Functional neurology refers to neurological symptoms that are considered "functional" rather than due to identifiable organic disease. Two case studies are presented: a 16-year old girl with functional weakness and jerking movements, and a 34-year old woman with a sudden onset tremor. Investigations for functional disorders are typically minimal, while management involves explanation, psychiatry/psychology support like CBT, antidepressants, physiotherapy, and self-help resources. Prognosis is generally good, especially with early acceptance, short history, lack of other symptoms, and a supportive environment. The aims are to provide a swift diagnosis, consistent messaging to limit second opinions, and appropriate physical and psychological therapies.

1. Functional Neurology
What’s it all about?
Dr Naomi Warren

2. Content
 Background
 Clinical presentations
 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. Not specific to Neurology...
Speciality Symptom
Cardiology non-cardiac CP
Gastroenterology IBS
Respiratory chronic cough
Renal/gynae recurrent loin/pelvic
pain
Surgery chronic abdominal
pain
Rheumatology fibromyalgia
chronic fatigue
syndrome

6. Case 1
 16 yr 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

7. Hoover’s sign

8. Case cont….
 Explained
 Functional
 Not seizure
 Denied stresses initially
 Parents – due to leave UK  stress
 Treatment
 Physio
 Snowboarding!!
 www.neurosymptoms.org
 Good outcome

9. Functional weakness
 Half sudden onset
 Often with pain
 Examination
 Look for inconsistencies
 bed/day to day
 Hoovers sign
 Odd pattern
 Giving way
 Dragging leg
 Ass hemi sensory loss

10. Functional gait disorders
 gait disorders
 dragging leg
 crouching gait
 tightrope gait without
falling
 Rhombergs
 Wibble and wobble
but don’t fall down

11. Case 2
 34 yr old R handed woman
 FT administrator
 Sudden onset tremor right hand 4 days
previous
 Present constantly
 No previous history

12.  video

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
 Violent
 No “tonic” phase
 Fast resp
 Post ictal
 Crying
 No true confusion
• Not helpful
Incontinence
Injuries
• Some help
Tongue biting - lateral

16. Other functional presentations
 Cognitive decline
 subjective cognitive problems although can
usually give a very clear account of themselves
 Visual loss
 tunnel vision or
 blindness with preserved pupil reflexes and
optico-kinetic nystagmus
 Globus
 Dysphonia

17. 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

18. Management
 Explanation
 Key
 Psychiatry/ology
 To help manage symps
 CBT
 Antidepressants
 Physio
 Pain team
 www.neurosymptoms.
org
 Give diagnosis
 Tell what don’t have
 Mechanism
 Understanding
 Emphasise common
 Reversible
 “stress/mood makes it
worse”
 Self help
 Consistency

19. Prognosis
Good Bad
Acceptance Strong belief 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

20. Primary + secondary care 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

21. Conclusion
 Very common problem in neurology
 Huge cause disability
 Needs swift investigation and mgmt
 Careful explanation
 Appropriate psychological help
 Questions?