UMEM Educational Pearls

Category: Neurology

Title: Functional Neurological Disorders in the ED

Keywords: functional neurological disorder, FND, stroke mimic, non-epileptic seizure (PubMed Search)

Posted: 4/28/2021 by WanTsu Wendy Chang, MD
Click here to contact WanTsu Wendy Chang, MD

Functional neurological disorders (FND) are unintentional and involuntary.
Imaging and electrophysiological studies have shown cerebral dysfunctions in attention and perception, which may explain why symptoms often improve with distraction.
Diagnosis requires demonstration of inconsistency and/or incongruency with recognized neurological or medical conditions.
- No clinical sign alone is diagnostic.
- Patients may have comorbidities such as multiple sclerosis, stroke, or epilepsy.
Hoover’s sign and drift without pronation have been described as positive signs for FND.
- These can also be seen in patients with pain, neglect, or apraxia.
Avoid maneuvers that may harm the patient, such as dropping their arm onto their face.
- A high-pitched tuning fork applied to the nostrils is an effective stimulus to assess responsiveness.
Avoid using terms like non-organic, psychogenic, or pseudoseizure.
When counseling a patient, avoid only explaining what conditions they do not have or attributing symptoms to psychological problems or stress.
- Instead, name the diagnosis, explain that their symptoms are real and common, and emphasize that symptoms are potentially reversible.
Early diagnosis of FND is associated with improved physical and psychological outcomes.

Bottom Line: Functional neurological disorders (FND) are commonly encountered in the ED. A thorough neurological exam may reveal positive signs suggestive of FND. Early diagnosis and referral to specialists may improve outcomes.

References

Finkelstein SA, Cortel-LeBlanc MA, Cortel-LeBlanc A, Stone J. Functional neurological disorder in the emergency department. Acad Emerg Med. 2021 Apr 18 [Online ahead of print]

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