Psychiatric Comorbidities Complicate a Neurologic Diagnosis: A Case Report Highlighting Interdisciplinary Collaboration

Research Objectives: To illustrate the value of interprofessional collaboration and use of objective measures for a patient undergoing inpatient rehabilitation with serious psychiatric comorbidities

Design: Case Study

Setting: Inpatient Rehabilitation Hospital

Participants: A 22-year old female with a history of obsessive compulsive disorder, severe anxiety, and major depressive disorder with psychotic features was admitted from an inpatient psychiatric hospital to an acute inpatient rehabilitation facility (IRF) with an admitting diagnosis of Functional Neurologic Disorder (FND).

Interventions: The patient participated in standard treatment for FND, including physical therapy, occupational therapy, music therapy, neuropsychology, and psychiatry. Despite the interdisciplinary approach, functional mobility did not progress as expected. On exam, the patient presented with absent reflexes, decreased range of motion, and no response to electrical stimulation. The patient’s atypical presentation and interdisciplinary collaboration prompted an electromyography (EMG) study. Results were consistent with diffuse polyaxonal neuropathy. She was subsequently transferred to an acute care hospital for further evaluation.

Main Outcome Measures: Functional performance, deep tendon reflexes, range of motion, EMG results

Results: The patient presented to an IRF with the diagnosis of FND, with functional goals of performing functional mobility without skilled assistance. Physical exam findings, lack of response to electrical stimulation, and EMG findings prompted further work up, which revealed the presumed diagnosis of Guillain Barre Syndrome. The patient received intravenous immunoglobulin with good effect. Upon return to IRF, updated care plans were implemented to focus on facilitating a safe discharge home, using a wheelchair, with less focus on psychiatrically based interventions.

Conclusions: This case study exemplifies the value of interdisciplinary collaboration to provide appropriate and effective patient care. It also highlights the complexities of working with patients who have rarer diagnoses and psychiatric comorbidities. It demonstrates the importance of using objective testing, even after the initial neurological work up in the acute setting. Finally, this case raises attention to the issue of implicit bias in healthcare generally and provides an opportunity for acute rehabilitation teams to consider protocols to combat it.

Author(s) Disclosures: The authors have no conflicts of interest to disclose.