Functional neurological symptoms

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  Emergency

  If any of the following are present or suspected, please refer the patient to the emergency department (via ambulance if necessary) or follow local emergency care protocols or seek emergent medical advice if in a remote region.

  Adult

  Stroke/transient ischaemic attack (TIA)

  • Patient with acute neurological symptoms of a stroke; multiple/crescendo TIA
  • New acute symptoms

  Progressive loss of neurological function

  • Acute onset severe:
    
    • ataxia
    • vertigo
    • visual loss
  • Acute severe exacerbation of known MS

  Seizures/epilepsy

  • Status epilepticus/epilepsy with concerning features:
    
    • first seizure
    • focal deficit post-ictally
    • seizure associated with recent trauma
    • persistent severe headache > 1 hour post-ictally
    • seizure with fever

  Headache/migraine

  • Headache with concerning features:
    
    • sudden onset/thunderclap headache
    • severe headache with signs of systemic illness (fever, neck stiffness, vomiting, confusion, drowsiness)
    • first severe headache age > 50 years
    • severe headache associated with recent head trauma
    • recent onset headaches in young obese females
    • headaches with papilledema
    • >50 years with raised CRP/ESR or if giant cell arteritis or vasculitis suspected

  Movement disorders

  • Ocular

  Other referrals to emergency
  

  • Altered level of consciousness
  • Bilateral limb weakness with or without bladder and/or bowel dysfunction
  • Acute rapidly progressive weakness (Guillain-Barre Syndrome, myelopathy)
  • Delirium/sudden onset confusion with or without fever

  Paediatric

  Seizures/epilepsy

  • New onset seizures that require emergency care/advice
  • Status epilepticus (convulsive or non-convulsive)
  • Developmental/cognitive/psychiatric regression accompanying new onset or ongoing epileptic seizures
  • New onset seizure with new neurological deficit (e.g. focal weakness, speech impairment, cognitive impairment) – call 000 for emergency assessment for stroke and transport to the Emergency Department
  • Specific seizure types with epileptic encephalopathy risk e.g. infant with possible epileptic spasms
  • High initial seizure burden (>5 seizures, before first AED), excluding typical absence seizures
  • Neonate / infant (<12-month-old) with epileptic seizure onset

  Headaches/migraine

  • Headache with papilledema or change in vision/double vision (excluding established migraine with visual aura) or new neurological examination findings (e.g. sixth nerve palsy, gait disturbance, focal weakness)
  • Headaches that wake at night or headaches immediately on wakening
  • New severe headaches
  • Sudden onset headache reaching maximum intensity within 5 minutes (= explosive onset)
  • Focal neurological features
  • Associated with significant persisting change of personality or cognitive ability or deterioration in school performance

  Functional neurological symptoms

  • The patient is unable to mobilize safely or has frequent falls/seizure like attacksAddition

  Movement disorder

  • Abrupt onset or deterioration of a movement disorder
  • Acute onset of ataxia / chorea
  • Impairment of function i.e. walking, attend school

  Hypotonic infant

  • Tachypnoea (signs of respiratory distress such as accessory muscle use are NOT seen in patients with neuromuscular disorders)
  • Feeding difficulties with weight loss

  Gait abnormality, isolated motor delay or focal weakness

  • Acute onset of (or rapidly progressive) weakness e.g. Guillain Barre syndrome, transverse myelitis
  • Acute onset focal weakness (suspected stroke – call 000)
  • Breathing difficulties (NB tachypnoea may be the only sign of respiratory distress in a child with a neuromuscular condition)
  • Feeding or swallowing difficulties
  • Acute foot drop or acute onset focal neuropathy

  Stroke

  • Acute stroke – call 000 and request urgent transfer (timelines apply for t-PA and thrombectomy for embolic/thrombotic stroke)

  Other neurological conditions

  • Developmental/ intellectual impairment or behavioural / psychiatric disorders with regression
  • Acute encephalopathy, acute confusional state, altered level of consciousness
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  Other useful information for referring practitioners Not and exhaustive list

  • Refer to HealthPathways or local care pathway
  • A functional neurological disorder (FND) is a condition in which patients experience neurological symptoms such as weakness, sensory symptoms (e.g. pain sensitivity/numbness, sound distortion, visual changes etc), abnormal movements (sometimes seizure-like, 'non-epileptic seizures') or loss of awareness / dissociation). The brain of a patient with functional neurological symptom disorder is structurally normal, but functions incorrectly at times, with capacity to return to normal function. A diagnosis of a co-morbid psychological/psychiatric disorder is not required in this condition. This disorder is considered due to 'software glitches' in automatic brain networks, not under direct control of the patient. Symptoms of functional neurological disorders are clinically recognisable but are not categorically associated with a definable organic disease. FND is a clinical diagnosis based on history and examination. Physical examination can demonstrate positive confirmatory findings of FND. If the clinical presentation is consistent, investigations for other conditions are not necessary.
  • In the majority of cases it is thought inappropriate for children to wait more than 6 months for an outpatient initial appointment
  • Referral from a health practitioner other than a General Paediatrician may be accepted if there is limited access to public Paediatric services in the patients' local area
  • A change in patient circumstance (such as condition deteriorating) may affect the urgency categorisation and should be communicated as soon as possible.
  • Clinical urgency is the dominant consideration in the prioritisation of a referral for a child currently in out of home care (OOHC), or at risk of entering or leaving OOHC

  Clinical resources

  • If you have a reason to suspect a child in Queensland is experiencing harm, or is at risk of experiencing harm, you need to contact Child Safety Services
  • Functional Neurological Disorder (FND): a patient's guide
  • Sheffield NHS trust patient leaflets:
    • Functional Symptoms: A short guide for patients and families
    • Taking control of your functional symptoms
  • Health management plan for functional attacks
  • Sensory grounding information sheet
  • Statement of Intent

  Patient resources

  • Sheffield NHS trust patient leaflets:
    
    • Functional Symptoms: A short guide for patients and families
    • Taking control of your functional symptoms
    • Taking control of your non-epileptic attacks
    • Nonepileptic attacks – a short guide for patients and families
  • Epilepsy Action Australia: Psychogenic Non-epileptic Seizures Fact Sheet
  • Mayo Clinic: Functional Neurological disorders/conversion disorder
  • Functional Neurological Disorder (FND): a patient's guide