Neuromodulation Using Computer-Altered Music to Treat a Ten-Year-Old Child Unresponsive to Standard Interventions for Functional Neurological Disorder

Abstract

CASE HISTORY Marie-Therese, known as MT by family and friends, was a ten-year-old girl in Year 5 of primary school referred to the Mind-Body Program by a pediatrician for treatment of functional somatic symptoms—unsteady gait, blurry vision, periods of confusion or appearing dazed, and persisting headache—that had been triggered in the context of a viral illness. MT lived with her parents, a younger sister, and her grandmother. Both parents worked full time as architects. The family history included rheumatoid arthritis (mother), epilepsy (uncle), and type 2 diabetes (grandfather) on the mother’s side of the family, and colorectal cancer (grandfather) on the father’s side. MT had been diagnosed with celiac disease at age 6, which was being managed with a gluten-free diet. Presentation In the three weeks prior to referral, MT had been ill with a viral infection: a runny nose, sneezing, nasal congestion, and frontal headaches. In the second week of this illness, she developed blurriness in the right eye, neck stiffness, pain on eye movement, facial pain, lethargy, and anorexia. With a working diagnosis of partially treated meningitis, she was admitted to hospital for intravenous antibiotics (five-day course). A swab returned rhinovirus positive. In the third week of this illness, her headache persisted, the blurred vision spread to both eyes, and she developed additional neurological symptoms: unsteady gait and difficulty speaking (mumbling). Some days later she became confused, appeared “dazed” and slow to respond to the pediatrician’s questions, and developed slurred speech, right-hand weakness with an occasional tremor, right jaw twitching, and ongoing unsteadiness that required a walking frame for mobility. Routine bloods—full blood count, electrolytes, inflammatory markers, and thyroid function tests—were normal. A contrast-enhanced CT scan and an MRI were also normal, with an incidental finding of Chiari malformation (4 mm). A lumbar puncture was deemed potentially unsafe and therefore was not performed. A review by a neurologist yielded the diagnosis of functional neurological disorder (FND) and comorbid complex/chronic pain (see Text Box 1).*Text Box 1 Summary of MT’s Positive Rule-In Signs for Functional Neurological Disorder in the Neurology Examination Repeated neurology examinations with MT yielded positive rule-in signs—listed below—consistent with FND: •A very dramatic, sudden onset of symptoms, occurring spontaneously or in the context of an identifiable stressor—in this case rhinovirus infection and incidental finding of a Chiari malformation on CT. •Mixed neurological signs that were not clinically congruent in their origin. For example, MT’s unsteady gait was subsequently complicated by right-hand weakness, which became a right-hand tremor, which then reverted back to right-hand weakness (back and forth, back and forth, back and forth). •MT’s leg and right-arm weakness varied with distraction. •MT’s tremor could be entrained (made to follow a particular frequency), and it increased with attention and decreased with distractibility. •MT’s symptoms varied with distractibility. They were better when she was engaged in an activity she liked—for example, coloring in—and worse when her parents focused on the symptoms. Psychological Medicine Assessment with MT and Her Family The family assessment with our team—a child and adolescent psychiatrist, a clinical psychologist, and two pediatric trainees on their psychological medicine rotation—took place via telehealth in the midst of the COVID-19 pandemic. The family were seated in one clinic room, and each member of the team in a separate room. Developmental History: Summary of Key Issues MT’s early developmental history—in utero, delivery, developmental milestones in the first five years—were all unremarkable. MT had been an outgoing and happy preschooler. She underwent tonsillectomy and adenoidectomy when she was three years old and had been diagnosed with celiac disease at six years of age (Year 1 at school) after she had experienced persistent abdominal pain and was found to be anemic. MT also began to experience recurring headaches. MT showed an aptitude for learning, and her school reports described her as a conscientious and bright student. There was a history of school stress, beginning in Year 1 of school and continuing into Year 5. MT reported that her years at school had been made very stressful because her class had been ongoingly disrupted by children with behavioral problems (confirmed by MT’s school teacher). In this context MT also described her distress pertaining to a variety of issues: failing to receive acknowledgment from her teacher for working well (Year 1); the stress of a strict teacher constantly yelling at the class, making MT’s ears hurt (Year 2); loss of a close friend (who left that school), feelings of loneliness and exclusion, and experiences of being bullied (Year 3); the loss of her teacher, who left due to stress and