A Case Report of Headache and Weakness Diagnosed as Functional Neurological Disorder 2025 Wilson et al

[Andy]

Abstract

Background

Cerebral venous sinus thrombosis (CVST) is a rare diagnosis and is estimated at 1.32-1.57 per 100,000 cases. Patients with CVST often present with headache, seizures, focal motor deficits, encephalopathy, or aphasia, and can be fatal in 3%-15% of cases. Newer diagnostic criteria indicate functional neurological disorder (previously known as conversion disorder) as a “rule in” diagnosis that should be given only if patients meet strict criteria.

Case Report

A 26-year-old woman with a past medical history of depression during pregnancy, anxiety, and migraines, presented to a large emergency department in the United States with headache, unilateral weakness, spastic movement, numbness, and “feeling off.” At the time of presentation, she had a Glasgow Coma Scale score of 14 and was approximately 7 weeks postpartum and had resumed oral contraceptives 11 days prior. After a normal head computed tomography scan, she was discharged with a diagnosis of anxiety reaction and headache, with question of possible conversion disorder. The patient returned the next morning with worsening weakness and inability to walk. Given that she was only intermittently following commands, she was admitted for seizure monitoring, with particular concern for psychogenic nonepileptic seizures. A magnetic resonance imaging scan ordered by the admitting hospitalist indicated left thalamic infarct secondary to cerebral venous thrombosis.

Why Should an Emergency Physician Be Aware of This?

CVST should be considered on the differential for premenopausal women presenting with headache, altered mental status, and focal neurological deficits. The diagnosis of functional neurological disorder was previously thought of as a diagnosis of exclusion, however, it is now a diagnosis of inclusion using specific positive findings.

Paywall

 

[Peter T]

I don’t understand this abstract, are they saying the putative FND diagnosis was a good thing or a bad thing? Are they saying rule in criteria for FND are a step forward or a step backwards?

My take away, which may not be what the authors intended, is that if you plan to have significant subsequent neurological problems don’t let your doctors know you have mental health issues.

 

[Andy]

The way I read it is that they are warning against applying a diagnosis of FND when the criteria for FND is not met as diagnoses such as this can be missed.

 

[dave30th]

The way I read it is that they are warning against applying a diagnosis of FND when the criteria for FND is not met as diagnoses such as this can be missed

Yup. They're challenging the specific FND diagnosis but accepting the construct as valid if the "strict" criteria are met--even though I don't see the rule-in criteria as being particularly strict. Presumably the paper indicates that there were no observable "rule-in" signs to justify the FND diagnosis.

 

[SNT Gatchaman]

First described in 1825 by French physician Ribes, cerebral venous sinus thrombosis (CVST) is a rare and difficult-to-diagnose coagulopathic condition. The disease, most commonly affecting females of reproductive age, is a major cause of stroke in young adults and can have varied clinical presentations. Though there are numerous presenting symptoms, the most common include headache, seizure, focal motor deficits, altered mental status, and aphasia. Varied presenting symptoms, along with the low sensitivity of computed tomography (CT) imaging and the low incidence of the disease, leads to frequent misdiagnosis.

A similarly presenting disease is conversion disorder, a psychogenic disorder that has overlapping generalized symptoms with CVST. Conversion disorder, termed “functional neurological disorder” (FND) in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), may also present with focal motor deficits, numbness, and tremors. Functional neurologic disorder is also rare, with an estimated incidence of 4-5 per 100,000, with up to 70% of cases found in females. FND is characterized by the presence of medically unexplainable symptoms, and strongly correlates with a history of psychiatric disease. Despite its similarities to CVST, FND should be reserved for patients who meet strict criteria.

She was instructed to follow up as an outpatient with her primary care provider and psychiatrist.

She returned to the ED the next morning with family who stated that overnight, she began having mood changes and tremors. The tremors occurred approximately every 20 min, mostly in the right arm and leg, and lasted a few seconds at a time. As a result, her mother called the ED. She was reportedly told by staff who answered the phone that the ongoing weakness and altered mental status might be from lorazepam. Around 4:00 am, however, the patient’s mother found her difficult to arouse and noticed her defecating and urinating on herself and making gagging sounds. The tremors had not stopped, and she was lying on a mattress in the living room, verbally responsive but unable to respond verbally.

Upon her return to the ED, she was only responsive to pain and was slightly hypertensive at 140/99 mm Hg. […] After independent review of the previous day’s laboratory values, the physician noted “pseudoseizure-like activity,” which was later described as head rolling, gnashing of teeth, and several tremoring episodes. The patient was admitted for observation at 9:13 am with the diagnosis of altered mental status that was thought likely to be from pseudoseizures. As an inpatient, magnetic resonance imaging with magnetic resonance venography (MRI/MRV) of the brain subsequently revealed mild hydrocephalus and extensive cerebral venous thrombosis (CVT), as well as infarcts involving the caudate nucleus and thalamus. She was transferred to the intensive care unit, started on a heparin drip, and phenytoin and dexamethasone were initiated. After discharge, she continued to experience gradually improving aphasia, functional motor deficits including impaired mobility, and cognitive deficits.

Functional neurological disorder, previously known as conversion disorder by DSM-IV, is a psychiatric disorder that causes neurological symptoms. There are two main criteria for diagnosis according to DSM-5: a neurological disorder is present, and there is an incompatibility between clinical findings and a recognized neurological condition. The main shift from DSM-IV criteria is that FND is no longer a “rule-out” diagnosis, but requires positive findings to make the diagnosis. Two overarching findings observed in all FND subtypes include symptom variability and a grimacing expression while following the clinician’s instructions during the physical examination (2).

"Grimacing" is new. I can't recall seeing that described previously. The reference is —

[2] Cerebral Venous Thrombosis: an Update (2019)

which doesn't even mention FND.

The references are more generally chaotic. Eg in the discussion of cerebral venous sinus thrombosis —

Other indirect signs may include the “cord sign,” that is, a cord-like hyperdensity within the thrombosed vessel that is seen in approximately 5% of cases (5).

[5] is Functional Neurological Disorder is a Feminist Issue (2023) which needless to say does not discuss imaging, vessels or coagulation.

This case adequately demonstrates the common pitfalls that clinicians can fall victim to when trying to make CVST and FND diagnoses. CVST is historically a difficult diagnosis, with an approximately 1-in-18 to 1-in-30 rate of misdiagnosis according to a retrospective cohort study.

Erm yes... it's also a pitfall the patient can fall victim to. Like this poor 26 year old new mother whose life is now ruined by diagnostic delay, because of this insane bias toward FND diagnosis and systematic psychologisation of biological disease.

 

[Liie]

These kinds of cases are really interesting and I think they are great examples to use as arguments against the psychosomatic proponents.

 

[Sean]

Two overarching findings observed in all FND subtypes include symptom variability and a grimacing expression while following the clinician’s instructions during the physical examination (2).​

WTF?!?

Every time you think these idiots couldn't possible get any worse, there they go and prove you wrong.

Every. Freaking. Time.

 

[dave30th]

grimacing? How is that defined? Maybe they just were havng gas and about to fart?

 

[Utsikt]

I grimace when I’m exposed to normal noises and regular daylight because it hurts. I guess I have an FND.

 

[Peter T]

I grimace when yet another heavy vehicle drives over the verge outside my house meaning yet more reseeding is required, I must have FND too.

 

[rvallee]

The diagnosis of functional neurological disorder was previously thought of as a diagnosis of exclusion, however, it is now a diagnosis of inclusion using specific positive findings.

After a normal head computed tomography scan, she was discharged with a diagnosis of anxiety reaction and headache, with question of possible conversion disorder.

Sure, Jan.

But, really, why are you lying?

There are two main criteria for diagnosis according to DSM-5: a neurological disorder is present, and there is an incompatibility between clinical findings and a recognized neurological condition.

They know the first sentence I quoted is false. They even show they know it's false, but pretending is part of the con.

 

[rvallee]

A similarly presenting disease is conversion disorder, a psychogenic disorder that has overlapping generalized symptoms with CVST

Do they just not bother reading what they write? First of all, conversion disorder is not a disease, and second, it literally allows for any and all symptoms in any sequence or form for any reason whatsoever, and so by definition literally always overlaps with everything. This is a totally invalid argument.

Functional neurological disorder, previously known as conversion disorder by DSM-IV, is a psychiatric disorder that causes neurological symptoms.

Ah, a disorder, after all, but also, no, it does not 'cause' any such thing. It is merely a preferred explanation, like how rain causes water to fall down from the sky is only descriptive, but explains nothing about how and why it occurs.

The difference in professionalism and expertise between when health care is based on valid biomedicine and when it isn't is really shocking, it's a complete night-and-day shift. All the skills developed carefully over a decade of education and training basically become as wild as an otter on meth.

 

[rvallee]

grimacing? How is that defined? Maybe they just were havng gas and about to fart?

I'm assuming they mean something more like wincing in pain and discomfort. You can be in pain and discomfort, by definition, but you are not allowed to show it. Or you are allowed, as long as it's expected, and just the right way, at the right time, for the right reasons that allow the fact to be observed as a fact, rather than judged as excessive.

We have to be ill, and show it, as otherwise we "don't look ill", but not too much, because otherwise it's judged to be too much, so we have to be ill in the "just right" way, or it doesn't count. We can't know the way, it changes arbitrarily all the time, and the exact same sequence of facts and things can mean the opposite at other times for reasons we cannot know, because when we do they are laughably absurd and so we reject them, thus being defiant in our rejection that we have a psychological disorder. Or whatever.

 

[dave30th]

[5] is Functional Neurological Disorder is a Feminist Issue (2023) which needless to say does not discuss imaging, vessels or coagulation.

Are these AI-generated errors?

 

[SNT Gatchaman]

I doubt it, could be the journal mucking up the reference listing (or the authors).

 

[Sean]

You can be in pain and discomfort, by definition, but you are not allowed to show it. Or you are allowed, as long as it's expected, and just the right way, at the right time, for the right reasons that allow the fact to be observed as a fact, rather than judged as excessive.

Exactly.

plus ça change, plus c'est la même chose​