Of all the medical specialties it may be argued that neurology, more than any other, provides the most exacting test of one’s clinical skill. OK, I am a little biased but that does not mean I’m wrong. I mean, the echocardiogram got rid of the cardiology examination and the respiratory and gastro exams were only ever making up the numbers. And honestly, when your endoscope is your best friend, who cares about anything else. As for rheumatology, well all their patients end up on steroids and methotrexate regardless of the diagnosis so it doesn’t really count and besides when those drugs doesn’t work, you know that the neurology referral can never be far away.
Bravado aside, it is true that until recently, there was very little for a neurologist to go by in terms of making a diagnosis aside from his/her clinical acumen. Even now, neurology clinical meetings are dominated by heated discussion that focuses on ensuring meticulous documentation of clinical abnormalities as a prelude to further investigation and treatment. Even for experienced neurologists, this process is at times difficult. Of all the challenges that are thrown at a neurologist, one of its greatest tests is separating out weakness that is ‘neurological’ from that which is ‘functional’. In other words, working out whether there is a clear neurological diagnosis at hand or whether the symptoms are based in other social and psychological factors, possibly coupled with underlying biological vulnerability.
A few years ago, Stone and colleagues from Edinburgh provided an outstanding review article in JNNP http://jnnp.bmj.com/content/76/suppl_1/i13.extract that served as a comprehensive overview of the presenting features, pathophysiological mechanisms and possible treatment strategies for patients with functional disorders. Table 2 in that review showed the many different ways in which clinicians communicate this diagnosis to patients. The authors provided the novel parameter of ‘number needed to offend’ to demonstrate how poorly some of these communication methods were received by patients. At the top of the list was ‘symptoms all in the mind’, followed by ‘hysterical weakness’ and then ‘psychosomatic weakness’. The paper also provided a range of more effective ways of establishing rapport and helping patients overcome their deficits.
In the most recent issue of JNNP, McCormack and colleagues have taken management of these conditions a step further http://jnnp.bmj.com/content/85/8/895.abstract . They have undertaken a retrospective review of the management of motor conversion disorders in an inpatient neuropsychiatry unit. In contrast to the long-term impairment that we often see in this condition, the authors demonstrated that patients treated in their unit experienced marked improvements in functioning. The authors correctly mention that further prospective studies would be useful in providing a reliable evidence base for the management of these conditions.