Functional neurological disorder: A practical guide to an elusive Dx
The complexity of this disorder poses a clinical challenge like few others.
PRACTICE RECOMMENDATIONS
› Avoid using stigmatizing terminology (eg, adding the prefix “pseudo” or the adjective “hysterical”) to characterize a suspected functional neurological disorder (FND) or a medically unexplained disorder. C
› Refrain from ordering functional magnetic resonance imaging as part of the routine evaluation of suspected FND. C
› Validate the patient‘s concerns with an appropriate diagnostic label; use layman’s terms to discuss the diagnostic parameters of FND and the cause of symptoms; and emphasize treatment possibilities and plans. C
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
Convey the diagnosis with sensitivity. Inquire about the patient’s perceptions and impairments to best personalize your diagnostic explanations. Delivery of the diagnosis might affect the patient’s acceptance and compliance with further testing and treatment of what is generally a persistent and treatment-resistant disorder; poor delivery of diagnostic information can impair the patient–physician relationship and increase the risk of disjointed care. Many patients find that improved patient–physician communication is therapeutic.29
Let the patient know that you’re taking her seriously. Validate patient concerns with a nonstigmatizing diagnostic label; discuss the diagnostic parameters and cause of symptoms in layman’s terms; and emphasize the potential for reversibility.30 Some patients are not satisfied with having a diagnosis of FND until they are reassured with normal results of testing and provided with referral; even then, some seek further reassurance.
Key tenets of managing care for patients who have been given a diagnosis of FND include:
- nonjudgmental, positive regard
- meaningful expression of empathy
- multidisciplinary coordination
- avoidance of unnecessary testing and harmful treatments
- descriptive and contextual explanations of the diagnosis.
Last, keep in mind that the course of treatment for FND is potentially prolonged and multilayered.
CASE
After many visits with his family physician and the neurology and cardiology specialists, as well as an extensive work-up, the physician approaches Mr. D with the possibility of a diagnosis of FND and proposes a multidisciplinary plan that includes:
- a course of physical and occupational therapy
- development of individualized cognitive behavioral tools
- weekly personal and marital counseling
- initiation of a selective serotonin reuptake inhibitor for anxiety
- monthly visits with his family physician.
Months after his return from deployment for evaluation and treatment, Mr. D is able to return to military duty. He reports that his quality of life has improved.
CORRESPONDENCE
Roselyn W. Clemente Fuentes, MD, FAAFP, Eglin Family Medicine Residency, 307 Boatner Road, Eglin AFB, FL 32547; roselynjan.w.fuentes.mil@mail.mil.
