Functional Movement Disorders: Diagnosis & Management

Podcast Transcript

Intro: Neuro Pathways, a Cleveland Clinic podcast, exploring the latest research discoveries and clinical advances in the fields of neurology, neurosurgery, neuro rehab, and psychiatry.

Glen Stevens, DO, PhD: Patients with functional movement disorders represent one of the more common disorders referred to the modern neurologic clinic. Despite its prevalence, the mechanisms underlying functional movement disorders remain poorly understood. In today's episode of Neuro Pathways, we'll discuss managing patients with functional movement disorders. I'm your host Glen Stevens, neurologist, neuro-oncologist in the Cleveland Clinic's Neurologic Institute. I'm very pleased to have doctors Xin Xin Yu and Taylor Rush join me for today's conversation. Dr. Yu is a staff neurologist in the Center for Neurological Restoration and co-director of The Functional Movement Disorders Clinic in Cleveland Clinic's Neurological Institute. Dr. Rush is a clinical health psychologist and co-director of The Functional Movement Disorders Clinic in Cleveland Clinic Center for Neurological Restoration. Xin Xi, Taylor, welcome to Neuro Pathways.

Xin Xin Yu, MD: Thank you for having us.

Taylor Rush, PhD: Yes. Thank you.

Glen Stevens, DO, PhD: We'll start with Dr. Yu. Functional movement disorder can be a complex diagnosis for both patients and clinicians alike. Given that's the case, can you start off today's conversation by explaining for our listeners how your team diagnosis patients with functional movement disorder.

Xin Xin Yu, MD: Glen, in the last 10 years, our understanding and approach to functional neurological symptom disorder in general have really evolved. They're having major and important changes in the DSM-5 criteria for FMD. As you know, traditionally viewed as a primarily psychological disorder, now a psychological stressor is no longer required to make the diagnosis. Another important change is that it is no longer a diagnosis of exclusion, but rather a routine diagnosis that can be accurately made based on clinical signs that are inconsistent and incongruent with other known neurological disorders. We really rely on assessing for those clinical features that are unique to FMD, such as distractible or entrainable tremor, give away weakness, Hoover's sign, sensory loss that doesn't follow any anatomical or physiologic pattern, et cetera.

Glen Stevens, DO, PhD: Certainly historically the diagnosis of functional movement disorder has been one of exclusion rather than inclusion. Can you describe some of the unique challenges or concerns that physicians may face when diagnosing patients with functional movement disorders?

Xin Xin Yu, MD: I think with these changes in the diagnostic criteria, we're actually now more empowered and more confident in making a diagnosis than comparing the past as it was really impossible nor cost-effective to rule everything out based on the prior DSM-4 criteria. Now we can rely on identifying these positive clues that are unique to FMD, but there's still a concern or fear that many providers share with us that once committed to the FMD diagnosis, we may be missing on other possibilities. However, longitudinal studies in FMD research tell us otherwise. When FMD patients are followed over time, changes in the diagnosis occurs rarely, meaning that mistakes are actually uncommon, but we believe that FMD patients should be monitored over time by neurologist to reinforce the education, to be able to track their treatment progress as well as look for any other clinical signs that may emerge that may indicate an alternative diagnosis.

Glen Stevens, DO, PhD: I expect that presenting a functional movement disorders diagnosis to a patient needs to be handled delicately. How do you approach this in your practice?

Xin Xin Yu, MD: I think empathy is really the key; building a therapeutic alliance through active listening, providing validation of their symptoms and taking the time to explain the condition in simple language really lays the foundation to help patients to understand the problem, accept the diagnosis, and also to adhere to treatment plans. Sometimes patients are rather relieved to hear that there is a name to their condition and potential treatment.

Glen Stevens, DO, PhD: I think this is an excellent opportunity to bring Dr. Rush into the conversation. FMD is commonly encountered in the movement disorders clinic has just discussed and treatment often requires interdisciplinary care. Dr. Rush, can you describe how your team manages these patients and your typical course of treatment?

Taylor Rush, PhD: Typically, patients present to me after they have been diagnosed with FMD. Oftentimes either by Dr. Yu or one of our other neurologists who strongly suspects this diagnosis. When patients come in to see me, it can sometimes be a little precarious at first because they'll say, I don't know why I'm here. I think perhaps my neurologist thinks that this is all in my head. They often aren't real sure how to approach me. I usually start out by saying that I'm a part of your treatment team. We know that you are a person and you're not just a set of symptoms that are presenting to clinic. When you're dealing with symptoms like these, it can affect your mental health as well as your physical health. I'm here to be able to teach you the right tools to help manage these symptoms as best as possible so that you can have the best quality of life as possible.

My approach to treatment is typically cognitive behavioral therapy. This is, in the simplest terms, how do our thoughts, feelings and behaviors all affect one another? How do we better understand how people respond to their symptoms? What goes on in their mind when they start to experience their symptoms? For many, it's that there's a lot of bells and whistles that are going off because they see it as a threat. They see it as dangerous and they see it as something that they can't control. We try to work on ways to appraise those symptoms differently so that they see them as less of a threat and are able to manage them a bit more effectively. We work on that.

We work on stress management. I tell all of my patients that I'm not here to tell you that stress caused your symptoms, but I've really yet to encounter a condition that stress makes better. If we can manage your stress, we can likely take a layer off of how these symptoms affect you. We talk about triggers, because for a lot of people there may be environmental or their sensory triggers for their symptoms. How do we manage some of those triggers, or how do we slowly desensitize people to those triggers? We work on relaxation strategies, mindfulness strategies, sleep hygiene strategies, how they can better pace their activities so that they're not over extending or under extending themselves as well as sometimes creating better boundaries and implementing assertive communication with friends, family, coworkers, so that they feel as empowered as possible to move forward with their best life.

Glen Stevens, DO, PhD: It sounds like having a clinical health psychologist integrated early into the treatment regimen is an excellent idea. Anything else with your multidisciplinary approach? Do you do a back and forth with the clinicians? Is there anyone else involved specifically in the interdisciplinary team?

Taylor Rush, PhD: Yes, absolutely. The team expands or contracts depending on the patient's needs. The three legs to the stool that are typically involved include myself, Dr. Yu, and one of our trained physical therapists. I think that the physical therapy and the behavioral therapy go very well hand-in-hand because we're working on ways to help people manage these symptoms, and sometimes anxiety can get in the way of them making progress in PT, and sometimes they need to work on some of the strategies that they're using in behavioral therapy in physical therapy. They work in tandem quite well.

Then depending on the patient and what types of symptoms they're having, we can also include occupational therapy, speech therapy. There've been some patients who've been very interested in integrative medicine type interventions with diet and other things, so we've looped them in as well for some of our patients. We really want to make sure that we stay as connected as possible to all the right providers. We are in constant communication through our electronic medical records, through phone calls, through emails, through pages so that we can all stay seamlessly involved in this patient's care

Glen Stevens, DO, PhD: COVID has been a challenge to all of us. It seems like examining patients is very important in the diagnosis and then management of these patients. Could either of you talk about your challenges with managing FMD patients during COVID and telemedicine?

Xin Xin Yu, MD: Yes. In the very beginning, when the pandemic began, it was difficult to maintain that close relationship with our patients who often are from different states, difficult to come in due to the concerns for infection. However, we also used the pandemic as a catalyst to help really facilitate the development of a virtual platform called the Virtual Shared Medical Appointments. We began that particular service since July, and we have been doing that twice a month for both clinical assessment and also education opportunities. These are 90 minutes sessions conducted online using Cleveland Clinic's MyChart Zoom application. We find that it allows us to provide a patient with more education, and also it is a powerful platform to have patients to see, hear and share with each other their stories, which often can be difficult to achieve in real life. We realize that these patients often feel marginalized, especially during this difficult time with COVID. We started this service to try to provide additional access for them.

Glen Stevens, DO, PhD: Dr. Rush, comments about how it's affected you in your practice?

Taylor Rush, PhD: I would definitely concur with Dr. Yu that the virtual SMAs have been a wonderful way for us to not only remain connected with our patients, but for them to be able to connect with each other. For my practice specifically, I think I'm actually busier because of what virtual platforms have allowed. I oftentimes would have to refer folks to providers nearby where they lived, and that may be in Cincinnati or Dayton, because they're not going to drive three to four hours to come see me, but now they're like, Oh, you're just a Zoom call away. I would much rather follow up with you given that you specialize in this.

At this point, I would say that it's actually made my practice busier. Whereas before, I think we're all a little wary of some of the virtual visits and how well can it replicate some of what we do in person. While it's definitely different, I think for a lot of people they've kind of gotten over that fear and now virtual communication is just so ingrained in what we do because of everything that's happened that most people actually are very comfortable with it. I hope that that continues well after COVID so that we can continue to reach people in a way that we didn't before.

Glen Stevens, DO, PhD: Good. From your personal perspective, what do you feel are some of the biggest challenges with diagnosing and treating patients with FMD?

Xin Xin Yu, MD: There is a very wide spectrum of phenotypes for functional neurological symptom disorder. We often see the functional movement disorder subtype because Dr. Rush and I are working in the Movement Disorder Clinic. However, patients with FMD can present to epilepsy, multiple sclerosis teams, stroke services, and not uncommonly, we also have encountered patients with FMD who also have other underlying organic neurological disorder. To name a few, Parkinson's disease, epilepsy. It does become a little bit more complicated when two different conditions co-exist.

We find that there often is this natural tendency to focus on treatment of the organic condition and place less emphasis on the functional component. Maybe the lateral may have been viewed as not real or perhaps less serious, but we often see the functional components either as disabling or many times more debilitating than the organic counterpart. We feel strongly that both conditions must be assessed and deserve equal attention. That's one of the challenges and one of the things to consider and really crucial for patient's overall prognosis. One other common concern I hear is that how do I know the patients are not malingering? I wanted to touch upon that. Research shows that malingering is uncommon. Most FMD are very genuine. In our experience, some of our patients are among one of the most motivated group of patients. The often voice the desire to get better and really start living again.

Glen Stevens, DO, PhD: Most centers aren't fortunate to have a Dr.Yu and a Dr.Rush looking after their FMD patients, so we will see these patients at some point. Any key takeaways that you want providers like myself to take from this conversation as it relates to caring for patients with functional movement disorders?

Taylor Rush, PhD: One important takeaway is to ensure that providers listen to their patients. It's often the case that we are not someone's first evaluation. They've been evaluated in many other contexts with many other physicians and many patients come in feeling a bit jaded about the whole process because they don't feel like they get heard and that they're unable to really tell some of their story. I think that when patients come in and you're suspecting FMD, it is important to listen to what they're saying and validate what it is that they've been through, because that is what helps to get a foothold into the right treatments, because then they'll trust you. Even if you yourself don't treat FMD, you can at least be able to offer them a better direction than perhaps they would otherwise go if they didn't trust you. I do think that that is a key component to making sure that you can get those patients on the right track.

Glen Stevens, DO, PhD: Well, Xin Xin and Taylor, thank you very much for joining us. I really appreciate your time and insights today. Thank you.

Xin Xin Yu, MD: Thank you.

Taylor Rush, PhD: Thank you so much for having us.

Outro: This concludes this episode of Neuro Pathways. You can find additional podcast episodes on our website, ClevelandClinic.org/neuropodcast or subscribe to the podcast on iTunes, Google Play, Spotify, or wherever you get your podcasts. And don't forget you can access real-time updates from experts in Cleveland Clinic's Neurological Institute on our consult QD website. That's consultqd.clevelandclinic.org/neuro or follow us on Twitter @CleClinicMD, all one word and thank you for listening.