PM FN NEURO DIS

2019 Top Stories in Neurology: Functional Neurological Disorders Can Be Treated

Patients with functional (psychogenic) neurological disorders have not been neurologists’ favorite patients. Certainly, they can be complex and difficult, but part of the problem has been the difficulty in making a diagnosis and finding the right treatment. These disorders have been neglected for many years by both neurologists and psychiatrists, and training in taking care of these patients has been lacking. Meanwhile, the use of medical resources by these patients has been high, with concomitant high cost to the healthcare system. All of this has been a major problem because these patients are common. Recently, there has been a resurgence of interest with more research and education, including the establishment of a new society, the Functional Neurological Disorder Society.1 In relation to diagnosis, there is an emphasis on positive diagnostic features; this is not a diagnosis only of exclusion.2 In relation to treatment, it is clear that the first step is conveying the diagnosis and getting the patient to accept the diagnosis. A number of treatment options are available, many still relying on help from our psychiatry colleagues.

One Story of the Week this year showed that adherence to psychotherapy can be valuable in the treatment of functional seizures, often called psychogenic nonepileptic seizures (PNES).3 This report from the Brigham and Women’s Hospital (BWH) in Boston dealt with 105 patients with PNES who were referred for psychotherapy of various types to either therapists at BWH or local to where the patients lived. Cognitive behavioral therapy (CBT) has the best evidence for efficacy in patients with PNES,4 but this was not always used. At BWH, the treatment was a manualized regimen of 12 weekly hour-long mindfulness-based psychotherapy sessions. Patients were followed up between 12 and 24 months later, and the investigators were able to collect information on 93 patients. Adherence was defined as at least 8 sessions within 16 weeks of the referral. Adherence with the psychotherapy led to reduction in seizure frequency (84% compared with 61% in the nonadherent group; P=.021), improvement in quality of life (P=.044), and reduction in emergency department utilization (P=.040). However, there wasn’t any difference in PNES freedom, defined as a period of 3 months without seizures, between the two groups.

In this study, the psychotherapy was not standardized, and some patients may well have gotten antidepressant or antianxiety drugs as well. This is likely not a problem since patients do differ and treatment is likely best if individualized. Apparently lacking, however, was continuing involvement of the neurologist in the patients’ care. Although there are no data on this aspect, it is likely that such continuing involvement should be helpful, showing an interest in the patients’ well-being and promoting adherence. Only 40% of the patients were adherent, and presumably this would have been higher with neurologist involvement. Therapy can only be successful if followed.

It is being recognized that successful treatment may well require a multidisciplinary team. Often, there are social problems that need to be dealt with in addition to psychological aspects. In the area of functional movement disorders, there have been a number of trials of psychologically supported physical therapy and these have been successful even without extensive psychotherapy.5

About 20 years ago, there were some follow-up studies of patients with functional disorders who showed essentially no change over long follow-up periods. The situation has now changed, and, if neurologists will take charge of management, they can make a big impact on many persons’ lives.