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MPR
What challenges might a PCP face in diagnosing CD?
Dr Tsui
Functional neurological disorders present as medical symptoms, such as paralysis, some type of altered motor or sensory function, weakness, paralyzed limbs, pain, or pseudo seizures. It can be tricky to distinguish these from actual neurological disorders.
MPR
What are the components of the workup a patient should receive in the primary care setting?
Dr Tsui
The PCP should take a detailed history, including symptoms in all organ systems, pain, fatigue, sleep disturbances, memory, and concentration problems. It is also important to note that these patients often have a history of depression, anxiety, and panic attacks, as well as other somatic disturbances, such as headaches, sleep difficulties, fibromyalgia, chronic pain, irritable bowel syndrome, and multiple chemical sensitivities.
A thorough physical examination and neuroimaging and laboratory studies to investigate specific complaints are also necessary. Routine laboratory tests, CT scan and MRI of the brain or spine should be performed at the first visit. Other neuroimaging studies may also be necessary. It is important to bear in mind that certain autoimmune-related neurological diseases as well as amyotrophic lateral sclerosis (ALS) may also be normal, so a neurology follow-up and ongoing monitoring of symptoms may be advisable.
MPR
When should a PCP refer a patient to a specialist?
Dr Tsui
In my experience, PCPs are usually good at noticing when symptoms might be somatoform in nature and identify them as medically unexplained, e.g. when physical examination and imaging results do not match up with reported or displayed symptoms. If a PCP suspects that the cause of a patient’s symptoms may have a non-organic basis, administering the 15-item Patient Health Questionnaire (PHQ-15) can be very helpful. It is a quick screening tool that can be used in a primary care environment.
MPR
In what way is the PHQ-15 useful?
Dr Tsui
Patients are asked to rate how often their physical symptoms are bothersome. These symptoms include a wide range of symptoms, including fatigue, dyspeptic complaints, stomach and back pain, pain in the joints or limbs, sleeping difficulties, headaches, chest pain, bowel complaints, menstrual pain or problems, dizziness, shortness of breath, palpitations, pain or problems during sexual intercourse, and fainting. A cutoff of 10 has been found to have significant accuracy in suggesting somatoform disorder. If a patient scores high on the PHQ-15, and the exam suggests symptoms that do not quite match up, then the PCP can refer the patient to a specialist.
MPR
How might the PCP discuss the possibility of a CD diagnosis with the patient?
Dr Tsui
Communicating this diagnosis can be tricky and must be done with sensitivity. Patients often think there is an underlying medical pathology that is yet to be uncovered and may get upset and go elsewhere to get another opinion. As a consequence, some people with these symptoms end up going to multiple specialists. So how the diagnosis is communicated is essential. It is especially important to note that one has to be certain all treatable medical conditions are ruled out. If they are not, then I would support seeing other specialists in search of appropriate diagnosis and treatment.
It begins with building rapport and developing a trusting therapeutic relationship with the patient. It is also necessary to take time to adequately explain and educate the patient about the condition.
Explain the findings and how they do not match up with the symptoms. The provider can say, “You have been to so many specialists who also have not found a cause for your symptoms. What do you make of this?” Asking open-ended questions allows patients to come to their own conclusions.
The PCP should communicate and emphasize that the symptoms are not “all in the head,” and acknowledge that they are very distressful. The provider can say, “the brain is complex and the way we process information is complicated. Since all the bases have been covered, in terms of finding a physiological cause for your symptoms, it might be helpful to consider other approaches. So let’s try physical therapy to get you functioning again, and consider seeing a mental health specialist, not necessarily to receive medications, but to discuss your experience and figure out the best course of action.”
It is important to find the patient’s source of motivation because that will contribute to the treatment plan, and the patient will understand that the physician shares the same goals, such as returning to work, participating in family life, or becoming independent. Working toward a common goal and moving in a stepwise fashion can lead to improvements and once people start seeing improvements, the motivation builds on itself.
