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Therapeutic sedation for functional (psychogenic) neurological symptoms

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Abstract

Background

Patients with severe functional (psychogenic) neurological symptoms such as paralysis and fixed dystonia present a therapeutic challenge, particularly if no movement is possible during physiotherapy. Sedation has been discussed as a treatment for functional neurological symptoms for 100 years but technique, use of video and outcome has not been systematically described.

Methods

Therapeutic sedation of patients with severe functional neurological symptoms with propofol and follow up at a neuroscience centre.

Results

Of eleven patients (median duration 14 months), five were cured or had major improvement with sedation. At follow up (median 30 months) four were asymptomatic, two were significantly improved and one had minor improvements. We describe a standardized anesthetic and physician technique, refined over consecutive treatments.

Conclusion

In carefully chosen patients, therapeutic sedation with propofol can be a useful adjunctive treatment for patients with severe functional neurological symptoms. The treatment deserves randomized evaluation.

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.

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