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I read the article entitled "Patients with Parkinson disease are prone to functional neurological disorders" by Hallett M published in the Journal of Neurology, Neurosurgery and Psychiatry (Published Online First: 16 March 2018. doi: 10.1136/jnnp-2017-317684). I want to congratulate the author for this successful article, and make some contributions.
The article particularly mentions certain aspects of the clinical presentation, medical history and examination of patients, which should raise the suspicion of a functional disorder (1). I think it is important to remember patients with functional disorders will not always adhere to these criteria and clinicians should perhaps consider trialling suspected patients on either cognitive behavioural therapy (CBT) or physiotherapy to assess if they experience any improvement with these strategies. There is increasing evidence to show CBT and physiotherapy are beneficial for patients with functional disorders, hence they may be useful in confirming the diagnosis (2)(3).
Furthermore, the author suggests patients with functional symptoms and no sign of Parkinson's Disease should not be pursued further for a diagnosis of Parkinson's Disease. I think a difficulty is often deciding what classifies as a sign of Parkinson's Disease. The cardinal symptoms of bradykinesia, resting tremor, muscular rigidity and postural instability are commonly subtle within patients, making...
Furthermore, the author suggests patients with functional symptoms and no sign of Parkinson's Disease should not be pursued further for a diagnosis of Parkinson's Disease. I think a difficulty is often deciding what classifies as a sign of Parkinson's Disease. The cardinal symptoms of bradykinesia, resting tremor, muscular rigidity and postural instability are commonly subtle within patients, making them a challenge to distinguish from normal limits. This is made even more difficult if a functional disorder is also suspected. Clinicians should therefore consider demonstrating reduced levels of the presynaptic dopamine active transporter (DAT) using a DaTscan, if available, to aid their diagnosis of Parkinson's Disease as the author suggests in another of their articles (4). Guidance surrounding the use of a DaTscan from the National Institute for Health and Care Excellence (NICE) does not currently account for this indication, however it may be worth considering for future recommendations (5).
1. Wissel BD, Dwivedi AK, Merola A, et al Functional neurological disorders in Parkinson disease J Neurol Neurosurg Psychiatry Published Online First: 16 March 2018. doi: 10.1136/jnnp-2017-317378.
2. Nielsen G, Stone J, Matthews A, et al Physiotherapy for functional motor disorders: a consensus recommendation J Neurol Neurosurg Psychiatry 2015;86:1113-1119.
3. Conwill M, Oakley L, Evans K, Cavanna A. CBT-based group therapy intervention for nonepileptic attacks and other functional neurological symptoms: A pilot study. Epilepsy & Behavior. 2014;34:68-72.
4. Hallett M. Psychogenic Parkinsonism. Journal of the neurological sciences. 2011;310(1-2):163-165. doi:10.1016/j.jns.2011.03.019.
5. National Institute for Health and Care Excellence. Parkinson’s disease in adults NICE guideline NG71 [Internet]. Nice.org.uk. 2017 [cited 12 April 2018]. Available from: https://www.nice.org.uk/guidance/ng71/chapter/Recommendations#diagnosing....