Functional Neurological Disorder

Question 1

Symptoms of functional limb weakness

Answer 1

Heaviness on one side
Dropping things- lack of coordination/strength
Limb feels abnormal / detached

Question 2

What conditions may functional limb weakness mimic?

Answer 2

Stroke

Multiple Sclerosis

Question 3

Indications of functional disorder

Answer 3

Normal tests and scans
Pattern
No change in reflexes
Collapsing weakness
Hoover's sign
Dragging of affected leg
Difference in power when on the bed versus walking

Question 4

What is Hoover’s sign?

Answer 4

Patient cannot push foot of affected limb into bed

Lift unaffected limb, power returns to affected to keep foot flat

Question 5

What is a typical sign of Multiple Sclerosis in patient’s gait?

Answer 5

Swinging of leg

Question 6

Symptoms that can accompany functional weakness

Answer 6

Low mood
Frustraition
Anxiety
Worry

Question 7

4 Situations that may lead to functional weakness arising

Answer 7

After trauma or in pain
Illness with faitgue and/ bed rest
Waking up from anaesthetic/ arising from sleep
After episode of dissociation/ panic attack

Question 8

What is complex regional pain syndrome?

Answer 8

Pain in one or more limbs occurring after physical injury or minor soft tissue issues eg. carpal tunnel

Question 9

Diagnostic criteria for Complex Regional Pain Syndrome

Answer 9

Budapest

Question 10

Describe the 4 points of the Budapest Criteria

Answer 10

1. Continued pain that is disproportionate to the inciting event
2. One symptom from three of the four following categories
   - Sensory; hyperesthesia, allodynia
   - Sudomotor; edema , and or sweating changes, and or sweating assymetry
   - Vasomotor; temperature changes, and or skin colour changes, and or skin colour assymetry
   - Motor/trophic; decreased range of motion, and or motor dysfunction(weakness, tremor, dystonia) and or trophic changes (nails, hair)
3. Must display at least one sign at time of evaluation in two or more of the following categories:

Sensory: evidence of hyperalgesia (to pinprick) and/or allodynia (to light touch and/or deep somatic pressure and/or joint movement)

Vasomotor: evidence of temperature asymmetry and/or skin color changes and/or asymmetry

Sudomotor/edema: evidence of edema and/or sweating changes and/or sweating asymmetry

Motor/trophic: evidence of decreased range of motion and/or motor dysfunction (weakness, tremor, dystonia) and/or trophic changes (hair, nail, skin)

4. There is no other diagnosis that better explains the signs and symptoms

Question 11

What is allodynia?

Answer 11

Painful response to non-painful stimulus, eg. brushing hair

Question 12

What is sudomotor activity?

Answer 12

Change in blood flow or skin colour

Question 13

Other names for dissociative attacks

Answer 13

Non-epileptic seizures
Dissociative seizures
Psychogenic seizures
Functional seizures/attacks

Question 14

What condition can dissociative attacks mimic?

Answer 14

Epilepsy

Question 15

Two main types of dissociative attack

Answer 15

With movement - thrashing, like generalised seizure

Without movement- fall to ground, motionless, unresponsive for several minutes

Question 16

Specific features of dissociative attack

Answer 16

Long duration
Abnormal movements of head and limbs
Prolonged period of unresponsiveness
Appearance of eyes and mouth during attack
Warnings
Patient finds it more difficult to describe attacks

Question 17

Key indiciations in diagnosis of dissociative attack

Answer 17

Normal EEG

Normal scans

Question 18

4 Categories of how dissociative attacks occur

Answer 18

1. At random
2. At rest, not distracted
3. With hyperventilation
4. With depersonalisation, derealisation

Question 19

Describe 4 common Functional Sensory symptoms

Answer 19

1. Altered sensation down one side - face, arm leg, (hemisensory syndrome)
2. Feeling that limb doesn’t belong
3. Fleeting sensations - twitches, buzzing, electric shock
4. Visual - intermittent blurring, double vision, weakness

Question 20

Which side is more commonly affected by functional sensory symptoms?

Answer 20

Left

Question 21

How are functional sensory symptoms diagnosed?

Answer 21

Mainly on history taken by neurologist
Examine - some weakness and reduced sensation
Tests and scans normal

Question 22

Five situations in which functional sesnory symptoms may arise

Answer 22

After injury/with pain
With hyperventilation
After illness with fatigue /bed rest
After an episode of dissociation, panic attack
Migraine
No obvious cause

Question 23

4 main symptoms of Functional movement disorders

Answer 23

Tremor
Jerks/twitches
Spasm/contractures
Gait problems

Question 24

5 features of functional tremor

Answer 24

Tremor disappears transiently
Changes in rhythm when copying with unaffected/good limb - Entrainment test
Difficulty making rhythmical movements with good hand/leg
Times when tremor absent
Variable frequency
Tremor gets worse when someone tries to hold limb still

Question 25

How is functional myoclonus characterised?

Answer 25

Jerks in anitcipation of loud noise | Presence of brainwave - Bereitschaftpotential

Question 26

Describe benign twitches

Answer 26

Twitches common to eye and fingers, frequency increased in individuals with functional disease. Common in doctors and medical students who believe they have MND

Question 27

Where do functional spasms most commonly occur

Answer 27

Wrists and hands

Question 28

Which spasm is likley to occur during hyperventilation?

Answer 28

Carpopedal spasm

Question 29

In which other condition does carpopedal spasm occur?

Answer 29

Low calcium

Question 30

Describe functional dystonia

Answer 30

Position that is fixed - usually hands or feet | Associated with weakness of limb and pain

Question 31

5 types of functional gait disorder

Answer 31

Excessive slowness Walking on ice pattern - cautious, feet far apart, legs stiff Crouching - associated fear of falling Sudden knee buckling - functional weakness in leg common finding Unsteady, sudden sidesteps

Question 32

Why might functional movement disorders occur?

Answer 32

Commonly associated with injury or pain

Question 33

Physiotherapy techniques for functional tremor

Answer 33

Introduce a voluntary tremor Interfere with rhythm of tremor - someone make tapping movement to copy; change rhythm so hard to follow - if tremor correlates with external rhythm, try manipulate into stopping Breaking habit - pattern- in the brain

Question 34

What is chronic fatigue syndrome?

Answer 34

Persisting tiredness with no other neurological symptoms, longer than 6 months. Not due to a detectable underlying medical or neurological condition

Question 35

Locations of pain in patients with functional neurological symptoms

Answer 35

Back pain Neck pain Widespread joint and muscle pain - fibromyalgia; especially with faitgue and unrefreshing sleep Complex Regional Pain

Question 36

Functional Cognitive Disorder

Answer 36

Issue with memory or concentration not caused by disease or damage to the brain

Question 37

Symptoms of functional cognitive disorder

Answer 37

Going blank Losing track while doing things or in conversation Mental fuzziness/sluggishness Misplacing things - keys, phone Forgetting periods of time - autopilot Forgetting details of books or film or holidays Forgetting words that seem on tip of tongue

Question 38

Functinal speech and swallowing symptoms

Answer 38

``` Slurred speech Stuttering speech Word finding difficulty Hoarse/Whispering speech - Functional dysphonia Functional aphonia (losing speech completely) Foreign accent syndrome Swallowing problems - globus, globus pharyngis ```