Functional neurological disorders in patients with brain tumours

Aims Signs and symptoms that develop in people with brain tumours are often attributed to their tumour. The prevalence and management of functional neurological symptoms in brain tumour patients have received little attention. This is surprising because functional neurological symptoms complicate management greatly and misdiagnosis can lead to inappropriate treatment and iatrogenic side-effects. Therefore, we investigated the presentation, diagnosis and management of functional neurological disorders (FND) in patients who had a brain or meningeal tumour. Method A retrospective case review was performed from 2017 - 2021 to identify adult brain tumour patients who developed a functional neurological disorder that caused significant disability necessitating expedited investigations. All patients attended a regional neuro-oncology centre. We recorded type of brain tumour and diagnostic investigations. The onset of functional symptoms was divided into three time windows: before tumour diagnosis, after diagnosis and before treatment or after tumour treatment. A neuropsychological review looked for evidence of previous adverse life events. Therapeutic interventions for functional neurological disorder and their outcomes were documented. The case review was combined with a systematic review of the literature to identify the published presentations of functional neurological disorder in the adult brain tumour population. MEDLINE, EMBASE and PsycINFO databases were searched for studies published between January 1980 and February 2021. Results Six patients (5 female, 1 male) were identified from the case review with a median age of 41 (range 29 - 56) years old. Four patients had non-epileptic attack disorder, which was diagnosed with videotelemetry of habitual attacks. One patient had a functional hemiparesis with normal central motor conduction time. One patient had a functional speech disorder with normal EEG. Half of these patients had functional neurological symptoms prior to surgery/oncological treatment. Five patients (83%) were referred for further neuropsychiatric or psychological evaluation. A history of significant psychological trauma prior to the brain tumour diagnosis was elicited in four (66%) patients. Conclusion Patients with either a brain or meningeal tumour may develop functional neurological symptoms. Our findings suggest the possibility that diagnosis of a brain tumour may precipitate a debilitating functional neurological disorder. The neurobiological basis for functional neurological disorders is being actively investigated. There are suggestions in the literature that some brain diseases increase the risk of developing a functional neurological disorder. Further work is needed to determine whether this is true for patients with brain tumours. Increased awareness of functional neurological disorders will improve management. Withdrawal of unnecessary treatment, such as anticonvulsant drugs, reduces the risk of iatrogenic side effects. Initiation of multi-disciplinary care pathways, e.g. physiotherapy, speech and language therapy and psychological treatments, promotes recovery. Collectively, these interventions improve our patients’ quality of life.

#3119 Diagnosis and management of functional neurological symptoms: Saudi Arabia experience

ObjectivesTo explore the opinion of todays neurologist and psychiatrist in the kingdom of Saudi Arabia regarding pathogenesis, diagnosis, treatment and outcome. It is a replication for Dutch experience with Functional Neurological symptoms Disorder (FND).MethodsA multi-centres Cross-sectional study was conducted in Saudi Arabia started from November 2019 and still ongoing. The target populations were a qualified psychiatrists or neurologists. Data were collected through an electronic questionnaire.ResultsThere were 70 respondents, 37.1% were female and 62.9% males. A 15.5% were Neurologists and 72.4% psychiatrists. Three questionnaires were taken out due to incompletion error. Most neurologists and psychiatrists believed that FND is a disorder of functioning of the nervous system together with psychogenic factors. However, 100% of psychiatrist believed that a prior psychological stress is a cause of the disorder (among other causes) while 86.84% of neurologists. Also found that, a 71% of patients who referred to neurologist were evaluated initially by a general practitioner, while 85% of the patients who referred to psychiatrist; were evaluated by neurologists. Eventually, most of the neurologists and the psychiatrists diagnosed patients by conversion disorder (13/38 of neurologist and 13/20 of psychiatrists).ConclusionOur preliminary conclusion is comparable for Dutch experience that is not considered purely a psychiatric disorder and counted disordered brain functioning together with psychogenic factors responsible for FNS. However, the majority of the psychiatrists in our study diagnose FND as conversion disorder.

Psychogenic pseudo-myasthenic ptosis – management with ayurvedic medicines and Smriti meditation

Objectives Patients presenting with functional neurological symptoms like non-epileptic seizures and weakness have an underlying psychological component and tend to persist for a prolonged time, despite repeated evaluations and interventions. Ayurveda, with its holistic approach to health and disease, can provide better management for such disorders, in the form of customized treatment protocols and unique methods of psychotherapy. Case presentation The patient presented with drooping of both eyelids, initially diagnosed as ocular myasthenia, and later found to have psychogenic pseudo-myasthenic ptosis. She was evaluated based on ayurvedic parameters and managed successfully with ayurvedic treatment modalities of sodhana (dosha elimination), samana (pacifying), and a novel psychotherapy technique of Smriti meditation. Conclusions A holistic approach to the patient, as expounded by Ayurveda, is vital in evaluating and managing functional neurological complaints. Smriti meditation, in combination with selected ayurvedic medicines, is effective in managing psychosomatic manifestations as demonstrated in the present case.

Functional motor phenotypes: to lump or to split?

Introduction Functional motor disorders (FMDs) are usually categorized according to the predominant phenomenology; however, it is unclear whether this phenotypic classification mirrors the underlying pathophysiologic mechanisms. Objective To compare the characteristics of patients with different FMDs phenotypes and without co-morbid neurological disorders, aiming to answer the question of whether they represent different expressions of the same disorder or reflect distinct entities. Methods Consecutive outpatients with a clinically definite diagnosis of FMDs were included in the Italian registry of functional motor disorders (IRFMD), a multicenter data collection platform gathering several clinical and demographic variables. To the aim of the current work, data of patients with isolated FMDs were extracted. Results A total of 176 patients were included: 58 with weakness, 40 with tremor, 38 with dystonia, 23 with jerks/facial FMDs, and 17 with gait disorders. Patients with tremor and gait disorders were older than the others. Patients with functional weakness had more commonly an acute onset (87.9%) than patients with tremor and gait disorders, a shorter time lag from symptoms onset and FMDs diagnosis (2.9 ± 3.5 years) than patients with dystonia, and had more frequently associated functional sensory symptoms (51.7%) than patients with tremor, dystonia and gait disorders. Patients with dystonia complained more often of associated pain (47.4%) than patients with tremor. No other differences were noted between groups in terms of other variables including associated functional neurological symptoms, psychiatric comorbidities, and predisposing or precipitating factors. Conclusions Our data support the evidence of a large overlap between FMD phenotypes.

Queen Square Guided Self Help for Functional Neurological Symptom Disorder

Objective: Functional Neurological Symptoms (FNS) are disabling symptoms without macro-structural cause. While inpatient treatment confers important benefits, it is resource intensive and hence it is important to optimize its efficiency. Methods: We developed a brief, internet-based preparatory therapy based on psychoeducation and CBT, termed the Queen Square Guided Self-help (QGSH) to maximize the efficacy of the inpatient FNS treatment at the National Hospital for Neurology and Neurosurgery. Results: The QGSH aims to ensure that prior to admission the patient understands 1) The diagnosis of FNS , 2) The five areas CBT model and 3) The use of Goal setting in rehabilitation. It has now run since 2017 and 191 patients have taken part in the inpatient FNS program, with 122 of these have participated in the QGSH. It runs for up to twelve weeks and includes original videos and patient worksheets, as well as signposting to existing published resources. Information is sent weekly by e-mail and content is delivered in the form of eleven modules built around online video sessions.Conclusion: We believe that the set of materials used in QGSH has the potential to benefit patients with FNS and can support clinicians wishing to develop their expertise. It could help with the development of new FNS services, and we are in the process of developing it into a standalone service. We hope that the experience of the Queen Square team can be used to help patients and clinicians to improve the provision of FNS services.

The Profile of Brain Tumor Cases in RSUD Dr Soetomo, Surabaya

Brain tumor is a condition affecting many people worldwide.Patients often had similar functional neurological symptoms even if the type of tumors diagnosed were entirely different at a later stage.Some of the neurological symptoms were tingling in the feet, changes in eyesight,tremors in the extremities, headaches or migraines and more. Patients who suffer from brain tumor go through a screening process to identify the cause of the problem. Factors such as age and gender was observed in this study which affected the data distribution of brain tumors. This study aimed to find the data distribution of the brain tumor cases in RSUD Dr Soetomo. The results obtained showed that the highest number of brain tumor found were meningiomas followed by unspecified brain neoplasms as the second highest and adenomas being the third highest tumor type found in RSUD Dr Soetomo. The total number of female patients with brain tumor were higher than that of males. The median age of the patients was found to be 45. The highest number of tumor cases were seen in the adult age group followed by teens, children and elderly. The benign tumor type is found to be higher in number as compared to malignant. The number of supratentorial tumors are also found to be higher than infratentorial overall. Keywords: age; gender; brain tumor

Nocebo-Hypothesis Cognitive Behavioral Therapy (NH-CBT) for Persons With Functional Neurological Symptoms (Motor Type): Design and Implementation of a Randomized Active-Controlled Trial

Introduction: Functional Neurological Symptom Disorders (FNSD) are associated with high levels of disability and immense direct and indirect health costs. An innovative interdisciplinary rehabilitation approach for individuals with functional neurological symptoms of motor type–Nocebo-Hypothesis Cognitive Behavioral Therapy (NH-CBT)—combines CBT and movement retraining with video feedback embedded in a comprehensive explanatory model of the etiology of FNSD.Methods: This protocol describes the development and implementation of a phase II, parallel group, randomized controlled trial with blinded outcome assessors to compare the efficacy of NH-CBT with an active control condition (supportive counseling and movement retraining). Individuals meeting diagnostic criteria of an FNSD or psychogenic movement disorder will be randomly assigned to one of the 8-week interventions. Self-report scales of motor and other physical symptoms, symptom-related psychological variables, and assessor ratings of participants' mobility will be administered at baseline, and at 8- and 16-week follow-up. Adverse events will be monitored across all sessions and therapeutic alliance will be measured at the end of therapy. The primary statistical analysis will test the hypothesis that NH-CBT is more effective than the control intervention at the 8-week follow-up.Discussion: The therapeutic strategies of NH-CBT are theory-driven by assumptions of the predictive coding model of the etiology of FNSD. Strengths and limitations of this trial will be discussed.Trial registration: Australian New Zealand Clinical Trials Registry (ANZCTR; identifier: ACTRN12620000550909).