Management of patients with functional neurological symptoms
| Management stage | Suggested approach | References and further reading |
|---|---|---|
| Initial assessment | Demonstrate that you believe and are interested in symptom and severity | Craig,40 Williams and House,47 |
| Elicit history of other symptoms, previous contacts with health service | Page and Wessely,67 | |
| Find out what patient has been told about his symptom by other doctors | Creed and Guthrie,71 | |
| Elicit patient’s own beliefs about the symptom | Fink et al,106 | |
| Screen for significant psychiatric disorder (especially depression and anxiety) | Morriss et al108 | |
| Show interest in impact of symptoms on patients’ life | ||
| Ask about life events | ||
| Obtain history from partner/relative/friend if possible | ||
| Review previous clinical records if possible | ||
| Arrange appropriate tests (if necessary) | ||
| Communication of diagnosis | Admit uncertainty if investigations incomplete/inconclusive | Page and Wessely,67 |
| Clarify with the patient how structural disease has been excluded | Jackson and Kroenke,72 | |
| (taking account of patient’s specific health concerns) | Morriss et al,108 | |
| Reframe symptoms (“I can see that since you lost your wife….”) | Coia and Morley113 | |
| Give a positive explanation of the symptom | ||
| Convey the potential for substantial recovery | ||
| Be honest and direct with patents (copying clinic letters is a good | ||
| way of reiterating important issues) | ||
| Acute symptomatic therapy | Discuss potential acute/remote stressors | Richardson and Engel114 |
| Suggest that symptoms are likely to improve | ||
| Encourage activity rather than rest/consider physiotherapy | ||
| Psychiatric medication | Ask the patient’s view (will they take the tablets?) | O’Malley et al,98 Soloff,99 |
| Consider antidepressants even in the absence of overt | Stone et al102 | |
| depressive/anxiety symptoms | ||
| Explain length of treatment, possibly delayed effectiveness, | ||
| lack of addictive potential | ||
| Referral for psychological/ | Point out that reducing stress and learning ways of coping with symptoms | House115 |
| psychiatric assessment | are useful to all patients regardless of the nature of their symptoms | |
| Consider joint appointment | ||
| Be optimistic but avoid raising expectations to levels | ||
| which are likely to disappoint | ||
| Psychological management | Consider patient held treatment plan, or patient held records | Goldberg et al,73 Guthrie,85 |
| options | Identify goals for treatment | Bleichhardt et al,87 |
| Work on identifying predisposing, precipitating, and perpetuating factors | Sharpe et al,96 | |
| Look at potentially problematic patterns in interpersonal relationships | Roth and Fonagy,97 | |
| Identify ongoing life stressors | Fink et al,106 | |
| Identify and address patterns reinforcing abnormal behaviour | Morriss et al108 | |
| Reframe and reattribute the links between psychological factors and symptoms | ||
| Consider the use of specific psychotherapeutic techniques by those | ||
| with appropriate training (for example, cognitive behavioural and | ||
| analytical, interpersonal, behavioural psychotherapy) | ||
| Use appropriate evidence based psychological interventions | ||
| to treat anxiety and depression if present | ||
| Discuss relapse prevention | ||
| Consider goodbye letter to patients on completion of work | ||
| reinforcing issues discussed and recording progress made. |