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Ed Sum, functional neurological symptoms
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.
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Ed Sum, functional neurological symptoms
- 1. Functional Neurological Symptoms inMultiple 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-5criteria: (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 ofimpairments 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 interestby 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 • Diagnosticemphasis 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 separateFMD 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 processingin 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 incontrolling 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 relationshipbetween 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 MSPractice? • 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 explanationby 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 AugmentedPsychodynamic 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 PilotDelphi Study • Develop a preliminary set of consensus recommendations for the assessment of FND by OTs
- 26. Consensus – veryimportant 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 PsychiatricAssociation (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
Editor's Notes
- #2 Thank yous
- #3 Ooohs, aaahs and hmmmms – especially those with greater understanding of neuroanatomy
- #4 Across neurological practice
- #6 Typically visual acuity loss with concentric peripheral vision loss - rather than hemianopia (very rare)
- #7 Relatives report more anxiety and more willing to accept psychological explanation
- #12 Hoover’s sign : weakness of hip extension which returns to normal with contralateral hip flexion against resistance. ‘I can see that when you try to push that leg down on the floor its weak, In fact the harder you try the weaker it becomes. But when you are lifting up your other leg, can you feel that the movement in your bad leg comes back to normal? Your affected leg is working much better when you move your good leg. What this tells me is that your brain is having difficulty sending messages to the leg but that problem improves when you are distracted and trying to move your other leg. This also shows us that the weakness must be reversible / cannot be due to damage”. Hip Abductor Sign: Weakness of hip abduction which returns to normal with contralateral hip abduction against resistance. Similar to Hoover’s sign. Distraction or entrainment of a tremor: Abolishing tremor by asking the patient to copy rhythmical movements or generate ballistic movements with the contralateral limb (i.e. index to thumb tapping at different speeds). ‘When you are trying to copy the movement in your good hand can you see that the tremor in your affected hand improves? That is typical of functional tremor’.
- #13 non-conscious avoidance or coping mechanism
- #15 Predisposing - 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 Precipitating - Abnormal physiological event (drugs, sleep deprivation), injury, negative life event, panic attack, dissociation Perpetuating – abnormal movement pattern through plasticity, deconditioning, illness and recovery beliefs, avoidance, secondary gain, awaiting further investigations, organic causation
- #16 Individuals with DS show reduced accuracy in interpreting facial emotion A combination of implicit hypervigilance and explicit misinterpretation of facial emotion in people with DS, possibly linked to adverse life events Might increase likelihood of: emotional arousal/distress, interpersonal difficulties, maladaptive beliefs Psychological interventions might increasingly focus on emotional factors, such as: Emotion recognition and mentalisation training
- #17 Supervised learning – cerebellum Reinforcement – basal ganglia Unsupervised – cortex
- #18 Might lead to an overestimation of threat and self-relevance, possibly through retrieved episodic memories linked to negative life events Such 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
- #19 freezing behaviour - reduced body motion and increased muscle tone Efforts to control upcoming feelings by cognitive reappraisal prompted the involvement of sensorimotor areas in patients with FNS in contrast to frontocortical areas in HC It rather suggests an imbalance of frontocortical-sensorimotor involvement in the effort to regulate negative emotions.
- #20 TPJ – aberrant connectivity
- #24 occupational therapist, physiotherapists, neurologists and neuro-psychiatrists set of recommendations for physiotherapy treatment FMD is conceived as an involuntary but learned habitual movement pattern driven by abnormal self directed attention Psychological treatment may be more effectively delivered after or alongside physiotherapy