Functional neurological
Symptoms Disorder
(FND)
DOES THE BODY RULE THE MIND, OR DOES THE MIND RULE THE BODY? I DON’T KNOW
THE SMITHS
WAQAS AHMED USMANI
17/078
Also known as:
Hysteria
Psychogenic disorder
Dissociative motor disorder
Conversion disorder
Functional neurological symptoms disorder (FNS/FNSD)
Misdiagnosis: feigning, shell shock
Functional Neurological Disorder
DSM-5 criteria: (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)
FND a none man land
Structure- Organic- Neurology
Brain
Inorganic-psychiatry/Psychology
FND is a condition at the interface between the specialties of neurology and psychiatry. Conventional
tests such as MRI brain scans and EEGs are usually normal in patients with FND. This had led,
historically, to the condition being relatively neglected by both clinicians and researchers. However, it
is now established that FND is a common cause of disability and distress, which may overlap with
other problems such as chronic pain and fatigue. Encouraging studies support the potential reversibility
of FND with specifically tailored treatments. New scientific findings are influencing how patients are
diagnosed and treated which is creating an overall change in attitude towards people with FND.
Older ideas that FND is “all psychological” and that the diagnosis is made only when someone has
normal tests have changed since the mid-2000s. The new understanding, including modern
neuroscientific studies, has shown that FND is not a diagnosis of exclusion. It has specific clinical
features of its own and is a disorder of the nervous system functioning in which many perspectives are
necessary. These vary a lot from person to person. In some people, psychological factors are important,
in others they are not.
Symptoms
Symptoms of functional neurologic disorders may vary, depending on the type of
functional neurologic disorder, and they're significant enough to cause impairment and
warrant medical evaluation. Symptoms can affect body movement and function and the
senses.
Signs and symptoms that affect body movement and function may include:
• Weakness / paralysis
• Abnormal movements
• Swallowing problems
• Altered speech
• Memory loss
• Sensory loss / paraesthesia
• Impaired vision
Seizures / non-epileptic attacks
Signs and symptoms that affect the senses
may include:
Signs and symptoms that affect the senses may include
Numbness or loss of the touch sensation
Speech problems, such as inability to speak or slurred speech
Vision problems, such as double vision or blindness
Hearing problems or deafness
Episodes of altered awareness
• Dissociative (non-epileptic) seizures, blackouts and faints: these symptoms can overlap and can look like epileptic seizures
or faints (syncope)
Symptoms often fluctuate and may vary from day to day or be present all the time. Some patients with FND may experience
substantial or even complete remission followed by sudden relapses of symptoms.
Other physical and psychological symptoms are commonly experienced by patients with FND but may not be present. These
include: chronic pains, fatigue, sleep problems, memory symptoms, bowel and bladder symptoms, anxiety and depression.
Symptom duration and severity
Symptoms may come and go, or they may persist, and they can vary in their severity and
location.
In most cases, symptoms resolve in a short time-period. However, in some people, they
may continue for months or years and can hinder a person’s ability to work and carry out
everyday activities.
According to FND Hope, a non-profit patient advocacy organization for people with
FND, symptoms of FND can be as debilitating as multiple sclerosis (MS) or
Parkinson’s disease.
Causes
Historically, has traditionally been viewed as an entirely psychological disorder in which repressed psychological stress
or trauma gets ‘converted’ into a physical symptom. This is where the term ‘conversion disorder’ comes from.
Psychological disorders and stressful life events, both recent and in childhood, may be risk factors for developing the
condition in some patients, but they rarely provide a full explanation for the cause of the condition and are absent in
many patients. Patients do not have to be depressed, anxious or the survivor of adverse childhood experience to develop
FND.
The exact cause of functional neurologic disorders is unknown. Theories regarding what happens in the brain to result in
symptoms are complex and involve multiple mechanisms that may differ, depending on the type of functional neurologic
disorder.
Basically, parts of the brain that control the functioning of your muscles and senses may be involved, even though no
disease or abnormality exists.
Symptoms of functional neurologic disorders may appear suddenly after a stressful event, or with emotional or physical
trauma. Other triggers may include changes or disruptions in how the brain functions at the structural, cellular or metabolic
level. But the trigger for symptoms can't always be identified.
Risk Factors
Factors that may increase your risk of functional neurologic disorders include:
Having a neurological disease or disorder, such as epilepsy, migraines or a movement disorder
Recent significant stress or emotional or physical trauma
Having a mental health condition, such as a mood or anxiety disorder, dissociative disorder or
certain personality disorders
Having a family member with a functional neurologic disorder
Possibly, having a history of physical or sexual abuse or neglect in childhood
Women may be more likely than men to develop functional neurologic disorders.
Affected Populations
The exact prevalence of FND is unknown. However, research suggests FND is the second
most common reason for a neurological outpatient visit after headache/migraine;
accounting for one sixth of diagnoses. This means FND is as common as multiple
sclerosis or Parkinson’s disease.
FND can affect anyone, at any time, although it is uncommon in children under 10. FND
is more likely to affect women than men for most symptoms, although when patients
present over the age of 50 then it occurs equally in both groups.
Diagnosis
FND is diagnosed on the basis of positive physical signs, and usually requires a neurologist or a doctor
familiar with neurological diagnosis. Some examples of these signs are:
• Hoover’s test is for of functional leg weakness – the patient may have difficulty pushing their “bad” leg
down (hip extension), but when they are asked to lift up their “good” leg, movement in the “bad” leg
returns transiently to normal.
• The tremor entrainment test for functional tremor – this is when the shaking of an arm or leg becomes
momentarily better when the person concentrates on copying a movement that the examiner makes.
• Dissociative (non-epileptic) seizures can often be recognised by a trained health professional using a
combination of typical features such as: an episode of violent limb thrashing in which the eyes remain
closed, side-to-side head movements, or an event lasting longer than 5 minutes where the eyes are closed,
hyperventilation during a shaking attack or tearfulness on recovery.
Treatment
In general, doctors recommend a combination of treatments. These treatments include:
Psychotherapy. People with FND related to a stressful or traumatic event, or an underlying mental health condition, may benefit from
working with a psychotherapist or psychologist. Some individuals with FND undergo cognitive behavior therapy (CBTTrusted Source
).
Physical therapy. The physical symptoms of FND, such as impaired movement or muscle weakness or pain, may be treated with
physical therapy.
Medication. Anti-anxiety drugs or antidepressants may help to treat the stress or anxiety that contributed to the onset of FND.
Transcranial magnetic stimulation (TMS). This treatment uses magnetic fields to stimulate certain parts of the brain. Some
reportsTrusted Source suggest TMS is beneficial for people with FND, but there is limited evidence at this stage.
Lifestyle changes. Engaging in activities that alleviate stress and anxiety, such as yoga, meditation, and progressive muscle relaxation,
may be helpful for some people with FND. Eating a balanced diet, getting enough sleep, fostering positive relationships, and
maintaining a good quality of life also contribute to stress reduction.
Speech Therapy: For patients with speech symptoms as part of FND, speech therapy is an important part of treatment. Like physical
therapy, the approach is different from that used, for example, after a stroke and patients benefit from seeing therapists confident in
this area.
Prognosis
1/3 better
1/3 improve
1/3 stay the same or worse
Pt with acute onset may response better than chronic
References
www.neurosymptoms.org
Functional and Dissociative Neurological Symptoms: a patient’s guide.
Free website with self-help information about all aspects of FND.
Written by Dr. Jon Stone, Neurologist, Edinburgh, UK http://www.neurosymptoms.org/
Accessed March 14, 2018.
Non-Epileptic Attacks. Free website with self-help information about dissociative (non-epileptic) attacks. Written by Prof. Markus
Reuber, Neurologist, Sheffield, UK http://www.nonepilepticattacks.info/ Accessed March 14, 2018.
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