Functional Neurological Symptom Disorder: A Continuing Conundrum for the Perioperative Physician, 2023, Chin and Kumaraswami

[Andy]

Abstract

Functional neurological symptom disorder (FNSD) or functional neurological disorder (FND) or conversion disorder, is a syndrome of neurological complications unexplained by neuropathology. The term FNSD or FND is now preferred, as conversion disorder is not an etiologically neutral term and is thus falling from use by researchers and clinicians in the field.

We report a case of new-onset postoperative neurological deficit in a patient who had undergone uneventful general anesthesia for a urology procedure. Postoperatively, in the post-anesthesia care unit, the patient was found to be unable to move her upper and lower limbs. Organic pathology was excluded and a diagnosis of FNSD was made. Four weeks after the surgery, the patient was only able to ambulate with the help of a mechanical walker device.

It is now suggested that procedures involving anesthesia are relatively common triggers for the development of FNSD. The occurrence of FNSD in the postoperative period is increasingly being attributed to the effects of anesthesia, the hypothesis being that it arises from the abreactive or dissociative effects of anesthetic agents. Another theory is the vulnerability of the anesthetized state which may evoke previous traumatic experiences. Psychiatric co-morbidities such as anxiety and depression may be seen in these patients. Preoperative psychological assessment may help identify patients at risk for FNSD. If postoperative neurological deficit occurs, detailed neurological, metabolic, and psychiatric assessments should be done with FNSD being a diagnosis of exclusion.

We present this case to increase awareness regarding this uncommon condition which can cause significant distress to the patient and healthcare team. Management should comprise honest disclosure, reassurance of recovery, and reinforcement of alternative coping strategies. The development of preoperative screening tools may help identify patients at risk for this disorder.

Open access, https://www.cureus.com/articles/163...-conundrum-for-the-perioperative-physician#!/

 

[SNT Gatchaman]

See also Post-operative Incomplete Quadriplegia Caused by Conversion Disorder in a Female After Gynecological Surgery: A Case Report (2022)

 

[SNT Gatchaman]

The term FNSD or FND is now preferred, as conversion disorder is not an etiologically neutral term and is thus falling from use by researchers and clinicians in the field.

And yet —

the hypothesis being that it arises from the abreactive or dissociative effects of anesthetic agents. Another theory is the vulnerability of the anesthetized state which may evoke previous traumatic experiences.

Abreactive
n. the expression and consequent release of a previously repressed emotion, achieved through reliving the experience that caused it (typically through hypnosis or suggestion).

FNSD FFSD

 

[Ash]

 

[Hutan]

I think it's worth looking at this paper for a bit, because on the face of it, FND sounds quite plausible. The case study subject reports paralysis, but tests of sensation and reflexes show that there is still nerve function, and a raised hand drop test shows that she can control the limb sufficiently to stop it falling on her face. She is reported to have been anxious, she is reported to have stress in her life.

We report a case of new-onset postoperative neurological deficit in a patient who had undergone uneventful general anesthesia for a urology procedure. Postoperatively, in the post-anesthesia care unit, the patient was found to be unable to move her upper and lower limbs. Organic pathology was excluded and a diagnosis of FNSD was made. Four weeks after the surgery, the patient was only able to ambulate with the help of a mechanical walker device.

Case studies as anti-litigation, reputation-protecting paper trails

Phillip Chin
Anesthesiology, New York Medical College/Westchester Medical Center, Valhalla, USA
Sangeeta Kumaraswami
Corresponding Author
Anesthesiology, New York Medical College/Westchester Medical Center, Valhalla, USA

As with many of these papers, the authors are not independent parties. The two authors (there are only two) are anaesthesiologists in the hospital where the incident occurred. These are not people without a conflict of interest. There is no neurologist author.

We present our case to increase awareness regarding this uncommon disorder which can present unique challenges.

Within the last year, she had undergone a laparoscopic surgery and a colonoscopy with an uneventful induction and emergence at our hospital.

Human subjects: Consent was obtained or waived by all participants in this study.

Consent or waiver - it makes a difference. We don't know if the patient signed a waiver in return for compensation, or free rehabilitation care.

Conflicts of interest:

In compliance with the ICMJE uniform disclosure form, all authors declare the following:
Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work.
Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.
Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

It seems difficult to square this conflicts of interest declaration with what we can reasonably infer from this paper - that these two anaesthesiologists were directly involved in the incident. Either they do have an interest or the case study has been fabricated to increase credibility of the concept.

This paper is not a collaboration with the patient. There is no sign that the patient agrees with the events are presented here, in fact there is not even any thanks given to her, there are no Acknowledgements. I imagine it would be fairly easy for people who know this woman to identify her, from the details given about her age and medical history.

It's therefore hard to know what is really going on in this case. We hear of the woman repeatedly asking about whether the anaesthetic could have caused the problem, so it doesn't sound as though she was buying the story she was being given of it being FND. And the last we hear is that a month later, she still doesn't have full mobility.

It is best to avoid discussing that symptoms are purely psychological because it may actually be detrimental and worsen the symptoms [4].

There's more than a whiff of 'but we were traumatised too!':

We present this case to increase awareness regarding this uncommon condition which can cause significant distress to the patient and healthcare team.

New-onset neurological deficit in the postoperative period is distressing not only for the patient, but also for the medical staff involved in the patient’s care. Members of the healthcare team may suffer from apprehension, depression, and fear of litigation. A second victim phenomenon occurs when healthcare providers experience emotional or physical distress as a result of traumatic clinical events [12]. Support programs may help second victims navigate the post-event experience and offload associated emotional labor.

I don't deny that it must be difficult when a patient develops a problem, and you are the medical professional in the firing line. I expect it is difficult to directly blame other medical professionals involved in the patient's care - hospital lawyers won't be encouraging that. The patient is vulnerable in this situation, and is an easy target of blame.

 

[Hutan]

Possibility of inaccurate representation of the patient's symptoms
So, bearing in mind that the authors appear to have a conflict of interest and that their paper almost certainly had to have sign off by their hospital's legal team, what evidence is there in the paper against this being a case of FND?

I think the woman's medical history is relevant.

A 63-year-old woman presented for ambulatory surgery for placement of a midurethral sling for urinary incontinence. Her medical history was significant for breast cancer. Her surgical history included two breast surgeries, hysterectomy, and colonoscopies. She reported delayed awakening and postoperative nausea and vomiting with some of her previous surgeries and was anxious about a similar experience with this surgery. Within the last year, she had undergone a laparoscopic surgery and a colonoscopy with an uneventful induction and emergence at our hospital.

She has had two breast surgeries and a hysterectomy - perhaps for cancer? Perhaps the breast surgeries were for implant placement and removal - implants can cause inflammatory diseases. We aren't told what the recent laparoscopic surgery or the colonoscopy was for, but it is clear that this woman is not in the best of health. She is now in the hospital for "placement of a midurethral sling for urinary incontinence". The urinary incontinence must have a cause. Is there a disease reducing nerve function to the bladder (and potentially elsewhere)? Did one of the medical interventions she has had reduce nerve function to her lower body?

Her companion reports that the woman had had a previous similar incident:

Meanwhile, the patient’s companion shared that a similar episode had occurred one year earlier, when the patient had undergone a computed tomography scan with contrast of the abdomen. The patient had developed bilateral upper and lower extremity weakness after the procedure. She had been taken to the emergency room where neuroimaging was done and was reported as being normal. The patient had been discharged home and the neurological deficit had resolved after a few hours.

Could it be that the woman has a metabolic issue causing periodic muscle weakness that might explain the urinary incontinence?

So, there's the question of what symptoms the patient actually had

Postoperatively, in the post-anesthesia care unit, the patient was found to be unable to move her upper and lower limbs.

During her week-long stay at our hospital, minimal improvement in motor function with little movement in the fingers and legs, was noted. She continued to require support for activities of daily living. After one week, she was transferred to a rehabilitation facility where she gradually began to regain function of her upper and lower extremities. She was discharged from the rehabilitation facility three weeks later at which time she was only able to ambulate with a mechanical walker device.

It isn't clear from this whether there was a total loss of function in arms and legs, or only reduced function in her fingers and legs. If, as seems mostly likely, that it was the latter, then the 'gotcha moments' of intact sensation and reflexes, and this 'raised hand drop test' where the arm was moved to avoid the hand dropping on the person's face seem much less confirmatory of FND. Someone unable to move their fingers but with hand and arm function could avoid a dropping hand falling on their face. Those of us who have experienced doctors inaccurately hearing and recording symptoms can imagine that the description reported here may not adequately reflect the woman's experience. Perhaps the loss of function in the fingers is a red herring?

 

[Hutan]

Possibility of inadequate assessment

One hour later, it was noticed that the patient was unable to move her bilateral upper and lower extremities. The patient was able to speak and appropriately communicate. Physical examination showed intact sensation and reflexes in both the upper and lower extremities. Vital signs and laboratory parameters were unremarkable. A neurology consultation was requested. A hand raise drop test was done which showed that when the patient’s arm was raised and then released, it did not fall on the patient’s face but behind her head or above her head. A computed tomography scan of the head and cervical spine was done and was negative for signs of stroke or cervical spine injury. Magnetic resonance imaging of the spine was negative for spinal cord ischemia.

From
Diagnostic accuracy of computed tomography perfusion in patients with acute stroke: A meta-analysis

Magnetic resonance imaging (MRI), particularly diffusion weighted imaging (DWI) and apparent diffusion coefficient maps, is considered the most reliable imaging test for acute ischemic stroke [4], [16]. MRI is in general though to be better than computed tomography (CT) for diagnosing acute stoke [4]. However, adding CT perfusion (CTP) to non-contrast CT increases the diagnostic accuracy of detecting acute ischemic stroke [14]. Within the first few hours of symptom onset, CTP is at least twice as sensitive as non-contrast-enhanced CT alone [14], [17]. It also has the advantage that it is more widely available in the emergency department setting compared to MRI.

That meta-analysis found that computed tomography to be substantially worse than MRI with DWI at detecting strokes. The pooled sensitivity of computed tomography with perfusion was 56% (assessed against MRI with DWI). That means that, if you have a stroke, the imaging would only identify the stroke slightly more than half of the time. One type of computed tomography with perfusion only had a specificity of 26%. It's important to note that the study is looking at CT perfusion imaging - CT scanning without perfusion is noted to have worse accuracy, less than half as good. The paper that is the subject of this thread does not specify what type of CT scanning was done.

I'm not saying that this woman did have a stroke, but just noting that we tend to assume that if imaging is done and it finds nothing, then there was nothing. In fact, there can be lots of reasons why a physical issue is not identified, including tools that are not very good at identifying problems.

Couple the fact that the tools for identifying problems are far from 100% reliable with an incentive to not find fault with something that the medical professionals did during the latest episode or in previous work, and therefore not to look very hard, and there is substantial scope for physical causes of symptoms to be missed. And then there's the widespread belief that subjecting a patient to extensive testing only serves to increase their false illness beliefs....

 

[rvallee]

Aside from how bleak and morally bankrupt this looks to me, it's so disappointing how medicine misses out on so many opportunities (most of them? all of them?) to learn about how the human body works, and instead defaults to trying to avoid blame for their own failures. In this case it even looks like an active one, rather than the more typical failure of figuring out what is happening at all. It's even common to do that for forgotten surgical instruments, but everything about is gagged, never recorded anywhere. So it's impossible to learn because the problem is always covered up.

It's very transparent to me that all of MUS/FND and the myriad acronyms are used as a weapon against liability and obligations, including the obligation to change past failed practices. It looks clearly to be the case here, although certainly opinions will vary.

Even worse is that people who are supposed to be scientists, although I guess in this case they are clinicians, used theory when they meant hypothesis, and even at that it's merely a suggestion at best, spitballing at worst. MDs make really bad scientists in general, they are too caught up in their immediate work and individual cases to look at the bigger picture. Especially in a case with so many obvious health problems and past procedures. It's as if their perspective is laser-focused and simply sees nothing else than whatever doesn't cause them problem. The system is very poorly built to allow for good outcomes.

It's well-established that medicine has a lot more to learn, that what they can do is still very limited. And still they will argue that if they can't figure it out easily, it can't be anything else than repressed trauma, or some imaginary nonsense that legally gets them off the hook, but binds them into immorality. In my opinion. This is very bleak reading. This antiscience absolutely doesn't belong in academic or medicine. Or in any expert profession.

 

[Amw66]

It would be interesting if there were a male comparative case to see if the same procedures and diagnosis were found.
Sorry, but being female is part of this problem..

Are there figures for sex split in FND diagnoses ?
@dave30th

 

[bobbler]

Aside from how bleak and morally bankrupt this looks to me, it's so disappointing how medicine misses out on so many opportunities (most of them? all of them?) to learn about how the human body works, and instead defaults to trying to avoid blame for their own failures. In this case it even looks like an active one, rather than the more typical failure of figuring out what is happening at all. It's even common to do that for forgotten surgical instruments, but everything about is gagged, never recorded anywhere. So it's impossible to learn because the problem is always covered up.

It's very transparent to me that all of MUS/FND and the myriad acronyms are used as a weapon against liability and obligations, including the obligation to change past failed practices. It looks clearly to be the case here, although certainly opinions will vary.

Even worse is that people who are supposed to be scientists, although I guess in this case they are clinicians, used theory when they meant hypothesis, and even at that it's merely a suggestion at best, spitballing at worst. MDs make really bad scientists in general, they are too caught up in their immediate work and individual cases to look at the bigger picture. Especially in a case with so many obvious health problems and past procedures. It's as if their perspective is laser-focused and simply sees nothing else than whatever doesn't cause them problem. The system is very poorly built to allow for good outcomes.

It's well-established that medicine has a lot more to learn, that what they can do is still very limited. And still they will argue that if they can't figure it out easily, it can't be anything else than repressed trauma, or some imaginary nonsense that legally gets them off the hook, but binds them into immorality. In my opinion. This is very bleak reading. This antiscience absolutely doesn't belong in academic or medicine. Or in any expert profession.

Yep, the past traumas quote seems a straight laugh on the following theme, surely just boundary testing to see if you can get away with blaming someone coming round having been affected by anaesthesia must instead 'have past traumas being resurrected' as their possible cause, or maybe they just need to get away with that doubt like when someone can't prove they got covid at work even though they didn't go anywhere else etc.


the functional overlay never getting removed even after a new diagnosis also looks obviously like practising political medicine and not neurology. Then building yourself a literature of how great it is to accidentally miss Parkinsons or CJD and diagnose FND first before you get too many of them. No idea why it is a good idea, because they fail to explain that part.

Also shows how the idea of the way the literature works 'sorting out these problems through back and forth' fails when one group has standards that mean they jot off manifestos from the top of their head every rainy Sunday, or each time they have an intern they need to find a task for they get them to do a retrospective cherry-picking 'findings' across select years. And the 'other', if said group even wanted to let them into the ring of the literature, actually have standards that mean they have to you know do all the ethics panels and recruiting controls and designing things in a ball ache way. Which costs money beyond their tenure and time.

But I do still wonder why we don't have any CJD or Parkinson's experts in the comments or replies saying 'erm, my first choice wouldn't be to dump them under a functional overlay because after all getting them to a proper diagnosis and clinic with support designed for that prognosis etc' and wonder whether they have had the same treatment the respondents here had when replying to Peter Denton White's recent anomolie claims manifesto ...

 

[bobbler]

I think it's worth looking at this paper for a bit, because on the face of it, FND sounds quite plausible. The case study subject reports paralysis, but tests of sensation and reflexes show that there is still nerve function, and a raised hand drop test shows that she can control the limb sufficiently to stop it falling on her face. She is reported to have been anxious, she is reported to have stress in her life.



Case studies as anti-litigation, reputation-protecting paper trails


As with many of these papers, the authors are not independent parties. The two authors (there are only two) are anaesthesiologists in the hospital where the incident occurred. These are not people without a conflict of interest. There is no neurologist author.




Consent or waiver - it makes a difference. We don't know if the patient signed a waiver in return for compensation, or free rehabilitation care.

It seems difficult to square this conflicts of interest declaration with what we can reasonably infer from this paper - that these two anaesthesiologists were directly involved in the incident. Either they do have an interest or the case study has been fabricated to increase credibility of the concept.

This paper is not a collaboration with the patient. There is no sign that the patient agrees with the events are presented here, in fact there is not even any thanks given to her, there are no Acknowledgements. I imagine it would be fairly easy for people who know this woman to identify her, from the details given about her age and medical history.

It's therefore hard to know what is really going on in this case. We hear of the woman repeatedly asking about whether the anaesthetic could have caused the problem, so it doesn't sound as though she was buying the story she was being given of it being FND. And the last we hear is that a month later, she still doesn't have full mobility.



There's more than a whiff of 'but we were traumatised too!':



I don't deny that it must be difficult when a patient develops a problem, and you are the medical professional in the firing line. I expect it is difficult to directly blame other medical professionals involved in the patient's care - hospital lawyers won't be encouraging that. The patient is vulnerable in this situation, and is an easy target of blame.

Yeah it just feels like there needs to be a new law (which I'm aware would need to be adopted by country probably) and regulation/standard for submission to journals that these items can only be submitted where the author is an assigned independent without any connections or conflicts.

I say this because there is indeed surely a safeguarding issue, imagining the way the US healthcare system works then we are talking about people being put in situations where they can't afford to survive to get to the point where they might take action they'd have a full right to without the 'deal' of rehab or care that might come with strings regarding allowing something to be written without their sign-off.

But also because these are supposed to add to the literature, and if it was done by a proper independent investigator then it would actually add useful and helpful advice and knowledge as it builds up - and if these 'second victims' were so traumatised then having such reasuring and accurate and validated information on prevalence, prognosis etc would be a game-changer.

We also wouldn't doubt why someone thought it OK for a doctor to think someone left paralysed should be put in a situation where their arm and hand would drop on their own face - which when it is 'dead' isn't light and is not a small thing so doesn't feel like the best and kindest test from an appropriateness point of view, even if they thought someone was faking (deserving) or that there were other reasons this wouldn't happen.

But I guess then you have the other layer of administrators letting said people in - and all this in a timeframe where e.g. someone having a stroke might have a critical time-period. So then you think about regulations perhaps needing to leave the situation of 'and if you didn't invite them in' would it make you look like you are hiding something vs if you did?

But surely this isn't the answer - it really doesn't feel like a typing up of the TV programmes where they apparently have a review of whatever case and all the clinicians get to learn and comment from it. And it does feel just by its nature of being post-procedure of it sitting in some twilight between medical literature and will be used legally. Which feels like it is trying to add to some sort of case law whilst getting the right to dictate what is written by it being written only by one side?

And I agree on the privacy issue. In most spheres of e.g. market research any group with less than 5 cannot even have figures published to questions as it makes them potentially identifiable (the only male under 40 with a disability doesn't like the CEOs communication strategy). Then there is GDPR on identifiability. Insinuating all sorts as well as trawling through what might be factual history seems pretty inappropriate given the implications (employment, relationships, religion)

Worrying trend I can't believe is allowed and doesn't have an easy way to have stopped it already.