A Review and Expert Opinion on the Neuropsychiatric Assessment of Motor Functional Neurological Disorders

Functional neurological (conversion) disorder (FND) is a prevalent and disabling condition at the intersection of neurology and psychiatry. Advances have been made in elucidating an emerging pathophysiology for motor FND, as well as in identifying evidenced-based physiotherapy and psychotherapy treatments. Despite these gains, important elements of the initial neuropsychiatric assessment of functional movement disorders (FND-movt) and functional limb weakness/paresis (FND-par) have yet to be established. This is an important gap from both diagnostic and treatment planning perspectives. In this article, the authors performed a narrative review to characterize clinically relevant variables across FND-movt and FND-par cohorts, including time course and symptom evolution, precipitating factors, medical and family histories, psychiatric comorbidities, psychosocial factors, physical examination signs, and adjunctive diagnostic tests. Thereafter, the authors propose a preliminary set of clinical content that should be assessed during early-phase patient encounters, in addition to identifying physical signs informing diagnosis and potential use of adjunctive tests for challenging cases. Although clinical history should not be used to make a FND diagnosis, characteristics such as acute onset, precipitating events (e.g., injury and surgery), and a waxing and waning course (including spontaneous remissions) are commonly reported. Active psychiatric symptoms (e.g., depression and anxiety) and ongoing psychosocial stressors also warrant evaluation. Positive physical examination signs (e.g., Hoover's sign and tremor entrainment) are key findings, as one of the DSM-5 diagnostic criteria. The neuropsychiatric assessment proposed emphasizes diagnosing FND by using "rule-in" physical signs while also considering psychiatric and psychosocial factors to aid in the development of a patient-centered treatment plan

The role of evidence-based guidelines in the diagnosis and treatment of functional neurological disorder

Evidence-based clinical practice guidelines, based on systematic reviews of existing evidence, play an important role in improving and standardizing the quality of patient care in many medical and psychiatric disorders, and could play an important role in the diagnosis and treatment of functional seizures and other functional neurological disorder (FND) subtypes. There are several reasons to think that evidence-based guidelines might be especially beneficial for the management of FND. In particular, the interdisciplinary and multidisciplinary teamwork necessary for the care of people with FND, the current lack of formal clinical training in FND, and the rapidly expanding body of evidence relating to FND all make guidelines based on systematic literature reviews especially valuable. In this perspective piece, we review clinical practice guidelines, their advantages and limitations, the reasons why evidence-based guidelines might be especially beneficial in the diagnosis and treatment of FND, and the steps that must be taken to create such guidelines for FND. We propose that professional organizations such as the American Academy of Neurology and the American Psychiatric Association undertake guideline development, ideally to create a co-authored or jointly endorsed set of guidelines that can set standards for interdisciplinary care for neurologists and mental health clinicians alike

Multicenter clinical assessment of improved wearable multimodal convulsive seizure detectors

Objective New devices are needed for monitoring seizures, especially those associated with sudden unexpected death in epilepsy (SUDEP). They must be unobtrusive and automated, and provide false alarm rates (FARs) bearable in everyday life. This study quantifies the performance of new multimodal wrist-worn convulsive seizure detectors. Methods Hand-annotated video-electroencephalographic seizure events were collected from 69 patients at six clinical sites. Three different wristbands were used to record electrodermal activity (EDA) and accelerometer (ACM) signals, obtaining 5,928 h of data, including 55 convulsive epileptic seizures (six focal tonic–clonic seizures and 49 focal to bilateral tonic–clonic seizures) from 22 patients. Recordings were analyzed offline to train and test two new machine learning classifiers and a published classifier based on EDA and ACM. Moreover, wristband data were analyzed to estimate seizure-motion duration and autonomic responses. Results The two novel classifiers consistently outperformed the previous detector. The most efficient (Classifier III) yielded sensitivity of 94.55%, and an FAR of 0.2 events/day. No nocturnal seizures were missed. Most patients had <1 false alarm every 4 days, with an FAR below their seizure frequency. When increasing the sensitivity to 100% (no missed seizures), the FAR is up to 13 times lower than with the previous detector. Furthermore, all detections occurred before the seizure ended, providing reasonable latency (median = 29.3 s, range = 14.8–151 s). Automatically estimated seizure durations were correlated with true durations, enabling reliable annotations. Finally, EDA measurements confirmed the presence of postictal autonomic dysfunction, exhibiting a significant rise in 73% of the convulsive seizures. Significance The proposed multimodal wrist-worn convulsive seizure detectors provide seizure counts that are more accurate than previous automated detectors and typical patient self-reports, while maintaining a tolerable FAR for ambulatory monitoring. Furthermore, the multimodal system provides an objective description of motor behavior and autonomic dysfunction, aimed at enriching seizure characterization, with potential utility for SUDEP warning

Management of Somatoform Disorders: A Neuro-Psychiatric Perspective

Somatoform disorders (SD) present in adults and children with a combination of neurologic signs, underlying psychological conflicts and comorbid psychiatric disorders. The majority of SD do not have a laboratory test to confirm the diagnosis. The exception to the rule is in psychogenic nonepileptic seizures (PNES), where the gold standard of video electroencephalography and adjunctive tests are used in establishing the diagnosis of PNES

Non-Neuroanatomic Disorders in the 21st Century: Somatoform Disorders

A century ago, neurology and psychiatry were practiced in a unified framework as neuropsychiatry. In the early 20th century, divisions occurred in the fields and lines were drawn between those who evaluated and treated patients with epilepsy, strokes, and migraines, and those with anxiety, depression, and schizophrenia. These divisions resulted in a dichotomous view of the brain/mind and influenced how we assessed the two patient populations

Non-Neuroanatomic Disorders in the 21st Century: Somatoform Disorders

A century ago, neurology and psychiatry were practiced in a unified framework as neuropsychiatry. In the early 20th century, divisions occurred in the fields and lines were drawn between those who evaluated and treated patients with epilepsy, strokes, and migraines, and those with anxiety, depression, and schizophrenia. These divisions resulted in a dichotomous view of the brain/mind and influenced how we assessed the two patient populations

Epilepsy and Seizures

Psychiatric disorders can be identified in 25–50% of patients with epilepsy, with higher prevalence among patients with poorly controlled seizures. These disturbances include depression, anxiety, psychotic disorders, and cognitive and personality changes occurring in the interictal or periictal (preictal, ictal, postictal) states. We focus on four areas in patients with epilepsy: (1) more frequent comorbid psychiatric disorders, (2) integrated symptoms secondary to epilepsy, (3) stigma and psychosocial consequences of epilepsy, and (4) nonepileptic seizures. In this chapter, we will call attention to pertinent elements of the history in the patient with seizures, diagnostic workup, assessment of comorbidities, and consequences of treatment of the seizure disorder (including medications, resective surgery, and neuromodulation) and of the psychiatric comorbidity

Treatment of Psychogenic Nonepileptic Seizures

Purpose of Review Psychogenic nonepileptic seizures (PNES) are the most common Functional Neurological Disorder/Conversion Disorder subtype. Significant advances have been made related to diagnosis, neurobiology, and treatment. In this review, we summarize updates in diagnosis and management over the past 3 years. Recent Findings Although evidence is mixed for the treatment of PNES, psychotherapeutic modalities remain a powerful instrument to empower patients and reduce seizures. A multidisciplinary, holistic approach is beneficial. While seizure freedom in all patients may not be the achieved endpoint in this chronic, paroxysmal disorder, quality of life can be improved with treatment. Additional treatment modalities and further research are needed for patients who are refractory to current treatment. Summary Evidence-based therapies exist for PNES, and recent findings represent an increased understanding of the clinical and neurophysiologic aspects of PNES