OBJECTIVE: To evaluate headache comorbidity in a cohort of patients with functional movement disorders by assessing the prevalence, clinical characteristics, and temporal relationship of headache with the onset of functional symptoms.
BACKGROUND: Functional movement disorders are common and potentially treatable. Although headache is frequent in these patients, few studies have evaluated their headache features.
METHODS: This observational cohort study included consecutive patients with functional movement disorders evaluated in our Functional Movement Disorders Unit between October 2021 and November 2022. Clinical and demographic features from clinical charts were reviewed, and patients completed a self-administered questionnaire designed by the authors that included headache characteristics, disease duration, treatments received, and the Headache Impact Test-6. Headache type was classified as per the Classification of Headache Disorders, third edition (ICHD-3).
RESULTS: A total of 51 patients with functional movement disorders were included. Of those, 40 (78%) reported having recurrent headache. Headache intensity was moderate-severe in 33/40 (83%), and about two-thirds experienced headache >9 days/month. Disability secondary to headache was high (median [interquartile range] Headache Impact Test-6 score 62 [49-66]). Based on the ICHD-3, 23/40 (58%) of patients with headache met the criteria for migraine or probable migraine, 11/40 (27%) for tension-type headache, two of 40 (5%) for new daily persistent headache, and one of 40 (3%) for primary exercise headache, while three of 40 (7%) were unclassifiable. The onset of headache occurred before the functional movement disorder in 28/40 (70%), after the functional movement disorder in five of 40 (12%), and simultaneously in six of 40 (15%). In this last group, four of the six (67%) patients described a daily headache from the onset, and two met the criteria for new daily persistent headache.
CONCLUSIONS: Headache is a frequent condition in patients with functional movement disorders and an additional burden of disability beyond their motor symptoms. We found that, besides migraine and tension-type headache, new daily persistent headache may be a comorbid phenotype in patients with functional movement disorders and should be further studied in larger prospective studies.

UNASSIGNED: Functional neurological disorders (FNDs) are increasingly recognized in the general population and neurology clinics, and there is evidence that patients with neurological disorders are more likely to have a FND. This study was designed to identify the clinical features of FNDs among patients with movement disorders when the two disorders coexist.
UNASSIGNED: The clinical histories and video recordings of 150 consecutive patients with tremors were examined: the types of tremor included essential tremor; essential tremor plus; dystonic tremor; tremor associated with dystonia; and drug-induced, myoclonic, orthostatic, task-specific, parkinsonian, Holmes, and unclassified tremor. Using criteria for \"possible\" and \"probable\" coexistent FND, clinical features that helped differentiate between functional and other neurological tremors were identified.
UNASSIGNED: There were 27 (18%) patients with functional manifestations, and 17 (11% of full sample) of these patients had signs suggestive of comorbid functional tremor. Patients with comorbid functional manifestations were younger at presentation, and these patients had greater severity of tremor, particularly upper limb postural tremor. Functional manifestations were not more commonly observed among patients with any particular type of tremor, except for patients with Holmes tremor, who were more likely to have comorbid functional neurological manifestations.
UNASSIGNED: About 18% of patients with diverse types of tremors also had comorbid functional neurological manifestations. Of the coexistent FNDs, functional tremor was the most common. Patients with co-occurring functional and other neurological tremors presented for evaluation at a younger age and had greater severity of arm tremor than those without comorbid functional neurological manifestations.

BACKGROUND: Since the COVID-19 pandemic, movement disorder clinics have seen an increase in patients with an unusual type of tic-like symptoms: young adults with abrupt onset complex behaviors. It was quickly suspected that these patients suffered from functional neurological symptoms, later named Functional Tic-Like Behaviors (FTLB). Subsequent research on the differential diagnosis between FTLB and tics has been substantial and led to the development of diagnostic checklists.
OBJECTIVE: We conducted a theoretical reappraisal of the FTLB literature to clarify the validity of the concept and its diagnostic implications.
METHODS: This paper addresses several key aspects of the current FTLB literature: circular reasoning, the complications of the FTLB phenomenology and demographics, the impact of FTLB on tic literature at large, and issues with alignment of the FTLB concept with the diagnostic criteria for functional disorders.
RESULTS: The clinical approach to FTLB might involve circular reasoning due to a lack of clinical benchmarks. The FTLB phenomenology and demographics may need more work to ensure a lack of bias and a proper description of this patient group including a clear distinction from tics. The impact of the FTLB discussion on the wider literature needs consideration. The validation of positive signs may help with both these endeavors and pave way to the inclusion of FTLB within psychiatric classification systems. Furthermore, the coexistence of FTLB and tics within the same patient needs to be addressed.
CONCLUSIONS: More research may be needed to fully establish the diagnosis of FTLB and differentiate it from tics.

OBJECTIVE: To compare persons with epilepsy (PWE) to those with psychogenic non-epileptic seizures (PNES) on measures of depression, anxiety, and alexithymia subscales (i.e., difficulty identifying emotions, difficulty describing emotions, and external-oriented thinking).
METHODS: In this retrospective study, 235 epilepsy patients and 90 patients with PNES were evaluated between 2012 and 2020 at the Northeast Regional Epilepsy Group. These patients had completed the Toronto Alexithymia Scale (TAS-20), The Center for Epidemiologic Studies - Depression Scale (CES-D) and The State-Trait Anxiety Inventory (STAI). Background information was collected regarding work/student/disability status at the time of the evaluation history of psychiatric diagnosis; psychological trauma; and involvement in psychotherapy either at the time of the evaluation or prior.
RESULTS: Significant differences between PWEs and those with PNES were found not only in historical data (e.g., Psychiatric History, History of Trauma, and History of Therapy) (p < .001) but also on measures of Depression (p = .002) and Anxiety (p < .001). ANOVA analysis also revealed significant differences in the distribution of the TAS-Total score, TAS-Describing emotions, and TAS-Identifying emotions. Using logistic regression (stepwise model) the optimal set of predictors for a differential diagnosis of epilepsy and PNES was combination of TAS-Identifying emotions score, history of psychological trauma, and history of therapy. The accuracy of the prediction was determined to be 80.2 %.
CONCLUSIONS: Although higher alexithymia rates are present in PNES and PWEs, clinicians may find a combination of TAS-Identifying Emotion score, history of trauma, and history of psychotherapy useful in supporting a differential diagnosis. Also, a subgroup may exist among those with PNES with high levels of alexithymia, depression, and anxiety that may require a different treatment approach focused on addressing difficulties in identifying and describing their emotions and their other symptomatology.

OBJECTIVE: We investigated perceived invalidating environment during childhood and stress-coping strategies in patients with; functional dissociative seizures (FDS, n=26), drug-resistant epilepsy patients with no psychiatric comorbidity (DREnc, n=23), and drug-resistant epilepsy patients with psychiatric comorbidity (DREpc, n=34).
METHODS: We performed a cross-sectional study. Patients underwent Video Electroencephalography to confirm the diagnosis and completed a psychiatric assessment supported by clinical instruments. Invalidating environment and stress coping were studied through the ICES and CAE questionaries, respectively. A series of multinomial logistic regression analyses were performed with the explored variables.
RESULTS: The maternal negative response model predicted a higher probability of FDS condition. A chaotic family type increased the likelihood of DREpc instead of FDS. DREpc and FDS patients displayed many different behaviors to cope with stress other than trying to solve the problem, the most used strategy in the DREnc group. Parental invalidation was higher in DREpc than in FDS.
CONCLUSIONS: Our results deepen the data provided by previous studies indicating that multiple variables of biosocial origin have significant effects on these groups of patients. The presence of an invalidating environment may predict FDS but also the presence of psychiatric disorders among DRE. Psychotherapeutic strategies to enhance these variables might be necessary for this population.

Functional Neurological Disorders (FNDs) are characterized by the symptoms experienced by the individuals but also by how they express personal experiences and concerns related to the clinical condition. Access to care programs for functional neurological symptoms appears challenging and may entail circular, self-perpetuating healthcare pathways. Given the challenging and misleading interpretations around FND, in advocating for care pathways beyond medical therapies, we designed a scoping review to map recently suggested practices and interventions. We identified 31 relevant papers published between January 2018 and December 2022. Most of the literature was gathered from the US and UK healthcare experiences, with documented interventions provided by multi-professional teams or stand-alone psychotherapists. We found different care pathways addressing either motor or non-motor manifestations. Persons with Functional Motor Disorder are more likely to be referred to physical therapy first, while Persons suffering from Non-Epileptic Seizures are to mental health services. A narrow focus was given to minor components of multimodal approaches (e.g. social workers, and occupational therapists). High heterogeneity was found between assessment instruments as well, reflecting different perspectives in selecting treatment outcomes (e.g., reduction of non-epileptic events, psychological functioning, motor symptoms). Among healthcare professionals, neurologists and (neuro)psychiatrists are typically engaged in formulating and delivering diagnoses, while treatment is often administered by physiotherapists and/or psychologists. In the context of FNDs, the complex etiopathological nature of the condition, including comorbidities, suggests the recommendation of multidisciplinary treatments adopting a stepped care model progressing from standard to higher level individualized modules may better suit individual complexities.

We introduce here a general model of Functional Neurological Disorders based on the following hypothesis: a Functional Neurological Disorder could correspond to a consciously initiated voluntary top-down process causing involuntary lasting consequences that are consciously experienced and subjectively interpreted by the patient as involuntary. We develop this central hypothesis according to Global Neuronal Workspace theory of consciousness, that is particularly suited to describe interactions between conscious and non-conscious cognitive processes. We then present a list of predictions defining a research program aimed at empirically testing their validity. Finally, this general model leads us to reinterpret the long-debated links between hypnotic suggestion and functional neurological disorders. Driven by both scientific and therapeutic goals, this theoretical paper aims at bringing closer the psychiatric and neurological worlds of functional neurological disorders with the latest developments of cognitive neuroscience of consciousness.

OBJECTIVE: Chronic Idiopathic urinary retention is poorly understood. One small study suggests higher than expected rates of functional neurological disorder and pain comorbidity which may have implications for understanding the disorder. We investigated the frequency of functional neurological disorder, chronic pain other medical and psychiatric comorbidity, triggers of urinary retention, results of urodynamic assessment, medication history, management, and outcome in patients with chronic idiopathic urinary retention.
METHODS: A consecutive retrospective electronic notes analysis was undertaken of patients with chronic idiopathic urinary retention presenting to a secondary care urology clinic between Jan 2018-Jan 2021, with follow-up to their most recent urological appointment.
RESULTS: 102 patients were identified (mean age of 41.9 years, 98% female). 25% had functional neurological disorder (n = 26), most commonly limb weakness (n = 19, 19%) and functional seizures (n = 16, 16%). Chronic pain (n = 58, 57%) was a common comorbidity. Surgical and medical riggers to urinary retention were found in almost half of patients (n = 49, 48%). 81% of patients underwent urodynamic assessment (n = 83). Most frequently no specific abnormality was reported (n = 30, 29%). Hypertonic urethral sphincter was the most identified urodynamic abnormality (n = 17, 17%). We noted high levels of opioid (n = 50, 49%) and benzodiazepine (n = 27, 26%) use. Urinary retention resolved in only a small number of patients (n = 6, 6%, median follow up 54 months), in three cases spontaneously.
CONCLUSIONS: This preliminary data suggests idiopathic urinary retention is commonly comorbid with functional neurological disorder, and chronic pain, suggesting shared mechanisms.

BACKGROUND: We performed this study to improve understanding of the relationship between functional tic-like behaviors (FTLBs) and quality of life, loneliness, family functioning, anxiety, depression, and suicidality.
METHODS: This cross-sectional study assessed self-reported quality of life, disability, loneliness, depression, anxiety, family functioning, tic severity, and suicide risk in age- and birth-sex matched youth with FTLBs, Tourette syndrome (TS), and neurotypical controls. We performed specific subanalyses comparing individuals with FTLBs who identified as transgender/gender diverse (TGD) with cisgender individuals.
RESULTS: Eighty-two youth participated (age range 11 to 25, 90% female at birth), including 35 with FTLBs, 22 with TS, and 25 neurotypical controls. A significantly higher proportion of participants with FTLB identified as TGD (15 of 35) than TS (two of 22) and neurotypical control (three of 25) participants. Compared with neurotypical controls, individuals with FTLBs had significantly lower quality of life, greater disability, loneliness, social phobia, anxiety symptoms, depressive symptoms, and suicidality. Compared with individuals with TS, individuals with FTLBs had more school/work absences due to tics, had more depressive symptoms, were more likely to be at high risk for suicidality, and had disability in self-care and life activity domains. There were no significant differences between cisgender and TGD participants with FTLB in any of the domains assessed.
CONCLUSIONS: Youth with FTLB have unique health care needs and associations with anxiety, depression, sex, and gender.

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