Your experiences Deciphering Neurological Presentations a Perspective From Neuropsychiatry Mike Dilley Maudsley Hospital michael.dilley@slam.nhs.uk Think about the last patient that your saw with a neurological symptoms What was their major concern when they saw you? How many of you heard about cognitive, emotional or behaviouralproblems from your patient or their carers? How many of you suspected that there was something else happening for the patient that wasn t explained by their neurological disease alone? Neurology, Psychology & Psychiatry such strange bedfellows? All illness has both psychological and physical dimensions. This may seem a startling claim, but on reflection it is uncontroversial. Diseases don t come to doctors, patients do and the processes by which patients detect, describe, and ponder their symptoms are all eminently psychological. Butler & Zeman, JNNP, 2005 It s all in the brain? Cognitive, emotional and behavioural involvement in neurological conditions is common Stone et al, JNNP Psychological upset can present as neurological symptoms Neurological conditions can cause psychological symptoms Neurological conditions can directly cause psychiatric manifestations Disease as only one cause of symptoms Stone et al, JNNP 2005 What do we call symptoms without disease? Pure symptomatic labels e.g. low back pain, chronic fatigue Symptom syndromes e.g. persistent post concussion syndrome Non-diagnoses that describe what it is not rather than what it is e.g. non-epileptic seizures, non-organic, medically unexplained Diagnoses that imply an as yet unestablished disease cause e.g. reflex sympathetic dystrophy
Functional Symptoms are everywhere! Wessely et al, Lancet, 1999 Historical diagnoses that do not fit in to any of these categories, e.g. hysteria Official psychiatric diagnoses: Conversion disorder Somatisationdisorder; Briquet ssyndrome; Somatic Symptom Disorder Dissociative motor disorder Hypochondriasis or Health Anxiety Disorder Factitious disorder conscious simulation for care Malingering simulation for financial or material gain The Number Needed to Offend Stone et al, BMJ, 2002 Functional e.g. weakness, sensory disturbance etc. Avoids physical vs. psychological Breaks down functional/reversible vs. structural/irreversible Allows a way in to treatment of function Allows for both physical and psychological treatment strategies How Common are Functional Symptoms? One third of new neurology outpatients have symptoms regarded by neurologists as not at all or somewhat explained by disease Carson et al, JNNP, 2000 Functional paralysis has a similar incidence to MS at around 5/100 000 10 20% of specialist epilepsy referrals have non-epileptic attacks 50% of patients with status epilepticus Reuberet al, Epi Beh, 2003 Why bother with functional symptoms? Many doctors think that patients exaggerate or make up their symptoms in order to gain sympathy or financial benefit Some believe the symptoms but do not think they are neurological and should be dealt with by someone else Some believe that if there is not a psychiatric diagnosis, psychiatry has no role GP s see these patients frequently and struggle to get specialists to manage them
How to approach the history Patients with functional neurological symptoms compared to those with symptoms associated with disease have similar disability and more distress Carson et al, JNNP, 2000 Symptoms persist at follow up but only rarely become explained by disease For neurologists (and indeed anybody working with neurological presentations) functional symptoms account for up to a third of workload Drain the symptoms dry Make a list of symptoms and don t interrogate each one until the patient is finished Enquire about pain, fatigue, sleep, memory and concentration problems Leave mood until the end *The more physical symptoms a patient presents with the more likely their primary problem will not be explained by disease Wessely et al, Lancet, 1999 Disability Disability and how to ask about it What is a typical day like? How much of the day do you spend in bed? How often do you leave the house? Particular attention to whythe patient is disabled Does it match the neurological impairment? Is there another explanation? Consider using a Life Chart Where to start when symptoms are chronic ask When did you last feel well? Onset & Course Dissociative Symptoms Depersonalisation Derealisation Common in patients with epilepsy and migraine and in patients with functional paralysis and non-epileptic attacks May just say I get dizzy Common descriptions of dissociation I felt as if I was there, but not there, as if I was outside of myself I was spaced out, in a place all of my own Things around me didn t seem real, it was like I was watching everything on television My body didn t feel like my own I couldn t see but I could hear everyone, I just couldn t reply
Doctors & Beliefs Ask about which doctors the patient has seen previously Warns you about previously rejected explanations and treatments Shows your interest in them and their frustrations Ask about illness beliefs What do you think is causing this? What should be done? Is it reversible or irreversible? Work, money, the law and relationships Ask about work is it unpleasant? Is benefit money comparable to that earned at work? Is the patient involved in a personal injury case? May oversimplify, but may be barriers to recovery Mood and emotions Be aware that your questions can arouse defenses about a psychiatric dismissal Make sure you have asked about all somatic symptoms and then ask questions about emotions Frame the questions in the context of the somatic symptoms How to ask about emotions Do your symptoms ever make you feel down or frustrated? How much of the time do your symptoms stop you enjoying things? Do you ever have attacks where you have lots of symptoms at once? When do those happen? Is it when you leave the house? The key to later confidence in discussing emotions When to ask about abuse? A common association with functional symptoms In primary care the consultation time may not allow for any discussion of it Getting to the bottom of things quickly does not improve outcome May be best left to a later consultation or to someone else Above all else Review and summarise the notes GP s and primary health care professionals have unique access to correspondence from specialists it may be the only place where everything is together
Examination When considering functional motor or sensory signs: Inconsistency is evidence that signs are functional, but doesn t tell you whether they are consciously or unconsciously produced Positive functional signs do not exclude disease it may be both All physical signs have limited sensitivity, specificity and inter-rater reliability La belle indifference Apparent lack of concern about the nature or severity of disability or symptoms No discriminatory value and is seen in those with neurological disease too Stone et al, BMJ, 2007 Often the patient will be making an effort to appear cheerful for fear of being labelledas depressed Functional Weakness Hoover s Sign Look for evidence of inconsistency Gait on entering and leaving surgery What happens to weakness when the patient has to take their clothes off or get something from their bag? Investigations When should I request a test? The patient remains uncertain of the diagnosis even though you are and have done your best to explain it You are uncertain of the diagnosis (and will likely refer to a specialist for an opinion too) Investigations can temporarily reassure but can also be addictive Tests and referrals should happen as soon as possible to avoid focus on disease search vs. recovery
A strategy to explain a diagnosis of functional symptoms Explain what they do have You have what we call functional weakness of your arm, that s where there is no damage to the brain but it isn t functioning in the way that it did before your symptoms started Let them know you believe them I don t think that you are putting on your symptoms, they re real and not in your imagination Explain what they don t have It s very positive that we have ruled out multiple sclerosis, epilepsy, Parkinson s disease, stroke etc Tell them that you have seen it before and it s common I have seen lots of people like you who have similar difficulties Tell them that it is reversible As there isn t any damage, there s every chance that the symptoms can get better Emphasise their role in getting better Whilst you can t bring this on or control it at will, there are lots of things that you can do to improve things Above all, be honest! Explain that there is a treatment approach that combines physical rehabilitation and psychological strategies so that the functional problem can be managed from both directions and the brain can re-learn how to function again Provide them with written information and an opportunity to ask questions Saying that you don t know is better than pretending that there is an answer for everything After all, we have the same difficulties explaining what causes PD, MS, migraine etc. Acknowledging that the explanation is that there is no explanation But, that that does not mean that there is not a solution Questions