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Title: Functional neurological disorder in acute stroke and mental health services : a mixed methods assessment of experiences, prevalence, associated clinical factors, and treatment
Author: O'Connell, Nicola
Awarding Body: King's College London
Current Institution: King's College London (University of London)
Date of Award: 2018
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Functional neurological disorders (FND) present as neurological disease for which no organic cause can be found. These disorders are common, debilitating, and patients can present to a range of medical services. Little is known of the prevalence of patients with functional symptoms presenting to stroke settings, their experience once admitted to stroke wards, the demographic and clinical features of functional motor disorder (FMD) patients treated in psychiatric settings, or their response to psychological treatment. This thesis addresses this paucity of evidence. A systematic review and meta-analysis found functional stroke patients consistently present to stroke settings, constituting 1.7% (95% CI: 1.3% - 2.2%) of all patients with suspected stroke, with weakness the most commonly presenting functional symptom. A qualitative study using in-depth interviews with 14 hyper acute stroke clinicians, found participants named a range of potential causes of functional stroke presentations, but many felt unsure in how to discuss a functional diagnosis with patients. In a survey of 120 staff in hyper acute stroke wards in England, 90% of clinicians stated they do not believe there are clear guidelines on how to manage functional patients and 95.8% believed further research is necessary. A qualitative study involving interviews with 30 patients with functional stroke symptoms at one hyper acute stroke ward found many reported strong negative emotions in response to their admission and while on the ward, many believed they had had a stroke. Two months after discharge, many patients were uncertain about the cause of their admission and 40% experienced residual physical symptoms. Many expressed a desire for a more detailed explanation about the potential cause of their symptoms. A case-control study of 322 FMD patients found the disorder more commonly affects women, patients more frequently work in social or health care settings, patients often have carers or are themselves carers, and more frequently have comorbid physical and functional disorders when compared to a random sample of psychiatric patients from South London and the Maudsley NHS Trust. We found no association between experience of childhood sexual or physical abuse and an FMD diagnosis; however tentative evidence suggests patients experience precipitating events that could be defined as ‘disruptions to interpersonal relationships’. Finally, our case-control cognitive behavioural therapy (CBT) study indicates that both FMD patients and patients with organic disease respond to outpatient CBT. Half of the FMD group saw improvements in their physical symptoms, and measures of psychological distress and depression showed significant clinical improvement between first and last treatment sessions. Dropout rates from treatment were comparable between FMD and control patients. We conclude that functional disorder symptoms occur in multiple medical settings and present to newly established hyper acute stroke wards. A lack of understanding amongst clinicians about the nature of FND coupled with increasing financial pressure on the health service may serve to entrench patients’ symptoms, and worsen experiences in medical settings. Within mental health services, FMD appears to have distinct epidemiological characteristics but the fragmentation of neurological and mental health services mean patients are often under-served and lack continuity of care.
Supervisor: David, Anthony Sion ; Wessely, Simon Charles Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available