Tales of functional neurological disorder from the ED

Patients with a functional neurological disorder (FND) are increasingly presenting to the EDs, posing unique challenges for initial assessment and management.1 This article aims to highlight the diversity of FND presentations, emphasising the importance of thorough initial evaluation and the need for prompt, multidisciplinary intervention. By exploring various case studies, we will demonstrate effective strategies for early management and the critical role of involving appropriate specialist teams to ensure optimal patient outcomes. A 21-year-old female presented to the ED 1 week following a minor neck injury from a low-speed motor vehicle accident. At the time of the incident, she had mild neck stiffness and discomfort, and underwent a CT cervical spine which was normal. She now represented, reporting the sudden onset of severe neck pain with associated paraplegia and paraesthesia from the waist down after rapidly turning her head, and hearing a 'pop'. She had no significant medical history, prior history of similar presentations, or mental health diagnoses. She took no regular medications and denied illicit drug use. She reported some increased work stresses, but no additional stressors otherwise. On examination, she was in obvious pain and distress. A neurological assessment demonstrated patchy sensory and motor deficits in both lower limbs that did not align with a single myotomal or dermatomal pattern. A rectal examination revealed absent anal tone. Deep tendon reflexes in the lower extremities were diminished, and Babinski's sign was bilaterally equivocal. A CT spine was obtained on advice from the Orthopaedic spinal team while awaiting MRI. The CT was reported as normal, and the patient was observed in ED overnight with no change in her symptoms. Subsequent MRI spine was also normal. In the absence of organic findings, and given the non-anatomical distribution of sensory and motor deficits, a FND was diagnosed. The patient was admitted by Neurology, educated about the diagnosis, and received multidisciplinary team (MDT) input, including psychology for cognitive-behavioural therapy and physiotherapy. She spontaneously recovered with no residual deficits during admission. She was discharged with ongoing outpatient therapy. In summary, FND can present with dramatic neurological symptoms that at times, do not align with typical anatomical patterns.2 The diagnosis is usually clinical, supported by the absence of structural abnormalities on imaging and inconsistencies in the neurological examination.3 Furthermore, it is important to note that many neurological conditions may have normal structural imaging.2 A 29-year-old male presents from a community mental health clinic with seizure-like activity. He had travelled from interstate for the first part of his gender reassignment appointment. He had a known history of functional seizures, well managed by his private neurologist. He had an in-depth understanding of his condition and its triggers, including stress and anxiety, and was in a supportive relationship with his partner, who was similarly well-educated on functional seizures and could manage his episodes. Upon arrival to the ED, the patient was observed to have 3 min of tonic–clonic activity. However, the movement pattern did not align with epileptiform seizure activity: he was noted to have closed eyelids with guarding to corneal touch, no tongue biting, and no incontinence. There were intermittent pauses in the movements during the 3 min, and no post-ictal state. The patient advised this was consistent with his functional seizures. He had no significant physical examination findings, and no residual neurological deficits. Laboratory findings were unremarkable, including normal sodium and glucose. The patient received diazepam for its anxiolytic effect. Given his history and understanding of functional seizures, further investigations for new-onset epilepsy were deemed unnecessary at this time. He was observed for 4 h in ED, with no further seizure-like activity. He was discharged into the care of his partner and advised to follow up with his own neurologist and mental healthcare providers for ongoing management of functional seizures and stress related to his transgender care. Although this case highlights emotional stress causing an exacerbation of an underlying FND, it is important to take note that FND should not be diagnosed just on the basis of recent stress. Clinical features of other pathologies have also been known to increase in times of stress, for example, movement disorders, multiple sclerosis or epilepsy. A 36-year-old female presented with 1 week history of worsening focal seizures characterised by intermittent left shoulder spasms. These episodes lasted 10–30 s and resolved spontaneously. The patient had a history of right-sided temporal lobe epilepsy, currently taking sodium valproate. Her usual semiology included shoulder spasms, similar to those experienced currently. She reported no obvious triggers for lowering her seizure threshold but had noted polyuria and polydipsia. She had no other medical history. Her physical examination was unremarkable, other than observable intermittent left shoulder spasms while fully conscious and aware of these occurring. Bedside tests showed a urine dipstick positive for glucose, a negative beta-hCG and a blood sugar level (BSL) of 26 mmol/L. She was initially admitted under General Medicine as it was suspected newly diagnosed type 2 diabetes mellitus was contributing to a decreased seizure threshold. During admission, her BSLs were stabilised, and she received comprehensive diabetes education, with planned community follow-up with a diabetic educator for ongoing lifestyle changes. Neurology was consulted for ongoing seizure management, and advised commencing clobazam during her acute illness. However, her EEG did not reveal epileptiform activity during observed spasmodic episodes, prompting a diagnosis of FND. An MDT approach was engaged with Neurology and Psychiatry providing education into her neurological disorder. She experienced improvement in her seizure-like activity prior to discharge. This case underscores the complexity of managing patients with concurrent epilepsy and FND, highlighting that functional episodes can occur in individuals with an epileptiform seizure disorder.4 Effective management requires an MDT approach to address both neurological and psychological aspects of the condition.5-7 The cases presented highlight the diverse manifestations and complexities of FND and underscore several critical learning points for effective management. FND can present with a wide range of symptoms that often do not follow typical anatomical or physiological patterns, making diagnosis challenging. Effective management requires a multidisciplinary approach, including neurology, psychiatry, physiotherapy and psychological support.2, 5-8 Education and support for both patients and their families is crucial in managing triggers, preventing unnecessary hospital visits and maintaining functionality and well-being in society. None declared.