Call to end speciality ‘buck passing’ of functional neurological disorders


By Geir O'Rourke

6 Jun 2022

A rule-in approach and multidisciplinary care are needed to end the “buck passing” between neurologists and psychiatrists over patients with functional neurological disorder, Australian clinicians are arguing.

The call to arms comes amid growing popular interest in FND, defined in the DSM-5 as the occurrence of somatic neurological symptoms due to malfunction of the nervous system, rather than neuropathology or neurological disease.

Writing in the MJA, the group says the condition can be serious and often debilitating if not diagnosed or treated early, contributing to up to 8% of hospital admissions for acute stroke based on recent UK evidence.

But despite some anecdotal evidence of high prevalence, it remains relatively obscure in Australia, according to authors of a perspective led by Dr Elizabeth Pepper, a neurologist at John Hunter Hospital in NSW.

“For the past half century, the clinical management of FND has been subject to a great deal of buck‐passing between neurologists and psychiatrists, thanks in no small part to traditional models of service delivery shaped by notions of the presence or absence of organicity,” they wrote.

“Fortunately, advances in evidence‐based treatments and new pathophysiological models for FND have catalysed a shift in these outdated models, and consequent recognition of the need for truly multidisciplinary care is slowly changing the culture of FND care in Australia.”

Overinvestigation is harmful

But greater clinician awareness and a revamp of models of care were required, they argued, stressing a need to avoid “exhaustive, prolonged and potentially harmful investigation in a futile quest to exclude rare organic disorders”.

They said patients presented at all ages, usually with seizure‐like attacks, gait difficulties, movement disorders, cognitive or speech issues, disordered vision, as well as associated pain, fatigue and gut or respiratory symptoms.

“For example, lower limb weakness due to FND may vary with distraction, posture or activity, and the often‐cited Hoover sign may be demonstrable,” they wrote.

“Australian neurologists are now encouraged to take a rule‐in approach to FND diagnosis, aimed at minimising iatrogenic harm.”

Best practice management would include neurology, psychiatry, GPs as well as ED and rehabilitation physicians and allied health.

Empathy and a positive diagnostic explanation were also “fundamental” to the success of any following treatment, the authors added.

“Individualised, multidisciplinary treatment plans must address the most prominent presenting core and non‐core symptoms for the individual patient,” they wrote.

“Given the current constraints around health care resources, we suggest the most pragmatic way forward will be to develop a stepped care approach, building capacity in primary and secondary care settings, with specialist FND clinics at the apex.”

“It is time, therefore, for FND to become everyone’s business; all of us need to take responsibility for our own part in the health care journey of people with FND.”

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