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coming up next we have dr. David Perez.bridging neurologic and psychiatric.perspectives in fnd he's an assistant in.neurology and psychiatry at.Massachusetts General Hospital assistant.professor of neurology Harvard Medical.School he is also a fnd researcher and.clinician very happy to be here it's.exciting and you're going to talk about.bridging neurologic and psychiatric.perspectives in fnd do you find there to.be dealing with other medical.professionals kind of the same confusion.of where does F&B fit and kind of always.wanting everyone wanting to put it in.one box or another and finding it.doesn't really fit I think this is the.conversation I'm eager to have with you.and with the fnd community today may be.just the start I want to thank you for.organizing this it's terrific and I also.want to acknowledge the climate we're in.there's been tremendous challenges with.Koba 19 with social distancing I.certainly feel that somewhat regretful.that we're all not coming to Boston to.continue to celebrate with the fnd.conference but maybe that will be next.year and there'll be a lot of excitement.on this and Bridget before I share my.slides I have prepared about a 35 minute.talk for the audience largely sharing my.personal perspective and my journey.through neurology training psychiatry.training and neuroscience and I will.tackle my own perspective and how to.think about the overlap between.neurologic and psychiatric framings of F.and D and then I'm hoping we can have a.conversation at the end with some.questions that you can lead that sound.reasonable that is the plan so that.sounds fantastic.very good let me go ahead and share my.screen give me a moment or two just to.work through this for a second.and we can see your screen so you're.ready and I'm going to move a couple of.things around so I can see everything.and Bridget you can hear me okay and you.can see you and the screen both so.whenever you're ready let me just take a.moment to make sure we can advance okay.wonderful so for the group these are my.disclosures and maybe we'll also begin.with some disclaimers I would love to.give brain imaging talk and this is.something that I gave when I last had.the opportunity to speak to F and D hope.on but this is not a brain imaging.lecture in fact while there may be a.couple of brain imaging slides as I've.mentioned I really want to take more of.a personal stance in communicating at.least my own perspective and how I think.about F and D from both a clinical.perspective and from both a research.perspective and the questions just as.Bridget set the stage for that I will.come back to and give my answers on is.how do we formulate F indeed it is F in.the neurologic disorder is it a.psychiatric disorder is it a.psychological disorder I think you'll.see at the end that my perspective is.both clear but nuanced and I really want.to hope to convey my thinking to the.group on on this topic and I think to be.able to do that it really also requires.that I deconstruct my own journey of how.I've come to think about this problem so.I want to start there and for me the.journey begins about 20 years ago at.Columbia University where I first began.to study neuroscience in a course called.mind brain and behavior it's interesting.very much even in the title brain and.mind put together.and following this course and developing.rather significant passion for this area.really upfront I was very lucky I was.connected to the lab of Eric Kandel and.some of you may know that Eric Kandel.trained as a psychiatrist he also won.the Nobel Prize in Physiology or.medicine for fundamental insights in.learning and memory and I had the.opportunity as an undergraduate in.college to spend two and a half years.working in Eric's lab under the guidance.of Michael Rogan Michael was phenomenal.really I credit Michael with being my.first mentor and Michael as a senior.research scientist actually did his PhD.work with Joe LeDoux who himself is a.pioneer in how we think about the.emotional brain and fundamental nerve.scientific insights into emotion and how.we acquire fear and safety and other.such biological processes with Michael I.was in planting depth electrodes into.the lateral amygdala and the dorsal.striatum we were trying to understand.the physiological correlates of how.rodents acquire how rodents learn to.associate certain cues with fear States.and how rodents can also go on to.associate other cues when safety States.times where you can become more.expansive and exploratory in your.behavior and in the context of working.in Eric's lab it never once dawned on me.as an undergraduate that I was.conducting psychiatric research it never.once dawned on me that I was in a.psychiatric lab I saw this as brain.science and we were asking questions.related to motion processing in the.context of performing brain science so.an early lesson that really has stuck.with me to this day.and that I've put in writing in various.formats is that the brain doesn't.separate into neurologic and psychiatric.circuits I went on to medical school and.for much of my early educational.experiences there with coursework the.tradition of an integrated approach.continued and then we started on the.journey of clinical clerkships and.that's where things actually became.rather different it became very clear.the kinds of questions that neurologists.were asking and it became very clear the.kinds of patient populations that.psychiatrists were exposed to the.approaches were different a focusing.focus on brain anatomy on localizing the.lesion one patient at a time.was very much the language of the.neurologic approach and yet some of the.more complex and in my mind also.interesting brain conditions were seeing.primarily by psychiatrists this really.created attention in how I sort of.[Music].sought-after what kind of path I wanted.to carve out for myself in interviewing.for residences I actually interviewed.for residences in built neurology and.psychiatry and what I found very.interesting there is while I was pleased.to report that people were receptive.across the aisles it's also interesting.that within Neurology when I would.interview for various programs they were.sort of felt that all of my interests.were encompassed within neurology.departments then you can fast forward.two weeks later and I would interview in.the psychiatry department and the.framing was that all of my interests.could be encompassed within the.psychiatry department really kind of.placing a challenge that maybe the path.that I needed to carve out was a bit.different and frankly there were some.mentorship challenges in thinking about.this interface thankfully at NYU they.have a dual training program in.neurology and psychiatry and so I also.had the opportunity to.in clinic in real-time how patients with.complex brain conditions were evaluated.using an intra disciplinary approach one.that really cuts across the lens used by.neurologists and the lens used by.psychiatrists it's also really fortunate.that I write back to Columbia and.reconnected with Michael Rogan at that.time he was moving from basic science.work to learning to conduct fMRI studies.in the laboratory of joy Hirsch and it.was really within this context of.learning that there can be a holistic.way of thinking about complex brain.problems being exposed to dual trainees.and also learning that within our fields.there is much yet to be learned and so.marrying clinical neurology with.clinical psychiatry and then tools to be.able to disentangle levels of complexity.in the brain that we don't quite yet.understand fMRI and ultimately.structural MRI techniques allowed a.window into this that I was very much.gravitating to that led me to the next.seven years of dual training across the.Harvard system and really just by my.luck it so happens that I also happen to.again walk in the same shoes of Eric.Kandel who not only did he train in.psychiatry but some of the same.facilities where I did my psychiatric.training Eric did his psychiatric.training and here's a quote from Eric.that I think is very relevant to my own.experience had I not trained in.psychiatry I most likely would not be.working on the problems I now work on.and love and this is something I feel.very strongly about had i not trained in.both maroc neurology and psychiatry I'm.not sure I would be asking the kinds of.questions both on the research side and.pursuing the kind of clinical career in.pursuing without this viewpoint.I also think that while I won't delve.into it a bit later so I'll say I'm a.comment or two about it now my own.perspective in clinical work in F and D.when I think about a versatile tool box.is that for me when I first meet.patients I am very much leveraging.almost 50/50 a neurologic framing and a.psychiatric framing and it really varies.patient to patient what tools I reach.for that being said I find that for.follow-up care I'm really relying.tremendously on the skills that I've.learned in psychiatry and so on as I.reflect back on kind of my own journey I.am I think it's important to at least.state that out loud what tools am i.reaching for and maybe that adds value.to how we can think about our field.moving forward as I reflect on my.journey through training and neurology.and then moving from becoming training.in Neurology to then crossing over and.training in psychiatry much of the.exercise that I was doing early on and.kind of mid training was learning to map.brain symptom learning to map symptoms.onto brain networks and this is a.language that's very familiar to.neurologists and clinical.neuroscientists in fact this kind of.language has allowed neurologists to.make fundamental insights into.psychiatric disorders so for example.some of you may be familiar with Helen.may Burke who is a pioneer and how we.think about treatment refractory.depression she has set the stage that.the sub general anterior cingulate the.area on the brain map highlighted in red.it is important for modulating or.shifting our mood States so patients for.example with a major depression it's not.so much that they're sad or depressed.and that's the hallmark of the condition.we've all experienced these symptoms in.our day to day lives it's the inability.to get out of that mood state being.stuck in that rut that's so critical and.Helen main bergs applied some very.important network science to highlight.the role the subject of single in this.area there's others who are thinking.very deeply using a similar approach.some of you may be familiar for example.within the Harvard community of Michael.Fox again a neurologist who's really a.pioneer and how we understand.relationships between lateral brain.networks the dorsal lateral prefrontal.cortex and these medial brain networks.such as a sub general anterior cingulate.and ultimately we're never really.talking about one brain area we're.talking about networks and patterns of.activity across brain areas this is very.much a neuro scientific approach to.complex brain disease it's been the.language that's been argued for how we.can bring together in a rich way.neurologic thinking and psychiatric.thinking some of these papers are from.the early 2000s it should be no surprise.that Eric is among those who's written.about this topic and then many have.continued to update this perspective in.recent years my own journey however.after finishing my dual training and.beginning to practice I realized that I.was no longer practicing the neurology.that I finished residency performing I.was performing I was practicing.neurology differently and what I.realized as I kind of thought about this.some more is I was relying on the.biopsychosocial formulation to put.patients clinical picture in context.also a hallmark of how we think about.brain disease and kind of behavioral.neurology of brain behavior.relationships but I've now started to.really emphasize to by directionality of.this and that life experiences and.behaviors also shape our brain.structurally and functionally.and while categories remain and continue.to be important psychiatry has taken.this perspective of thinking trans.diagnostically the lines between.categories of diagnoses are fairly.blurry and understanding core.dimensional constructs that may be.important in the pathophysiology is.really the kind of language being used.in modern day Biological Psychiatry.no surprise that I've taken some of.these perspectives to argue for the.importance of a trans diagnostic.perspective and how we think about the.motor phenotype of functional.neurological disorder with many.overlapping characteristics in patients.with non-epileptic seizures functional.movement disorders functional in.weakness so having deconstructed a.little bit for the F and D hope audience.my personal journey let's shift gears.for a few minutes and talk about the.challenges and the challenges are not.subtle across the aisle so for.psychiatry some psychiatrists lack a.playbook through which to evaluate and.conceptualize neurologic symptoms.they're not receiving training on how to.evaluate patients whose chief complaint.is a tremor or a dragging limb or.trouble walking and no surprise a fair.amount of psychiatrists are also less.proficient in the neuro exam and the.ruling diagnosis by clinical features is.one of the massive breakthroughs in our.field I think over the past 20 years so.we certainly don't want to lose hold of.this and then let me just be as frank.and as blunt as I can be the conversion.disorder model fails and it fails.because one size does not fit all in.functional neurological disorder period.let's talk about the challenges for a.neurology and I think that they're not.any less important one of the things.that I've realized working hand-in-hand.with many excellent neurologists is how.do they develop a patient-centered.treatment plan and put simply the rule.in signs the semiological features by.themselves do not allow for a.patient-centered treatment plan and what.I would argue is that to develop a.patient-centered treatment plan one.the prevailing models that were relying.on and continued continuing to rely on.in our modern conceptualization of F and.E is the biopsychosocial formulation.this is the formulation that requires to.some degree a psychiatric screen a rich.psychosocial screen and is the hallmark.of how psychiatry is taught with very.little emphasis on the biopsychosocial.formulation in neurologic training.broadly here's a nice example by Suzanna.pick with work that comes out of Technic.to Nicholson's lab really updating the.biopsychosocial formulation for F and D.with an emphasis on emotion processing.as one such example from 2018 and the.challenges have been operationalized we.know from work done by Richard Coonan.and others using interviews that really.across the aisle neurologists and.psychiatrists struggle with working with.patients with the level of complexity of.FMD that they're encountering clinically.some neurologists feel uncomfortable in.the psychiatrist chair and there's.debate about how involve psychiatrists.should be in the assessment and.management thankfully some of this has.changed there's been some really.positive advancements but we have a long.way to go and I think that remains very.clear in my own mind.in fact we wrote this practical.neurology article entirely because many.excellent neurologists especially with.some of the educational materials that.have come out and facin the rule ensigns.neurologists know how to diagnose F&B.where I find the struggle is greatest.isn't a long longitudinal follow-up is.in trying to understand when treatments.not working.how do you explore that when treatments.not working in psychotherapy how do you.listen and how do you listen with.purpose and maybe listening with purpose.in a way where you can catalyze and.energize the treatment so this is.something that I personally have found.it is an area of relative weakness for.neurologists let's think for a moment.about the biology Mike the biology give.us some clarity in how we can think.about function or logical disorder I.think the answer is yes but let's look.really carefully so some of you may have.followed work coming out of my lab over.the past six or seven years which is.also consistent with work coming out of.other labs internationally that there.appears to be a role for the salience.Network in the pathophysiology of.functional neurological disorder and yet.when we look at large-scale meta.analyses looking at accessing patterns.the most common areas that are atrophied.in patients with classic psychiatric.disorders mood and anxiety conditions.are the insula and the dorsal anterior.cingulate.similarly this same brain network shows.patterns of atrophy striking patterns of.atrophy in traditionally conceptualized.neurologic conditions such as forms of.frontal temporal dementia what may be.more defining of the pathophysiology of.function neurological disorder that we.need to continue to think deeply about.as a community is not so much is there a.network that F and D maps on to but it.may be patterns are different how.different brain regions communicate with.one another may be patterns of.information flow between certain core.areas of the salience network in areas.involved in motor control and in sensory.processing and bodily processing more.broadly.let's think about another a really.important biological concept there's.been a lot of enthusiasm about the fact.that increasingly it's recognized that a.core function of our brain or higher.order function is our predictive brain.with the framing of predictive.processing as being the overarching.framework for this and some really.groundbreaking work done by Mark Edwards.is in highlighting the role for.predictive processing in the.pathophysiology of function of the.logical disorder now disturbances and.predictive processing or likely.nonspecific to F and D there may be a.whole range of disorders across their.logic and psychiatric conditions where.disturbance is in predictive processing.may be important just a link between.this slide by the way and the former.slide is that a higher-order brain.region that is hypothesized to be.critically involved in predictive.processing is the salience network with.the temporoparietal junction being.another important core component in.prediction so the specificity of the.prediction error relating to sensory or.motor function that may help us.understand F and D the core biological.processes such as predictive processing.more broadly really cut across disorders.the same way involvement of discrete.brain networks cuts across disorders.across the spectrum of neurology and.psychiatry.so how do we bridge this divide and.here's one perspective that I think may.may help move the field forward and.that's the lands of the neuropsychiatric.perspective and here's a definition by.Yudof ski inhales but really is.synonymous with my definition of.neuropsychiatry foundational to any.definition of neuropsychiatry is the.indelible inseparability of brain and.thought of mind and body and of mental.and physical in terms of the history of.neurology and psychiatry some of you may.know that it's a who's who both.psychiatrists and neurologists in the.early histories of our field that.identified as neuro psychiatrists.and I want to call attention to in.particular Stanley come from Oh Stanley.Cobb was a neurologist who ultimately.went on to start a psychiatry department.and in 1943 here's his quote I need to.move something from the screen so I can.see it well I solved a mind-body problem.by stating there is no such problem.there are of course many problems.concerning the mind and the body and all.the intermediate levels of integration.of the nervous system what is but I wish.to emphasize is that there is no problem.of mind versus body because biologically.no such the economy can be made the.dichotomy is an artifact there is no.truth to it and the discussion has no.place in science in 1943 I think really.is striking and forward-thinking.perspective and this is part of the.language of why I think maybe back to.the future might be with some new.advancements might be the way we can.think about these issues this is a list.for again kind of D stigmatizing what.are their psychiatric disorders these.are disorders across neurology and.psychiatry many common conditions people.have heard.so how do we bring this back in a.concrete way to functional neurological.disorder and that's where I think it.becomes even more nuanced it's a.balancing act for some with F&D.neurological and medical factors play.critical roles in disease risk in.bringing symptoms on and in maintaining.symptoms we can think for example about.the important role of head trauma and.the development of non-epileptic.seizures or the important role of.peripheral limb injury in the.development of a functional dystonia.with potentially a superimposed complex.regional pain syndrome for others with.empathy.psychiatric and psychological factors.and psychosocial factors play critically.important roles in disease risk and.bringing symptoms on and in maintaining.symptoms we can think for example about.patients who are having post-traumatic.stress disorder symptoms for in the.midst of a rien cing fact and.superimpose in that re-experiencing.effect is a non epileptic seizure or an.event of paroxysmal functional limb.weakness.we can think about patients whose.non-epileptic seizures lower the lines.between panic attacks and non-epileptic.seizures and really we can even think.about the pathophysiology of both and.might might there be some shirt elements.there's also an old literature but a.really important literature suggests.that focal neurologic symptoms are not.unique to neurology in fact described in.1986 where patients who were presenting.with panic attacks who had concurrent.functional neurologic symptoms.superimposed.the author's argued then focal.neurologic symptoms should not exclude a.diagnosis of panic attack we might ask.in 20/20 might be called this.differently might we call this an.episode of function or logical disorder.we might but I think it really.highlights how interrelated the.boundaries are how blurry these.boundaries are when we think about this.balancing act for many it can also be a.bit of book where neurologic and medical.factors and also psychiatric.psychological and psycho.psychosocial factors are relevant.to answer this question directly I.trained in neurology and psychiatry and.it's been transformative to how I think.about F of D but is this necessary for.expert F and D clinicians unequivocally.the answer is no but I think that an.element of shared expertise our.neurologists developing shared expertise.in psychiatry and psychological concepts.and clearly our psychiatrists developing.increased expertise in the neurology.that's really where the neuropsychiatric.perspective is so important and then.ultimately it's a team sport and it's.about bringing together a rich set of.viewpoints that are all empowered with.value and with openness so for me these.two statements are synonymous functional.neurological disorder is a condition at.the interface of neurology and.psychiatry the statement function or.logical disorders and neuropsychiatric.disorder means the same thing to me I.could also understand that some people.may prefer one statement or the other I.don't have strong opinions on this.particular perspective these are.overlapping in my mind and our tree of.how to conceptualize this is certainly.much more broad than neurologic and.psychiatric perspectives one I want to.highlight up front that I'm using a.medical model but I'm very much.overlapping psychiatry with psychology.but one can even take that prior.statements and say the interface of.neurology psychiatry and psychology just.to be explicit and then there's much to.learn from our allied colleagues in.rehabilitation disciplines physical.therapy occupational therapy speech and.language the list goes on.why an inclusive perspective why might.we need this let's take this in three.separate parts.I think clinically we want to energize.the best and brightest across neurology.psychiatry psychology and all the allied.disciplines to really meet the call for.caring for this condition expressing.interest in this condition and think and.thinking deeply together about the.problems that lie with function or.logical disorder how we do better in the.future I think from a research.perspective we also want to maintain a.diverse research agenda and how we.understand this disorder and ultimately.how we develop more effective treatments.and then societally can we once and for.all break down the walls of this.inherently artificial divide between.physical health and mental health I.think this is a really a landmark moment.as a community to be able to make some.progress in this area as well let's also.be transparent we want to avoid the.mistakes in the past and these are.mistakes in the distant past and they're.not so distant past and I'm very happy.to acknowledge that I continue to learn.every day and I'm finding even these.conversations were having as a community.very educational.for frankly my continued girls and.developments that will be career law and.so I think that a continued premium in a.rule in diagnosis based on physical.examination and semiological features is.foundational this has been a major.breakthrough we also don't want to jump.to conclusions.I get asked fairly often in patient.encounters why given patient has FMD and.I'm honest I don't know why patients.develop and develop fnd and any given.clinical encounter and I certainly don't.know after one visit.I have had the experience that some.patients who recover learn for.themselves why they develop F&D and.sometimes they share that with me and.that's been really really educational.empowering and really the list of.adjectives goes on we need partnership.and partnership from clinicians.researchers patients advocacy groups.other stakeholders now I think a.particularly important group to learn.from his patients was recovered how they.think about their condition once they're.in this state of having moved on and.whatever they learned about their brain.their mind their body I think this is a.really rich opportunity so back to the.initial questions.so as fnd a neurologic condition yes is.it a psychiatric condition yes.is it a psychological disorder yes but.the equation is different for each.patient and as we think about an.inclusive framing of F and D.conceptually I think each statement by.itself is a bit incomplete.I would clearly state that the.statements F and D is a psychiatric.disorder unqualified is incomplete I.also feel the same way about the.statements F and D is a neurological.disorder unqualified isn't complete this.is my opinion and this really brings us.back to this framing of the interface of.neurology and psychiatry synonymous with.this framing of a neuropsychiatric.disorder.and as we wrap up it's really.highlighting this cautionary note which.is one size does not fit all any patient.may be somewhere on this spectrum and.each patient story is valid each patient.story is important but allowing kind of.our framing that sometimes forgiving.patients the equation may be a bit.different and as we wrap up let me just.bring it back for a moment because I.can't resist to brain circuits in the.kind of language that we've been.discussing for a rich but nuanced and.rather heterogeneous formulation of.functional neurological disorder so when.we think about the biology and number of.studies have shown that the amygdala is.hyper connected to motor control areas.not all studies have shown this but many.have and our group very recently has.shown that an a potentially important.variable is that the magnitude of.childhood physical abuse the more.patients had reported experiencing.childhood physical abuse it's a more.coupled the amygdala connectivity.profile was to premotor areas to motor.output regions what's really important.about this diagram I want to spend a.moment on is this for those who may be.less familiar with the childhood trauma.questionnaire phase four or five means.no trauma on physical abuse okay and.there are a number of patients who are.scoring as no trauma in this domain.their relationships are quite different.then patients who are scoring in the.higher domain when we perform these.within group correlation analyses.variability in the data actually.increases power it allows us to perform.these calculations what this variability.in the data also means is that there.potentially are groups of patient.that are behaving differently and that.are a biologically distinct we don't.know the answers to this but these are.the kinds of questions that were eager.to ask so thinking a little bit about.might there be circuits specific.subtypes of function and logical.disorder I don't know but these are the.kinds of questions that in the lab we're.looking forward to asking in the next.phase of things and there is a long list.of people to thank I think one of the.things I wanted to be clear about in.this talk is I've conveyed to the group.my opinion and I've conveyed to the.group my opinion in large part through.the lens of my own educational and.clinical journey and I'm thankful for a.large group and growing group of people.I get to exchange ideas with on a.regular basis they don't always agree.but there are many people to thank and.so on I'm in in tremendous debts and.gratitude to both MGH colleagues and.colleagues elsewhere but also up front.that not everyone necessarily agrees.with the viewpoints I put forth here I.do want to acknowledge two people in.particular and that is Indra bag and Tim.Nicholson again my viewpoints convey.here on my own but I very much enjoyed.in the recent weeks and months having.rich conversations with both of them on.this topic at the intersection of.neurology and psychiatry thank you very.much and I'm really grateful to have to.be hope for this webinar on this.opportunity thank you that was very.interesting and I think we've had a few.questions come in one that I think that.you you really pointed out that's also.important that just kind of shows where.we're at in the climate of research is.that like I said a lot of this are comes.from your perspective and your.viewpoints and their other doctors we.have dr. Edwards on last week I think it.was and he had a little bit of a.different perspective on some things but.I think that just goes to show if we.it's wonderful that we're opening up.door to all these different views and.exploring because that's really the only.way we're gonna find answers is being.open to all these different ideas and.concepts one question that I had was do.you feel is it fair to say that we're.not only changing the perspective of fnd.but we're actually trying to push for.this change in the concept of how we.view the mind even though it's been out.there no one's really ever had to push.it so far saying like no it really it's.time to stop looking at them is to.separate brain and mind we look these.are really interesting these are complex.neuro scientific questions they're also.really complex societal questions right.and I think that's also what makes it so.interesting I'm far from someone who has.all the answers but I think about the.mind as a higher order construction.through interactions of brain networks.so ultimately there is no mind without.brain and so it's a bit of a.reductionistic view but I think it's.view that frankly I'm not we don't know.as a scientific community what patterns.of connectivity what patterns of.oscillations what patterns of synchrony.ultimately lead to the creation of a.mind and awareness we don't know this.but it they're immensely interesting.questions and I don't think we're wrong.if we're looking for the seed of the.mind within the brain and thinking about.levels of complexity you may not yet.have the tools to ask the kind of.question with the level of resolution.that we need to get there but it's super.interesting and I do think that as an F.and E community maybe together we can.also create a little bit of societal.change that again this divide of.physical health and mental health.artificial let's break down the walls.we're talking about health and we know.across many many many disorders.that one's brain health and the levels.of complexities of that is interrelated.to our body health and so I am hoping we.can learn together and change the.language wonderful a question that we do.have is he's asking about predictive.processing and the question is is that a.universal mechanism which people with.fme process and share along the same.pathway or is it a balancing act based.on the nature of your job role or trauma.type and unique to the individual yeah.that's a great question I mean I think.the short answer is that those are rich.research questions I don't think we have.the answers yet I also I don't think we.know for example is FMD an inherent.predictive processing problem or is it.one of the several mechanisms that play.a role in the pathophysiology of.functional logic Explorer the short.answer is I'm not sure I wonder if it.might be one of the one of several.mechanisms but again I think that um we.are just beginning to push the.boundaries of what kinds of tools what.kinds of tasks what kinds of.neuroimaging analyses can be run to.really tease that apart so the short.answer is I'm not sure and unfortunately.that's the answer with a lot of.questions with then fnd I think - so I.don't think that's uncommon another.question that we have is in regards to.dystonia and fnd yes if you class focal.dystonia under F and D oh do you class.focal dystonia under F in D and.therefore if treatment should follow.similar treatment course if not q direct.me to someone who's researching focal.dystonia is that something that you've.looked into specifically I guess I think.the short answer there are many forms of.dystonia some forms of dystonia are.functional dystonia some forms of.dystonia are more idiopathic or.genetically driven and they have.distinct mechanisms there are some.specialized dystonia clinics and this.question they may want to look into a.specialized dystonia clinic where they.can tease apart the various ranges of.presentations and understand this is.fall into the category of a functional.dystonia which really very much fits.into our conversation today or is this.distinct well I know there was specific.research done on dystonia that was they.felt that was functional and organic and.their blood flow patterns were exactly.the opposite it's my understanding and.so they can see the difference in those.scans too and I don't know how they.compare with other functional symptoms.but that's well said and I think one of.the things - I've highlighted before but.I'll say again is with our advanced.brain imaging techniques these are.research techniques we ultimately hope.that they will deliver biomarkers that.might help stratify patients in.different ways and if that.stratification is relevant it's relevant.because maybe certain groups respond to.different treatments and so we want to.know that through brain signatures and.obviously pair patients up as fast as.possible to the most effective treatment.we're pretty far from that and none of.the quantitative imaging either.functionally or structurally is in any.way ready for clinical use we're using.it in the lab largely first to focus on.pathophysiology if we can more.rigorously define the biology then maybe.a second wave is to then understand how.the biology might inform treatment and.patient stratification are there other.types of scans that can be used that.this can be seen with like for instance.SPECT scans anything that's not.typically used or something that's been.being kind of looked at or explored some.of the newer avenues of research that.you've come across clinical perspective.I think the short answer is no SPECT.scans PET scans these are nuclear.medicine or.is that our again research techniques.and they come with different risk.benefit ratios including exposure to.radiation but one of the points that I.really tried to highlight very clearly.in my talk is a tremendous advance of.the rule in diagnosis of F and D based.on physical examination based on.semiological features for patients with.paroxysmal events like seizures I think.there's even more work to be done in.understanding the specificity of those.ruling signs but that's been a.tremendous advance and I think we really.want to hang our hats on our physical.exam on our observation skills for.diagnosis but then the gap between.diagnosis and treatment response some.patients do marvelously well with.physical therapy others can do very well.with integrated physical therapy and.cognitive behavioral therapy and still.others despite our very best efforts.continue to be stuck and really sick and.they can all have the same diagnosis.functional neurological disorder so.that's really I think what we don't.understand yet and what I'm excited.about as a field I hope we can.understand during our careers.we can take just getting down to the.ends maybe just one last question one or.two how long have you seen a patient.maintain recovery without significant.relapse what's a good question I think.one of the things that brings me great.joy right is when patients assist me in.the conversation about discharging.themselves from clinic I think this is.really great.right it's one of the joys I say look I.am NOT in the business of creating.patients who are lifelong patients.brings me tremendous joy when they may.say dr. Perez it's nice coming into the.clinic or explants coming into Boston.but frankly my life's very busy and I'm.pulled in different directions and I'm.doing well and so I'm really engaged in.those activities and I think of that as.a major success you know ultimately I.think that um we and others.need to do more prospective work about.patients who disengage in treatment who.are well for a year or two years what.happens five years out ten years out.are they remaining well I don't have the.answers to that but I've seen patients.who are well four years and I take great.joy in that discharge conversation great.last question what do you hope to see.research progression in say the next.year where do you hope to see it the.next year I think it's a great question.it's ambitious one and the scale.research and F and D is moving in my own.opinion tremendously fast it's really.exciting and there's tremendous work.being done frankly worldwide I think to.make the kind of forward steps that.would ultimately lead to biomarkers that.would lead to biologically informed new.treatments that would lead to predictive.biomarkers really allowing us to have.more informed conversations about what's.the trajectory are going to look like is.it gonna be a fast recovery is it gonna.really be something that may have.multiple relapses what what does the.future hold I think that that's gonna.take some time and that's certainly a.multi-year journey maybe decades but I.think that when I compared the progress.F and D is immensely complex and I'm.using the lens of the advancements made.in other psychiatric and neurological.conditions and I think I want to inform.my comment on that and that's I hope I'm.wrong.I hope the pace is faster but it may.take us some time that being said we may.not fully understand all the biology but.a really important point.many many many patients can get better.with the standard of care our standard.of care now with the physical.interventions physical therapy.occupational therapy speech and language.the evolving toolbox of psychotherapy.tools there.great and for many they can work very.well they also don't work well for quite.a number of patients so and I think when.I first meet a patient I don't know so I.really want to encourage a strong sense.of optimism because the treatments may.very well work and then I think for.those that the treatments don't work for.we need to think about working harder.and we need to maybe go back to the.drawing board about what we're missing I.don't have all the answers there yet.I think those are really good points to.maintain that sense of hope that we.don't there's a lot of illnesses that we.don't necessarily understand all the.brain mechanisms behind them but there.are treatments that can help patients.and so it's nice to know that we're.looking at fnd from both perspectives.and that we're looking for treatments.while we're also looking for you know.the science behind some of those and.that keep up that just because something.didn't work maybe something else might.work and really even just physical.therapy and occupational therapy and how.those are also making such a huge.difference in patients and so it's.wonderful to see that change.dr. Pres thank you so much for some time.with us today and going through all that.brain science and we really appreciate.the work that you're doing so Bridget.it's my pleasure I'm very grateful and.I'm grateful to the fnd hope community.thank you very much.

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649 F Medical Examination Report Form FAQs

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How should we get the medical examination report filled for IISER?

Go to a registered medical practitioner(If it's a person you know, it's better). He/She would do the rest. Don't forget the proof of your blood group and also the details of your glasses() if you wear any. Also, fill the first part of the report(luke application number, stream, etc.) which are to be filled by you. Don't put your signature. You should sign it in front of the medical practitioner. Most likely there are going to be medical tests. So, don't worry, the doctor would take care of the rest.

How can I retrieve my AKTU password for filling out the examination form?

Just go to the aktu erp and click on forgot password. your user id is your aktu roll no. If this doesn't work then please contact to the control of Examination of your college.

How much does it cost for medical examination for green card?

Since USCIS changes fees for form submissions and other things in this process continuously, this is a moving target as far as the answering goes. But there is a year or two old fees list here: Green Card Application FAQs

How much does a medical examination cost?

It depends on the complexity, where you are located, and how long they spend on it. I have done this a couple times and charged $500 but it took me most of a day to review and summarize.

How much is Form I 693?

Since USCIS changes fees for form submissions and other things in this process continuously, this is a moving target as far as the answering goes. But there is a year or two old fees list here: Green Card Application FAQs

Does insurance cover immigration medical exam?

No. Medical marijuana is not covered by health insurance. Most treatments/medications that are covered by insurance are first approved by the FDA or some other governmental agency. As marijuana is not approved for use on the federal level, it has no approval in health insurance.

What is included in a medical examination?

Per my knowledge, there is no need to undergo any medical examination to apply H1B. How ever there is question in form: Do you have a communicable disease?" Does the U.S. consider an illness like the flu, or a cold to be a communicable disease? If you have any communicable disease such as Gonorrehea, Leprosy, Syphilis in the past and cured then its fine - but you should carry certificate that you no longer have the disease while going to the Interview.

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