You've made the diagnosis of functional neurological disorder: now what?

Abstract

Patients with functional neurological disorders (FND)/conversion disorder commonly present to outpatient clinics. FND is now a 'rule in' diagnosis based on neurological examination findings and semiological features. While neurologists may be more comfortable diagnosing patients with FND, there is only limited guidance as to how to conduct follow-up outpatient visits. Using clinical vignettes, we provide practical suggestions that may help guide clinical encounters including how to: (1) explore illness beliefs openly; (2) enquire longitudinally about predisposing vulnerabilities, acute precipitants and perpetuating factors that may be further elucidated over time; (3) facilitate psychotherapy engagement by actively listening for potentially unhelpful or maladaptive patterns of thoughts, behaviours, fears or psychosocial stressors that can be reflected back to the patient and (4) enquire about the fidelity of individual treatments and educate other providers who may be less familiar with FND. These suggestions, while important to individualise, provide a blueprint for follow-up FND clinical care.

Keywords: conversion disorder; functional movement disorders; neuropsychiatry; psychogenic nonepileptic seizures.

Figure 1

The patient that questions the diagnosis. This vignette focuses on an individual who initially appeared receptive to the diagnosis of functional neurological disorder (FND), but at follow-up has clearly not yet accepted the diagnosis and has been non-adherent to referrals. In this context, it is important to explore transparently and non-judgmentally the patient’s illness beliefs, while also conveying the message that buy-in to the diagnosis is a critical first step in the treatment.

Figure 2

The importance of longitudinal assessments and the ‘mind–body overload’ concept. This vignette focuses on the importance of initially and longitudinally accessing for predisposing vulnerabilities, acute precipitants and perpetuating factors during outpatient care. This patient initially denied depression and anxiety; however, at follow-up, she showed an overwhelmed affect and missed several physical therapy sessions. The patient discloses that she has been caring for her ill mother. The physician takes an empathic stance and acknowledges the negative affect. She then introduces the concept of ‘mind–body overload’. This discussion allows for a well-received referral to psychotherapy. FND indicates functional neurological disorder.

Figure 3

The role of the clinician as catalyst for treatment efficacy. This vignette depicts a patient with psychogenic nonepileptic seizures in psychotherapy reporting that therapy is ‘not helping’. The focus of this conversation is an enquiry about the content discussed during psychotherapy to assess treatment fidelity. It also provides the opportunity to listen actively for brief statements that potentially reflect maladaptive thoughts, behaviours and/or fears that can be reflected back to the patient and highlighted for further exploration in psychotherapy.

Figure 4

The importance of enquiring about the details of each treatment. This vignette identifies a patient reporting that physical therapy is not working. The physician asks about the specific details of sessions and learns that the therapy has been largely limited to seated exercises in the context of avoidance on the part of the patient and therapist. The physician discusses the theme of avoidance with the patient, mentioning that symptoms sometimes increase before they decrease. She then reaches out to the physical therapist to provide education and coordinate care.