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Milano BA, Moutoussis M, Convertino L. The neurobiology of functional neurological disorders characterised by impaired awareness. Front Psychiatry 2023; 14:1122865. [PMID: 37009094 PMCID: PMC10060839 DOI: 10.3389/fpsyt.2023.1122865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/24/2023] [Indexed: 03/18/2023] Open
Abstract
We review the neurobiology of Functional Neurological Disorders (FND), i.e., neurological disorders not explained by currently identifiable histopathological processes, in order to focus on those characterised by impaired awareness (functionally impaired awareness disorders, FIAD), and especially, on the paradigmatic case of Resignation Syndrome (RS). We thus provide an improved more integrated theory of FIAD, able to guide both research priorities and the diagnostic formulation of FIAD. We systematically address the diverse spectrum of clinical presentations of FND with impaired awareness, and offer a new framework for understanding FIAD. We find that unraveling the historical development of neurobiological theory of FIAD is of paramount importance for its current understanding. Then, we integrate contemporary clinical material in order to contextualise the neurobiology of FIAD within social, cultural, and psychological perspectives. We thus review neuro-computational insights in FND in general, to arrive at a more coherent account of FIAD. FIAD may be based on maladaptive predictive coding, shaped by stress, attention, uncertainty, and, ultimately, neurally encoded beliefs and their updates. We also critically appraise arguments in support of and against such Bayesian models. Finally, we discuss implications of our theoretical account and provide pointers towards an improved clinical diagnostic formulation of FIAD. We suggest directions for future research towards a more unified theory on which future interventions and management strategies could be based, as effective treatments and clinical trial evidence remain limited.
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Affiliation(s)
- Beatrice Annunziata Milano
- Institute of Life Sciences, Sant'Anna School of Advanced Studies, Pisa, Italy
- Faculty of Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Michael Moutoussis
- Wellcome Centre for Human Neuroimaging, University College London, London, United Kingdom
- Max Planck UCL Centre for Computational Psychiatry and Ageing Research, University College London, London, United Kingdom
- National Hospital of Neurology and Neurosurgery (UCLH), London, United Kingdom
| | - Laura Convertino
- Wellcome Centre for Human Neuroimaging, University College London, London, United Kingdom
- National Hospital of Neurology and Neurosurgery (UCLH), London, United Kingdom
- Institute of Cognitive Neuroscience, University College London, London, United Kingdom
- *Correspondence: Laura Convertino,
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Lagrand TJ, Jones M, Bernard A, Lehn AC. Health Care Utilization in Functional Neurologic Disorders: Impact of Explaining the Diagnosis of Functional Seizures on Health Care Costs. Neurol Clin Pract 2023; 13:e200111. [PMID: 36865642 PMCID: PMC9973286 DOI: 10.1212/cpj.0000000000200111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Accepted: 10/10/2022] [Indexed: 01/13/2023]
Abstract
Background and Objective The objectives of this study were to investigate health care utilization costs of patients with video-electroencephalography (VEEG)-confirmed functional seizures (FS), determine whether patients who received a satisfactory functional neurologic disorder (FND) diagnosis explanation had reduced health care utilization compared with those with a poor explanation; and to quantify the overall health care costs 2 years prediagnosis and postdiagnosis for those receiving a different explanation. Methods Patients with VEEG-confirmed pure FS (pFS) or mixed (functional seizure plus epileptic seizures) diagnosis between July 1, 2017, and July 1, 2019, were evaluated. Explanation of the diagnosis was determined "unsatisfactory" or "satisfactory" using self-developed criteria, and health care utilization data were collected using an itemized list. The subsequent costs 2 years post-FND diagnosis were compared with those 2 years before, and cost outcomes were compared between both groups. Results In patients who received a satisfactory explanation (n = 18), total health care costs were reduced from $169,803 to $117,133 USD (-31%). An increase in costs was found ($73,430 to $186,553 USD = +154%) in patients with pPNES after an unsatisfactory explanation (n = 7). On an individual level, 78% with a satisfactory explanation saw a reduction in total health care costs per year (mean $5,111 USD to $1,728 USD), and in 57%, an unsatisfactory explanation led to an increase (mean $4,425 to $20,524 USD). A similar effect was seen from explanation on patients with a dual diagnosis. Discussion The method of communicating an FND diagnosis has a significant impact on subsequent health care utilization. Those receiving satisfactory explanations demonstrated reduced health care utilization, whereas an unsatisfactory explanation resulted in additional expenses.
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Affiliation(s)
- Tjerk J Lagrand
- Department of Neurology (TJL, MCD, ACL), Princess Alexandra Hospital, Woolloongabba, Brisbane, Queensland, Australia; QCIF Bioinformatics (AB), Institute for Molecular Bioscience, The University of Queensland, Brisbane; and University of Queensland (ACL), Brisbane, Australia
| | - Maryon Jones
- Department of Neurology (TJL, MCD, ACL), Princess Alexandra Hospital, Woolloongabba, Brisbane, Queensland, Australia; QCIF Bioinformatics (AB), Institute for Molecular Bioscience, The University of Queensland, Brisbane; and University of Queensland (ACL), Brisbane, Australia
| | - Anne Bernard
- Department of Neurology (TJL, MCD, ACL), Princess Alexandra Hospital, Woolloongabba, Brisbane, Queensland, Australia; QCIF Bioinformatics (AB), Institute for Molecular Bioscience, The University of Queensland, Brisbane; and University of Queensland (ACL), Brisbane, Australia
| | - Alexander C Lehn
- Department of Neurology (TJL, MCD, ACL), Princess Alexandra Hospital, Woolloongabba, Brisbane, Queensland, Australia; QCIF Bioinformatics (AB), Institute for Molecular Bioscience, The University of Queensland, Brisbane; and University of Queensland (ACL), Brisbane, Australia
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