Letter to the Editor – Towards an Outpatient Model of Care for Motor Functional Neurological Disorders: A Neuropsychiatric Perspective [Letter]

Dear editor

We have read the article written by Saxena et al “Towards an Outpatient Model of Care for Motor Functional Neurological Disorders: A Neuropsychiatric Perspective” with great interest. The authors address relevant information and provide a sound outpatient model.¹ However, some significant issues concerning patients with functional neurological disorders (FND) may be missing in their model which we want to discuss in more detail.

The authors focus on patients with FND, especially the spectrum of motor FND (mFND). They introduce a practical guide and refer to this guide as a neuropsychiatric approach to the assessment and management of mFND with “[…] a comprehensive assessment guiding the development of a patient-centered treatment plan benefits from interdisciplinary neurologic, psychiatric, allied mental health and rehabilitation perspectives.” Furthermore, they state that specialized tertiary care centers as well as community-based care have to be included in this approach to offer the aforementioned patient-centered care. The authors thus provide an approach that is very useful for clinicians in which the value of state-of-the-art diagnostics including neuropsychiatric screening and a “rule-in” neurological examination is emphasized. Also, they provide assistance in how to deliver the diagnosis of (m)FND and offer an overview of several psychotherapy modalities for mFND. Therefore, their perspective paper is of substantial importance for clinicians working in the field of FND. However one pivotal clinical characteristic of patients with (m)FND, cognitive impairments, is only marginally addressed and should, in our opinion, play a more central role in the neuropsychiatric evaluation and treatment of (m)FND.

In a review, McWhirter et al² state that “Cognitive symptoms are common […] improve diagnosis and identify effective treatments.” Results of other studies also show that patients with FND present themselves with severe cognitive impairments, primarily within (but not limited to) the domain of information processing speed (eg, Brown et al,³ De Vroege et al⁴). Saxena et al only briefly mention cognitive symptoms when addressing traumatic brain injuries (as part of the physical injuries). Furthermore, cognitive symptoms may have a negative effect on treatment outcome and would therefore fit perfectly in their neuropsychiatric approach. After all, they refer to a recent study in which cognitive behavioral therapy did not show a significant treatment effect in patients with mFND and we wonder how many of the 368 patients included in that specific study may have suffered from cognitive symptoms and may have hampered treatment results. In general, we do know that the current treatment options are limited effective and the role of cognitive symptoms may therefore be pivotal to address more extensively in the presented neuropsychiatric approach.

We agree that the biopsychosocial formulation is helpful in clinical practice and the presented neuropsychiatric approach is useful for the assessment and management of mFND. However, based on our own experience, which is supported by some recent studies, we suggest that cognitive symptomatology needs to be addressed more explicitly in this approach. Particularly, since cognitive symptoms can also lead to another therapeutic pathway in which cognitive symptoms are treated⁵ prior to the more conventional psychotherapeutic intervention. We thank Saxena et al for their perspective article and emphasizing the cognitive aspects of mFND may further improve the comprehensive and effective treatment of mFND.