Trick or treat?
Showing patients with functional (psychogenic) motor symptoms their physical signs
Abstract
Functional (psychogenic) motor symptoms are diagnosed on the basis of positive signs of inconsistency or incongruity with known neurologic disease. These signs, such as Hoover sign or tremor entrainment, are often regarded by neurologists as ‘tricks of the trade,' to ‘catch the patient out, ' and certainly not to be shared with them. In this reflective article, the authors suggest that showing the patient with functional motor symptoms their physical signs, if done in the right way, is actually one of the most useful things a neurologist can do for these patients in persuading them of the accuracy of their diagnosis and the potential reversibility of their symptoms.
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Copyright © 2012 by AAN Enterprises, Inc.
Publication History
Published online: July 3, 2012
Published in print: July 17, 2012
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The authors report no disclosures relevant to the manuscript. Go to Neurology.org for full disclosures.
Authors
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M.E. and J.S. conceived of the article, executed the project, and revised drafts.
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I read with interest the recent article by Stone and Edwards. [1] Their experience was that if patients with functional motor symptoms were shown their physical signs, they could be persuaded of the accuracy of their diagnosis and the potential reversibility of their symptoms. While this may be true, my personal experience of patients with non-epileptic events has varied. Many patients feel vindicated when shown the non- epileptic event captured on video-EEG monitor. Their complaints finally stand justified in the eyes of their doctor and loved ones. That said, patients rarely if ever completely stop having their typical events after this. In a few patients, the event frequency may exacerbate and new events with previously unreported clinical semiology may be reported. [2] These patients are frequently lost to follow up only to seek medical care in another institution under another physician where invariably diagnostic work-up is repeated. This also adds to health care costs to society as a whole. Explicitly telling patients that their events are psychogenic in origin has its own challenges. The discussion is invariably 'rough' for the physician--sometimes heated-- and the psychogenic explanation is not readily accepted by most patients. I tell my patient that there is no organic basis to the symptomatology and advise that underlying psychogenic factors need to be aggressively addressed rather than say that the events are real, not imagined, or "all in the mind".
1.Stone J, Edwards M. Trick or treat?: Showing patients with functional (psychogenic) motor symptoms their physical signs. Neurology 2012;79:282-284.
2. McKenzie P, Oto M, Russell A, Pelosi A, Duncan R. Early outcomes and predictors in 260 patients with psychogenic nonepileptic attacks. Neurology 2010;74:64-69.
For disclosures, contact the editorial office at [email protected].
In our article, we suggested that being transparent with patients may, among other things, help in persuading them of the diagnosis, which in turn can help with treatment. [1] We did not suggest that it would, in isolation, result in improvement. There are many patients with functional (psychogenic) symptoms in whom improvement cannot be achieved. We acknowledge that many physicians and patients find the process of explanation 'rough'. In our experience, this is often because neurologists tend to explain the symptoms in purely psychological terms. This can often be interpreted by patients as an accusation that they are feigning their symptoms even if this is not what the doctor believes. We are arguing for the demonstration of these signs in the context of an alternative strategy [3], based on a view that both brain and mind are involved in these symptoms. [4] In our day-to-day experience, this avoids a 'rough'experience for the patient and doctor without compromising treatment.
3. Stone J. Functional Symptoms in Neurology - the Bare Essentials.Practical Neurology 2009;9:179 -189.
4. Edwards MJ, Adams RA, Brown H, Parees I, Friston KJ. A Bayesian account of "hysteria". Brain 2012:doi:10.1093/brain/aws129.
For disclosures, please contact the editorial office at [email protected]