OBJECTIVE:In this exploratory study, the authors used subjective participant data to investigate sleep disturbance in functional neurological disorder (FND) and its impact on FND symptoms. METHODS:An online questionnaire was designed in collaboration with FND charities and administered to 373 adult participants with a self-reported FND diagnosis. RESULTS:Most participants (86%) were women, and most (73%) perceived their sleep quality over the past 3 months as poor. Almost all (93%) reported nonpositive dream content, with 78% experiencing nightmares at least once per week. Self-rated bad sleep quality increased by 41 percentage points since the onset of FND, and the frequency of nightmares also significantly increased. Obesity was highly prevalent (44% with a body mass index >30 kg/m²), but formally diagnosed sleep-related breathing disorders were rare (8%). Many participants (46%) noticed symptom improvement after a good night's sleep. Most (88%) reported worsening of functional symptoms when falling asleep, during sleep, or when waking up. About one-quarter noted symptom changes after specific dreams or nightmares, with almost all (97%) reporting negative changes, which were more common among participants reporting poor sleep quality. Moderate rates of sleep paralysis and functional seizure were observed. Among those who experienced functional seizures, 74% reported that they arose during sleep. CONCLUSIONS:These findings support the common perception of poor sleep quality, nightmares, and negative dreams among individuals with FND and suggest that self-reported sleep and dream content may also influence FND symptoms. However, the authors recognize a high risk for selection and recall bias.
Functional neurological disorder (FND) is an often-disabling condition with a complex path to diagnosis, further challenged by limited availability of evidence-based treatment resources. Providers hoping to offer treatment resources face the challenge of identifying effective and sustainable implementation of interventions. The existing literature provides limited guidance on the logistics of creating specialized programs for FND outside of tertiary care centers or high-resource medical settings. Members of a multidisciplinary treatment team may find it challenging to identify program development resources that provide a unified perspective on each member's role and how they function together. The authors' FND program at the Stanford University School of Medicine has recently fielded a high number of requests by clinicians, health care staff, and administrators across the United States for collaboration to start new programs. Frequently asked questions include the criteria for patient selection, what personnel to include, how to ensure prompt staff responses to FND symptoms, when to hospitalize patients, how to obtain funding for services, and more. The intended audience for this review includes seasoned and new clinicians, allied health professionals, and nonclinicians, including administrators. The authors discuss diagnosis and evidence-based treatment strategies and provide guidance on practical issues, including work, disability, and driving. The authors' program experience is highlighted as an example, and alternative working models are discussed. The aim of this article is to improve providers' knowledge and confidence and remove frequently encountered barriers to program development. The authors seek to provide a resource that may help connect those in need of care to FND services.
The semiology of clinical phenomena is central to neurological reasoning. When clinical manifestations occur in combination (e.g., weakness plus sensory loss), they are traditionally analyzed by considering anatomical localization (e.g., right-sided weakness and aphasia implicate the left cerebral cortex) and disease pattern recognition (e.g., tremor, bradykinesia, and rigidity indicate parkinsonism). The authors introduce a third, complementary approach-phenoconsonance-that relates neurological phenomena to each other not by their anatomical localization or disease pattern recognition but by their shared phenomenology. The authors identify the main components of the description of neurological phenomena in relation to where, what, and how neurological function is affected: examples for "where" include left-arm deficits in left brachial plexopathy or left hemispace neglect in right parietal lesions; examples for "what" include motor strength, visuospatial reasoning, or abstract planning; and examples for "how" include slowness, incoordination, or difficulty with initiation, because either the same function can be disrupted in qualitatively different ways-movement can be slowed or uncoordinated-or the same qualitative abnormality can apply to different functions-slowing may characterize movement, and it may also characterize thinking. The where, what, and how of neurological phenomenology correspond in the authors' synthesis to spatial phenoconsonance, domain phenoconsonance, and qualitative phenoconsonance, respectively. The historical context and conceptual underpinning of the notion of phenoconsonance are reviewed, as is its usefulness for the study of brain-behavior relationships in the evaluation and treatment of individuals with neurological and neuropsychiatric disorders.
OBJECTIVE:Traumatic brain injury (TBI) often involves injury to limbic structures that may be linked to posttraumatic psychological health difficulties. The authors investigated whether the relationship of amygdala and hippocampal volumes with anxiety differed among children with TBI versus children without a history of TBI over time since injury. METHODS:Structural MRI scans were acquired for children ages 8-15 years at 7 weeks (time point 1) and 14 months (time point 2) after a TBI (N=51) as well as for age-matched healthy control (HC) children (N=36). The Screen for Child Anxiety Related Emotional Disorders (SCARED) was administered at both time points. Generalized linear models were used to evaluate the relationship of limbic volumes, experimental group, time of scan, and their interactions with SCARED scores. Pubertal status at time point 1, sex, and total gray matter volume were included as covariates. RESULTS:The group × volume × time interaction was statistically significant for both structures bilaterally. Relative to the HC group, children with TBI showed altered directionality of the relationship of amygdala and hippocampal volumes with SCARED scores that changed between the two time points. During the subacute stage of recovery, higher self-reported anxiety was associated with larger amygdala and hippocampal volumes. During the chronic stage, higher anxiety was associated with lower volumes. SCARED scores were higher among girls than among boys when limbic volumes were controlled for. CONCLUSIONS:TBI significantly affected the typical relationship between amygdala and hippocampal volumes and anxiety scores, suggesting that limbic volumes may serve as markers of later developing psychological health.
