Functional non-epileptic attack.

Abstract

Introduction A functional non-epileptic attack (FNA) is a common form of functional neurological disorder characterised by paroxysmal, involuntary changes in movement, responsiveness and/or sensation. FNAs are not caused by ictal epileptiform activity, but rather a complex interplay of predisposing biological, psychological and social factors. FNAs are a common problem that ambulance paramedics are likely to encounter in the pre-hospital setting. Unfortunately, lack of clinician understanding and stigma are barriers to good patient outcomes. Research Aims To offer paramedics an evidence-based approach to the assessment and care of patients experiencing a suspected FNA. Methods A review of English language literature published since 2013 was conducted using PubMed, Medline, and Google Scholar. Additionally, expert opinion was sought from a multidisciplinary team comprising of a neurologist and clinical nurse consultant who specialise in functional neurological disorder. Results A total of 29 studies were selected for inclusion, and 3 clinical experts were consulted. This review highlights the complexity of FNA as a biopsychosocial condition with multifactorial aetiology. The long-entrenched belief has been that FNA is purely a psychological problem; however, recent studies support a neurobiological basis for the pathophysiology of FNA. Recognition of FNA in the emergency department is poor, and patients are too often subjected to iatrogenic harm with unnecessary sedation and intubation. In many cases, FNA can be accurately identified from the event semiology alone. This review describes key clinical features that paramedics can use to distinguish between functional versus epileptic seizure activity. Additionally, this review highlights the importance of good communication and working towards a relapse management plan for patients with frequent exacerbation of symptoms. Conclusion There is a potential role for paramedics to improve clinical outcomes in FNA through excellent pre-hospital assessment. A good description of the presenting illness can help to avoid iatrogenic harm, support a timely diagnosis of FNA and facilitate referral to appropriate specialist care. Furthermore, there needs to be better collaboration at the ambulance/hospital interface to ensure continuity of care for these patients.