REVIEW

Functional neurological disorders:

the neurological assessment as
treatment
Jon Stone

Correspondence to ABSTRACT their functional disorders such as irritable

Dr Jon Stone, Department of
The neurologist’s role in patients with bowel syndrome and functional dyspep-
Neurophysiologie Clinique/
Clinical Neurophysiology, functional disorders has traditionally been sia.4 Functional gastrointestinal disorders
University of Edinburgh, Western limited to making the diagnosis, excluding a now occupy a standard part of their cur-
General Hospital, Edinburgh EH4 ‘disease’ and pronouncing the symptoms to be riculum for training, practice and research.
2XU, UK; [email protected]
‘non-organic’ or ‘psychogenic’. In this article, As a consequence, gastroenterologists have
This article first appeared in I argue that there are multiple opportunities primary responsibility for the management
Neurophysiologie Clinique/ during routine assessment of a patient with a of patients with these disorders, even
Clinical Neurophysiology.1 It has functional disorder for the neurologist to take though they may call on members of the
been edited and updated for
Practical Neurology but is largely the lead with treatment. These opportunities multidisciplinary team to help.
the same article and is occur throughout history taking, during the Other specialties, such as cardiology
published here with thanks and examination and, with greatest potential for and neurology, have not developed in the
permission of Dr Jean treatment, at the end of the consultation. same way. Interest in this area from neu-
Michel-Guerit, editor of that
journal as well as Elsevier. Elements of the neurologist’s discussion that rologists actually declined over the 20th
may be most useful include (a) emphasis that century for many reasons. These include
Accepted 14 October 2015 symptoms are genuine, common and the success of the clinico-anatomic
potentially reversible; (b) explanation of the method, the dualistic split from psychiatry
positive nature of the diagnosis (ie, not a and prevailing notions that the diagnosis
diagnosis of exclusion); (c) simple advice about of ‘conversion disorder’ (requiring evi-
distraction techniques, self-help techniques and dence of psychic conflict) and treatment
sources of information; (d) referral on to (psychodynamic unravelling of the pre-
appropriate physiotherapy and/or psychological sumed conflict) were essentially the terri-
services; and (e) offering outpatient review. tory of psychiatry rather than neurology.5
I also discuss how new diagnostic criteria for For most of the 20th century, the pen-
Diagnostic and Statistical Manual of Mental dulum swung strongly towards a psychi-
Disorders-5 and changes proposed for atric model of functional disorder/
International Classification of Diseases may conversion disorder. However, in the
facilitate changes that allow neurologists to last 10–20 years, the pendulum has
bring their management of patients with started to swing back with increasing
functional disorders in line with other numbers of biological studies. It will
multidisciplinary neurological disorders in the hopefully come to rest on a model
outpatient clinic. where both ‘neurology and psychiatry’,
‘brain and mind’ are equally important
in considering the diagnosis and treat-
INTRODUCTION ment of these disorders.6–8
Doctors in nearly all medical specialties In this article, I give a personal view
see patients with physical symptoms that regarding features of the neurological
are genuine but cannot be explained on assessment that I believe the general neur-
the basis of a recognised ‘organic’ disease. ologist can use for the day-to-day benefit
Around 30–50% of outpatient visits in of their patients with functional disorders.
primary and secondary care are for this Some of this advice is evidence based,
To cite: Stone J. Pract Neurol
Published Online First: [ please
reason.2 3 from prognostic or treatment studies, but
include Day Month Year] Some specialties, such as gastroenter- much is not and derives from 15 years of
doi:10.1136/practneurol- ology, have developed a pragmatic subspecialty interest and referrals of
2015-001241 approach to the diagnosis and treatment of patients, often perceived by colleagues to

Stone J. Pract Neurol 2015;0:1–11. doi:10.1136/practneurol-2015-001241 1

REVIEW

be ‘difficult’ or at the ‘hard end’ of the spectrum of which to ‘pin’ the symptoms (when it did not feel like
functional neurological disorders. that was the case to the patient and indeed there may
My experience is that there are very few patients not have been one to find);
who are truly ‘difficult’ to have a consultation with. ▸ not being given a chance to explain and discuss what
Many consultations are time consuming. Many patients thoughts they had about the cause and treatment of the
give ‘wandering’ histories that need frequent ‘reining symptoms (eg, Lyme disease, ‘crumbling bones’ or stroke);
in’ and considerable patience. There are many patients ▸ not being given a diagnosis, treatment or anything that
whom I have been unable to help. But with only a they can read about afterwards;
couple of exceptions the ‘recipe’ presented here creates ▸ not being given enough time.
consultations that virtually never result in an angry or To this familiar list I would add that patients with
complaining patient, even though this is a common acute functional motor symptoms or dissociative
scenario in many neurology services.9 Sometimes, (non-epileptic) attacks commonly experience deper-
single consultations have been highly therapeutic sonalisation (a feeling that they are disconnected from
without needing any other intervention. In many their body) or derealisation (a feeling of being discon-
others, consultations appear to have helped patients nected from their surroundings) in conjunction
make improvements and to work more effectively with with the onset of their symptoms (or with their
other health professionals. Even when a patient’s symp- attacks).15–17 Patients often find it hard to describe
toms and disability remain the same, I am struck how dissociative symptoms because (a) they may lack the
often patients with functional disorders report ‘peace words for the symptoms and (b) they worry that the
of mind’ and improved quality of life after developing symptoms sound ‘crazy’. Conversely, explaining that
a good understanding of their diagnosis. I’m aware that these terms are medical words for a common ‘trance-
a ‘recipe’ on a printed page may not be enough. Some like state’ that has nothing to do with ‘going crazy’
colleagues of mine appear to ‘say the right things’ but can be both therapeutic and helpful for explaining the
still have unhappy patients, perhaps because those col- mechanism of symptoms.
leagues rushed the consultation or do not fundamen- With these ‘bad experiences’ in mind, here are some
tally believe that the patient has anything much the suggestions for therapeutic aspects of history taking.
matter with them. When some of my neurologist col-
leagues ‘roll their eyes’ or make comments such as, 1. ‘Drain the symptoms dry’—Asking the patient to make a
“No, I think she is genuine/real” (ie, not functional), list of all their symptoms does not take as long as you
they are reminders of the professional ambiguity that think. It may seem perverse to want to ask about fatigue,
characterises views about whether patients with func- sleep disturbance, pain, poor concentration and dizziness
tional disorders are deserving of help or not.10 in someone who has already volunteered eight symptoms.
The suggestions here allow a model of care, like However, a complete list of current symptoms at the start
those in gastroenterology, where functional disorders of a consultation helps a patient to feel unburdened and
such as migraine or multiple sclerosis become part of prevents symptoms ‘popping up’ later on (eg, when they
the accepted repertoire of conditions that a neurolo- are leaving the room). Questions about fatigue and sleep
gist diagnoses and then takes responsibility for man- often reveal that these are the main problems—the
aging. Here I am arguing that, as with those patient may be relieved to be asked about them as they
conditions, the neurological assessment should not be may have expected that the doctor would not wish to
regarded as a prelude to treatment, but the first stage hear from a patient who is ‘tired all the time’.
of treatment itself.11 2. Asking about dissociation—Obtaining a history of deper-
For a systematic description of terminology,12 com- sonalisation and derealisation may require questions that
ponents of the assessment13 and pitfalls in diagnosis,14 are slightly more ‘leading’ than normally advised. Often
I direct the reader elsewhere. patients say they have not had any symptoms at the
onset of acute functional motor symptoms or dissociative
THERAPEUTIC ELEMENTS OF HISTORY TAKING (non-epileptic) attacks.18 They will, however, often
The purpose of taking a history is not just to obtain admit to symptoms of dissociation or panic if asked by
information—ideally, it also enables the patient to feel questionnaire19 or in the right way during assess-
unburdened and to gain confidence in the doctor ment.17 20 Questioning might proceed as in box 1.
before the diagnosis has even been discussed. Hopefully it can be seen from this exchange
Patients with functional disorders have often had that the patient has unburdened themselves of a
bad experiences with previous doctors. Some frightening symptom that initially they were reluc-
common reasons for this include tant (or found hard) to discuss and received a pre-
▸ not getting a chance to describe all their symptoms; liminary explanation that it is common and has
▸ feeling that their symptoms were being ‘dismissed’ or nothing to do with ‘being crazy’. As I will explain
that they were ‘disbelieved’; later, it is often the patient’s perceived failure to
▸ a perception that the doctor was most interested in obtain recognition that the symptoms are ‘real’
looking for some kind of psychological problem upon and ‘not crazy’ that so often forms the largest

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improve is likely to have a worse prognosis than the
Box 1 Discussing dissociation during the history in patient who is unsure and looking for answers.21 22
a way that is therapeutic for the patient 4. What happened with the other doctors?—When asked
what they think is wrong, many patients will say, “I
Doctor: Did you get any warning symptoms before your don’t know”, despite a documented previous discussion
blackout? of the diagnosis of a functional disorder. Why did the
Patient: No doctor, none. patient not believe the first explanation? Allow the
Doctor: Did you feel dizzy when it started, even just for a patient to vent their frustration at previous health
few seconds? encounters. You do not need to pass judgement on what
Patient: A bit maybe. happened, but the patient is likely to find this discussion
Doctor: What was the dizziness like? therapeutic.
Patient: I don’t know really—it’s hard to describe. 5. Go easy on ‘psychological’ questions—Neurologists are
Doctor: If I told you there are three main sorts of dizzi- often tempted to dive in to questions about depression,
ness—a lightheaded feeling that you might faint, a anxiety, stress or abuse because they have been condi-
feeling that you are moving even though you are still tioned to believe that this is the right thing to do. It is
and a spaced out feeling as if you were not quite there actually not necessary to ask the patient about their
—which of these would you say it was most like? mood and levels of anxiety, either to make a diagnosis or
Patient: The third one and the first one to begin treatment. Studies show that only around half of
Doctor: Tell me about that spaced out feeling in your the patients have a comorbid anxiety or depression. Such
own words. Don’t worry about sounding silly. The more things can often be inferred anyway from questions
detail you can give me, the more I can help. about day-to-day activities, for example, if they look
Patient: Well it was strange really—it was like I was forward to watching ‘Top Gear’ on television, then they
floating and people around me were really far away. It probably are not depressed (or demented). Patients with
was horrible. functional motor symptoms have rates of recent life stress
Doctor: How long did it go on for? and prior abuse not much different to the general popula-
Patient: It must have been a couple of minutes tion.23 Questions about prior psychological trauma such
Doctor: Was it scary? Did it get scarier as time went on? as physical and sexual abuse are likely, in any case, to be
Patient: Yes it was really frightening—It felt like I was unnecessarily intrusive for a first assessment unless it is
going crazy… clear that the patient wishes to discuss it. If these things
Doctor: Actually what you are describing is called dissoci- do need to be discussed, most patients prefer to discuss
ation—it’s nothing to do with going crazy at all. It’s a them once they have confidence in the doctor and the
trance like state that people often have when they diagnosis (ie, at a second appointment). Premature and
develop symptoms—I’ll explain later. clumsy questioning is commonly ‘antitherapeutic’ by
raising suspicion in the patient that you think their symp-
toms are ‘all in the mind’ (even if that is not what you
barrier to successful rehabilitation and good think!). In many patients though, it is quite straightfor-
outcome.21 Providing early reassurance that the ward and reasonable to ask about depression and anxiety
consultation is not heading down the path of the as part of a systems enquiry. Instead of asking blunt ques-
patient being labelled as ‘crazy’ puts the patient at tions like, “Are you depressed/anxious?”, it may be more
ease and into a state where they may find it easier helpful to ask, “Do your symptoms get you down/make
to discuss other aspects of the history. you worried?”. The core of generalised anxiety is exces-
3. Ask what the patient thinks is wrong and what should be sive worry that the person finds difficult to control.
done—Medical students (in the UK at least) are now Instead of asking, “Do you have panic attacks?” (patients
taught to routinely ask about ‘Ideas, Concerns and may, but not recognise them as such), ask, “Do you have
Expectations’ although this is a habit that has passed by attacks where you have lots of symptoms all at once—is
many older doctors. But these lines of questioning are that scary?”.
essential in allowing the neurologist’s explanation to be 6. Time—Probably the hardest problem to solve from my
tailored to the patient’s prior concerns. Therefore, initial list of patient ‘bad experiences’ is not having
someone who thinks their bones are crumbling in their enough time. Ideally the patient with complex and chronic
neck and has been unhelpfully told by their general functional disorders should be given at least an hour for a
practitioner that they have cervical spondylosis will need new patient assessment, especially if they have seen many
a discussion of what a normal MR scan of cervical spine other specialists. In many neurological services, this is not
looks like at the age of 40. A patient who believes they possible. This compromises what can be delivered, but in
have Lyme disease or multiple sclerosis will require my own practice I still think most of these components
something different. This discussion becomes thera- can be fitted in to a 30 min consultation (and I do have to
peutic when the patient or family experiences relief in do that as well!). It may be worth reflecting though that a
getting their worst fears and concerns out into the open. neurosurgeon does not try to remove someone’s pituitary
The patient who is adamant that they will never gland in the same time they would expect to decompress a

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carpal tunnel and perhaps neurologists should be less rigid 1. The diagnosis is positive and not negative. It is a clinical
about spending the same time with every patient. bedside diagnosis and not a diagnosis made because a scan is
normal. Indeed, the scan may be abnormal and it may still
THERAPEUTIC FEATURES OF THE EXAMINATION be a functional tremor. These positive signs are now required
Showing patients their positive signs to make a diagnosis of functional neurological disorders in
The diagnosis of functional neurological disorders Diagnostic and Statistical Manual of Mental Disorders—5
should be made on the basis of positive features on (DSM-5).38 The presence of psychological stressors is no
the examination, not on the absence of disease longer required. I discuss DSM-5 at the end of this article.
(table 1).24–26 2. The signs demonstrate the potential for reversibility—for
Something that follows on from this is that func- example, hip extension returns transiently to normal
tional disorders can also be diagnosed in the presence during contralateral hip flexion against resistance.
of existing disease such as multiple sclerosis or 3. The signs demonstrate the role of attention and the
Parkinson’s disease.34–36 Sticking to this rule with benefit of distraction—for example, the more the patient
patients is important in avoiding diagnostic mistakes pays attention to the limb and tries to move it the worse
but also therapeutic in helping patients to understand it is. Conversely, when they are distracted the movement
they do not have an absence of a condition (ie, non- is much better.
organic), they have a positively identifiable condition We find in our own practice that this simple demon-
with positive criteria. stration of the nature of the diagnosis is one of the most
In an article entitled ‘Trick or Treat?: showing therapeutic parts of the consultation. Our patients even
patients with functional ( psychogenic) motor symp- practice these physical signs at home to help to persuade
toms their signs’,37 Mark Edwards and I argued that themselves and family members that the diagnosis is
sharing physical signs such as Hoover’s sign and the correct. It is perhaps then worth rehearsing what the
tremor entrainment test with patients fulfilled several explanation of a Hoover’s sign would sound like during
valuable functions. a consultation as shown in box 2.

Table 1 Examples of positive signs in functional disorders that can be shared with a patient to explain the diagnosis
Positive finding
Motor symptoms
Hoover’s sign27 (figure 1) Hip extension weakness that returns to normal with contralateral hip flexion against resistance
Hip abductor sign28 Hip abduction weakness returns to normal with contralateral hip abduction against resistance
Other clear evidence of inconsistency For example, weakness of ankle plantar flexion on the bed but able to walk on tiptoes
Global pattern of weakness Weakness that is global, affecting extensors and flexors equally
Movement disorder
Tremor entrainment test29 Patient with a unilateral tremor is asked to copy a rhythmical movement with their unaffected limb: the
tremor in the affected hand either ‘entrains’ to the rhythm of the unaffected hand, stops completely or
the patient is unable to copy the simple rhythmical movement
Fixed dystonic posture30 A typical fixed dystonic posture, characteristically of the hand (with flexion of fingers, wrist and/or elbow)
or ankle (with plantar and dorsiflexion)
Typical ‘functional’ hemifacial overactivity31 Orbicularis oculis or orbicularis oris over-contraction, especially when accompanied by jaw deviation and/
(figure 2) or ipsilateral functional hemiparesis
Balance/gait
Reduced postural sway with distraction32 Abnormal sway that resolves during tasks such as assessing numbers written on the back or using a
phone
Non-epileptic attacks26
Prolonged attack of motionless Paroxysmal motionlessness and unresponsiveness lasting longer than a minute
unresponsiveness
Long duration Attacks lasting longer than 2 min without any clear cut features of focal or generalised epileptic seizures
Closed eyes Closed eyes during an attack, especially if there is resistance to eye opening
Ictal weeping Crying either during or immediately after the attack
Memory of being in a generalised seizure Ability to recall the experience of being in a generalised shaking attack
Presence of an attack resembling epilepsy A normal EEG does not exclude frontal lobe epilepsy or deep foci of epilepsy but does provide supportive
with a normal EEG evidence
Visual symptoms33
Fogging test Vision in the unaffected eye is progressively ‘fogged’ using lenses of increasing dioptres whilst reading an
acuity chart. A patient who still has good acuity at the end of the test must be seeing out of their
affected eye
Tubular visual field The patient has a field defect of the same width at 1 m as at 2 m

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Figure 1 Hoover’s sign of functional leg weakness. Reproduced with permission from BMJ publications.13

A ‘HANDS ON’ WAY OF IMPROVING DOCTOR physiotherapists but which psychologists and psychia-
PATIENT RAPPORT trists rarely avail themselves of. There is no reason,
We live in an age of technological medicine, but many however, why these professionals should not also
patients still appreciate the thoroughness and skill of a learn selected skills. Psychiatrists I work with have
physical examination. The physical examination pro- successfully incorporated these features into their
vides ‘hands on’ contact, a basic transaction that practice.
patients have expected from health professionals for
millennia. There are also many aspects of the neuro- THERAPEUTIC ASPECTS OF THE EXPLANATION
logical examination that have the potential to ‘break Diagnoses and explanations in medicine are often, in
the ice’, such as the plantar response, finger–nose test themselves, therapeutic. The patient with migraine will
and knee jerks. The opportunity to share a smile with be less likely to worry about a brain tumour when they
a patient whose affect has been flat throughout an realise that pain from a brain tumour would not remit
assessment should not be underestimated. as well as relapse. Even patients with motor neurone
disease who are devastated and shocked at the news of
AN OPPORTUNITY TO REINFORCE NORMAL a terminal illness may report a sense of relief that a
FINDINGS cause has been found for their problems. Diagnostic
During the examination, some doctors say very little. limbo is a difficult state for anyone to be in.
Explaining what you are doing and mentioning that
things are normal as you go along helps improve
confidence and transparency. COMMON APPROACHES
Neurologists who are confident about the diagnosis of
These aspects of the physical examination are thera- a functional disorder are often less confident about
peutic opportunities open to physicians and transmitting that information to the patient. There are

Figure 2 Functional facial overactivity can look like facial weakness—typically with platysma overactivity, jaw deviation and/or
contraction of orbicularis oculis. Reproduced with permission from Stone J.1

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which for most conditions is not found in the name

Box 2 An example of how to show a patient their of the disorder. The doctor may talk about inflamma-
Hoover’s sign37 tion or autoimmune disease but this is mechanism not
aetiology—‘how’ not ‘why’. When doctors do discuss
Doctor (testing weak hip extension): Try to keep your aetiology, then normally phrases such as, “It’s just one
foot flat on the floor for me. of those things/bad luck”, indicate to the patient that
Patient (in a sitting position): I can’t do it. it is not their fault. It is also true that if you can see it
Doctor (testing contralateral hip flexion against resistance on a scan or have heard of the condition then gener-
but holding other hand under the patient’s weak thigh): ally patients do not believe a priori that it is their fault
Now, concentrate on lifting up your good right leg. Look anyway.
at that right leg and focus on keeping it up in the air. Following this initial discussion, the patient with
Now, can you feel that when you do that, the power in multiple sclerosis or epilepsy may be directed to
your left leg has come back to normal? I can’t get that sources of information on the web and, with a bit of
left foot off the floor now. luck, an appointment with a specialist nurse so that
Patient (and the partner): That’s weird. they can have support and further information for
Doctor: This test is called Hoover’s sign. It’s a positive their chronic condition. Patients with chronic condi-
sign of a genuine problem called functional leg weak- tions like diabetes and epilepsy are encouraged to self-
ness. I can see that you were really trying to keep your manage and optimise their conditions, but the neur-
left foot on the floor but your leg was weak. But ologist or another physician will see the patient from
because the movement comes back to normal when you time to time for review, active treatment where appro-
move your other leg, that shows me that the weakness priate, and certainly in the case of multiple sclerosis,
can’t be due to damage anywhere in the nervous system. at least once more to answer questions.
Patient: So what’s going on then? So, translating this approach to functional disorders
Doctor: Your brain is having trouble sending a message gives us a plan outlined in table 3. Tell the patient what
to your leg to make it move, but when you are distracted they have first (and discuss what it is not later). Discuss
the automatic movements can take place normally. This the positive evidence for the diagnosis from the history
test shows me that there is a problem with the function and examination and explain why it cannot be seen on
of your nervous system, not damage to it. It’s basically a any scans. Some discussion of mechanism is helpful—a
problem with the function of the nervous system—a bit problem with the software of the brain communicating
like a software problem instead of a hardware problem. to the limbs (functional motor disorders) or a trance-
Shall I show you again? like state (dissociative (non-epileptic) attacks)—espe-
cially when linked to the examination findings or
symptoms of dissociation. If the question of ‘why’
several common approaches to this problem. It is arises, then it would seem quite reasonable to say that
worth rehearsing the pitfalls of each of these this varies from person to person, that there are
approaches (table 2). various triggers including injury, pain, panic attacks and
life stress but that in many people it is not clear and
GIVING A POSITIVE DIAGNOSIS may well be ‘one of those things’.
One solution to these problems is to approach the As with other chronic disease management, being
problem in the same transparent and straightforward honest and transparent, encouraging the patient to
way you do for other patients seen in the neurology understand their condition, providing self-help infor-
clinic (table 3). Discussions about terminology go mation (such as http://www.neurosymptoms.org or
round and round 12 40 41 (and probably always will). I http://www.nonepilepticattacks.info) and optimising
increasingly find that is not so much the precise ter- function are important. Specialist nurses or allied
minology but the overall attitude of the doctor that health professionals dedicated to this area hardly exist
matters. but would be a great advantage, given the size and
Consider how you tell a patient that they have mul- complexity of the problem.
tiple sclerosis. Generally you start, within the first few If your current approach to talking to patients with
sentences at least, by telling the patient that they have functional disorders is different from how you
multiple sclerosis. There is then usually a discussion approach other disorders, it is worth asking yourself
about why the diagnosis has been made—typical why. Do you have an ambivalent attitude to the
symptoms, signs on examination and an abnormal patient and a concern that the symptoms are volun-
MRI that a doctor will preferably show to the patient. tary? Are you changing your approach because you
The conversation does not start with a discussion think they need a psychosocial formulation on the
about all the neurological diseases the patients do not first assessment? Or perhaps you view these patients
have (although that may come later). Neither does the as ‘not having a diagnosis’ rather than having a
conversation typically move early towards aetiology, diagnosis?

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Table 2 Features of some common explanations offered by neurologists to patients for functional disorders and their associated problems
Strategy Comments
1. Making no diagnosis: no neurological disease (includes the term The patient is likely to go elsewhere to seek a diagnosis
‘non-organic’)
2. Making an ‘unexplained’ diagnosis, eg, these things are common in ▸ The patient is likely to go elsewhere to seek a diagnosis
neurology and we don’t really know why they happen
▸ Many neurological disorders have known pathology ‘unexplained’ or
‘unknown’ cause, eg, multiple sclerosis/Parkinson’s disease
▸ Neurologists should be familiar with functional disorders and be able
to make a positive clinical diagnosis, eg, migraine/Parkinson’s disease
3. Making an incomplete diagnosis—eg, telling someone with a 3-week This may be acceptable to the patient (and be easier for the neurologist) but
history of functional hemiparesis triggered by migraine that they just leads to a missed opportunity to understand symptoms and their potential for
have migraine39 reversibility
4. Trying to explain that the problem is psychological—eg, explaining ▸ Likely to be rejected by most (80%) of patients
that these symptoms are often ‘stress-related’
▸ Often equated by patients as an accusation that the symptoms are
‘made up’ or ‘imagined’
▸ Many patients with these symptoms do not have identifiable stress or
psychiatric disorder
▸ This is, however, consistent with referral for psychological treatment
5. Making a functional diagnosis ▸ Consistent with a disorder of nervous system functioning
▸ Does not leap to conclusions about the cause
▸ Could be interpreted as something irreversible that cannot be
improved with physical or psychological rehabilitation.

Table 3 Some suggested ingredients for a therapeutic explanation for patients with functional neurological disorders
Ingredient Example
Explain what they do have… “You have functional weakness”
“You have dissociative seizures”
Emphasise the mechanism of the symptoms rather Weakness: “There is a problem with the way your brain is sending messages to your body—its a
than the cause problem with the function of your nervous system”
Seizures: “You are going into a trance-like state a bit like someone being hypnotised”
Explain how you made the diagnosis Show the patient their Hoover’s sign or dissociative seizure video
Indicate that you believe them “I do not think you are imagining/making up your symptoms/mad”
Emphasise that it is common “I see lots of patients with similar symptoms”
Emphasise reversibility “Because there is no damage, you have the potential to get better”
Explain what they do not have “You don’t have multiple sclerosis, epilepsy”, etc
Emphasise that self-help is a key part of getting better “This is not your fault but there are things you can do to help it get better”
Metaphors may be useful “There’s a problem with the software of the nervous system rather than the hardware”
Introducing the role of depression/anxiety “If you have been feeling stressed/low/worried, that will tend to make the symptoms even
worse” (often easier to achieve on a second visit)
Use written information Send the patient their clinic letter. Give them some written information, eg, http://www.
neurosymptom.org, http://www.nonepilepticattacks.info
Stop the antiepileptic drug in dissociative seizures If you have diagnosed dissociative (non-epileptic) attacks and not epilepsy, stop the antiepileptic
drug
See the patient again “I’ll see you again. Please have a read of my letter and the information I have given you and
come back with questions”
Making the physiotherapy or psychiatric referral “My colleague X (or my colleague Dr X) has a lot of experience and interest in helping patients
(preferably at a second visit) with functional movement disorder—he won’t think you are crazy either”

ARRANGING A FOLLOW-UP VISIT again to go over the diagnosis. At that second visit, if
Table 3 also expands on other things that might be the first one has gone well, other issues may emerge
said by a neurologist during a 5–10 min period at the and referral to physiotherapy or psychiatry is likely to
end of a consultation. In addition to explanation, the flow more naturally from the consultations. If the first
neurologist treating functional disorders like multiple consultation did not go well, this might be because
sclerosis or epilepsy would normally see the patient the patient needs more time to understand it, or it

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might be that the patient is fundamentally not moti- with functional movement and gait disorder. For
vated or interested to pursue the diagnosis and treat- example, a recent randomised trial of 3 weeks of
ment suggested. If that is the case, then it would be inpatient physical rehabilitation for patients with
sensible for the neurologist to defer referral to other functional gait disorder of 9 months duration
services on the grounds that they are unlikely to be showed a mean 7-point change in a 15-point func-
able to help someone who does not have some confi- tional mobility scale compared with controls.49
dence in their diagnosis (see below). Either way, a Another prospective study of 47 patients with a
follow-up visit from a neurologist can play a useful 5-year history of symptoms undergoing similar
role in determining who might benefit from more physically oriented 5-day physical treatment (with
treatment and who probably will not. A follow-up no formal psychological treatment) recorded a good
visit also allows a neurologist the chance to learn outcome in 55% at follow-up.50 Cognitive-behav-
from experience by finding out when they have com- ioural therapy was shown to be a promising treat-
municated well and when they have not. ment for patients with dissociative (non-epileptic)
attacks in a randomised-controlled trial with a
NEUROLOGISTS CAN DO number needed to treat of 5, and there is a UK mul-
COGNITIVE-BEHAVIOURAL THERAPY ticentre trial ongoing (http://www.codestrial.org).47
Physicians often believe that cognitive-behavioural Multidisciplinary care also now has some evidence
therapy is a rather complex ‘black box’ treatment that base.48 51–53
only trained therapists can carry out. In fact, when a
neurologist alters a patient’s view about their diagno- WHEN TREATMENT FAILS
sis during a single consultation (eg, the patient came The implication of a stepped-care approach is that if
in thinking it was multiple sclerosis/brain damage and the first step—the neurological assessment and
left believing they had a functional disorder and explanation—fails, then there is no foundation upon
potential for recovery) then that is cognitive therapy. which to build further treatment. Psychologists and
If the patient then changes their behaviour as a result physiotherapists who work with these patients often
of their new cognition, then that is cognitive- comment how hard their jobs are when the initial
behavioural therapy. Arguably, a neurologist is better neurological consultation has gone badly and the
placed than anyone else to shift fundamental miscon- patient still believes they are a ‘medical mystery’.
ceptions that a patient may have about their diagnosis. Conversely, further therapy appears much easier when
In addition to altering basic beliefs about their dis- the patient has some understanding of their diagnosis,
order, neurologists are in a position to offer simple especially its potential for reversibility.43 In some
tips for rehabilitation. For example, they can explain patients, reiteration of that first step by the neurologist
about doing more on bad days and less on good days, may improve the situation. However, a substantial
using distraction techniques during movement (with proportion of patients cannot understand or accept
music, talking, altered gait pattern) or distraction tech- their diagnosis or benefit from treatment, however
niques before a dissociative (non-epileptic) attack. carefully and sympathetically it is explained to them.
Common features of patients in whom treatment fails
STEPPED CARE FOR FUNCTIONAL NEUROLOGICAL include:
DISORDERS ▸ inability to repeat back anything about their diagnosis on
A group of health professionals working in this area the second visit after a sympathetic initial consultation;
in Scotland proposed a stepped-care model for treat- ▸ personality disorder;
ing patients with functional neurological disorders. ▸ very fixed views about an alternative diagnosis;
Step 1 of treatment is the neurological consultation ▸ the presence of a legal case;
model described here.42 The neurologist then has a ▸ very longstanding and/or physically disabling symptoms.
key role in triaging and making onward referrals to Clinicians should be cautious with this list as many
the multidisciplinary team, which ideally involves patients with these features can be helped. It is also
physiotherapy, psychiatry/psychology, speech therapy important to recognise, however, that there is a group
and occupational therapy. My personal preference for of patients with functional disorders who do under-
step 2 is a brief intervention either by a physiotherap- stand their diagnosis, do comply with treatment but
ist (for functional motor symptoms) or psychologist do not have much improvement.
(for non-epileptic attacks). Step 3 is more complex It is important for all health professionals to recog-
multidisciplinary treatment. nise when treatment has not helped or is not going to
Describing further treatment with physiother- help. It is not fair to ask a patient or therapist to con-
apy43–45 and/or psychological treatments46–48 is tinue treatment that will probably fail and be demora-
beyond the scope of this article. In brief though, lising for both parties. Instead, neurologists should be
there are now detailed recommendations regarding willing at times to acknowledge that, as with many
the content of physiotherapy45 and there is good neurological disorders, they do not currently have a
evidence emerging for its role in treating patients treatment that can help the underlying symptom and

8 Stone J. Pract Neurol 2015;0:1–11. doi:10.1136/practneurol-2015-001241

 REVIEW

they should focus instead on enabling the patient and diagnosis from neurologists and better interdisciplinary
protecting them from harm. In my own practice, I say working between neurology and psychiatry.
to the patient that I am sorry I cannot help their
underlying condition and that I do not regard this as CONCLUSION
their fault. For some patients in this situation, aids Neurologists have always been the primary doctors
such as wheelchairs or house adaptations are appropri- responsible for making a diagnosis of functional
ate, even though these should be avoided in the patient neurological disorders. In contrast, they often do not
with rehabilitation potential. My views are similar with take responsibility for treatment. I have argued that
respect to disability financial benefits. They are appro- there are multiple opportunities within a routine
priate for patients who are genuinely disabled, regard- history taking, examination and explanation to begin
less of the cause, but may create an obstacle to therapy for the patient with a functional disorder. A
recovery in those who are on a pathway to recovery method of explanation that simply mirrors that used
(whether they have a functional disorder or multiple for other neurological conditions may be best. This
sclerosis). These things can be discussed explicitly with emphasises what the problem is (and not what it is
the patient. A blanket approach of viewing disability not), why the diagnosis is being made, emphasises
benefits as inappropriate for patients with functional reversibility but does not depend on aetiological
disorders is not correct in my view or in the view of assumptions that may be incorrect. A successful con-
the UK Department of Work and Pensions. I ask the sultation should be the beginning of treatment, not
patient’s primary care physician to monitor for the prelude to treatment. New diagnostic criteria and
comorbid treatable conditions, such as depression or structures in DSM-5 and ICD-11 will hopefully
anxiety, and will offer to review if there are new neuro- encourage neurologists to regain responsibility for the
logical symptoms causing concern. management and not just the diagnosis of functional
neurological disorders.

CLASSIFICATIONS: RECENT CHANGES AND

IMPLICATIONS FOR PRACTICE Take home messages
The diagnostic criteria for functional neurological disor-
ders in the DSM-538 emphasise the importance of posi-
▸ The neurological assessment for functional disorders
tive physical criteria in making the diagnosis (box 3).
can be the start of treatment, not just a prelude to
Patients no longer must have had recent psychological
diagnosis.
stressor (even though some will have). These new cri-
▸ Make a diagnosis based on positive signs and share
teria bring the diagnosis of functional disorders back
them with the patient.
into a form that neurologists should be comfortable
▸ Effective explanation, by a neurologist can alter key
with using. In addition, the International Classification
cognitions and behaviours in patients with functional
of Diseases (ICD), tenth revision is also being revised
disorders.
for its 11th edition in 2017. For the first time, func-
▸ Neurologists have a role in triaging to both physio-
tional neurological disorders should appear in the neur-
therapy and psychotherapy evidence-based treatment.
ology section as well as in the psychiatry section.54 55
One of the hopes of these revised international criteria
is that they will encourage greater confidence in the
Funding JS is supported by an NHS Scotland Career Research
Fellowship.
Box 3 Diagnostic and Statistical Manual of Mental Competing interests JS runs a free self-help website www.
Disorders—5 criteria for conversion disorder (func- neurosymptoms.org mentioned in this article. He makes no
tional neurological symptom disorder) money from the site.
Provenance and peer review Commissioned. Externally peer
reviewed. This paper was reviewed by Mark Edwards, London,
1. One or more symptoms of altered voluntary motor or UK.
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