Neuromodulation Using Computer-Altered Music to Treat a Ten-Year-Old Child Unresponsive to Standard Interventions for Functional Neurological Disorder

CASE HISTORY Marie-Therese, known as MT by family and friends, was a ten-year-old girl in Year 5 of primary school referred to the Mind-Body Program by a pediatrician for treatment of functional somatic symptoms—unsteady gait, blurry vision, periods of confusion or appearing dazed, and persisting headache—that had been triggered in the context of a viral illness. MT lived with her parents, a younger sister, and her grandmother. Both parents worked full time as architects. The family history included rheumatoid arthritis (mother), epilepsy (uncle), and type 2 diabetes (grandfather) on the mother’s side of the family, and colorectal cancer (grandfather) on the father’s side. MT had been diagnosed with celiac disease at age 6, which was being managed with a gluten-free diet. Presentation In the three weeks prior to referral, MT had been ill with a viral infection: a runny nose, sneezing, nasal congestion, and frontal headaches. In the second week of this illness, she developed blurriness in the right eye, neck stiffness, pain on eye movement, facial pain, lethargy, and anorexia. With a working diagnosis of partially treated meningitis, she was admitted to hospital for intravenous antibiotics (five-day course). A swab returned rhinovirus positive. In the third week of this illness, her headache persisted, the blurred vision spread to both eyes, and she developed additional neurological symptoms: unsteady gait and difficulty speaking (mumbling). Some days later she became confused, appeared “dazed” and slow to respond to the pediatrician’s questions, and developed slurred speech, right-hand weakness with an occasional tremor, right jaw twitching, and ongoing unsteadiness that required a walking frame for mobility. Routine bloods—full blood count, electrolytes, inflammatory markers, and thyroid function tests—were normal. A contrast-enhanced CT scan and an MRI were also normal, with an incidental finding of Chiari malformation (4 mm). A lumbar puncture was deemed potentially unsafe and therefore was not performed. A review by a neurologist yielded the diagnosis of functional neurological disorder (FND) and comorbid complex/chronic pain (see Text Box 1).*Text Box 1 Summary of MT’s Positive Rule-In Signs for Functional Neurological Disorder in the Neurology Examination Repeated neurology examinations with MT yielded positive rule-in signs—listed below—consistent with FND: •A very dramatic, sudden onset of symptoms, occurring spontaneously or in the context of an identifiable stressor—in this case rhinovirus infection and incidental finding of a Chiari malformation on CT. •Mixed neurological signs that were not clinically congruent in their origin. For example, MT’s unsteady gait was subsequently complicated by right-hand weakness, which became a right-hand tremor, which then reverted back to right-hand weakness (back and forth, back and forth, back and forth). •MT’s leg and right-arm weakness varied with distraction. •MT’s tremor could be entrained (made to follow a particular frequency), and it increased with attention and decreased with distractibility. •MT’s symptoms varied with distractibility. They were better when she was engaged in an activity she liked—for example, coloring in—and worse when her parents focused on the symptoms. Psychological Medicine Assessment with MT and Her Family The family assessment with our team—a child and adolescent psychiatrist, a clinical psychologist, and two pediatric trainees on their psychological medicine rotation—took place via telehealth in the midst of the COVID-19 pandemic. The family were seated in one clinic room, and each member of the team in a separate room. Developmental History: Summary of Key Issues MT’s early developmental history—in utero, delivery, developmental milestones in the first five years—were all unremarkable. MT had been an outgoing and happy preschooler. She underwent tonsillectomy and adenoidectomy when she was three years old and had been diagnosed with celiac disease at six years of age (Year 1 at school) after she had experienced persistent abdominal pain and was found to be anemic. MT also began to experience recurring headaches. MT showed an aptitude for learning, and her school reports described her as a conscientious and bright student. There was a history of school stress, beginning in Year 1 of school and continuing into Year 5. MT reported that her years at school had been made very stressful because her class had been ongoingly disrupted by children with behavioral problems (confirmed by MT’s school teacher). In this context MT also described her distress pertaining to a variety of issues: failing to receive acknowledgment from her teacher for working well (Year 1); the stress of a strict teacher constantly yelling at the class, making MT’s ears hurt (Year 2); loss of a close friend (who left that school), feelings of loneliness and exclusion, and experiences of being bullied (Year 3); the loss of her teacher, who left due to stress and was followed by multiple substitute teachers (Year 4); and teasing and bullying by a group of girls (Year 5). MT and her parents described how her stress level had dropped substantially (from 9/10 to 4/10) during the two months—during the pandemic—that she did schoolwork from home and engaged in extra tuition in preparation for selective school tests. Her stress level rose again (to 8/10) on returning to school. She became more withdrawn and had stopped talking to her parents—in particular, her mother—about her difficulties relating to school. Her headaches became severe, and she was admitted to hospital for review by a neurologist (including an MRI). In a parallel process, the family themselves had been stressed following the birth of MT’s sister (for MT, Year 3) because the sister suffered from severe colic followed by night terrors. Formulation The psychiatrist shared the team’s formulation at the end of the family assessment. She highlighted that in 50% of cases, FND was triggered by a physical stressor—such as a viral illness—and that MT’s presentation fit this pattern. She also acknowledged that MT had a long history of stress at school and that she had experienced stress-related headaches (see above). Using a visual metaphor the psychiatrist explained the current medical understanding of FND and comorbid pain (see Figure 1),2,3 adding that changes in cognitive function were seen in approximately 10% of pediatric cases and were understood to be related to the release of brain stress hormones and to hyperventilation.4 The psychiatrist noted that throughout the assessment, MT’s breathing rate had ranged from 30–50 breaths per minute (≥99th percentile).4,5 She also noted that MT had appeared very flat during the assessment (flat affect and slumped posture), and indicated that the team would further assess her mood and mental state more generally since comorbid depression and anxiety were common in FND.3 The psychiatrist told the family that with treatment, most young children achieved a full recovery.6 Finally, she discussed the treatment program in detail (see Text Box 2).7 MT was offered admission into the Mind-Body Program following the two-week break for school holidays.Figure 1: Visual representation of the formulation. In explaining the neurobiology of FND to MT and her parents, we used this visual metaphor alongside the following language: “The red ball represents the brain regions that underpin salience detection, arousal, and emotional states—the brain stress systems, for short. The pink ball represents brain areas involved in motor processing—motor-processing regions, for short. The yellow ball represents brain areas involved in sensory processing—sensory-processing regions, for short. The spikey ball represents pain-processing regions—pain maps, for short. When all is well, the brain stress systems get on with their job, as do the motor-, sensory-, and pain-processing regions, and they interact together in a balanced way. In FND the relationship between the brain stress systems and motor-, sensory, and pain- processing regions changes and becomes unbalanced. The brain stress systems become larger and stronger, and they disrupt motor and sensory processing and amplify pain.” © Kasia Kozlowska Box 2 Key of the Mind-Body Program for FND in the of physical to motor function and Psychological of to the child of and and to a in the of and distress to the child to her emotional to pain and stress a state of to with pain, the brain stress systems, and comorbid anxiety and depression Family with additional problems in family that be to the and of the stress therefore the the family in their anxiety and of and in that at parents to the program family school function and the FND MT made at home during the Her headaches worse as she to and she had developed the of In this context her parents and the family became that the diagnosis of FND was the Mind-Body Program not children diagnosis not been or parents do not the to be on the team the admission on and the family to from the neurologist and second from a second neurologist and a the included two additional to the because of MT’s symptoms of gait, back pain, difficulty and difficulties talking and a functional diagnosis of FND was at all included MRI of the and Mind-Body Program weeks after the family assessment MT was admitted into the Mind-Body Program (see Text Box MT was very (see Figure The of the admission was for MT, her parents, and the Visual representation of the time frame of MT’s constantly functional symptoms during the six of her illness. functional most children her MT to in all of the were for She was to in a generally had to in her or of her or was to her the the found it to with MT, to visual and to in The to MT her state (including of that functional to to in and to and as well as and sensory stress all MT in a state of that was in an rate and an of the to in rate on the Her of anxiety and mood became to her her to and was and to the the anxiety as to and to and MT in the of the school her as the teacher, who was used to with functional somatic symptoms, the from the symptoms. 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