Healthcare and Medical News for Atlanta Physicians

Functional Neuro-Psychiatric Disorders in General Medicine

By Jorge L. Juncos, MD and Jennifer J. Hawkins, APC, NCC, CCTP

Functional disorders were previously known as psychogenic and conversion disorders.1 These entities consist of a series of neuropsychiatric and medical conditions in which individuals present with sensorimotor or somatic symptoms not explained by current or other know conditions. The change to the phrase functional and somatoform disorders was based on a new and more robust understanding of the mechanisms involved.2-5 This led to the realization that the physical symptoms can be the result of maladaptive neural circuit changes provoked by negative or noxious experiences (e.g. trauma or conflict, past or present).6-8 These experiences can lead to organ malfunction (somatoform disorders) or physical symptoms known as Functional Neurologic Disorders (FND).9-11

In patients with FND, metabolic changes in the brain corresponding to the above circuit changes can be demonstrated using functional imaging (fMRI) and other techniques.8,12-15 Though these techniques are only available in research laboratories, others like electroencephalography have been used as potential biomarkers.16-18 Efforts like these and others have helped advance our diagnostic confidence and research in the field, especially in epilepsy. Biomarkers are otherwise sorely lacking.

Table 1

Examples of functional and somatoform disorders

 

Conditions Functional symptoms
FND – Neurology Functional movement disorders
–  Functional tremor, dystonia
PNES*
Functional blindness
Somatoform disorders
Rheumatology Fibromyalgia, chronic fatigue syndrome
Orthopedics Chronic back pain
Ear Nose and Throat PPPD**
Atypical facial pain
Functional dysphonia
Infectious disease Chronic fatigue syndrome
Cardiology POTS∞
Non-cardiac chest pain
Palpitations with negative investigation
Gastroenterology Functional dyspepsia
IBS±, Globus pharyngis

*PNES-Paroxysmal non-epileptic seizure; **PPPD–Persistent, postural-perceptual dizziness;
∞POTS – Postural orthostatic tachycardia syndrome; ∞IBS – irritable bowel syndrome
Adapted from Carson A, Hallett M, Stone J Handbook of Clinical Neurology, Vol 139

Research over the last 10 years, summarized below, has led to more effective ways of communicating the diagnosis and to modest gains in the treatment of FND and somatoform disorders.19 Rather than psychologizing symptoms, today’s narratives recognize the important contribution from foundations of these illnesses – physical, psychological and social.

We now understand that functional symptoms are not just due to anxiety and stress. This assumption led to frequent misdiagnoses and engendered mistrust in patients. It also makes these conditions more refractory to treatment, more chronic and more expensive to manage.

Primary care practitioners (PCPs) and non-psychiatric specialties are likely to see these cases first. We hope to initiate the process of making the generalist part of the team that brings attention to these conditions early, and for this we need to start building an effective referral system, which today does not currently exist.11,19

We chose to focus on FND as an example of somatoform disorders that the authors are most familiar with. We have tried to keep the comments broad enough to include somatoform disorders that are more commonly seen in medicine but with which they share fundamental clinical and etiologic characteristics (e.g., organ and system malfunction without detectable damage). [See Table 1.] In addition, the autonomic nervous system (ANS) is thought to drive many of the FND symptoms. Some of today’s therapies target the ANS (see bottom-up therapies below) and have become standard tools to attenuate FND/somatoform symptoms. 20-22 ANS dysfunction is triggered by the same noxious sensory experiences/trauma that led to FND.

The FND/somatoform phenotype can also be influenced by exteroceptive and interoceptive experiences. For instance, patients may develop physical symptoms similar to or as an extension of pre-existing symptomatology. Examples of these are: paralysis or numbness in multiple sclerosis, non-electrical seizure-like activity in epilepsy (psychogenic non epileptic seizure, PNES), irritable bowel syndrome in peptic ulcer disease and persistent cardiac symptomatology in individuals with a previous but stable cardiac history. That is, the functional symptom may have been ‘modeled’ after symptoms of a pre-existing condition.17,23 The existence of patients with mixed symptoms makes medical and neurologic follow-up of these cases imperative.

Diagnosis. The diagnosis is typically made by a neurologist based on the presence of positive physical signs and symptoms (see Table 2) and a supportive history.1,24-28 The overarching elements of the history are a loss of agency over the symptoms (the dissociative feeling that you are no longer in control of that body part).29,30

This perception is due to an acquired abnormality in sensory-motor processing. Using functional imaging (fMRI), these areas of cerebral dysfunction have been localized primarily to network processing in limbic and cognitive orbitofrontal regions.24,29,31 Historical elements that support the diagnosis include a prior history of FND or other unexplained symptoms, and pre-existing conditions like anxiety and obsessive-compulsive disorder.32

Table 2

Select findings and diagnostic clues in FND

Organ system involved Finding
Language Sudden mutism or speech difficulties
Vision Vision loss with normal exam
Sensory system Pain syndromes
Numbness or anesthesia that crosses midline
Motor system Paralysis of rapid onset, with Hoover sign*, collapsing weakness
Improvement with distraction
Variable  weakness
Functional tremor – intermitten and distracable with entrainment
Extreme slowness and fatige
Gait disorders Variable improvement
Undue effort when performing a simple walking movement
Falling towards or away from MD
Sudden knee-buckling

*Hoover sign: failure to attempt to extend the leg in bed while trying to elevate.
For more on positive neurologic signs and the criteria for diagnosis of
FND, see DSM-V and references.46-49

Precipitating events are helpful but not necessary. However, psychiatric symptoms like depression and anxiety, though common, are necessary to make the diagnosis. Furthermore, even when present, they are not thought of as responsible for the symptoms. In fact, in some series, >50% may not have (or not acknowledge initially) these symptoms.33-35 This does not mean that the symptoms should be ignored. Their presence will aggravate FND or any other medical condition.

Similarly, a history of trauma is present in close to 70% of patients but is notoriously difficult to elicit, particularly in emergency and primary care settings.36 Patients who deny any of the above symptoms tend to become apprehensive if the physician insists on pursuing this line of questioning prematurely. Open-ended questions and, during the exam, focusing on the physical symptoms they came to see you for is the best strategy to develop an alliance with the patient first.

It is also essential to not try to prematurely reassure the patient by telling him that his symptoms are simply due to anxiety or stress. This will usually have the opposite effect.

Many of the approaches used to treat these various conditions (see Table 1) converge, and this convergence can be exploited during therapy, the diverse presentations of these conditions notwithstanding.21,23

Validated FND diagnostic criteria are summarized here, and in the references.1,24,30,32 Table 2 presents a list of these criteria, especially the positive physical findings, along with supportive historical elements. The latter are helpful when present but are not a requirement. In the absence of positive signs, the work up may need to be extended.37

Over the years, we have learned about now-discredited criteria for FND or somatoform disorders. Some of these are: the expectation of a placebo response only in FND,38 and that la belle indifference and histrionic personality have much diagnostic validity.

The systematic approach to diagnosis elaborated in the references notwithstanding, we are still wrong on occasion. This humbling realization is in part due to the lack of biomarkers and the intrinsic difficulty of some of the cases. In the last five years, for instance, we have encountered rare cases initially diagnosed as having FND but who turned out to have progressive systemic sclerosis, multiple sclerosis or autoimmune encephalitis. So vigilance and caution are of the essence in managing these conditions.

Psychiatric Issues. FND is still listed in the DSM-V as a psychiatric condition. Much like post-traumatic stress disorder (PTSD), it rarely exists in a vacuum. Many of these patients also experience depression, suicidality, anxiety, personality disorders, substance abuse problems, and other psychosocial problems that may need to be addressed before the functional symptoms.39-41

General Management. The first step in the management of FND is to convey the diagnosis, in an effective and compassionate way, as with any other condition. The second priority is to educate the patient in an effort to dispel the negative archaic notions that still plague this field.18,40,42 For this, the patient can also be directed to supplemental material available online like the FND Guide (neurosymptoms.org) by Jon Stone, MD, and the Functional Neurologic Society website (fndsociety.org). On these sites, the authors explain the changes in brain networks that lead to FND (and likely somatoform) symptoms. For example,  changes to the communication/network systems are explained as “software issues” that cannot be visualized on routine imaging and other diagnostic studies (e.g., no “hardware issues”).20,43,44

Although FND is oftentimes diagnoses and treated by specialists, PCPs should be emboldened to make at least an initial, even if provisional, diagnosis in cases where all criteria are clearly met. They should also be encouraged to obtain consultation liberally and to remain informed on the ultimate diagnosis and disposition of the patients.19,45

Specific Therapies: Established and mostly psychologic therapies in the field include cognitive behavioral therapy (CBT), psychodynamic psychotherapy and dialectical behavioral therapy. Exposure therapy is helpful when dealing with specific phobias.

The most relevant and effective therapy may vary and should be determined by the therapist. Neurologists and PCPs contribute to this effort by ensuring that the diagnosis remains correct and by treating co-morbid conditions as needed (e.g., seizures in PNES).

Can we define a catalyst to FND symptoms that may help direct the therapy? In psychologic terms, are the symptoms due to abnormal “bottom-up” processes in which the persistence of organic symptoms generate psychologic consequences? Or is it that abnormal “top-down” psychologic processes are generating physical symptoms (see trauma below)?35,40,50-53

The patient must accept the diagnosis and a formulation of “how this happened”, in order for a collaborative therapeutic relationship to develop. The therapist should expect to be challenged on this and will meet resistance in many cases where the symptom itself has meaning to the patient and may serve a purpose. In these cases, maintaining communication with the other treating medical specialists or neurologists will be essential.

CBT is a prime example of top-down processing. It comes from the idea that different beliefs will yield different outcomes. Bottom-up strategies addresses the body’s reaction to a perceived stimulus (interoception). Interoception can be distorted following traumatic events. Because these two processes can coincide in one person, many therapists address the dichotomy by combining top-down and bottom-up approaches.

Bottom-up approaches consist of somatic exercises that help transition the patient from a hypervigilant/hyperaroused state (with presumed heightened sympathetic tone) to a more relaxed state (with increased vagal tone closer to normal). This approach acknowledges that alterations to ANS function mediate many of the symptoms in FND and somatoform disorders.7,21,54-57 For instance, vase breathing, and other relaxation techniques are easy to learn and provide direct access to the ANS. By acquiring better control of the ANS (through therapy), the patient can begin addressing the symptoms of FND and somatoform disorders.

Trauma. As noted above, trauma has an etiologic role in many cases of FND.5,22,36 Research on trauma offers another tenable hypothesis with evidence to further explain the mechanisms of functional illness. Trauma is defined as past event(s) that outweighed the individual’s ability to cope. Biochemically, at the time of the traumatic event, there is activation of the hypothalamic-pituitary-adrenal (HPA) axis with a flooding of hippocampal cortisol receptors.58 This flooding overwhelms the hippocampus ability to timestamp the traumatic memory.

“Timestamping” involves assigning the “when” and the “for-how-long” of the memory.59 The flooding leads to improper filing (unlike a normal memory). When the system is not flooded, this results in autobiographical memory impairment (repression?), an adaptive mechanism to deal with bad memories.60 When overwhelmed, it can lead to faulty timestamping a traumatic memory, which can disrupt daily life in the form of flashbacks, triggers and nightmares, and thus a constant flow of negative energy – classically described in PTSD. It can also lead to a funneling of this energy into dissociation and somatoform/FND symptoms.31 This maladaptive processes can lead to suffering and disability.14

A word on Eye Movement Desensitization and Reprocessing (EMDR). This is a technique used by a therapist who specialize in trauma.6,13,21,57 When trauma is relevant to a case of FND or somatoform disorder (as it can be in up to 70% cases), a bottom-up strategy may be a good start to address the physical discomfort. EMDR uses interoceptive deactivation exercises that help reprocess (finally file?) the memory, decreasing its amplification through networks that include the amygdala.61

From a top-down perspective, EMDR can also provide elements of CBT that challenge the self-defeating narratives and other negative cognitions of many patients. This is facilitated through activation of the hemispheres using directed and alternating saccadic eye movements, or other sensory modality. This leads to the facilitation of the reprocessing, and ultimately the proper filing of the memory. Though not hypnosis, the saccadic eye movements are reminiscent of a similar technique used in hypnosis.62

In Atlanta and nationwide, the current care of FND and somatoform disorders is grossly inadequate. There are not enough clinicians to assess and treat these patients. This is compounded by not having approved treatment plans except for the ones discussed above. These typically require a team approach that does not exists in most institutions and are not covered by most insurances. Training and funding for research in this field keeps slipping through existing gaps between neurology and psychiatry.

The need for more capacity in the system and a more effective approach is pressing, as the number of patients coming through the general clinics is overwhelming. It has been estimated that $256 billion, or 16% of healthcare expenditure, is spent annually on these conditions.63 Locally, through the creation of interdisciplinary teams of physicians and like-minded therapists, we could start building capacity in the system to avert this crisis in the care of FND.

References

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Dr. Juncos headshotJorge L. Juncos, MD

Dr. Juncos is an Emeritus associate professor of neurology at Emory University School of Medicine. He received a BS from the University of Puerto Rico and an MD from Columbia University in NYC. He trained at Columbia University and Harvard University affiliate hospitals receiving board certification in both specialties. He completed a movement disorders fellowship at the Experimental Therapeutics Branch of the National Institutes of Health and is a member of the American Academy of Neurology and the International Parkinson and Movement Disorders Society.

Jennifer hawkinsJennifer J. Hawkins, APC, NCC, CCTP

Ms. Hawkins is a mental health clinician in private practice at North Star Counseling in Atlanta. She specializes in trauma and autonomic nervous system dysregulation in disorders that bridge psychology, psychiatry and neurology. These include anxiety, depression and trauma-related conditions like PTSD and functional neurological disorders (FND). She uses integrative approaches that in addition to trauma-informed care and cognitive behavioral therapy (CBT) include hypnosis and Eye-Movement Desensitization and Reprocessing (EDMR).

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