- Case 1 involves a 35-year-old female with multiple nonspecific symptoms who strongly believes she has MS despite normal exams and scans. The diagnosis is delusion of illness. - Case 2 is a 26-year-old female diagnosed with MS who contacts help lines frequently about new symptoms despite normal exams. Her symptoms suggest functional overlay in addition to her organic MS. - Case 3 is a 50-year-old male with a remote history of numbness and current foot drop. His exam is consistent with clinical MS despite non-contributing scans.

1. Treating virtual symptoms
Functionality in MS
Wojciech Pietkiewicz

2. Objectives
• To be able to tell with good probability what is
organic and what is not in your MS patient
• To be able to understand where non-organic
problems come from
• To be able to tell the diagnosis to the patient
• To know how to approach the condition
To make sense of the idea of psychosomatic
disease

3. What we will talk about
• Problems with definitions and glossary
• Where the problem possibly comes from
• How to diagnose it
• How to tell the patient about the diagnosis

4. Case1
• 35 yo female presented for fourth opinion on her
multiple symptoms
• Her twin sister has MS
• Her scans show some white matter changes that
can be interpreted as demyelination
• Her neurological examination is normal and her
symptoms are multiple, non-focal/ non
characteristic. She has tiredness, pain all over,
bladder and bowel symptoms. Came with the list
of 20 other problems
• The symptoms have been there for 7 years

5. • The opinion is that she cannot be given the diagnosis
of MS at that stage
• To this she reacts with verbal abuse
• She has a fixed belief that doctors communicate
secretly with an agenda to show her that she is wrong
• She is convinced her symptoms are MS related and she
has print-outs from the Internet to prove this.
• She has no idea what benefit she would get from the
diagnosis and the question makes her verbally
aggressive.
• She has written many formal complaints about four
trusts and escalated them to The Ministry Of Health

6. Case2
• 26 yo with newly diagnosed MS has contacted MS Help
Line due to new onset of pins and needles in her both
legs (on the top of the previous symptoms). She feels
tired and dizzy
• Over the last 9 months she contacted MS help line 15
times and was seen in MS relapse clinic 5 times and ad-
hoc in MS clinic 5 times
• Her scans show changes typical for MS although there
is no clear activity on numerous scan follow-ups.
• Neurological exam is non-contributing
• In spite of numerous complaints she remains with good
health -mobility wise

7. Case3
• 50 yo male presented with r foot drop
• 20 years ago he had numb hand on the left but
the GP said it would go over time (although he
did not know what it was). It indeed improved
and he quickly forgot about it
• No other symptoms. Neurological examination
shows 3+ reflexes in r leg and up going plantar on
that side
• MR head a few non specific white matter changes

8. ?

9. • Case1:
– Multiple nonspecific abnormalities
– Non contributing examination and scans
– Very strong views on diagnosis
– No reasonable rationale for the diagnosis
– Complete resistance to any other opinion than her
own
– Multiple opinions with the same outcomes but in
spite of this the patient will not accept she does
not have MS at this stage

10. • Multiple complaints to authorities
• Conspiracy theory on medical professionals
who communicate about her before she is
seen and want to penalise her for trying to get
to “the truth”

11. Main diagnosis
• Delusion of illness (not a functional/
psychosomatic disease)

12. • Case2:
– Multiple symptoms
– Established diagnosis of MS
– No clear activity on abnormal scans
This patient’s symptoms typical for MS but the
number of abnormalities and complaints is in
contrast with the objective findings.

13. Diagnosis
• MS (organic disease)
• Functional/psychosomatic symptoms being
main presentation
(or significant functional overlay)

14. • Case3
– Not too pronounced but clearly focal symptoms
– Scarce presentation
– Contributing examination
– Non-contributing scans

15. Likely diagnosis
• Clinical MS

16. Somatisation disorder/functional
disorder
• A longstanding tendency to have symptoms
unexplained by disease
• Usually starting before the age of 30
• Mostly women
• At least one ‘‘conversion’’ symptom, four pain
symptoms, two gastrointestinal symptoms
(usually irritable bowel syndrome) and 1
sexual symptom (dyspareunia,
dysmenorrhoea or hyperemesis gravidarum)

17. Dissociative seizure/motor disorder
(conversion disorder)
• Suggests dissociation as an important mechanism
• Most often refers to two particular experiences:
depersonalisation, a feeling of disconnection
from one’s own body and derealisation, a feeling
of disconnection from one’s environment
• A motor or sensory symptom or blackouts not
compatible with disease
• Causes distress and
• May be related to psychological factors

18. Hypochondriasis
• Excessive and intrusive health anxiety about
the possibility of serious disease which the
patient has trouble controlling.
• Seeking repeated medical reassurance
• This only has a short-lived effect
• A form of addiction which can only be
overcome by a better explanation for
symptoms

19. Factitious disorder
• Symptoms are consciously fabricated for the
purpose of medical care (not money)
• These patients often have a personality
disorder
• Very challenging to diagnose and even more
to pass the diagnosis

20. Munchausen syndrome
• Describes someone with factitious disorder
who wanders between hospitals, typically
changing their name and story
• Seeking medical attention and often
potentially harmful treatments

21. Malingering
• Means making up symptoms for material gain

22. Problems with nomenclature
• Functional implies in the broadest possible sense a problem due to
a change in function (of the nervous system) rather than structure.
• Non-organic, non-epileptic etc all have the problem of describing
what the problem is not rather than what it is.
• Psychosomatic is supposed to mean an inter-action between mind
and body but in practice is interpreted in the same way as
‘‘somatisation’’, the psychological influence on the body.
• Psychogenic suggests an entirely psychological explanation for
symptoms.
• Medically unexplained is a neutral term but one that patients’ may
easily interpret as the doctor not knowing what the diagnosis is
(rather than not knowing why they have the problem).

23. Worth to know
• You quickly learn that there are as many
opinions on what a functional disorder is as
health care professionals.
• Truly functional symptoms account for around
50% of consultations in neurology clinics
• The most commonly confused organic disease
with psychosomatic illness is a migraine
• There is no single subject on functional illness
in any medical training

24. • MS clinics are extremely susceptible and there is
a general feeling of abundance of those
symptoms among MS patients.
• MS by definition is hosting clusters of symptoms
(by time and/or site). It is therefore mimicking
functional symptoms and the other way round.
• Tiredness is seen in almost all MS patients whilst
it is also a hallmark of functional disease.
• Pain is seen in 60% MS patients whilst it is
practically always present in functional patients.

25. Statistics in neurology outpatients
• 50% have at least one functional symptom of some kind, even
if it is not their main problem.
• 30% of new neurology outpatients have main presenting
symptoms that are only ‘‘somewhat or not at all explained’’ by
a disease. This includes patients with ‘‘functional overlay’’.
• 15% have a primary functional/psychological diagnosis
(including pain and fatigue unexplained by disease).
• 5% have seizures, weakness, sensory symptoms or movement
disorder which is thought by the neurologist to be
functional/non-organic
• On average new neurology patients with functional symptoms
are just as disabled as and even more distressed than those
with a neurological disease.

26. Neurology inpatients
• 1–10% of neurology inpatients have a primary
‘‘functional’’ diagnosis.

27. Statistics of conversion symptoms
• Dissociative/non-epileptic seizures account for
about 20% of referrals to ‘‘first fit’’ clinics and to
specialist epilepsy clinics.
• 50% of admissions to hospital with ‘‘status
epilepticus’’ are in fact dissociative
seizures/‘‘pseudostatus’’.
• Functional weakness has an annual incidence of
at least 5/100 000, similar to multiple sclerosis.
• Functional movement disorders account for 5–
10% of patients seen in a movement disorders
clinic.

28. Examples of functional disorders
• Gastroenterology: irritable bowel syndrome (IBS)
• Endocrinology: borderline thyroid function
• Respiratory: chronic cough,
• Rheumatology: fibromyalgia, chronic back pain
• Gynecology: chronic pelvic pain, dysmenorrhoea (not all)
• Cardiology: atypical/non-cardiac chest pain, palpitations
(not all)
• Infectious diseases: (post-viral) chronic fatigue syndrome
(CFS/ME)
• Ear, nose and throat: globus, functional dysphonia
• Neurology: dissociative seizures, functional weakness and
sensory symptoms

29. How? And why?

30. • Always think how our brains were made
• Consider Mother Nature made us between 2
and 1 million years ago and our brains are not
very much different since
• From evolution point of view survival is the
only thing that counts
• Our bodies and brains that rule them are
made for survival

31. Some time ago…

32. • No surgeries
• No doctors
• No Tesco's
• No tablets
• No ‘Health and Safety’
• No ‘Infection Control’
• No rehab
• No vaccinations

33. Instead:
• Eating only what found or chased successfully.
• Food acquired at high cost usually of physical
activity
• Extremely high risk of trauma
• Prolonged periods of starvation
• Small groups of people extremely dependent
on one another

34. So what happened if you had a flue?
• Naturally you would like to get better as quickly as
possible.
• Being equipped with a mind which is a perfect
invention you would tend to use it to override the
healing time.
• You would therefore be tempted to get up before you
are cured.
• Is idea of you deciding when to get up good from
survival point of view?
• There must have been a mechanism that would replace
your judgement. Otherwise lazy would survive and
those full of energy would be at risk.

35. The mechanisms are still there today
• Extreme fatigue during the illness
• Achiness or frank pain all over
• Tenderness of tissues
• Feeling ill, useless
• Having poor concentration/memory
• Dizziness

36. • It is unlikely to be very fatigued and in pain and
run after food
• Assumed illness/injury can be healed
• The infection will not be spread
So next time you have flue like illness and you
straggle to raise your head from the pillow you
know what sense it makes. Other than this there is
no real medical evidence what the mechanism of
fatigue is.

37. Illness behaviour
• Trying to save the limb that is in pain (would be
switched to weakness not to use it)
• Harbour symptoms on one side (more attention
to the affected side)
• Avoiding walking when imbalanced
• Avoiding moving head when dizzy
• Using walking aids or help of other people to
balance
• Wearing dark glasses due to lightsensitivity

38. Illness behaviour reflects the propensity of the
brain to limit processing of mismatched bits of
information

39. Is it really functional?
• The more symptoms the more likely (this
applies to MS patients as well)
• The vaguer symptoms the more likely
• As a rule 3 or more unrelated symptoms
implies the patient should see a psychologist.
• Specifically for MS number of symptoms
would be in opposition to normal examination
and lack of activity on scans. Can the patient
have 10 relapses per year?

40. Is it malingering?
• Patients concentrate on their symptoms not impact
• Do not seem to seek help
• Get aggressive on slightest suspicion the consultation does
not go well for them
• Prize your knowledge and trust you are a clever doctor when
they walk in but question your competency when you do not
appreciate how ill they are
• Take time to describe symptoms
• Blunt response to any treatment or have multiple side effects
to any drug.
• Never get better only worse
• Do equally poorly on easy tests and difficult ones
• Do not learn on the same test

41. • Don’t believe all the physical diagnoses in the medical notes. They may
not be correct. ‘‘Asthma’’ may be panic disorder, the appendix or uterus
may have been normal even though surgically removed.
• Don’t go into expressions of ‘‘depression’’ or ‘‘anxiety’’.
• Don’t make a diagnosis of functional symptoms because someone has an
obvious psychiatric problem/personality disorder. Patients with psychosis
are not especially liable to functional symptoms, and patients with any
psychiatric disorder may be harbouring a neurological disease.
• Don’t avoid a diagnosis of a functional problem because someone seems
too ‘‘normal’’. ‘‘Normal’’ people, including those with no
depression/anxiety or previous history can get functional symptoms too
• Don’t misinterpret ‘‘exaggeration to convince’’ as ‘‘exaggeration to
deceive’’. The patient who groans and sighs in an excessive way is more
likely to be doing so to show you how bad their symptoms are (when they
really do have them) rather than making up their symptoms from scratch
in an attempt to deceive you
• Do not expect patients with functional symptoms to have depression,
panic or anxiety.

42. Practical points for weakness
• Extremely weak leg but still can walk
• Variable strength at examination
• Grimacing during passive movement but
otherwise normal behaviour
• Lack of effort
• Give way weakness
• Usually extensors weaker than flexors
• Falls into your arms whilst examining walking,
gait typically with outstretched hands

43. Practical points for pain
• Extreme pain when you try to move the limb but then
moves it freely
• When you stretch the leg excruciating pain at 5 degrees
but when sitting stretch 90% with no pain
• Level of pain 12/10 but patient can talk and smile
• Rotation sign in LBP. Ask the patient to stand with their
feet on the ground and swing their whole body. Pain in
the back is at odds with the manoeuvre which does not
really mobilise the back.
• Axial loading. Low back pain on pressing on the head.
• Superficial tenderness—extreme pain from light
pressure over a wide area of the back

44. Practical points for loss of sensation
• No characteristic distribution (neither the nerve
nor root nor central)
• Patchy
• Variable in time and space even during one
examination
• Sensory level at easy to remember areas: the
whole limb or from the umbilicus or split half.
• Bizarre distribution of proprioception loss
• All neurology on one side (eye, ear, sensation,
weakness)

45. What to do?
• Test vibration sense on both sides of the
forehead
• “say ‘yes’ when you feel it and say ‘no’ when
you don’t”
• Re-test the levels and patchy areas

46. Practical points for movement
disorders
• Tremor disappears with distraction—eg, counting
backwards in sevens. Tremor of Parkinson’s disease may
be more noticeable during distraction.
• Variable frequency is more helpful than variable
amplitude.
• Entrainment—ask the patient to make arhythmical
movement with their ‘‘good’’ side. They will either not be
able to do it (and be unable to explain why) or the
rhythm will entrain to the same rhythm as the affected
limb.
• Alteration with weight or attempted immobilisation—
functional tremor typically worsens when an arm is
weighted or if an examiner attempts to make it still by
holding on to it.

47. Typical ‘functional patient’ trait
(practical but not evidence based)
• The patient has had more than two opinions on the medical problems
• Has multiple symptoms and has to come with a list to remember them (as
per definition more than two at a time but usually easily exceeding 10)
• Some patients come with lists of symptoms containing over 50 items
• Start the medical history with “where to start?”
• Have very meticulous description of their symptoms sometimes day by
day for years taking fat layers of handwriting or endless printouts “for your
perusal”
• Have lack of insight into the symptoms and have unreasonable
expectation you are going to go through every bit with them
• You have an internal and rather unprofessional feeling you regret you have
asked

48. Typical ‘functional patient’ trait
(practical but not evidence based)
• Put a lot of effort to convince their symptoms are not made up
• Assume you would not believe them
• It transpires at any time of the consultation that the patient ‘already
heard something similar’ and they did not come to see you to hear
it again
• Twist other opinions or reports that fit their view on organic
background (artificially created objectiveness)
• Have a strong tendency to quote others rather than answer directly
• Tend to use proxies to describe how badly they feel
• Fabricate statements of other healthcare professionals which are
not confirmed in documentation
• Consultations tend to take double to triple time

49. Why do people have functional
disorders and why it is so common in
chronic conditions?
• Brain plasticity plays main role in rendering the symptoms.
• There are mechanisms in the brains that are protective and
adjust attention depending on importance of symptoms in
particular individuals.
• Even common cold can trigger tiredness. Recovery may not
be enough for the brain to decide the organism is ready to
resume normal activity. Trying to overcome fatigue in a
natural mechanism of willingness to recover quickly triggers
the protective mechanism and turns the “knob” down. As a
result more tiredness appears.
• Chronic conditions will host a lot of organic symptoms out
of which any single one can trigger exaggerated symptoms
that will not have any reflexion in anatomical damage.

50. Approach
• You have established that your patient might
have at least functional overlay.
• Do you think it is MS itself or maybe
functional problems are main problem?
• How are you going to decide what to tell?
• Will you tell it is MS or psychosomatic or
both?

51. Very reassuring

52. Scientific

53. Unsure-reassure

54. Knowledge based

55. Helpful

56. How to handle it
1 Tell as soon as you suspect. It is easier to reverse the diagnosis of a
functional disorder than the other way round.
2 Explanation during first consultation is often enough to cure. The longer it
takes the worse prognosis.
3 The fewer tests the better. The more complaints the fewer tests. Always
mention you know they will be normal. The same relates to consultations.
4 Ask for a second opinion but mention it is to reassure not to check if you are
right
5 Refer to a psychologist/psychiatrist with the interest in functional disorders
6 Most of patients will respond to good physiotherapy with a person with the
experience in functional disorders
7 Aids can be an obstacle to recovery. This applies to all diseases and it worth
mentioning it to the patient.
8 Refer to a good source: neurosymptoms.org
9 Emphasise you believe your patient. Do not be dismissive or suspicious. The
patient’s distrust will cause failure of treatment.

57. Give the chance of normality!
• It really depends how you sell it!
• It is normal for every one to have functional symptoms
• Patients need to understand that their symptoms are
as real as anyone else’s or worse as they may not be
easily explained
• The main barrier is usually a patient thinking medical
professional doubt the reality of their symptoms
• Patients have to be reassured that the background of
their problems may be explored sufficiently to exclude
organic cause
• Multiplying tests and opinions is harmful and it needs
to be explicitly expressed to the patients

58. Examples of common functional
mechanisms that helps explaining
things to the patients
• In a way everything we feel or learn is
“functional”
• Scratching your head when you know little
insects are around you
• Parenthood
• Falling in love
• Knowing how to drive a car
• Hating spiders

59. Don’ts
• Openly question a diagnosis of a functional
disorder of another professional
• Be afraid of the implications of the misdiagnosis
• Use suggestion of a psychology-related problem
• Use a lot of tests to prove you are right
• Ask for a row of opinions
• Tell the patient only what they do not have
• Give the patient vague replacement diagnosis

60. Do’s
• Specifically patients with MS need to be
reassured they will be treated seriously as any
other ones.
• It helps to explain that treatment of
psychosomatic/functional problems is the
same for MS patients.

61. Basics of management
• Treatment should be explained early.
• Psychologist/psychiatrist with special interest in
the disorders is the main specialty.
• The treatment is with understanding/
desensitisation/pacing/distraction
• It is long term
• The key to success is to convince the patient they
have psychosomatic disease
• Understanding the idea of it is crucial.

62. Pacing
• Patients and healthcare professionals often
miss the main point in understanding what
pacing is
• For many it is adjusting lifestyle and being
careful about not overdoing things or
increasing some dose of exercise slowly
• Pacing almost looks like ‘do not make it worse’
treatment

63. • Remember the mechanism od brain “watching”
what you do and downregulating the maximum
effort you can do exercising or using your senses.
• Discovering what makes your brain thinks is too
much for you is the only way to approach it.
• The system cannot be ridden (it is the whole
point of its existence to prevent it). It can be only
rewired and the mechanisms are those of slow
udjustment.
• The goal should be recovery.

64. Examples of successful treatments
• Exercising balance on Wii board for dizziness
• Adjusted pacing for chronic fatigue
• Regulating lifestyle and regular sleep for
generalised pain and allodynia (FM-like
symptoms)
• Learning the pattern of distraction of
disturbing symptoms
• Neurosymptoms.org

65. Thank you