TY - JOUR
T1 - A review and expert opinion on the neuropsychiatric assessment of motor functional neurological disorders
AU - American Neuropsychiatric Association Committee for Research
AU - Perez, David L.
AU - Aybek, Selma
AU - Popkirov, Stoyan
AU - Kozlowska, Kasia
AU - Stephen, Christopher D.
AU - Anderson, Jordan
AU - Shura, Robert
AU - Ducharme, Simon
AU - Carson, Alan
AU - Hallett, Mark
AU - Nicholson, Timothy R.
AU - Stone, Jon
AU - Lafrance, W. Curt
AU - Voon, Valerie
N1 - Funding Information:
This article presents independent research funded by NIHR.
Funding Information:
Dr. Perez has received grant support from a Massachusetts General Hospital Physician-Scientist Career Development Award and the Sidney R. Baer, Jr. Foundation; he has also received funding from NIH and honoraria for continuing medical education lectures on functional neurological disorder. Dr. Popkirov has received a speaker’s fee from Novartis. Dr. Stephen has received funding from UPenn Orphan Disease Center Million Dollar Bike Ride/National Tay-Sachs and Allied Diseases Association; he has served on the scientific advisory board of Xenon Pharmaceuticals for a study on ATP1A3-related disorders; he has received research grant support from Sanofi-Genzyme for a longitudinal study of video oculography in late-onset GM2 gangliosidosis; and he has received financial support from Biogen, Biohaven, Cadent, and Sanofi-Genzyme as an investigator in clinical trials. Dr. Hallett is supported by the National Institute of Neurological Disorders and Stroke Intramural Program; he holds patents for an immunotoxin for the treatment of focal movement disorders and the H-coil for magnetic stimulation; in relation to the latter, he has received license fee payments from NIH (from Brainsway); he serves on the medical advisory boards of Brainsway, Cadent, and CALA Health; he receives royalties and/or honoraria from Cambridge University Press, Elsevier, Springer, and Oxford University Press; he has received research grant support from Allergan for studies of methods to inject botulinum toxins, Med-tronic for a study of deep-brain stimulation for dystonia, and CALA Health for studies of a device to suppress tremor. Dr. Nicholson has received grant support from a United Kingdom National Institute for Health Research (NIHR) Clinician Scientist Award. Dr. Aybek has received noncommercial funding and honoraria for medical education from the Swiss National Research Foundation (grant PP00P3-176985). Dr. Stone has received research grant support from a National Research Scotland Career Fellowship; he also performs expert witness work in medicolegal settings, receives honoraria from UpToDate, and runs a free self-help website (www.neurosymptoms.org) for patients with functional neurological disorder. Dr. LaFrance receives editor’s royalties from Cambridge University Press and author’s royalties from Oxford University Press; he receives research grant support from the U.S. Department of Defense (grant W81XWH-17-0169 [principal investigator]); he serves on the advisory board of the Epilepsy Foundation New England Professional; he has received honoraria for the American Academy of Neurology Annual Meeting Annual Course; he has served as a clinic development consultant for Cleveland Clinic, Emory University, Oregon Health and Science University, Spectrum Health, and the University of Colorado Denver; and he has provided medico legal expert testimony. The other authors report no financial relationships with commercial interests. Received January 29, 2020; accepted April 23, 2020; published online Aug. 11, 2020.
Funding Information:
The views, opinions, and/or findings presented in this article are those of the authors and should not be construed as an official position, policy, or decision of the U.S. Department of Veterans Affairs, U.S. Federal Government, the NIHR, or the United Kingdom Department of Health and Social Care. Dr. Perez has received grant support from a Massachusetts General Hospital Physician-Scientist Career Development Award and the Sidney R. Baer, Jr. Foundation; he has also received funding from NIH and honoraria for continuing medical education lectures on functional neurological disorder. Dr. Popkirov has received a speaker?s fee from Novartis. Dr. Stephen has received funding from UPenn Orphan Disease Center Million Dollar Bike Ride/National Tay-Sachs and Allied Diseases Association; he has served on the scientific advisory board of Xenon Pharmaceuticals for a study on ATP1A3-related disorders; he has received research grant support from Sanofi-Genzyme for a longitudinal study of video oculography in late-onset GM2 gangliosidosis; and he has received financial support from Biogen, Biohaven, Cadent, and Sanofi-Genzyme as an investigator in clinical trials. Dr. Hallett is supported by the National Institute of Neurological Disorders and Stroke Intramural Program; he holds patents for an immunotoxin for the treatment of focal movement disorders and the H-coil for magnetic stimulation; in relation to the latter, he has received license fee pay-ments from NIH (from Brainsway); he serves on the medical advisory boards of Brainsway, Cadent, and CALA Health; he receives royalties and/or honoraria from Cambridge University Press, Elsevier, Springer, and Oxford University Press; he has received research grant support from Allergan for studies of methods to inject botulinum toxins, Med-tronic for a study of deep-brain stimulation for dystonia, and CALA Health for studies of a device to suppress tremor. Dr. Nicholson has received grant support from a United Kingdom National Institute for Health Research (NIHR) Clinician Scientist Award. Dr. Aybek has received noncommercial funding and honoraria for medical education from the Swiss National Research Foundation (grant PP00P3-176985). Dr. Stone has received research grant support from a National Research Scotland Career Fellowship; he also performs expert witness work in medicolegal settings, receives honoraria from UpToDate, and runs a free self-help website (www.neurosymptoms.org) for patients with functional neurological disorder. Dr. LaFrance receives editor?s royalties from Cambridge University Press and author?s royalties from Oxford University Press; he receives research grant support from the U.S. Department of Defense (grant W81XWH-17-0169 [principal investigator]); he serves on the advisory board of the Epilepsy Foundation New England Professional; he has received honoraria for the American Academy of Neurology Annual Meeting Annual Course; he has served as a clinic development con-sultant for Cleveland Clinic, Emory University, Oregon Health and Science University, Spectrum Health, and the University of Colorado Denver; and he has provided medico legal expert testimony. The other authors report no financial relationships with commercial interests.
Publisher Copyright:
© 2021, American Psychiatric Association. All rights reserved.
PY - 2021/1
Y1 - 2021/1
N2 - 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 pro-posed 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.
AB - 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 pro-posed 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.
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U2 - 10.1176/appi.neuropsych.19120357
DO - 10.1176/appi.neuropsych.19120357
M3 - Article
C2 - 32778007
AN - SCOPUS:85091082101
VL - 33
SP - 14
EP - 26
JO - Journal of Neuropsychiatry and Clinical Neurosciences
JF - Journal of Neuropsychiatry and Clinical Neurosciences
SN - 0895-0172
IS - 1
ER -