Top

Journal of Neurology

Published in:

Open Access 01-09-2020 | Conversion Disorder | Original Communication

Outcomes of a 5-week individualised MDT outpatient (day-patient) treatment programme for functional neurological symptom disorder (FNSD)

Authors: Panayiota Petrochilos, M. S. Elmalem, D. Patel, H. Louissaint, K. Hayward, J. Ranu, C. Selai

Published in: Journal of Neurology | Issue 9/2020

Abstract

Aim

We report results from a 5-week MDT treatment programme, with individualised sessions, for a selected group of patients with FNSD, delivered in a neuropsychiatric outpatient setting. Primary aims were to (1) reduce symptoms, (2) improve functional performance and (3) improve health status.

Methods

Treatment involved individual sessions of neuropsychiatry, cognitive behavioural therapy, physiotherapy, occupational-therapy, education and family meetings. Outcome measures collected at the beginning and end of treatment and at 6 months, were patient and clinician reported. Aims were assessed by the following: symptom reduction (PHQ15, PHQ9, GAD7, SPIN, Rosenberg); health and social functioning (HONOS, WSAS); functional performance (COPM); health status (EQ-5D-5L) and patient-rated perception of improvement (CGI).

Results

Analyses of 78 patients completing the programme and attending a 6-month review revealed high-baseline levels of disability compared to EQ-5DL population norms and high rates of disability and psychopathology as indicated by the WSAS and mental health indices (PHQ9, GAD7, SPIN, Rosenberg’s self-esteem). At baseline, 92.3% met the IAPT caseness threshold for depression and 71% met the IAPT caseness threshold for anxiety. A Friedman ANOVA over the three time points and Dunn-Bonferroni post hoc tests indicated statistically significant improvements from admission to discharge and admission to 6-month follow-up. Sustained improvements were seen in somatic symptoms (PHQ15), depression (PHQ9), anxiety (GAD7), health and social functioning (HONOS), functionality (COPM), health status (EQ-5D-5L) and patient-rated clinical global improvement (CGI).

Conclusion

An MDT can effectively deliver an outpatient programme for FNSD which can serve as an alternative to costlier inpatient programmes. Early identification and treatment of co-morbidities is advised.

Available only for authorised users

American Psychiatric Association, DSM-5 Task Force (2013) Diagnostic and statistical manual of mental disorders: DSM-5™, 5th edn. American Psychiatric Publishing, Inc. https://doi.org/10.1176/appi.books.9780890425596

Keynejad R, Carson A, David A, Nicholson T (2017) Functional neurological disorder: psychiatry’s blind spot. The Lancet Psychiatry 4(3):e2–e3CrossRefPubMed

Levenson J, Sharpe M (2016) Chapter 16—the classification of conversion disorder (functional neurologic symptom disorder) in ICD and DSM. Handb Clin Neurol 139:189–192. https://doi.org/10.1016/B978-0-12-801772-2.00016-3CrossRefPubMed

World Health Organization (2018) ICD‐11 for mortality and morbidity statistics (ICD‐11 MMS) 2018 version. https://icd.who.int/browse11/l-m/en.

Carson A, Lehn S (2016) Chapter 5—Epidemiology. Handb Clin Neurol 139:47–60. https://doi.org/10.1016/B978-0-12-801772-2.00005-9CrossRefPubMed

Stone J (2019) Functional neurological disorder (FND): a patient’s guide. https://www.neurosymptoms.org. Retrieved 28th August 2019

Crimlisk H, Bhatia K, Cope H et al (1998) Slater revisited: 6 year follow-up study of patients with medically unexplained motor symptoms. BMJ 316(7131):582–586CrossRefPubMedPubMedCentral

Carson A, Ringbauer B, Stone J, McKenzie L, Warlow C, Sharpe M (2000) Do medically unexplained symptoms matter? A prospective cohort study of 300 new referrals to neurology outpatient clinics. J Neurol Neurosurg Psychiatry 68(2):207–210. https://doi.org/10.1136/jnnp.68.2.207CrossRefPubMedPubMedCentral

Carson A, Stone J, Hibberd C et al (2011) Disability, distress and unemployment in neurology outpatients with symptoms ‘unexplained by disease’. J Neurol Neurosurg Psychiatry 82:810–813. https://doi.org/10.1136/jnnp.2010.220640CrossRefPubMed

10.

Feinstein A, Stergiopoulos V, Fine J, Lang AE (2001) Psychiatric outcome in patients with a psychogenic movement disorder: a prospective study. Neuropsychiatry Neuropsychol Behav Neurol 14(3):169–176PubMed

11.

Goldstein L, Mellers J (2006) Ictal symptoms of anxiety, avoidance behaviour, and dissociation in patients with dissociative seizures. J Neurol Neurosurg Psychiatry 77(5):616–621CrossRefPubMedPubMedCentral

12.

Dimaro L, Dawson D, Roberts N et al (2014) Anxiety and avoidance in psychogenic nonepileptic seizures: the role of implicit and explicit anxiety. Epilepsy Behav 33C:77–86. https://doi.org/10.1016/j.yebeh.2014.02.016CrossRef

13.

Hendrickson R, Popescu A, Dixit R et al (2014) Panic attack symptoms differentiate patients with epilepsy from those with psychogenic nonepileptic spells (PNES). Epilepsy Behav 37:210–214. https://doi.org/10.1016/j/yebeh.2014.06.026CrossRefPubMed

14.

Howorka J, Nezadal T, Herman E (2007) Psychogenic non-epileptic seizures, prospective clinical experience: diagnosis, clinical features, risk factors, psychiatric comorbidity, treatment outcome. Epilept Disord 9:52–58. https://doi.org/10.1684/epd.2008.0156CrossRef

15.

Aybek S, Hubschmid M, Mossinger C, Berney A, Vingerhoets F (2013) Early intervention for conversion disorder: neurologists and psychiatrists working together. Acta Neuropsychiatr 25:52–56. https://doi.org/10.1111/j.1601-5215.2012.00668.xCrossRefPubMed

16.

LaFrance W Jr, Baird G, Barry J, Blum A, Webb A, Keitner G et al (2014) Multicenter pilot treatment trial for psychogenic nonepileptic seizures: a randomized clinical trial. JAMA Psychiatry 71(9):997–1005. https://doi.org/10.1001/jamapsychiatry.2014.817CrossRefPubMed

17.

Nielsen G, Buszewicz M, Stevenson F, Hunter R, Holt K, Dudziec M, Riccardi L, Marsden J, Joyce E, Edwards M (2017) Randomised feasibility study of physiotherapy for patients with functional motor symptoms. J Neurol Neurosury Psychiatry 88:484–490. https://doi.org/10.1136/jnnp-2016-314408CrossRef

18.

Jordbru A, Smedstad L, Klungsoyr O, Martinsen E (2014) Psychogenic gait disorder: a randomized controlled trial of physical rehabilitation with one-year follow-up. J Rehabil Med 46:181–187. https://doi.org/10.2340/16501977-1246CrossRefPubMed

19.

Jacob A, Kaelin D, Roach A, Ziegler C, Lafaver K (2018) Motor retraining (MoRe) for functional movement disorders: outcomes from a 1-week multidisciplinary rehabilitation program. PM&R 10:1164–1172. https://doi.org/10.1016/j.pmrj.2018.05.011CrossRef

20.

Jacob A, Smith C, Jablonski M, Roach A, Paper K, Kaelin D, Stretz-Thurmond D, LaFaver K (2018) Multidisciplinary clinic for functional movement disorders (FMD): 1-year experience from a single centre. J Neurol Neurosurg Psychiatry 89:1011–1012. https://doi.org/10.1136/jnnp-2017-316523CrossRefPubMed

21.

Demartini B, Batla A, Petrochilos P, Fisher L, Edwards MJ, Joyce E (2014) Multidisciplinary treatment for functional neurological symptoms: a prospective study. J Neurol 261:2370–2377. https://doi.org/10.1007/s00415-014-7495-4CrossRefPubMedPubMedCentral

22.

McCormack R, Moriarty J, Mellers J, Shotbolt P, Pastena R, Landes N, Goldstein L, Fleminger S, David A (2014) Specialist inpatient treatment for severe motor conversion disorder a retrospective comparative study. J Neurol Neurosurg Psychiatry 85(8):895–900. https://doi.org/10.1136/jnnp-2013-305716CrossRefPubMed

23.

Czarnecki K, Thompson J, Seime R, Geda Y, Duffy J, Ahlskog J (2012) Functional movement disorders: successful treatment with a physical therapy rehabilitation protocol. Parkinsonism Relat Disord 18:247–251. https://doi.org/10.1016/j.parkreldis.2011.10.011CrossRefPubMed

24.

Nielsen G, Stone J, Matthews A et al (2015) Physiotherapy for functional motor disorders: a consensus recommendation. J Neurol Neurosurg Psychiatry 86:1113–1119. https://doi.org/10.1136/jnnp-2014-309255CrossRefPubMed

25.

Wing J, Beevor A, Curtis R, Park S (1998) Health of the nation outcome scales (HoNOS). Research and development. Br J Psychiatry 172:11–18. https://doi.org/10.1192/bjp.172.1.11CrossRefPubMed

26.

Kroenke K, Spitzer R, Williams J (2002) The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosom Med 64:258–266. https://doi.org/10.1097/00006842-200203000-00008CrossRefPubMed

27.

Lowe B, Kroenke K, Herzog W (2004) Measuring depression outcome with a brief self-report instrument: sensitivity to change of the Patient Health Questionnaire (PHQ-9). J Affect Disord 81:61–66. https://doi.org/10.1016/S0165-0327(03)00198-8CrossRefPubMed

28.

Spitzer R, Kroenke K, Williams J, Löwe B (2006) A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med 166(10):1092–1097. https://doi.org/10.1001/archinte.166.10.1092CrossRefPubMed

29.

Rosenberg M (1965) Society and the adolescent self-image. Princeton University Press, PrincetonCrossRef

30.

Connor K, Davidson J, Churchill L, Sherwood A, Foe E, Weisler R (2000) Psychometric properties of the Social Phobia Inventory Scale (SPIN). A new self-rating scale. Br J Psychiatry. 176:379–386CrossRefPubMed

31.

https://euroqol.org/eq-5d-instruments/eq-5d-5l-about. Accessed 27 Aug 2019.

32.

Law M, Baptiste S, McColl M, Opzoomer A, Polatajko H, Pollock N (1990) The Canadian occupational performance measure: an outcome measure for occupational therapy. Can J Occup Ther 57(2):82–87CrossRefPubMed

33.

Mundt J, Marks I, Shear M, Greist J (2002) The work and social adjustment scale: a simple measure of impairment in functioning. Br J Psychiatry 180:461–464. https://doi.org/10.1192/bjp.180.5.461CrossRefPubMed

34.

Busner J, Targum S (2007) The clinical global impressions scale: applying a research tool in clinical practice. Psychiatry (Edgmont) 4(7):28–37

35.

The Improving access to Psychological therapies Manual – 2018. https://www.england.nhs.uk/publication/the-improving-access-to-psychological-therapies-manual. Accessed 25 Aug 2019.

36.

Feng Y, Devlin N, Herdman M (2015) Assessing the health of the general population in England: how do the three- and five-level versions of EQ-5D compare? Health Qual Life Outcomes 13:171. https://doi.org/10.1186/s12955-015-0356-8CrossRefPubMedPubMedCentral

37.

Nielsen G, Riccardi L, Hunter R, Demartini B, Joyce E, Edwards M (2015) Outcomes of a 5-day physiotherapy programme for functional (psychogenic) motor disorders. J Neurol 262(3):674–81. https://doi.org/10.1007/s00415-014-7631-1CrossRefPubMed

38.

Cameron I, Crawford J, Lawton K (2008) Reid I Psychometric comparison of PHQ-9 and HADS for measuring depression severity in primary care. Br J General Pract 58:32–36. https://doi.org/10.3399/bjgp08X263794CrossRef

Title: Outcomes of a 5-week individualised MDT outpatient (day-patient) treatment programme for functional neurological symptom disorder (FNSD)
Authors: Panayiota Petrochilos
M. S. Elmalem
D. Patel
H. Louissaint
K. Hayward
J. Ranu
C. Selai
Publication date: 01-09-2020
Publisher: Springer Berlin Heidelberg
Keywords: Conversion Disorder
Anxiety
Published in: Journal of Neurology / Issue 9/2020
Print ISSN: 0340-5354
Electronic ISSN: 1432-1459
DOI: https://doi.org/10.1007/s00415-020-09874-5

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Outcomes of a 5-week individualised MDT outpatient (day-patient) treatment programme for functional neurological symptom disorder (FNSD)

Abstract

Aim

Methods

Results

Conclusion

At a glance: The ONWARDS insulin icodec trials

Springer Medicine

Abstract

Aim

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 9/2020

Prevalence and risk factors of silent brain infarcts in patients with AF detected by 3T-MRI

Application of “Mentzer’s PML case definition” to natalizumab-treated patients in the setting of strict MRI-based pharmacovigilance

Józefa Franciszka Joteyko (1866–1928)

The contribution of enhancing lesions in monitoring multiple sclerosis treatment: is gadolinium always necessary?

Exome sequencing in 38 patients with intracranial aneurysms and subarachnoid hemorrhage

A nerve conduction study predicts the prognosis of sporadic amyotrophic lateral sclerosis