Management of Functional Neurologic (Conversion) Disorders

Educational Objectives

The goal of this program is to improve management of functional neurologic disorders (FND). After hearing and assimilating this program, the clinician will be better able to:

1. Identify core principles of motor retraining in FND.
2. Develop multidisciplinary strategies that incorporate rehabilitation and psychotherapeutic approaches for management of FND.

Summary

Approach to functional neurologic disorder (FND): the first step is to obtain an accurate diagnosis; after diagnosis, patients should be transitioned to appropriate treatment, which involves a multidisciplinary team approach, followed by regular follow-up or maintenance treatment; review and expert opinion by Perez et al (2021) was published on the neuropsychiatric assessment of motor FND on behalf of the American Neuropsychiatric Association (ANPA) Committee for Research; Baslet et al (2021), on behalf of the ANPA Committee on Research, published evidence-based practice for the clinical assessment of psychogenic nonepileptic seizures (PNES)

Treatment: inpatient treatment has been shown to have the highest success rate, but it may not be feasible because of insurance restrictions; Perez et al (2021) reviewed a decade of progress in motor FND, including clinical trials, tools for diagnosis, pathophysiologic models, and treatment; the review evaluated randomized controlled trials on botulinum neurotoxin, online education and self-help, physiotherapy, multidisciplinary rehabilitation, and cognitive behavioral therapy (CBT)

Multidisciplinary rehabilitation: Czarnecki et al (2012) described a historical cohort study of patients who underwent physical therapy (PT) rehabilitation; the multidisciplinary rehabilitation program (specifically, the motor retraining program) consisted of a 1-wk program that was based on integrating FND-specific PT, mental practice training, and CBT-based interventions for FND; principles of the program included relearning normal movement control through a stepwise approach in a multidisciplinary setting; the treatment team consisted of a neurologist, physiatrist, psychologist, physical therapist, occupational therapist, speech and language therapist, and social worker; after an initial evaluation, patients underwent rehabilitation for 3 hr and psychotherapy for 1 hr per day; pre-evaluation consisted of neurologic evaluation to confirm the diagnosis, patient education, outpatient PT evaluation, setting of expectations and explanation of the program, and outpatient psychology assessment, along with identification of psychological stress factors; significant improvement in patient outcomes was observed at the end of the week

Physiotherapy: Nielsen et al (2015) developed a consensus recommendation for physiotherapy for treatment of functional motor disorders, which discussed techniques to normalize abnormal movements for specific symptoms

Occupational therapy (OT): Nicholson et al (2020) developed a consensus recommendation for OT for treatment of FND; this incorporates psychotherapy by the therapist, and patients are taught to identify helpful thoughts, beliefs, and behavior; self-management is part of the treatment specifically directed for FND

Guided self-help: working through a workbook helps the patient with understanding symptoms, identifying triggers, solving problems, and coping

Cognitive behavioral therapy: Espay et al (2019) evaluated patients with functional tremor who underwent functional magnetic resonance imaging before and after 12 wk of CBT; significant changes were recorded in the anterior cingulate and paracingulate cortex, with increased activation at baseline and decreased activation after CBT during processing of basic emotions

Clinical video telehealth (CVT): LaFrance et al (2020) found that patients disclosed histories of trauma and abuse or those associated with traumatic brain injury at the same levels through CVT as compared with in-clinic visits; the study demonstrated a similar reduction in seizures in patients treated via CVT compared with those treated in the clinic

Pharmacologic agents: pilot study found that a serotonin selective reuptake inhibitor (SSRI) led to a greater reduction in seizures compared with placebo; a pilot multicenter trial by LaFrance et al (2014) randomized patients to 1 of 4 treatment arms (CBT-informed psychotherapy [CBT-ip], CBT-ip plus SSRI, SSRI alone, or standard medical care [SMC]); significant reduction in seizures, reduction in comorbid symptoms, and improvement in functioning and quality of life were observed in the arms that included CBT-ip; the SSRI arm had a significant reduction in depression, whereas the SMC arm showed no reduction in seizures or secondary outcome improvements; based on these findings, SMC is not sufficient for patients with PNES

Comorbidities: treatment of comorbidities (eg, anxiety, depression, personality traits or disorders, post-traumatic stress disorder) is important

Therapeutic model: physical manifestations of FND include PENS, movement disorder, gait disorder, and cognitive disorder; patients with FND develop catastrophic thinking and fear symptoms, become hypervigilant to internal somatic cues, avoid external cues and stimuli, and develop disuse disability and depression, leading to a vicious cycle; using the tools in the treatment toolkit, patients make the links and later break them, thereby transitioning to a virtuous cycle in which patients confront their fears and move into recovery; although a few sessions use CBT (eg, relaxation training), this model is not a conventional CBT and uses different psychotherapeutic modalities, eg, psychoeducation, interpersonal therapy, motivational interviewing, and mindfulness (eg, to identify pre-seizure aura); using these tools, patients realize how the past may influence present symptoms; this model has been incorporated in a workbook (Taking Control of Your Seizures: Workbook), which patients and therapists can use; this intervention is being used by psychiatrists, psychologists, social workers, neuropsychologists, neurologists, and epileptologists

Neurobehavioral therapy (NBT): components of treatment include rehabilitation and psychotherapeutic approaches (eg, conventional CBT, mindfulness, psychodynamic); NBT is an integrated holistic approach that evaluates the whole person from a biopsychosocial and spiritual perspective in a patient-led and therapist-guided therapy and uses specific elements of various psychotherapies

Disorder of communication: FND can be conceptualized as a disorder of communication and language; it is a disorder of expression where people are unable to express distress in a healthy verbal manner and may express them as physical symptoms; FND may be a cognitive dyspraxia of the self

Readings

Baslet G, Bajestan SN, Aybek S, et al. Evidence-based practice for the clinical assessment of psychogenic nonepileptic seizures: a report from the American Neuropsychiatric Association Committee on Research. J Neuropsychiatry Clin Neurosci. 2021; 33(1):27-42. doi:10.1176/appi.neuropsych.19120354; Czarnecki K, Thompson JM, Seime R, et al. Functional movement disorders: successful treatment with a physical therapy rehabilitation protocol. Parkinsonism Relat Disord. 2012; 18(3):247-251. doi:10.1016/j.parkreldis.2011.10.011; Espay AJ, Ries S, Maloney T, et al. Clinical and neural responses to cognitive behavioral therapy for functional tremor. Neurology. 2019; 93(19):e1787-e1798. doi:10.1212/WNL.0000000000008442; LaFrance WC, Baird GL, Barry JJ, et al. Multicenter pilot treatment trial for psychogenic nonepileptic seizures: a randomized clinical trial. JAMA Psychiatry. 2014; 71(9):997-1005. doi:10.1001/jamapsychiatry.2014.817; LaFrance WC, Ho WLN, Bhatla A, et al. Treatment of psychogenic nonepileptic seizures (PNES) using video telehealth. Epilepsia. 2020; 61(11):2572-2582. doi:10.1111/epi.16689; Nicholson C, Edwards MJ, Carson AJ, et al. Occupational therapy consensus recommendations for functional neurological disorder. J Neurol Neurosurg Psychiatry. 2020; 91(10):1037-1045. doi:10.1136/jnnp-2019-322281; 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. doi:10.1136/jnnp-2014-309255; Perez DL, Aybek S, Popkirov S, et al. A review and expert opinion on the neuropsychiatric assessment of motor functional neurological disorders. J Neuropsychiatry Clin Neurosci. 2021; 33(1):14-26. doi:10.1176/appi.neuropsych.19120357; Perez DL, Edwards MJ, Nielsen G, et al. Decade of progress in motor functional neurological disorder: continuing the momentum. J Neurol Neurosurg Psychiatry. Published online March15,2021:jnnp-2020-323953. doi:10.1136/jnnp-2020-323953.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. LaFrance was recorded at American Neuropsychiatric Association 2022 Annual Meeting, held virtually on March 16-19, 2022, and presented by the American Neuropsychiatric Association. For more information about upcoming CME activities from this presenter, please visit Anpaonline.org. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.75 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.75 CE contact hours.

Lecture ID:

PS512002

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.