Mind Over Function – A Case Report on Acute Inpatient Rehabilitation for Functional Neurological Disorder in a Patient with Gender Dysphoria

Case Diagnosis: Acute motor weakness and mutism in a patient with chronic functional neurological disorder (FND) and psychogenic non-epileptic seizures (PNES) complicated by gender dysphoria

Case Description or Program Description: A 22-year-old patient with a history of gender dysphoria, autism spectrum disorder, PNES, and FND (diagnosed in 2022) was admitted to acute inpatient rehabilitation (IPR) following acute hospitalization for diffuse pain and lower extremity weakness. The onset of symptoms was linked to the inability to receive gender-affirming surgery. Psychiatry and neurology were consulted along with therapy disciplines for co-management.

Setting: Inpatient Rehabilitation Hospital

Assessment/Results: Examination on admission revealed lower extremity weakness and mutism. The patient primarily communicated with text-to-speech device. MRI and EEG work up were negative. Functional status on admission was minimal assist for mobility and ADLs. During admission, functional status declined to dependent level for mobility and ADLs. At time of discharge, the patient achieved independence for mobility and supervision for ADLs. The total length of stay was 16 days.

Discussion (relevance): Functional neurological disorder is caused by changes in the brain network. Symptoms of this disorder are not correlated with structural changes in the brain or nervous system. Patients who identify as transgender encounter unique stressors, including societal rejection and stigmatization. These stressors increase the risk of developing FND and can lead to relapses of symptoms. Patients experiencing acute exacerbations benefit from inpatient rehabilitation, which provides access to coordinated care from multiple specialties, including neurology and psychiatry, to provide support and enhance resiliency. This patient developed coping strategies and received affirming education through neurology, neuropsychology, and psychiatry. This contributed to the patient’s ability to engage in rehabilitation and regain function with the assistance of physical, occupational, speech, and recreational therapies.

Conclusions: Patients with FND, PNES and gender dysphoria benefit from the multi-disciplinary care provided in an inpatient rehabilitation setting.