Assessing and Managing Functional Neurologic Disorders

Kathrin LaFaver, MD; Indu Subramanian, MD; David L. Perez, MD


June 16, 2022

This transcript has been edited for clarity.

Indu Subramanian, MD: It is so exciting to have you all join us again today. We're going to be talking about a really hot topic: functional neurologic disorders, and more specifically, functional movement disorders during the pandemic. There's been an increased attention focused on this at the American Academy of Neurology. There were some presentations on tic disorders that were functional that had arisen during the pandemic.

We're so excited to have my co-host, Dr Kathrin LaFaver, join us from Saratoga Springs, New York. She's a movement disorder neurologist in private practice there. She's found an amazing speaker today whom we will both interview on this topic: Dr David Perez.

Kathrin, do you want to tell us why you chose David and why he's joining us today?

Kathrin LaFaver, MD: I'm very pleased to have David join us today. David is one of the prominent researchers and clinicians on the topic of functional neurologic disorders. He's a certified psychiatrist and neurologist, and the leader of the Functional Disorder (FND) Research Study Group at Massachusetts General Hospital in Boston. We couldn't have a better person. We had the pleasure of co-editing a book together on integrative treatment approaches to functional movement disorders. Welcome, David.

David L. Perez, MD: Wonderful to be here with both of you. Thank you for having me.

Subramanian: David, maybe we could start with learning a little bit about functional neurologic disorders, and more specifically, functional movement disorders. Tell us about that.

Perez: Functional neurologic disorder, which we'll abbreviate as FND, is a condition that lives at the intersection of neurology and psychiatry. There are a variety of ways that patients with FND can present. They can exhibit abnormal movements, seizure-like events, nondermatomal sensory deficits, cognitive symptoms, and dizziness.

There is now a rule-in approach to use physical examination signs to distinguish FND from other neurologic conditions. We can think of functional movement disorder as one of the main subtypes of functional neurologic disorder.

Subramanian: Kathrin, maybe you could tell us a little bit about something that every neurologist should know about functional movement disorders.

LaFaver: I'd be happy to. In general, I would say every neurologist really needs to be familiar with how FND can present and how to get patients to a diagnosis. Unfortunately, traditionally, there's been a bit of a reluctance for many neurologists to actually make the diagnosis because of a certain discomfort level. Many neurologists feel they don't really know about the topic and don't know how to help patients. That often leads to a significant delay in diagnosis and, therefore, to a delay in care.

As David was saying, this kind of rule-in approach is looking for the positive signs, the typical examination features, whether that is an abnormal tremor that is very variable and untrainable. There is a large amount of literature on this available now. People do need to educate themselves, and it should also be really an integral part of neurology residencies to make neurologists very familiar with the diagnosis and treatment of these conditions.

As always, for our neurologic patients, it's very important to get a psychosocial history because these disorders live in a biopsychosocial borderland. We need to consider all these factors to understand why people get FNDs and to help them move forward. Communication and many, many things are really important. Understanding how to diagnose, how to communicate a diagnosis, and then develop a treatment plan are all important.

Subramanian: Interesting. I think that so many disorders are in this borderland. As Parkinson's disease neurologists, we see so many things that are at this intersection of psychiatry and neurology. I think this multidisciplinary team approach is just so important.

David, you're really well trained to do that because you're both a neurologist and a psychiatrist. Maybe you can tell us a little bit about the treatments that are available for FND, as we're referring to it — the functional neurologic disorders.

Perez: It's a great question. I'll start by highlighting for our audience that, in terms of functional movement disorders, there is a range of phenotypes. Patients can present with tremor, with limb weakness, with dystonia, with textured jerks, and with difficulty in walking. If you extend the spectrum, patients may also exhibit speech output difficulties.

As Kathrin nicely pointed out, we really want to take an integrated approach to the assessment — one that emphasizes the poor neurologic features to guide diagnosis, but one that also helps put the patient in context using the biopsychosocial model, ultimately to help guide the patient to the most evidence-based treatment within the various moving parts that relate to their own personal equation for developing functional neurologic disorder.

What are the mainstays of treatment? For functional movement disorders, the mainstays of treatment include physical rehabilitation and psychotherapy. There's been much work done by a range of leaders internationally in this area. For our audience, the key feature to highlight is that there are now consensus recommendations for physical therapy, occupational therapy, and speech and language, each published in the Journal of Neurology, Neurosurgery & Psychiatry (JNNP). This is a great guide for physical rehabilitation experts, who may not be as proficient in the management of this population; that certainly accelerates the learning curve.

Then we can think about psychotherapy, with the most robust evidence to date being available for cognitive-behavioral therapy. In a nutshell, cognitive-behavioral therapy is a guided exploration between the patient and the psychotherapist to explore potential relationships between their physical symptoms — specifically in this case, their abnormal movements, thought patterns, behaviors, emotions, and life factors, looking for any particular relationships that may lead to symptom amplification or the perpetuation of their specific symptoms.

Subramanian: There are so many gaps in this field, right? I think you mentioned, Kathrin, that many of the patients when they come in, sometimes they don't feel like they're fully heard. They get sort of confusing pictures when they leave. I think neurologists and physicians in general feel quite uncomfortable sometimes in addressing some of these care needs. I think education and empowerment, both at the physician level and the patient level, are so key.

How are you guys working toward addressing these gaps, and what are the gaps in this field?

LaFaver: Thank you for this question. As you were pointing to, I think the biggest gap is the dissemination of knowledge at this point. I would say that our field in general has in the past decades seen a large amount of progress in understanding FND better on a scientific level and developing treatments. Unfortunately, as someone who has started, in the past several years, two different treatment programs, I've seen a very dire need of patients being referred from all over the country.

We have decided to help address this problem by partnering with many great specialists from multiple disciplines, such as psychiatrists, other specialists, and neurologists, and put together a treatment manual for functional movement disorders. They'll link that in show notes. It's an interdisciplinary, case-based approach with practical tips and knowledge. I think that everyone, whether a physician or any healthcare professional in the mental health sphere, will find this a very useful and practical guide toward helping these patients.

The second gap is, as you were mentioning, a destigmatization of these disorders. I think people, unfortunately, often have negative experiences with the healthcare system, whether it is going to the emergency room and being perceived as someone who might be malingering or drug-seeking, or whether that is to really find a physician who is willing to not just diagnose them or see them one time, but be longitudinally invested in the care.

Again, I think the educating like we're doing today, just talking about the importance of FND, is very important. There are certainly more resources available for those who want to take a deeper dive.

Subramanian: Great. You guys have done so much work, so many publications. Kudos to you. Where can neurologists and these other kind of allied health professionals learn more? Are there meetings? Are there ways that they can interact with each other? Tell me a little bit more about that.

Perez: It's an exciting time in the field. As we've pointed out today, functional neurologic disorder and functional movement disorders as a subtype are highly prevalent. We're seeing this as neurologists across outpatient, inpatient, and emergency department settings.

There is now a new professional society, the Functional Disorder Society, and it has its inaugural meeting in Boston from June 19 to 21. It has both in-person and virtual capabilities. It's a multidisciplinary professional society, cutting across the clinical neurosciences and the rehabilitation specialists.

Kathrin and I have been very involved in the society, and we use this opportunity as a time to invite others to join us and to join this very collaborative and multidisciplinary international community so that we can think comprehensively about the best management strategies for functional disorder, identify the gaps, and move forward collaboratively.

Subramanian: You're trying to attract, it sounds like, neurologists, movement disorder specialists, or epilepsy doctors, people like that. It sounds like psychiatrists, psychologists, rehab specialists from occupational therapy (OT), speech therapy, and physical therapy. Is there anyone I missed? Who else are you guys trying to invite?

Perez: Social workers, and really anyone who's interested in this population or encountering this population clinically. Research scientists are welcome as well. It's both a clinical professional society and a research-based society. We're looking for all interested comers.

Subramanian: Awesome. Well, that's amazing. Great work. It's so timely. We're just seeing this explosion, as we said, of tics in this space, disseminated through social media. As a last question, why do you think that's happening in this COVID-19 time frame? This was highlighted at the American Academy of Neurology (AAN) meeting. Maybe, Kathrin, I can just ask you that.

LaFaver: There's not a simple answer for this. What you're referring to, there was a phenomenon of what was dubbed as TikTok tics, and we actually did an interview on that during the last day of the meeting. That's probably available still in Medscape for more details.

Social isolation during the pandemic and many psychological stress factors of the pandemic have been thought to make young adults in particular more vulnerable to functional neurologic disorders. There's a potential phenomenon of social contagion, meaning seeing other people via social media with abnormal movements and having that as a modeling effect.

Again, it's a complex topic and there is certainly more to learn. There are many papers now available for more details. Thanks again. Join us in Boston. We'll join David. It will be a wonderful meeting — very hands-on and very practical. We hope to connect with many people interested in this field.

Subramanian: Thank you so much, both of you, for your time and amazing knowledge.

Perez: Thank you very much.

LaFaver: Thank you.

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