Roselyn W. Clemente Fuentes, MD, FAAFP; Functional neurological Merima Bucaj, DO, FAAFP; Sundonia J. W. Wonnum, PhD, LCSW ­disorder: A practical guide Eglin Family Medicine Residency, Eglin Air Force Base, FL (Dr. Clemente to an elusive Dx Fuentes); Abrazo Health Network Family Medicine Residency, Phoenix, AZ The complexity of this disorder poses a clinical challenge (Dr. Bucaj); Defense Health Headquarters, Falls Church, like few others. VA (Dr. Wonnum)

roselynjan.w.fuentes. [email protected]

CASE u The authors reported no PRACTICE John D,* a 25-year-old patient with an otherwise unremarkable potential conflict of interest RECOMMENDATIONS relevant to this article. medical history, describes 2 months of daily , lower- ❯ Avoid using stigmatizing extremity weakness, and unsteady gait that began fairly sud- The opinions and assertions terminology (eg, adding contained herein are the private denly during his first deployment in the US Army. He explains views of the authors and are not the prefix “pseudo” or the to be construed as official or as that these symptoms affected his ability to perform his duties adjective “hysterical”) to reflecting the views of the US Air and necessitated an early return stateside for evaluation and Force Medical Department or the characterize a suspected US Air Force at large. functional neurological treatment. disorder (FND) or a Mr. D denies precipitating trauma or unusual environmen- doi: 10.12788/jfp.0155 medically unexplained tal exposures. He reports that, stateside now, symptoms con- disorder. C tinue to affect his ability to work and attend to personal and ❯ Refrain from ordering family responsibilities. functional magnetic Asked about stressors, Mr. D notes the birth of his first child resonance imaging as part approximately 3 months ago, while he was deployed, and mari- of the routine evaluation of tal stressors. He denies suicidal or homicidal ideation. suspected FND. C * The patient’s name has been changed to protect his identity. ❯ Validate the patient‘s concerns with an appropriate diagnostic label; The challenge of identifying use layman’s terms to discuss and managing FND the diagnostic parameters A functional neurological disorder (FND) is a constellation of FND and the cause of of psychological, physiological, and neurological symptoms, symptoms; and emphasize without an identifiable organic etiology, a conscious decision, treatment possibilities and or secondary gain for the patient,1 that adversely impacts func- plans. C tioning in 1 or more significant life domains. Strength of recommendation (SOR) Given the high throughput of patients in primary care prac- A Good-quality patient-oriented tices, family physicians can expect to encounter suspected cases evidence of FND in their practices. Regrettably, however, a lack of famil- B Inconsistent or limited-quality patient-oriented evidence iarity with the disorder and its related problems (eg, nonorganic  C Consensus, usual practice, , sensory loss, nonepileptic , and abnormal opinion, -oriented evidence, case series movements) can add as much as $20,000 in excess direct and indirect costs of care for every such patient.1 In this article, we synthesize the recent literature on FND so that family physicians can expand their acumen in understanding, identifying, and evaluating patients whose presentation suggests FND. CONTINUED

MDEDGE.COM/FAMILYMEDICINE VOL 70, NO 2 | MARCH 2021 | THE JOURNAL OF FAMILY PRACTICE 69 An underrecognized entity false-negative finding because of an atypical A precise estimate of the prevalence of FND presentation. It is important to avoid misdi- is difficult to determine because the disorder agnosis by prematurely closing the differen- is underrecognized and misdiagnosed and tial diagnosis; instead, keep in that a because it is often accompanied by the con- medically unexplained diagnosis might be founding of psychological and physiological better explained by conducting a robust so- comorbidities. A 2012 study estimated the cial and medical history and obtaining addi- annual incidence of FND to be 4 to 12 cases tional or collateral data, or both, along with for every 100,000 people2; in primary care appropriate consultation.4,9 and outpatient settings, preva- Misdiagnosis can lead to a circuitous and lence is 6% to 22% of all patients.3,4 Stone and costly work-up, with the potential to increase colleagues identified functional neurological the patient’s distress. You can reduce this symptoms as the second most common rea- burden with early recognition of FND and son for outpatient neurology consultation,5 centralized management of multidisciplinary with 1 nonepileptic patient seen for care, which are more likely to lead to an accu- every 6 epileptic patients, and functional rate and timely diagnosis—paramount to em- weakness presenting at the same rate as mul- powering patients with access to the correct tiple sclerosis.6 information and meaningful support needed Demographics of patients with FND to enhance treatment and self-care.9 Remain cautious vary, depending on presenting neurologi- ❚ Bias, haste, and dismissal are unpro- about making a cal symptoms and disorder subtype. Exist- ductive. Even with a clear definition of FND, diagnosis of FND ing data indicate a correlation between FND it is not uncommon for a physician to rapidly by exclusion; and younger age, female sex, physical dis- assess a patient’s clinical signs, make a diag- an atypical ability,7 and a history of abuse or trauma.3,8 nosis of “unknown etiology,” or openly ques- presentation A challenge in concretely ascertaining the tion the veracity of complaints. Furthermore, might lead to prevalence of FND is that conditions such as be aware of inadvertently characterizing an incorrect or fibromyalgia, chronic pelvic , globus hys- FND using the prefix “pseudo” or the term false-negative tericus, and nonepileptic seizures can also “hysterical,” which can be psychologically finding. be characterized as medically unexplained discomforting for many patients, who legiti- functional disorders, even within the network mately experience inexplicable symptoms. of neurology care.4 Such pejoratives can lead to stigmatizing and misleading assessments and treatment Misdiagnosis and bias paths4—courses of action that can cause ear- are not uncommon ly and, possibly, irreparable harm to the pa- Ambiguity in classifying and evaluating FND tient–physician relationship and increase the can affect physicians’ perceptions, assess- patient’s inclination to go “doctor-shopping,” ment, and care of patients with suggestive with associated loss of continuity of care. presenting symptoms. A major early chal- lenge in diagnosing FND is the inconsistency Why is it difficult of characterizing terminology (pseudoneu- to diagnose FND? rological, somatic, dissociative, conversion, The latest (5th) edition of the Diagnostic psychogenic, hysterical, factitious, functional, and Statistical Manual of Mental Disorders medically unexplained 9,10) and definitions in (DSM-5) describes conversion, somatoform the literature. Neurological symptoms of un- disorder, and FND synonymously. DSM-5 identifiable organic cause can greatly dimin- diagnostic criteria for ish quality of life4; FND is a scientifically and are11: clinically useful diagnosis for many combina- • a specified type of symptom or deficit tions of nonrandomly co-occurring symp- of altered voluntary motor or sensory toms and clinical signs. function (eg, weakness, difficulty swal- ❚ The pitfall of misdiagnosis. Remain lowing, slurred speech, seizures) cautious about making a diagnosis of FND by • clinical evidence of the incompatibil- exclusion, which might yield an incorrect or ity of the symptom or deficit and any

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recognized neurological or medical CASE u disorder ❚ History. Mr. D’s history is positive for light • incapability of better explaining the alcohol consumption (“2 or 3 cans of beer on symptom or deficit as another medical weekends”) and chewing tobacco (he reports or . stopping 6 months earlier) and negative for • The symptom or deficit causes distress . The family history is posi- or impairment that (1) is clinically tive for maternal hypertension and paternal significant in occupational, social, or suicide when the patient was 10 years old (no other important areas of function or other known paternal history). (2) warrants medical evaluation. ❚ Physical findings. The review of sys- tems is positive for intermittent palpitations, The overarching feature of these criteria lower-extremity weakness causing unsteady is the inconsistency of symptoms with recog- gait, and generalized headache. nized neurological, physiological, or psy- Vital signs are within normal limits, in- chiatric conditions. Although identification cluding blood pressure (120/82 mm Hg) and of psychological factors can help clarify and heart rate (110 beats/min). The patient is provide a treatment direction, such identifi- not in acute distress; he is awake, alert, and cation is not essential for making a diagnosis oriented × 3. No murmurs are heard; lungs of FND. Malingering does not need to be re- are clear bilaterally to auscultation. There is futed as part of establishing the diagnosis.12 no tenderness on abdominal palpation, and Ask the patient In contrast, the World Health Organiza- no hepatomegaly or splenomegaly; bowel to list all of his tion’s ICD-10 Classification of Mental and Be- sounds are normal. No significant bruising or or her symptoms havioural Disorders groups diagnostic criteria lacerations are noted. at the beginning for FND among the dissociative disorders13: ❚ Neurology exam. Cranial of the interview; • Clinical features are specified for the II-XII are intact. Pupils are equal and reactive this can help individual (mo- to light. Reflexes are 2+ bilaterally. Muscle elucidate a tor, sensory, convulsions, mixed). strength and tone are normal; no tremors are complex or • Evidence is absent of a physical disor- noted. Babinski signs are normal. A Romberg ambiguous der that might explain symptoms. test is positive (swaying). presentation. • Evidence of psychological causation is Mr. D has an antalgic gait with significant present in clear temporal association swaying (without falling); bent posture; and with stressful events and problems or unsteadiness that requires a cane. However, disturbed relationships, even if the pa- he is able to get up and off the exam table tient denies such association. without assistance, and to propel himself, by rolling a chair forward and backward, without Note the emphasis on psychological causa- difficulty. tion and exclusion of purposeful simulation of symptoms, as opposed to a primarily un- Conducting a diagnostic conscious disconnection from the patient’s examination body or environment. ❚ Taking the history. Certain clues can aid in ICD-10 guidelines acknowledge the dif- the diagnosis of FND (TABLE 1).15 For example, ficulty of finding definitive evidence of a the patient might have been seen in multiple psychological cause and recommend provi- specialty practices for a multitude of vague sional diagnosis of FND if psychological fac- symptoms indicative of potentially related tors are not readily apparent.14 Of note, many conditions (eg, chronic , allergies and patients with FND are affected psychologi- sensitivities, fibromyalgia, and other chronic cally by their condition, with an impact on pain). The history might include repeated mood, behaviors, and interpersonal interac- to investigate those symptoms (eg, tions, although not necessarily to a clinically laparoscopy, or hysterectomy at an early age). diagnostic degree. Therefore, a psychiatric Taking time and care to explore all clinical diagnosis alone is not a necessary precursor clues, patient reports, and collateral data are for the diagnosis of an FND. therefore key to making an accurate diagnosis. CONTINUED

MDEDGE.COM/FAMILYMEDICINE VOL 70, NO 2 | MARCH 2021 | THE JOURNAL OF FAMILY PRACTICE 71 TABLE 1 Signs, symptoms, and other findings of FND15a

Alexithymia or inability to describe feelings verbally (associated with increased risk of somatization) Close association with psychological stressors Denial of possible psychiatric cause of symptoms History of coexisting functional disorder History of multiple surgeries and extensive multispecialty work-up History of psychiatric symptoms or disorders Histrionic personality traits Marked inconsistency on repeat physical examination No serious injuries associated with falls or assumed seizures Nonanatomic distribution of abnormalities Normal Notable worsening of signs of the disorder in the presence of other people Persistent symptoms despite tailored medical treatment Vague or inconsistent description of symptoms by the patient A coexisting FND, functional neurological disorder. a A normal neurological examination or the presence of any of the listed in this TABLE does not definitively psychiatric exclude an organic cause. A thorough evaluation and treatment plan still need to be implemented before making a diagnosis diagnosis might of FND. be associated with distress from the Note any discrepancies between the se- signs and clues, and balance them with the presenting verity of reported symptoms and functional patient’s report (or lack of report). Endeavor functional ability. A technique that can help elucidate to demonstrate positive functional signs, neurological a complex or ambiguous medical presenta- such as a positive Hoover test, which relies symptoms—not tion is to ask the patient to list all their symp- on the principle of synergistic muscle con- linked to the toms at the beginning of the interview. This traction. You might see evidence of inconsis- FND diagnosis has threefold benefit: You get a broad picture tency, such as weakness or a change in gait, itself. of the problem; the patient is unburdened of under observation, that seemingly resolves their concerns and experiences your valida- when the patient is getting on and off the tion; and a long list of symptoms can be an exam table.16 TABLE 215-24 describes areas af- early clue to a diagnosis of FND. fected by FND, characteristics of the disorder, Other helpful questions to determine the and related diagnostic examinations. impact of symptoms on the patient’s well-­ TABLE 315,18,19 reviews validated special being include inquiries about16: exams that can aid in making the diagnosis. • functional impairment Additional special tests are discussed in the • onset and course of symptoms literature.15-24 These tests can be helpful in • potential causal or correlating events narrowing the differential diagnosis but have • dissociative episodes not been validated and should be used with • previous diagnoses and treatments caution. • the patient’s perceptions of, and emo- Some clinical signs associated with FND tional response to, their illness might be affected by other factors, includ- • a history of abuse. ing socioeconomic status, limited access to health care, low health literacy, poor com- ❚ The physical examination to deter- munication skills, and physician bias. Keep mine the presence of FND varies, depending these factors in mind during the visit, to avoid on the functional area of impact (eg, motor, contributing further to health disparities neurological, sensory, speech and swallow- among groups of patients affected by these ing). Pay particular attention to presenting problems.

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TABLE 2 The physical examination in suspected FND15-24 Functional area Diagnosis Alternative Characteristics Diagnostic observations and of impact terminologya examinations Motor Functional gait Hysterical gait Ambulatory dysfunction Normal reflexes, muscle tone, and abnormality strength Astasia–abasia Variable gait pattern, with rapid fluctuation over Absence of fall-related injury minutes Motor inconsistency18,19b Other patterns that do not Dragging monoplegic gait16,19b commonly duplicate those of neurological Uneconomic posture (eg, camptocormia [bent-spine syndrome])16 Involves uneconomic postures, slowness, fatigue, “Walking-on-ice” pattern16 and trembling Pseudoataxia16 Able to catch self before Sudden knee-buckling16 falling16 Normal neurological function on magnetic resonance imaging17 Chair test18,19b Functional Pseudo-paralysis Sudden onset of symptoms Hoover test18,19b paralysis or with involvement of a single Abductor sign18,19b weakness limb or half of the body Abductor finger sign18,19b Weakness does not follow anatomic patterns16 Spinal injury test18,19b Inconsistency on repeat Motor inconsistency18,19b examination16 Normal reflexes, muscle tone, and sphincter function Collapsing weakness (intermittent weakness)16,19 Co-contraction of antagonist muscle16,19 Negative Babinski signs16 Functional magnetic resonance imaging (left hemisphere or anterior and medial prefrontal activation)17 Functional Psychogenic Can mimic tremor, Motor inconsistency18,19b movement movement parkinsonism, , Abnormal movement stops when disorder disorder dystonia, tics, and dyskinesia, distracted but has atypical onset, course, or manifestations16 Variability of unwanted movements in distribution, frequency, and amplitude16 Rapid onset (unusual in organic disease)16 Increased weighted amplitude (organic tremor decreases)16 Dystonia waxes and wanes16 Electromyography20

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CASE u monitor; laboratory testing (including a com- The work-up over the next month for Mr. D plete blood count, comprehensive metabolic includes numerous studies, all yielding results panel, thyroid-stimulating hormone, creatine that are negative or within normal limits: vi- kinase, erythrocyte sedimentation rate, C-­ sual acuity; electrocardiography and an event reactive protein, vitamin B12, folate, and vita-

MDEDGE.COM/FAMILYMEDICINE VOL 70, NO 2 | MARCH 2021 | THE JOURNAL OF FAMILY PRACTICE 73 TABLE 2 The physical examination in suspected FND15-24 (cont'd)

Functional area Diagnosis Alternative Characteristics Diagnostic observations and of impact terminologya examinations Neurological Nonorganic Pseudo- Alteration of Normal pupils, corneal reflexes, plantar coma precipitated by and reflexes, and sphincters presence of an observer Bell phenomenon, in which the eyes roll Slumps to floor without up when the lids are raised—unlike in hitting head21 true coma, in which the eyes remain in a neutral position21 Offers resistance on physical exam Avoids unpleasant stimuli Uncooperative upon “wake Caloric testing with cold water, up” with nonorganic coma, due to intact and (might have nausea and vomiting22) Nonepileptic Hysterical Paroxysmal and involuntary Normal electroencephalographic activity seizures seizures events with changes in (including when sleep deprived and the level of consciousness, during 24-hour monitoring)24 Psychogenic behavior, motor activity, and seizures Tip-of-tongue biting (instead of lateral autonomic function23 biting)24 Seizures are frequent and Clenched teeth, as opposed to open occur in front of an observer24 mouth, during “tonic” phase Characteristic pelvic thrusting, Consider measuring the serum prolactin side-to-side head shaking, level within 20 min of a seizure (the asymmetric limb-shaking24 level is increased 300% in ); Can act out or recall what however, false-positive results are seen occurred during the seizure with syncope and false-negatives are seen with partial seizures; also, the test is Long duration, eyes closed, often performed incorrectly16 asynchronous movements, frequent recurrence in the same context24 Occurrence of seizures waxes and wanes No post-ictal Sensory Functional Pseudo-blindness Normal pupillary response and ophthalmologic optokinetic nystagmus (fixation reflex)15 Pseudo- — syndromes ophthalmologic Unable to sign name or bring fingers syndrome together in front of eyes, which the patient should be able to do16 Functional Numbness or All sensory modalities Increased pulse (20-30 beats/min) or anesthesia anesthesia (touch, pain, vibration, withdrawal from painful stimuli applied proprioception) disappear at to the “numb” part15 a discrete border (joint, skin Hemisensory syndrome or midline crease, midline)—unlike true splitting16,19b sensory loss, in which borders overlap16 Vibratory loss on half of the , sternum, or pelvis with the tuning fork test is physiologically impossible due to bone conduction19 Nonanatomic sensory loss19b Migrating sensory loss19b Erroneous identification with a proprioception test of the big toe

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TABLE 2 The physical examination in suspected FND15-24 (cont'd) Functional area Diagnosis Alternative Characteristics Diagnostic observations and of impact terminologya examinations Speech and Functional Globus hystericus Muteness swallowing aphonia Hysterical Normal cough Functional aphonia — Normal laryngoscopy15 Pressured whispering16 Functional dysphagia Sensation of something in throat16 Stutter or extremely slow speech with long pauses16 FND, functional neurological disorder. a The authors caution against using "pseudo"/"hysterical" in conversation with patients, although these terms may still be encountered in the literature. b See TABLE 3.

min D); magnetic resonance imaging of the tion coexist. For example, a patient with and lumbar spine; lumbar puncture; and epilepsy might also have dissociative seizures electromyography. atop their organic disorder. Neurological dis- The score on the 9-item Patient Health ease is considered a risk factor for an over- Questionnaire for is 4 (severity: lying FND—just as the risk of depression or “none or minimal”); on the 7-item General- anxiety runs concurrently with other chronic ized scale, 0 (“no anxiety .14 disorder”). ❚ Focus on clinical signs to narrow the ❚ Referral. A neurology work-up of head- differential. A thorough social and medical ache, lower extremity weakness, and unsteady history and physical examination, as discussed gait to address several diagnostic possibilities, earlier, help narrow the differential diagnosis including and , is of organic and medically unexplained dis- within normal limits. A cardiology work-up of orders. Well-defined imaging or laboratory palpitations is negative for arrhythmias and protocols do not exist to guide physicians to a other concerning findings. definitive diagnosis, however. Mr. D declines psychiatric and psychologi- ❚ Psychiatric conditions can coexist with cal evaluations. the diagnosis of FND, but might be unrelated. A systematic review of the literature showed Building a differential diagnosis that 17% to 42% of patients with FND had a is a formidable task concurrent anxiety disorder. Depression dis- The differential diagnosis of FND is vast. It orders were co-diagnosed in 19% to 71% of includes neurological, physiological, and patients with FND; dissociative and person- psychiatric symptoms and disorders; somati- ality disorders were noted, as well.25 How- zation; and malingering (TABLE 4).6 Any dis- ever, coexisting psychiatric diagnosis might order or condition in these areas that is in the more likely be associated with distress from differential diagnosis can be precipitated or the presenting functional neurological symp- exacerbated by stress; most, however, do not toms, not linked to the FND diagnosis itself.12 involve loss of physical function.12 In addi- This shift in understanding is reflected in the tion, the diagnosis of an FND does not neces- description of FND in the DSM-5.11 sarily exclude an organic disorder. A patient’s presentation becomes com- CASE u plicated—and more difficult to treat—when Mr. D reports debilitating at return functional symptoms and an unrelated un- office visits. Trials of abortive triptans pro- derlying or early-stage neurological condi- vide no relief; neither do control

MDEDGE.COM/FAMILYMEDICINE VOL 70, NO 2 | MARCH 2021 | THE JOURNAL OF FAMILY PRACTICE 75 TABLE 3 Specialized tests for FND15,18,19 Functional area Validated test Instructions of impact (sensitivity, specificity) Motor Hoover test Relies on the principle of synergistic muscle contraction.18,19 (94%, 99%15,18,19) 1. Place a hand under the heel of the patient’s impaired leg, while pressing down on the good leg with the other hand. Ask the patient to lift the good leg against resistance. If you feel counter-pressure under the impaired leg, this normally means that the leg is not paralyzed from an organic cause. 2. Switch hand positions. Ask the patient to lift the impaired leg. If you do not feel counter-pressure under the heel of the good leg, the patient is not being compliant.15,19

Abductor sign Instruct the patient to abduct each leg. Oppose this movement with your hands placed (100%, 100%15,18,19) on the lateral surfaces of the patient’s legs. When the paretic leg is abducted, the good leg stays in organic paresis but moves in the hyperadducting direction in nonorganic paresis.15,18,19 Abductor finger sign Relies on the same principle as the Hoover sign. (100%, 100%18,19) Test the abduction of fingers in the healthy hand. The fifth finger of the presumed affected hand will display synkinetic abduction.18,19 Spinal injury test Passively position the legs in a flexed posture when the patient is lying in bed. When (100%, 97.9%18,19) the paretic leg falls, the test is considered negative; when it stays in a flexed posture, the test is considered positive.18,19

Collapsing give-way The limb collapses from a normal position with a light touch, or normal strength is weakness developed and suddenly “gives way” (collapses).18,19 (63%, 97%18,19)

Co-contraction of During strength testing, an antagonist muscle contracts simultaneously when an antagonist muscles agonist muscle contracts voluntarily. (17%, 100%18,19) The sign is positive if simultaneous contraction of agonist and antagonist muscles results in little or no movement. The sign can be measured with surface electromyography.18,19 Motor inconsistency The patient’s assertion of the impossibility of a given movement of a muscle even (13%, 98%18,19) though a different movement using the same muscle is possible. Example: A patient with complete plegia of a limb when tested supine stands on the previously plegic limb and walks out of examination room.18,19

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(beta-blockers, coenzyme Q10, magnesium, occupational , , psychol- onabotulinumtoxinA [Botox], topiramate, and ogy, and other mental health professionals) valproate). Lower-extremity weakness and un- establishes a team-based approach that can steadiness are managed with supportive devic- increase the patient’s sense of support and re- es, including a cane, and . duce excessive testing and unnecessary medi- cations, surgeries, and other treatments.26 Importance of establishing Family physicians are in the ideal posi- a multidisciplinary approach tion to recognize the patient’s functional ca- The complexity of FND lends itself to a multi- pacity and the quality of symptoms and to disciplinary approach during evaluation and, provide timely referral (eg, to Neurology and eventually, for treatment. The assessment Psychiatry) for confirmation of the diagnosis and diagnostic intervention that you provide, and then treatment. along with the contributions of consulted spe- Evidence-based treatment options include: cialists (including neurology, physical and • psychotherapy, with an emphasis on

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TABLE 3 Specialized tests for FND15,18,19 (cont'd)

Functional area Validated test Instructions of impact (sensitivity, specificity) Sensory Midline splitting Sensory loss of half the body (with face, trunk, arm, and leg involvement) with a clear (20%, 93%19) edge on the midline. The sign is positive if the patient reports precise splitting of sensation in the midline during sensory exam.19 Splitting Placing a tuning fork on the right or left side of the forehead or the sternum is thus of vibration expected to be felt identically because the same bone is involved. The sign is positive (95%, 14%19) if there is a reported difference in the sensation of the tuning fork placed over the left side, compared to the right side, of the sternum or frontal bone.19

Nonanatomic Diminished sensation fitting a nondermatomal pattern. sensory loss Classically, the following findings are considered nonanatomic19: (74%, 100%19) • truncal deficits that have only an anterior level but not a posterior level • sharply demarcated boundaries at the shoulder or at the groin • sensory loss follows the strict outline of a stocking–glove distribution unilaterally • involvement of only half of a limb.

Inconsistency or Inconsistency and nonreproducibility of sensory signs in repeated sensory testing. changing pattern No precise description exists of how to perform the repeated tests.19 of sensory loss (79%, 70%19) Gait Dragging The leg is dragged at the hip behind the body instead of performing circumduction.19 monoplegic gait (8.4%, 100%19) Chair test The inability to stand or walk despite normal function in bed, in a patient who was (89%, 100%19) observed performing well in propelling a chair. The sign is positive when the patient is observed propelling a swivel chair better than walking.19

FND, functional neurological disorder.

cognitive behavioral therapy imaging is not the recommended standard of • physical therapy care in the initial work-up of FND because of • psychopharmacology its cost and the fact that the diagnosis is princi- • promising combinations of physical pally a clinical undertaking.17,28 and psychological treatment to im- prove long-term functionality.27 Call to action ❚ Offer a generous ear. Begin the diagnostic A promising pursuit by listening carefully and fully to the diagnostic tool patient’s complaints, without arriving at a di- The most significant update in the FND litera- agnosis with unwarranted bias or haste. This ture is on functional for assessing endeavor might require support from other the disorder. Early findings suggest an intricate clinical staff (eg, nurses, social workers, case relationship between mind and body regarding managers) because the diagnostic process the pathological distortion in FND. And, there can be arduous and lengthy. is clear evidence that neuroimaging—specifi- ❚ Convey the diagnosis with sensitivity. cally, functional magnetic resonance imaging— Inquire about the patient’s perceptions and shows changes in brain activity that correspond impairments to best personalize your diag- to the patient’s symptom report. That said, nostic explanations. Delivery of the diagnosis

MDEDGE.COM/FAMILYMEDICINE VOL 70, NO 2 | MARCH 2021 | THE JOURNAL OF FAMILY PRACTICE 77 TABLE 4 ❚ Key tenets of managing care for pa- Differential diagnosis of FND6 tients who have been given a diagnosis of FND include: Neurological and physiological conditions • nonjudgmental, positive regard Autoimmune limbic encephalitis • meaningful expression of empathy Cortical blindness (secondary to ) • multidisciplinary coordination Epilepsy • avoidance of unnecessary testing and Laryngeal dystonia harmful treatments • descriptive and contextual explana- Multiple sclerosis tions of the diagnosis. Movement disorders Spinal or brain injuries or disorders Last, keep in mind that the course of treat- Stiff person syndrome ment for FND is potentially prolonged and Stroke multilayered. Psychiatric conditions Anxiety disorders CASE u After many visits with his family physician and the neurology and cardiology specialists, Depersonalization and de-realization disorder as well as an extensive work-up, the physi- There is clear Depressive disorders cian approaches Mr. D with the possibility of evidence that a diagnosis of FND and proposes a multidisci- functional Panic attacks plinary plan that includes: magnetic • a course of physical and resonance Other occupational therapy imaging reveals • development of individualized changes in brain cognitive behavioral tools Iatrogenic activity that • weekly personal and marital counseling correspond with Malingering • initiation of a selective serotonin the report Substance use reuptake inhibitor for anxiety of symptoms. FND, functional neurological disorder. • monthly visits with his family physician.

Months after his return from deployment for evaluation and treatment, Mr. D is able might affect the patient’s acceptance and to return to military duty. He reports that his compliance with further testing and treat- quality of life has improved. JFP ment of what is generally a persistent and CORRESPONDENCE treatment-resistant disorder; poor delivery Roselyn W. Clemente Fuentes, MD, FAAFP, Eglin Family of diagnostic information can impair the Medicine Residency, 307 Boatner Road, Eglin AFB, FL 32547; [email protected]. patient–physician relationship and increase the risk of disjointed care. Many patients find

that improved patient–­physician communi- References 29 cation is therapeutic. 1. Konnopka A, Schaefert R, Heinrich S, et al. Economics of medi- ❚ cally unexplained symptoms: a systematic review of the litera- Let the patient know that you’re tak- ture. Psychother Psychosom. 2012;81:265-275. ing her seriously. Validate patient concerns 2. Carson AJ, Brown R, David AS, et al; on behalf of UK-FNS. Functional (conversion) neurological symptoms: research with a nonstigmatizing diagnostic label; dis- since the millennium. J Neurol Neurosurg Psychiatry. 2012;83: cuss the diagnostic parameters and cause of 842-850. 3. Stone J, Carson A, Duncan R, et al. Who is referred to neurology symptoms in layman’s terms; and emphasize clinics?—the diagnoses made in 3781 new patients. Clin Neurol the potential for reversibility.30 Some patients Neurosurg. 2010;112:747-751. 4. Evens A, Vendetta L, Krebs K, et al. Medically unexplained neu- are not satisfied with having a diagnosis of rologic symptoms: a primer for physicians who make the initial FND until they are reassured with normal encounter. Am J Med. 2015;128:1059-1064. 5. Stone J, Reuber M, Carson A. Functional symptoms in neurology: results of testing and provided with referral; mimics and chameleons. Pract Neurol. 2013;13:104-113. even then, some seek further reassurance. 6. Stone J, Warlow C, Sharpe M. The symptom of functional

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CONTINUED FROM PAGE 58 absence of appropriate physician oversight.8 and management visits. JAMA Intern Med. 2015;175:101–107. doi:10.1001/jamainternmed.2014.6349 This issue is so concerning to me that I co- 4. Muench, U, Perloff J, Thomas C, et al. Prescribing practices by authored a book on the subject.8 I encourage nurse practitioners and primary care physicians: a descriptive analysis of Medicare beneficiaries. Journal of Nursing Regula- all physicians to educate themselves on this tion. 2017;8:21-30. doi: https://doi.org/10.1016/S2155-8256(17) topic and make practice decisions with the 30071-6 5. Sanchez GV, Hersh AL, Shapiro DJ, et al. Outpatient antibiotic evidence in mind. JFP prescribing among United States nurse practitioners and phy- sician assistants. Open Forum Infect Dis. 2016;10:ofw168. doi: 10.1093/ofid/ofw168. 6. Lohr RH, West CP, Beliveau M, et al. Comparison of the quality of patient referrals from physicians, physician assistants, and nurse References practitioners. Mayo Clin Proc. 2013;88:1266‐1271. doi:10.1016/j. 1. Laurant M, van der Biezen M, Wijers N, et al. Nurses as substi- mayocp.2013.08.013 tutes for doctors in primary care. Cochrane Database of Syst Rev. 7. Nault A, Zhang C, Kim KM, et al. Biopsy use in skin diag- 2018;(7):CD001271. doi: 10.1002/14651858.CD001271.pub3 nosis: comparing dermatology physicians and advanced practice 2. Flynn, BC. The effectiveness of nurse clinicians’ service delivery. professionals. JAMA Dermatol. 2015;151:899-901. doi:10.1001/ AJPH. 1974;64:604-611. jamadermatol.2015.0173 3. Hughes DR, Jiang M, Duszak R. A comparison of diagnostic im- 8. Al-Agba N, Bernard R. Patients at Risk: The Rise of the Nurse Prac- aging ordering patterns between advanced practice clinicians titioner and Physician Assistant in Healthcare. Universal Publish- and primary care physicians following office-based evaluation ers; 2020.

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