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Symptoms Disorder
(FND)
Does the body rule the mind, or does the mind rule the body? I don’t
know
THE SMITHS
Yunxia Wang, MD
Neurohospitalist
Vascular Neurologist
Objective
• Make FND diagnosis based on the clinical presentation and positive
neurological exam.
• Reduce the risk of the patient with structural neurologic disease
receiving the diagnosis of a functional disorder simply because they
have psychiatric comorbidity or symptom onset coincides with recent
stress
FND a none man land
•Inorganic-psychiatry/Psychology
Hysteria
Ancient Greece: wandering womb
Wandering womb is the cause of all female disorders
Thomas Willis (1622 to 1675),
Bertha Pappernheim
2/27/1859-5/28/1936
Sigmund Freud on Anna O. Case
• Dr. Breuer's patient was a girl of twenty-one, of high intellectual gifts. Her
illness lasted for over two years, and in the course of it she developed a
series of physical and psychological disturbances which decidedly deserved
to be taken seriously. She suffered from a rigid paralysis, accompanied by
loss of sensation, of both extremities on the right side of her body; and the
same trouble from time to time affected her on her left side. Her eye
movements were disturbed and her power of vision was subject to
numerous restrictions. She had difficulty of the posture of her head, she
had a severe nervous cough. She had an aversion to taking nourishment,
and on one occasion she was for several weeks unable to drink in spite of a
tormenting thirst. Her powers of speech were reduced, even to the point of
her being unable to speak or understand her native language. Finally, she
was subject to conditions of 'absence',(1) of confusion, of delirium, and of
alteration of her whole personality, to which we shall have presently to
turn our attention.
Frued and Breuers’ HysteriaTheory
• Hysterical symptoms derive from undischarged "memories"
connected to "psychical traumas." These memories originated when
the nervous system was in a special physiological condition or
"hypnoid state"; they then remained cut off from consciousness.
Hysterical symptoms resulted from the "intrusion of this second state
into the somatic innervation," a mind-to-body process Freud and
Breuer called "conversion.“
• Freud and Breuer collaboration ended later because their different
approach to hysteria
• Freud became the father of psychoanalysis
FND interface of neurology and psychiatry
• Separation of psychiatry from Neurology
Published by AAAS
From: Neural Correlates of Recall of Life Events in Conversion Disorder
A: DLPFC, B:rFIC
CDLPFC
From: Neural Correlates of Recall of Life Events in Conversion Disorder
Case controlled study. 12 conversion disorder, 13 health control
JAMA Psychiatry. 2014;71(1):52-60. doi:10.1001/jamapsychiatry.2013.2842
From: Neural Correlates of Recall of Life Events in Conversion Disorder
.
Neural Correlates of Recall of Life Events in Conversion
Disorder
J Stone etal: Clin Neurol Neurosurg. 2010 Nov;112(9):747-51. doi: 10.1016/j.clineuro.2010.05.011. Epub 2010 Jun 19.
Who is referred to neurology clinics?--the diagnoses made in 3781 new patients
How comman:In pt service
• CT of head negative
What do you do
MRI to rule out stroke
Or tPA
• Complex Migraine
• Seizure
• Conversion disorder
• Global aphasia most common symptom of mimics
Winkler DT. Thrombolysis in Stroke Mimics: Frequency, Clinical Characteristics, and Outcome. Stroke 2009:40:1522-25
Chernyshev OY. Safety of tPA in stroke mimics and neuroimaging-negative cerebral ischemia. Neurology 2010; 74: 1340 -
1345.
Stroke Mimics Treated with Thrombolysis: Further
Evidence on Safety and Distinctive Clinical Feature
• Prospective Registry; Jan 2004 to Dec 2011; 621 were treated with
tPA
• 606 were ischemic stroke(97.5%)
• 15 were stroke Mimic(2.4%)
• 5 FND
• No ICH or disability in FND pt received tPA
• The use of intravenous thrombolysis appears to be safe in stroke
mimic patients, The safety of thrombolysis in stroke mimic suggests
that delaying or withholding treatment may be inappropriate.
• Cullin M etal Cerebrovasc Dis 2012;34:115–120, Midrid Spain
How to manage the pt
• Tell the Dx
• With detailed hx, neurological exam and necessary neurological test
FND is a diagnostic consideration, not a rule out dx.
• Helpful to show the pt the signs of FND( Hoover Signs)
• Tell them that it is not in their mind
• Some pts have stress and some of them do not
• Unrelated to their social economic status
• Plan to continue to care the pt.
Common pitfalls
• Great news, you do not have a stroke/seizure and we do not know
what going on with you
• These are all stress related
• It always gets better
• It is all in your head and you are faking.
• What we know
• It is not dangerous, pt can be disabled just as stroke, MS pts
• Share other pt’s story; search for a diagnosis, misunderstood by family and
• Common features of other pt; disassociation symptoms.
• Reassure them they are not alone, your pts are from high function pt,
lawyers, business man,
• It is not uncommon.
• Avoid to tell pt what you do not know
Management: challenges
• Lack of literature,
• Not well studied
• Pathophysiology was not well understood
• Heterogeneous symptoms presentation make a randomized trial very
difficult
• Very difficulty to study medical intervention
Pt with clear Stress/trauma inducers
• Referral to Psychologist
• Trauma Release Excise
• Mindful stress reduction
• CBT
• Physical Therapy
• Processing need remains for prospective interventional study/ies
Prognosis
• 1/3 better
• 1/3 improve
• 1/3 stay the same or worse
• Pt with acute onset may response better than chronic
Summary
• FND will be here to stay and it should not be a dx of exclusion
• Neurologist plays an important role in making the Dx
• Understanding neurobiology of FND could open the window for us to understand and management
structural neurological condition such as RMCA stroke