Um, so welcome everyone. Joining me is Dr. Daniel Goodman, an associate professor at the Shirley Ryan Ability Lab, and we'll be kind of tag-teaming this talk throughout, and I appreciate any questions. We'll have questions at the end. And today we'll be going over these learning objectives really starting kind of with the background of what is FND? And so one of the reasons that I got really interested in And then also thinking about which patients succeed and which patients fail in our programs. So, we'll be talking a lot about that. But first, I wanted to get a poll of the people in the room. And since we didn't have Poll Everywhere held up, I want you to hold your hands up for, kind of don't hold your hand up if you're not comfortable at all with managing, diagnosing, or treating FND. Hold your hand up super high if you love treating these patients and you really enjoy working with this population. And somewhere in the middle, if you're like, I kind of like this, I'd like to learn more, or I'm sort of comfortable with FND. So, what do we got here? Cool, so we've got some straight up in the air hands, some a lot in the middle, and a couple hands are down. Great, awesome. So, for those whose hands are straight up in the air, we'll be looking to your insight and expertise as well, kind of at the end of the session, because I think part of this is really learning from each other, because these cases and these patients come with such unique presentations, to learn how best to treat them. So, I'd like to step back a little bit and look more at the umbrella of what, where FND fits in underneath somatoform disorders, because I think it's important to know what is FND and what is not FND, because FND does respond well to rehabilitation and some of these other approaches do not. So, in the umbrella of somatoform disorders, somatization. about what the symptoms mean. And a clear point here is that now we understand that somatoform disorders can be a very distinct entity from depression and anxiety. So saying that the person is anxious and that's why they're having these physical symptoms is not kind of how we talk about it these days. And that 40% of people with somatoform disorders do not have a concurrent diagnosis of, or active diagnosis of depression and anxiety. So this is kind of a busy slide, just showing you kind of the whole branch under the DSM-5 of the somatic symptom disorders and all of the different subcategories. And I think really important to think about is on the far left, the somatic symptom disorder is a separate entity. can be much harder to manage in isolation with rehab only, as opposed to kind of what we're really focusing on today, FND, formerly known as conversion disorder. And I was talking to a friend yesterday who does MSK, and he was like, you know what, I saw a patient with FND yesterday in clinic actually, and I had to look it up because I didn't know what FND was, and I was like, really? And he was like, oh, but then I saw that FND is convergent. So I'm forgetting that there are people maybe who came to this session understand or know at least what FND is, but there are people out in the world who still haven't heard of FND, and so just thinking about that history or background of people may have heard of conversion disorder, so you can use that term, but that's not the current term that we are using now kind of in the research. So, under the DSM-5, the FND definition is kind of you have to fit all of these criteria so that there are one or more symptoms of altered voluntary motor or sensory function. The second point's the most important, kind of an incompatibility between the symptom and a recognized neurologic medical condition that another medical or mental disorder doesn't better explain it, and that it results in significant distress and impairment in areas of functioning. And so, kind of more simply, people think about FND as the brain's inability to send and receive signals properly, rather than kind of disease-causing or blocking that pathway, like a brain tumor might or a stroke. So this kind of neural network dysfunction, it's changing how the network is interacting or communicating across each other, not that there's a change in the structure of the brain itself, so there is no structural pathology in the brain, and that we really don't think psychologically traumatic experience, that's not necessary. And under FND. And for the purposes of kind of rehab and what we can really do for patients, we really want, I'm just going to give a little background about FMD, so Functional Movement Disorders. So this is kind of in one study looking at a cohort, a large cohort of people with FMD, 61% had a motor predominant feature to their presentation. And that many of these patients are being referred to movement disorder clinics. Not all of these patients are showing up at your hospital. Or that they've kind of gone through a variety. Um, so about 22% of given in the past few years compared to, let's say, like five or 10 years ago. I'm just seeing a higher number of these patients on consults. So I'll be curious kind of at the end to hear what other people are seeing in terms of trends. Kind of in looking at a meta-analysis of patients with FND, a higher percentage of people of these patients are women, but not all. So I've had one of our FND clinic days, it was like an all-male day. And the mean age of onset is 39.6 years. You can kind of see there's a higher percent, the most prevalent presentations are going to be the motor, mixed motor, tremor, and weakness presentations. And that kind of, in all of these different presentations, that kind of average age of mid-30s to 40s. And just kind of looking and thinking again about this pathophysiology. So what they're starting to do in the research world is looking at functional MRIs and comparing, let's say, like a functionally hemiplegic patient to a patient with a stroke, kind of in that same, with the same pattern of weakness, and kind of seeing what the differences in brain networks are. And so we're seeing abnormal neural mechanisms in several areas, particularly kind of the amygdala, so kind of our limbic system, hypoactivity in our temporal parietal junction, also hypoactivation in the supplemental motor areas, and all the premotor cortex. So really what's happening here is this kind of change in how the sense of agency of movement is altered because of this hypoactivation of these networks. And so there is a relative disconnect between the supplemental motor area and areas that would normally select or inhibit movement, like the prefrontal cortex. And so movements occur without a person feeling like that's something that they initiated. And that kind of disconnect suggests that that didn't feel like me making the movement. They're also seeing kind of with these functional movements in the supplemental motor area, is that important part kind of selecting action selection and movement preparation? So those of you who see like brain tumor patients with supplemental motor area syndrome, think about this as a network problem in that same area where they don't have that kind of selective motor activation, but there may be some automatic movements. And so with that, I'm going to pass this on to Dr. Goodman. Goodman. Hello. Good morning, everyone. Happy to be here. Happy to see everyone here in the audience and those online. Appreciate it. My own particular interest in functional movement disorders, I think, really started as a resident and rotating through and seeing some of these patients, particularly on our consultation services, being able to subsequently learn how they improved through the inpatient rehab side of things. Subsequently now, I'm the medical director of our consultation services, and I primarily see all of the patients who have suspected functional movement disorder or a functional neurologic disorder, which has only kind of helped to enhance my interest and desire in treating these patients and researching as well. One of the things that Dr. Lam had mentioned is this idea of the diagnosis and the frequency at which we're seeing these. I will agree. We've seen a really high increase in frequency of these patients, particularly with the onset of COVID-19, the social isolation, anxiety. Although these are not necessary for the diagnosis, they oftentimes can contribute as well. So we're going to talk a little bit more specifically about the diagnosis and how to make the diagnosis. Fortunately or unfortunately, there's really no single biomarker to confirm the diagnosis, which does make this particularly challenging. It is really based on history, symptoms. Physical exam is extremely important for this testing, but also considering the differential diagnosis of the presentation. Sounds pretty straightforward, but certainly, as we'll see, is not, or as you've seen yourself, is not always so straightforward. This is a nice slide. This is from a paper that specifically talked about functional movement disorders, though I think it does work really well for all functional neurologic disorders. It's a nice algorithm. So starting with, there's this idea of a functional syndrome. Maybe a patient's presenting with some symptoms that are non-physiologic, or there's a, quote, functional overlay that they're seeing, something along those lines, some sort of suspicion. Certainly taking good history, certainly understanding, was this a rapid onset? Was this progressive onset? Trying to understand, was there potentially a psychological element or a medical element that contributed to this? But also, again, thinking about, could there be another diagnosis that may be involved here? And then positive signs. So in the past, I think, as research and time has evolved, not only switching from this idea of conversion disorder to functional neurologic disorder, but also changing from thinking about that this is a rule-out diagnosis. You must rule out all other diagnoses before considering this. That's not the case as much anymore. There's a lot of positive signs. There's a lot of research pointing to positive signs that can help to, quote, rule in this diagnosis. So identifying those, but also considering, what are some of those rule-out diagnoses? What are some of the things that may mimic the syndrome that we're seeing? What investigations, what studies may need to be done as well? And in some cases, maybe it's so clear-cut as far as the positive signs that we're seeing, maybe you don't feel that there are additional tests that are needed. Many times, when we're talking about inpatient rehab or those patients that are in the acute care hospital potentially going to inpatient rehab, because the symptoms are so weak and they're primarily motor syndromes, most of those patients undergo some level of testing. We'll talk a little bit more detail about that. And then the diagnosis, FMD or FND. Does it fit? Does it not fit? Could there be comorbidity there as well? So again, this is a nice algorithm to think about. It really outlines broad scope, high level, what we're thinking about. So I'll talk about some examination strategies. So the consistency of the examination is a really important factor, particularly when we're looking at these motor syndromes when we're talking about going to inpatient rehab. But there are other changes in vision, changes in sensation, other symptoms, sensory symptoms that may be variable as well. So are they consistent? If you're seeing this patient, if you're admitting them to your inpatient unit or you're seeing them in acute care hospital, is it consistent? Is it inconsistent with another neurologic disorder? Or is there something that you're seeing on that examination in the history that is consistent with another disorder? Key thing is it doesn't adhere to typical patterns in many ways. There's a lot of different variability. Dr. Lamb showed that umbrella term or that umbrella picture. So there's really a lot of different forms. But it doesn't really follow with a neurologic, musculoskeletal, or other disorder. But you also need to think about, OK, if there's another disorder that looks similar to this that this may be mimicking, what do we need to do to flush that out? Whether that's on examination, looking at reflexes, diagnostic testing, thinking about what the understanding of that known disorder is and comparing that to see if there's consistency or not. I have a balance here because it's rule-in versus rule-out syndromes. There's been much more increased focus on these rule-in syndromes or these symptoms and examination findings. And there's much more emphasis on that as the research is coming out more and more. But again, you can't ignore the rule-out. Oh, this could look like a myelopathy. This could look like a stroke. We should rule those out. So balancing that does take some practice as well. If you're not sure, then perhaps err on the side of let's get some testing or has testing already been done? Many times when patients make their way to us, either if we're seeing them in outpatient, certainly if we're seeing them in the acute care hospital, many of these tests have already been done. They came in. There was thought of an acute stroke. There was thought of an acute seizure. So the emergency department or neurologic teams have probably already obtained a lot of the necessary testing for that. There's been a fair amount of studies out there that have looked at validation of these positive signs. So specificities range upwards of 64% to 100%. Sensitivities, much wider variability, but upwards of 100%. I think it depends on the confidence and experience of the examiner as well as the presentation and whether it's an isolated FND syndrome or a comorbid FND syndrome. There is good interrelator reliability. We're not going to go through. You could spend an entire talk doing all positive motor signs. We're not going to go through that, but there are a lot of good research out there. But I am going to focus on a few of the things that we look at. So variability, Parkinsonian-looking tremors, maybe there's variability in frequency, amplitude, maybe with weakness. Maybe the person cannot lift their arm, but then all of a sudden you're asking them to do a functional task where you walk in the room and they're texting on their phone. So there's a lot of variability that we can see with that as well as this inconsistency. Distractibility, sometimes we'll ask patients to count serial sevens backwards from 100 or state the months of the year backwards. As you distract them, maybe that tremor frequency changes. Maybe it diminishes. Whatever those symptoms are may change when there's distractibility. Interestingly also, sometimes we see enhancement. So when you're focused on something specific, it gets more pronounced. Oh, I'm having a lot of tremors in this hand. OK, let's test out that hand. Let's look at that hand. As they're doing it, those tremors get worse and worse and start to spread even into maybe the arm, the neck, the trunk, versus, OK, let's examine your foot now. And you're focused on the foot, but on the side, you're looking over at their hand, and that hand tremor has stopped now. So again, there's some of these where it enhances, but it also can distract very easily. So thinking about that, it's not just we're doing this exam maneuver. We're looking at that. It's looking at the whole thing. It's always sort of having that half a thought onto what is the presenting symptom while you're testing something else. Patients in the bed, I can't move my legs. I'm weak. They can't do manual motor testing. They've got strength of like zeros to ones. And then all of a sudden, it's like, OK, why don't we sit at the edge of the bed? And it's not conscious, but they can move their legs over and start to sit at the edge of the bed. So again, you see some of that as well. Other positive signs? So tremor, one of the interesting things with tremor is we can see entrainment, meaning whatever that frequency is that we're seeing, if you ask them to do something else, maybe they've got a hand tremor or foot tremor, you ask them to start tapping. With a different limb, the tremor of the functional limb may entrain and match that frequency. And so you can see that change. You can have them do it faster. Maybe it goes faster. Maybe it goes slower. Doesn't work for everybody, but again, as you're kind of building evidence and building evidence for FND or something else, you can use that. Co-contraction, so there can be a lot of co-contraction of muscles that also doesn't quite fit spasticity, myelopathy. It doesn't fit Parkinsonian-type features either. Whack-a-mole, so this idea, if you play the game whack-a-mole, you whack one spot, it pops up in another spot. So sometimes what you'll see in some patients, particularly with, I think, functional movement disorders, is if you can suppress it in one area, it may pop up in another area of the body. And then you suppress that, it may pop up in another area. So they call that the whack-a-mole sign. Other things regarding movement is it may seem like there's variable effort, or maybe there is variable effort. But again, some of that is related to the variable strength, the distractibility. It may depend on the other tasks or other elements of what they're doing. Uneconomical patterns, so particularly with gait disorders, abnormal functional gait disorders, patients have a lot of extra movements. If you had seen a patient with a stroke or a patient with an incomplete spinal cord injury, and they're ambulatory, they have adapted to find a way that is the most economical to get them from point A to point B. Some of these movements are grossly abnormal, uneconomical, also can potentially be distractible as well, but other potential signs as well. This is a video. I don't know if we can get this video to play. This is a functional tremor. Yes. 86, 79, 72. You could see that variability. You can see that distractibility. They're changing the frequency. The frequency of that other limb is changing. Now that they're focused on a single task, maybe the frequency is increasing. Very kind of classic presentation. This is a really nice video. Dr. Lam found this. Nice work. All right, wonderful. Thank you. So again, that's just a nice example of how to see that. And these are things that we do regularly on an examination when we're evaluating these patients. So when patients are coming inpatient rehab, you want to be quite sure that you're treating the proper diagnosis. Is there some other diagnosis that we need to evaluate? Is there something else that we need to test? So the common things that we're seeing, we're seeing those psychogenic non-epileptic seizures. Typically, they're having an EEG done, usually neurology or even the emergency department has done this. Ideally, you can capture events on EEG to, again, confirm that they're having seizures or confirm that they're not having seizures. Hemiparesis, any weakness that can certainly present like a stroke, intracranial tumor, spinal tumor, demyelination, and some other abnormalities. So oftentimes, we're getting MRIs, sometimes of the entire neuro axis, brain through entire spinal cord, to really rule things out or, again, rule in, depending on what we may be seeing. Many times before we're even seeing them on consults, these are already done or they're in the works. Patients presenting with paraplegia or even tetraplegia, think about, OK, are we getting spinal imaging, typically MRIs? Sometimes we're thinking, oh, they've maybe had a comorbid trauma or they've had another comorbid issue. Maybe we're even looking at, like, could this be a plexopathy and maybe so even getting imaging of that or even potentially getting EMGs. Sometimes we're doing EMGs for patients that may look to have a neuropathic-type element, a peripheral nerve injury or plexopathy. So some of you may be doing that, again, depending on the timing and presentation based on history. I could probably go on all day about diagnostic pitfalls. One of the important things about treating these disorders is you can't have a big ego about this either because things may change. Imaging may change. The presentation may change. I don't like to think of myself having a big ego about this, though my head is inflated today. But that being said, you have to sort of give yourself a little bit of a break, too, in understanding this and treating this because it can be very challenging. So a lot of neurologic disorders or other psychiatric disorders, particularly those somatoform disorders, may appear consistent with FND. So pitfall is failing to consider other diagnoses, again, based on history, exam, understanding other physiologic and neurologic patterns. Maybe they've got an overlapping diagnosis. I'll talk a little bit more about that. Maybe they're coming in and they've already got a diagnosis of FND, and everybody's kind of dismissing that and being like, oh, this is FND because we know they have FND. Or they've got PNES, so they're coming in with seizure-like episodes. Do they warrant an EEG? Do they warrant other testing just because they carry that diagnosis? Too much emphasis on a single sign. Again, I talked about a lot of different positive signs. Relying too much on one sign can sort of blind you to making that. Inappropriate or inaccurate interpretation of testing. People love the Hoover sign. People talk about the Hoover sign all the time. The Hoover sign is oftentimes overused or used inadequately. People will say, oh, they have a positive Hoover sign, and we go in and see them, and we're like, they actually have a negative Hoover sign. So understanding the tests, understanding the imaging, and understanding how that can have interplay with this variability and distractibility of the examination as well. Assuming that a bizarre gait pattern or even a bizarre symptom is functional because you don't have a better explanation for it. Maybe it is, but maybe it's not. So sometimes thinking outside the box and thinking about other things that may be contributing here. Bias. Thinking about patient factors, we put up that other slide. At least that particular study, most of the patients were women, the women tend to be diagnosed a little bit earlier in age. Thinking about that internal bias and how do you remove that and really look at this patient? Maybe they have a history of anxiety. Sex, gender, irrelevant. Maybe they have some other syndrome that certainly maybe puts them at risk of this, but you can't necessarily say just because of that that you're not considering other diagnoses. And there is functional imaging. So SPECT imaging, functional MRIs can show some findings. They can show abnormalities and changes in blood flow. But even still, even within the same patient, those may change over time. We're not regularly looking at those. They're really not into the mainstream yet. I'm curious, Dr. Lambert, later when you talk, if you guys are ever looking at functional imaging as well, I'd be curious to know about that though. We're not looking at this in most cases, particularly when we're in the inpatient, acute care side of things, looking to admit patients to inpatient rehabilitation. The comorbid disorders. This is where it gets really a bit challenging. You can certainly have coexisting disorders where functional neurologic disorder is one of those disorders. One of the things we're oftentimes seeing in the documentation or question is like, oh, there's a functional overlay. Patient has multiple sclerosis and they have a functional overlay. It's not really precise terminology, but as someone who sees functional neurologic disorders, I understand what they're trying to say. They're basically trying to say that we've got MS, but these other symptoms, these other exam findings, these other things that we're seeing are not consistent with MS or whatever the underlying neurologic disorder is. What gets really challenging is when you have a comorbid disorder that the FND can actually mimic that same underlying disorder. So for example, someone with a history of PNES can also have a seizure disorder. I actually see it quite frequently. So is this true epileptic seizures? Is this PNES? Could both be happening. Maybe you have a TBI patient, traumatic brain injury patient who has underlying hemiparesis and spasticity and now they're coming in with worsening spasticity or worsening hemiparesis changes in those symptoms. Do they have a new stroke? Do they have a new evolution of their TBI? Is it functional? How do you tease these out? It can be quite challenging. Patient with myelopathy, maybe they've got spasms, they've got spasticity, they've got clonus, maybe they've got an infection and now all of a sudden they've got worsening abnormal movements. Where do you separate that? Is this related to myelopathy with infection or undertreated spasticity versus functional. Can be, again, quite challenging. I have a couple of patients who have a history of cardiac arrest and a post hypoxic myoclonus who also have functional tremors. Where do you draw that line? We kind of treat both, both many times. But the tremors that we're seeing, there's some element of them that is distractible. It is variable. So again, can be really quite challenging, especially when these patients show up in the hospital and people aren't familiar with FND or familiar with some of these other rehabilitation kind of diagnoses or sequelae. Again, think about other neurologic disorders where FND is not consistent. The symptoms are not looking like FND. We have this other underlying neurologic disorder or suspecting another neurologic disorder. Where do you draw that line? Try to delineate that. Try to discuss that with the patients. There's a lot of things to sort out. And again, sometimes we may not always know exactly where one starts and one begins or how much overlap there is. The good news is oftentimes in inpatient rehabilitation, we can treat both. But we definitely, if we really have a high suspicion for FND, we make sure that we're treating that element as well. All right. All right. Communication is really, really important for these patients. Explaining the rationale, explaining the mechanism. Right? We talk about maybe a hardware-software issue. Maybe some of you have heard that kind of terminology before, but thinking about the hardware being the brain, the actual nerves themselves, versus a software issue, the function of the nerves, those networks. There's abnormal pathology. Sometimes we talk about like a smartphone like a smartphone and a glitchy app, right? Thinking about how do you, what do they do to, you know, these symptoms are, the hardware itself is fine. The structure, the memory, the case of the phone is fine. But the app, the function is glitchy. Genuine symptoms, making sure that they understand that. These are genuine symptoms. This is not all in their head, though it is related to brain dysfunction, but not related to brain structure. Talk about prognosis and resources. And in most cases, again, there are some cases that are refractory. But in most cases, they actually have a really good prognosis. There's no structural pathology. If it's truly an isolated FND syndrome, we expect them to get better. Discussing this with the patients, the explanation, the understanding, empathetic approach, that in and of itself can be therapeutic for them as well. Just understanding. Someone understands me. I'm not making this up. They've oftentimes been dismissed for years, months to sometimes years, right, for these patients. So someone understands me. This is a real disorder, right? That in and of itself helps reduce that anxiety, reduce those questions, help them to move forward. It is important to gauge their understanding of that, particularly if we're looking to bring them inpatient rehab. That's important for recovery. It's important for outcomes. Sometimes you'll see this term non-organic. Non-organic is really not specific, especially when you're talking about exam findings. Again, that's more of a judgment call. So I personally don't like that term. I like terms like non-dermatomal, non-physiologic, non-myotomal. They're more precise. And there can oftentimes be a lot of stigma associated with these patients as well. And so using these terms kind of helps to reduce some of that stigma as well. All right, we're going to turn on Dr. Lam's microphone as well. We're going to kind of do a little back and forth here. So she's going to provide some additional insight. Yeah, also, we got a couple of questions in from the virtual. So some great questions here, kind of thinking about, again, how do we differentiate this from malingering? If someone, if Neuro says they have FND, but then they're starting to develop something that looks like spasticity, even though the MRI is negative, how do we kind of tease that out? I think this just really points to the fact that you need to trust your own and have a really good understanding of your own diagnostic skills. So we should be experts in being able to measure spasticity. Is it really a velocity-dependent tone? What is the pattern that's coming out? Is it proximal to distal? Is it just in isolated muscles? Is it in patterns that we would see in a stroke? And then in terms of kind of differentiating this from malingering and factitious disorder, this is where I rely really heavily on my rehab psychology colleagues. So I started our outpatient, our intensive rehab program for FND with my co-director, Dr. Ivan Moulton, who's a rehab psychologist. And I think having a person like that involved in the evaluation of these patients to prepare them for rehabilitation is really crucial to make sure that our rehabilitation plan is successful. And then in terms of diagnosis, I think there's a huge back and forth between, depending on which neuroattending is on, and their own comfort level with the diagnosis and giving the diagnosis of FND. They try to punt it to us to be giving the diagnosis. And I think that's important for us to be able to back up the diagnosis, to be able to confirm, yes, this is, in fact, a Hoover sign. We can see the inconsistency in how they're walking and how they're giving their strength on exam. But that I really do pressure the neurology teams to be clear in ensuring that the workup is done, that the person's not left at the end of the day wondering if this is MS. We have a patient who thought he had ALS. And he did have upper motor neuron signs, because he had cervical stenosis and a cervical myelopathy. So we did his rehab for his incomplete SCI. And at the end of rehab, he still thought he had ALS, even though the EMGs were negative and everything. So I think he's still thinking he has a progressive disease. And in doing so, it has not improved, unfortunately. We got him a little bit better from rehab. And then he started declining again. So I think this buy-in piece, having good communication with the patient, being really clear about your goals and your functional outcomes, but it can be challenging when there is an underlying or comorbid neurologic diagnosis, that these people with MS, with a real diagnosis of MS, are waiting for that next lesion to happen, that next demyelinating process to happen. And that can bring a lot of worry and fear that can precipitate symptoms. I think also on that same note, when you're trying to think about, could this be a malingering picture of something else, factitious? Sometimes we don't, honestly. Sometimes we tease that out later, or it becomes apparent later. It's one of the pitfalls and one of the challenges of not having a really specific test that can help this. But if we're consistently seeing these inconsistencies, then that can help guide us to that. And also understanding, as Dr. Lam said, about the psychology element of that as well. So one quick thing about functional imaging. Do you guys rely on functional imaging at all? Or do you guys use that? We don't do that right now. There's some cool research on it, but we haven't been doing that for F&E. Yeah, neither do we, but just curious. All right. I'm going to hand over to Dr. Lam again. All right. One of the other questions that came on virtual was about, well, how do we justify inpatient rehab? And so I'll talk a little bit about, how do we make sure these patients are ready for rehab? And then talk about that justification for inpatient rehab. So one of the key points that's borne out in the literature, but also that we've seen, is that it's important to have an interdisciplinary approach towards these patients. Ideally, if you do have support from rehab psychology or a mental health person in your team, that's extra important. And I think it's key to also know that the therapists are working together so that each person isn't working in isolation. But we do a lot of team huddles and communications about where this person is in their recovery and whether or not they're making progress towards improvement, or where they're getting stuck. And in our team, our rehab psychologist helps to coordinate that approach and then provides the cognitive behavioral therapy that is integral to also treating this diagnosis. Sorry. That's this side. So I think the other points about beginning rehabilitation. So thinking about, we've already talked about, we have to give the diagnosis. And that, ideally, that's had their evaluation completed with no outstanding differential. Like, oh, we'll rule out MS later. And that they should be told that they have it in clear, supportive, that's key, supportive, unambiguous terms. I've definitely walked into the room and they're like, well, that neurologist has told me it's all in my head because I'm anxious and that I have a history of anxiety. And that's, I feel like I'm not trying to make this happen. And so I think using that language around kind of re, sometimes our role is kind of going back in and kind of sweeping it up a little bit to help people be more confident in the diagnosis and understanding that their prognosis recovery is good if they really do feel that this fits with how they're presenting. So kind of having that buy-in. And then this is kind of the malingering part. Being clear, there's no clear evidence for secondary gain. And we've definitely had some patients show who, who in one breath is like, I really want to get better. I want to be able to walk again. And then the second breath, and I'm really hoping to get social security disability so I don't have to work again because my F and D symptoms. And it's like trying to tease out, well, I get that you're in a financial straits because you can't work because of this. But if we get better, then we don't need to go through SSDI. So it's like how much of their focus is actually just on this getting SSDI versus like actually getting better. And that kind of like secondary intention piece. And then, like I pointed out before, that whole umbrella of somatoform disorders, like making it clear that it's not one of the other somatoform disorders, and really that it's kind of F and D, or as much isolated F and D as possible. It's going to make it a better rehab case. So again, looking at that umbrella, which of kind of these pieces under the umbrella are most appropriate for a rehab program? We really think about the kind of motor related ones, right? So for inpatient rehab, we have to have at least two out of three disciplines, right, PTOT speech needs. And so if people are presenting with new functional weakness, a pretty significant gait movement disorder, that those may qualify. They kind of check that box for meeting criteria for inpatient rehab. We have one in consideration right now, one of our hospitals who also presented actually with functional swallow, so to the point where they put in an NG tube because she hadn't eaten for two weeks. And they're like, well, we can't bring her on just swallow alone. And I'm like, well, the PT note here says that her walking is so inconsistent that she's shuffling. Her OT note says she can barely put on her clothes and that she can't get to the toilet. So I think we've got enough to work on here. But if we're just focused on one of them, we do need to look at the whole picture and like make sure that we do have kind of at least those two out of three disciplines addressed. And then kind of, so the, we rarely, I think it's not often that we will add in the speech for functional cognitive disorders. I think oftentimes we encourage patients that if we can really use our three hours a day to focus on the functional gait disorder, that their kind of neuro fatigue and their functional cognitive disorders might improve because they are spending so much energy, like physical energy on this abnormal gait. And that if we can fix that and also just do CBT to help them with kind of understanding what's going on with their body and kind of reconnect those networks that their functional cognitive things get better. But every now and then we have a patient who maybe also had like a concussion or a kind of a mild TBI that kicked off the whole thing. And so we do need to kind of work on some of those functional cog or speech issues. A lot of these patients will come also with some psychogenic non-epileptic seizures, so PNES. PNES alone by itself isn't really enough to bring them into inpatient rehab, right? These kind of episodic intermittent symptoms or people with like intermittent spasms that come like every several hours or something like that. It's gonna be really hard to justify doing three hours of therapy if for two hours of the day they have the symptoms and the other like 22 hours of the day they don't. So those patients wouldn't be appropriate for inpatient rehab per se. And then when we're thinking about suitability for actually participating in rehab therapies, can we identify specific treatment goals that the therapists are gonna work on? Again, these intermittent symptom people, it's really hard to work on a goal if they're not presenting with the symptoms at the time that the therapist is working with them. If the patient themselves has no confidence or openness to the diagnosis, then it's really hard to make progress with that. If they're really concerned they have progressive ALS, they're just gonna keep worrying about that and have progressive symptoms. There is a bit of a caveat there though because some of it is like showing them that working with therapies is helping them move a little bit more or do a little bit more. That can help both reinforce the validity of the diagnosis, reinforce how well rehab can help them and maybe kind of get them on the same page of like, oh, my goal is ultimately to walk and now I can move my leg because of therapy then we can, maybe now I believe in it a little bit more. And then again, that hasn't received a determinative diagnosis of FMD. So in some levels this can limit potential for improvement. Again, if they're worried that this is MS or something else. But we actually have educated our therapists a lot on this diagnosis so that they can help document and just, because they're spending like 45 minutes with a patient on the acute care side. So we're asking them to document the inconsistencies that they're seeing. Like they've seen enough abnormal gaits and enough stroke patients and all these other, but they're like, if we're seeing a walk that's not consistent with something they've seen before, we just have them describe it. Like what does it look like when they're moving in and out of bed? Patient says they can't lift their leg but they're able to kind of do this transfer with min assist or like standby assist, which wouldn't be expected if they had zero out of five strength. So kind of using those therapists as extra tools to support the diagnosis. And then point out to the patient, look, you're able to do X with therapies even though you can't move your legs. This is showing us that your voluntary kind of, your voluntary actions are impaired through this network glitch, but that physically your body can do it. So we're gonna use rehab to help you retrain that. I think another thing that comes up a lot, questions from the therapist is, well, the patients, you know, the nurses are like the patient's falling, like they fell last night, they're falling again tomorrow. And I think when we're worried, like when they will fall again, you know, hospital being hospital, really worried about their kind of fall rate, right? We don't wanna get danged for fall rates, but falls in FND are considered low risk for injury, that there is some automatic preservation within the body system, even if they can't control. So they might look out of control, they may have a near fall or kind of lean into a wall, but that it's very unlikely for them to actually fall and hurt themselves. And so it takes a lot of work to make sure the team is comfortable with stepping back and actually allowing for those near falls and loss of balances to occur and kind of ignoring it, not to the point where it doesn't happen, but like allowing it to happen and then moving forward with therapy instead of being like, oh, let's call the falls nurse and let's make sure the rapid response team comes, like try to reduce that alarm. We've definitely had a couple of cases though where people have FND, we're working on their gait retraining and they fall and they actually do injure themselves, like hit their knee or kind of tear their back out or what have you. And so in those cases, it's important to have as the physiatrist have examined them before and I do a lot of prescreening to make sure, does this person also have pretty significant like hip OA or kind of peripheral neuropathy from their chemotherapy from however many years ago that also puts them at risk for falls or are they having kind of syncope, are they having hypotension, orthostasis or something else that could put them at risk? So doing that medical evaluation, if someone actually injures themselves with an FND fall, then you should be kind of putting on your diagnostic hat and thinking what other factors could put them at fall risk. And then the other thing that comes up a lot is, okay, this person also has PNES, what are we supposed to do when they have a episode in the middle of our session? So the key is kind of in training people, your therapists and your nursing staff to recognize what is a typical PNES seizure versus if someone also has comorbid epilepsy, what those typical epileptic seizures are like. So most people with epilepsy know, okay, I have seizure type A and seizure type B and this is how long those typically can happen. And then this is kind of the PNES features that might occur. And so kind of being clear about knowing what those episodes look like for this particular patient and making sure that the staff isn't raising alarm with each of those, allowing them to pass and settle and moving forward again. But it is again, important to make sure, you know, if someone has epilepsy, which ones are the PNES episodes and which ones are not and being clear with the team about what's what. And then if the therapists are able to, then coach them in to some techniques which we'll talk about later to help them move forward. I think another key point is if you or one of your team members doesn't, really still thinks at the end of the day, even though there's more literature out about FND now, still believe that it's all in their head or they just want to get out of going to work, that those providers should not be involved in treatment. And we kind of know which therapists on our teams, like which teams are kind of more willing to work with these patients or kind of have more understanding of how to coach these patients through. And so try to put the FND patients on those teams or do more education and training with our team members. So I think this is like super key. If you also don't believe that this patient can get better or like frustrated about this diagnosis, then you shouldn't be treating it. And hopefully this session helps you become more comfortable with this and confident. So just going through a couple of different approaches. This is the one that we use at UW. It's a protocol approach where we're working patients through a structured hierarchy of increasing difficulty. It doesn't matter if the hierarchy is linked to the problem. So we kind of use the same protocol for someone with functional weakness, functional paralysis, functional gait disorders, functional tremors. The point is more that there's steps and they have to pass each step to move forward. And that if we don't, if we can't reduce our symptoms with a certain step, that we move back a step, keep working there and then move forward again. And if we can't progress further, then we need to look at what other factors are keeping someone from progressing. And we actually don't just keep pushing it. We actually discharge patients early from the program if they're not progressing. And say, maybe there's some other factors we need to work on here. Or like your chronic pain is interfering so much with your kind of brain networks that until that is better treated, we're not gonna be able to move forward with your rehab program. So this is kind of an example of like side by side, like what our PT program might look like. Starting with super basic, like we kind of talk to them like, we are retraining your body from the ground up. Weight shifting, just in standing, then unlocking the knees, then marching in place, and then walking, and then walking in uneven, crowded spaces. Kind of more dynamics, balanced stuff with a lot of external stimuli. And then OT, we kind of have a parallel thing that they're working on so that their OT isn't progressing further than where PT is working at. And that nursing also kind of knows what equipment a patient should be using. So we're actually not, in inpatient rehab, we're not having patients who aren't at the walking stage walking in the room or outside of the room. We're having them kind of stuck in that thing, so we're reinforcing normalized movements at that stage. And again, you've never made a protocol before, what if the protocol is wrong? Never done this before. It doesn't really matter exactly what's in each protocol. It's more that we believe that this is kind of a motor retraining model, that it's tied to normalizing function, and that we have clear rules to progress them through it. And then kind of an alternative approach, I think the literature kind of coming out of Great Britain that works a lot on this, and kind of attentional validation of normal movement. So this is kind of, you know, taking the PT example where, oh, well, you couldn't lift your legs for me on manual muscle testing, but look, you were able to come to the edge of the bed and scoot your legs over. That takes motor movement. So kind of, we are validating and showing you that your muscles are working, and that we just need to kind of reconnect that. Or using distractability to distract them from a task, and then seeing, look, your leg moved now that we are distracting you, or look, your tremor reduced, and kind of showing them that actually it's just those patterns that are glitching, and that we can kind of help retrain out of it. I like this diagram. This is actually done by a patient who experienced, who has FND gait, and kind of expressing, like, what's happening, this glitch, right, that we have normal default motor pathways. We end up developing these default FND symptoms. And to learn to change out of that, PT kind of rehab is one of those approaches, but that there are other therapy tools that need to be incorporated to help people change and shift back into normal function. So I'll go through some of those therapy tools, including kind of just exercise, like regetting people back in tune with using something like an exercise bike or something, which is just kind of repetitive movements, can kind of get those motor patterns running again. Encouraging automatic movements over isolated movements can be helpful. So instead of focusing on just, you know, bicep curls, we're going to focus on kind of pulling the sheets towards you or kind of scratching your face or kind of feeding, like, those kinds of tasks, so task-specific or automatic movements over the isolating movements. I think some key things we use a lot, and our therapists actually coach our patients a lot on, is rest resets, so kind of this nervous system regulation. If our symptoms are starting to escalate during a session, to stop, take two breaths, kind of feel your feet on the floor, ground in, and try to use things, whether it's grounding, progressive motor relaxation, breath work, to reconnect kind of that mind-body connection to then try to get them out of those symptoms again in the middle of a session. And there's a lot more in the literature, and we'll have a little references page at the end. I think the other key point is that all of us, everyone on the team, can address psychological targets, so not just our rehab psychologists. They're going to be doing some in-depth sessions in cognitive behavioral therapy and kind of looking at these, but I think all of us can point out and remind people about and understand these targets, that in a lot of these patients, it's a selective attention problem, right, that their symptoms are over-perceived. They're kind of over-focusing on them, right, so focusing on the tremor makes the tremor get way worse, that patients are catastrophizing or worrying a lot about a diagnosis or a disease, so that's why that communication of the diagnosis and confirming that it's not something that's progressive or kind of structural is important, and that one of the things our team also really tries to coach people on is to reduce high healthcare utilization. Like, okay, well, if you get these PNES episodes, you know the skills to quiet yourself down. You don't need to go to the ED the next time that you have them, and that you don't need to then not go to school because you had a PNES episode at the beginning of the day, or if you have one in the middle of the school day, kind of do your resets and move on, so kind of teaching people to move forward and kind of stay active in their social kind of activities, and another thing we work a lot on is not just coaching the patient, but who's around them, who's either, you know, I mean, they're trying to help the patient. They're trying to support them, but sometimes that can be overly supportive or kind of overly reinforcing of the disabling role, and so there is some work that we have to do for family members, too, and just quickly, you know, pointing out these kind of common beliefs that patients are kind of going through their head, that if it hurts when I'm doing something that's harmful, if I have symptoms, there's going to be an identifiable kind of structural cause. If I don't worry about my health, I'm likely to become ill, and like all of these things, I have to have a doctor or, you know, a specialist look at my symptoms every time they crop up, so trying to kind of quiet these down a little bit, and then kind of pointing out some things that our therapists should avoid is, I mean, that it's important to coach the whole team on how to help treat these patients, but if the therapist is like super worried about the kind of rigidity, you know, that they're seeing on the exam, and they're like, oh, have you thought about Parkinson's or this person's falling a lot? Like, let's stop therapy and make sure that there's not something else going on, or like, oh, well, your hamstrings are showing that they're weak, so we're going to really focus on strengthening hamstrings. Again, trying to help them understand that we're not trying to focus on the symptoms, actually. We're just trying to help them progress through kind of motor retraining. Trying not to give them more equipment. I mean, in our program, we start with the wheelchair at the basic level, and then we take things away. If we never kind of add things on to whatever their presentation is, if we can help it, or send people home with walkers and things like that, or, you know, you should have a walker on hand just in case these happen again. Like, that's really what we try to avoid doing. And I'll be curious what Dr. Goodman does with that. And then we've had some therapists, like, well, it seems like you must have some really, like, really significant trauma that you need to work with. And we're like, ask the therapist to step out of, like, you do not need to be the psychologist in this role. We don't need to delve into their, like, mysterious past or try to figure out why this is happening for them. But that's not their role, so kind of not having them figure it out for us. And I think there's a lot of terms out there that can still be stigmatizing, psychosomatic, malingering, it's all in your head, these kinds of things, so trying to coach them on how to actually talk about this diagnosis. That's a little bit more accepting for the patient. And then what are we looking for? So, awesome if we can get a patient who comes in with, you know, functional paralysis to walk out completely normal with normal strength. We've had plenty of patients who go through our rehab program in with a lot of symptoms, some even after, like, years of symptoms and come out fully normalized. But other things, you know, just looking at, you can measure objective skills, improving kind of gait speed, things like that. But I think the most important thing, for me anyways, is that a positive outcome is helping people understand and control their symptoms and reduce healthcare utilization related to their FND and kind of have more knowledge and kind of ownership of their own symptoms. So again, in that awareness of their triggers or stressors, kind of that symptom resets and kind of that reduced anxiety about their symptoms. Because for a lot of these patients, they will reoccur. So again, the question earlier about, like, how do we justify inpatient rehab and get insurance to cover this? And honestly, it's hard. For many of these people who have straightforward FND with really no other kind of comorbid medical diagnoses, they don't have, they don't, insurances aren't finding what's that medical necessity for inpatient rehab. Every now and then you'll have someone who also has, like, chronic pain and you're, like, adjusting their pain medications or something like that. Or maybe they do have a diagnosis of MS or, you know, prior stroke, and so you're working on spasticity and some other things. But for many, it's like, you have to convince the insurance that the gold standard for treatment for this is rehabilitation, that a coordinated rehabilitation approach is really the most effective for getting these people from coming into the, you know, I've, like, gone to the insurance, like, well, this person's come into the ED five times in the past, like, three months, has gotten no specific diagnosis until now, and we have a program that can treat this patient and get them out of the EDs, back home, back working, and, like, not using up your insurance dollars. So wouldn't you want us to do your rehab? And we can do this in two weeks and be done with it. And, you know, sometimes insurances will be like, sorry, that still doesn't meet medical criteria. So one of our patients actually discharged with a walker and, like, to the outpatient, where, of course, she couldn't get into therapies in a timely fashion, started falling, came back in two weeks later, and we submitted again, and I put in a much stronger, like, do you see, this is why I said we should do this the first time around so that we wouldn't have this, like, readmission, and they did approve it the second time. But it required two ED admission, like, ED to hospital admissions to get insurance to agree to do what we wanted to do, and then we got this person home with no assistive device. And so we kind of created this outpatient program to mimic inpatient because we were getting so many denials. So this is kind of, we have some data to show you just about, like, positive outcomes that we developed because the patients were getting discharged from the hospital with an FND diagnosis and no insurance approval for FND. They were getting into maybe PT, but then three weeks later, an OT slot would open up, and then rehab psychology was booked out for three months. So they weren't getting, like, CBT at the same time. And the therapists were getting super burned out because they're like, the patient still doesn't understand their diagnosis. They haven't worked through their kind of illness anxiety. And so we created this kind of tool to screen patients, make sure they A, knew what their diagnosis, had a clear kind of understanding of it that I'm screening for. Do they have a neuropathy? Do they have some other medical issue that we need to address, like a sleep disorder? This person is untreated OSA is super fatigued and is like, has no energy to even do like an intensive program, those kinds of things. And then kind of putting people through our program. So of the people who made our screening and kind of get seen by our whole team, and we're like, we can work with this person, they're motivated. Then we put them through a three week program. And so we're doing a bunch of tests. So looking everything from like gait speed, strength. So just like their gait speeds improving kind of, but their measures are all over the place. This is a mix of like functional gait, like functional tremors, functional weakness, all different motor presentations. We do kind of a scale of the psychogenic movement disorders for the people who have like tremors and stuff and seeing if the frequency of those and severity and duration of those symptoms are improving, which most of them are. And then most importantly, looking at like, are these people functioning better at the end of the program? And most of them did. We had one patient who really just didn't progress. So that's declined to zero over there. But again, our program is in one size fits all. And you're gonna have people who don't respond well to rehabilitation. And there may be other factors contributing to that. And then we do kind of look at their anxiety and depression scales, but not all of them have depression or anxiety on our screening. Sorry, we're gonna talk about this later. So really kind of the, from the FND symptoms website or neurosymptoms.org, this is kind of the chart that shows, you know, before rehab treatment, like symptoms might look like this chart on the left. You know, they may have fluctuating symptoms or like things that get better or worse. And that hopefully with rehab, that over time they have less kind of lows, more control over those swings and just kind of an overall better like milieu of symptoms. So bringing back Dr. Goodman to kind of how your rehab program or thoughts there. Wonderful, is this on? Yep, great. All right. Thank you very much. I wanted to reiterate a couple of things there actually. This idea of kind of avoiding to be alarmist for the PNES symptoms, I think is really important. We do see that, it seems to be when there is a lot of attention brought to them, they do seem to have more exacerbations or reduced kind of recovery time. So not being alarmist, talking them through it, moving on, moving forward, whether that's on the inpatient or outpatient side of things, we are seeing that be positive as well. We also similarly, I think, avoid adding on additional equipment. I think that is really important, particularly for those with an isolated FND syndrome. Certainly if someone truly needs equipment or they're just not recovering at the pace at which they were hoping or still having some impairments and they do need equipment, certainly we will help set them up for that. But yes, trying to avoid kind of the escalation of that. There are a couple of questions as well. Let me get to those as well. As far as the inpatient rehab, yes, we are dealing with some issues with the insurance. We've actually, I found it not had a lot of challenges with that actually. There are a couple of insurance groups, particularly the Medicare Advantage groups that are giving us the most trouble, but private insurance, Medicaid, we're not having a lot of issues getting those patients to inpatient rehab, even for like an isolated, non-comorbid FND syndrome. There is a question on here about, I've seen some MRI negative strokes, neuro said it was FND, but then patients did develop spasticity and did really seem to be an MRI negative stroke. Ask if we could discuss further a little bit on that. Certainly a challenge. I think if we're talking about the inpatient rehab side of things, when there is a question of FND or particularly when you can't identify this on imaging, perhaps treating both of those perhaps treating both, saying, okay, this does look like it can be consistent with an MRI negative stroke, but then also not ignoring that FND element, especially if you have another, it's important to certainly take into account what your consultation colleagues are thinking, particularly if it's a neurology team, but maybe having that discussion with the inpatient rehab team as well and saying, hey, they're calling this FND. I'm not really convinced. We do have a lot of disagreements, I think, with neurology. On some of these. And this does get to another comment that another person had said, and it said, I find my neurology and psychiatry colleagues are reluctant to diagnose FND. Interestingly, I've actually had the opposite. I think some of our colleagues are over-diagnosing or over-calling FND where we're actually at a disagreement and I insisted on getting an EMG or other imaging because I was not convinced. And so, again, sometimes I'm right, sometimes they're right, it's okay. We're all colleagues and we all work together to try to figure that out. But I think it's important to have those colleagues and if the colleagues that you're working with are not comfortable with that, I'll say, I'm lucky I'm in Chicago, Seattle. These are big epicenters of rehab and large urban centers with a lot of research and multiple hospitals. Trying to identify certain providers within your community that are more comfortable with these diagnoses and try to establish more of a relationship or a process with them. That could be both on the medical side as well as the psychology side. Having those community psychologists are really important, particularly when you're looking at discharge from inpatient rehab to then kind of help sustain function in the community. Another question about when you're admitting someone to IRF with a comorbid disorder such as TBI or MS, which IGC do you use, FND or the MSTBI? I think oftentimes we're primarily doing FND, though it also depends on perhaps the severity of what their other symptoms are, but I think we primarily do FND. I think for us it's really, okay, so someone has MS, we know they have MS, but they don't have a new lesion on their imaging, this admission, that I'm calling an FND. I think we also had one patient who had a new lesion, but it was so tiny, small. We knew that it's not in an area that could account for the physical symptoms that they're experiencing it. So it's like knowing how to look at the imaging and be like, yes, you have a new lesion, and no, that doesn't explain your entire right hemiparesis because it's in this tiny part of the parietal lobe. And so trying to look at those things and being really clear on how to tease that out. And then sometimes we had a TBI patient with already a movement disorder that had the overlay. The therapist was like, what do we focus on? And in that point, it's like, well, they had hemiparetic spastic gait at baseline, so I think we just have to do a progressive, that, like a focused retraining program, and then just with the knowledge that some of these extra movements they're experiencing are due to FND, as opposed to just focusing on those extra movements because their gait was already at baseline abnormal. So. I think similarly, kind of focusing on saying, we're gonna treat both. We're gonna focus on the treatment of both for that. Yeah, okay. I found that, another comment, I found that communicating the diagnosed individuals personality disorders particularly challenging. Any tips for communicating with individuals with comorbid psychiatric illness? You are not wrong. This is particularly challenging, right? Perhaps their understanding or lack of understanding or lack of acceptance may be directly related to their personality disorder. Particularly when we're talking about admitting patients to inpatient rehab, I've had some patients where it was very clear functional neurologic disorder, but their personality disorder was so strong and they had such barriers to acceptance that we actually did not admit that patient inpatient rehab. Same. Okay, yeah. Yeah, we're screening, that's what our rehab psychologists screen for on the consult side, actually, is for things like really significant borderline personality disorder or other personality disorders, a really significantly strong disability conviction, kind of these other things, like very significant depression or other things that need to be treated before we can really work on, like that's so distracting for the patient and such a focus of where their brain is at that they wouldn't be able to participate in an intensive rehab program or that they're not buying in. Yeah. I don't know that there's a great treatment option for some of those patients, honestly. Some have gone home and we worked on treating them as outpatient, another patient had gone to a skilled nursing facility. I'm sure it was not a great option for them, but also that wasn't, particularly in this world where we're dealing with insurance issues and challenges, like we really wanna make sure that we're gonna be successful in the patients we do select for inpatient rehab. We only have a couple more minutes. Our last couple slides are just like resources for you guys, so anyone in the room have some questions? Great comment. So just to repeat for the whole room to hear that she's reinforcing the concept that we are not just treating the patient We are treating their ecosystem their environment their families the people who have been supporting them at home and Explaining what's going on with them and how they can keep them from having kind of recurrent symptoms once they leave the inpatient You know the protected bubble of our inpatient rehab unit some of the resources that we're gonna put up as well are really helpful for patients to to have but also to Have provide those resources for the family so that they can educate themselves as well and have a better understanding Though again, they may also there may be some stigma associated with that that you're you're trying to overcome some of those those barriers We have another question Sorry in the back over there. Yeah Question is any role for TMS in the treatment of these patients. I haven't seen anything in the literature yet I don't know if anyone in this room has like we don't have a TMS treatment in our Facility or so. We don't do that either. I think that most of the evidence is around CBT Same same with us. I'm not familiar in the front here My question is how do you deal with it? So, her question is, she's from Sydney, so welcome all the way from Down Under. And they get a lot of patients, there's always, for some patients, you might get a feel that there's a conscious component to things versus a subconscious component, right? And the subconscious component is where we think the F and D lies, and then conscious may be some of this malingering. I think that's a challenging thing to tease out, and is the person needing respite and getting out of their environment that is very stressful to be in a hospital where they can be cared for, kind of be in that disabled role. And I think that's, again, where having a rehab psychologist kind of onboard with your team to help tease those things out and kind of reinforce with the patient that, you know, you can't stay here forever with this indwelling catheter that you don't really need, because we know your bladder physiology works, but that every time we take it out, you don't pee on your own, and is that a conscious or a subconscious thing? That can be challenging. Yep, and our time is up, and I know that the plenary session is happening here, so if you guys have any further questions, feel free to find us, we'll be hanging around a little bit. Thanks so much for your attention. Thank you.

Functional Neurologic Disorder

conversion disorder

somatoform disorders

interdisciplinary collaboration

misdiagnosis

cognitive-behavioral therapy

rehabilitation protocols

symptom management

insurance coverage

patient education

psychiatric disorders