What is the role of Nocebo (Negative Placebo) Hypothesis Cognitive Behavioral Therapy (CBT) in treating Functional Neurological Symptom Disorder (FNSD)?

From the Guidelines

The most effective approach for managing Functional Neurological Symptom Disorder (FNSD) is through Cognitive Behavioral Therapy (CBT) that incorporates principles to address the nocebo effect, as it has shown promising results in reducing symptoms and improving quality of life. This therapy specifically targets the nocebo effect—the phenomenon where negative expectations lead to worsening symptoms—which is believed to play a significant role in FNSD. According to a recent study published in the Journal of Neurology, Neurosurgery and Psychiatry 1, incorporating principles from cognitive–behavioural therapy (CBT) can aid treatment of FND, and there have been promising results from trials of specific CBT for functional movement disorders and dissociative seizures.

Key Components of CBT for FNSD

• Helping patients notice and challenge unhelpful thoughts, such as catastrophising or ‘all or nothing’ thoughts 1
• Informing therapy with CBT principles, even without formal CBT training, to address anxiety and other factors that may contribute to FNSD symptoms 1
• Using techniques such as breathing techniques, progressive muscle relaxation, grounding strategies, visualization, distraction, thought reframing, mindfulness, and integrating activities of enjoyment to manage anxiety and reduce symptoms 1

Benefits of CBT for FNSD

• Addresses the core mechanisms maintaining functional symptoms: heightened attention to the body, dysfunctional beliefs about symptoms, and avoidance behaviors that prevent disconfirmation of these beliefs
• Helps patients understand how their beliefs and expectations about symptoms can influence their physical experiences
• Enables patients to develop alternative explanations for their symptoms and test their fears through behavioral experiments

By prioritizing CBT that addresses the nocebo effect, healthcare providers can offer patients with FNSD a promising treatment approach that has the potential to improve symptoms, reduce anxiety, and enhance quality of life.

From the Research

Nocebo Hypothesis Cognitive Behavioral Therapy for Functional Neurological Symptom Disorder

• Nocebo Hypothesis Cognitive Behavioral Therapy (NH-CBT) is a treatment approach for Functional Neurological Symptom Disorder (FNSD) that has shown promising results in reducing symptoms and improving patient outcomes 2, 3, 4.
• The basis for NH-CBT is consistent with a predictive coding aetiological model of FNSD, which suggests that symptoms are caused by a nocebo effect 2.
• NH-CBT involves telling patients that their symptoms are caused by a nocebo effect, followed by physical activity aimed at changing the patient's belief about their body 2.
• Studies have demonstrated the efficacy of NH-CBT in reducing non-epileptic seizures, a subtype of FNSD, with significant improvements in seizure frequency and secondary measures 2.
• A pilot randomized controlled trial found that NH-CBT resulted in large within-group effects on primary and secondary outcomes, including motor symptoms, mobility, and symptom perception 4.
• Remote delivery of NH-CBT, such as through teletherapy or internet-guided CBT, may be a promising approach to increase access to treatment for patients with FNSD 5.

Key Findings

• A consecutive case series study found that 93% of patients with FNSD achieved full symptom remission with NH-CBT 2.
• A randomized controlled trial found that NH-CBT resulted in significant improvements in motor symptoms, mobility, and symptom perception compared to an active control condition 4.
• NH-CBT has been shown to be effective in reducing non-epileptic seizures, with 7 out of 10 patients becoming seizure-free at least 2 weeks before post-treatment assessment 2.

Implications for Treatment

• NH-CBT may be a useful treatment approach for patients with FNSD, particularly those with motor symptoms 2, 3, 4.
• Remote delivery of NH-CBT may increase access to treatment for patients with FNSD, particularly those in rural or underserved areas 5.
• Further research is needed to fully establish the efficacy and effectiveness of NH-CBT for FNSD 3, 4.