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Functional Neurology 2017
- 1. Functional Neurology What’s itall about? Dr Naomi Warren
- 2. Content Background Clinicalpresentations Investigations Management Future aims
- 3. Background Historically: hysteria(the “wandering womb”) conversion disorders dissociative disorders psychogenic medically unexplained non-organic psychosomatic functional
- 4. Functional symptoms Common… 15%new outpatient neurology 1-10% of inpatient neurology admissions 50% of “status epilepticus” 10% of “first fits” 5% of movement disorders Patients are just as distressed as patients with disease
- 5. Case 1 16yr old girl – sporty Ankle injury 2/52 previous 4/52 right weakness leg 3/7 jerking body movements – intermittent o/e – dragging R leg behind her On bed – no movement R leg +ve Hoover’s sign Reflexes normal Episode jerking body – 2 mins
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- 7. Case cont…. Explained Functional Not seizure Denied stresses initially Parents – due to leave UK stress Treatment Physio Snowboarding!! www.neurosymptoms.org Good outcome
- 8. Functional weakness Halfsudden onset Often with pain Examination Look for inconsistencies bed/day to day Hoovers sign Odd pattern Giving way Dragging leg Ass hemi sensory loss
- 9. Functional gait disorders gait disorders dragging leg crouching gait tightrope gait without falling Rhombergs Wibble and wobble but don’t fall down
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- 11. Case 2 34yr old R handed woman FT administrator Sudden onset tremor right hand 4 days previous Present constantly No previous history
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- 13. Functional movement disorders Can be more difficult to identify Mostly sudden onset Eg after injury Tremor Disappears with distraction, entrainment, variable
- 14. Other mvmt disorders- rarer Dystonia Fixed, often painful Beware - often organic disease looks unusual Myoclonus often axial Tics
- 15. Non-epileptic attacks Aura Not stereotyped Variable time Attack Violent Long/multiple Eyes closed No “tonic” phase Fast resp Post ictal Crying No true confusion • Not helpful Incontinence Injuries • Some help Tongue biting - lateral
- 16. Investigations? Minimal tests Often need MRI in weakness Reassure pt/docs ?functional overlay Explain You think the tests will be normal Incidental findings Video EEG in seizures
- 17. Management Explanation Key Psychiatry/ology To help manage symps CBT Antidepressants Physio Pain team www.neurosymptoms. org Give positive diagnosis Tell what don’t have Mechanism Emphasise common Reversible “stress/mood makes it worse” Self help
- 18. Prognosis Good Bad Acceptance Strongbelief permanent Young age Long history Short history Delayed diagnosis Lack other symps Anger at diagnosis Change in marital status after diagnosis Multiple other symps Anx/depression Pampering carer Helpful family Personality disorder Financial benefit
- 19. Primary + secondarycare aims To understand/believe the condition To provide swift diagnosis To give a consistent message (limit 2nd opinions) To give appropriate psychological and physical therapies Unless self limiting and clearly functional – refer to neurology
- 20. Conclusion Very commonproblem in neurology Huge cause disability Needs swift investigation and mgmt Careful explanation Appropriate psychological help Questions?