Functional symptoms and disorders are the second commonest reason for a neurology outpatient visit after headache.
Functional NEUROLOGICAL disorder includes the following symptoms which may be suitable either for a general neurology appointment or in some cases a specialist FND clinic.
- Functional limb weakness or paralysis
- Functional movement disorders like tremor, dystonia, gait disorder and jerks
- Functional/Dissociative Seizures/ Attacks – events that look like epileptic seizures or syncope
- Persistent Postural Perceptual Dizziness and Functional Cognitive Disorders are in a grey zone but we regard them as part of FND
FND should not be used to describe ALL functional symptoms and disorders. It doesn’t for example include Chronic pain/Fibromyalgia, persistent fatigue or Functional Gastrointestinal problems such as Irritable Bowel Syndrome. Those disorders may commonly arise through similar central mechanisms and are often present in people with FND.
DCN Clinical Services for FND available to Primary Care
- Neurology – Prof Jon Stone and Dr Ingrid Hoeritzauer, Consultant Neurologist do specialist FND clinics, especially for diagnostic queries.
- Neuropsychiatry – Prof Alan Carson, Dr Killian Welch, Dr Laura McWhirter and Dr Ally Rooney – do general neuropsychiatry clinics and will provide specialist assessment for FND patients including formulation and treatment.
Services for FND available to DCN Clinicians
There is heavy demand for FND specific therapies, and we have found referrals from outside neurology have often not been appropriate, so DCN clinicians currently act as gatekeepers.
- Neurophysiotherapy – FND Neurophysiotherapy expertise exists especially at Astley Ainslie, DCN, CRABIS (West Lothian) and Roodlands.
- Neuropsychology – This is primarily in DCN (Lothian) and CRABIS (West Lothian). Generally only short course of sessions – e.g. 4-5 can be offered.
- Occupational therapy – Via Astley Ainslie Hospital, CRABIS
- Speech and Language therapy –Astley Ainslie Hospital, DCN, CRABIS, Roodlands
Other Services
People with FND commonly have comorbidities including chronic pain, persistent fatigue or mental health problems. If FND symptoms are not the dominant issue it may be more appropriate for them to be managed in pain, fatigue or mental health services.
Who to refer:
- People with neurological symptoms where FND is suspected such as limb weakness, tremor or seizures should be referred to general neurology in the first instance
- Patients with suspected Persistent Postural Perceptual Dizziness (PPPD) and Functional Cognitive Disorder can also be referred.
- Neurology triage will arrange for some patients, e.g. those already diagnosed elsewhere, to be seen in specialist FND clinics but there are too many patients for all to be seen direct in FND clinics
Who not to refer:
- Patients for whom you require advice about chronic pain should be referred to the chronic pain service
- Patients with other functional disorders including functional GI disorders (including swallowing issues and bowel problems) and functional bladder disorders.
- Patients whose primary problem is chronic fatigue syndrome /myalgic encephalomyelitis should be referred via the CFS/ME pathway
- Patients with persistent cognitive symptoms after covid can be referred via the Long Covid pathway
Referrals from outside of NHS Lothian
Patients with FND from outside NHS Lothian are generally only seen when referred from secondary care (usually neurology) from NHS Borders, Fife, Forth Valley and Dumfries and Galloway, with whom NHS Lothian has service level agreements. NHS Fife and NHS Forth Valley have their own FND pathways.
How to refer:
- Via SCI Gateway
- Royal Infirmary of Edinburgh- Neurology or Neuropsychiatry- Basic Sign Referral
- neurosymptoms.org – self help website and app for people with FND and associated symptoms run by Prof Jon Stone with Scottish Government funding from 2020. Please direct patients to specific relevant pages or use the ‘recommender’ Do not use for people with functional disorders who do not have FND
- FND Hope UK – fndhope.org.uk
- FND Action – fndaction.org.uk
- Scottish Government – Health Improvement Scotland – FNS pathways document
- CRABISWestLothian.aspx
Related resources for patients
- headinjurysymptoms.org – self help website for people with a mild head injury and post-head injury symptoms/post-concussion syndrome
- Chronic pain – see this resource page – https://apps.nhslothian.scot/refhelp/chronic-pain-management
Persistent fatigue – https://apps.nhslothian.scot/refhelp/guidelines/Pages/ChronicFatigueSyndromeME.aspx
