This document discusses functional neurological symptoms in multiple sclerosis. It defines functional neurological disorder and lists common signs and symptoms. Research shows that approximately 10% of neurology patients have a functional disorder. While initially thought to be purely psychiatric, functional disorders are now understood to involve both neurological and psychological factors. The cerebellum and limbic system may play a role in converting emotions into physical sensations. Occupational therapy aims to comprehensively assess patients' functioning and identify treatment goals. Physiotherapy focuses on minimizing attention to symptoms and retraining normal movement patterns. Psychotherapies like CBT can help address emotional processing difficulties. Functional symptoms appear to exist on a continuum and may be more common in MS patients than previously recognized.

1. Functional Neurological
Symptoms in Multiple Sclerosis
Ed Sum
Specialist Occupational Therapist &
Practice and Professional Development Therapist,
Sherwood Forest Hospitals NHS Foundation Trust
@musedNeuroOT
e.sum@nhs.net

2. The ‘F’ Word
• “Functional overlay” in MS – signs and
symptoms severity/disabling on top of MS
• What do we feel and say in the office?
not real, secondary gain, using up resources, feigning,
emotional, challenge, observed movements but paralysis
reported
• Aim: no answers! – but encourage openness
to ideas throughout the conference

3. 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)

4. Also known as:
• Hysteria
• Psychogenic disorder
• Dissociative motor disorder
• Conversion disorder
• Functional neurological symptoms disorder
(FNS/FNSD)
• Shell shock (?FND, ?misdiagnosis, ?feigning)

5. Typical Signs / Symptoms include:
• Weakness / paralysis
• Abnormal movements
• Swallowing problems
• Altered speech
• Memory loss
• Sensory loss / paraesthesia
• Impaired vision
• Seizures / non-epileptic attacks

6. • Self-reporting of impairments can be higher
than objective measures and compared to
organic disease
• More costs with hospital attendances,
investigations, receiving benefits and less
likely to be in work, more distress, disability,
social isolation cf. other neurological
conditions

7. • Functional stroke – and ‘overlay’
• Functional Parkinson’s
• Functional coma
• Psychogenic non-epileptic seizures (PNES) /
Dissociative seizures (DS) / Non-epileptic
Attack Disorder (NEAD)
• Functional motor disorder (FMD)

8. ‘Dissociation’ – Continuum
• Common – everyday dissociation –
daydreaming, fantasising, reading
• Derealisation / depersonalisation
• Disorders / problematic – PTSD, dissociative
disorders, multiple personalities

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

10. • Initial interest by Charcot, neurologist –
physiological cause
• Freud’s model – repression of painful
experiences and conversion to physical
symptoms – psychiatric – ‘hysteria’ became
renamed ‘conversion disorder’
• Return to neurology as Freud lost favour
• But neurology and psychiatry converge now??

11. • Reconceptualised
• Diagnostic emphasis on positive neurologic
findings while eliminating the requirement for
a precipitating stressor
• Positive signs – entrainment test / Hoover’s
sign
• ‘Software’ versus ‘hardware’

12. • 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

13. Research
• Research separate FMD and PNES – and all
those other terms!
• Similar profiles of patients suggest that FMD
and PNES may not be separate (Hopp et al.,
2012)
• Warning – neuro theory coming up!

14. Dissociative Seizures / PNES
• See the work of Brown and Reuber (2016)
• ‘Towards an integrative theory of Psychogenic
Nonepileptic Seizures’
• Predisposing factors
• Precipitating factors
• Perpetuating factors

15. Facial emotion processing in DS
• People show a fast and automatic attentional
bias to emotional faces
• An ongoing ‘risk assessment’ of the social
environment?
• Awareness that people with DS may be
sensitive to non-verbal emotional expressions
• Misinterpretations might lead to difficulties in
therapeutic and social relationships

16. Cerebellum
• Role in controlling motor function
• Also emotional processing - extensive
connections with limbic regions
• Role of vermis in emotional memory
• Cerebellar-hippocampus circuit subserves
defensive behaviour - ?disturbed emotional
learning in FND

17. • Functional 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
• Clinical risks if exploring with trauma / actions
perceived as a threat – trigger seizures?

18. • More specifically, higher activity of the vermis
in response to negative stimuli - FND is
associated with exaggerated defensive
behaviour – freezing response
• A possible network where psychological
stressors elicit defensive behaviour and effect
motor function
• This defence behaviour becomes well learnt

19. Functional Motor Symptoms
• May be consequence of attending to the
impairment
• Attention to a functionally weak limb
increases the perception of the symptom
• Right temperoparietal junction implicated –
perception of inability to initiate movement
and self-agency of movements

20. • 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

21. Relevance to MS Practice?
• Substantiates the old hypothesis?
• Imbalance of frontocortical and sensorimotor
activity specifically related to emotion
regulation
• Psychophysiological model of a conversion of
(aversive) feelings into (aversive) somatic
sensations in FND

22. • Clear explanation by medical doctor for FND -
does it happen?
• MS – different opportunities/challenges?

23. Physio for FMD (Nielson et al.,
2015)
• Minimise self focused attention via distraction
or preventing the patient 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

24. Psychotherapies
• 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

25. OT: A Pilot Delphi Study
• Develop a preliminary set of consensus
recommendations for the assessment of FND
by OTs

26. Consensus – very important to include:
• Outline of what a standard day looks like
(from rising to going to bed)
• Level of independence in personal care and
domestic activities
• Work/life roles
• Function
• Cognition

27. • Activity analysis
• Identification of therapy goals and rate
priority
• Outcome measurement
• Getting an idea of their understanding of their
diagnosis to guide future sessions

28. Other items
• Posture / tone
• Spasticity management
• List of symptoms with known triggers and
easing factors
• Driving
• Engagement in leisure interests
• Previous therapy input and what they have
found helpful / unhelpful

29. • Social / family support
• Home and local environment
• Using the COPM
• Mood
Consensus Recommendations for OT Ax and Rx:
• Clare Nicholson – Occupational Therapist
• National Hospital for Neurology and
Neurosurgery, Queen Square, London

30. Other Information
• Neurosymptoms.org:
http://www.neurosymptoms.org/
• Functional Neurological Forum:
http://www.fnforum.org/
• e.sum@nhs.net
Local Authority Occupational Therapists interested in joining working party?

31. For your consideration
• Does this offer a different paradigm?
• Is FND more common in your practice than
you appreciated?
• FND as a continuum of impact of symptoms?
• How will you reflect on the learning from the
rest of the conference?

32. References
• American Psychiatric Association (2013) Diagnostic and statistical manual
of mental disorders (5th
edition). Arlington: American Psychiatric
Publishing.
• Brown R & Reuber M. Towards an integrative theory of Psychogenic
Nonepileptic Seizures. Clin Psychol Rev 2016;47:55-70.
• Healthcare Improvement Scotland (2012) Stepped care for functional
neurological symptoms. Edinburgh: Healthcare Improvement Scotland.
• Hopp, J.L., Anderson, K.E., Krumholz, A., Gruber-Baldini, A.L., Shulman,
L.M. (2012) Psychogenic seizures and psychogenic movement disorders:
Are they the same patients? Epilepsy & Behavior, 25, pp.666–669.
• 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