Should patients with suspected conversion disorder (Functional Neurological Disorder, FND) presenting with facial droop, right-sided weakness, and abnormal gait be referred to a movement disorder specialist?

From the Guidelines

Patients with suspected conversion disorder presenting with facial droop, right side weakness, and abnormal gait should be referred to a neurologist, as the diagnosis of functional neurological disorder (FND) is made by a neurologist using 'positive clinical signs' and can be diagnosed alongside other neurological conditions 1. The referral to a neurologist is crucial because these symptoms can mimic serious neurological conditions like stroke, and a thorough neurological evaluation is necessary to rule out organic causes before confirming a diagnosis of conversion disorder. The neurologist will conduct a comprehensive assessment including a detailed neurological examination and may order appropriate imaging studies such as MRI or CT scans to exclude structural lesions. They may also perform specialized tests like electromyography (EMG) or nerve conduction studies to evaluate neuromuscular function. Conversion disorder is a diagnosis that requires careful consideration of psychological factors and neurological disease, and the neurologist's expertise is crucial in distinguishing between these possibilities. Early referral can prevent delayed diagnosis of treatable neurological conditions while also facilitating appropriate psychological interventions if conversion disorder is confirmed. The specialist can also coordinate multidisciplinary care involving psychiatry, psychology, and physical therapy, which is often beneficial for patients with conversion disorder, as supported by the principle that patients with atypical findings or uncertainty about their evaluation should be further evaluated expeditiously, usually including referral to a specialist 1. Key points to consider in the referral process include:

• The importance of a thorough neurological evaluation to rule out organic causes of symptoms
• The use of 'positive clinical signs' in the diagnosis of FND
• The potential benefits of multidisciplinary care involving psychiatry, psychology, and physical therapy
• The need for early referral to prevent delayed diagnosis of treatable neurological conditions.

From the Research

Diagnosis and Referral

• Patients with suspected conversion disorder, characterized by symptoms such as facial droop, right side weakness, and abnormal gait, require a comprehensive diagnosis to rule out underlying somatic disorders 2.
• A positive diagnosis of conversion disorder is essential, and it is not a matter of malingering or factitious disorder 2.
• The diagnosis should be delivered in a sensitive and appropriate manner, explaining to patients that their physical complaints have a psychological cause 2.

Role of Specialists

• Coordination between specialists, including movement specialists, and general practitioners is crucial in the treatment of conversion disorder 2.
• Physical therapy has been shown to be effective in managing patients with conversion disorder, with techniques such as behavioral modification and shaping forming the basis of treatment 3.
• Psychotherapy is also emerging as a first-line intervention for functional neurological (conversion) disorder, with a focus on emotion processing and related psychological constructs 4.

Treatment Approach

• A biopsychosocial model should guide longitudinal treatment, incorporating psychotherapy and physical therapy as needed 4.
• Ignoring abnormal movement patterns and reinforcing correct movement patterns using feedback and praise can be an effective approach in physical therapy 3.
• Patients with conversion disorder may present with symptoms similar to those of other neurological conditions, such as multiple sclerosis, highlighting the importance of accurate diagnosis and referral to appropriate specialists 5.