Ingrid Hoeritzauer

Therapeutic sedation for functional (psychogenic) neurological symptoms

BACKGROUND Patients with severe functional (psychogenic) neurological symptoms such as paralysis and fixed dystonia present a therapeutic challenge, particularly if no movement is possible during physiotherapy. Sedation has been discussed as a treatment for functional neurological symptoms for 100 years but technique, use of video and outcome has not been systematically described. METHODS Therapeutic sedation of patients with severe functional neurological symptoms with propofol and follow up at a neuroscience centre. RESULTS Of eleven patients (median duration 14 months), five were cured or had major improvement with sedation. At follow up (median 30 months) four were asymptomatic, two were significantly improved and one had minor improvements. We describe a standardized anesthetic and physician technique, refined over consecutive treatments. CONCLUSION In carefully chosen patients, therapeutic sedation with propofol can be a useful adjunctive treatment for patients with severe functional neurological symptoms. The treatment deserves randomized evaluation.

Functional neurological disorders: mechanisms and treatment.

Functional neurological disorders are common problems in neurologic practice. In the past decade there has been an increasing interest in this group of disorders both from a clinical as well as research point of view. In this review, we highlight some of the most salient and exciting publications from recent years focusing especially on new findings illuminating mechanism and studies examining treatment.

Fowler's syndrome of urinary retention: A retrospective study of co-morbidity.

To study the frequency of pain, psychological, or functional disorders in patients with Fowlers syndrome.

'Scan-negative' cauda equina syndrome: Evidence of functional disorder from a prospective case series.

Abstract In the first prospective comparison of ‘scan-negative’ (n = 11) and ‘scan-positive’ (n = 7) patients with cauda equina syndrome (CES) we found that Hoovers sign of functional leg weakness but not routine clinical features differentiated the two groups (p < 0.02). This offers a new direction of study in this area, although magnetic resonance imaging is still required for all patients with possible CES.

Functional Disorders in Neurology: Case Studies

Functional, often called psychogenic, disorders are common in neurological practice. We illustrate clinical issues and highlight some recent research findings using six case studies of functional neurological disorders. We discuss dizziness as a functional disorder, describing the relatively new consensus term Persistent Posturo-Perceptual Dizziness (PPPD), axial jerking/myoclonus as a functional movement disorder, functional speech symptoms, post-concussion disorder with functional cognitive symptoms and finally advances in treatment of dissociative seizures and functional motor disorders.

Complex regional pain syndrome and functional neurological disorders: time for reconciliation

There have been many articles highlighting differences and similarities between complex regional pain syndrome (CRPS) and functional neurological disorders (FND) but until now the discussions have often been adversarial with an erroneous focus on malingering and a view of FND as ‘all in the mind’. However, understanding of the nature, frequency and treatment of FND has changed dramatically in the last 10–15 years. FND is no longer assumed to be only the result of ‘conversion’ of psychological conflict but is understood as a complex interplay between physiological stimulus, expectation, learning and attention mediated through a Bayesian framework, with biopsychosocial predisposing, triggering and perpetuating inputs. Building on this new ‘whole brain’ perspective of FND, we reframe the debate about the ‘psychological versus physical’ basis of CRPS. We recognise how CRPS research may inform mechanistic understanding of FND and conversely, how advances in FND, especially treatment, have implications for improving understanding and management of CRPS.

‘Cryptogenic Drop Attacks’ revisited: evidence of overlap with functional neurological disorder

Objective In their 1973 BMJ paper ‘Cryptogenic Drop Attacks’, Stevens and Matthews described 40, mostly middle-aged, female patients with drop attacks of unknown cause. Although clinically common, there has been little on this topic since. We aimed to determine clinical features, comorbidity and outcome of patients with drop attacks. Methods We carried out a retrospective review of patients with cryptogenic drop attacks seen consecutively by one clinician (JS) between 2006 and 2016. Demographics, phenomenology, duration and frequency of attacks, attack description and comorbid diagnoses were recorded. Patients were followed up with a notes review. Results 83 patients with cryptogenic drop attacks were predominantly female (89%, n=79), mean age 44  years. The majority (93%, n=77) could not remember the fall itself and almost half (43%, n=36) experienced prodromal dissociative symptoms. Mechanical trips or syncope preceded drop attacks, historically, in 24% (n=20) of cases. Persistent fatigue (73%, n=61), chronic pain (40%, n=33), functional limb weakness (31%,n=26) and dissociative (non-epileptic) attacks 28% (n=23) were common, with the latter usually preceding or emerging from drop attacks. At follow-up (88%, mean 38 months), 28% (n=23) had resolution of their drop attacks. Predisposing (but non-causative) disease comorbidity was found at baseline (n=12) and follow-up (n=5). Conclusions Cryptogenic drop attacks are associated with high frequency of comorbid functional somatic and functional neurological disorders. Patients commonly have prodromal dissociative symptoms and in some there was a clear relationship with prior or subsequent dissociative (non-epileptic) attacks. Some cryptogenic drop attacks may be best understood as phenomena on the spectrum of dissociative attacks.

THE CLINICAL FEATURES AND PROGNOSIS OF SCAN NEGATIVE URO-NEUROLOGICAL DISORDERS

Background Studies from our group have shown that around half of patients presenting with cauda equina syndrome (CES) have normal imaging, many of whom may have evidence of a functional neurological disorder. We have also shown high rates of comorbidity of functional neurological disorders in patients with idiopathic chronic urinary retention (including Fowlers syndrome). Aims To determine what proportion of patients with ‘scan negative’ CES and chronic dysfunctional voiding have a functional disorder by clinical consensus. To determine distress, disability and ongoing symptoms in patients with ‘scan positive’ and ‘scan negative’ CES three months after symptom onset. To determine frequency of comorbid functional disorders, distress, disability and physical function in patients with voiding dysfunction and a control urological group. Project Plans: The Back or Leg Pain with Bladder symptoms study (BLB) study is a prospective case control study of all patients admitted with possible CES to the Western General Hospital, Edinburgh. The Overview of Comorbidity in Chronic Urinary Retention (OCCUR) study is a prospective cohort study and retrospective notes review of patients with Chronic Urinary Retention (including Fowlers syndrome) via the urodynamic clinics in Glasgow, Edinburgh and London.

“CRYPTOGENIC DROP ATTACKS” REVISITED

Background Drop attacks are idiopathic falls occurring predominantly in middle aged women without warning, not due to change in posture or head movement associated with immediate recovery. Drop attacks have been attributed to cardiovascular, structural, musculoskeletal, epileptic, vestibular and (very rarely) functional/ psychogenic causes. Methods Notes review of a consecutive case series of patients with drop attacks seen by one of the authors (JS) in a neurology setting. Results Preliminary data demonstrates that of 88 patients with drop attacks 79 were female, mean age 44 (range 16–78), mean duration of attacks 61 months (1–388). Secondary drop attacks were recorded rarely (n=2, cataplexy, Chiari malformation). Dissociative symptoms during a brief prodrome (n=40) and after the attack (n=9) were common. Characteristically, patients did not recall the fall itself. Twenty six patients had episodes of dissociation unrelated to their drop attacks (n=19 dissociative seizures with loss of consciousness, n=14 had dissociation with preserved consciousness). There were high levels of fatigue (n=61), sleep disturbance (n=59), chronic pain (n=40) and comorbid functional neurological disorders (n=51). Some patients improved with techniques used in dissociative seizures. Conclusions Idiopathic drop attacks may be best understood in many cases as a type of functional disorder.

Fowler's Syndrome of Urinary Retention: A Retrospective Study of Co-Morbidity

Aims To study the frequency of pain, psychological or functional disorders in patients with Fowlers syndrome. Methods We carried out a retrospective chart review of patients with a diagnosis of Fowlers syndrome attending the Uro-Neurology centre at the National Hospital for Neurology and Neurosurgery between 2009–2013 looking at triggering events, physical and psychological comorbidities. Results Of 62 patients with clinical and electromyographic diagnosis of Fowlers syndrome, 31 (50%) had unexplained chronic pain syndromes, 12 (19%) of these were taking opiates. 15 (24%) had ‘functional’ neurological symptoms. Abdominopelvic surgery with general anaesthesia was the leading trigger (n=21, 35%). Conclusions We found high levels of co-morbidity with patients having some form of pain (50%), a probable functional disorder (24%) or psychological symptoms (31%). There are several potential explanations for this association including the effect of developing an apparently unexplained distressing condition, confounding effect of opiate use or referral bias. The findings suggest a need for prospective systematic study of comorbidity for this disabling condition.