Ep. 197: Functional Neurological Symptoms Co-existing with Movement Disorders: Clinical Challenges and Opportunities

00:00:00: Welcome to EANcast, your weekly source for education research and updates from the European Academy of Neurology.

00:00:15: Hello!

00:00:15: And welcome to the EANCast Weekly Neurology.

00:00:19: My name is Sanma Aiebeck.

00:00:21: I'm a professor of neurology at the University of Fribourg in Switzerland.

00:00:25: This month's topic are functional nautical disorders.

00:00:29: In todays episode we will talk about possible overlap between movement disorders and function-movement disorders.

00:00:36: My guests today are Dr.

00:00:38: Gabriela Gilmore and Dr.

00:00:40: Kasia Smilowska.

00:00:42: So, welcome!

00:00:44: And thank you for joining us today.

00:00:46: To start with I'd be happy if, Kasia You could define functional analytical symptoms and describe how they commonly appear within movement disorders.

00:00:59: Thank-you very much for having me Today.

00:01:02: it's a great pleasure.

00:01:04: So let me start with the broader picture because I think that it's important context.

00:01:11: Functional neurological disorders, FND is really an umbrella term.

00:01:16: under that umbrella you have functional seizures sensory symptoms speech disorders function cognitive disorder and then functional movement disorders FMD which we are focusing on today And now.

00:01:33: functional neurological symptoms are generally experienced alertation in motor sensory or cognitive performance, which are distressing, impairing and totally real.

00:01:46: When those symptoms express themselves in the motor domain—and that's FMD— they can look like any movement disorder phenotype.

00:01:55: Tremor is most common followed by dystonia, myoclonus gait disorders.

00:02:01: Less frequently you see functional Parkinsonism, functional ticks, stereotypes facial movements disorders and in a large multi-center Italian study almost half of the patients presented with a mixed phenotype so more than one motor symptom occurred simultaneously.

00:02:23: And then what defines FMD?

00:02:26: across all these phenotypes are two core features, which is inconsistency and incongruence.

00:02:33: Inconsistency means that the movements arise so it's changed with distraction ,with attention .and with voluntary tasks performed by the same body part.

00:02:44: And incongrance mean that the pattern simply doesn't fit.

00:02:53: Thank you very much.

00:02:54: Could you please continue by briefly explaining the mechanisms behind the co-occurrence of functional movement disorder with disorders like Parkinson's disease or dystonia, ticks in terms of biopsychosocial model overlap of motor control problems and emotional motor networks?

00:03:14: Yeah, sure.

00:03:15: So the short answer is that brain networks generate functional symptoms are largely the same network that's disrupted by so-called organic disease.

00:03:28: The co-occurrence isn't coincidental it's more like logical coincidence.

00:03:35: First they neuroimaging.

00:03:38: in FMD It consistently implies a set of regions, which are the amygdala supplementary motor area, insula basal ganglia talamos dorsolateral prefrontal cortex and cerebellum.

00:03:55: So those are networks involved in sense of agency emotional motor integration response inhibition shift from automatic to conscious motor control.

00:04:09: And now, when you look again through that list those are precisely the networks that are being disrupted in Parkinson's disease and dystonia or in pig disorders.

00:04:20: The organic pathology of functional vulnerability share this same anatomical substrate.

00:04:28: so it is not a coincidence.

00:04:31: these diseases may co-cure the framework that has really unified the field and predictive coding dysfunction.

00:04:42: So we now understand, as a interference machine it constantly generates prediction about sensory consequences of movement... ...and updates those predictions by comparing them with incoming sensory feedback.

00:05:00: And when there is mismatch-a-prediction error In FMD, this updating process goes wrong.

00:05:09: The brain overweights its prior expectations relatively to the actual sensory feedback and symptoms emerge from that imbalance.

00:05:20: And in PD dopamine plays a crucial role in the exact process.

00:05:25: So dopamine helps balance bottom-up sensory information against top down predictions.

00:05:32: So when dopaminergic neurons begin to die and we know that this process starts upto fourteen years before clinical diagnosis, the balance is being disrupted.

00:05:44: And early dopaminergic loss may increase likelihood of mismatch between predicted sensory consequences of plant movements.

00:05:54: And that mismatch is precisely what drives the disrupted sense of agency we see in FMD.

00:06:05: So, In a very real-sense early PD pathology may generate condition for functional symptoms to emerge.

00:06:13: and third there's loss motor.

00:06:17: This is a particularly elegant parallel.

00:06:21: So again, in PD the loss of autonomic movements that are effortless background and non-conscious motor execution we normally take for granted forces patients into effortful top down conscious control off every movement.

00:06:38: so they have to think about walking They have to thing about arm swing And that conscious over monitoring of movement is mechanically almost identical to what we observed in FMD.

00:06:54: So PD and FMD share a final common pathway, so movements that should be automatic became constantly attended And this attention itself destabilized motor output.

00:07:10: Thank you very much for the overview I think now really a good view of the definition and some key mechanisms that you highlighted, in particular highlighted also these new findings.

00:07:24: In a way that prodromal functional symptoms could be linked to Parkinson's disease And this will open I think A lot understanding.

00:07:35: But now, I would like to go back to the diagnostic challenges really for how to make that diagnosis.

00:07:42: And I'd like to turn to you Gabriella if could outline what are key positive signs that help differentiate functional symptoms from movement disorders?

00:07:54: Yeah thank-you for inviting me today and i'm really pleased to be here!

00:07:58: You know...I think it's a place to start in.

00:08:01: answering this question is as we've been talking about is to focus on the fact that functional neurological disorder and functional neurological symptoms are ruled in.

00:08:12: And so, we can recognize this condition based on the presence of these positive clinical features, So this is a bit of conceptual shift, but the way we need to think about it in order to feel confident in recognizing these symptoms in our patients who have coexisting movement disorders.

00:08:38: And really should not be pressured having one single unifying diagnosis.

00:08:44: In terms how to recognize and examine for positive signs I would emphasize that inconsistency matters most And so we can see inconsistency in different ways.

00:08:59: Probably the most important way is with variability, So We've talked a little bit about this already.

00:09:05: but In practice what we might look for in a gait disorder or if somebody has a tremor Is changing patterns of abnormal movements over the course of the visit?

00:09:22: potentially a change in amplitude, although I wouldn't count that as being the only positive sign because we know amplitude changes for all tremors.

00:09:30: And we also can try maneuvers to see variability in different ways.

00:09:36: so distractibility is another important positive sign for functional symptoms and what we are seeing is disappearance of abnormal movements when patient's attention is directed elsewhere.

00:09:50: So this is, I find especially useful when we think about a tremor in somebody with Parkinson's disease.

00:09:55: So classically arresting tremor will become more prominent with mental distraction.

00:10:00: so... With my patients with Parkinsons i often have them relax their hands into the lap and tell me that months of year backwards for example which tends to bring out the tremor more whereas in case of functional tremor We may actually see it at opposite pattern And that tremor well reduce during that mental distraction.

00:10:18: So those are a few ways to kind of look for distractibility in that context.

00:10:24: Other positive signs to look for, for tremor would include entrainment so trying to change the frequency of the tremor using an externally cued rhythm.

00:10:34: and then we can think about other patterns functional symptoms like weakness where you might see a Hoover sign or give way weakness, Or in dystonia we may see co-activation.

00:10:46: Where there's simultaneous contraction of agonist and antagonist muscles with fixed posturing in patients with functional dystonian.

00:10:56: One sort of caveat In terms of variability that I would war...or i should say inconsistency That it would warrant for is Beware quote, bizarre gait.

00:11:06: And if you see somebody with a bazaar gate really ask yourself why is this bizarre?

00:11:10: What makes it odd in way that changes and as variable or their consistency in the bizarreness which case may not be functional.

00:11:20: So I think challenge when we think about all these positive signs how do then apply them to patient who already has other abnormalities of movement?

00:11:29: And so really I think spending your time watching the patients throughout the visit, watching the patient in different contexts.

00:11:36: So like during the examination when you're having your assessment and they are performing automatic movements even while their waiting room is very helpful... ...and if i'm video it's really helpful as well!

00:11:47: Yeah thank-you so much

00:11:48: Gabriella!!

00:11:49: I liked that fact about how we highlight now this shift of paradigm with a way to make positive diagnosis based on positive signs.

00:11:57: And actually, most of the signs or a large number have been now validated in terms of specificities and sensitivities that are pretty high.

00:12:07: But still sometimes it is challenging.

00:12:09: so could you walk us through common diagnostic pitfalls?

00:12:14: Or scenarios where misinterpretation of a sign is likely?

00:12:19: Yeah absolutely I think.

00:12:21: one thing i would emphasize before even getting to pitfalls really focusing on the entirety of the clinical picture, and one positive sign or possibly a positive sign for FND isn't necessarily enough.

00:12:34: And you want to think about the entire clinical context?

00:12:39: When I think about challenges in pitfalls and diagnosis there are four main ones that i'd like talk today.

00:12:47: The first thing is anchoring on the known diagnosis.

00:12:52: So if you have a patient who has a known diagnosis of Parkinson's disease, for example.

00:12:57: It is common to then attribute all new symptoms as they emerge that establish neurological diagnosis without revisiting whether there are potentially any condition happening like functional neurologic disorder.

00:13:11: so an example might be if the patients with Parkinson's had a new onset fixed foot posturing or dystonia.

00:13:17: this could easily be sort of attributed off period dystonia.

00:13:22: but when you actually spend more time through the assessment, you may realize that this is fixed at onset which would be very atypical for an off-period dystonia and it doesn't respond to levodopa.

00:13:32: And then that may sort of pull in this new diagnosis or these new concern of Fendi.

00:13:38: another example maybe a patient with longstanding Tourette syndrome who has relatively well controlled ticks who then develops functional ticks with, you know much more significant disability occurring later in life.

00:13:54: So I think the clinical pearl here is asking yourself does this symptom respond to that disease-specific treatment and way i expect?

00:14:03: or Is something else going on like the emergence of functional symptoms?

00:14:08: The next pitfall would be dismissal rather than drawing in the possibility of a dual diagnosis, FND and another movement disorder.

00:14:21: So sometimes when our functional component is suspected this may lead to under investigation of neurologic features and vice versa.

00:14:32: so I would encourage listeners never be afraid make two diagnoses.

00:14:39: these conditions aren't mutually exclusive And in fact, we're having an entire podcast episode about this issue because we recognize that these actually very commonly occur together with more than half of patients with FND.

00:14:51: Having additional neurologic disorder.

00:14:54: so don't be afraid to have two diagnoses.

00:14:58: Yeah thank you very much.

00:14:59: That's very important.

00:15:01: yeah did You want add something?

00:15:03: More on that Gabriella

00:15:05: I think maybe i had said four pitfalls but Maybe i'll just talk About one last One which would Be An Overreliance On Psychiatric History.

00:15:12: So if you're meeting a patient who has a significant psychiatric comorbidity, I wouldn't use this as evidence of a functional diagnosis.

00:15:21: We no longer require psychiatric comorability or history of trauma in order to make a diagnosis of FND and similarly we know that these things are really common in other conditions anxiety depression is very common in Parkinson's disease for example.

00:15:37: so always use those functional signs to rule in this diagnosis.

00:15:42: Thank you so much for this very important point indeed, thank you!

00:15:47: So now that we've talked about the way to make the diagnoses I'd be happy to have your view also Kasia on clinical relevance and particularly prevalence of how common are functional symptoms in Parkinson's disease or other movement disorders?

00:16:06: Yeah, thank you for that question.

00:16:08: I

00:16:08: think that clinicians in general underestimate how common this is and these leads to misdiagnosis and produce real harm.

00:16:19: so In general population FND prevalence it's about two percent

00:16:25: And then

00:16:25: in general neurology It would be even up to one-third of the consultations.

00:16:33: and in movement disorder clinics specifically, FMD accounts for up to twenty percent of the patients.

00:16:42: And now when we think about Parkinson's disease is a large cohort of nearly one thousand patients across neurodegenerative diagnosis.

00:16:52: FND was most relevant.

00:16:54: in Lewy body dimension it's up to twelve percent or seven percent.

00:17:05: And I think that every neurologist should know, in approximately up to fifty per cent of published cases where FMD and PD occur the functional symptoms appeared first so before the PD diagnosis was made.

00:17:25: The mean latency across studies is around four years but one cohort it almost fifteen years before the diagnosis of PD.

00:17:34: In general, FMD may in many cases be a prodromal manifestation of neurodegeneration and that has profound implications for how we follow these patients.

00:17:48: Thank you very important!

00:17:51: What are known risk factors or clinical correlates which increase likelihood of functional overlay?

00:17:59: So in general, the risk factors for functional movement disorders are the physical factors like trauma with minor injuries surgeries or severe illnesses.

00:18:13: that frequently proceeds the onset of symptoms and it can act as a trigger.

00:18:19: for the brain to develop the abnormal movement patterns.

00:18:23: Then, psychological stressors which we need be very conscious and also careful so that major life stressors like loss of loved ones or severe work pressure some financial strain then early lives adversity like the childhood abuse and traumatic experiences which are being sometimes reported.

00:18:50: Then, anxiety disorders, depression and PTSD.

00:18:55: we also know that FMD is more common in women but it of course can affect anyone and symptoms usually start with around late days but some functional seizures if we think about the epilepsy can start in late twenties.

00:19:15: And then there is some occupational risk, There are some evidence that suggests higher incidence among health care professionals probably due to increased exposure to neurological symptoms

00:19:29: And also possibly to stress.

00:19:31: like health care professionals are exposed to stress or multifactorial, right?

00:19:36: So yeah.

00:19:37: Yeah and thanks for pointing all of these factors.

00:19:40: they're very important when we assess and propose treatment to this patients.

00:19:45: talking about that the impact on daily life Gabriella could you tell us more?

00:19:52: how do functional symptoms influence the course prognosis or disability level in patients with movement disorders?

00:20:00: Yeah, I would think about this probably as a compounding effect on disability because there's disability that is going to come from Movement Disorder and also disability coming form the FND itself.

00:20:15: Having FND and Movement Disorders leads significantly greater disability than either condition alone.

00:20:21: Studies looking at patients with Parkinson's disease and FND found reduced quality of life, higher rates of falls, reduced mobility.

00:20:29: And greater caregiver burden in patients both compared to a patient with Parkinson diseases alone.

00:20:36: so definitely significant disability.

00:20:39: We know as well that there is an impact on how the disability responds to standard neurological treatment.

00:20:48: So when patients with Parkinson's disease, for example also have functional neurological disorder this can often appear especially if the FND is not recognized as an inadequate response to lipidopa which can lead to escalations in therapy.

00:21:00: And so patients may then start having more and more side effects into problems without therapy like dyskinesias hallucinations impulse control disorders and may even go on to more invasive treatments like deep brain stimulation, when really the FND has been failed to be recognized and managed accordingly.

00:21:22: When we think about the prognosis from the FND side of things... We know generally in large groups of patients that there's a variable prognosus with data suggesting FMD had better outcomes diagnosed early and managed proactively with things like transdisciplinary or multidisciplinary rehabilitation, which we'll talk about I'm sure later in this episode.

00:21:46: In terms of the prognosis specifically for patients with FND and other movement disorders it's a bit less clear in the literature.

00:21:54: This is definitely our research gap.

00:21:56: so hard to know exactly what you expect from The Prognosis perspective

00:22:01: And are there specific treatment strategies that differ?

00:22:04: when FND occurs alongside a non-functional movement disorder?

00:22:11: That's a good question, and I was sort of reflecting on this.

00:22:14: And i don't think so!

00:22:16: The key is to make sure that you're treating both conditions though So... Don't forget to treat the underlying movement disorder.

00:22:24: Make sure that it's well managed.

00:22:26: For example if there are Parkinson's disease Clearly and carefully at delineate, whether there are things like motor fluctuations or dyskinesias that are happening.

00:22:35: That would warrant a change in treatment there.

00:22:38: so that's obviously a bit unique for patients who have this comorbidity.

00:22:42: but I think in terms of treating the FND itself i would go through my standard treatment pathways individualized to the patient.

00:22:51: So you know if patients have functional movement disorders and motor symptoms physiotherapy um it piece of the treatment for these patients, focusing on motor retraining attentional redirection self-management strategies and reducing fear avoidance behaviors.

00:23:12: And how does this differ when somebody also has Parkinson's disease?

00:23:16: Now I think ideally your rehab team would have some familiarity with FNB and with PD or other movement disorders And I think thinking as well about how that's explained to patients and so they can really understand where their symptoms are coming from, and understanding why these treatments are both being sort of used.

00:23:36: Other things to think about would be psychological interventions for FNDs—so things like cognitive behavioral therapy can be useful to address maintaining factors, illness belief, chastrophysiation avoidance fears etc... And you can really sort of think of psychotherapy as being brain retraining, just like physiotherapy is brain retraigning in these patients.

00:23:59: Thinking about medications from the FND perspective we don't have any medicines that are specifically indicated for FND but it's important to think about comorbidity Like anxiety depression pain and whether any specific treatments or required.

00:24:12: there again I would caution Listeners to avoid just escalating Parkinson's medications unnecessarily when it is FND symptoms that may be driving the disability.

00:24:25: And I would avoid things like benzodiazepines, where there are functional seizures present.

00:24:30: and then you know i think the piece thats particularly unique with patients with movement disorders.

00:24:35: develop FND for patients with FND in general its importance of education really helping patients understand what is happening How are these symptoms being generated and how is that different from the other movement disorder that's present?

00:24:50: Yeah, thank you because what you just said also it very important.

00:24:55: Because before we can even offer all of our efficient treatment as you mentioned but need this step to really explain the diagnosis for patients.

00:25:04: I'd like now turn back to Kasia and ask you, what do think are the most effective communication strategies when explaining functional symptoms to patients?

00:25:17: Especially if they already have an established neurological diagnosis like we mentioned PD.

00:25:21: I

00:25:23: think that this conversation is crucial and fundamental.

00:25:28: What we've already discussed are positive signs And i think we should start first to establish it what we do see and don't, but based on the positive signs.

00:25:42: We should start with going through PD findings first.

00:25:47: so for example that patient has a tremor, bradykinegia then move to the positive sign which is functional symptoms.

00:25:58: And this sequencing, I think matters for the patients because a patient needs to feel that their established diagnosis is not being taken away before they can hear about something being added.

00:26:20: For example, tremor is entraining to the rhythm or disappearing when they tap a different beat with the other hand.

00:26:29: And this makes the diagnosis more visible and demonstrative.

00:26:34: I think it sometimes speaks for itself.

00:26:40: We also shouldn't go straight into stress factor So we should not say that all of these are related to anxiety because Usually, this conversation is being closed before it even opens.

00:26:55: So instead we should build a narrative that here are your neurological diagnosis and what does to your nervous symptoms?

00:27:05: And how the brain processed with movement signals?

00:27:09: Then of course you know words matter.

00:27:14: so avoid... terms as real, psychogenic historical or typical one that this is all in your head.

00:27:24: And then we should refer to the functional term because this is etiologically neutral, increasingly recognized and describes what actually is happening.

00:27:35: Then many of patients have been through years of diagnosis uncertainty and they are feeling disbelieved by multiple clinicians.

00:27:47: so before you explain the mechanism acknowledge years.

00:27:55: And then we should make cautious predictions for futures, those which are for the acute onset presentation probably early treatment will lead to much better outcomes and for patients with years of established functional symptoms We should be honest that this would take time.

00:28:17: Yeah,

00:28:20: thank you.

00:28:20: I very much like your practical approach and uh i like also the fact that You highlighted The term real because I think most of our listeners now probably are not talking about hysteria anymore But we still sometimes slip once in a while this word off.

00:28:38: it's not a real Parkinson or It's not a genian myoclonus.

00:28:42: And these really convey the message that there are two categories of disorders, and being really neutral about it is very good.

00:28:50: so we should probably stop using this terms.

00:28:53: Yeah exactly!

00:28:54: Sometimes you know...it's natural when they think I want to explain.

00:29:00: So we need to be cautious about them.

00:29:04: Showing signs also helps in communication like your highlighted.

00:29:10: I'd like to turn now into another approach.

00:29:14: We've discussed already with you, Gabriella a lot of the role of the physio and the psychology or rehab specialist that often also know those dual diagnosis but could tell our listeners when can neurologists handle themselves?

00:29:32: Or should they consider referral for specialized FND services?

00:29:38: Can you comment on

00:29:39: this?

00:29:40: Absolutely, I think that's a great question.

00:29:42: And and i think probably the answer differs a little bit depending upon where you are and what sort of specialized FND service may or may not be available.

00:29:51: so I can speak a little to our service in Calgary but also just In general thinking about You know What?

00:29:58: Are The referral criteria at your local center is really important.

00:30:02: So you Know what kind of specialized fndService offer.

00:30:05: I Think globally.

00:30:07: it's often dedicated inpatient or outpatient program that assesses patients with FND and can provide higher levels of integrated or multidisciplinary care.

00:30:21: There's also often opportunities for education, group-based therapies etc... So when we think about the situations where you might want extra help for your patient I would first think.

00:30:38: And so the idea being that not every patient is going to require these intensive FND services, and many may get better or manage their symptoms well with.

00:30:50: Their family physician there GP or neurologist alone for example.

00:30:55: So if you have a patient who maybe has moderate to severe functional disability that hasn't responded to some initial brief interventions That would be good candidate for an FND service.

00:31:06: patients not responded or had difficulty with symptom management despite trying a physiotherapy, or psychology services.

00:31:14: Or patients with complex presentations repeated emergency department visits they may also benefit from these services.

00:31:22: and you know in terms of diagnostic uncertainty especially as we're talking about patients that have dual diagnoses in this podcast I think for patients who have very complex symptoms that are hard to understand.

00:31:36: This is when getting somebody with a lot of experience seeing patients with FND can be really helpful, and the other piece to think about as if this service available to you has integrated neurologies in psychiatry or psychological care?

00:31:57: Yeah,

00:31:58: thank you very much.

00:32:00: triage will clearly depend on what is available But more and more services are being developed worldwide.

00:32:06: So this is very positive.

00:32:08: Thank You Gabriella.

00:32:09: one thing sorry I'll also mention Is i think it's really important to Think about the relationship you as a a clinician have with that service and how it's framed, that referral to your patients.

00:32:19: And I think developing a shared care model and not simply feeling like you're referring the patient away and not conveying that to your patient is really helpful in order to develop that rapport with your patients so they can understand rationale for these referrals.

00:32:36: Thank you.

00:32:36: We're arriving at the end of this podcast, but there are two things that I'd like to pick your brains too.

00:32:43: so maybe I can start with Kasia on practical take-home messages?

00:32:49: Could you tell us what would be key warning signs that neurologists should watch in everyday clinic when they think a functional overlay and have that

00:32:58: investigated?".

00:33:01: Yes, so in terms of PD the acute onset of new moderate symptoms that doesn't feed PD is expected gradual trajectory.

00:33:11: So for example big or huge fluctuations between days are spontaneous remissions because we know that PD does not spontaneously remit.

00:33:23: And then we should look also for the suggestibility.

00:33:26: So changes in the symptom with expectation or suggestion of intervention and a kind of mismatch between objective PD severity, and reported disability.

00:33:39: so For example when patient level functional impairment seems to be greater than this one that we score in UPDRS or other clinical examination that could predict functional overlay, and it should be of course considered.

00:33:59: Thank you!

00:34:00: And would you like to provide two-to three quick practical recommendations for clinicians managing these patients with MICT, Functional and Other Orders?

00:34:11: The first one that I would recommend is to diagnose based on positive signs and never by the exclusion.

00:34:41: Parkinson's, so we should remember that if we know that FMD can proceed PD by years a patient that is presenting with functional Parkinsonism today particularly.

00:34:53: If they are over fifty then this may be the prodromal phase of neurodegeneration And we should check for hypostmia, ask about REM sleep behavior and look for the autonomic symptoms.

00:35:08: We should definitely follow these patients so that diagnosis of FMD in this case shouldn't never be a discharge diagnosis.

00:35:17: it's just beginning with ongoing clinical relationship built by our patient.

00:35:26: Thank you And to close our discussion, Gabriella could you guide us in future direction?

00:35:33: For example what do think are currently the research gaps that still exist and how do you envision the future model of care for these patients.

00:35:44: Yeah I definitely think as we've highlighted already today there're quite a few gaps especially.

00:35:52: So a few things that we are at the highlighted today, or the limitations that we currently have in our understanding of prevalence and natural history when it comes to comorbidity of movement disorders end FND.

00:36:03: There's a lot of opportunity in this space to develop biomarkers And certainly as biomarker they're being developed for conditions like Parkinson's disease with the alpha synuclein seed amplification assay.

00:36:16: The opportunity for development of biomarkers from the FND side will also be extremely helpful.

00:36:23: And as we talked about earlier in our podcast today, thinking about mechanisms and what this teaches us on brain and neural networks that are involved with FND and other movement disorders.

00:36:42: when there is a dual diagnosis, if there are more specific recommendations when it comes to treatment.

00:36:48: And then in terms of your final question around future models I think i would just emphasize that you know FND as we've seen historically doesn't fit into a siloed model of care and I think the future really should be integrated clinics that combine different services so that we can treat people instead of individual diseases.

00:37:11: Thank you so much to both of you for today's episode and sharing your experience with these patients.

00:37:19: I wish all the best!

00:37:21: Thank You, Gabriela.

00:37:22: thank you Kasia.

00:37:34: This has been EANcast Weekly Neurology.

00:37:38: Be sure follow us on Apple Podcasts, Spotify or your preferred podcatcher.

00:37:43: You can also listen to this and all of our previous episodes on the EAN campus, E&Cast weekly neurology is your unbiased and independent source for educational and research-related neurological content.

00:38:18: Although all the contents are provided by experts in their field, it should not be considered official medical advice!