New collaboration to improve treatment of functional neurologic disorders
The ongoing COVID-19 pandemic puts all of our coping skills to the test. Children and adolescents are particularly vulnerable, with a rapidly growing number experiencing novel mental health symptoms. Many will exhibit abnormal physical and psychological manifestations that can lead to a functional neurologic disorder (FND), a dysfunction of the brain's normal mechanisms to control the body. Psychogenic non-epileptic events are one of the more common presentations, along with functional gait disorders, functional motor/sensory dysfunction, among others. People with FND frequently find themselves on a diagnostic odyssey – moving between different health care providers before achieving the correct diagnosis and treatment. The presentation often leads to fear, uncertainty about where to seek help, mistrust in the health care system and repeat visits to the emergency room. Untreated, this condition can have a significant and long-lasting impact on a person's mental and physical health. A new clinical collaboration between Cook Children's Psychology, Psychiatry and Neurology departments seeks to close the treatment gap.
The modern pathophysiological understanding of FND challenges its long-held characterization as an isolated psychological disorder, such as hysteria or conversion disorder. Integral to this new framework is an acknowledgement that FND is a neuropsychiatric disorder that exists at the intersection of the brain and mind. Studies have shown that FND symptoms are the result of impaired high-order cognitive functions involving a person's attention, sense of self control or agency, executive function, or working memory in the context of widely accepted emotional or traumatic triggers.
Initial evaluation should be thorough and consciously unbiased. As a diagnosis of exclusion, it is important to consider all possible etiologies and continue to do so if symptoms persist. Distinguishing FND symptoms from organic disorders requires an understanding of well-known clinical differences often referred to as ‘positive signs.' For example, positive signs for non-epileptic events would include events clearly preceded by an emotional trigger, asynchronous movements with eyes closed, prolonged duration, and the absence of a post-ictal phase and others. Some presentations may require further investigation with EEG, neuroimaging and evaluation by a specialist before an accurate diagnosis is possible. This evaluation should be sought urgently, as longitudinal studies have demonstrated a delay in diagnosis, and can contribute to a poor prognosis.
If FND is not quickly and accurately diagnosed with an empathetic and informative explanation of the condition and treatment plan, it can lead to prolonged symptoms with profound impacts on the patient's quality of life. Prognosis can be greatly improved when a primary care physician is able to recognize the symptoms for what they are, provide the proper reassurance, and outline a clear care plan to avoid a misleading and often difficult to reverse misdiagnoses. For patients whose symptoms do not remit, FND guidelines recommend a multidisciplinary approach with their primary care physician (PCP), psychotherapists, neurologists, psychiatrists, physical therapists, occupational therapists, and/or speech therapists.
Who should be referred to the Functional Neurologic Disorders clinic?
Cook Children's Jane and John Justin Neurosciences Center is proud to announce the opening of a new multidisciplinary Functional Neurologic Disorders Clinic, a collaboration among the departments of Neurology (Dave Shahani, M.D.), Psychiatry (Steve Chennankara, D.O.) and Psychology (Robin Ford, clinical therapist).
At this time, we are accepting referrals from neurologists who have already performed the appropriate diagnostics to exclude an organic etiology, discussed the diagnosis, and yet their patient continues to exhibit symptoms with a progressive decline in psychosocial performance.
The clinic's goal is to provide patients with challenging symptoms, a joint visit with neurology and clinical therapy to attain a comprehensive understanding of their diagnosis and a clear outline of their treatment plan. The treatment plan emphasizes engagement with the patient, return to school and all activities as quickly as possible, lifestyle modifications and continued follow-up with their clinical therapist and PCP.
Referrals are currently accepted from inpatient services at Cook Children's, as well as outpatient referrals from neurologists after review of records by clinic staff. Referrals can be sent via Epic referral to Neurology with request for FND clinic or by calling 682-885-2500. We look forward to evolving the scope of this clinic in the future with the hope of expanding knowledge and access for providers and patients experiencing this treatable condition.