David Perez

Dr. David Perez, is a dual trained Neurologist-Psychiatrist and Cognitive-Affective Neuroscientist. He is an Associate Professor of Neurology & Psychiatry at Harvard Medical School. Clinically, Dr. Perez is the founding director of the Functional Neurological Disorder Unit at the Massachusetts General Hospital and the director of the MGH FND Research Group. 

Dr Perez talks about his early fascination with bringing brain and mind together in research and how this has energized him to create 'brain teams'. He advocates working across disciplines and across specialities to learn from and educate each other with the aim of creating precise and effective treatments for FND.  Dr Perez gives advice on how to create a dream team for treating and researching FND and muses on the pscyhopathophysical signatures of FND. 

It's an energized and energetic podcast and one sure to bring hope to patients and clinicians of all kinds interested in FND.

https://www.massgeneral.org/neurology/research/functional-neurology-research-group

https://connects.catalyst.harvard.edu/Profiles/display/Person/86553

Transcript

Copy Transcript Copied

SPEAKER_00 0:07

Welcome to the Functional Neurologic Disorder Society podcast. I'm your host, Erica Cotton, coming to you from Chicago, Illinois, with a special thanks to Michael Romeo, our production engineer, coming to us from Australia, and our content curator, Ingrid Hertzauer, from the UK. My guest today is Dr. David Prez. Dr. Prez is a dual-trained neurologist and cognitive effective neuroscientist and associate professor of neurology and psychiatry at Harvard Medical School. Clinically, Dr. Prez is the founding director of the Functional Neurologic Disorder Unit at Massachusetts General Hospital, and the director of the MTH FD Research Group. It was a pleasure to have this more clinically oriented FD discussion today, including Dr. Prez's interesting career path into the field of FD, the changing clinical landscape of FD conceptualization and diagnosis, specifically the necessity of role and science rather than FD being concerted diagnostics of collections, F and Director Hospital Works or specialty such as the emergency department, application and patient science. And lastly, and perhaps most importantly, we discussed the protection medicine framework for those concepts that specialized in F ⁇ D care. We discussed the hope of this precision medicine approach starting with F and D training in neurology and psychiatry and advocating for ACTME coverage of medical knowledge, clinical skills, communication, and collaboration specifically for F and D, as is currently done for all other common medical conditions. So with that, here is my very enjoyable conversation with Dr. David Press. Well, thank you so much, David, for joining me today and agreeing to talk to our lovely audience. And it was great seeing you at the American Neuropsychiatric Association meeting. Always a pleasure. And for our listeners, if you'd want to get started with your academic background, how you arrived at including FND in your work and kind of the career path you're on.

SPEAKER_01 1:58

Erica, thank you so much for the invitation and the opportunity to have this conversation with you all. I guess we're starting with a bit of background. So it's it's been an interesting and fun journey. Um when I was an undergraduate at Columbia University. So I majored in neuroscience and behavior. And that first introductory neuroscience class for me was really transformative. And I remember um in the midst of that uh course um seeking a summer research opportunity. And I was, you know, very green and just eager to learn and eager to work hard. Um and I was connected to the laboratory of Eric Kendell. Um I worked in the lab for two years as an undergraduate, and it has proved very energizing and catalyzing. Um, you know, for our listeners, Eric uh is trained as a psychiatrist, and he won the Nobel Prize in Medicine or Physiology in 2000. And when I worked there for about 20 hours a week for much of two years, it never once dawned on me that I was working in a psychiatric research lab. Um, what dawned on me is that I was working in a cutting-edge uh basic science research lab that really was at the forefront of learning and memory. I had the opportunity to study the neurocorrelates and behavioral features of conditioned safety versus conditioned fear. And um, following my undergraduate work, I went to medical school at NYU. And I remember early on there really um specifying interests in both neurology and psychiatry. At times people would wonder if I was a bit confused in really uh working uh to pursue both. But I was fortunate that NYU had a dual training program and still does in uh neurology and psychiatry. So during medical school, I sought out uh that group and um really sought their advice and had the opportunity to see clinically how they integrated neurologic and psychiatric perspectives. And that, um, like my experience with Eric Kandell's um research team, proved energizing as well. And then my fourth year of medical school, um uh having already consolidated an interest clinically in this space, I went back to Columbia and um spent much of my fourth year doing research. Michael Rogan, who was a research scientist in Eric Kandel's lab, he was now moving his basic science research to translational fMRI research in the lab of Joy Hirsch, who was at Columbia at that time. And I just thought it was a perfect uh reunion where um there's so much that we can uh provide clinically with a rich integrated neuropsychiatric perspective, but there are so many gaps. And I thought that systems-level neuroscience and brain imaging was really one of the tools to fill in the gaps. Uh long story short, I found my uh way to the Harvard system and trained across neurology and psychiatry uh in the Boston area. And I was searching for ways to think about um integrating my core interests in neuroanatomy, in the neuro exam, in affective neuroscience, and brain behavior relationships more broadly. And I just saw this enormous gap in functional neurologic disorder, clinically and research-wise, and I can say more about it, Erica, but that gap, um, including the really significant scientific gap that was present and still exists, those were the things that um uh proved energizing at that sort of third level, and I've continued to move forward in this direction ever since.

SPEAKER_00 6:22

What a delightful background story. Um, and fairly focused pathway on the brain from early on, which is excellent. It's a good segue, actually, and into speaking of gaps and advancing the field of FND, as you noted, seemed to have a long way to go. But you and your teams have taken very significant steps in propelling the field forward. I think one of those first steps was especially for the field, transitioning FND from a diagnosis of exclusion to having rule-in signs for FND. Do you want to tell our listeners a bit about that shift and that change and especially the distinction and the importance of rule-in features?

SPEAKER_01 7:03

Sure. Um, it's certainly been a paradigm shift. I will say that, you know, rule-in signs have certainly been around in neurology for a number of decades. Um, I think that um the real emphasis on their use, on their communication to patients, and on neurology being front and center in the diagnostic evaluation is really, I think, what's been transformative over the past couple of decades. Many of our listeners are well versed in functionalological disorder, but there are a range of rule-in signs across the motor, seizure, um, speech, and voice spectrum of uh functionalological disorder, certainly cognitive features that help rule in functional cognitive disorder. And there are established criteria for persistent postural perceptual dizziness. As I think about rule in science and as I think about where we need to go across the clinical neurosciences in this, is A, education is key. Um, amongst the leaders, I think that um we're we're really defining an updated standard of care for how to diagnose patients with F D. But this really hasn't trickled down across the general neurologists and a range of mental health professionals. Many trainees get few, if any, lectures in F D. So these are things to really target and push forward. And then I think something that I might add as we think about rule in signs, is that we want these rule-in signs to be robustly present. Something I've been very cognizant of over the past decade as we've you know thought deeply about developing and growing an F D program, is we want to ensure that when we make a diagnosis of F D, that it's highly specific. So several years ago, we wrote you know cautionary notes to really think about some common pitfalls in making a diagnosis of FD. And one of the things I emphasize is if you're questioning was there an element of variability, or if you're questioning was there a subtle element of entrainment, um, those features may in fact be rule and science for F and D, but if not robustly present, you know, uh take caution, be thoughtful, keep an open mind. This is important. And something I'm not sure I've said in other settings is I also think the context is really important for rule and science. And what I mean by that is, for example, um I attend on the neurology consult service, and we can think about patients with altered mental status and delirium, right? And cross-sectionally, um uh features of motor inconsistency and motor and persistence in the setting of a waxing and waning mental status is fairly ubiquitous for um uh patients who are encephalopathic. Uh and so the rule-in signs, you know, a number of them have high specificity, but put them in context. And I think the context plus the rule-in sign really allows us to stand on great footing as we make this diagnosis and then think about how to close that gap between diagnosis and treatment.

SPEAKER_00 10:32

Great. In in that vein, and especially settings in which diagnosis might be more relevant or be first being considered often is an emergency room setting versus inpatient or outpatient settings. If people are admitted to inpatient after an ED visit and presenting to the emergency room, are there things individuals should keep in mind when it comes to considering F and D in the emergency room context? What to be mindful of, what to be wary of?

SPEAKER_01 11:03

Great question. Um recently they've changed our neurology consult service. And when I'm on service um two blocks of the year, I start my rounds um at 7:30 in the morning with our neurology residents in the emergency room. Uh this kind of work keeps me really grounded to understand the complexities of things. The emergency room is um very full with patients. You know, we have patients um, you know, I think regrettably in the hallway and um long wait lists. I also think about our neurology residents who are seeing a tremendously large volume of patients and very quickly, including I um uh you know will often emphasize that in the neurology, uh in the emergency room, patients are not getting a comprehensive neurologic evaluation. What they're generally getting is a problem-focused uh neurologic evaluation to really think about acute neurologic emergencies. Um the pace of the consult uh and the pace of care is very quick. So, with this background in mind, we have major gaps, F and D and the emergency room. How do we close these gaps? Well, one is are our um expert practitioners making um uh partnerships with emergency room physicians. I think this is critical. So um we had gone and given various F and D related lectures to emergency room physicians as well as trainees, including PAs, nurse practitioners, nurses, really important because we know that um the language and communication, education related to F and D is critical. And then I think in the emergency room, the other piece that we need to think more about is operational, operationalizing pathways. So, what should happen if a patient presents with their first episode of functional neurologic symptoms to the emergency room with a high degree of um disability and severity? They're unable to walk out, right? We've thought about these things. Um what happens when a patient who has an established diagnosis of F and D, for example, with recurrent functional seizures, presents to the emergency room with a cluster of functional seizures. How is the emergency room thinking about this population? Um and there are other uh considerations in various different groups. But I think the first piece here is crosstalk, education, and updating our emergency room clinicians broadly, not just the physicians, about this entity of F D and how we think about it in 2024, including the language that we use around it. This is really important. Emergency room is busy, but we also want our patients well cared for and not um uh amplifying the distress by using antiquated terms or making assumptions that are far from being correct.

SPEAKER_00 14:20

Yeah, that's I often hear from you know patients or where we see a patient's diagnostic trajectory and the timeline from symptom onset to diagnosis is generally delayed by years even. And part of that process, I think, is is by nature of what you described, where a patient has symptoms, presents to the ED, whose function is to rule out essentially that there's not, that there are not life-threatening emergent neurologic issues present, but not necessarily rule in or completely diagnose an FND. So a patient with FND goes to the ED and gets told, well, you haven't had this. It's not, you know, insert, neurologic condition, stroke, whatever. And then they're sent home and oftentimes not told what else to do or necessarily follows up, especially if it's an episodic thing, you know, where it's okay, maybe that was just a one-off and that was strange. Let's let's carry on. And then it's not until it becomes a more persistent or debilitating problem that a person is then sent to the emergency room enough times and then told, no, you really need to follow up with neurology to then receive an appropriate diagnosis, um, which is a good segue, I think, into considering once a person is diagnosed, generally in an outpatient setting or after an inpatient admission, in which they can get a full evaluation with a neurology team, developing a what to do next, right? The multidisciplinary treatment and how even developing those programs have certain challenges and obstacles and how to integrate all those pieces. And I know your team has had a lot of experience and pioneered a lot of these programs. And I think it'd be great if you could share any of your insights and sort of lessons learned from trying to create treatment programs.

SPEAKER_01 16:06

Uh Erica, great reflections first on your part too, um, and excellent work. Um, just a uh to come back to what we were just talking about for a moment first, which is in the emergency room. Um, certainly on the neurology side, we want to rule out acute neurologic emergencies. This is this is critical. The other piece is if the neurologist and other clinicians are picking up rule-in signs to document those clearly. Um, that can be very helpful because we all know that um there can be significant fluctuations. And then that critical component of ensuring that there's follow-up, particularly in the general neurology setting, I think is really important. It also can be an opportunity for clinicians to share briefly what they suspect might be going on. Again, based on their neurologic examination, the signs that they've appreciated, and noting that there may be other complaints, right, that require context, that widespread body pain, that fatigue, that cognitive clouding, a range of symptoms that frankly aren't given full evaluation in the emergency room. And these are the reasons why that comprehensive neurologic evaluation, generally in the outpatient setting, is a great place to start following the emergency room. Um, you offered a question, um, Erica, about building programs. Um, help set the stage for me a little bit. Where would you like me to start in terms of um talking about that a little bit?

SPEAKER_00 17:34

Great. Good question. It's it's a broad question for sure, mainly because I think there are broad needs. As you just outlined very eloquently, patients present with a range of conditions that are variously considered or included at different stages of the diagnostic and treatment process, and very much dependent on the setting of those presentations and what patients have access to versus smaller rural medical centers versus large academic medical centers. Why don't for the sake of starting with an ideal and then moving towards challenges and gaps, which there are many, let's start with an ideal setting. So, what if you had to define an ideal treatment for FND, what would that look like in terms of multidisciplinary program?

SPEAKER_01 18:26

Great question. I can almost answer it succinctly. I'm not sure there's an ideal um program, but I do think that um there are potentially a variety of good ways to think about building a program. Um let me share with our listeners um uh how we've started and what we've learned. And you know, I think that um our program at Mass General uh began when I joined the faculty uh July 2014. And as this happened, I think the first thing I tried to do was really to teach our system across the board, um, including reaching out to colleagues in physical therapy, occupational therapy, speech and language, psychiatry, behavioral medicine, psychology, social work. And in those conversations, it was a lot of crosstalk. For example, I would uh present the consensus recommendations for physical therapy, uh, which were the first set of recommendations um published in the field. And I would raise my hand up and say, look, I am not a physical therapy expert. Right? I am sharing a bit how neurologists and psychiatrists think about F and D in that date and time. And here's what I hear from uh others, including leading physical therapists like Glenn Nielsen, um, and that community, how they're proposing to assess and manage this population from their skill set. I was really happy to see that people raised their hand and said, actually, we've been seeing this population for quite some time. And refreshingly, many of what uh many of the excellent points made in the consensus recommendations are themes that we're doing here as well. What we've lacked is partnership. And what we've also lacked is real clarity in the notes and clinical treatment plan, what's happening with a given patient, so that there can be a common language and a common perspective for treatment. So, with this outreach, what was fortunate in my setting was that we had um people who readily wanted to take the lead in physical therapy, occupational therapy, and speech and language. My dual training in neurology and psychiatry certainly um uh helped us live at that intersection. And then some of the self-guided psychotherapy workbooks, um uh, including uh the the first one published based on the Sharp et al. clinical trial and neurology in 2011. This allowed us to develop a playbook for assessment, biopsychosocial informed, the neuropsychiatric approach, capital N, capital P, thinking about um not only a rule-in diagnosis and education, but what else is traveling with this patient who's sitting in front of you who may have a functional movement disorder or functional seizure? The importance of formulation. We can talk more about that in a few minutes, but in that context, thinking about physical rehabilitation interventions, outpatient based in our program. Um Based on the phenotype and frequently coupling that with skills-based psychotherapy. And as our program um educated and grew, our best success is that more people raised their hand. Ellen Godina is a social worker psychotherapist who was previously working in the NeuroICU for a number of years, and she expressed a strong interest in this brain-mind-body interface and has been our lead psychotherapist for a number of years now. And Dan Milstein, a psychologist, joined the last couple of years. And that's really how with Julie Maggio in PT, Jessica Ranford and Julie McLean in occupational therapy, Jennifer Freeburn in speech and language, we've added colleagues in psychiatry, Caitlin Adams, who I've known for years and worked closely with, Margaret Tuttle, another psychiatrist with interest in this area, and our partners in psychotherapy. These have been the building blocks of our program. Last comment before I turn it back to you, Erica, is the importance of culture and community. We really learn from each other. And the biggest success, I think, in building this program has been our F and D unit rounds. We meet monthly. And in our monthly rounds, we discuss clinical successes as well as clinical challenges. It's truly horizontal in the sense that we listen when our physical therapy colleagues say, maybe this patient needs something else before we approach physical therapy based on the consensus recommendations. Or, you know, might there be a comorbidity that needs more careful thought of? And all of us speaking the same language, all of us coming together, all of us sort of learning how each of us thinks about these problems, this has been amazing. And when I'm busy and running off and running late for various things, what I've so enjoyed is that it's the team saying, I'm looking forward to FD rounds in half hour. I have a couple cases to bring up. And I've just seen this example over and over again that this community aspect I think is foundational to building uh a multidisciplinary and interdisciplinary program. One other really important comment that um goes without saying, but just because it's so critical, is energizing our neurologists. And I've been uh so fortunate to work closely with uh Dr. Sarah Finkelstein, who did a fellowship in the UK with John Stone and Alan Carson. And Sarah is now the associate director of the FD unit here with us. And then Chris Stephen uh has been a card-carrying member of the unit for a long time and is a master clinician in um all things movement disorders, and has really helped us in some of the challenging movement disorder cases to render an astute opinion.

SPEAKER_00 25:21

Yeah, wonderful. I think you're highlighting essential pieces. And if I can maybe summarize for our listeners who might be less familiar with these pieces, is because FND falls in between the realms of neurology and psychiatry, neurology often for diagnosis, psychiatry and psychotherapy, and physiotherapy and speech therapy and occupational therapy for treatment, in addition to sleep medicine and pain specialists, et cetera, a multidisciplinary team is often thought to be essential for crafting a very individualized patient-centered treatment plan, which MGH's model has really pioneered and demonstrated a lot of use and appropriateness in terms of considering each individual patient needs, which leads me to one other topic I was hoping you could share with our listeners and a paper that you and your colleagues had completed on precision medicine in F and D and the need to have an individualized framework. But I'm wondering if you could tell our listeners a little more about what prompted the development of that paper and your thoughts and future directions for precision medicine in FND and what that looks like.

SPEAKER_01 26:37

Great. Thank you, Erica. Um, as we think about precision medicine, which is um, I think uh the standard that we're all um aiming for, this notion of patient-centered care. Um some of you listening in have previously heard me talk about the importance of the biopsychosocial model and the biopsychosocial formulation. I think what's so critical there is that it was a medical internist who published in science in 1977 this notion that a singular focus on biomedicine, a singular focus on pathophysiology, which is so, so critical, and a huge passion of mine as I think about our research efforts, in many clinical instances will fail to deliver patient-centered care if you don't think about the overall context. And that's where, as we think about training the next generation of clinicians in how to assess and manage patients with FD, our viewpoint is that you certainly start with the neurology and with the chief complaint. And you also want to think about what might be covarying in terms of physical symptoms along with the chief complaint, really the importance of sleep trouble, pain, fatigue, cognitive symptoms, etc. But early on in the evaluation, we also advocate for two strategic detours. The first being the importance of the social history. And I think this is one of my passions in in medicine is really getting to know my patients. Um and so having an opportunity to pivot for a few minutes and ask questions pertaining to Mr. or Mrs. Jones, help me to get to know you as a person a bit. Where'd you grow up? What was life like for you growing up? You sit and listen. As information comes in, there may be follow-up questions. Critically important is help me understand how you're doing now. What's a typical week like for you? Who are your supports? This notion of being able to sit and walk a little bit in the patient's shoes. I also find that that first strategic detour is an important um first step into then taking a focused psychiatric screen. So, Mr. and Mrs. Jones, if it's okay, I'd like to shift topics for a moment or two uh again. Um, in the last couple of months, help me understand how you've been doing emotionally. Now, I never got taught in psychiatry to ask a question um framed as, you know, how have you been doing emotionally? What I have found though is that it's a relatively neutral question, right? Um it allows patients to say, I'm doing the best I can. It's been awful. I'm having a real tough time. You know, who wouldn't be frustrated and upset and relatively distraught by what's going on? Um and that neutral question may also lead to saying, I'm having a really tough time emotionally and very depressed, or my PTSD symptoms are um, you know, quite a bit flared up. This is important. In that precision medicine approach, right, all of the history is nonspecific to the diagnosis, really critical. You round out the rest of what we call the history of present illness, uh, including past medical history, medications, allergies, family history, et cetera. We've talked about the importance of a neuroexam and rule in signs. Um, we'll frequently pause um and re-review the workup that's happened now that we've met the patient and we have them sitting in front of us. And we will internally ask ourselves um as we uh begin to have a conversation about what our opinion is. Have the signs been robustly present? Are we worried about a major neurologic comorbidity that requires um uh its workup? Or are ruling signs present? They're robust, and there are no other signs pointing us in an alternative direction, right? If it's the latter, it's an opportunity to communicate the diagnosis. I oftentimes say that it's important to um uh state your opinion, do so transparently, and then pause, really, so that you're not talking at the patient for prolonged lengths of time. You're gauging their response. Most people have not heard about a functional logical disorder, and that's really where a nice detour into neurosymptoms.org is so critical. After you've communicated the diagnosis and after you gauge their response, right? I think the other piece that happens internally is based on your assessment and based on your very work in progress formulation, are there special features in the given case? What might I mean by that? So, for example, we've encountered some individuals where their functional neurologic symptoms um directly overlap with dissociation and flashbacks related to a very decompensated post-traumatic stress disorder. In such instances, we might put at the top of the list connecting such a patient to our specialized PTSD unit and potentially encouraging a trauma-focused psychotherapy approach. Let's take the whole other gamut, right? Which is um some individuals might have intellectual disability and a functional logical disorder. Um that will give us pause at times for at least a traditional form of skills-based psychotherapy. In such instances, some of the sensory processing and sensory modulation work that our occupational therapists are leading here, we found helpful in such instances. And there is a great range of other possibilities, like, for example, the patient being in a wheelchair for five years. Maybe there is a functional dystonia. Might you be worried about the possibility of contractures? And do you want to bring in very early in the treatment plan a physiatrist to really be a co-pilot? And a physiatrist in the U.S. is a physical medicine and rehabilitation specialist. Uh, and if we suspect that uh muscle wasting and contractures and these sorts of things um are at play, then their expertise can be very valuable. So um there are too many to count versions of this. The important thing is to set up the initial consultation and subsequent follow-up so you can assess the moving parts. This is how we close the gap between diagnosis and a patient-centered treatment plan.

SPEAKER_00 34:03

I really appreciate all of those case examples and walking our listeners so nicely through diagnosis to treatment form formulation and then the multiple team members that could be present depending on the different type of presentation. Slight segue, brief tangent maybe, but I I think one that's very relevant and uh highly present in the patient experience of diagnosis and treatment planning is kind of the split that's happened between psychiatry and neurology, um, as well as the general, probably persistent or pervasive belief that mind and body are separate and what's considered medicine and what's not considered medicine, or what's considered a neurologic brain problem versus something that's in someone's head, um, or even psychiatry and most mood disorders being considered somehow non-biologic or not having a biologic origin for a lot of individuals, um, it being more an issue of will or uh personal power or preferences or choices. Um and I I think, at least in my experience, watching patients, they kind of live that split that has occurred in medicine, where one group went, you know, this is brain, this is biological, and another group became less biologically validated for lack of a better word. And patients are kind of getting shuffled back and forth, you know, where the neurologist says, no, go see psych, and psych says, Oh no, I think this might might be neuro. And then after someone makes a diagnosis, well, who's who's covering my care? Who's who's leading this? Who's the quarterback, so to speak? Where which realm do these patients fall in? And I think it's it's ironic that this realm question comes up in medicine and the distinction between neurology and psychiatry that's a bit artificial, um, other than scope and scale, obviously. Um, but even in how a lot of people are thinking about this disorder, I think this disorder has an interesting way of bringing out very strong opinions and emotions in people as they're not patients, but providers or people who hear about it, feeling very strongly that it's either just in someone's head or they're they're faking, um, or it's not real, or it's just if they tried harder, versus other people who believe it's it is brain and biologically based, and everything's biologically based. And linking it back to specifically to one of the aspects of the precision medicine model that you were describing of quote unquote getting to know someone, right, in in a medical context or in a medical visit. You're describing aspects of their upbringing, their daily functioning, um, their mood, their educational history, um, that tells a lot of people would also consider that brain function. I know neuropsychologists do that. So that's part of us understanding how how a person's brain has worked in the world, what their brain's experience, what their brain's been exposed to. And it's just so fascinating that even though a lay person would probably consider neurology, psychiatry, neuropsychiatry, and neuropsychology greatly overlapping. I think even within our little realms here, we we probably tend to emphasize or think about these things in different ways. And I'm wondering, in your practice, how you help patients bridge that gap or understand some of the shortcomings of modern medicine distinctions, as well as the way a lot of our field and our colleagues think about these conditions. How do you help patients bridge that gap that they are so often fallen into or pushed back and forth over?

SPEAKER_01 37:41

Erica, such great reflections. Um I think this is actually one of the areas that I'm um you know currently most passionate about and energized about. Um uh physical health and mental health equal health, period. Um, you know, I've I've said over and over again the brain doesn't separate into neurologic circuits and psychiatric circuits. Um, you know, uh when we think about idiopathic psychiatric conditions, we think about these as network-based brain disorders, right? And yet um societal structures have this uh separation between um what we call mental health and what we sort of call physical health. But I think we need a new paradigm here. Um and you know, one of the things that I've uh enjoyed and learned, frankly, from the residents I've worked with is when I'm on the consult service, I've had some residents introduce themselves as um part of the brain team. You know, we're one of the brain teams in the hospital. And I've uh I've really enjoyed that. And you know, the minute I heard it, I sort of paused and um uh acknowledged that that this is fantastic. And so as we think about brain clinicians or um brain doctors, right? Um, that in my mind should equal neuropsychologists, psychologists, psychiatrists, neurologists, right? We all specialize in the same organ, the brain. Um, there are um uh issues of scale, and what I mean by that is macroscopic lesions, like uh a CNS tumor or an acute stroke, or more subtle network-based disturbances. But subtle network-based disturbances cut across neurology and psychiatry as well. So I think we need a new playbook here. We need a playbook of integrating uh the brain clinical sciences. We can even ask the question: is this language one of brain medicine? And um, we also need an integrated classification system across the full spectrum of brain-mind disorders, period. One classification, one that is inclusive of brain disorders seen in neurology, and one that is inclusive of all of psychiatry, which equals brain disorders as well. These are some of the issues. And how do I talk to patients about it? I acknowledge the challenge. You know, I acknowledge that um, you know, we're taught to think about this in um certain ways, but neuroscientifically and clinically, it works quite a bit different. So um I share with them those reflections and I um uh encourage them to be curious and open-minded about uh these kinds of potentially modified ways of thinking about these issues.

SPEAKER_00 40:52

Wonderful. I I love the thoughts that I love everything is the brain, right? So I mean psychiatric processes are brain processes too, neurologic processes are brain processes. Um this conversation or this piece lends itself to two other topics I'd want to uh pick your brain a little more about for our listeners. Um, one being how to address the training gaps, right? And and starting to close some of those gaps between neurology and psychiatry and everyone's preparedness in the medical field for interacting with FND, treating FND, diagnosing. Um, but then similar or relatedly, I should say, and that's sort of from the clinic perspective, right? How do we close this gap? We'll improve clinical training, improve improve clinical communication and collaboration. And then from an alternate end of the spectrum being the research perspective and the clinical, the neurosciences perspective and brain imaging perspective, um, sort of from the from the bottom up uh versus the clinic down approach to closing some of these gaps. But let's start with I know you and your colleagues have proposed some ACGME aspects like medical knowledge, clinical skills, communication, and collaboration for training in neurology and psychiatry that might close some of these gaps. And wondering if you could say a little more about that and your hopes for how this might be implemented and how soon it might be implemented.

SPEAKER_01 42:24

Erica, there was a paper led by um Sarah Finkelstein and Angelo O'Neill with a nice um uh with great contributions from a number of other people published in Neurologic Clinics on this um particular question. Our readership may be interested in a deeper dive there. Also, um Barbara Doretsky and Tracy Milligan and others um have a complimentary article um specifically in functional seizures and um educational initiatives. Um maybe just a pearl about this is I um I think a lot about how to energize various communities, um, how to close the education gap. Part of it is also um uh raising interest and increasing interest. So I think that, for example, for mental health professionals, um, this patient population presents with physical chief complaints. Um, I would argue that most mental health professionals um lack a clear playbook to conceptualize um physical symptoms. And yet, in many, many instances, this patient population is also intrinsically interesting from a deep uh psychological and neuropsychological perspective. Um, and once we allow our mental health colleagues, uh, psychiatrists, psychologists, neuropsychologists, social workers, a window into how this is intrinsically interesting, I think that's how we energize that group. On the converse side, or relatedly, there are a number of clinicians who are interested in breaking down the walls and the barriers between neurology and psychiatry and psychology. And this is exactly the kind of condition that helps us do that. So that's the second way of energizing. And then I think that I would also argue that the biology of this and a range of insights from concept generation to predictive processing to notions of self-agency and action authorship, these are really cool and quite complex neuroscientific constructs. And these constructs have an emerging biology, but there's still a lot to learn. And so I think we want to engage the clinician scientists in seeing wow, this is also a body of an area of research where we can transform thinking, not only in this patient population, but neuroscientifically in a number of domains. So I'm hopeful that that some of these avenues will be ways to close the gap.

SPEAKER_00 45:22

Wonderful. I I love that you the word energizing has come up frequently from you, and I think that's just such a wonderful word to help expand knowledge and interest of FND across these disciplines and foster continued momentum and progress and growth and continuing to harness the current interest and enthusiasm of individuals currently working with this condition and sort of leading to an infectious interest or enthusiasm that hopefully will spread across multiple disciplines. One area that I've been really pleased to see interest and enthusiasm is in the effective neurosciences and from primary neuroscience researchers or primary neuroimaging researchers who would not consider themselves primary clinicians in identifying pathophysiology mechanisms, pathways, markers of FND. I think would greatly add to FND's quote unquote credibility. Not that I think it it it needs, well, it needs it from a societal image perspective, right? I think it would be great if that could be present for people to feel more validated about their condition and to uh uh help in professionals communicate more explicitly about it, um, as well as have it sort of be legitimized by some other professionals who take a more dualist point of view. Um but I know your team has done a good bit of brain imaging research. And I'm wondering brain imaging research has a few hurdles, um, especially with translation into clinical practice. Often research doesn't translate necessarily fully into clinical practice or it lags. Um, but where you see the field of brain imaging currently being at for FND? What do we know? Briefly, um, and then where you're hoping it can go and any barriers or hurdles you see.

SPEAKER_01 47:19

Great question, a rich question. I might just take pockets of that, uh, Erica, for um the sake of being succinct. Um, you know, there's been quite a number of groups now internationally who are using multimodal um advanced brain imaging techniques to delve into uh the neuromechanisms of functional logical disorder, to understand relationships between mechanisms and risk factors. And I think we're all keenly interested in also um discovering and further understanding mechanisms that relate to recovery from functional logical disorder and potentially biomarkers that might predict treatment responsiveness to um uh a set of different treatments. So these are some of the um both um uh pieces of information that are known and some of I think the gaps that that various research groups, including uh my own research lab, is um very much looking to uh roll up our sleeves and learn more about. A couple of uh quick pearls would be uh in my opinion, what's critically important now in brain imaging research mechanistically is um the addition of psychiatric and neurologic controls. We know that um patients with F and D are mechanistically and etiologically heterogeneous. We also know that there are a range of comorbidities in a number of patients, including uh chronic post-traumatic stress disorder, major depression, migraine headaches, etc. And so our reliance on healthy control comparison groups can really only go so far. And we need to think about, as we're um currently recruiting and um analyzing in my own lab uh currently, uh the use of uh psychiatric controls, um, a comparison group that has a history of major depression, generalized anxiety disorder, post-traumatic stress disorder. This will allow us to further disentangle um really important critical nodes in the pathophysiology of F D that might be more specific for FD versus um a matched psychiatric control population. By the way, the complexity here is quite high because the overlap and the overlap between F and D and some of its comorbidities might actually implicate that there's an element of shared pathophysiology. So these aren't um uh using research terms, um nuisance uh uh variables or um or such. We just really need to triangulate what components of the mechanisms might overlap with some of the concurrently present conditions and what features might um uh present relatively unique components to F and D. This is increasingly complicated as one gets into predictive processing and notions of biomarkers and neurosignatures. There may not be one specific neurosignature. The way that one can imagine there are a multiplicity of ways to scramble the computer system so that it's crashing, right? And so um uh we I think have to think in both hypothesis-driven fashion and in large-scale data-driven fashion to really understand the complexity of all this. But I would highlight for our listeners that uh psychiatric controls, neurologic controls, longitudinal follow-up uh imaging in the same cohorts, and also bridging that gap so that we're using uh a rich battery of psychometric measures. We're getting um adjunctive measures such as uh blood and autonomic profiles. We can think about growing uh data in kind of an international way so that we can ultimately think about genetic and epigenetic fashion, but uh variables, but that's quite a bit away because the sample sizes needed for that are really in the thousands. And um uh as we come together and as we uh the F and D Society has helped so much in this way, this is the task for the next few decades, is continuing to work together and further approximate the specificity of some of the features biologically that relate to F and D.

SPEAKER_00 52:04

That's such a fabulous answer. Um, across you basically just laid out a large framework of progression considering the underlying mechanisms or discovery of the underlying mechanisms from a multifaceted perspective and sort of across the layers of possible mechanistic influencing factors on that note. And and I appreciate the highlighting the need for comparisons to other existing psychiatric conditions and conditions where there may be considerable considerable overlap, unlike in chronic pain as well, um, or chronic fatigue, or in addition to the psychiatric ones like PTSD or other anxiety disorders. Um on that note, I'm wondering within within this research, your perspective on the utility, given you noted uh very aptly that functional neurologic disorders are very heterogeneous. They can present in such a variety of ways and after a variety of aspects, you know, after a concussion, after nothing at all, um, with a history of trauma, without a history of trauma, with comorbid pain, with comorbid sleep. And there's so many ways that we could either split these conditions, right, split them all down into their various subcomponents, or lump them together. And large lumping, you know, has already happened in our field between functional seizures versus functional movements versus functional cognitive versus uh dizziness. What's do you have a preference or an inkling towards lumping versus splitting, or do you see varying degrees of utility for each different approach? I'm very, very curious your perspective on this.

SPEAKER_01 53:46

I think both approaches are um of interest and likely helpful. Uh I probably share with our audience that as I sort of live at the intersection of neurology and psychiatry, I'm very much a lumper and an integrator rather than a splitter. Um, I see so many patients who present with mixed symptoms. I see patients who present with one phenotype who go on to develop uh distinct neurologic symptoms over their course of the longitudinal trajectory. I see patients who present with functional seizures and full body shaking. And as they get better somewhat, they stop having their big events. And now they have events of stuttering speech and tremulous movements. So has the diagnosis changed? Do they now have a functional speech and functional tremor? Or is the diagnosis functional seizures, right? It's very dynamic. Uh, I know, Erica, you do some great work in a variety of areas, including functional cognitive disorder. And we can think about uh the cognitive clouding, the element of dissociation that we see in a large subset of this population. Also, overlaps between persistent postural perceptual dizziness and in some instances also a concurrent functional gait. So I think there's a lot to learn transdiagnostically, both within F D and transdiagnostically across a range of conditions, as you've highlighted as well, that sit in neurology or psychiatry, but are frequently found in F and D. And certainly, yes, um uh subtype specific investigations can be helpful. But um at least our current lab preference is to really leverage uh the number of commonalities, to also think about individual differences. And as we ask questions about biological subtypes, I'm not sure if uh a focus on the externally presenting features is going to prove as informative as potentially understanding biological subtypes driven by um by distinct uh neuroscircuit patterns or potentially adjunctive markers like autonomic features. So um uh these are questions that need to be asked, but uh I am certainly more a lumper than a splitter, although both are important.

SPEAKER_00 56:27

Thank you. I I very much appreciate the the perspective and and the commentary. Um I I think there's there's definitely utility in both, and I appreciate anyone who's willing to do any work in FND at this point to share in the enthusiasm and the excitement and any uh nugget of information or research or energy put into understanding these conditions, whether specific or broad, is likely going to be a helpful contribution to a very evolving and uh a hole with so many or a field with so many many gaps and many holes in it. Uh but I I really appreciate your personal thoughts and perspectives as well as leadership um in pioneering a lot of these these aspects and this work from ranging from clinical initiatives and clinical practices and training down to bench research and bench science, which is just such a lovely spectrum to see with within one individual and their their collaborations. So I also want to be mindful of your time for today, David.

SPEAKER_01 57:32

Erica, thank you so much for this conversation. It's been very fun.

SPEAKER_00 57:36

Thank you. I really, really appreciate it. It's been so great hearing your perspectives and great. Thank you for being a podcast guest as well. Listening to this podcast gets you access to a 50% discount for new FNDS membership. Use code FNDS006.