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!