Short communicationTherapeutic sedation for functional (psychogenic) neurological symptoms
Introduction
Sedation with anesthetic agents has been used since at least the First World War for investigation and treatment of functional (psychogenic) neurological symptoms [1], particularly in patients who were unresponsive to other treatments such as hypnosis. The technique of narcoanalysis or abreaction was a method of facilitating psychotherapy by gaining information from the patient that they were unwilling or unable to talk about in normal consciousness.
By contrast, the idea of using suggestion under anesthesia, not to talk to the patient, but to demonstrate to the patient the possibility of recovery of a paralyzed, weak or dystonic limb and exclude contractures [12] has received scant attention. Older methods of sedation made this difficult however and only 15 cases of rehabilitation during anesthesia (moving the affected limb) were described in a systematic review of abreaction for conversion disorder since 1920 [3]. Sodium amytal, thiopentone or intravenous benzodiazepines were most commonly used in these older studies [3]. We chose propofol for its pleasant anxiolytic effects, and the rapidity with which any oversedation can be corrected.
We describe our experience of therapeutic sedation as an adjunctive treatment for eleven patients with severe and persistent functional neurological symptoms. In particular we describe a focus on movement and rehabilitation during the procedure, the use of propofol as a short acting anesthetic agent, and of video recording in aiding the patient's recovery [2], [4]. We suggest a standardized method for the procedure that could be formally investigated as a treatment for functional (psychogenic) neurological symptoms.
Section snippets
Methods
We performed a retrospective analysis of all patients receiving therapeutic sedation for functional neurological symptoms in our unit over the period 2002–2012. We recorded initial and long term outcomes using the Modified Rankin Scale. All patients were diagnosed by a consultant neurologist (JS). None had additional neurological diagnoses. Cases were chosen whose symptoms firstly could not be temporarily reversed during examination. For example most patients with unilateral functional leg
Results
Eleven patients were sedated, eight female and three male (Table 2, Supplementary Video and Supplementary Case Vignettes). Eight patients had functional limb paralysis (two with associated functional dystonia), one functional mutism, one functional dystonia alone and one functional coma (i.e. prolonged motionless unresponsiveness lasting 5 days but not truly comatose) [7]. Six patients were seen as day cases, five as inpatients. One patient was fully anesthetized to assess contractures. Three
Discussion
A systematic review of prognosis in functional motor symptoms, which made up the majority of our patients target problems, showed variable but generally poor outcome [8]. The positive results in some of our patients who had presented with severe disability in relation to their functional disorder suggests that adjunctive treatment with a video-recorded therapeutic sedation is worth considering as part of a wider treatment by a multidisciplinary team [9]. We emphasize that we do not recommend it
Author contributions
JS conceived of the study, executed the project, made the videotapes and revised drafts; IH edited videoclips, researched literature and wrote the first draft; KB added anesthetic detail and revised drafts; AC executed the project, reviewed literature and revised drafts.
Data access, responsibility and analysis
JS had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Conflicts of interest
None.
Funding
None.
Full financial disclosures for the past year
JS: Employed by NHS Lothian; Honoraria received from the Movement disorders Society, Pfizer and UCB for lectures; Expert Testimony fees in UK medicolegal practice; Creator of www.neurosymptoms.org — free self help website for patients with functional movement disorder.
IH: Employed by Belfast Health and Social Care Trust
KB: Employed by NHS Lothian
AC: Employed by NHS Lothian; Expert Testimony fees in UK medicolegal practice, Honoraria received from High-Med Beijing for lectures and JNNP for
Video consent
Authorization signed by the patient has been obtained in compliance with any laws regarding patient authorizations relating to the use or disclosure of protected health information of the jurisdiction(s) to which the patient and the physician are subject.
References (19)
- et al.
The treatment of some common war neuroses
Lancet
(1917) Psychogenic unresponsiveness
Neurol Clin
(2011)- et al.
Physiotherapy for functional (psychogenic) motor symptoms: a systematic review
J Psychosom Res
(2013) Role of anesthesia in the diagnosis and treatment of psychogenic movement disorders
- et al.
Abreaction for conversion disorder: systematic review with meta-analysis
Br J Psychiatry
(2010) - et al.
The amobarbital sodium interview in conversion disorders: use of video feedback in therapy
J Am Osteopath Assoc
(1995) - et al.
Trick or treat? Showing patients with functional (psychogenic) motor symptoms their physical signs
Neurology
(2012) The bare essentials: functional symptoms in neurology
Pract Neurol
(2009)- et al.
The prognosis of functional (psychogenic) motor symptoms — a systematic review
(2013)
Cited by (31)
Functional Movement Disorder: Assessment and Treatment
2023, Neurologic ClinicsThe clinical management of functional neurological disorder: A scoping review of the literature
2023, Journal of Psychosomatic ResearchTreatment of Functional Movement Disorders
2020, Neurologic ClinicsCitation Excerpt :It is often helpful to wait with tapering of medications until the patient is engaged in other treatment modalities and learns strategies to deal with worsening or reemerging symptoms. For severe FMD without benefit from other treatments, sedation with propofol to show the reversibility of symptoms such as fixed dystonia may have a role, usually combined with psychoeducation and multidisciplinary treatment.79 A recent double-blinded randomized controlled study compared injections with botulinum neurotoxin versus placebo in jerky and tremulous FMD and found no difference in symptom improvement between the treatment groups.80
Motor functional neurological disorders
2019, Pratique Neurologique - FMCMotor functional neurological disorders: An update
2018, Revue NeurologiqueThe most promising advances in our understanding and treatment of functional (psychogenic) movement disorders
2018, Parkinsonism and Related DisordersCitation Excerpt :In small studies of psychodynamic psychotherapy, one uncontrolled study showed benefit [28], while another in a randomized control trial did not [29]. There has been some anecdotal evidence for therapeutic sedation and one open trial of 11 patients using propofol in a standardized technique [30]. Five improved and maintained benefit at follow up at a mean of 30 months.