High prevalence and associated health and social costs require a shift in care paradigms for functional neurological disorders.
If legendary neurologist Professor Jean Marie Charcot worked in an Australian hospital in 2022, more so than in 19th-century Paris, he might still be excited about at least one of his pet themes. The contemporary name of the neurological condition that Charcot called hysteria is a “functional neurological disorder” (FND), a condition that is very common in the practice of neurology today, but which is also increasingly appearing in popular culture. For example, TikTok tic has recently generated both academic and popular debate, 1 and the FND after vaccination for coronavirus disease 2019 (COVID-19) 2 is an increasingly well-known reason for neurology consultation. in the Australian emergency departments.
All practicing physicians see somatic symptom disorders (formerly known as “somatoforms”) in their patients, and most experience some discomfort when making a clear diagnosis and managing them. FND can be understood as a somatization that presents neurological symptoms, and as with all somatic symptom disorders, the high prevalence and associated health costs require a change in the way patients with FND are cared for. From this perspective, we outline the clinical, health resource, and service delivery issues surrounding FND in Australia, and propose a way to improve the picture for people with FND and the doctors who provide their care.
FND – Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5): 3 Conversion Disorder (Functional Neurological Symptom Disorder); International Classification of Diseases, 11th Revision (ICD-11): F44 (Dissociative Neurological Symptom Disorder) 4 – is the onset of neurological symptoms due to malfunction, rather than neuropathology or neurological disease, of the nervous system . FND presents with several basic neurological symptoms, often simultaneously, and of duration ranging from acute onset to decades. Basic symptoms include seizure-like attacks, gait difficulties, tremors and other movement disorders, cognitive and speech problems, vision disorders, and abnormal function of other special senses. Patients with FND often report additional associated symptoms, such as chronic pain, fatigue, and intestinal and respiratory symptoms, and although comorbid psychiatric conditions and psychological stressors are common, they are not universal.5,6 FND can occur throughout the spectrum of age and often coexists. with other neurological conditions. The diagnosis, therefore, requires careful clinical evaluation, but when possible should be made early by identifying the typical clinical features of the FND and without a thorough, prolonged and potentially harmful investigation in a useless search to rule out disorders. rare organics. For example, weakness of the lower extremities due to FND can vary with distraction, posture, or activity, and the often-cited Hoover sign may be demonstrable.7 Australian neurologists are now encouraged to take an approach. normative for the diagnosis of FND, with the aim of minimizing iatrogenicity. damage.7.8
Epidemiology of Functional Neurological Disorders: A Common Problem with Inadequate Health Funding
FND is an anecdotally common neurological condition. Although the prevalence of FND in the Australian community is unknown, 74% of 152 GPs in the Hunter region of New South Wales reported seeing patients with “neurological symptoms due to somatization” at least monthly. in a 2021 survey (unpublished data). The reported prevalence of FND in international outpatient series of neurology patients varies according to the characteristics and definition of the clinic, with neurological symptoms “nothing” or only “slightly explained by an organic disease” in up to a third of patients. 8 A published Australian neurology clinic. The series reported FND in 15% of patients.9 About 8% of acute stroke admissions may be due to FND, 10.11 and a recent report that FND accounts for 9% of neurology hospital admissions in Nova Zealand is consistent with the anecdotal neurology of Australian public hospitals. experience.12 NSW 2001–2016 Healthcare Patient Collection includes an average of 566 patients with ICD code F44 per year for the entire state.13
The direct costs of using FND-related healthcare are high (e.g., in 2019, the estimated cost in the U.S. was $ 900 million), 14 with delayed diagnosis, recurrent visits of medical care and repeated research contribute. Australia-specific data on healthcare use are scarce, but a Victorian cohort of patients with non-epileptic seizures (who underwent a video electroencephalogram between 2009 and 2014) reported average costs of use of pre-diagnosis medical care per patient of A $ 26,468.15 According to the authors’ knowledge. , only pilot data are available for FND’s Australian healthcare costs more broadly (unpublished data).
At least as important are the hidden costs of FND, especially when it is not diagnosed and treated early, as FND can cause a chronic and significant disability at any age. In the 2018 National Mental Health Commission-sponsored survey of 179 Australians and carers living with FND, around 50% stated that quality of life was poor or worse, 70% could not work and most they had financial difficulties.16 Many seek the support of the National Disability Insurance Plan and Centrelink.
Therapeutic communication of diagnosis is key
Following the evaluation, we state that the way in which the diagnosis of FND is presented to the patient strongly sets the stage for their future management and health outcomes. . A structured diagnostic explanation, which provides the opportunity and time to explore the patient’s understanding and beliefs, can lay the groundwork for a productive therapeutic relationship and facilitate effective use and health care outcomes. The use of one of these structured approaches in a study of newly diagnosed patients with non-epileptic (functional) seizures showed an improvement in patient understanding and acceptance of the diagnosis while reducing negative emotions and the frequency of short-term symptoms.17 Likewise, contempt. The approach to communicating the diagnosis can jeopardize the patient’s confidence in the validity of their disease experience, making them feel angry, embarrassed, and strongly rejecting the discussion about the diagnosis and treatment plan.18 In our own clinical practice, there is a strong emphasis on fostering optimism and developing a collaborative and individualized management plan with the patient’s disease narrative at the center.
Multidisciplinary management is essential in functional neurological disorders
Over the past half century, the clinical management of FND has undergone a number of changes between neurologists and psychiatrists, thanks in large part to traditional models of service delivery modeled on notions of presence or absence of organicity.19 Fortunately , advances in evidence-based treatments and new pathophysiological models for FND have catalyzed a change in these obsolete models, and the consequent recognition of the need for truly multidisciplinary care is slowly changing the culture of FND attention in Australia. Clinical formulations of FND genesis and maintenance have evolved from older notions of “mental conflict” and “conversion” to psychological difficulties and previous traumatic events to consider a wider range of cognitive, emotional, and physical factors. socials.20 The science behind these changes includes neurobiological experiments that suggest a malfunction of unconscious predictive systems important for normal movement, sensation, and cognition, and neuropsychological models that emphasize abnormalities in higher-order cognitive functions. especially attention and action (sense of control) .21
A detailed review of the evidence base for treatment is beyond the scope of this article. Instead, we refer readers to recent reviews and consensus statements22,23,24 and limit ourselves to emphasizing the fundamental principles of treatment.
First, the empathic and positive diagnostic explanation is critical to the success of any treatment that follows. Second, individualized and multidisciplinary treatment plans should address the most prominent basic and non-basic presentation symptoms of the individual patient. Third, the Allied health team, which includes physiotherapists, occupational therapists and speech therapists, should base the therapy on a biopsychosocial formulation that addresses disease beliefs, symptom-focused attention biases, aberrant movement patterns. and functional limitations. Finally, there is evidence of both psychodynamic and cognitive-behavioral approaches in FND management, although the evidence for cognitive-behavioral therapy is of higher quality.24
Development of sensitive and resource-sensitive care models for functional neurological disorders and the role of clinical consortia
Reported dissatisfaction with the experience of Australians ’healthcare interactions with FND16 reflects systemic problems in clinical care pathways. We need to adopt an FND care model shaped by patients ’experiences. Best practice management includes neurology, psychiatry, general practitioners, emergency services, and rehabilitation physicians, as well as clinical psychologists and related health professionals, although not all of them may be necessary for to each patient.16 Effective communication between these stakeholders and the patient is essential to prevent the fragmented care and negative health care experiences that remain common in FND. Given the current limitations around health resources, we suggest that the most pragmatic way will be to develop a step-by-step care approach, increasing the capacity of primary and secondary care …