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Semin Neurol 2019; 39(01): 102-114
DOI: 10.1055/s-0038-1676844
Review Article
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Functional (Psychogenic) Neurological Disorders: Assessment and Acute Management in the Emergency Department

Jordan R. Anderson
1   Department of Neurology, Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
2   Department of Psychiatry, Alpert Medical School, Brown University, Rhode Island Hospital, Providence, Rhode Island
,
Vihang Nakhate
3   Functional Neurology Research Group, Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
,
Christopher D. Stephen
3   Functional Neurology Research Group, Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
,
David L. Perez
3   Functional Neurology Research Group, Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts
4   Department of Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
› Author Affiliations Funding D.L.P. was supported by the Sidney R. Baer Jr. Foundation and the Massachusetts General Hospital Physician-Scientist Career Development Award.
Further Information

Publication History

Publication Date:
11 February 2019 (online)

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Abstract

Functional neurological disorders (FND) are complex and prevalent neuropsychiatric conditions. Importantly, some patients with FND develop acute onset symptoms requiring emergency department (ED) evaluations. Historically, FND was a “rule-out” diagnosis, making assessment and management in the ED difficult. While the rapid triage of potential neurological emergencies remains the initial task, advancements have altered the approach to FND. FND is now a “rule-in” diagnosis based on validated neurological examination signs and semiological features. In this perspective article, we review signs and semiological features that can help guide the initial assessment of FND in the acute setting. Thereafter, we outline potential approaches to introduce a suspected diagnosis of FND to patients in the ED, while emphasizing the need for a comprehensive neurological evaluation. Physical and occupational therapy may be useful adjunct assessments in some individuals. Notably, clinicians in the ED setting are important members of the interdisciplinary approach to FND.

Keywords

conversion disorder - psychogenic nonepileptic seizures - functional movement disorders - functional paralysis
 

  • References

  • 1 Stone J, Carson A, Duncan R. , et al. Who is referred to neurology clinics?--the diagnoses made in 3781 new patients. Clin Neurol Neurosurg 2010; 112 (09) 747-751
    CrossrefPubMedSearch in Google Scholar
  • 2 Stone J, Carson A, Duncan R. , et al. Symptoms ‘unexplained by organic disease’ in 1144 new neurology out-patients: how often does the diagnosis change at follow-up?. Brain 2009; 132 (Pt 10): 2878-2888
    CrossrefPubMedSearch in Google Scholar
  • 3 Merkler AE, Parikh NS, Chaudhry S. , et al. Hospital revisit rate after a diagnosis of conversion disorder. J Neurol Neurosurg Psychiatry 2016; 87 (04) 363-366
    CrossrefPubMedSearch in Google Scholar
  • 4 Carson A, Lehn A. Epidemiology. Handb Clin Neurol 2016; 139: 47-60
    Search in Google Scholar
  • 5 Barsky AJ, Orav EJ, Bates DW. Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity. Arch Gen Psychiatry 2005; 62 (08) 903-910
    CrossrefPubMedSearch in Google Scholar
  • 6 Perez DL, LaFrance Jr WC. Nonepileptic seizures: an updated review. CNS Spectr 2016; 21 (03) 239-246
    CrossrefPubMedSearch in Google Scholar
  • 7 Förster A, Griebe M, Wolf ME, Szabo K, Hennerici MG, Kern R. How to identify stroke mimics in patients eligible for intravenous thrombolysis?. J Neurol 2012; 259 (07) 1347-1353
    CrossrefPubMedSearch in Google Scholar
  • 8 Stone J, LaFrance Jr WC, Brown R, Spiegel D, Levenson JL, Sharpe M. Conversion disorder: current problems and potential solutions for DSM-5. J Psychosom Res 2011; 71 (06) 369-376
    CrossrefPubMedSearch in Google Scholar
  • 9 Stone J, LaFrance Jr WC, Levenson JL, Sharpe M. Issues for DSM-5: conversion disorder. Am J Psychiatry 2010; 167 (06) 626-627
    CrossrefPubMedSearch in Google Scholar
  • 10 McKee K, Glass S, Adams C. , et al. The inpatient assessment and management of motor functional neurological disorders: an interdisciplinary perspective. Psychosomatics 2018; 59 (04) 358-368
    CrossrefPubMedSearch in Google Scholar
  • 11 Galli S, Tatu L, Bogousslavsky J, Aybek S. Conversion, factitious disorder and malingering: a distinct pattern or a continuum?. Front Neurol Neurosci 2018; 42: 72-80
    PubMedSearch in Google Scholar
  • 12 Perez DL, Young SS, King JN. , et al. Preliminary predictors of initial attendance, symptom burden, and motor subtype in a US functional neurological disorders clinic population. Cogn Behav Neurol 2016; 29 (04) 197-205
    CrossrefPubMedSearch in Google Scholar
  • 13 Matin N, Young SS, Williams B. , et al. Neuropsychiatric associations with gender, illness duration, work disability, and motor subtype in a U.S. functional neurological disorders clinic population. J Neuropsychiatry Clin Neurosci 2017; 29 (04) 375-382
    CrossrefPubMedSearch in Google Scholar
  • 14 McKenzie PS, Oto M, Graham CD, Duncan R. Do patients whose psychogenic non-epileptic seizures resolve, ‘replace’ them with other medically unexplained symptoms? Medically unexplained symptoms arising after a diagnosis of psychogenic non-epileptic seizures. J Neurol Neurosurg Psychiatry 2011; 82 (09) 967-969
    CrossrefPubMedSearch in Google Scholar
  • 15 Stone J, Carson A. Functional neurologic disorders. Continuum (Minneap Minn) 2015; 21 (3 Behavioral Neurology and Neuropsychiatry): 818-837
    PubMedSearch in Google Scholar
  • 16 Kranick S, Ekanayake V, Martinez V, Ameli R, Hallett M, Voon V. Psychopathology and psychogenic movement disorders. Mov Disord 2011; 26 (10) 1844-1850
    CrossrefPubMedSearch in Google Scholar
  • 17 Stone J, Warlow C, Sharpe M. The symptom of functional weakness: a controlled study of 107 patients. Brain 2010; 133 (Pt 5): 1537-1551
    CrossrefPubMedSearch in Google Scholar
  • 18 Roelofs K, Keijsers GP, Hoogduin KA, Näring GW, Moene FC. Childhood abuse in patients with conversion disorder. Am J Psychiatry 2002; 159 (11) 1908-1913
    CrossrefPubMedSearch in Google Scholar
  • 19 Ludwig L, Pasman JA, Nicholson T. , et al. Stressful life events and maltreatment in conversion (functional neurological) disorder: systematic review and meta-analysis of case-control studies. Lancet Psychiatry 2018; 5 (04) 307-320
    CrossrefPubMedSearch in Google Scholar
  • 20 Reuber M, Howlett S, Khan A, Grünewald RA. Non-epileptic seizures and other functional neurological symptoms: predisposing, precipitating, and perpetuating factors. Psychosomatics 2007; 48 (03) 230-238
    CrossrefPubMedSearch in Google Scholar
  • 21 Pareés I, Kojovic M, Pires C. , et al. Physical precipitating factors in functional movement disorders. J Neurol Sci 2014; 338 (1-2): 174-177
    CrossrefPubMedSearch in Google Scholar
  • 22 Chen DK, Sharma E, LaFrance Jr WC. Psychogenic non-epileptic seizures. Curr Neurol Neurosci Rep 2017; 17 (09) 71
    CrossrefPubMedSearch in Google Scholar
  • 23 Reuber M, Brown RJ. Understanding psychogenic nonepileptic seizures - phenomenology, semiology and the integrative cognitive model. Seizure 2017; 44: 199-205
    CrossrefPubMedSearch in Google Scholar
  • 24 Kerr WT, Janio EA, Braesch CT. , et al. An objective score to identify psychogenic seizures based on age of onset and history. Epilepsy Behav 2018; 80: 75-83
    CrossrefPubMedSearch in Google Scholar
  • 25 Bowman ES, Markand ON. Psychodynamics and psychiatric diagnoses of pseudoseizure subjects. Am J Psychiatry 1996; 153 (01) 57-63
    CrossrefPubMedSearch in Google Scholar
  • 26 Direk N, Kulaksizoglu IB, Alpay K, Gurses C. Using personality disorders to distinguish between patients with psychogenic nonepileptic seizures and those with epileptic seizures. Epilepsy Behav 2012; 23 (02) 138-141
    CrossrefPubMedSearch in Google Scholar
  • 27 Asmussen SB, Kirlin KA, Gale SD, Chung SS. Differences in self-reported depressive symptoms between patients with epileptic and psychogenic nonepileptic seizures. Seizure 2009; 18 (08) 564-566
    CrossrefPubMedSearch in Google Scholar
  • 28 Dixit R, Popescu A, Bagić A, Ghearing G, Hendrickson R. Medical comorbidities in patients with psychogenic nonepileptic spells (PNES) referred for video-EEG monitoring. Epilepsy Behav 2013; 28 (02) 137-140
    CrossrefPubMedSearch in Google Scholar
  • 29 Thomas AA, Preston J, Scott RC, Bujarski KA. Diagnosis of probable psychogenic nonepileptic seizures in the outpatient clinic: does gender matter?. Epilepsy Behav 2013; 29 (02) 295-297
    CrossrefPubMedSearch in Google Scholar
  • 30 Salinsky M, Spencer D, Boudreau E, Ferguson F. Psychogenic nonepileptic seizures in US veterans. Neurology 2011; 77 (10) 945-950
    CrossrefPubMedSearch in Google Scholar
  • 31 Salinsky M, Storzbach D, Goy E, Evrard C. Traumatic brain injury and psychogenic seizures in veterans. J Head Trauma Rehabil 2015; 30 (01) E65-E70
    CrossrefPubMedSearch in Google Scholar
  • 32 Westbrook LE, Devinsky O, Geocadin R. Nonepileptic seizures after head injury. Epilepsia 1998; 39 (09) 978-982
    CrossrefPubMedSearch in Google Scholar
  • 33 Dworetzky BA, Strahonja-Packard A, Shanahan CW, Paz J, Schauble B, Bromfield EB. Characteristics of male veterans with psychogenic nonepileptic seizures. Epilepsia 2005; 46 (09) 1418-1422
    CrossrefPubMedSearch in Google Scholar
  • 34 LaFrance Jr WC, Deluca M, Machan JT, Fava JL. Traumatic brain injury and psychogenic nonepileptic seizures yield worse outcomes. Epilepsia 2013; 54 (04) 718-725
    CrossrefPubMedSearch in Google Scholar
  • 35 LaFrance Jr WC, Reuber M, Goldstein LH. Management of psychogenic nonepileptic seizures. Epilepsia 2013; 54 (Suppl. 01) 53-67
    CrossrefPubMedSearch in Google Scholar
  • 36 Espay AJ, Aybek S, Carson A. , et al. Current concepts in diagnosis and treatment of functional neurological disorders. JAMA Neurol 2018; 75 (09) 1132-1141
    CrossrefPubMedSearch in Google Scholar
  • 37 Daum C, Gheorghita F, Spatola M. , et al. Interobserver agreement and validity of bedside ‘positive signs’ for functional weakness, sensory and gait disorders in conversion disorder: a pilot study. J Neurol Neurosurg Psychiatry 2015; 86 (04) 425-430
    CrossrefPubMedSearch in Google Scholar
  • 38 Daum C, Hubschmid M, Aybek S. The value of ‘positive’ clinical signs for weakness, sensory and gait disorders in conversion disorder: a systematic and narrative review. J Neurol Neurosurg Psychiatry 2014; 85 (02) 180-190
    CrossrefPubMedSearch in Google Scholar
  • 39 Gould R, Miller BL, Goldberg MA, Benson DF. The validity of hysterical signs and symptoms. J Nerv Ment Dis 1986; 174 (10) 593-597
    CrossrefPubMedSearch in Google Scholar
  • 40 Chabrol H, Peresson G, Clanet M. Lack of specificity of the traditional criteria for conversion disorders. Eur Psychiatry 1995; 10 (06) 317-319
    CrossrefPubMedSearch in Google Scholar
  • 41 Fasano A, Valadas A, Bhatia KP. , et al. Psychogenic facial movement disorders: clinical features and associated conditions. Mov Disord 2012; 27 (12) 1544-1551
    CrossrefPubMedSearch in Google Scholar
  • 42 Rolak LA. Psychogenic sensory loss. J Nerv Ment Dis 1988; 176 (11) 686-687
    CrossrefPubMedSearch in Google Scholar
  • 43 Toth C. Hemisensory syndrome is associated with a low diagnostic yield and a nearly uniform benign prognosis. J Neurol Neurosurg Psychiatry 2003; 74 (08) 1113-1116
    CrossrefPubMedSearch in Google Scholar
  • 44 Bogousslavsky J, Regli F, Uske A. Thalamic infarcts: clinical syndromes, etiology, and prognosis. Neurology 1988; 38 (06) 837-848
    CrossrefPubMedSearch in Google Scholar
  • 45 Paciaroni M, Bogousslavsky J. Pure sensory syndromes in thalamic stroke. Eur Neurol 1998; 39 (04) 211-217
    CrossrefPubMedSearch in Google Scholar
  • 46 Kim JS. Pure sensory stroke. Clinical-radiological correlates of 21 cases. Stroke 1992; 23 (07) 983-987
    CrossrefPubMedSearch in Google Scholar
  • 47 Kim JS, Bae YH. Pure or predominant sensory stroke due to brain stem lesion. Stroke 1997; 28 (09) 1761-1764
    CrossrefPubMedSearch in Google Scholar
  • 48 Kim JS. Lenticulocapsular hemorrhages presenting as pure sensory stroke. Eur Neurol 1999; 42 (03) 128-131
    CrossrefPubMedSearch in Google Scholar
  • 49 Bassetti C, Bogousslavsky J, Regli F. Sensory syndromes in parietal stroke. Neurology 1993; 43 (10) 1942-1949
    CrossrefPubMedSearch in Google Scholar
  • 50 Baker JH, Silver JR. Hysterical paraplegia. J Neurol Neurosurg Psychiatry 1987; 50 (04) 375-382
    CrossrefPubMedSearch in Google Scholar
  • 51 Nadarajan V, Perry RJ, Johnson J, Werring DJ. Transient ischaemic attacks: mimics and chameleons. Pract Neurol 2014; 14 (01) 23-31
    CrossrefPubMedSearch in Google Scholar
  • 52 Barbey A, Aybek S. Functional movement disorders. Curr Opin Neurol 2017; 30 (04) 427-434
    CrossrefPubMedSearch in Google Scholar
  • 53 Hallett M. Functional (psychogenic) movement disorders - clinical presentations. Parkinsonism Relat Disord 2016; 22 (Suppl. 01) S149-S152
    CrossrefPubMedSearch in Google Scholar
  • 54 Kenney C, Diamond A, Mejia N, Davidson A, Hunter C, Jankovic J. Distinguishing psychogenic and essential tremor. J Neurol Sci 2007; 263 (1-2(: 94-99
    CrossrefPubMedSearch in Google Scholar
  • 55 Thenganatt MA, Jankovic J. Psychogenic tremor: a video guide to its distinguishing features. Tremor Other Hyperkinet Mov (N Y) 2014; 4: 253
    PubMedSearch in Google Scholar
  • 56 Roper LS, Saifee TA, Parees I, Rickards H, Edwards MJ. How to use the entrainment test in the diagnosis of functional tremor. Pract Neurol 2013; 13 (06) 396-398
    CrossrefPubMedSearch in Google Scholar
  • 57 Baik JS, Lang AE. Gait abnormalities in psychogenic movement disorders. Mov Disord 2007; 22 (03) 395-399
    CrossrefPubMedSearch in Google Scholar
  • 58 Elwischger K, Rommer P, Prayer D, Mueller C, Auff E, Wiest G. Thalamic astasia from isolated centromedian thalamic infarction. Neurology 2012; 78 (02) 146-147
    CrossrefPubMedSearch in Google Scholar
  • 59 Takahashi K, Osaka A, Tsuda H, Ogasawara H. Isolated astasia caused by a localized infarction in the suprathalamic white matter. J Gen Fam Med 2017; 18 (05) 275-278
    CrossrefPubMedSearch in Google Scholar
  • 60 Sheffler LR, Chae J. Hemiparetic Gait. Phys Med Rehabil Clin N Am 2015; 26 (04) 611-623
    CrossrefPubMedSearch in Google Scholar
  • 61 Avbersek A, Sisodiya S. Does the primary literature provide support for clinical signs used to distinguish psychogenic nonepileptic seizures from epileptic seizures?. J Neurol Neurosurg Psychiatry 2010; 81 (07) 719-725
    CrossrefPubMedSearch in Google Scholar
  • 62 Seneviratne U, Minato E, Paul E. How reliable is ictal duration to differentiate psychogenic nonepileptic seizures from epileptic seizures?. Epilepsy Behav 2017; 66: 127-131
    CrossrefPubMedSearch in Google Scholar
  • 63 Syed TU, LaFrance Jr WC, Kahriman ES. , et al. Can semiology predict psychogenic nonepileptic seizures? A prospective study. Ann Neurol 2011; 69 (06) 997-1004
    CrossrefPubMedSearch in Google Scholar
  • 64 Dworetzky BA, Weisholtz DS, Perez DL, Baslet G. A clinically oriented perspective on psychogenic nonepileptic seizure-related emergencies. Clin EEG Neurosci 2015; 46 (01) 26-33
    CrossrefPubMedSearch in Google Scholar
  • 65 Herskovitz M. Stereotypy of psychogenic nonepileptic seizures. Epilepsy Behav 2017; 70 (Pt A): 140-144
    CrossrefPubMedSearch in Google Scholar
  • 66 Asadi-Pooya AA, Tinker J, Fletman EW. How variable are psychogenic nonepileptic seizures? A retrospective semiological study. J Neurol Sci 2017; 377: 85-87
    CrossrefPubMedSearch in Google Scholar
  • 67 Erba G, Bianchi E, Giussani G, Langfitt J, Juersivich A, Beghi E. Patients' and caregivers' contributions for differentiating epileptic from psychogenic nonepileptic seizures. Value and limitations of self-reporting questionnaires: a pilot study. Seizure 2017; 53: 66-71
    CrossrefPubMedSearch in Google Scholar
  • 68 De Paola L, Terra VC, Silvado CE. , et al. Improving first responders' psychogenic nonepileptic seizures diagnosis accuracy: development and validation of a 6-item bedside diagnostic tool. Epilepsy Behav 2016; 54: 40-46
    CrossrefPubMedSearch in Google Scholar
  • 69 Jin B, Wu H, Xu J. , et al. Analyzing reliability of seizure diagnosis based on semiology. Epilepsy Behav 2014; 41: 197-202
    CrossrefPubMedSearch in Google Scholar
  • 70 Wasserman D, Herskovitz M. Epileptic vs psychogenic nonepileptic seizures: a video-based survey. Epilepsy Behav 2017; 73: 42-45
    CrossrefPubMedSearch in Google Scholar
  • 71 Duncan R, Oto M. Predictors of antecedent factors in psychogenic nonepileptic attacks: multivariate analysis. Neurology 2008; 71 (13) 1000-1005
    CrossrefPubMedSearch in Google Scholar
  • 72 Reuber M, Qurishi A, Bauer J. , et al. Are there physical risk factors for psychogenic non-epileptic seizures in patients with epilepsy?. Seizure 2003; 12 (08) 561-567
    CrossrefPubMedSearch in Google Scholar
  • 73 Wissel BD, Dwivedi AK, Gaston TE. , et al. Which patients with epilepsy are at risk for psychogenic nonepileptic seizures (PNES)? A multicenter case-control study. Epilepsy Behav 2016; 61: 180-184
    CrossrefPubMedSearch in Google Scholar
  • 74 Chernyshev OY, Martin-Schild S, Albright KC. , et al. Safety of tPA in stroke mimics and neuroimaging-negative cerebral ischemia. Neurology 2010; 74 (17) 1340-1345
    CrossrefPubMedSearch in Google Scholar
  • 75 Glauser T, Shinnar S, Gloss D. , et al. Evidence-based guideline: treatment of convulsive status epilepticus in children and adults: report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr 2016; 16 (01) 48-61
    CrossrefPubMedSearch in Google Scholar
  • 76 Beleza P, Pinho J. Frontal lobe epilepsy. J Clin Neurosci 2011; 18 (05) 593-600
    CrossrefPubMedSearch in Google Scholar
  • 77 Baslet G, Seshadri A, Bermeo-Ovalle A, Willment K, Myers L. Psychogenic non-epileptic seizures: an updated primer. Psychosomatics 2016; 57 (01) 1-17
    CrossrefPubMedSearch in Google Scholar
  • 78 Carson A, Lehn A, Ludwig L, Stone J. Explaining functional disorders in the neurology clinic: a photo story. Pract Neurol 2016; 16 (01) 56-61
    CrossrefPubMedSearch in Google Scholar
  • 79 Gardiner P, MacGregor L, Carson A, Stone J. Occupational therapy for functional neurological disorders: a scoping review and agenda for research. CNS Spectr 2018; 23 (03) 205-212
    CrossrefPubMedSearch in Google Scholar
  • 80 Ranford J, Perez DL, MacLean J. Additional occupational therapy considerations for functional neurological disorders: a potential role for sensory processing. CNS Spectr 2018; 23 (03) 194-195
    CrossrefPubMedSearch in Google Scholar
  • 81 LaFrance Jr WC, Baker GA, Duncan R, Goldstein LH, Reuber M. Minimum requirements for the diagnosis of psychogenic nonepileptic seizures: a staged approach: a report from the International League Against Epilepsy Nonepileptic Seizures Task Force. Epilepsia 2013; 54 (11) 2005-2018
    CrossrefPubMedSearch in Google Scholar
  • 82 Jacob AE, Kaelin DL, Roach AR, Ziegler CH, LaFaver K. Motor retraining (MoRe) for functional movement disorders: outcomes from a 1-week multidisciplinary rehabilitation program. PM R 2018 ; doi: 10.1016/j.pmrj.2018.05.011
    PubMedSearch in Google Scholar
  • 83 Nielsen G, Stone J, Edwards MJ. Physiotherapy for functional (psychogenic) motor symptoms: a systematic review. J Psychosom Res 2013; 75 (02) 93-102
    CrossrefPubMedSearch in Google Scholar
  • 84 Nielsen G, Stone J, Matthews A. , et al. Physiotherapy for functional motor disorders: a consensus recommendation. J Neurol Neurosurg Psychiatry 2015; 86 (10) 1113-1119
    CrossrefPubMedSearch in Google Scholar
  • 85 Adams C, Anderson J, Madva EN, LaFrance Jr WC, Perez DL. You've made the diagnosis of functional neurological disorder: now what?. Pract Neurol 2018; 18 (04) 323-330
    CrossrefPubMedSearch in Google Scholar