Ed Sum - Functional overlay

1. Ed Sum
Specialist Occupational Therapist &
Practice and Professional Development Therapist
@musedNeuroOT
Management of Functional Overlay
MS Trust Annual Conference
6th
November 2018

2. Aims: Ooo… Ahhh… Hmmm…
• Explore functional neurological symptoms in pwMS
• Reflect on own practice
• Consider conceptual models of functional neurological
symptoms / disorder
• Feel confident with standard, high quality interventions
• Consider other approaches based on your area of
practice

3. Case study
• ‘Kay’ - Born 1976
• Requested by MS Specialist Nurse – seen Spring 2016
- ?transitioning into to secondary progressive phase
• Numbness in lower limbs and hands
• Focussed effort when walking – falls / trips; used 4
wheeled walker; left leg locking or giving away –
compensate with reliance on upper limbs and vision

4. • Diplopia left eye
• Wheelchair outdoors
• Fatigue++
• Spasms and pain in lower limbs overnight
• Ataxia
• Poor sleep
• Seizures
• Some constant and some variable symptoms

5. • Farmer’s wife. Loves her dog more than husband 
Husband diagnosed with cancer. Father-in-law also lives
with them
• Physiotherapy
• Occupational Therapy (for fatigue management)

6. ‘Functional Overlay’
• Signs and symptoms – severe / disabling on top of
diagnosis / compared with organic disease eg. functional
stroke
• Self-reporting of impairments can be higher than objective
measures
Stressors – but ?report anxiety / stress
‘Problems’ appear to go or be less severe when not being
watched / in different contexts

7. Functional Neurological Symptoms
• Weakness / paralysis
• Abnormal movements – spasms, myoclonic jerks, dystonia
• Swallowing problems
• Altered speech
• Memory loss
• Sensory loss / paraesthesia
• Impaired vision – acuity with peripheral loss
• Dizziness / vertigo
• Seizures / non-epileptic attacks

8. FNS or FND?
• Consensus: ‘Functional Neurological Disorder’
DSM-5 criteria: (FND) presents as altered voluntary
movement or sensory function, which are not compatible
with other recognised conditions; the symptoms or deficits
causes significant distress or impairment in functioning
Patients may present with psychological stressors but not a
requirement
(American Psychiatric Association, 2013)

9. • More costs with hospital attendances, investigations,
receiving benefits and less likely to be in work
• More distress, disability, social isolation
cf. other neurological conditions

10. Also known as…
• Hysteria
• Psychogenic disorder
• Dissociative motor disorder
• Conversion disorder
• Functional neurological symptoms disorder (FNS/FNSD)
• Psychogenic non-epileptic seizures (PNES) / Dissociative seizures (DS) / Non-
epileptic Attack Disorder (NEAD)
• Functional motor disorder (FMD)
• Shell shock (?FND, ?misdiagnosis, ?feigning)
• Factitious Disorder – mental disorder; Malingering

11. • Approximately 10% of neurology out-patients present with
functional neurological disorder (Healthcare Improvement
Scotland, 2012)
• Neurological condition is a risk factor for FND!!!
• Anecdotally???
• 5% misdiagnosis – similar to other neurological conditions

12. • Charcot (Neurologist) – physiological cause
• Freud - repression of painful experiences and conversion
to physical symptoms – psychiatric – ‘hysteria’ became
renamed ‘conversion disorder’

13. Conceptualised
• Interplay of physiological stimulus, expectation, learning
and attention
• Diagnostic emphasis on positive neurologic findings while
eliminating the requirement for a precipitating stressor
• Positive signs – Hoover’s sign / entrainment test
• ‘Software’ versus ‘hardware’

14. • Hypothetically - a shift of emotion processing to
sensorimotor deficits
Reduced frontocortical, but enhanced sensorimotor
involvement, in emotion regulation - conversion of
(aversive) feelings into (aversive) somatic sensations
• Suggestion that they may have reduced cognitive control
- non-conscious avoidance or coping mechanism

15. Brown and Reuber (2016)
• Predisposing factors
- genetic factors affecting personality, vulnerabilities in
nervous system, perception of childhood experience as
adverse, personality traits, poor attachment/coping style,
neglect / abuse, poor family functioning, copying other’s
symptoms

16. • Precipitating factors
- abnormal physiological event (drugs, sleep deprivation),
injury (fracture), negative life event, panic attack,
dissociation
?MS symptoms – optic neuritis – CIS

17. • Perpetuating factors (secondary and tertiary
complications)
- abnormal movement pattern through plasticity,
deconditioning, illness and recovery beliefs, avoidance,
secondary gain, awaiting further investigations, organic
causation

18. Elevated arousal
Protective factors
Activation of signs / symptoms
Health beliefs
Threat perception
Internal / external cues
Reduced
arousal

19. Pathways
• Connections between limbic structures involved in
memory and emotion, with motor pathways in cerebellum,
but also basal ganglia, supplementary motor area and
prefrontal regions
- networks for the selection and regulation of defensive
motor behaviour in aversive emotional contexts

20. Cerebellum
• Emotional processing - extensive connections with limbic
regions
• Role of vermis in emotional memory - relationship
between the vermis and hippocampus - fear-related
memories
• ?defensive behaviour may reflect a disturbance in
emotional learning in FND, leading to exacerbated
behavioural reactions in particular contexts

21. • FND is associated with exaggerated defensive behaviour
– freezing response
• A possible network where psychological stressors elicit
defensive behaviour and effect motor function

22. Sensorimotor
• Attention to a functionally weak limb increases the
perception of the symptom
• Right temporoparietal junction implicated – perception of
inability to initiate movement and self-agency of
movements
• Efforts to control upcoming feelings by cognitive
reappraisal prompts the involvement of sensorimotor
areas

23. • Caudate – dorsal striatum structure – favours habitual
implicit well-learned movement - rather than goal-directed,
explicit controlled movement
Caudate dysfunction – no efficient selection and assembly
of motor actions – leads to abnormal behaviour patterns

24. Interventions
• Facial processing - fast and automatic attentional bias to
(negative) emotional faces and reduced accuracy to
interpreting facial emotions
• An ongoing ‘risk assessment’ of the social environment?
• Misinterpretations might lead to difficulties in therapeutic
and social relationships
• Might increase likelihood of: emotional arousal/distress,
interpersonal difficulties, maladaptive beliefs

25. • FND – clear diagnosis and explanation
• Brief Augmented Psychodynamic Interpersonal Therapy –
to address emotion processing difficulties
• CBT, Mindfulness, Acceptance and Commitment Therapy
• Where symptoms attributed to stress or emotional state –
related to favourable outcomes

26. • Physio for FMD (Nielson et al., 2015)
• Minimise self focused attention via distraction or prevent
from cognitively controlling movement
• Stimulate automatically generated movement
• Break down learned patterns of abnormal movement to
retrain normal patterns
• Education important
• Link with psychological approaches – concurrent/after

28. • Readiness for intervention
• Education – FND and stress response
• Occupations – include work
• Aids / adaptations / splints
• Housing
• Cognitive-behavioural approaches
• Across practice settings
• Sensory modulation impairments – sensory based
interventions – grounding as one aspect

29. • Solution Focussed Brief Therapy
- Focus on finding solutions in the present and explore
hopes for the future
- Quicker resolution rather than explore the past

30. Reflection: So… for pwMS
• Assessment – do we diagnose MS and FND? Different
opportunities?
• Is FND more common in your practice than you
appreciated?
• Communication?
• Interventions - a different paradigm?
• Clinical risks of exploring trauma / actions perceived as a
threat?

31. Kay
• Fatigue management – exploration
• Disclosure – shelter with her dog
• Accessed neuropsychology
• New partner – physiotherapy regarding positioning
• Moved to another county to join her partner

32. • Neurosymptoms.org:
http://www.neurosymptoms.org/
• Functional Neurological Forum:
http://www.fnforum.org/

33. References
• American Psychiatric Association (2013) Diagnostic and statistical manual of
mental disorders (5th
edition). Arlington: American Psychiatric Publishing.
• Brown, R. & Reuber, M. (2016) Towards an integrative theory of Psychogenic
Nonepileptic Seizures. Clin Psychol ,47, pp.55-70.
• Healthcare Improvement Scotland (2012) Stepped care for functional
neurological symptoms. Edinburgh: Healthcare Improvement Scotland.
• Nielsen, G., Stone, J., Matthews, A., Brown, M., Sparkes, C., Farmer, R.,
Masterton, L., Duncan, L., Winters, A., Daniell, L. and Lumsden, C. (2015)
Physiotherapy for functional motor disorders: a consensus recommendation. J
Neurol Neurosurg Psychiatry, 86(10), pp.1113-1119.
http://jnnp.bmj.com/content/86/10/1113