Author’s Accepted Manuscript image

The Inpatient Assessment and Management of Motor

Functional Neurological Disorders: An
Interdisciplinary Perspective

Kathleen McKee, Sean Glass, Caitlin Adams,

Christopher D. Stephen, Franklin King, Kristin
Parlman, David L. Perez, Nicholas Kontos
www.elsevier.com/locate/bios

PII: S0033-3182(17)30268-2
DOI: https://doi.org/10.1016/j.psym.2017.12.006
Reference: PSYM846
To appear in: Psychosomatics
Cite this article as: Kathleen McKee, Sean Glass, Caitlin Adams, Christopher
D. Stephen, Franklin King, Kristin Parlman, David L. Perez and Nicholas
Kontos, The Inpatient Assessment and Management of Motor Functional
Neurological Disorders: An Interdisciplinary Perspective,
Psychosomatics,doi:10.1016/j.psym.2017.12.006
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 1

The Inpatient Assessment and Management of Motor Functional Neurological

Disorders: An Interdisciplinary Perspective

Kathleen McKee,1 Sean Glass,2,3,4 Caitlin Adams,3,4,5 Christopher D. Stephen,1 Franklin

King,4 Kristin Parlman,6 David L. Perez,2,3* Nicholas Kontos4*

1. Movement Disorders Unit, Department of Neurology, Massachusetts General

Hospital, Harvard Medical School, Boston, MA
2. Neuropsychiatry Unit, Department of Psychiatry, Massachusetts General
Hospital, Harvard Medical School, Boston, MA
3. Functional Neurology Research Group, Cognitive Behavioral Neurology Unit,
Department of Neurology, Massachusetts General Hospital, Harvard Medical
School, Boston, MA
4. Consultation Liaison Psychiatry Service, Department of Psychiatry,
Massachusetts General Hospital, Harvard Medical School, Boston, MA
5. Inpatient Psychiatry Service, Department of Psychiatry, Massachusetts General
Hospital, Harvard Medical School, Boston, MA
6. Department of Physical Therapy, Massachusetts General Hospital, Boston, MA
*equal contributions

Corresponding Authors:

Nickolas Kontos MD and David L. Perez MD, MMSc

Massachusetts General Hospital

55 Fruit Street, Boston, MA 02114

Emails: nkontos@mgh.harvard.edu; dlperez@nmr.mgh.harvard.edu

 2

Abstract

Background: Motor functional neurologic disorders (FND) — previously termed

‘hysteria’ and later ‘conversion disorder’ — are exceedingly common and frequently

encountered in the acute hospital setting. Despite their high prevalence, patients with

motor FND can be challenging to accurately diagnose and effectively manage. To date,

there is limited guidance on the inpatient approach to the neuropsychiatric evaluation of

patients with functional (psychogenic) neurologic symptoms.

Objective: In this perspective article, the authors outline an inpatient multidisciplinary

approach involving neurology, psychiatry, and physical therapy as core components for

the assessment and acute inpatient management of motor FND.

Discussion: A case vignette of a patient with motor FND is presented followed by

discussion of general assessment principles. Thereafter, a detailed description of the

neurologic and psychiatric assessments is outlined. Delivery of a “rule in” diagnosis is

emphasized and specific guidance for what can be accomplished post-diagnosis in the

hospital is suggested. We encourage an interdisciplinary approach beginning at the

early stages of the diagnostic assessment once an individual is suspected of having

motor FND.

Conclusions: Practical suggestions for the inpatient assessment of motor FND are

presented. It is also important to individualize the diagnostic assessment based on the

features of each case. Future research should be conducted to test best practices for

motor FND management in the acute inpatient hospital setting.

 3

Keywords: Conversion Disorder, Psychogenic Nonepileptic Seizures, Functional

Movement Disorders, Somatization, Neuropsychiatry

Introduction

Motor functional neurological disorders (FND) are a subset of functional

(psychogenic) neurological conditions that include psychogenic nonepileptic seizures

(PNES), functional weakness, and functional movements such as tremor, dystonia, and

gait abnormalities(1-3). As the earlier terms hysteria and conversion disorder reflected

psychological theories that do not universally apply, the Diagnostic and Statistical

Manual of Mental Disorders-5 (DSM-5) uses FND synonymously with conversion

disorder(4, 5). “Functional,” rather than psychogenic, is the preferred term for somatic

signs presenting at the intersection of neurology and psychiatry(6).

FND is common, with 30% of neurology outpatients lacking a traditional

neurologic explanation for their complaints, and half of those manifesting FND(7, 8).

Although sensory FND (e.g. vision, hearing, tactile sensory loss) is prevalent, this article

focuses on motor functional neurological symptoms given that these presentations

commonly result in emergency room visits and acute hospitalizations. Individuals

presenting with sudden onset functional weakness are a common stroke mimic(9); on

epilepsy monitoring units, rates of PNES are 20-30%(10). Despite calls for a team-

based approach(11-13), a coherent and consistently utilized approach to the

assessment and acute inpatient management of motor FND has not been widely

adopted.
 4

FND is characterized by sensory-motor neurologic symptoms not explained by

other traditional diagnoses, as compared to feigning or malingering in which symptoms

are intentionally produced for secondary gain. To move away from approaching FND as

a diagnosis of exclusion or a “rule-out” diagnosis, DSM-5 diagnostic criteria for FND no

longer requires the identification of a precipitating psychological stressor nor the

exclusion of feigning(5). In a “rule-in” approach, FND is considered on the differential

diagnosis based on specific physical signs and semiologic characteristics(14-16).

Advantages to this approach include increased diagnostic clarity and early

multidisciplinary collaborations. Leveraging these opportunities requires the coordinated

involvement of neurologists, psychiatrists, physical and occupational therapists, and

other allied professions(17-20). In this perspective article, a case vignette of motor FND

is presented as a platform to discuss the neurologic and psychiatric assessments,

delivery of diagnosis and inpatient management of motor FND. An additional aim of this

article is to serve as an educational resource for inpatient clinicians caring for patients

with FND.

Case Vignette

A 25-year-old single, employed female abruptly develops a convulsion at work following

a minor head bump. She is brought to the emergency department (ED) where she has a

non-focal examination and a normal head computed tomography scan. She is

discharged but re-presents the next day with another event. She exhibits asynchronous

side-to-side head and limb shaking for 10 minutes with forced eye closure. There is no

post-ictal confusion, but she subsequently develops bilateral upper extremity tremors
 5

and gait impairment. Neurology is consulted: her tremor is noted to be variable in

frequency and when she is asked to tap a rhythm with the unaffected limb the tremor in

the affected limb mirrors the frequency of the tapped rhythm (i.e. an entrainable tremor).

A positive right Hoover sign is also appreciated. She undergoes brain magnetic

resonance imaging that is unremarkable and is admitted for video-

electroencephalography (EEG). She has two further similar events on video-EEG

without epileptiform activity. Psychiatry and physical therapy (PT) are consulted. On

psychiatric interview, she describes triggered and untriggered panic attacks,

longstanding affective dysregulation with interpersonal encounters and childhood

emotional abuse. She also acknowledges increased heart rate and shortness of breath

preceding her convulsions. She is a single parent and reports difficulty finding daycare

options. The patient is presented with a diagnosis of Functional Neurological Disorder,

described as real, common and treatable. She is given educational material from

www.neurosymptoms.org. She is evaluated and treated by PT and discharged home

with outpatient physical therapy, neurology and psychiatry referrals.

General Assessment Principles

To establish a diagnosis, initiate acute treatment, and develop discharge plans

for adults with FND, clinicians must perform careful medical and family histories,

psychiatric and psychosocial screenings, and a comprehensive neurological

examination assessing for the presence of findings specific for FND(14, 15, 21).

Pediatric/adolescent FND may have some nuances that are not the focus of this article

but have been reviewed elsewhere(22, 23). Importantly, depending on provider

 6

expertise, clinicians may cover all aspects of the assessment themselves or may

collaborate with neurology and psychiatry consultants to perform a comprehensive

assessment. The development of shared (overlapping) expertise among neurologists

and psychiatrists is encouraged to facilitate neuropsychiatric assessments and acute

management goals. However, some neurologists may be uncomfortable performing

psychiatric screenings(24) and some psychiatrists are uncomfortable with the

neurologic examination and differential diagnosis(25); as such, neurologic and

psychiatric assessments are discussed separately. We also suggest that FND-related

psychiatric assessments and PT evaluations outlined below be performed in parallel to

any additional diagnostic testing that may be necessary if motor FND is considered

likely. Patients may resist answering psychiatric questions after delivery of the

diagnosis(26), but are generally receptive to similar questions if presented as part of

standard clinical evaluations.

Neurologic Assessment

The neurologic interview and examination are core features of the assessment of

FND. History taking should begin with attention to the chief complaint and then broaden

to include fatigue, pain, sleep, cognitive disturbances, and dizziness among other

symptoms. Although this may be somewhat time-consuming when a patient has a pan-

positive review of systems, it is important for building trust. The history should also

elucidate symptom onset, as many patients with FND have sudden onset with maximal

severity early in the disease course(27). Attention should be paid to a precipitating

event, which may include a minor physical injury (including mild head trauma or limb
 7

injury)(28-32) or panic attack(33, 34). Asking about medical co-morbidities, past

surgeries and medication allergies may be helpful to elicit somatization tendencies.

Other medically unexplained diagnoses such as fibromyalgia, irritable bowel syndrome,

chronic fatigue and/or chronic pain disorders are frequently co-morbid with FND(35-39).

Exploring the patient’s day-to-day functionality, experiences with other healthcare

providers, and illness beliefs is also helpful as it will inform an individualized approach to

delivering the diagnosis and treatment planning(5, 27, 40, 41).

If a patient has had multiple negative experiences with other healthcare providers

it may take longer to build rapport; alternatively, if the patient has not been given a clear

diagnosis previously they may be relieved to finally have one. Providers should avoid

placing FND higher on their differential diagnosis simply because an individual has a

psychiatric history or exhibits affective dysregulation. It is important to emphasize that

the history is neither sufficiently sensitive nor specific on its own to diagnose FND(5, 27,

40, 41). Future efforts may yield tools that assist in a standardized assessment of

suspected FND(42), although at present there are no universally validated tools.

The neurologic examination is subsequently performed to detect “rule-in”

sensory-motor findings and semiological features indicative of FND(14-16). For this

patient’s convulsions, the differential includes epileptic seizure (ES), convulsive

syncope, and psychogenic nonepileptic seizure (PNES). The long duration of her

shaking episode argues against convulsive syncope. The asynchronous body

movements, forced-eye closure, and lack of post ictal confusion suggest PNES over

ES. Table 1 summarizes signs that help differentiate PNES and ES. Notably, urinary

incontinence is non-specific(43).
 8

In the clinical workup for PNES, it is important to attempt to capture a typical

event with video-EEG(41). Convulsive seizures, if related to epileptiform activity, should

have an EEG signature; thus, EEG can reliably differentiate most PNES subtypes from

ES. A diagnosis of documented PNES, the highest degree of diagnostic certainty, is

made when the history is suggestive of seizures and a typical event with semiologic

features suggestive of PNES is captured on video-EEG(41). Examples of EEG strips

during a PNES event are also available in the literature(44). In locations where inpatient

video-EEG is unavailable, the video recording of typical events reviewed by a clinician

with expertise in diagnosing seizures and the lack of an electrographic correlate during

typical events on ambulatory EEG are sufficient to make a diagnosis of clinically-

established PNES(41, 45). In our example, the patient was admitted for video-EEG

which captured typical events without epileptiform activity immediately before, during, or

after the ictus. Of note, a particular challenge is differentiating PNES from frontal lobe

seizures, which can present with bizarre semiology, and mesial frontal and amygdalar

epileptic foci that may not be well detected on routine scalp EEG(46).

The patient’s neurologic examination in the ED also showed features of

functional weakness and functional tremor. Patients with PNES may develop other

functional neurological symptoms(12) or exhibit mixed features at presentation(38).

Table 2 lists specific signs that can assist in diagnosing other functional motor

disorders(14, 15, 40). For example, signs suggestive of functional weakness including

the Hoover sign, collapsing/give-way weakness and motor inconsistencies have

diagnostic specificities ranging from 85-99.9%, indicating that when present, there can

be confidence in the diagnosis of functional weakness(15, 21). Similarly, for functional

 9

tremor an observed variability in the frequency or direction of abnormal movements, as

well as features of tremor entrainment, have high diagnostic specificity(47-49). A

dragging, monoplegic gait has over 90% specificity for a functional gait(50).

Explaining these signs to the patient can aid their understanding and acceptance

of the diagnosis; for example: “I notice that you are able to show me full strength for a

moment before your arm seems to collapse”(51). Caution should be taken when

appreciating only marginally positive functional signs, and bizarre features should not

necessarily be assumed functional simply because the examiner has not previously

encountered them. In our vignette, the presence of an entrainable tremor and a Hoover

sign support a “rule-in” motor FND diagnosis.

Psychiatric Assessment

The psychiatric assessment in FND is different than that of an individual

presenting with isolated mood disturbance. Patients may be reluctant to be seen by a

psychiatrist and may view the consultation as confirmation that clinicians believe

symptoms are “all in their head.” Similar difficulties may also occur when psychiatric and

psychosocial questions are posed by neurologists if not approached tactfully.

Like the neurological assessment, it is important to begin with the patient

discussing their chief complaint. Creating time early in the interview for the patient to list

all their physical symptoms may limit new complaints appearing later. Inquiring if the

patient has concerns or ideas about a specific medical/neurologic diagnosis will help

assess illness beliefs and health anxiety. It is advisable to avoid blunt questions about

depression and anxiety at the beginning of the interview. Many with FND do not believe

affective symptoms or psychosocial difficulties are related to their physical complaints

 10

(connections, when present, are indirect at best). As such, it may be helpful to initiate a

psychiatric review of symptoms by qualifying that the interviewer would like to “ask

some questions about mood and anxiety” while also assuring the patient that “this does

not imply that these factors are necessarily relevant.” Similarly, taking an empathic

stance after reviewing the patient’s physical symptoms may provide a natural transition

to discuss mood symptoms and coping. A combination of open-ended and specific

questions is beneficial. It is important to review past psychiatric hospitalizations,

suicidality, mental health treatments (e.g. psychopharmacology, psychotherapy,

transcranial magnetic stimulation, electroconvulsive therapy), and alcohol and drug use

to detect high-acuity psychiatric symptoms that may have management implications.

Patients with FND may be hospitalized during their initial FND manifestation or after

years of struggling with symptoms. Physicians should tailor their assessment of

predisposing, precipitating, and perpetuating factors based in part on illness duration

(See Table 3)(52-54).

Predisposing and Precipitating Factors

In general, predisposing factors are more remote, occurring during development

and early adulthood, and can influence the later onset of a FND. These can include

psychiatric co-morbidities, maladaptive personality traits, insecure attachment, adverse

life events, alexithymia, family dysfunction, intellectual disability, and/or co-morbid

medical/neurological conditions, among other factors(18, 55). Precipitating factors occur

closer in time to symptom onset and can be broadly grouped as physical or emotionally-

valenced precipitants, including minor physical injuries or panic attacks(31).

 11

It is important to consider predisposing and precipitating factors as part of the

development of a neurobio-psycho-social formulation(56-59). However, the assessment

of predisposing factors should continue during outpatient care, and an exhaustive

review of predisposing factors is often beyond the scope of an initial inpatient

assessment. Many common predisposing factors may, however, be elucidated by

gathering routine psychiatric, psychosocial and developmental histories using open-

ended questions such as, “what was life like for you growing up?” Assuming the

interviewer has sufficient time to inquire sensitively, direct questions about past abuse

and other traumatic events can be explored when appropriate. Identification of past

trauma may facilitate an exploration of hyperarousal and dissociation in the context of

screening for post-traumatic stress disorder.

In addition, patients with paroxysmal FND symptoms may report autonomic

arousal and agoraphobia-like avoidance behaviors that overlap with panic disorder(33,

34, 60, 61). One study identified that the most prominent predisposing and/or

precipitating factors were traumatic experiences, family dysfunction, and

bereavement(53). Importantly, a given factor may fit into one or more category. In

addition, while a comprehensive assessment of psychological mechanisms may be too

wide-ranging and potentially activating to explore in the inpatient setting, these

important components in patients with FND may be discussed as part of longitudinal

outpatient care. Several of these psychological factors and mechanisms are well

discussed elsewhere(62, 63).

 12

Perpetuating Factors

Perpetuating factors impede or limit patients’ recovery. Examples of perpetuating

factors include a lack of acceptance of the diagnosis, other co-morbid somatic symptom

disorders(64), avoidance behaviors(65), and the development of medical problems such

as de-conditioning in the setting of chronic wheelchair use(66). In addition, exploring a

patient’s support systems may be helpful. Identification of perpetuating factors may be

particularly important in the context of a prolonged illness or hospitalization despite a

confirmed diagnosis of FND.

In our vignette, common predisposing, precipitating and/or perpetuating factors

are described, including a physical precipitating event, psychiatric/psychological factors

(panic attacks, affective dysregulation), and social/family dysfunction (childcare

difficulties).

Delivery of the Diagnosis

The delivery of a FND diagnosis is the first and one of the most important steps

in treatment(19, 26, 67-69). As such, and because FND can be a perplexing diagnosis

to patients, special consideration should be given to approaches that facilitate

acceptance and engagement. It is common for patients to enter this discussion

apprehensively in the setting of past negative experiences with doctors. In a recent

commentary(19), Jon Stone described common reasons provided by patients for their

negative experiences including: not being given a clear diagnosis or treatment plan,

frustration over not being able to fully describe their symptoms, feeling as though their
 13

symptoms were “dismissed” or not believed, and a sense that their symptoms were

“labeled” as psychological without consideration of other etiologies.

In delivering the diagnosis of FND we have found it helpful to follow a

communication approach which has been supported by both clinical research studies

and expert recommendation(26, 68). This includes the following steps:

1) Name the condition (e.g. functional neurological disorder, functional movement

disorders, psychogenic nonepileptic seizures etc.)

2) State clearly that FND is common, real AND treatable

3) Address that you do not believe that the patient is “crazy” and that they are not

“making up their symptoms.”

After verbalizing points 1-3, it may be advisable to pause and ask if the patient has

questions. It can also be helpful to reference the findings that helped make the

diagnosis; this provides confidence that the clinician is making a “rule-in” diagnosis(51)

and helps address concerns regarding alternative diagnoses. If the patient appears

receptive, providers can subsequently:

4) Provide a brief explanatory model such as FND being a “software not a

hardware problem” as proposed by Stone(40). Use of examples from everyday

life such as rapid heart rate, dry mouth, and/or tremor before public speaking,

gastrointestinal upset before an exam, and headache accompanying a stressful

situation may also be useful models.

5) Provide educational materials on FND from websites such as

www.neurosymptoms.org or www.fndhope.org.
 14

If the patient remains engaged, the clinician can reiterate that FND is treatable, that

there are no “quick fixes,” and that physical therapy and cognitive behavioral therapy

are two main treatments.

Some patients may begin to ask a series of questions about the diagnosis, at

which point repeating some of the statements above in a sensitive and empathic

manner as well as encouraging patients to spend time reviewing the education

materials can be good starting points. In addition, many patients will be receptive to

physical and occupational therapy given that these are “physical treatments for physical

symptoms.” If resistance to psychotherapy is raised (and the individual has a low

burden of psychiatric comorbidities), additional discussion of this treatment modality can

generally be deferred to outpatient providers.

Some may ask “what is the cause of my FND” or they may ask if a specific factor

caused their FND. It can be helpful to explain that specific events (e.g. minor head

injury) did not cause FND “the same way that being hit by a car might cause a leg

fracture”, but a proximal event could be a “precipitating” factor. In addition, many

patients will learn for themselves the causes of their FND during successful treatment,

and attempts by providers to make explicit connections between physical symptoms,

thoughts, behaviors, emotions and life factors for the patient should generally be

avoided. Oversimplified interpretations will generally impede patient acceptance.

Alternatively, we recommend that when asked about causes, providers may state “I am

not sure why you have FND as every case is different, however, I often find that patients

who engage well in treatment learn for themselves the answer to this question.” At

times, neuropsychiatric mechanisms can be further discussed including those related to

 15

stress physiology and brain (mind)-body connections. Additional considerations include

involving family members in the discussion as their engagement may also be important

in the early therapeutic process.

Acute Management

In contrast to the standard of care for other neurological conditions, too often

once an inpatient diagnosis of FND is made, a rapid, same-day discharge is planned. In

our experience, a poorly executed, rapid discharge can leave patients without a clear

post-hospitalization plan and perpetuates repeated emergency department visits.

Following diagnosis, it may be prudent in some cases to take at least one additional

hospital day to perform several steps: 1) initiate appropriate medication adjustments

and/or discontinuations; 2) allow for a period of inpatient PT and/or occupational therapy

assessments that may serve as primary treatment as well as determining the patient’s

post-discharge needs; 3) coordinate care with outpatient providers including primary

care physicians, outpatient neurologists and psychiatrists; 4) for those with high acuity

psychiatric symptom burden (e.g. major depression, suicidality) coordinate an outpatient

mental health plan including outpatient referrals if necessary; 5) create an opportunity

for the patient to ask follow-up questions and to participate in discharge planning. In

addition, care coordination between inpatient teams, nursing staff and allied

professionals is important. Differing etiological explanations or explicit linking of patients’

FND symptoms to “stress” or “anxiety” are over-simplified and can adversely affect

engagement. Specific caution should be taken to avoid suggesting that the patient is

“feigning” as this can be particularly deleterious.

 16

Medication Adjustments

Medication adjustments warrant specific consideration in the inpatient acute

management of FND. For example, patients with PNES are often on anti-epileptic

medications and these should ideally be tapered in the setting of their video-EEG

evaluation(70). If patients are on high doses or multiple anti-epileptic drugs, this should

be done carefully to avoid withdrawal symptoms or a provoked seizure. Similarly,

patients with functional movement disorders may be on anticholinergics, muscle

relaxants and/or benzodiazepines which can be tapered with explanation as to why this

is occurring(19). In addition, while initiation of psychotropic medications in the inpatient

setting is generally deferred to outpatient providers as patients with FND may be prone

to medication hypersensitivities and/or intolerances(38), consideration can be given to

psychotropic medication adjustments if psychiatrically indicated.

Physical Therapy

The acute inpatient PT assessment and management is tailored to specific

functional motor symptoms with helpful guidance provided by the Nielsen et al

consensus guidelines(18). Notably, published before and after video recordings are

available demonstrating the significant improvement possible after physical therapy

treatment(71). Patients with severe motor symptoms that impede outpatient

participation may be screened for an acute rehabilitation hospital admission(72). Clear

communication with the accepting team regarding the FND diagnosis and treatment

recommendations are important to prevent misunderstandings. PT/OT staff should also

be encouraged to communicate when possible to their corresponding counterparts(18).

 17

Some centers have specialized inpatient rehabilitation programs that can be

considered(72).

For our case, the PT evaluation emphasized assessing functional mobility. She

could rise independently from seated to standing positions with minimal assistance and

demonstrated a smooth execution of movement. Gait was characterized by a lag in right

leg advancement, resulting in her leg dragging behind her. Physical therapy, over two

sessions, focused on: education to enhance her understanding of FND, retraining

movement with diverted attention, demonstrating that normal movement can occur, and

changing maladaptive behaviors related to symptoms(18). She engaged in a strategy of

sliding feet “like you are skating” with gradual progression of lifting feet for stepping.

Distraction with conversation minimized abnormal movements and this was brought to

the patient’s attention to demonstrate that abnormal movements could improve. After

abrupt periods of unsteadiness, a strategy of counting backwards from 10 allowed her

to regain balance. The physical therapist discussed strategies that positively influenced

performance, set expectations for continued improvement and recommended outpatient

PT.

Conclusions

We advocate that the treatment of motor FND can be initiated in the hospital with

an early interdisciplinary approach, thoughtful delivery of the diagnosis, and in some

cases a brief period of post-diagnosis inpatient-care. Since patients with motor FND are

common in the hospital, it is important to develop an inpatient strategy that facilitates

continued outpatient care. An interdisciplinary approach in the assessment and inpatient

 18

management of motor FND is crucial as it allows for successful exchange across the

multiple care providers needed to diagnose and treat patients with motor FND. In

evaluating this population, emphasis should be given to detecting “rule-in” examination

findings that allow FND to be considered early in a patient’s presentation. Over the

course of the hospitalization, the spectrum of predisposing, precipitating and

perpetuating factors should be evaluated. Treatment begins with the delivery of the

diagnosis. Consideration of a brief post-diagnosis treatment period in the hospital allows

the assessment of treatment needs and enables a coordinated outpatient plan. Future

research should investigate aspects of the proposed interdisciplinary inpatient approach

to further optimize the inpatient treatment of motor FND.

Table Captions:

Table 1. Clinical features that aid the diagnosis of psychogenic nonepileptic

seizures (PNES) vs. epileptic seizures (ES). Adapted from Avbersek et al 2010.

Table 2. Neurologic examination signs that support the diagnosis of functional

weakness, functional movement disorders and/or functional numbness. Adapted

from Daum et al 2014 and Barbey & Aybek 2017.

Table 3. Predisposing, precipitating and perpetuating factors for the development

of and maintenance of functional neurological disorders. Note, the above list is not

exhaustive but rather is representative of the commonly encountered factors that are

relevant to consider in developing a patient-oriented neurobio-psycho-social

 19

formulation. Adapted from Nielsen et al 2015. GI indicates gastrointestinal; TBI,

traumatic brain injury.

Funding Source: D.L.P. was funded by the Sidney R. Baer Jr. Foundation and the

Massachusetts General Hospital Physician-Scientist Award.

Declaration of Interest: none

Disclosures: none
 20

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Table 1: Clinical features that aid the diagnosis of psychogenic nonepileptic

seizures (PNES) vs. epileptic seizures (ES).

Clinical features favoring PNES Clinical features Insufficient evidence

-Long duration: >2 minutes highly favoring ES -Gradual onset: commonly
suggestive (excluding status epilepticus) -Occurrence out of seen in PNES and focal ES
-Fluctuating course: brief pauses in rhythmic EEG-confirmed -Nonstereotyped events
movement, change in tempo over time sleep -Flailing / thrashing
-Asynchronous (non-rhythmic) movements: -Postictal confusion -Opisthotonus: backward
arms and legs jerking at separate times -Noisy/labored arch of head, neck, spine
-Pelvic thrusting: suggests PNES but can be breathing after -Tongue biting
seen in frontal lobe ES generalized -Urinary incontinence
-Side to side head or body movements: use convulsive event
with caution when considering partial or
frontal lobe ES
-Forced eye closure
-Ictal crying/weeping
-Memory recall of items presented during
ictus

Adapted from Avbersek et al 2010.

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Specific and Sensitive Signs

Hoover sign
Collapsing / give-way
weakness
Motor inconsistency
Tremor variability in
frequency and direction
Tremor entrainment
Dragging monoplegic gait
Midline splitting
Splitting of vibration
Non-anatomical sensory loss diminished sensation in a non-dermatomal pattern
Unvalidated Signs (use with caution)
Arm drop test
Tremor
Yes/no test
Psychogenic Romberg
Non-economic posture
Sudden knee buckling
Astasia-abasia
Table 2. Neurologic examination signs that support the diagnosis of functional
patient supine; place hand under paretic heel; ask patient to push down –
he/she cannot; ask patient to lift contralateral/normal leg up against
resistance; + if there is now downward pressure in paretic heel; may also be
performed in a seated position
limb collapses from normal position with only light touch / normal strength
suddenly gives way to sudden collapse during testing
patient unable to perform one movement with a muscle but can execute
other movements with the same muscle
on visual inspection, the rhythmicity of tremulous movements exhibits
clear inconsistencies in rate or direction
the rhythmicity of the abnormal movements takes on the same frequency of
volitionally performed movements in an unaffected body part
leg dragged at hip behind body instead of circumducted
+ if patient reports exact change in sensation at the midline on sensory
testing (caution if present in isolation, consider ruling-out a thalamic infarct)
+ if patient reports difference in vibratory sense of a tuning fork applied to
each half of frontal bone or sternum
+ if completely paretic arm when lifted above face and dropped does not hit
face (risk harming patient if hits face)
variability in amplitude; commonly seen in other movement disorders in the
context of fluctuations in arousal or exertion
during sensory testing, patient says yes when feels stimulus, no when not
large, variable amplitude, with sometimes buildup of sway; improvement
with distraction
a walking pattern that requires considerable effort – e.g. walking with flexed
knees
buckling during stance or walk but usually no falls (can be seen in chorea)
use of non-economical movements and exaggerated compensatory efforts
during gait testing

weakness, functional movement disorders and/or functional numbness.

Adapted from Daum et al 2014, and Barbey & Aybek 2017.

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Biological Psychological Psychosocial

Predisposing  Gender – female  Comorbid mood  Family
Vulnerabilities  Intellectual disability and anxiety functioning
 Epileptic seizures disorders  Adverse life
 Other nervous system  Dissociation events
vulnerabilities  Alexithymia  Financial status
 Co-morbid medically  Insecure  Peer support
unexplained attachment  Attitudes
syndromes (i.e. chronic  Illness perception towards health
fatigue, pain or GI  Temperament and disease
complaints) and maladaptive
personality traits
(i.e. neuroticism)
Precipitating  Abnormal physiological  Peripheral limb  Employment
Factors event(s), such as sleep injury difficulties
deprivation,  Head trauma  Marital strain
hyperventilation, (particularly mild  Other relational
palpitations TBI) stress
 Acute physical pain  Acute dissociative
event
 Panic attack
Perpetuating  Physiological  Negative  Provider
Factors hyperarousal expectation bias diagnostic
 Chronic pain  Negative uncertainty
 Chronic fatigue attentional bias  Social benefits
 Abnormal motor habit  Illness beliefs of being ill
formation including (often out of
 Deconditioning perception of awareness)
symptom  Pending
irreversibility litigation/disabili
 Fear of falling ty
 Avoidance of  Workmen’s
symptom compensation
exacerbation  Poor care
preventing coordination
treatment
participation
Table 3. Predisposing, precipitating and perpetuating factors for the development of and

maintenance of functional neurological disorders.

Note, the above list is not exhaustive but rather is representative of the commonly encountered

factors that are relevant to consider in developing a patient-oriented neurobio-psycho-social

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formulation. Adapted from Nielsen et al 2015. GI indicates gastrointestinal; TBI, traumatic brain

injury.