A Review and Expert Opinion on the Neuropsychiatric Assessment of Motor Functional Neurological Disorders, 2020, Perez, Stone, Hallett et al

[Andy]

Functional neurological (conversion) disorder (FND) is a prevalent and disabling condition at the intersection of neurology and psychiatry. Advances have been made in elucidating an emerging pathophysiology for motor FND, as well as in identifying evidenced-based physiotherapy and psychotherapy treatments. Despite these gains, important elements of the initial neuropsychiatric assessment of functional movement disorders (FND-movt) and functional limb weakness/paresis (FND-par) have yet to be established. This is an important gap from both diagnostic and treatment planning perspectives.

In this article, the authors performed a narrative review to characterize clinically relevant variables across FND-movt and FND-par cohorts, including time course and symptom evolution, precipitating factors, medical and family histories, psychiatric comorbidities, psychosocial factors, physical examination signs, and adjunctive diagnostic tests.

Thereafter, the authors propose a preliminary set of clinical content that should be assessed during early-phase patient encounters, in addition to identifying physical signs informing diagnosis and potential use of adjunctive tests for challenging cases.

Although clinical history should not be used to make a FND diagnosis, characteristics such as acute onset, precipitating events (e.g., injury and surgery), and a waxing and waning course (including spontaneous remissions) are commonly reported. Active psychiatric symptoms (e.g., depression and anxiety) and ongoing psychosocial stressors also warrant evaluation. Positive physical examination signs (e.g., Hoover’s sign and tremor entrainment) are key findings, as one of the DSM-5 diagnostic criteria.

The neuropsychiatric assessment proposed emphasizes diagnosing FND by using “rule-in” physical signs while also considering psychiatric and psychosocial factors to aid in the development of a patient-centered treatment plan.

Paywall, https://neuro.psychiatryonline.org/doi/10.1176/appi.neuropsych.19120357
Sci hub, https://sci-hub.tw/10.1176/appi.neuropsych.19120357

 

[Peter T]

Are we seeing a lot of work being done in order to develop a stereotype? What then happens to those people who fit in with that stereotype who then develop a life threatening medical condition?

I repeat here the example of a friend on mainland Europe, who had a complex medical history, displaying stress and anxiety. She had severe chest pain whenever bending forward after open heart surgery. She might be seen to fall into the functional or MUS stereotype. It took a lot of doctors visits, a period of psychotherapy and some doctor hopping before she got agreement for a simple chest X- ray that revealed the eleven inch long stainless steel surgical instrument left in her chest cavity. Fortunately she had refused the repeated instructions to exercise through the pain so her heart, lungs and diaphragm had not been badly bruised or punctured.

 

[Arnie Pye]

It took a lot of doctors visits, a period of psychotherapy and some doctor hopping before she got agreement for a simple chest X- ray that revealed the eleven inch long stainless steel surgical instrument left in her chest cavity

Just imagine what would have happened if they had done an MRI instead of an x-ray. How long did she have this metal surgical tool inside her chest? I hope she got lots and lots of money in compensation.

 

[Peter T]

Just imagine what would have happened if they had done an MRI instead of an x-ray. How long did she have this metal surgical tool inside her chest? I hope she got lots and lots of money in compensation.

It was eight months from the surgery to getting an X-ray, not sure how long then to getting it taken out. It took a number of years to sort the compensation, but what annoyed them most was the hospital never apologised.

 

[rvallee]

"expert"

Active psychiatric symptoms (e.g., depression and anxiety) and ongoing psychosocial stressors also warrant evaluation

This is basically where 99% of the "work" has focused on for the last several decades to absolute failure. How much more "evaluation" is warranted? With experts like this... Seriously just take random people off the streets and give them responsibility over this and they would absolutely do a better job. At least they would actually listen instead of waiting for their cue to gaslight.

They even have the explanation for why failure is so disastrous but can't see it:

neurologists, psychiatrists, and allied clinicians often report feeling ill-equipped to assess and manage FND

The biopsychosocial model identifying predisposing vulnerabilities, acute precipitants, and perpetuating factors is a prevailing conceptual formulation for FND

Those two things are closely related. You can't solve a problem by rejecting reality and substituting your own. Keep trying with your magical stuff and for sure one day magic will occur. Never change, just keep doing the same things you've been doing, the exact same way you've always done it, it's guaranteed to succeed as long as you define success as nothing.

These people are smart, SMART:

Although clinical history should not be used to make a FND diagnosis, characteristics such as acute onset, precipitating events (e.g., injury and surgery), and a waxing and waning course (including spontaneous remissions) are commonly reported

We performed a narrative review detailing the clinical history and diagnostic evaluation

They contradict themselves entirely within the first two paragraphs. Clinical history is not important, now here's a narrative review of clinical history. Go ahead and cherry-pick stuff for several decades more, I'm sure it will work by brute force and sheer gumption. Ridiculous.

 

[Sean]

In this article, the authors performed a narrative review...

Stopped there.