What do patients prefer their functional seizures to be called, and what are their experiences of diagnosis? - A mixed methods investigation

Factors associated with receiving a Functional Disorder diagnostic label: A systematic review

OBJECTIVES

Functional Disorders (FD) are highly prevalent conditions that are diagnosed based on the presence of specific patterns of somatic symptoms. Examples of FDs include Fibromyalgia and Irritable Bowel Syndrome. Many patients who meet the criteria do not receive a formal diagnostic label. This systematic review aims to assess factors associated with receiving an FD diagnostic label.

METHODS

A systematic search of PubMed, PsycINFO, and Embase was performed following the PRISMA guidelines. All research methodologies and languages were included with a focus on experiences and impacts of receiving/having an FD diagnostic label. Excluded studies were those not mentioning diagnostic labels, only involving single pain symptoms, and studies solely focusing on functional neurological symptoms. Screening, data extraction and quality ratings (using the QuADS instrument) were performed by two independent reviewers.

RESULTS

15 Studies were identified (10 quantitative and 5 qualitative). Our results show that female patients were more likely to receive an FD diagnostic label for their symptoms; other associations were less consistent and only found for specific labels or research designs. In general, quality of life and healthcare use did not seem to differ between patients with and without an FD diagnostic label. From the healthcare professional's perspective there was doubt about giving an FD diagnostic label, mainly due to concerns of harm for patients. Quality of included studies was rated low to moderate.

CONCLUSION

Better understanding of factors associated with receiving or having an FD diagnostic label, independently from symptom development can help healthcare professionals make evidence-based decisions in labelling or not; however, high quality studies on this topic are urgently needed.

Iatrogenic harm in functional neurological disorder

Functional neurological disorder (FND) is continuing to gain increasing recognition globally as a valid and potentially treatable disorder. Iatrogenic harm towards patients with FND is significant, however, and has been around for centuries. Despite advances in our understanding around the aetiology, pathophysiology and treatment of FND, many aspects of such harm continue to persist. Avoidance of iatrogenic harm has been highlighted by clinicians as one of the most important therapeutic considerations in FND; however, the sources and range of potential harms, or indeed ways to mitigate them, have not previously been summarized. Using a combination of clinical and research experience and scoping review methodology, this review aims to describe the main sources of iatrogenic harm towards patients with FND, including harm from misdiagnosis, delayed diagnosis and treatment, direct harm from professional interactions, other stigma-related harms, harm related to diagnostic overshadowing and over-diagnosis of FND. We also describe some potential ways to address and prevent such harms, such as ways to reduce misdiagnosis with a focus on rule in signs, optimizing teaching and communication, ensuring parity of FND with other medical conditions and continued integration of patient and professional organizations.

Stigma in functional neurological disorder (FND) - A systematic review

OBJECTIVE

The purpose of this systematic review was to evaluate stigma and Functional Neurological Disorder (FND) regarding: 1) prevalence and associated factors, 2) the nature and context of stigma in FND, and 3) stigma-reduction interventions.

METHODS

We searched four relevant databases from inception to December 2023, using search terms relevant to FND and stigma themes. We employed the method of synthesis by "aggregation and configuration" to synthesise and analyse the data into emergent themes.

RESULTS

We found 127 studies, spanning 148 countries, involving 18,886 participants. Of these, 4889 were patients, 13,123 were healthcare professionals, and 526 were caregivers. Quantitatively, stigma has been mainly studied in patients with functional seizures, and was higher than patients with epilepsy in three studies. Stigma experienced by patients is associated with poorer quality of life and caregiver burden. We found 10 themes and 29 subthemes revealing stigma as a systemic process, with intrapersonal, interpersonal and structural aspects. Few studies examined the perspective of caregivers, the public or online community. We identified six anti-stigma interventions.

CONCLUSION

Stigma in FND is a layered process, and affects patient quality of life and provision of care. Stigma needs to be addressed from the top structures, at governmental level, so that appropriate care pathways can be created, giving patients with FND parity of esteem with other medical conditions.

A meta-ethnographic synthesis of the experiences of stigma amongst people with functional neurological disorder

PURPOSE

Functional neurological disorder (FND) causes many neurological symptoms and significant disability. It is often misunderstood by medical professionals and the public meaning stigma is regularly reported. The aim of this review was to synthesise the qualitative findings in the literature to develop a more in-depth understanding of how people with FND experience stigma to inform future interventions.

METHOD

This review used a meta-ethnography approach. Five databases were searched (PsycINFO, Web of Science, CINAHL, MEDLINE, and EMBASE) in February 2021 and updated in July 2022 for qualitative papers in FND. Included papers were critically assessed using the critical appraisal skills programme (CASP) checklist. Data were analysed and synthesised utilising meta-ethnography.

RESULTS AND CONCLUSION

Sixteen papers were included in the final synthesis. Four major themes emerged: stigmatized by delegitimization; stigmatized by social exclusion and rejection; coping with stigma; and stigma and identity. The results identified negative, stigmatizing attitudes towards people experiencing FND symptoms in a variety of contexts including healthcare and other social institutions. The effects of stigma led to further exclusion for participants and appeared to trigger coping styles that led to additional difficulty. Stigma is a key part of the illness experience of FND and needs to be addressed.

The neurobiology of functional neurological disorders characterised by impaired awareness

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.

Stigma in functional seizures: A scoping review

OBJECTIVE

The purpose of this scoping review was to explore the extent, range and nature of knowledge on stigma in functional seizures (FS).

METHODS

This scoping review was conducted in accordance with the Joanna Briggs Institute Manual for Evidence Synthesis (JBIMES) guidelines and the five-step framework by Arksey and O'Malley. We searched for data sources written in English using MEDLINE, Scopus, EBSCOhost, Ovid, PubMed, Science Direct, Web of Science, Wiley Online Library, Microsoft Academic, Google Scholar, as well as grey literature sources, with no date limitations up to September 2021. The extracted data were analysed using basic frequency counts and thematic synthesis.

RESULTS

The systematic search yielded a set of 988 potentially relevant data sources, of which 70 met the inclusion criteria. The retrieved sources reflected data from 85 countries and 5949 study participants. The thematic synthesis highlighted the prevalence of FS stigma, as well as its potential origins, context and impact on patients and families. The majority of studies were conducted in healthcare settings with healthcare providers, with fewer data sources reporting on family, patient, and broader society perspectives relating to FS stigma.

CONCLUSION

Our scoping review suggests that FS stigma is prevalent but remains understudied. We need more research with a specific focus on stigma in FS, and factors that contribute to FS stigma (e.g. culture and context, naming of the condition), as well as accessible interventions and guidelines addressing FS stigma through education and training. Supportive attitudes and knowledge appear to be protective factors against FS stigma.