Kingrsquos Health Partners

Neurosciences

Functional Neurological

Disorder Masterclass

Neurological assessment in functional disorders

a positive approach

Dr Biba Stanton Consultant Neurologist Kingrsquos College Hospital

NHS Foundation Trust and South London and Maudsley NHS

Foundation Trust and Visiting Senior Lecturer Kingrsquos College

London

9th May 2019

bull Understand the importance of a positive approach to diagnosing functional symptoms

bull Know the key positive signs of FND in the neurological examination and their reliability

bull Feel confident in talking about the diagnosis of FND to your patients

Patient presents with symptoms

bull AampE medical ward outpatients

Diagnosis

bull History examination investigations

bull Recognise typical patterns and exclude other possibilities

Treatment

bull Explain the diagnosis

bull Treat what we can

bull Refer on to other professionals

bull Are we more concerned about over-diagnosing FND than other disorders and does this relate to stigma about mental distress

bull What are the potential harms of not making a clear diagnosis of FND

history

ldquoSymptoms not explainable by neurological diseaserdquo

ldquoSymptoms not explainable by neurological diseaserdquo

Picture from Stone et al 2005 JNNP

Highly reliable

bull Give way weakness

bull Hooverrsquos sign

bull Co-contraction

bull Splitting the midline

bull Splitting of vibration sense

bull Drift without pronation

Reliable

bull ldquoSpinal injury testrdquo

bull Sternocleidomastoid

bull Collapsing weakness

bull Systematic failure

bull Non-anatomical sensory loss

bull Leg dragging

bull Expressive behaviour

Suggestive

bull Falls always towards support

bull Non-economic posture

bull Knee buckling

bull Irregular drift

Not just about the way you explain the diagnosis

ldquojust be normalrdquo

Label Number needed to offend

All in the mind 2

Hysterical weakness 2

Psychosomatic weakness 3

Medically unexplained 3

Stress-related weakness 6

Chronic fatigue 7

Functional weakness 9

Stroke 9

Multiple sclerosis 22

bull Motor

bull Seizures

bull Pain ldquoa change in the way the brain processes sensory informationrdquo bull Acute pain arises from tissue damage but chronic pain usually arises from changes in pain

processing so that pain is perceived even though no tissue damage is present

bull Cognitive symptoms ldquoa problem with attention rather than memoryrdquo bull Depleted attentional reserve bull Cognitive hypervigilance bull Shift from automatic to effortful cognitive processing

bull Daum C Hubschmid M Aybek S The value of positive clinical signs for weakness sensory and gait disorders in conversiondisorder a systematic and narrative review J Neurol Neurosurg Psychiatry 2014 Feb85(2)180-90

bull Edwards M Functional neurological symptoms welcome to the new normal Practical Neurology Feb 2016 16 (1) 2-3

bull Stone J Functional neurological disorders the neurological assessment as treatment Stone J Pract Neurol2016167ndash1

bull Stone J1 Edwards M Trick or treat Showing patients with functional (psychogenic) motor symptoms their physical signs Neurology 2012 Jul 1779(3) 282-4

bull Kaski D1 Bronstein AM2 Edwards MJ3 Stone J4 Lancet Neurol Cranial functional (psychogenic) movement disorders 2015 Dec14(12)1196-205

bull Carson A1 Lehn A2 Ludwig L1 Stone J1 Explaining functional disorders in the neurology clinic a photo story Pract Neurol 2016 Feb16(1)56-61

bull Understand the importance of a positive approach to diagnosing functional symptoms

bull Know the key positive signs of FND in the neurological examination and their reliability

bull Feel confident in talking about the diagnosis of FND to your patients

Patient presents with symptoms

bull AampE medical ward outpatients

Diagnosis

bull History examination investigations

bull Recognise typical patterns and exclude other possibilities

Treatment

bull Explain the diagnosis

bull Treat what we can

bull Refer on to other professionals

bull Are we more concerned about over-diagnosing FND than other disorders and does this relate to stigma about mental distress

bull What are the potential harms of not making a clear diagnosis of FND

history

ldquoSymptoms not explainable by neurological diseaserdquo

ldquoSymptoms not explainable by neurological diseaserdquo

Picture from Stone et al 2005 JNNP

Highly reliable

bull Give way weakness

bull Hooverrsquos sign

bull Co-contraction

bull Splitting the midline

bull Splitting of vibration sense

bull Drift without pronation

Reliable

bull ldquoSpinal injury testrdquo

bull Sternocleidomastoid

bull Collapsing weakness

bull Systematic failure

bull Non-anatomical sensory loss

bull Leg dragging

bull Expressive behaviour

Suggestive

bull Falls always towards support

bull Non-economic posture

bull Knee buckling

bull Irregular drift

Not just about the way you explain the diagnosis

ldquojust be normalrdquo

Label Number needed to offend

All in the mind 2

Hysterical weakness 2

Psychosomatic weakness 3

Medically unexplained 3

Stress-related weakness 6

Chronic fatigue 7

Functional weakness 9

Stroke 9

Multiple sclerosis 22

bull Motor

bull Seizures

bull Pain ldquoa change in the way the brain processes sensory informationrdquo bull Acute pain arises from tissue damage but chronic pain usually arises from changes in pain

processing so that pain is perceived even though no tissue damage is present

bull Cognitive symptoms ldquoa problem with attention rather than memoryrdquo bull Depleted attentional reserve bull Cognitive hypervigilance bull Shift from automatic to effortful cognitive processing

bull Daum C Hubschmid M Aybek S The value of positive clinical signs for weakness sensory and gait disorders in conversiondisorder a systematic and narrative review J Neurol Neurosurg Psychiatry 2014 Feb85(2)180-90

bull Edwards M Functional neurological symptoms welcome to the new normal Practical Neurology Feb 2016 16 (1) 2-3

bull Stone J Functional neurological disorders the neurological assessment as treatment Stone J Pract Neurol2016167ndash1

bull Stone J1 Edwards M Trick or treat Showing patients with functional (psychogenic) motor symptoms their physical signs Neurology 2012 Jul 1779(3) 282-4

bull Kaski D1 Bronstein AM2 Edwards MJ3 Stone J4 Lancet Neurol Cranial functional (psychogenic) movement disorders 2015 Dec14(12)1196-205

bull Carson A1 Lehn A2 Ludwig L1 Stone J1 Explaining functional disorders in the neurology clinic a photo story Pract Neurol 2016 Feb16(1)56-61

Patient presents with symptoms

bull AampE medical ward outpatients

Diagnosis

bull History examination investigations

bull Recognise typical patterns and exclude other possibilities

Treatment

bull Explain the diagnosis

bull Treat what we can

bull Refer on to other professionals

bull Are we more concerned about over-diagnosing FND than other disorders and does this relate to stigma about mental distress

bull What are the potential harms of not making a clear diagnosis of FND

history

ldquoSymptoms not explainable by neurological diseaserdquo

ldquoSymptoms not explainable by neurological diseaserdquo

Picture from Stone et al 2005 JNNP

Highly reliable

bull Give way weakness

bull Hooverrsquos sign

bull Co-contraction

bull Splitting the midline

bull Splitting of vibration sense

bull Drift without pronation

Reliable

bull ldquoSpinal injury testrdquo

bull Sternocleidomastoid

bull Collapsing weakness

bull Systematic failure

bull Non-anatomical sensory loss

bull Leg dragging

bull Expressive behaviour

Suggestive

bull Falls always towards support

bull Non-economic posture

bull Knee buckling

bull Irregular drift

Not just about the way you explain the diagnosis

ldquojust be normalrdquo

Label Number needed to offend

All in the mind 2

Hysterical weakness 2

Psychosomatic weakness 3

Medically unexplained 3

Stress-related weakness 6

Chronic fatigue 7

Functional weakness 9

Stroke 9

Multiple sclerosis 22

bull Motor

bull Seizures

bull Pain ldquoa change in the way the brain processes sensory informationrdquo bull Acute pain arises from tissue damage but chronic pain usually arises from changes in pain

processing so that pain is perceived even though no tissue damage is present

bull Cognitive symptoms ldquoa problem with attention rather than memoryrdquo bull Depleted attentional reserve bull Cognitive hypervigilance bull Shift from automatic to effortful cognitive processing

bull Daum C Hubschmid M Aybek S The value of positive clinical signs for weakness sensory and gait disorders in conversiondisorder a systematic and narrative review J Neurol Neurosurg Psychiatry 2014 Feb85(2)180-90

bull Edwards M Functional neurological symptoms welcome to the new normal Practical Neurology Feb 2016 16 (1) 2-3

bull Stone J Functional neurological disorders the neurological assessment as treatment Stone J Pract Neurol2016167ndash1

bull Stone J1 Edwards M Trick or treat Showing patients with functional (psychogenic) motor symptoms their physical signs Neurology 2012 Jul 1779(3) 282-4

bull Kaski D1 Bronstein AM2 Edwards MJ3 Stone J4 Lancet Neurol Cranial functional (psychogenic) movement disorders 2015 Dec14(12)1196-205

bull Carson A1 Lehn A2 Ludwig L1 Stone J1 Explaining functional disorders in the neurology clinic a photo story Pract Neurol 2016 Feb16(1)56-61

bull Are we more concerned about over-diagnosing FND than other disorders and does this relate to stigma about mental distress

bull What are the potential harms of not making a clear diagnosis of FND

history

ldquoSymptoms not explainable by neurological diseaserdquo

ldquoSymptoms not explainable by neurological diseaserdquo

Picture from Stone et al 2005 JNNP

Highly reliable

bull Give way weakness

bull Hooverrsquos sign

bull Co-contraction

bull Splitting the midline

bull Splitting of vibration sense

bull Drift without pronation

Reliable

bull ldquoSpinal injury testrdquo

bull Sternocleidomastoid

bull Collapsing weakness

bull Systematic failure

bull Non-anatomical sensory loss

bull Leg dragging

bull Expressive behaviour

Suggestive

bull Falls always towards support

bull Non-economic posture

bull Knee buckling

bull Irregular drift

Not just about the way you explain the diagnosis

ldquojust be normalrdquo

Label Number needed to offend

All in the mind 2

Hysterical weakness 2

Psychosomatic weakness 3

Medically unexplained 3

Stress-related weakness 6

Chronic fatigue 7

Functional weakness 9

Stroke 9

Multiple sclerosis 22

bull Motor

bull Seizures

bull Pain ldquoa change in the way the brain processes sensory informationrdquo bull Acute pain arises from tissue damage but chronic pain usually arises from changes in pain

processing so that pain is perceived even though no tissue damage is present

bull Cognitive symptoms ldquoa problem with attention rather than memoryrdquo bull Depleted attentional reserve bull Cognitive hypervigilance bull Shift from automatic to effortful cognitive processing

bull Daum C Hubschmid M Aybek S The value of positive clinical signs for weakness sensory and gait disorders in conversiondisorder a systematic and narrative review J Neurol Neurosurg Psychiatry 2014 Feb85(2)180-90

bull Edwards M Functional neurological symptoms welcome to the new normal Practical Neurology Feb 2016 16 (1) 2-3

bull Stone J Functional neurological disorders the neurological assessment as treatment Stone J Pract Neurol2016167ndash1

bull Stone J1 Edwards M Trick or treat Showing patients with functional (psychogenic) motor symptoms their physical signs Neurology 2012 Jul 1779(3) 282-4

bull Kaski D1 Bronstein AM2 Edwards MJ3 Stone J4 Lancet Neurol Cranial functional (psychogenic) movement disorders 2015 Dec14(12)1196-205

bull Carson A1 Lehn A2 Ludwig L1 Stone J1 Explaining functional disorders in the neurology clinic a photo story Pract Neurol 2016 Feb16(1)56-61

history

ldquoSymptoms not explainable by neurological diseaserdquo

ldquoSymptoms not explainable by neurological diseaserdquo

Picture from Stone et al 2005 JNNP

Highly reliable

bull Give way weakness

bull Hooverrsquos sign

bull Co-contraction

bull Splitting the midline

bull Splitting of vibration sense

bull Drift without pronation

Reliable

bull ldquoSpinal injury testrdquo

bull Sternocleidomastoid

bull Collapsing weakness

bull Systematic failure

bull Non-anatomical sensory loss

bull Leg dragging

bull Expressive behaviour

Suggestive

bull Falls always towards support

bull Non-economic posture

bull Knee buckling

bull Irregular drift

Not just about the way you explain the diagnosis

ldquojust be normalrdquo

Label Number needed to offend

All in the mind 2

Hysterical weakness 2

Psychosomatic weakness 3

Medically unexplained 3

Stress-related weakness 6

Chronic fatigue 7

Functional weakness 9

Stroke 9

Multiple sclerosis 22

bull Motor

bull Seizures

bull Pain ldquoa change in the way the brain processes sensory informationrdquo bull Acute pain arises from tissue damage but chronic pain usually arises from changes in pain

processing so that pain is perceived even though no tissue damage is present

bull Cognitive symptoms ldquoa problem with attention rather than memoryrdquo bull Depleted attentional reserve bull Cognitive hypervigilance bull Shift from automatic to effortful cognitive processing

bull Daum C Hubschmid M Aybek S The value of positive clinical signs for weakness sensory and gait disorders in conversiondisorder a systematic and narrative review J Neurol Neurosurg Psychiatry 2014 Feb85(2)180-90

bull Edwards M Functional neurological symptoms welcome to the new normal Practical Neurology Feb 2016 16 (1) 2-3

bull Stone J Functional neurological disorders the neurological assessment as treatment Stone J Pract Neurol2016167ndash1

bull Stone J1 Edwards M Trick or treat Showing patients with functional (psychogenic) motor symptoms their physical signs Neurology 2012 Jul 1779(3) 282-4

bull Kaski D1 Bronstein AM2 Edwards MJ3 Stone J4 Lancet Neurol Cranial functional (psychogenic) movement disorders 2015 Dec14(12)1196-205

bull Carson A1 Lehn A2 Ludwig L1 Stone J1 Explaining functional disorders in the neurology clinic a photo story Pract Neurol 2016 Feb16(1)56-61

ldquoSymptoms not explainable by neurological diseaserdquo

ldquoSymptoms not explainable by neurological diseaserdquo

Picture from Stone et al 2005 JNNP

Highly reliable

bull Give way weakness

bull Hooverrsquos sign

bull Co-contraction

bull Splitting the midline

bull Splitting of vibration sense

bull Drift without pronation

Reliable

bull ldquoSpinal injury testrdquo

bull Sternocleidomastoid

bull Collapsing weakness

bull Systematic failure

bull Non-anatomical sensory loss

bull Leg dragging

bull Expressive behaviour

Suggestive

bull Falls always towards support

bull Non-economic posture

bull Knee buckling

bull Irregular drift

Not just about the way you explain the diagnosis

ldquojust be normalrdquo

Label Number needed to offend

All in the mind 2

Hysterical weakness 2

Psychosomatic weakness 3

Medically unexplained 3

Stress-related weakness 6

Chronic fatigue 7

Functional weakness 9

Stroke 9

Multiple sclerosis 22

bull Motor

bull Seizures

bull Pain ldquoa change in the way the brain processes sensory informationrdquo bull Acute pain arises from tissue damage but chronic pain usually arises from changes in pain

processing so that pain is perceived even though no tissue damage is present

bull Cognitive symptoms ldquoa problem with attention rather than memoryrdquo bull Depleted attentional reserve bull Cognitive hypervigilance bull Shift from automatic to effortful cognitive processing

bull Daum C Hubschmid M Aybek S The value of positive clinical signs for weakness sensory and gait disorders in conversiondisorder a systematic and narrative review J Neurol Neurosurg Psychiatry 2014 Feb85(2)180-90

bull Edwards M Functional neurological symptoms welcome to the new normal Practical Neurology Feb 2016 16 (1) 2-3

bull Stone J Functional neurological disorders the neurological assessment as treatment Stone J Pract Neurol2016167ndash1

bull Stone J1 Edwards M Trick or treat Showing patients with functional (psychogenic) motor symptoms their physical signs Neurology 2012 Jul 1779(3) 282-4

bull Kaski D1 Bronstein AM2 Edwards MJ3 Stone J4 Lancet Neurol Cranial functional (psychogenic) movement disorders 2015 Dec14(12)1196-205

bull Carson A1 Lehn A2 Ludwig L1 Stone J1 Explaining functional disorders in the neurology clinic a photo story Pract Neurol 2016 Feb16(1)56-61

ldquoSymptoms not explainable by neurological diseaserdquo

Picture from Stone et al 2005 JNNP

Highly reliable

bull Give way weakness

bull Hooverrsquos sign

bull Co-contraction

bull Splitting the midline

bull Splitting of vibration sense

bull Drift without pronation

Reliable

bull ldquoSpinal injury testrdquo

bull Sternocleidomastoid

bull Collapsing weakness

bull Systematic failure

bull Non-anatomical sensory loss

bull Leg dragging

bull Expressive behaviour

Suggestive

bull Falls always towards support

bull Non-economic posture

bull Knee buckling

bull Irregular drift

Not just about the way you explain the diagnosis

ldquojust be normalrdquo

Label Number needed to offend

All in the mind 2

Hysterical weakness 2

Psychosomatic weakness 3

Medically unexplained 3

Stress-related weakness 6

Chronic fatigue 7

Functional weakness 9

Stroke 9

Multiple sclerosis 22

bull Motor

bull Seizures

bull Pain ldquoa change in the way the brain processes sensory informationrdquo bull Acute pain arises from tissue damage but chronic pain usually arises from changes in pain

processing so that pain is perceived even though no tissue damage is present

bull Cognitive symptoms ldquoa problem with attention rather than memoryrdquo bull Depleted attentional reserve bull Cognitive hypervigilance bull Shift from automatic to effortful cognitive processing

bull Daum C Hubschmid M Aybek S The value of positive clinical signs for weakness sensory and gait disorders in conversiondisorder a systematic and narrative review J Neurol Neurosurg Psychiatry 2014 Feb85(2)180-90

bull Edwards M Functional neurological symptoms welcome to the new normal Practical Neurology Feb 2016 16 (1) 2-3

bull Stone J Functional neurological disorders the neurological assessment as treatment Stone J Pract Neurol2016167ndash1

bull Stone J1 Edwards M Trick or treat Showing patients with functional (psychogenic) motor symptoms their physical signs Neurology 2012 Jul 1779(3) 282-4

bull Kaski D1 Bronstein AM2 Edwards MJ3 Stone J4 Lancet Neurol Cranial functional (psychogenic) movement disorders 2015 Dec14(12)1196-205

bull Carson A1 Lehn A2 Ludwig L1 Stone J1 Explaining functional disorders in the neurology clinic a photo story Pract Neurol 2016 Feb16(1)56-61

Picture from Stone et al 2005 JNNP

Highly reliable

bull Give way weakness

bull Hooverrsquos sign

bull Co-contraction

bull Splitting the midline

bull Splitting of vibration sense

bull Drift without pronation

Reliable

bull ldquoSpinal injury testrdquo

bull Sternocleidomastoid

bull Collapsing weakness

bull Systematic failure

bull Non-anatomical sensory loss

bull Leg dragging

bull Expressive behaviour

Suggestive

bull Falls always towards support

bull Non-economic posture

bull Knee buckling

bull Irregular drift

Not just about the way you explain the diagnosis

ldquojust be normalrdquo

Label Number needed to offend

All in the mind 2

Hysterical weakness 2

Psychosomatic weakness 3

Medically unexplained 3

Stress-related weakness 6

Chronic fatigue 7

Functional weakness 9

Stroke 9

Multiple sclerosis 22

bull Motor

bull Seizures

bull Pain ldquoa change in the way the brain processes sensory informationrdquo bull Acute pain arises from tissue damage but chronic pain usually arises from changes in pain

processing so that pain is perceived even though no tissue damage is present

bull Cognitive symptoms ldquoa problem with attention rather than memoryrdquo bull Depleted attentional reserve bull Cognitive hypervigilance bull Shift from automatic to effortful cognitive processing

bull Daum C Hubschmid M Aybek S The value of positive clinical signs for weakness sensory and gait disorders in conversiondisorder a systematic and narrative review J Neurol Neurosurg Psychiatry 2014 Feb85(2)180-90

bull Edwards M Functional neurological symptoms welcome to the new normal Practical Neurology Feb 2016 16 (1) 2-3

bull Stone J Functional neurological disorders the neurological assessment as treatment Stone J Pract Neurol2016167ndash1

bull Stone J1 Edwards M Trick or treat Showing patients with functional (psychogenic) motor symptoms their physical signs Neurology 2012 Jul 1779(3) 282-4

bull Kaski D1 Bronstein AM2 Edwards MJ3 Stone J4 Lancet Neurol Cranial functional (psychogenic) movement disorders 2015 Dec14(12)1196-205

bull Carson A1 Lehn A2 Ludwig L1 Stone J1 Explaining functional disorders in the neurology clinic a photo story Pract Neurol 2016 Feb16(1)56-61

Highly reliable

bull Give way weakness

bull Hooverrsquos sign

bull Co-contraction

bull Splitting the midline

bull Splitting of vibration sense

bull Drift without pronation

Reliable

bull ldquoSpinal injury testrdquo

bull Sternocleidomastoid

bull Collapsing weakness

bull Systematic failure

bull Non-anatomical sensory loss

bull Leg dragging

bull Expressive behaviour

Suggestive

bull Falls always towards support

bull Non-economic posture

bull Knee buckling

bull Irregular drift

Not just about the way you explain the diagnosis

ldquojust be normalrdquo

Label Number needed to offend

All in the mind 2

Hysterical weakness 2

Psychosomatic weakness 3

Medically unexplained 3

Stress-related weakness 6

Chronic fatigue 7

Functional weakness 9

Stroke 9

Multiple sclerosis 22

bull Motor

bull Seizures

bull Pain ldquoa change in the way the brain processes sensory informationrdquo bull Acute pain arises from tissue damage but chronic pain usually arises from changes in pain

processing so that pain is perceived even though no tissue damage is present

bull Cognitive symptoms ldquoa problem with attention rather than memoryrdquo bull Depleted attentional reserve bull Cognitive hypervigilance bull Shift from automatic to effortful cognitive processing

bull Daum C Hubschmid M Aybek S The value of positive clinical signs for weakness sensory and gait disorders in conversiondisorder a systematic and narrative review J Neurol Neurosurg Psychiatry 2014 Feb85(2)180-90

bull Edwards M Functional neurological symptoms welcome to the new normal Practical Neurology Feb 2016 16 (1) 2-3

bull Stone J Functional neurological disorders the neurological assessment as treatment Stone J Pract Neurol2016167ndash1

bull Stone J1 Edwards M Trick or treat Showing patients with functional (psychogenic) motor symptoms their physical signs Neurology 2012 Jul 1779(3) 282-4

bull Kaski D1 Bronstein AM2 Edwards MJ3 Stone J4 Lancet Neurol Cranial functional (psychogenic) movement disorders 2015 Dec14(12)1196-205

bull Carson A1 Lehn A2 Ludwig L1 Stone J1 Explaining functional disorders in the neurology clinic a photo story Pract Neurol 2016 Feb16(1)56-61

Not just about the way you explain the diagnosis

ldquojust be normalrdquo

Label Number needed to offend

All in the mind 2

Hysterical weakness 2

Psychosomatic weakness 3

Medically unexplained 3

Stress-related weakness 6

Chronic fatigue 7

Functional weakness 9

Stroke 9

Multiple sclerosis 22

bull Motor

bull Seizures

bull Pain ldquoa change in the way the brain processes sensory informationrdquo bull Acute pain arises from tissue damage but chronic pain usually arises from changes in pain

processing so that pain is perceived even though no tissue damage is present

bull Cognitive symptoms ldquoa problem with attention rather than memoryrdquo bull Depleted attentional reserve bull Cognitive hypervigilance bull Shift from automatic to effortful cognitive processing

bull Daum C Hubschmid M Aybek S The value of positive clinical signs for weakness sensory and gait disorders in conversiondisorder a systematic and narrative review J Neurol Neurosurg Psychiatry 2014 Feb85(2)180-90

bull Edwards M Functional neurological symptoms welcome to the new normal Practical Neurology Feb 2016 16 (1) 2-3

bull Stone J Functional neurological disorders the neurological assessment as treatment Stone J Pract Neurol2016167ndash1

bull Stone J1 Edwards M Trick or treat Showing patients with functional (psychogenic) motor symptoms their physical signs Neurology 2012 Jul 1779(3) 282-4

bull Kaski D1 Bronstein AM2 Edwards MJ3 Stone J4 Lancet Neurol Cranial functional (psychogenic) movement disorders 2015 Dec14(12)1196-205

bull Carson A1 Lehn A2 Ludwig L1 Stone J1 Explaining functional disorders in the neurology clinic a photo story Pract Neurol 2016 Feb16(1)56-61

ldquojust be normalrdquo

Label Number needed to offend

All in the mind 2

Hysterical weakness 2

Psychosomatic weakness 3

Medically unexplained 3

Stress-related weakness 6

Chronic fatigue 7

Functional weakness 9

Stroke 9

Multiple sclerosis 22

bull Motor

bull Seizures

bull Pain ldquoa change in the way the brain processes sensory informationrdquo bull Acute pain arises from tissue damage but chronic pain usually arises from changes in pain

processing so that pain is perceived even though no tissue damage is present

bull Cognitive symptoms ldquoa problem with attention rather than memoryrdquo bull Depleted attentional reserve bull Cognitive hypervigilance bull Shift from automatic to effortful cognitive processing

bull Daum C Hubschmid M Aybek S The value of positive clinical signs for weakness sensory and gait disorders in conversiondisorder a systematic and narrative review J Neurol Neurosurg Psychiatry 2014 Feb85(2)180-90

bull Edwards M Functional neurological symptoms welcome to the new normal Practical Neurology Feb 2016 16 (1) 2-3

bull Stone J Functional neurological disorders the neurological assessment as treatment Stone J Pract Neurol2016167ndash1

bull Stone J1 Edwards M Trick or treat Showing patients with functional (psychogenic) motor symptoms their physical signs Neurology 2012 Jul 1779(3) 282-4

bull Kaski D1 Bronstein AM2 Edwards MJ3 Stone J4 Lancet Neurol Cranial functional (psychogenic) movement disorders 2015 Dec14(12)1196-205

bull Carson A1 Lehn A2 Ludwig L1 Stone J1 Explaining functional disorders in the neurology clinic a photo story Pract Neurol 2016 Feb16(1)56-61

Label Number needed to offend

All in the mind 2

Hysterical weakness 2

Psychosomatic weakness 3

Medically unexplained 3

Stress-related weakness 6

Chronic fatigue 7

Functional weakness 9

Stroke 9

Multiple sclerosis 22

bull Motor

bull Seizures

bull Pain ldquoa change in the way the brain processes sensory informationrdquo bull Acute pain arises from tissue damage but chronic pain usually arises from changes in pain

processing so that pain is perceived even though no tissue damage is present

bull Cognitive symptoms ldquoa problem with attention rather than memoryrdquo bull Depleted attentional reserve bull Cognitive hypervigilance bull Shift from automatic to effortful cognitive processing

bull Daum C Hubschmid M Aybek S The value of positive clinical signs for weakness sensory and gait disorders in conversiondisorder a systematic and narrative review J Neurol Neurosurg Psychiatry 2014 Feb85(2)180-90

bull Edwards M Functional neurological symptoms welcome to the new normal Practical Neurology Feb 2016 16 (1) 2-3

bull Stone J Functional neurological disorders the neurological assessment as treatment Stone J Pract Neurol2016167ndash1

bull Stone J1 Edwards M Trick or treat Showing patients with functional (psychogenic) motor symptoms their physical signs Neurology 2012 Jul 1779(3) 282-4

bull Kaski D1 Bronstein AM2 Edwards MJ3 Stone J4 Lancet Neurol Cranial functional (psychogenic) movement disorders 2015 Dec14(12)1196-205

bull Carson A1 Lehn A2 Ludwig L1 Stone J1 Explaining functional disorders in the neurology clinic a photo story Pract Neurol 2016 Feb16(1)56-61

bull Motor

bull Seizures

bull Pain ldquoa change in the way the brain processes sensory informationrdquo bull Acute pain arises from tissue damage but chronic pain usually arises from changes in pain

processing so that pain is perceived even though no tissue damage is present

bull Cognitive symptoms ldquoa problem with attention rather than memoryrdquo bull Depleted attentional reserve bull Cognitive hypervigilance bull Shift from automatic to effortful cognitive processing

bull Daum C Hubschmid M Aybek S The value of positive clinical signs for weakness sensory and gait disorders in conversiondisorder a systematic and narrative review J Neurol Neurosurg Psychiatry 2014 Feb85(2)180-90

bull Edwards M Functional neurological symptoms welcome to the new normal Practical Neurology Feb 2016 16 (1) 2-3

bull Stone J Functional neurological disorders the neurological assessment as treatment Stone J Pract Neurol2016167ndash1

bull Stone J1 Edwards M Trick or treat Showing patients with functional (psychogenic) motor symptoms their physical signs Neurology 2012 Jul 1779(3) 282-4

bull Kaski D1 Bronstein AM2 Edwards MJ3 Stone J4 Lancet Neurol Cranial functional (psychogenic) movement disorders 2015 Dec14(12)1196-205

bull Carson A1 Lehn A2 Ludwig L1 Stone J1 Explaining functional disorders in the neurology clinic a photo story Pract Neurol 2016 Feb16(1)56-61

bull Daum C Hubschmid M Aybek S The value of positive clinical signs for weakness sensory and gait disorders in conversiondisorder a systematic and narrative review J Neurol Neurosurg Psychiatry 2014 Feb85(2)180-90

bull Edwards M Functional neurological symptoms welcome to the new normal Practical Neurology Feb 2016 16 (1) 2-3

bull Stone J Functional neurological disorders the neurological assessment as treatment Stone J Pract Neurol2016167ndash1

bull Stone J1 Edwards M Trick or treat Showing patients with functional (psychogenic) motor symptoms their physical signs Neurology 2012 Jul 1779(3) 282-4

bull Kaski D1 Bronstein AM2 Edwards MJ3 Stone J4 Lancet Neurol Cranial functional (psychogenic) movement disorders 2015 Dec14(12)1196-205

bull Carson A1 Lehn A2 Ludwig L1 Stone J1 Explaining functional disorders in the neurology clinic a photo story Pract Neurol 2016 Feb16(1)56-61