functional neurological symptoms disorder

1. NEWER INSIGHT IN
FUNCTIONAL NEUROLOGICAL
DISORDER
DR.PRAMOD MEENA
SR NEUROLOGY
GMC,KOTA

2. DEFINITION
Four key diagnostic features of conversion disorder:
1. Neurological symptoms involving motor or sensory symptoms or
loss of consciousness
2. No evidence of organic disease that can explain the symptoms ??
3. Associated psychological stressors (relevant to onset of symptoms)
??
4. Conscious stimulation (feigning) is excluded ??
American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders, 5th ed, American Psychiatric Association, Arlington 2013.

3. ASSOCIATED PSYCHOLOGICAL FEATURES
• Primary gain: by internal conflicts outside their awareness.
• Secondary gain: pt take tangible advantages and benefits as a result
of being sick.
• LA BELLE INDIFFERENCE : patients inappropriately cavalier attitude
toward serious symptoms.
Vignuzzi, M., Stone, J., Arnold, J. et al. Quasispecies diversity determines
pathogenesis through cooperative interactions in a viral population

8. ICD-10-CM, International Classification of Diseases, 10th Revision, Clinical Modifification.

9. CLINICAL FEATURES

12. Functional limb weakness

13. Sonoo M (January 2004) Abductor sign: a reliable new sign to detect unilateral
non-organic paresis of the lower limb

17. a systematic review (Avbersek and Sisodiya, 2010)

18. Advise for functional seizure
1) Stop anticonvulsant
2) Look carefully for warning symptoms and teach distraction techniques
3) Recognize triggers for attacks

21. Facial spasm
• It usually ipsilateral to a functional hemiparesis.
• Nearly always due to unilateral over activity of the platysma muscle
which pulls the side of the lip downwards.
• Contraction of the orbicularis oculi muscle can lead to an
appearance with a depressed eyebrow which may be interpreted
incorrectly as ptosis.
Sapone, Anna, et al. "Spectrum of gluten-related disorders: consensus on new nomenclature and classification." BMC medicine 10.1 (2012): 1-12.

22. From Stone, J.,2009. The bare essentials: functional symptoms in neurology.PractNeurol 9, 179–
189, by permission of BMJ publications.)
Clenched fist and inverted plantiflexed foot

24. Case summary
• A 39-year-old woman p/w recurrent severe migraine, anxiety, and
social withdrawal. She developed a severe migraine with increasing
drowsiness. Her family reported that she appeared more and more
“spaced out” before apparently going to sleep. The family found that
they could not wake her and called an ambulance.
• O/E
she had normal physiologic and biochemical parameters; her eyes
were closed but resisting eye opening; there was no response to
painful stimuli such as nail bed or sternal pressure. MRI, EEG, lumbar
puncture, and extensive testing for metabolic and autoimmune
disorders were negative. Within 5 days she improved. ??????????

27. The eye gaze sign
Patient’s gaze is observed while turning the patient on to one side of
his or her body and then to the other side
• Functional Eyes deviate tonically toward the floor. When turned
over to the either side.
• Organic No spontaneous eye movements, roving eye movements,
or fixed gaze.
Henry and Woodruff, 1978;Dhadphale, 1980,

29. Edwards MJ, Stone J, Lang AE (June 2014). "From psychogenic movement disorder
to functional movement disorder: it's time to change the name“.

31. Functional Neurologic Disorders M. Hallett, J. Stone, and A. Carson, Editors
http://dx.doi.org/10.1016/B978-0-12-801772-2.00024-2 © 2016 Elsevier B.V. All rights
reserved

33. Functional Neurologic Disorders M. Hallett, J. Stone, and A. Carson, Editors
http://dx.doi.org/10.1016/B978-0-12-801772-2.00024-2 © 2016 Elsevier
B.V. All rights reserved

37. DIAGNOSIS
made by
A NEUROLOGIST
on the basis of
positive signs of inconsistency
Functional neurological symptoms, consultant neurologist and honorary senior lecturer Dr Richard J
Davenport, consultant neurologist and honorary senior lecturer 2013 Feb; 13(1): 80–83.

39. Treatment Algorithm
Health Improvement Scotland [2012]

40. Newer Specific Treatment
functional motor symptoms
• Physical aids and appliances/sickness
benefits
• Hypnosis.
• Sedation.
• Transcranial magnetic stimulation (TMS).

44. References
• Bradely’s 8th edition
• ICD-10-CM, International Classification of Diseases, 10th Revision, Clinical
Modification.
• American Psychiatric Association. Diagnostic and Statistical Manual
of Mental Disorders, 5thed, American Psychiatric Association,
Arlington 2013.
• Functional Neurologic Disorders (Handbook of Clinical Neurology) Editors:
Mark Hallett , Jon Stone, Alan Carson,oct.2016.
• Kranick S, Ekanayake V, Martinez V, Ameli R, Hallett M, Voon V
(August 2011). Psychopathology and psychogenic movement
disorders