Functional Stroke Symptoms: A Narrative Review and Conceptual Model, 2019, Chalder et al

[Andy]

Stroke services have been reconfigured in recent years to facilitate early intervention. Throughout stroke settings, some patients present with functional symptoms that cannot be attributed to a structural cause. Emphasis on fast diagnosis and treatment means that a proportion of patients entering the care pathway present with functional symptoms that mimic stroke or have functional symptoms in addition to vascular stroke. There is limited understanding of mechanisms underlying functional stroke symptoms, how the treatment of such patients should be managed, and no referral pathway or treatment. Predisposing factors vary between individuals, and symptoms are heterogeneous: onset can be acute or insidious, and duration can be short-lived or chronic in the context of new or recurrent illness cognitions and behaviors.

This article proposes a conceptual model of functional symptoms identified in stroke services and some hypotheses based on a narrative review of the functional neurological disorder literature. Predisposing factors may include illness experiences, stressors, and chronic autonomic nervous system arousal. Following the onset of distressing symptoms, perpetuating factors may include implicit cognitive processes, classical and operant conditioning, illness beliefs, and behavioral responses, which could form the basis of treatment targets. The proposed model will inform the development of theory-based interventions as well as a functional stroke care pathway.

Paywall, https://neuro.psychiatryonline.org/doi/10.1176/appi.neuropsych.19030075
Scihub, https://sci-hub.se/10.1176/appi.neuropsych.19030075

 

[Sean]

So, pretty much whatever the clinician wants it to be, then?

Tells us far more about what is going on in Chalder's mind than in those of patients.

Naked empire building.

 

[rvallee]

Even a hammer is capable of doing more than just hammering nails. Hell, a hammer makes a better boomerang than this crap makes for credible science. Just updating the graphics doesn't change the fact that it's the exact same thing that failed every time being reused over and over again. Pretty remarkable that the narrative is strictly that of people who have neither insight nor understanding of the experience. Like someone explaining to you what you did yesterday even though they weren't there.

At this point it's the people who keep funding this idiocy who are to blame. It's not like there are lives at stake, or something like that. Noooo, keep pumping the same BS for a full century, very normal and useful. At its core here it's literally the same stuff as the BPS model of ME, "strength of belief" and "physical attribution" of symptoms as basically being fear of being afraid and a risk factor. There's plenty of stuff about rousing reassurance and imaginary illness benefits of "intense attention" by medical professionals. As if that actually happens. Doesn't even score points for originality.

Literally every point from Wessely's early ME models is there. Even "some of them recover spontaneously". Illness-related beliefs. Fear avoidance. Imaginary benefits from all the "attention" from health services and family, which totally happen. Imaginary focus on symptoms, "catastrophizing", as if not thinking about them makes them magically go away. It's all there. It's the same damn thing. It could essentially be copy-pasted with some words changed here and there and it's the same thing. The "treatment" is IAPT-style CBT crap, of course.

Those whose emotional responses are dominated by physiological and behavioral components may be more likely to interpret symptoms as a deterioration in physical health, because they do not experience corresponding subjective cognitions

That the patients are not experiencing the subjective cognitions being imagined here is strong evidence that they are happening. Why not? I'd say you couldn't make this stuff up but that's literally what's happening here. Good grief.

I mean, here it literally argues some time-warping and reverse causality that the "event" is a precipitating factor of the "event". Not only is it turtles all the way down, the second turtle is also standing on the first turtle, which is itself standing on the second. Is there really no one with common sense involved with that process? Sorry but a volcanology paper arguing that the cause of a volcanic eruption is the eruption would be sent home to think about what they just said.

Instead, the occurrence of distressing physiological symptoms and the subsequent acute social response, including admission to an acute stroke unit, are key precipitating events, which initiate a cascade of responses that can sustain symptoms.

There is a strong clinical imperative for research to inform a clear care pathway for functional stroke

Correct. This ain't it, chief. This ain't even close to be it. These people are broken inside.

 

[Mithriel]

 

[Sly Saint]

Functional stroke symptoms: A prospective observational case series
2020
Chalder et al

Highlights
•
A proportion of patients admitted to acute stroke services have a functional neurological disorder which mimics stroke

•
Such cases followed prospectively show high levels of anxiety and maladaptive cognitive behavioural responses

•
After 2 months such patients show some physical recovery but remain symptomatic and impaired across other domains

•
A care-pathway and evidence-based guidelines for this group is required

Abstract
Objective
Functional symptoms are a common mimic of stroke in acute stroke settings, but there are no guidelines on how to manage such patients and scant research on their clinical profile. We explore the presentation of patients with functional stroke symptoms at admission and 2-month follow-up.

Methods
We conducted a prospective observational study across four SE London acute stroke units, with two-month follow-up. Demographic information, clinical data and GP attendances were recorded. Patients completed self-report measures: Cognitive Behavioural Responses Questionnaire short version, Brief Illness Perception Questionnaire, Hospital Anxiety and Depression Scale, Work and Social Adjustment Scale and Short Form Health Survey.

Results
Fifty-six patients (mean age: 50.9 years) were recruited at baseline; 40 with isolated functional symptoms, the remaining functional symptoms in addition to stroke. Thirty-one completed self-report follow-up measures. Of 56 participants, 63% were female. Patients presented symptoms across modalities, with unilateral and limb weakness the most frequent. There was inconsistent and ambiguous recording of symptoms on medical records. Approximately 40% of patients reported levels of anxiety and depression above the threshold indicating a probable diagnosis. Higher anxiety was associated with greater resting or all-or-nothing behaviours, embarrassment avoidance and symptom focussing on the CBRQ. Only SF-36 physical functioning improved at follow-up. Less than 50% who responded at follow-up were accessing a treatment, though 82% had ongoing symptoms.

Conclusion
Patients with functional symptoms in stroke settings report substantial distress, associated with cognitive-behavioural responses to symptoms. Follow-up data suggest recovery can be slow, indicating access to supportive interventions should be improved.

https://www.sciencedirect.com/science/article/abs/pii/S0022399919310943

Higher anxiety was associated with greater resting or all-or-nothing behaviours, embarrassment avoidance and symptom focussing on the CBRQ.

variations on the same theme

 

[Amw66]

How many more conditions can be " white labelled" in this way ?
Just change the description and provide more of the same from multiple providers.

 

[ladycatlover]

Sheesh, so now the b*****s are attacking stroke patients? I particularly liked this:

Patients presented symptoms across modalities, with unilateral and limb weakness the most frequent. There was inconsistent and ambiguous recording of symptoms on medical records.

And followed immediately by this:

Approximately 40% of patients reported levels of anxiety and depression above the threshold indicating a probable diagnosis.

Yeah well, you've been diagnosed with having a stroke, just get over yerself and get on with your life there's nothing wrong with you but a bit of anxiety and depression. These people are bloody UNBELIEVABLY CALLOUS!

 

[chrisb]

Wasn't this Goldberg's great discovery. That illness consists merely of anxiety and depression... whatever the illness.

 

[Mithriel]

What about TIAs, the small mini strokes which heal but show there is a problem?

 

[Milo]

What about TIAs, the small mini strokes which heal but show there is a problem?

@Mithriel their specialty is unexplained and unidentified pathology.