The term functional,despite alent. This finding mirrors the frequency drawbacks,1 is not used here as a of physical symptoms unexplained by synonym for psychogenic,butinsteadas diseases within medicine in general, such a way of describing a group of disorders as chronic widespread pain (fibromy- in which there is a functional rather than algia), chronic fatigue syndrome, and structural disturbance in nervous system irritablebowelsyndrome,whichareoften Supplemental digital content: 4 Videos accompanying this ar- functioning and where a biopsychosocial considered functional disorders. Studies ticle are cited in the text as model is critical in understanding their have shown that the proportion of pa- Supplemental Digital Content. 2 Videosmaybeaccessedbyclick- nature. In a study conducted by the tients in primary and secondary care medi- ing on links provided in the HTML, authors of this article of 3781 new cal clinics who have functional disorders PDF, and app versions of this 5 article; the URLs are provided in neurology outpatient visits in Scotland, ranges from 30% to 50%. Studies also the print version. Video legends functional diagnoses accounted for show that patients with functional dis- begin on page 833. 14% of all new visits,3 the second most orders have rates of disability and occu- common reason for a referral after head- pational impairment that match their

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Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited. KEY POINT counterparts with defined disease pro- ment of functional disorders as they h Functional disorders cesses and typically have higher rates of present in neurology. This joint effort account for between 6 psychological comorbidity. Functional between neurologists and psychiatrists one in ten to one in disorders are not a Western or modern has brought the field to the point where three presentations to invention. They have occurred histori- it is starting again to be considered a neurology, depending cally and occur around the world at a legitimate endeavor of clinical neurology how they are defined, similar frequency to that found currently as reflected in the new criteria of the and are a leading cause in the United States and Europe. Diagnostic and Statistical Manual of of disability and distress. Despite the prevalence of functional Mental Disorders, Fifth Edition (DSM-5)7 disorders in neurology practice, func- and the forthcoming International tional disorders have a low profile in Classification of Diseases, Eleventh neurology training curricula, textbooks, Revision (ICD-11).8 and research. There are several poten- This article presents a practical ap- tial reasons for this, including the split proach to thinking about, assessing, and between neurology and psychiatry at treating patients with functional disor- the turn of the 20th century, fears about ders in a neurologic setting. In particu- misdiagnosis (which reached their peak lar, we emphasize that neurologic with a study by British psychiatrist Eliot assessment does not need to be just a Slater in 1965, who suggested that most prelude to treatment, but can be the cases of ‘‘hysteria’’ were, in fact, misdiag- start of treatment itself. The article nosed cases of disease) and, perhaps also discusses how to build successful most importantly, ambivalence, espe- multidisciplinary teams for these pa- cially from neurologists, about whether tients including psychological and patients with functional disorders have physical therapies. a genuine disorder at all. Through much of the 20th century, functional disorders CHANGES IN TERMINOLOGY became almost invisible as a clinical AND CLASSIFICATION problem, although the evidence is that Terminology has been, and will proba- their frequency did not change. Neurol- bly continue to be, a problem for these ogists went about their jobs excluding disorders. Neurologists have tended to disease but rarely making positive diag- ignore the psychiatric terms of conversion noses or getting involved in manage- disorder (as referenced in the Diagnostic ment of functional disorders. Psychiatric and Statistical Manual of Mental Dis- models have dominated classification, orders, Fourth Edition [DSM-IV])9 and etiology, and treatment, especially dissociative motor/seizure disorder (as Freud’s conversion model, which pro- referenced in the International Classi- posed that stress was ‘‘converted’’ into fication of Diseases, Tenth Revision physical symptoms. In reality, however, [ICD-10]),10 perhaps partly because the few of these patients actually saw terms demand a psychosocial formula- psychiatrists for treatment. For patients, tion that neurologists have not been the net result has often been abandon- trained to assess. ment by health professionals with either no diagnosis or misdiagnosis with a Conversion Disorder (Functional disease label such as epilepsy or multi- Neurologic Symptom Disorder) ple sclerosis (MS). in the Diagnostic and Statistical In the past 20 to 25 years, slow but Manual of Mental Disorders, sustained progress has been made in Fifth Edition our understanding of the epidemiology, In the 2013 revision of the DSM,the clinical features, mechanisms, and treat- diagnostic criteria for conversion disorder

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were radically altered. The DSM-5 now this article have argued that this change emphasizes identification of positive could result in the following11: features, predominantly on examina- & Enable neurologists and psychiatrists tion, which are typical of a functional to develop a better mutual disorder. The previous requirement for understanding of how the diagnosis a psychological stressor has been dropped, is made and encourage psychiatrists as many patients do not have an identi- to learn relevant examination fiable stressor. Even in those who do techniques have a stressor, the relationship to the & Avoid the common situation where functional symptom may be hard to a psychiatrist fails to find any establish. In addition, a previous criteria psychological stressor and concludes in which the patient had to be deemed that the diagnosis must be incorrect to be ‘‘not feigning’’ has also been re- & Reduce the risk of the patient with moved since proving that a patient is disease receiving an erroneous not feigning is impossible. If there is diagnosis of a functional disorder feigning, then the patient has either simply because they have psychiatric factitious disorder or malingering. The comorbidity or symptom onset changes to the DSM-5 are summarized coincides with recent stress in Table 15-1. & Encourage the use of a The aim of the revised criteria in the shared, common language of DSM-5 is to highlight that the diagnosis functional disorder of functional neurologic symptom disor- & Remove the stigma of having a ders should be made positively on the ‘‘not-feigning’’ criterion basis of clinical assessment, and, in partic- Potential problems with the DSM-5 ular, physical examination. The authors of criteria include the unwieldiness of the

TABLE 15-1 Changes to Diagnostic Criteria from the DSM-IV (Conversion Disorder) to the DSM-5 (Functional Neurologic Symptom Disorder [Conversion Disorder])a

Criterion DSM-IV DSM-5 Comments Motor or sensory symptomI(( Icausing distress or difficulty for the patient (( Positive physical signs of internal inconsistency ,(Emphasizes how these disorders should or incongruity with recognized disease be diagnosed. Patient must have a psychological stressor (,Often not present. As a consequence, many patients without stressors rejected by psychiatry. Patient must be determined as ‘‘not feigning’’ (,Feigned symptoms are probably rare, are separately classified, and should not be considered a functional disorder. Proving feigning is hard. Proving ‘‘not feigning’’ is clinically impossible. DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; DSM-5 = Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. a Data from American Psychiatric Association.7,9

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Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited. KEY POINTS term functional neurologic symptom in Table 15-2. The neurologist’s prior- h Psychological causation disorder and the fact that the diagnosis ities are to get a full picture of physical is no longer required in still resides within a psychiatric classifi- symptoms and their impact on day-to-day the Diagnostic and cation, while the symptoms themselves function, followed by a detailed un- Statistical Manual of exist at the interface between neurolo- derstanding of the patient’s own un- Mental Disorders, Fifth gy and psychiatry. derstanding about what may be wrong Edition, which in and what investigation and treatment practice means that a Functional Neurologic Disorder the patient is seeking. The history may neurologist alone can and Dissociative Motor Disorder have many red flags suggesting a func- make the diagnosis of a in the International Classification tional disorder such as other functional functional neurologic disorder. The of Disease, Eleventh Revision symptoms, unnecessary surgery, or International Classification psychological comorbidity. Ultimately, In previous versions of the ICD, func- of Diseases, Eleventh tional disorders appeared only within however, all of these things could be Revision will include the psychiatry section as ‘‘dissociative misleading. The diagnosis of a func- functional disorders (conversion) motor/seizure/sensory dis- tional motor or sensory disorder should within a neurology orders.’’ In the current beta draft of the be made on the basis of positive find- category for the first time. ings of inconsistency or incongruity on ICD-11, due to be finalized in 2017, h A history of many the examination, and the diagnosis of functional disorders appear for the first previous functional dissociative attacks should be made time in the neurology section but also disorders or comorbid on the basis of the clinical features of remain in the psychiatry section within anxiety or depression the attack. dissociative disorders.8,12 This small but may be a red flag for a In addition, there is special value in diagnosis of a functional potentially profound change brings neu- looking especially hard for evidence of neurologic disorder, but rology in line with specialties like gas- physiologic or psychophysiologic triggers this alone should not troenterology, which have listed their at symptom onset that may help the lead to the diagnosis. functional disorders within their section neurologist explain a potential mech- of the ICD formanyyears.Thischange anism for the disorder to the patient. For sends a clear message that functional dis- example, in patients with either func- orders are part of the clinical neurology tional limb weakness or a functional curriculum, allows neurologists using ICD movement disorder, precipitants such as codes to make a functional diagnosis physical injury, panic attacks (often with (and bill explicitly where appropriate), dissociation), (Supplemental Digital Con- and encourages more accurate coding tent 15-1, links.lww.com/CONT/A142) for research and health care planning. and migraine are common.13,14 Since the 1900s, neurologists have recognized THERAPEUTIC ASPECTS OF that in patients vulnerable to functional HISTORY TAKING disorders, a physical trigger directs atten- Neurologists often find patients with tion abnormally to the limb and associ- functional disorders difficult to assess ates the experience with a belief about and treat. The following are suggestions what may be wrong (eg, ‘‘I haven’t just hurt about how to appropriately focus history my arm; it’s not working properly, and taking so that the consultation is both maybe I’m having a stroke.’’) (Case 15-1). adequate for assessment and therapeu- Understanding the symptom of dis- tic from the outset. sociation is useful for neurologists assessing functional neurologic disorders. Essential Elements of Dissociation refers to a feeling of discon- History Taking nection from either the surrounding Important elements of history taking world (derealization) or one’s own body in functional disorders are listed (depersonalization). Patients usually

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TABLE 15-2 Elements of Patient History Useful in Diagnosis and Treatment of Functional Neurologic Disorders

Historical Elements Comment Symptom list Ensure that you have elicited all the patient’s physical symptoms. This is important not only for diagnosis but also in building trust and confidence with a patient. Consider asking about fatigue, sleep, concentration, and pain in every patient. Day-to-day function Build a picture of what the patient can and cannot do. The patient may be focused on what they cannot do, but finding out what they can do gives clues about mood and anxiety. Onset: Weakness and Sudden onset (approximately 50% of patients): movement disorder Look for physical injury, panic attack, episode of dissociation, migraine, general anesthetic, drug side effect, viral illness, or another physiologic trigger that may help you explain back a mechanism to the patient. Gradual onset: Often associated with asymmetrical pain and fatigue. Onset: Dissociative Ask patients carefully about prodromal symptoms. (nonepileptic attacks) They are typically reluctant to discuss them, but they often describe panic, autonomic arousal symptoms, or dissociation if questioned sympathetically. The first event may have been either clear-cut syncope or a mechanical fall. Other functional disorders Consider if the patient has other diagnoses such as irritable bowel syndrome, fibromyalgia, or chronic fatigue syndrome, which are often considered functional disorders. Illness beliefs Consider what the patient thinks may be wrong. Consider if the patient or others think doctors have missed something (eg, Do they think they have nerve damage or do they think it is possible their symptoms could improve? What treatments do they think would help?). Experience with Enquire about the outcome of visits with other other doctors doctors. Allow the patient to vent their frustration if relevant.

struggle to describe feelings of being In dissociative (nonepileptic) attacks, ‘‘zoned out’’ or ‘‘in a place of their own,’’ patients commonly have symptoms of but they recognize the experience if it is either dissociation or panic just before described to them and are often relieved their attacks, although they are typically to discuss it (Supplemental Digital reluctant to describe these symptoms.15 Content 15-1, links.lww.com/CONT/ Many patients describe an intolerable A142). Dissociation occurs commonly feeling as their warning symptoms during panic attacks and states of fatigue, build. Their attacks can often be seen but it may be spontaneous. as a conditioned response, relieving

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Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited. Case 15-1 A 41-year-old woman presented acutely with apparent right face, arm, and leg weakness. She had no history of prior neurologic problems and ran her own company. A neurologic consultation was requested when two successive MRI scans, including a magnetic resonance angiogram (MRA), were normal. The patient’s history revealed that she had been watching television when she had felt ‘‘spaced out.’’ Although she had been busy at work, she had not felt stressed at that time. Her symptoms had evolved over 1 to 2 hours and were not, therefore, characteristically vascular. She experienced no headache. On examination she had overactivity of the platysma on the affected side (Figure 15-116)(Supplemental Digital Content 15-2, links.lww.com/CONT/A143) with global weakness of the right arm and leg and a positive Hoover sign (Supplemental Digital Content 15-3, links.lww.com/CONT/A144). Explaining the diagnosis of a functional disorder and, in particular, showing the patient the nature of her Hoover sign led her to have a high level of confidence in the diagnosis. With physical therapy from a therapist with expertise in functional motor disorders, she made a full recovery over several months. In hindsight, she felt she was stressed by her job at the time her symptoms appeared, and she returned to work in a different role.

FIGURE 15-1 Photographs of the patient in Case 15-1. Functional facial overactivity can look like facial weakness, typically with platysma overactivity, jaw deviation, and/or contraction of orbicularis oculis. In this patient, the functional facial overactivity is seen on the right, causing jaw deviation to the right (A, B) and platysma overactivity on the right (B).

Reprinted with permission from Stone J, Neurophysiol Clin.16 B 2014 Jon Stone, MB, ChB, FRCP, PhD. www.sciencedirect.com/science/article/pii/S0987705314000185.

Comment. The case demonstrates the importance of dissociation at onset (the description she gave of feeling spaced out), the need to be aware of functional facial spasm as a stroke mimic, and the relative importance of explanation and physical therapy compared to psychological treatment.

them of these undesirable symptoms.17 The treatment model presented in Patients with panic attacks may experi- Case 15-2 allows a neurologist to start ence unilateral sensory disturbance as a giving the patient an explanation of his or physiologic concomitant which may trig- her condition that is based on physiology ger more prolonged hemisensory dis- and cognitive mechanisms rather than turbance (Case 15-2). the traditional, ‘‘it must be due to stress’’

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KEY POINT h Looking for dissociative explanation that typically convinces nei- questions about childhood trauma, for symptoms and ther patients nor doctors (eg, How does example, intrusive and upsetting, and physiologic triggers at an argument with your partner cause a many neurologists may not have the skill onset helps a functional hemiparesis?). set to handle the reply appropriately. In neurologist provide an addition, childhood trauma is only pres- explanatory model for Elements of History That Can ent in a minority of patients, and for the mechanism Be Left for Later Assessments motor symptoms only at slightly higher of symptoms. Many clinicians feel they ought to be rates than disease controls. looking hard for either a recent stres- Similarly, an evaluation of anxiety and sor or a past traumatic event that may depression, while useful, is not essential be associated with a functional disor- at the first visit. A description of day-to- der. This information is not necessary day activity generally gives clues about for diagnosis and often not desirable on anhedonia, low mood, and anxiety. a first visit, where time is often limited. Explanatory models should focus initially Even if such events are present, the on potential mechanisms for symptoms focus for the neurologist should be on (eg, triggers such as injury, migraine, or making a clear, positive diagnosis. A panic attack) rather than attempting an wider assessment and formulation can etiologic formulation based on either life wait for later visits. Many patients find events or the presence of anxiety or

Case 15-2 A 17-year-old girl presented with multiple collapsing episodes, each consisting of suddenly falling to the ground with her eyes closed and then lying motionless and unresponsive for 30 seconds to several minutes. Her parents had become extremely anxious about the consequences of the episodes as she was missing a lot of school and social activity. Although she initially said she experienced no warning symptoms, with encouragement she admitted that she did quite often get a sudden scary feeling of being ‘‘spaced out.’’ Simultaneously, she felt ‘‘horrible’’ and ‘‘hot’’ for several seconds preceding the attack, which she found frightening. Both ECG and EEG during the episodes were normal. During treatment she began to admit that the feeling before the attacks was so horrible that she almost wanted the attack to happen to get rid of the way she felt, despite the fact that immediately afterward she still felt really upset about having had an attack. Treatment focused initially on explaining the nature of these episodes as dissociative (nonepileptic) attacks, in particular, on recognizing these warning symptoms as dissociation. The dissociative attacks were explained to her as something similar to a panic attack, which had become a habit she had developed as a response to her unpleasant warning symptoms. Using distraction techniques, encouraging her parents to allow her more independence, and liaising with her school about what to do when she had attacks, eventually led to resolution of the problem. At follow-up three years later, the patient was able to speak more freely about the dilemmas that she had been in at the time with respect to the attacks, although she didn’t think they had come about through any particular external stress. Comment. This case demonstrates the utility of detecting warning symptoms in dissociative (nonepileptic) attacks and how focusing treatment initially on this, rather than more generic issues, can result in the resolution of symptoms.

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Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited. KEY POINTS depression. As with psychological trauma, and a neurologic disease is important. h A recent stressor may or we are not suggesting these issues are Neurologic disease is a potent cause of may not be present and unimportant, just that they are not the functional symptoms, and so a diagnosis is not necessary for initial priority. of a functional disorder should raise either diagnosis or initial suspicion about the possibility of neu- treatment of a EXAMINATION rologic disease. Patients with limb weak- functional neurologic ness, for example, will often require disorder and, thus, can Finding positive features of a functional imaging of the brain and spine. Short be discussed at a later disorder on physical examination is of video EEG with suggestion has a high time with the patient. key importance in the diagnosis. A diag- yield for dissociative (nonepileptic) at- h Functional neurologic nosis should not be made by exclusion or tacks.30 disorders should be because the symptoms are bizarre. The diagnosed on the basis 18Y25 Importantly, there are many neuro- physical signs listed in Table 15-3 logic diseases with normal brain and of positive features of either demonstrate that the symptom spine imaging (eg, ALS, autoimmune either internal improves temporarily with focused at- encephalitis). In addition, a normal EEG inconsistency or incongruity on tention on a different body part (eg, during an attack may not exclude a deep Hoover sign for functional limb weak- examination, not as a focus of epilepsy (eg, in frontal lobe diagnosis of exclusion, ness (Figure 15-226)(Supplemental Digi- seizures). The appearance of the captured not because clinical tal Content 15-3, links.lww.com/CONT/ seizure is most important. The event features are bizarre, and A144), the entrainment test for functional should be typical of a dissociative not just because tests tremor (Supplemental Digital Content (nonepileptic) attack, with some of the are normal. 15-4, links.lww.com/CONT/A145), or typical features listed in Table 15-3. h Investigations are improved standing balance with dis- Although nonepileptic remains a dom- typically necessary even traction (Supplemental Digital Con- inant concept, the authors think it in patients with a tent 15-5, links.lww.com/CONT/A146), unhelpfully continues to define disso- clear-cut functional or represent a clinical phenotype that ciative attacks by what they are not, rather disorder, mainly to look is typical for the diagnosis (eg, a pro- than their typical features. This leads for the presence of a longed attack of unresponsiveness in not only to diagnostic error, but also comorbid neurologic disease rather than which the patient’s eyes are tightly creates problems when explaining the diagnosis to patients. because the diagnosis closed, a dragging gait with the hip in- is wrong. ternally rotated (Supplemental Digi- Although investigations may be necessary in many patients, it is important tal Content 15-6, links.lww.com/ to perform them quickly and with a CONT/A147), or a fixed dystonic pos- defined end point. When the diagnosis ture with ankle inversion [Figure 15-3] is clear at the bedside, explain in advance [Supplemental Digital Content 15-7, to the patient that, clinically, you think links.lww.com/CONT/A148]).27 they have a functional disorder and you In recent years, increasing evidence expect investigations to be noncontrib- has emerged regarding the validity of utory. Such an approach leads to con- these signs18,28,29 in diagnosis, although siderably less anxiety from patients and as with all physical signs, caution should also reinforces that you are not rely- be exercised. ing on the tests to make a diagnosis. Rather, you are performing the tests to INVESTIGATION make sure the patient does not have Positive signs on examination in combi- anything else. nation with a typical history may allow Patients with functional disorders can for a confident clinical diagnosis. How- benefit from neurologist follow-up not ever, considering the possibility that the only for treatment, but also, in some cases, patient has both a functional disorder to detect comorbid emerging neurologic

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a TABLE 15-3 Positive Diagnostic Signs in Functional Disorders

Sign Positive Finding Weakness Hoover sign18 (Figure 15-2) (Supplemental Digital Hip extension weakness that returns to normal with Content 15-3, links.lww.com/CONT/A144) contralateral hip flexion against resistance Hip abductor sign18 Hip abduction weakness returns to normal with contralateral hip abduction against resistance Other clear evidence of inconsistency Eg, weakness of ankle plantar flexion on the bed but patient able to walk on tiptoes Global pattern of weakness Weakness that is global, affecting extensors and flexors equally Dragging gait (Supplemental Digital A gait in which the forefoot remains in contact with the Content 15-6, links.lww.com/CONT/A147) ground, typically with hip externally or internally rotated Movement disorder/gait Tremor entrainment test19 (Supplemental Digital Patient with a unilateral tremor is asked to copy a rhythmical Content 15-4, links.lww.com/CONT/A145)20 movement with their unaffected limb; the tremor in the affected hand entrains to the rhythm of the unaffected hand, stops completely, or the patient is unable to copy the simple rhythmical movement Fixed dystonic posture21 A typical fixed dystonic posture, characteristically of the (Figure 15-3) (Supplemental Digital Content 15-7, hand (with flexion of fingers, wrist, or elbow) or ankle links.lww.com/CONT/A148) (with plantar and dorsiflexion) Typical functional hemifacial overactivity22 Orbicularis oculus or oris overcontraction, especially when (Figure 15-1) accompanied by jaw deviation or ipsilateral functional hemiparesis Distraction during standing23 (Supplemental Patients with an apparently positive Romberg sign Digital Content 15-5, links.lww.com/CONT/A146) are asked either to guess numbers written on their back or to carry out a complex motor task (eg, with a phone); in a functional gait problem, their balance will improve significantly Dissociative (nonepileptic) attacks24 Prolonged attack of motionless unresponsiveness Paroxysmal motionlessness and unresponsiveness lasting longer than 2 minutes Long duration Attacks lasting longer than 2 minutes (but be careful of misleading witness histories) Closed eyes Closed eyes during an attack, especially if there is resistance to eye opening

Ictal weeping Crying either during or immediately after the attack Memory of being in a generalized seizure Ability to recall the experience of being in a generalized shaking attack

Ictal hyperventilation During a generalized epileptic seizure respiration ceases, but commonly speeds up during a nonepileptic attack Presence of an attack resembling epilepsy with Normal EEG does not exclude frontal lobe epilepsy or deep a normal EEG foci of epilepsy but does provide supportive evidence Continued on page 827

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Sign Positive Finding Visual symptoms25 Fogging test Vision in the unaffected eye is progressively fogged using lenses of increasing diopters while reading an acuity chart; a patient who still has good acuity at the end of the test must be seeing out of their affected eye

Tubular visual field A patient is found to have a field defect, which has the same width at 1 meter as it does at 2 meters EEG = electroencephalogram. a Modified with permission from Stone J, Neurophysiol Clin.16 B 2014 Jon Stone, MB, ChB, FRCP, PhD. www.sciencedirect.com/science/article/ pii/S0987705314000185.

KEY POINT diseases that were not detectable at THE NEUROSCIENCE OF h Consider the need for initial presentation (eg, ALS or dementia). FUNCTIONAL DISORDERS follow-up in cases Frank misdiagnosis is no more common More than 20 studies have used functional where the possibility in functional disorders than any other neuroimaging techniques to explore the exists that a functional neurologic or psychiatric disorder (less mechanisms of functional neurologic disorder is arising in the than 4% at 5 years in published stud- disorders, predominantly limb weakness prodrome of a 31 ies ), and concern about misdiagnosis but also tremor and, more recently, neurodegenerative condition, but do not let should not be allowed to dominate the dissociative (nonepileptic) seizures.32 this possibility neurologist’s approach to the patient Differing paradigms and small numbers jeopardize treatment of as it will jeopardize the therapeutic of studies mean that there is not yet a the functional disorder. approach described below. clear model of the neural correlates of

FIGURE 15-2 Hoover sign of functional leg weakness. A, The physician tests left hip extension and finds it weak. B, The physician tests contralateral hip flexion against resistance, and hip extension on the left has become strong.

Reprinted with permission from Stone J, Pract Neurol.26 B 2009 BMJ Publishing Group. pn.bmj.com/content/9/3/ 179.short.

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FIGURE 15-3 Bilateral functional dystonia with characteristic ankle inversion and plantarflexion.

these symptoms. However, many studies factors, such as the importance of belief, suggest abnormal activity in networks with neurologic factors, such as an including anterior cingulate, ventromedial attentional modulation style that leads prefrontal cortex, parietal lobes, and to overly precise predictions about mo- supplementary motor area in keeping tor and sensory function based on with a disorder that has a basis in physiologic or minor pathologic sensa- attentional interference in motor activity tions, resulting in the loss of agency with inputs from emotional centers such for affected limbs.35 as the amygdala. Several studies have also explored differences to simulated MALINGERING symptoms, although developing para- Factitious disorder refers to the deliber- digms of real-world deception is chal- ate production of symptoms to receive lenging. Neurophysiologic studies have health care and attention and is some- also produced intriguing findings in times seen as a deceptive variant of self- 33 evoked potentials and impaired sen- harm. Malingering refers to deliberately 34 sory attenuation. Sensory attenuation producing symptoms for material (eg, is the normal human ability to turn down financial) gain and is not a medical sensations from internally generated diagnosis. Malingering looms large in the movements (eg, it is hard to tickle your- thoughts of many neurologists as the self). These data are in keeping with the positive clinical signs described in this idea that symptoms are generated via article do not distinguish whether or normal voluntary muscle pathways but not symptoms are genuine.36 The only are associated with a loss of ‘‘agency’’ ways to distinguish malingering from a (the feeling that he or she is in control of genuine disorder are to seek evidence of the action). A neuroscience of functional a major discrepancy between reported disorders is, therefore, once again emerg- and observed function or obtain a confes- ing, as it did in the late 19th century. This sion. It is worth remembering that a neuroscience integrates psychological discrepancy between reported symptoms

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Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited. & KEY POINT (eg, my pain is 11/10) and reported Telling the patient that they do not h Consider whether your function (eg, able to work through the haveaneurologicdiseaseand patients with functional pain) does not indicate malingering. expecting the patient to be satisfied. disorders are satisfied An interesting study using wrist watch This approach is common but is one with your consultations. accelerometers showed that patients that leaves the patient with a weak There may be a simple with functional tremor massively over- leg or tremor asking, ‘‘What is solution to improve estimated how much of the time their wrong with me?’’ communication, which tremor was present (84% versus 4%) & Prematurely attributing the functional may rely on following the paradigm of a compared to controls with essential symptoms to psychological problems. standard explanation tremor and Parkinson disease (58% ver- While psychological factors may be sus 25%).37 The fact that this occurs even used elsewhere in relevant in some, the connection is in a research study with the patients’ neurologic practice. rarely as straightforward as many full awareness of what is being mea- doctors presume. In addition, from sured shows the difficulty patients have in providing accurate reports. It seems the patient’s perspective, psychological likely that the patients with functional explanations are often interpreted tremor were experiencing their tremor as blame or, worse still, accusations whenever they thought about it or of malingering. looked at the affected limb. So if a pa- & Emphasizing a negative neurologic tient looks improved when walking to workup as the rationale for the the car after the appointment, is that a diagnosis. Patients who think the disorder of attention or exaggeration? diagnosis has been made simply Malingering does undoubtedly occur, because the tests are normal may, especially in medicolegal scenarios. How- quite rightly, think that this ever, other indicators suggest that ma- approach is not a robust way of lingering is an implausible explanation making a diagnosis. for the vast majority of patients with Rather than employing any of these functional disorders. These include per- three approaches, neurologists could con- sistence of symptoms on long-term sider using the same paradigm they use follow-up, clustering of functional dis- with neurologic disease. For example, orders, associated comorbidities, and, when diagnosing Parkinson disease, perhaps, most importantly, the consis- neurologists do not typically start the tent description of the experience by conversation with their patients by list- the patients themselves. ing all the conditions they do not have and then leaping to the largely unknown TREATMENT etiology of the condition. Instead, neu- Neurologic Assessment and rologists generally tell patients what con- Explanation of the Diagnosis dition they have been diagnosed with, The first step in treatment is educating the how the assessment has led to the diag- patient about the nature of their diagnosis. nosis, and something about the mech- Many neurologists find this process chal- anism of the problem in Parkinson lenging, which is unfortunate because, disease (eg, not enough dopamine). if handled like other neurologic diagnoses, it is not so problematic. Before making sug- Suggestions for Explanation gestions, it is worth examining some Applying the normal mode of explana- conventional approaches and why they so tion used for any other condition seen in often seem to end in unhappy patients neurologic practice for functional disor- and doctors. Some common reasons ders can work surprisingly well. A rigid why explanation goes wrong include: adherence to one type of explanation or

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KEY POINT h Emphasize to the terminology is not recommended; in- should be secondary to conveying patient what condition stead, physicians should tailor the dis- the actual diagnosis. they do have, rather cussion not only to their own views on & Use educational material such as than what they do not these disorders but also to the patient’s www.neurosymptoms.org or have. Make it clear you own beliefs and expectations elicited www.nonepilepticattacks.info. believe them and, if earlier in the history. The following Patient-run organizations such as possible, show them the strategies are worth considering: www.fndhope.org now provide signs that have led you useful material. to the diagnosis. Provide & Explain what condition the patient & Supplement your assessment with either written or online does have (eg, ‘‘You have a a copy of your clinic letter to the educational materials. functional movement disorder.’’). patient. This aids transparency, & Explain something about this ensures that you can agree on the diagnosis as the patient is unlikely to accuracy of the history, and have heard of it before (eg, ‘‘This enables the motivated patient is a common diagnosis in neurology. to improve. It means there is a problem with the software (the function) of the nervous Additional Roles for the system, rather than the hardware.’’). Neurologist After Diagnosis & Emphasize that their condition is a Many neurologists have been taught that genuine problem since the patient their role is simply to exclude disease in may be wondering, especially patients with functional disorders. In based on past experience, if the fact, the neurologist, as the doctor who neurologist considers the condition understands the diagnosis, is in a key made-up. For example, ‘‘This is a position to initiate and coordinate opti- genuine problem. I believe you,’’ mal care (Table 15-4). are helpful phrases to use. Follow-up for the patient with a com- & Show the patient how you reached plex functional disorder is essential so this diagnosis.38 In the authors’ as to review and reinforce the patient’s experience, one of the most useful understanding of the diagnosis. For interventions is to demonstrate the patients who understand that they have a physical signs that have led to the positive diagnosis, rather than just an ab- diagnosis. For example, show the sence of an alternative disease diagnosis, patient their Hoover sign, the and who are beginning to see that their entrainment test for tremor, or condition has the potential for reversibil- describe the salient features of the ity, further treatment with physical thera- attack. Explain how the sign shows py (first-line treatment choice for motor that they are, for example, weak or symptoms) or psychotherapy (first-line shaking, but also that when they are treatment for dissociative [nonepileptic] distracted, symptoms improve. This attacks) will be worthwhile. approach proves that the software, Alternatively, when a patient who not the hardware, is causing the returns from the initial appointment symptoms and that the potential for strongly disagreeing with the diagnosis improvement exists. For seizures, of a functional disorder and requesting explain the positive features of more investigations, there may be no the attack that are typical for a point embarking on further therapy. dissociative (nonepileptic) attack. Attempting therapy at this stage will just & It may be useful to outline why the be frustrating for the patient and the diagnosis is not a condition such as therapist. Instead, the neurologist should epilepsy or MS, but this explanation decide whether the patient needs further

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Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited. KEY POINT explanation and time to understand the tant to ensure which patients receive h Neurologists are best diagnosis. If further explanation appears appropriate review. placed to explain the futile, it may be reasonable to explain to diagnosis and the patient, ‘‘I believe you, but you don’t Physical Therapy coordinate further care believe me.’’ For motor symptoms such as gait disorder, of patients with functional Neurologists can also give patients limb weakness, and movement disorder, neurologic disorders. some basic advice about rehabilitation, the experience of the authors of this (eg, do more on your bad days, less on article, and increasingly supported by your good days) and specific symptom published studies, is that physical ther- management (eg, distraction techniques apy provided by someone who under- for attacks or simple exercises for motor stands functional disorders is the early symptoms). Neurologists should also rec- treatment of choice. ognize and treat obvious comorbidities Intuitively, if a patient has a problem such as depression and anxiety. with movement, then a therapist who can Diagnoses are not always clear-cut, and assess, analyze, and reeducate movement some patients may have both a functional will be helpful. Published studies are disorder and a neurologic disease.39 It coalescing around a model of physical is unlikely to be practical or necessary to therapy that reinforces the neurologist’s provide long-term follow-up with all explanation, encourages normal move- patients, so clinical judgment is impor- ment, utilizes the positive clinical signs

TABLE 15-4 Assessment and Treatment of Functional Neurologic Disorders: Moving From a Psychogenic to a Functional Model

Traditional Approach Suggested Replacement Emphasis on looking for Initial focus on physiologic triggers and recent stress or childhood abuse dissociative symptoms that help explain the mechanism of symptoms; exploration of more remote factors may be appropriate later in some, but not all, patients Overt questions about depression May be appropriate but not necessary for and anxiety diagnosis, and assessment can wait Diagnosis of exclusion based on Diagnosis based on positive diagnostic normal tests or bizarre nature criteria, not normal tests or because disorder of complaints appears bizarre Explanation as ‘‘stress-related’’ Explanation as a functional disorder of the or ‘‘psychogenic’’ nervous system which may or may not be influenced by stress Keep diagnostic ‘‘tricks’’ secret Show the patient their positive signs to from the patient enable them to understand how the diagnosisisbeingmade Neurologists see themselves purely Neurologist takes responsibility for as diagnosticians passing initiating and supervising treatment and responsibility for treatment elsewhere onward referrals Treatment is entirely psychological Treatment may involve combinations of physical therapy, psychological treatment, and other modalities

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KEY POINTS h Physical therapy for of the disorder to help in that process, psychologists should no longer be able to functional motor and builds in elements of a cognitive- conclude that they have nothing to offer symptoms, where behavioral approach to change in the patient with a functional disorder if 40Y42 expertise is present, may movement. Physical therapy for there is no comorbidity or recent stress. be the first-line functional disorders has some elements Studies of cognitive-behavioral ther- treatment of choice in common to rehabilitation for disorders apy for patients with dissociative (non- Y many situations. like stroke and MS, but also has many epileptic) attacks are encouraging.45 47 h Psychotherapy for elements that are different. For example, Cognitive-behavioral therapy is based functional neurologic someone with functional leg weakness on a model of attacks which overlaps disorders has an should be encouraged to think less about with that of panic disorder. Although increasing evidence their leg when they walk, not more. Some- patients are typically reluctant to de- base, particularly in one with functional tremor may benefit scribe warning symptoms, or may have relation to dissociative from being taught how to superimpose lost them over time, symptoms are often (nonepileptic) attacks. large sweeping movements on their present and helpful to identify as treat- tremor to gain control of the underlying ment targets.15 In this model, the rhythm. Detailed consensus recommen- attacks can be seen as a dissociative dations have recently been published de- response to autonomic arousal. Using scribing these techniques.43 Many of these learning theory and viewing the attacks treatments only make sense to patients as a form of conditioned response can with some confidence in the diagnosis help therapists unfamiliar with this of a functional disorder. However, for area start to see treatment targets from some patients, seeing their improvement a more familiar perspective. Cognitive- with treatment can be a powerful way to behavioral therapy may also be helpful gain that confidence. A randomized con- for a range of other functional disorders, trolled trial of rehabilitation using these especially in combination with other ther- principles showed dramatic benefits in 60 apies such as physical therapy or speech patients with functional gait disorder.40 therapy.48 Other forms of psychother- Similar retrospective41 and prospective apy such as those based on psychody- studies44 of daily outpatient rehabilitation namic or attachment models may also be for functional movement disorder have of value, depending on the patient.49 been similarly encouraging. Other Treatments Psychiatric Assessment and In some patients, considering less con- Psychological Therapy ventional treatments may be worthwhile. Patients with functional disorders have Hypnosis. Hypnosis has a long history a higher rate of comorbid psychiatric indicating benefit for some patients with disorders, predominantly anxiety, panic functional disorders and is also supported disorder, and depression, than disease by randomized trial evidence.50 controls. Obsessive-compulsive disorder, Sedation. Sedation has also been personality disorders, and posttraumatic used for more than 100 years both as a stress disorder are also overrepresented. form of abreaction (a process of reveal- Assessment and management of these ing facets of the history under sedation comorbid conditions can be highly benefi- which the authors of this article gener- cial to a patient with a functional disorder, ally would not endorse) but also as a way especially from someone who under- of demonstrating the potential for re- stands how these disorders interact with versibility in a patient where bedside one another. testingdoesnotallowthisapproach(eg, One of the implications of the new fixed dystonia, paraplegia, or mutism). DSM-5 criteria is that psychiatrists and For the latter, sedation is sometimes

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Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited. highly effective (Supplemental Digital of functional symptoms using concepts Content 15-8, links.lww.com/CONT/ such as dissociation and abnormally A149).51 focused attention in the context of etio- Transcranial magnetic stimulation. logic factors, which vary hugely between Various forms of electrotherapy have patients but still may include psychosocial been successfully applied to functional factors (Table 15-4). The neurologist’s disorders since the late 18th century, ability to explain the diagnosis and edu- primarily by application to the affected cate the patient is of critical importance to limb. Several studies have suggested that the subsequent likelihood of successful transcranial magnetic stimulation may treatment. Evidence is now emerging for have therapeutic potential.52,53 Separat- the utility of multidisciplinary treatment, ing out transcranial magnetic stimulation especially specific physical therapy (for as biofeedback (seeing the limb move), motor symptoms) and psychotherapy transcranial magnetic stimulation as a (for attacks or seizures). neuromodulator (which none of the published studies plausibly deliver), ACKNOWLEDGMENTS and the therapeutic effect of the clinician Theauthorswouldliketothankthe delivering the treatment, is the main patients who gave their permission for challenge in interpreting these studies. their photos and videos to be shown with Nonetheless, transcranial magnetic stim- this article and to Mark Edwards, MBBS, ulation warrants further study. for permission to reuse Supplemental Medication. Evidence exists that anti- Digital Content 15-4. depressants may help a range of functional disorders, but there is insufficient evidence that antidepressants effectively treat func- VIDEO LEGENDS tional neurologic disorders.54 In practice, Supplemental Digital those patients with comorbid anxiety or Content 15-1 depression may benefit. Acute dissociation and functional fa- Multidisciplinary rehabilitation. cial spasm. This video shows a 74-year- Published data support the view that old woman with recurrent episodes of there can be value in admitting some left functional hemiparesis. She describes patients with functional motor disorders acute dissociation at the onset of the for a combination of all of the treatments symptoms and demonstrates jaw devia- described above.55Y57 Infrequent outpa- tion to the left and left platysma contrac- tient sessions may not allow the prog- tion as part of functional facial spasm. ress in confidence required in some links.lww.com/CONT/A142 cases for successful rehabilitation. Reproduced with permission from Stone J, Carson A. Psychogenic, functional and dissociative neurological CONCLUSION symptoms. In: Daroff RB, Fenichel GM, Jankovic J, Functional disorders are a common cause Mazziotta JC, eds. Neurology in clinical practice. 7th B of disability and patient distress in neuro- edition. Philadelphia: Elsevier (In press). Elsevier. logic practice. The diagnosis should be made on positive grounds, not because Supplemental Digital tests are normal, and preferably using Content 15-2 signs on examination that also can be Right lower facial spasm.Thisvideo usefully shared with the patient. The older shows the patient in Case 15-1 who has conversion model, in which all patients right platysma contraction induced dur- were presumed to have stress, has given ing the examination with jaw deviation way to an emphasis on the mechanisms to the right, which gives a superficial

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appearance of weakness but is actually Neurol 2014;14(6):422Y424. B 2014 BMJ Publishing functional facial spasm/dystonia. Group Ltd. links.lww.com/CONT/A143 Supplemental Digital Content 15-6 B Jon Stone, MB, ChB, FRCP, PhD. Reproduced with permission. Functional left hemiparesis.Thisvideo shows a patient describing his limbs feel- Supplemental Digital ing alien and artificial. He has a typical Content 15-3 dragging gait of functional hemiparesis Right leg Hoover sign.Thisvideoshows with the hip internally rotated. With his a positive right leg Hoover sign in the pa- eyes closed, the patient’s bent foot feels tient in Case 15-1 who developed acute straight, in keeping with a distorted right facial spasm and a right hemiparesis cerebral map. and was initially thought to have had links.lww.com/CONT/A147 astroke. Reproduced with permission from Stone J, Carson A. links.lww.com/CONT/A144 Psychogenic, functional and dissociative neurological symptoms. In: Daroff RB, Fenichel GM, Jankovic J, B Mazziotta JC, eds. Neurology in clinical practice. 7th Jon Stone, MB, ChB, FRCP, PhD. Reproduced with edition. Philadelphia: Elsevier (In press). B Elsevier. permission. Supplemental Digital Supplemental Digital Content 15-7 Content 15-4 Bilateral functional dystonia. This Tremor entrainment test.Thisvideo video shows a patient with long-standing shows a patient with bilateral arm tremor. bilateral functional dystonia of both legs When asked to do mental arithmetic, the with characteristic internal hip rotation patient exhibits little difference in tremor. and ankle inversion. When copying cued movements in one hand, the contralateral tremor initially links.lww.com/CONT/A148 ceases, then entrains. Ballistic movements Reproduced with permission from Stone J, Carson A. lead to brief pauses. Psychogenic, functional and dissociative neurological symptoms. In: Daroff RB, Fenichel GM, Jankovic J, links.lww.com/CONT/A145 Mazziotta JC, eds. Neurology in clinical practice. 7th edition. Philadelphia: Elsevier (In press). B Elsevier. Reproduced with permission from Roper LS, Saifee TA, Parees I, et al. How to use the entrainment test in the Supplemental Digital diagnosis of functional tremor. Pract Neurol 2013;13(6): 396Y398. B 2013 BMJ Publishing Group Ltd. Content 15-8 Therapeutic sedation.Thisvideo Supplemental Digital shows two patients, the first with triplegia Content 15-5 and the second with fixed dystonia, Improvement of balance disorder with undergoing successful therapeutic seda- distraction. This video shows a patient tion with propofol. who presents acutely with falls and links.lww.com/CONT/A149 unsteadiness on standing. She describes Reproduced with permission from Stone J, Hoeritzauer I, dissociation during the falls and is un- Brown K, Carson A. Therapeutic sedation for functional steady when standing, but she becomes (psychogenic) neurological symptoms. J Psychosom Res Y B stable when testing eye movements. 2014;76(2):165 168. 2014 Elsevier. links.lww.com/CONT/A146 REFERENCES 1. Fahn S, Olanow CW. ‘‘Psychogenic Reproduced with permission from Scott S, Stone J. movement disorders’’: they are what they iPhone-responsive functional gait disorder. Pract are. Mov Disord 2014;29(7):853Y856.

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Copyright © American Academy of Neurology. Unauthorized reproduction of this article is prohibited. 2. Edwards MJ, Stone J, Lang AE. From disorders. J Neurol Sci 2014;338(1Y2):174Y177. psychogenic movement disorder to doi:10.1016/j.jns.2013.12.046. functional movement disorder: it’s time to 15. Hendrickson R, Popescu A, Dixit R, et al. change the name. Mov Disord Panic attack symptoms differentiate 2014;29(7):849Y852. doi:10.1002/mds.25562. patients with epilepsy from those with 3. Stone J, Carson A, Duncan R, et al. Who is psychogenic nonepileptic spells (PNES). V referred to neurology clinics? the diagnoses Epilepsy Behav 2014;37:210Y214. doi:10.1016/ made in 3781 new patients. Clin Neurol j.yebeh.2014.06.026. Neurosurg 2010;112(9):747Y751. doi:10.1016/ j.clineuro.2010.05.011. 16. Stone J. Functional neurological disorders: the neurological assessment as treatment. 4. Wessely S, Nimnuan C, Sharpe M. Functional Neurophysiol Clin 2014;44(4):363Y373. somatic syndromes: one or many? Lancet doi:10.1016/j.neucli.2014.01.002. 1999;354(9182):936Y939. 5. Nimnuan C, Hotopf M, Wessely S. Medically 17. Stone J, Carson AJ. The unbearable unexplained symptoms: an epidemiological lightheadedness of seizing: wilful study in seven specialities. J Psychosom Res submission to dissociative (non-epileptic) 2001;51(1):361Y367. seizures. J Neurol Neurosurg Psychiatry 2013;84(7):822Y824. doi:10.1136/ 6. Carson A, Stone J, Hibberd C, et al. Disability, jnnp-2012-304842. distress and unemployment in neurology outpatients with symptoms ‘unexplained by 18. Daum C, Hubschmid M, Aybek S. The value organic disease’. J Neurol Neurosurg of ‘positive’ clinical signs for weakness, Psychiatry 2011;82(7):810Y813. doi:10.1136/ sensory and gait disorders in conversion jnnp.2010.220640. disorder: a systematic and narrative review. J Neurol Neurosurg Psychiatry 2014; 7. American Psychiatric Association. Diagnostic 85(2):180Y190. doi:10.1136/jnnp-2012-304607. and statistical manual of mental disorders. 5th ed. Washington, DC: American Psychiatric 19. Zeuner KE, Shoge RO, Goldstein SR, et al. Association, 2013. Accelerometry to distinguish psychogenic from essential or parkinsonian tremor. 8. World Health Organization. ICD-11 beta draft: Neurology 2003;61(4):548Y550. doi:10.1212/ joint linearization for mortality and morbidity 01.WNL.0000076183.34915.CD. statistics. apps.who.int/classifications/icd11/ browse/l-m/en. Updated February 19, 2015. 20. Roper LS, Saifee TA, Parees I, et al. How to Accessed April 6, 2015. use the entrainment test in the diagnosis of 9. American Psychiatric Association. Diagnostic functional tremor. Pract Neurol 2013;13(6): Y and statistical manual of mental disorders: 396 398. doi:10.1136/practneurol-2013-000549. DSM-IV. Washington, DC: American Psychiatric 21. Schrag A, Trimble M, Quinn N, Bhatia K. The Association, 2000. syndrome of fixed dystonia: an evaluation of Y 10. Centers for Disease Control and Prevention, 103 patients. Brain 2004;127(pt 10):2360 2372. International Classification of Diseases, doi:10.1093/brain/awh262. Tenth Revision, Clinical Modification 22. Fasano A, Valadas A, Bhatia KP, et al. (ICD-10-CM). www.cdc.gov/nchs/icd/ Psychogenic facial movement disorders: icd10cm.htm. Updated September 26, 2014. clinical features and associated conditions. Accessed April 6, 2015. Mov Disord 2012;27(12):1544Y1551. 11. Stone J, LaFrance WC, Brown R, et al. doi:10.1002/mds.25190. Conversion disorder: current problems and 23. Wolfsegger T, Pischinger B, Topakian R. potential solutions for DSM-5. J Psychosom Objectification of psychogenic postural Y Res 2011;71(6):369 376. doi:10.1016/ instability by trunk sway analysis. J Neurol j.jpsychores.2011.07.005. Sci 2013;334(1Y2):14Y17. doi:10.1016/ 12. Stone J, Hallett M, Carson A, Bergen D, j.jns.2013.07.006. Shakir R. Functional disorders in the neurology 24. Avbersek A, Sisodiya S. Does the primary section of ICD-11: a landmark opportunity. literature provide support for clinical signs Y Neurology 2014;83(24):2299 2301. used to distinguish psychogenic nonepileptic 13. Stone J, Warlow C, Sharpe M. Functional seizures from epileptic seizures? J Neurol weakness: clues to mechanism from the Neurosurg Psychiatry 2010;81(7):719Y725. nature of onset. J Neurol Neurosurg doi:10.1136/jnnp.2009.197996. Y Psychiatry 2012;83(1):67 69. doi:10.1136/ 25. Chen CS, Lee AW, Karagiannis A, et al. jnnp-2011-300125. Practical clinical approaches to functional 14. Paree´ s I, Kojovic M, Pires C, et al. Physical visual loss. J Clin Neurosci 2007;14(1):1Y7. precipitating factors in functional movement doi:10.1016/j.jocn.2006.03.002.

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