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Slater was wrong, and the misdiagnosis rate at follow up for patients with functional neurological symptoms in modern case series is consistently under 10% and usually around 5%.5-7 This is the same rate as for other neurological and psychiatric conditions such as MS and schizophrenia. When neurologists do get it wrong, gait and movement disorders and patients with a psychiatric history probably because this biased the diagnosis ; figure disproportionately. 4. Aren't they just the worried well? Surely patients with `real' disease are much more deserving? This traditional attitude leads to irritable doctors and angry patients. Disease is just one of many causes of symptoms and illness. Normal physiology, psychology and the society we live in all play their part. We know that patients with functional symptoms are just as disabled and even more distressed than their diseased counterparts.11 There is a personal choice to make here about your role as a doctor; are you interested in helping all patients with symptoms, or only those whose symptoms are accompanied by disease? Assessing the patient with functional symptoms Table 1 outlines an approach to history taking in the patient with functional symptoms. We find that starting with an exhaustive list of the patient's physical symptoms `draining the symptoms dry' ; gets the consultation off to a good start and can actually save time later on. Eliciting the patient's fears and beliefs about their symptoms and their previous experience of doctors can be helpful in helping you to individualise the explanation you give them for their illness. Depression and anxiety are best asked about at the end of the history framing the question around the physical symptoms e.g. `has this weakness got you down?' rather than `do you feel depressed?' ; to avoid the patient assuming that you are jumping to unwanted psychological ; conclusions. Whilst all of this information is helpful in planning management, it does not really assist greatly in making the neurological diagnosis. For that we are particularly reliant on the physical examination Table 2 ; , partly to make sure there are no definite signs of organic disease but largely to look for positive physical signs that the symptom is functional. The most useful physical sign in the detection of functional paralysis is Hoover's sign Figure 1 ; . It simple to learn and use - but be careful in patients who might have neglect. Bedside tests for sensory symptoms are unreliable and isolated sensory symptoms are hard to distinguish with certainty from demyelination and other central causes. Checklists for diagnosing non-epileptic attacks are notoriously unreliable but the features listed in Table 1 are a starting point. Video EEG is the gold standard investigation although even this can miss frontal and other seizures with a deep source ; . Psychogenic movement disorders are increasingly recognised but are particularly difficult to diagnose.12 Intravenous sedation or hypnosis demonstrating reversibility over a significant length of time may be particularly useful both diagnostically and for treatment if handled sensitively. Further useful information on diagnosis of these and other symptoms is available elsewhere.12-17 Managing the patient with functional symptoms A good assessment is the basis for effective treatment. We try wherever possible to show the patient how we are making the diagnosis. This may include a demonstration of Hoover's sign or perhaps a videotape of an examination under sedation. Patients appreciate this as they can `smell' a doctor who appears to be keeping things from them.
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The patient gets out of breath and this is especially bad when walking up and down stairs. The patient was on medication for her blood pressure but the medications gave her headaches, flushes, heart palpitations, and pins and needles. In the last week, the patient got a severe headache and could not stand straight and was vomiting and shaking. Her husband measured her blood pressure at 210 110. The patient believes that the medication brought on her illness. Her father had a history of strokes. The patient sleeps 6 hours only. Treatment: Walk 15 minutes every day.
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Allergen-specific immunotherapy using therapeutic vaccines is an efficient treatment for allergic diseases including birch pollen allergy because it can affect the course of the disease and alleviate the symptoms. However, using the natural Ags in this therapy can cause severe reactions, including anaphylaxis. Therefore, peptidebased vaccines, such as defined T cell epitopes but not B cell epitopes binding to Ag-specific IgE on mast cells or basophils ; , would be safe and useful in this type of therapy. In a previous study, we described some T cell epitopes of Bet v 1 and found that peptide Bet v 11724 was recognized by Bet v 1-reactive T cells in the context of the HLA-DQ1 molecule 40 ; . It thought that desirable peptides for therapeutic vaccines should include promiscuous T cell epitopes, which can be recognized by CD4 T cells in the context of more than one MHC class II allele, to offer a broad population coverage 3 ; . In this study, we first selected potential HLA-DR-restricted CD4 T cell epitopes from the amino acid sequence of the Bet v 1 protein using a computer-based peptide MHC binding algorithm 30 ; to identify potential promiscuous epitopes for this Ag. Two of the highest-ranking potentially promiscuous sequences that were identified by this analysis were Bet v 1141156 and Bet v 151 68 data not shown ; . Bet v 1-specific IgE Abs in patients were not able to react to these two peptides, suggesting that two peptides do not contain epitopes recognized by Bet v 1-specific IgE Abs data not shown ; . Interestingly, Bet v 1141156 is quite similar to the sequence that was reported previously by Ebner and his colleagues 41 43 ; that contains immunodominant T cell epitopes. These authors reported that the segment of Bet v 1 encompassing residues 145158 contained T cell epitopes restricted by HLA-DR7.
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