SomatoformSomatoformSomatoform Disorders: Practice
Somatoform Disorders: Practice
Approaches in Neurology
Approaches in NeurologyNeurologyNeurology
Katherine H Noe MD PhDKatherine H. Noe, MD, PhDComprehensive Epilepsy Program
Department of NeurologyDepartment of NeurologyMayo Clinic Arizona
APM 56th Annual MeetingDisclosure: Katherine Noe, MD, PhD
• Company: NeuroPace, Inc.– Research Support
Relationship NOT considered directly relevant to– Relationship NOT considered directly relevant to the presentation
• Company: Eisai Pharmaceuticalsy– Research Support– Relationship NOT considered directly relevant to
h ithe presentation
Pseudoneurological SymptomsPseudoneurological Symptoms• "Spells" • Cognitive disordersSpells
– Seizures– Syncope
Cognitive disorders– Amnesia
• Motor disorders• Gait disorders
– Imbalance/FallsA t i / b i
Motor disorders– Weakness/paralysis– Dysarthria
D h i / l b– Astasia/abasia• Abnormal
Movements
– Dysphagia/globus
• Sensory disorders– PainMovements
– Myoclonus– Tremor
Pain– Parasthesias– Numbness
Bli d t l i i– Dystonia– Dyskinesia
– Blindness, tunnel vision– Deafness
Video ExamplesVideo Examples
Epidemiology• "Medically Unexplained Symptoms"
– 30% in general neurology clinic; 18% 30% ge e a eu o ogy c c; 8%conversion
– 5% of inpatient neurology admissionsp gy• Psychogenic Non-Epileptic Seizures
– 20% of referrals to tertiary epilepsy centers for20% of referrals to tertiary epilepsy centers for "refractory epilepsy"
– Estimated 2-33/100,000 in general populationEstimated 2 33/100,000 in general population• Psychogenic Movement Disorders
3 25% of referrals to movement disorder– 3-25% of referrals to movement disorder clinics
Stone J et al Brain 2009; Lempert T et al Acta Neurol Scand 1990; Allet J Curr Opin Psych 2006
Overlap with "Organic" Disease
• PNES + epilepsyPNES + epilepsy– 5-15%
3% in MCA population– 3% in MCA population• PMD + movement disorder
%– 10-15%• Long-term Follow-up
– <0.4% with subsequent "organic" diagnosis to explain symptoms @18 months from di idiagnosis
Allet J Curr Opin Psych 2006 19: 413; Ranawaya et al Mov Disord 1990 5: 127; Stone et al Brain 2009 132: 2878
Diagnostic EvaluationDiagnostic Evaluation• PNES • PMDPNES• History + Physical• Head MRI
PMD• History + physical• Assessment ofHead MRI
• Routine EEG• Video EEG
Assessment of witnessed movements by • Video-EEG
monitoring (GOLD STANDARD)
yneurologist
• Head MRIS )• Neuropsychological
testing• Movement
Neurophysiology gStudy
Who are these patients?Mayo Clinic Arizona Neurology Experience
PNES (n=116) PMD (n=56)PNES (n 116) PMD (n 56)
Female Gender 82% 82%
Age (years) 18-82 (mean 41)
22-79(mean 51)(mean 41) (mean 51)
Disabled 34% 24%
Unemployed 19% 33%
College 64% 85%CollegeEducated
64% 85%
Who are these patients?MCA Neurology Experience
PNES PMDPNES PMD
Sx Frequency 44% weekly 98% daily or t t39% daily constant
Sx Duration 33 months 56 months(mean)# Neurologists 60% 2 or more 50% 2 or moreSeen# Medications 0-8 0-8Prescribed Mean of 2 Mean of 2
Risk Factors/ComorbiditiesMCA Neurology Experience
PNES PMDPNES PMD
Abuse Hx 51% 32%
Incident Stress 63% 45%
Anxiety 52% 90%Anxiety 52% 90%
Depression 57% 53%
Chronic Pain 67% 75%
Fatigue 41% 57%g % %
Cognitive c/o 60% 45%
"Difficult to Treat" Patients in Neurology
Copyright ©2004 BMJ Publishing Group Ltd. Carson, A J et al. J Neurol Neurosurg Psychiatry 2004;75:1776-1778
Treatment AlgorithmsTreatment Algorithms
• Patient/Family educationPatient/Family education• Discontinuation of medications
prescribed for "organic" diseaseprescribed for organic disease• PT/OT• Psychiatry referral• Psychology referraly gy
– Cognitive behavioral therapy– Stress managementStress management
Outcomes• "Medically unexplained symptoms"
2/3 worse or no better at 1 year f/u– 2/3 worse or no better at 1 year f/u• PNES
– 25-50% improved with short follow-up– 2/3 with continued spells @ 4 years– Persistent high disability rates even with
spell resolution• PMD
Sharpe M et al Psychol Med 2009; Walczak et al Epilepsia 1995;Wyllie et al Neurology 1991; Reuber + Elger Epilepsy Behav 2003
Predictors of Poor OutcomePredictors of Poor Outcome
• Symptom durationSymptom duration• Older age
Di bilit t t• Disability status• Symptom count• Acceptance of diagnosis
– PatientPatient– Family– Treating physiciansTreating physicians
Barriers to CareBarriers to Care• Failure of neurologist to recognize the g g
diagnosis• Lack of understanding of somatoformLack of understanding of somatoform
disorders by neurologist = failure to educate/refer for treatmenteducate/refer for treatment
• Who is responsible for follow-up?Lack of access to ps chotherap• Lack of access to psychotherapy
• Disagreement between neurologist + psychologist/psychotherapist
Lack of Agreement on Diagnosis g gNeurologist vs. Psychiatrist
PNES
Harden et al, Epilepsia 2003; 44: 453. Survey @ Weill Medical College, Cornell
Lack of Agreement on DiagnosisNeurologist vs PsychiatristNeurologist vs. Psychiatrist
PMD• Survey of Movement Disorder Specialists (n=• Survey of Movement Disorder Specialists (n=
519)• 2/3 refer PMD to mental health providers for2/3 refer PMD to mental health providers for
treatment• Reported frequency with which mental healthReported frequency with which mental health
care providers questioned psychogenic etiology:– Sometimes .... 35%– Often...............14%– Always..............1% Espay et al Movmt Disord 2009
24: 1366
Somatoform Disorders in NeurologyConclusions
• Commonly encounteredCommonly encountered• Delays in diagnosis with associated
inappropriate medical treatments areinappropriate medical treatments are frequentM l i t t l ith thi• Many neurologists struggle with this patient population
• Improved standardization of terminology, diagnostic+ treatment algorithms would be beneficial
Thank you!Thank you!