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Functional Neurological Disorder: a Practical Guide to an Elusive Dx

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Functional Neurological Disorder: a Practical Guide to an Elusive Dx 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 headache, 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, paralysis, sensory loss, nonepileptic seizures, and abnormal opinion, disease-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 mind 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 neurology 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 seizure 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 pain, 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 conversion disorder 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 70 THE JOURNAL OF FAMILY PRACTICE | MARCH 2021 | VOL 70, NO 2 FUNCTIONAL NEUROLOGICAL DISORDER 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 mental disorder. stopping 6 months earlier) and negative for • The symptom or deficit causes distress substance abuse. 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
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