Improvement of functional paralysis following unexpected comatose states 2025 Klok, Stone et al

[Andy]

Abstract

Instances of recovery from a functional neurological disorder (FND) can shine a light on the nature of the condition and its potential treatment. Unexpected recovery of FND symptoms can occur after a comatose state or an anaesthetic, or after various other scenarios. Two illustrative cases exemplify the phenomenon.

A 59-year-old man had an 8-year history of functional paraparesis that had developed subacutely following a car crash. The paralysis recovered dramatically after an episode of medically induced coma, administered because of SARS-CoV-2 acute respiratory distress.

A 40-year-old woman had complete recovery of FND-related arm paralysis and associated chronic pain after a deliberate overdose that led to a comatose state necessitating a brief period of ventilation.

We compare these with similar recoveries in other scenarios, such as following hypnosis or extreme external stress. We discuss the potential mechanisms for recovery and the implications for FND treatment.

Paywall

 

[Peter T]

I guess advocates of the software issues model of FND like this idea as it is rather like the IT support cliché of ‘have you tried switching off and on again’.

 

[Utsikt]

I found a free version:

https://www.pure.ed.ac.uk/ws/portalfiles/portal/512111176/Improvement_of_functional_paralysis_following_unexpected_comatose_states_final_main_document_after_2nd_revision_accepted.pdf

 

[Utsikt]

There is some weird info included here by the authors.

The first case was fully dependent on a wheelchair.

His prior medical history included an unspecified adjustment disorder (when aged 39), depression (when aged 51) and post-traumatic stress disorder. Following a traumatic childhood of domestic violence, he had broken off contact with his abusers, voluntarily leaving this toxic environment and built a remarkably fulfilling life. He was married and had two children. Before the car crash, he was described as a hardworking, generous and physically strong person.

I don’t understand how this is relevant to the case? There’s a lot of info about the person, to the point that they could probably be identified quite easily by people that know them.

As he awakened, he subjectively felt as if someone was playing with his feet, until he realised that he was initiating these movements himself. His improvement continued over 10 days, and both the motor functions and sensory functions of his lower limbs recovered considerably. After one year of rehabilitation, he still had some disability, including impaired motor function of the arms and hands. After 12 months, he could walk again, up to 500 metres. The recovery was consistent with the original diagnosis of FND. At follow-up two years later, there had been no recurrence of the functional paraparesis

It seem like it wasn’t a complete cure by any means. Being able to walk 500m is obviously a large improvement compared to being fully dependent on a wheelchair, but the impairment is still substantial.

Then there’s this of course:

A diagnosis of FND was established. Education and rehabilitation therapy were provided, but without improvement.

I wonder why..

The second case had paralysis and pain in her left arm and pain + sensory issues in her left leg.

She had a previous history of bipolar disorder and agoraphobia with panic requiring hospitalisation that had prevented her from working for 8 years. She was a heavy smoker. She had a history of childhood adversity with emotional neglect and physical abuse.

Why is the last part relevant?

She was diagnosed with FND, and an associated chronic pain syndrome. She agreed with the diagnosis and co-operated with physiotherapy, but with no improvement. She had a course of hypnotherapy and was able to get into a trance and practised self-hypnosis, but without improvement in her symptoms.

No surprise here either..

[She] noticed that her left arm had completely recovered during this episode, with normal strength and no pain. She expressed surprise that this had happened. There was a mild relapse a few months later, which recovered with mild leg weakness but she could use her arm normally. There were no more significant FND relapses, and she lived for another 16 years until dying of an unrelated non-neurological condition.

Seems like essentially a full recovery, but of much less severe symptoms compared to the first case.

 

[Utsikt]

They propose four different mechanisms that might explain these observations:

Attentional shift. There is converging evidence from clinical, neurophysiological and functional neuroimaging studies of abnormalities in brain networks related to attention in people with FND. The most common clinical tests of motor forms of FND, such as Hoover’s sign and the tremor entrainment test, depend on demonstrating altered motor function in relation to altered attentional states. An overwhelming and unexpected comatose state is in essence a huge ‘distracting’ event for the brain of someone with FND, which may be sufficient to disrupt the most firmly lodged involuntary attentional dysfunction.

I don’t understand how a comatose event would be a «distraction» for «the brain».

Expectation of treatment effect/placebo. For cases of sudden recovery with planned treatment, the role of expectation is clearly paramount. But this is also likely to be true of an unexpected physical or psychological event, especially one that is surprising and physiologically demanding in nature. The placebo effect is larger when the nature of the intervention is more dramatic. Heeg et al. and Fiorio et al. hypothesise that FND shares common elements with nocebo effects.8,9 Specifically, they speculate that FND and nocebo responses are different phenotypic expressions of a similar underlying neurocircuitry or cognitive processing dysfunction, in which cognitive and emotional processes such as hyperarousal, attention bias and negative prediction bias play a common mechanistic role.9

Both the cases expressed surprise at their improvements. I have no idea about how placebo could have been involved because placebo is supposed to be due to a mental state of expecting something to happen. It seems like they just wanted to talk about a pet theory.

Physiological ‘resetting’ during comatose state?Could a comatose episode followed by recovery be regarded as a ‘resetting’ of the brain akin to the Control+Alt+Delete command on a computer? Could the FND theoretically have improved by such a ‘reboot’ of the nervous system?

It is interesting that they put so little effort into one of the more obvious (and in my opinion interesting) theories to explore.

Recovery in the context of unexpected intensive medical treatment. In both our cases, the comatose state was not experienced as a planned therapeutic event. It could, however, still be suggested that such a serious and dramatic event allows the affected individual to offer arational explanation for recovery, to themselves as well as family and friends. Such explanations are sometimes phrased as ‘saving face’. However, this is a problematic phrase that tends to insinuate that the individual has conscious control over symptoms. Another way of looking at this is to consider the social context of waking up in an intensive care unit. Such a context is itself a powerful placebo which can modulate expectation of physical change or recovery without the need for any deceptive or wilful behaviour.

This seems like more misplaced speculation, and is also identical to the second point.

They end with this warning for anyone wanting to try this themselves:

Importantly, general anaesthesia is well described as a precipitating event for FND, rather than a therapeutic one. A team in Melbourne found 36 published cases, predominantly motor, as well as 8 out of their 107 FND clinic patients whose onset occurred within 48 hours of anaesthesia.15 It seems likely that the dissociating and threatening nature of general anaesthetic is much more likely to worsen FND than to improve it.

Of course they have to include their weird speculations again.

I think they have some interesting cases here, but I’m no expecting these authors to be able to pick up on any eventual insights that can be gained from it. They are seemingly stuck in their own ways. Maybe it’s a Functional Researcher Disorder?

 

[Yann04]

They are seemingly stuck in their own ways. Maybe it’s a Functional Researcher Disorder?

I mean Jon Stone is literally on the author list so par for the course I’m afraid.