Functional Neurological Symptom Disorder (FND) Leading to the Development of Deep Vein Thrombosis (DVT), 2022, Othman et al

[Andy]

Abstract

Functional neurological symptom disorder (FND) remains a clinical challenge. It is one of the many mimics of cerebrovascular accidents, spinal cord disorders, and lower motor neuron disease. Patients often undergo an extensive workup to exclude other causes of neurological dysfunction before the diagnosis is made. FND is often associated with weakness and paralysis, yet we could not locate a case depicting symptoms severe enough to cause venous thromboembolism. We present a patient diagnosed with FND who subsequently developed deep vein thromboses (DVT) of the bilateral lower extremities. She was placed on systemic anticoagulation and her functional symptoms improved with physical therapy (PT). This case describes the need for early PT to improve function and prevent complications related to functional immobility.

Open access, https://www.cureus.com/articles/101...o-the-development-of-deep-vein-thrombosis-dvt

 

[Arnie Pye]

FND always suggests to me that doctors can't find a physical problem so they blame the patient's mental state. I looked at the paper itself and found these issues with the patient's test data:

In blood:
Sodium is very low in range.
Potassium is below range.
BUN (Blood urea nitrogen, usually part of a kidney function test) is above range.
Bicarbonate (HCO3) is below range.
Anion gap is above range.
Vitamin B12 is very low in range.
Vitamin D is deficient.
CRP (marker of inflammation) is 10 times the top of the range.

In CSF:
Red blood cells found - they aren't supposed to be there.
Lymphocytes top of range suggesting an infection.

I think it should be fairly obvious to a medically trained person (something I'm not) that the patient is quite unwell, with so many of her test results on the border of the range or above/below range. But they decide this is functional???? I'd love to know how this woman could have made these changes to herself.

She ended up being offered CBT (which she declined) and physical therapy (which she started), and, hey presto, within just a few days she ended up with DVT in both legs, probably brought on by the physical therapy. Why couldn't they have given her electrolytes, since hers were obviously on the fritz, and checked the state of her kidneys further? And did they decide to improve her B12 or her vitamin D? It would appear not.

After the woman's second hospital admission a few days later (with the DVTs) :

She was reevaluated by psychiatry and neurology, who supported her initial diagnosis of FND.

The whole tenor of the paper suggests they are patient-blaming, particularly her mental health, and they are completely uninterested in her physical health.

The first-line treatment for FND is to explain and educate the patient about the diagnosis to circumvent maladaptive behavior. Physiotherapy and CBT are strongly recommended. Additional treatment options mentioned in the literature include botulinum toxin, therapeutic sedation, hypnosis, transcranial magnetic stimulation, and electromyographic feedback [7,10]. Pharmacologic therapy currently has no direct role in the treatment of FND, but it may be used to treat coexisting psychiatric or neurological disorders [9].

This patient had a significantly elevated CRP for which we could not determine an organic cause. It is possible that the venous thrombosis caused the elevation, but it is mentioned in the literature that low-grade inflammation may be a mechanism for FND.

This patient presented with a severe case of FND subsequently leading to the development of acute lower limb DVT. She did not have any risk factors for the development of DVT except for her decreased mobility. We could not find any cases in the literature describing patients developing venous thrombosis related to debility caused by FND. Early mobilization in patients with FND is essential, even if therapy is limited to range of motion exercises to prevent complications, such as DVT. Further studies would be beneficial to determine the optimal modes of physical-based therapy in preventing complications and improving motor function in patients diagnosed with FND.

I think this paper makes it official - doctors have completely given up trying to cure people.

 

[rvallee]

Beyond parody.

 

[ukxmrv]

How would the PT set off the DVT? I don't know anything about this topic.

In the paper are they suggesting it was her inactivity that caused these?

 

[Arnie Pye]

In the paper are they suggesting it was her inactivity that caused these?

Yes. Her first presentation to hospital is described as follows :

A 55-year-old female presented to the hospital with minimal responsiveness, incomprehensible speech, and the inability to move her extremities. The history was obtained from family members who shared that she had felt weak, was having memory issues, and had progressive difficulty with ambulation for several weeks. The patient had also recently been under severe stress related to increasing difficulties taking care of her children with autism. The day before admission, the patient presented to an urgent care clinic due to nausea, vomiting, bilateral ear pain, and vertigo and she was prescribed meclizine and ondansetron. Emergency medical services (EMS) were called by her significant other on the day of admission, as she had worsening confusion, slurred speech, and minimal responsiveness.

I suspect that with previous inactivity and her dodgy electrolyte results that PT could have caused damage to muscles perhaps? Her circulation?

 

[Arnie Pye]

I actually wonder if part of the problems she is having stem from a vitamin B12 deficiency and possibly pernicious anaemia. In Japan, for example, treatment for B12 deficiency is started when the level drops below 500 (not sure of the units), whereas in the case of the patient described her B12 was 213 pg/mL.

According to this link, the symptoms of B12 deficiency are very diverse and include, amongst others, neurological and neuropsychiatric symptoms :

https://www.b12deficiency.info/signs-and-symptoms/

 

[Sean]

I think this paper makes it official - doctors have completely given up trying to cure people.

FND is just an excuse for medical ignorance, and the profession's cowardice in facing up to that.