Multidisciplinary team management of functional neurological disorder in the community
We read with interest the Rixon et al.1 paper detailing her team's experience in dealing with patients with functional neurological disorder (FND) in a hospital setting. We congratulate the authors on their short but effective inpatient therapy programme.
The authors’ frustration regarding the lack of formal psychiatric and psychological input at such an early stage of presentation of FND was palpable throughout the article. Several reasons could explain this issue, such as the large numbers of FND patients, the relatively short duration of stay in the hospital and the lack of resources.
Despite the fact that just over half of the report's subjects had a history of psychological issues no details were provided to determine the relevance of such history, such as the severity of these conditions or their corelation with the presenting symptoms. We do not feel that a history of a relatively common mental health issue such as depression or anxiety requires specialist long-term management.
When we devised our local community based FND rehabilitation programme in Wigan, UK, our starting point was to try to minimise the number of clinicians involved in the management, as contradictory and confused messages can not only just lead to misunderstandings and confusion but may also erode patients’ confidence in the expertise of the team and hinder their ability to construct a valid conceptual framework for the condition.
The core team members are a consultant in rehabilitation medicine and an occupational therapist. As patients are usually already diagnosed by secondary care clinicians, our medical input explains the diagnosis using the hardware/software analogy to explain and validate patients’ symptoms, their impact and also to challenge any self-blame or guilt by patients, families or friends. Symptom management for common issues such as pain, migraines and mood disorders is provided by the medical consultant.
The significant life event preceding the symptoms in many cases is addressed within the context of the 3P model (predisposers-precipitators-perpetuators).2 Rixon et al. identified fatigue as a major perpetuator of the symptoms and our experience mirrors their findings. Such patients follow the trajectory of myalgic encephalomyelitis/chronic fatigue patients (ME/CFS) with a life stressor precipitating the symptoms and fatigue exacerbating the relapses with worsening of not just the neurological deficits but also the general postexertional symptoms such as brain fog, pain and headaches.3
We feel that the term ‘fatigue management’ can encompass several helpful interventions and strategies addressing physical, cognitive and emotional stressors. Occupational therapists (OTs) are uniquely placed to provide that role as their work on the cognitive and emotional dimensions of the disease is put within the physical and functional environment of patients making the input more coherent and goal focused.
We also feel that such one-to-one bonding with patients should forge a more trusting and fruitful relationship. Needless to say, an experienced OT with mental health or neurological rehabilitation experience is needed to provide such a complex therapy programme. The OT is able to use cognitive behavioural therapy approaches to start exploring common issues such as anxiety and depression and refer on to specialist services if further input is required.4
The two members of the team have access to other clinicians such as physiotherapists and mental health clinicians that patients can access for more specialist input if clinically indicated for more complex physical or mental health issues. Having said that, the focus of the rehabilitation programme is to provide patients with a clear understanding of the condition and how to manage such an (unfortunately) long-term condition on a daily basis.
