Audit of Treatment of Functional Neurological Disorder Essay

Functional Neurological Disorder is a term used to collectively identify conditions where there is abnormal functioning of the nervous system that is not related to an organic cause. There is no disease process affecting the structure of the neurons, brain or spinal cord. The emotional centres of the brain often play a role in the disruption of normal brain signals leading to an array of functional symptoms; these include sensory, concentration, memory, fatigue, motor and seizures. As each patient has a unique set of symptoms, and there is no definitive cure for FND, it can be a difficult disease to treat. Unfortunately, despite the absence of a physical disease process, the prognosis of FND is poor, with one study that followed patients over 3 years finding a persistence of movement disorder in over 90% of patients1. Audit of Treatment of Functional Neurological Disorder Essay.

Somatised functional symptoms are recognised in a number of specialties as disorders such as fibromyalgia, irritable bowel syndrome, chronic fatigue and chronic pelvic pain2. As it is postulated that these disorders have a common aetiology, the treatment pathways are similiar2.

Giving the patient the diagnosis of a functional neurological disorder is thought to be the first step of treatment. A good explanation of the diagnosis as opposed to a dismissive and uninterested attitude can help to engage the patient and give them hope of recovery. According to a study published in 2009, ‘acceptance of diagnosis by patient’ is rated as an extremely important prognostic factor3. This illustrates the importance of patience, use of lay-mans terms and paraphrasing or use of examples to ensure the patient has a thorough understanding of the nature of their condition.

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There is significant evidence in support of both psychological treatment and anti-depressants as treatments for FND 2,4. Research has shown specifically that Cognitive Behavioural Therapy (CBT) is associated with a significant decrease in seizure frequency in patients suffering from non-epileptic attacks when compared with standard medical care 5 ( a normal neuropsychiatry appointment). This suggests that even if patients are unresponsive to some psychological interventions, it may still be worthwhile to explore other similar options. Physiotherapy is also of benefit, especially to patients with somatic motor symptoms, however the evidence base for this is limited6. Audit of Treatment of Functional Neurological Disorder Essay.

Aim:
To improve the care received by patients with Functional Neurological Disorders.

Objectives:
1. To ensure that all FND patients are referred to psychological therapy
2. To ensure that all FND patients are prescribed either an anti-depressant or an anxiolytic
3. To ensure that all FND patients are referred for physiotherapy if it is indicated
Standards:
Table 1: Standards used in the audit of the treatment of FND patients
Audit Criteria
Target
Exceptions
1. FND patients will be referred for psychological therapy.
100%

2. FND patients will be prescribed an anti-depressant/anxiolytic.
100%

3. FND patients will be referred to physiotherapy.
100%
Patients who don’t suffer from motor symptoms.

Methodology:
• The population for this audit was patients over the age of 18 years and diagnosed with a Functional Neurological Disorder
• A retrospective audit assessing all patients treated for a Functional Neurological Disorder between 2012 and 2019
• These patients were identified from clinical portal and patient notes at Carseview Centre, Dundee
• Data was collected from patients’ case notes using a data collection form (see Appendix A) Audit of Treatment of Functional Neurological Disorder Essay.
• Caldicott permission was obtained to access the patient records
• Data was input into and analysed using the Microsoft Excel programme
• Based on the results, patient were segregated into to one of two treatment groups (group 1 and group 2); group 1 is defined as patients that received optimal treatment and group 2 is patients who received suboptimal treatment
• Optimal treatment is defined as receiving both psychological intervention, antidepressant medication and physiotherapy (if indicated). Those classed as receiving suboptimal treatment did not receive one or more of the treatment classes.
• Improvement was defined as a report by patients or clinicians of reduction in severity or frequency of symptoms.

Results:
63 patients were referred to the FND clinic between 2012 and 2019. The number of patients in Group 1 is 36/63 (56%) and the number in group 2 is 28/63 (44%). The population comprised 15 men and 48 women. Symptom duration was variable with 44 patients showing a duration of 0-10 years, 15 a duration of 11-20 years and four patients with a duration of >21 years. Various manifestations of FND were reported in the population (table 2).

Table 2: Number of patients of FND presenting with each of the manifestations.
Manifestation
Number of Patients
Sensory
36
Motor
34
NEAD
30
Cognitive
10

The standards used in the audit are defined in table 1.
The numbers of each patients meeting the standards are shown in chart 1. The final column in chart 1 shows the number of patients receiving optimal treatment for their presentation – this means that both standard 1, 2 and 3 (if indicated) were met.

Chart 1: Numbers of patients with FND who did (Yes) or did not (No) meet the standards as defined in table 1.

The reasons why patients did not receive optimal treatment were grouped into three categories, those where the patient refused treatment (8 patients), those where a treatment was not offered (10) and those whose where referral waiting times impacted on the delivery of treatment (9) (chart 4).Audit of Treatment of Functional Neurological Disorder Essay.  There was a large difference in the proportions of male and female patients receiving suboptimal treatment with 5/15 (33%) of men and 4/48 (8%) of women declining either psychological therapy or antidepressant medication. The age at diagnosis also impacted on whether optimal treatment was achieved, with younger patients more likely to receive all treatment modalities (table 3). There were insufficient patient numbers to further assess the reasons why suboptimal treatment was more likely in the older age groups.
Age of Symptom Onset
Number of Patients
Number of Patients Receiving Optimal Treatment
10-30y
21
14 (67%)
30-50y
32
17 (53%)
50+ y
10
4 (40%)

Table 3: Table showing age of symptom onset and the percentage of each receiving optimal treatment.

Chart 2: Chart showing the reasons for suboptimal treatment of patients with FND

Table 4: The percentage of FND patients in each age group that received optimal treatment.
Age of Symptom Onset
Percentage Receiving Optimal Treatment
10-30y
14 (66%)
30-50y
17 (53%)
50+ y
4 (40%)

Patient improvement was recorded in 19 cases, and patients were classed as either improved or not improved (table 5). Nineteen patients were reported to have shown improvement in their symptoms.Audit of Treatment of Functional Neurological Disorder Essay.  No attempt was made to grade the improvement.

Table 5: The number patients with FND in each treatment group whose condition improved
Treatment group
Number Improved
1
12/36 (33%)
2
7/27 (26%)
Total
19 /63 (30%)

Patients were divided into five groups based on the duration of their symptoms and the percentage of patients in each group who had shown improvement in clinical signs is shown in chart 5. The highest proportion showing improvement in symptoms was found in those who had been symptomatic for 16-20 years (chart 5).

Chart 3: The percentage of patients with FND who showed improvements in their symptoms in each of the duration of disease groups.

Discussion
This audit analysed a small number of FND patients from NHS Tayside to assess the treatment delivered and identify any trends in improvement. 56% of patients received the optimal treatment and 44% did not.

There were several limitations within the data collection process. In order to mark a patient as having improved, either a reduction in severity or frequency of symptoms needed to have been documented. A lack of written evidence suggesting this had occurred resulted in an assumed lack of improvement. Future audits should have a more objective way of measuring this factor instead of relying upon notes which are often incomplete or inconsistent. It may also be useful to look at the timings of treatment as patients with a long history of symptoms may not have received all aspects of care throughout the duration of disease and this may therefore not constitute optimal practice.

Physiotherapy was the main constituent of the treatments not offered. This may be due to either a lack of recognition of the importance by clinicians or a lack of sufficiently trained physiotherapists. It may be easier to implement a physiotherapy regime when more guidance is available about the duration, indication and programme of therapy that should be given.

The medication category was very vague as it only assessed prescription of either anti-depressant or anxiolytic drug. There may be specific drugs within these categories that are more efficacious and appropriate than others. In order to further identify the role of medication in the treatment of FND, a study should be carried out with a larger cohort and should segregate patients depending on their specific drug treatment. Audit of Treatment of Functional Neurological Disorder Essay.

NHS Tayside covers a wide area and the patients had a wide variety of backgrounds and mental illnesses. There are many factors that are used to decide which psychological service is best placed to serve each patient. Research suggests that CBT is the most effective type of intervention for this disorder but this audit was unable to assess the programme that each patient underwent. This study found that patient compliance was also an issue as many people were very sceptical about the role of the psychologist in the treatment of their neurological symptoms. Although this study was small, it found that a quarter of male patients declined or did not engage with psychological therapy. This could be related to stigma, particularly among older men, or denial about the probably emotional trigger of their symptoms.

It is interesting to note that the percentage improvement in patients receiving best practice is only 7% higher than those who were lacking one or more treatments. It may be that the best practice should be re-evaluated or take other factors into account; such as patient acceptance of diagnosis, concordance with treatment, patient willingness to engage.

It is widely recognised that a complete reduction in symptoms (cure) is difficult to achieve and this outcome becomes less likely as time goes on. However in this study it was shown that the percentage improvement increases with duration of symptoms up to 20 years. There are a number of possible explanations for this. The longer a patient has been diagnosed, the more exposure they will have had to healthcare professionals to reassure and explain the disease. A better understanding of FND may reduce anxiety and mistrust, leading to a better rapport between healthcare professionals and the patient. Waiting times for clinics, psychology and physiotherapy can be long and it may be that the delay in receiving treatment contributes to the lack of improvement of patients with a shorter duration of symptoms. Audit of Treatment of Functional Neurological Disorder Essay. Finally, it may be a lack of evidence of improvement due to fewer notes, less detailed notes or reduced self-reporting from patients who have been symptomatic for less time.

This was a retrospective audit to assess the treatment of functional neurological disorders in Tayside. The small population size and lack of objective measurement method preclude any definitive judgement on trends. The data should be investigated further before being deemed significant.

Recommendation
• More thorough notes relating to improvement/consistency/worsening of symptoms
• It may be worth considering a simple questionnaire for patients to fill out about the frequency and severity of their symptoms – this could be completed before or during the clinic
• Further research should be carried out to find the most efficacious drugs
• Further research should be carried out to define the role of physiotherapy in treatment and the most suitable programme

Appendix

Patient Number
Sex
Age
FND Manifestation
Duration of Symptoms
Psychological Treatment
Medication
Physiotherapy
Optimal Treatment
Improvement
Appendix A: data collection template.

References:
1. Feinstein A e. Psychiatric outcome in patients with a psychogenic movement disorder: a prospective study. – PubMed – NCBI [Internet]. Ncbi.nlm.nih.gov. 2001 [cited 9 February 2019]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/11513100?dopt=Abstract

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2. Wessely S, Nimnuan C, Sharpe M. Functional somatic syndromes: one or many?. The Lancet [Internet]. 1999 [cited 9 February 2019];354(9182):936-939. Available from: https://www.sciencedirect.com/science/article/pii/S0140673698083202
3. Espay A, Goldenhar L, Voon V, Schrag A, Burton N, Lang A. Opinions and clinical practices related to diagnosing and managing patients with psychogenic movement disorders: An international survey of movement disorder society members. Movement Disorders [Internet]. 2009 [cited 9 February 2019];24(9):1366-1374. Available from: Audit of Treatment of Functional Neurological Disorder Essay. https://onlinelibrary.wiley.com/doi/full/10.1002/mds.22618
4. O’Malley PG e. Antidepressant therapy for unexplained symptoms and symptom syndromes. – PubMed – NCBI [Internet]. Ncbi.nlm.nih.gov. 1999 [cited 9 February 2019]. Available from: https://www.ncbi.nlm.nih.gov/pubmed/10628579?dopt=Abstract
5. Goldstein L, Chalder T, Chigwedere C, Khondoker M, Moriarty J, Toone B et al. Cognitive-behavioral therapy for psychogenic nonepileptic seizures: A pilot RCT. Neurology [Internet]. 2010 [cited 9 February 2019];74(24):1986-1994. Available from: http://n.neurology.org/content/74/24/1986?ijkey=51a9f300b32eed3c36e164a79fb5df1f214336ca&keytype2=tf_ipsecsha
6. Kim C, Kim B, Ryu W, Lee S, Yoon B. Impact of smoking cessation on the risk of subarachnoid haemorrhage: a nationwide multicentre case control study. Journal of Neurology, Neurosurgery & Psychiatry [Internet]. 2012 [cited 9 February 2019];83(11):1100-1103. Available from: https://jnnp.bmj.com/content/83/6/655?ijkey=53b62d5a453b6143133f0a0506c9d83e0a2f5262&keytype2=tf_ipsecsha. Audit of Treatment of Functional Neurological Disorder Essay.