What is the first line of treatment for functional neurological disorder?

First-Line Treatment for Functional Neurological Disorder

The first-line treatment for functional neurological disorder (FND) is education about the diagnosis combined with rehabilitation within functional activity and self-management strategies delivered through a multidisciplinary approach. 1

Understanding the Diagnosis

Education is a critical first step in FND treatment:

1. Explain the diagnosis clearly:

   • FND is a real, common, and disabling condition causing neurological symptoms outside the person's control
   • Symptoms result from a potentially reversible miscommunication between brain and body
   • FND is diagnosed by positive clinical signs (not a diagnosis of exclusion)
   • The condition can co-exist with other neurological conditions

2. Address key concepts:

   • Self-directed attention can worsen symptoms; redirecting attention can temporarily reduce them
   • The body's stress response can influence nervous system functioning
   • Symptom focus can exacerbate cognitive difficulties, fatigue, anxiety, and pain

Core Treatment Components

Occupational Therapy Interventions

1. Physical rehabilitation through guided activity:

   • Focus on gross rather than fine movements for retraining function
   • Encourage normal movement patterns and even weight distribution
   • Implement strategies to reduce muscle overactivity, pain, and fatigue
   • Avoid prolonged splinting or serial casting which can lead to muscle deconditioning

2. Cognitive and behavioral strategies:

   • Establish structured routines for high-risk activities
   • Use written daily plans to prevent activity overload
   • Implement sensory grounding techniques
   • Address hypersensitivity through graded sensory exposure

3. Self-management support:

   • Help patients develop an internal locus of control rather than dependency
   • Use interactive workbooks or therapy journals
   • Set flexible, patient-directed goals

Psychological Interventions

Both cognitive behavioral therapy (CBT) and psychodynamic therapy (PDT) show medium-sized benefits for:

• Physical symptoms
• Mental health
• Well-being
• Function
• Resource use 2

Treatment Approach Algorithm

1. Initial phase:

   • Deliver comprehensive education about FND
   • Establish therapeutic rapport
   • Agree on treatment parameters
   • Introduce self-management concepts

2. Active rehabilitation phase:

   • Implement occupational therapy interventions focused on function
   • Address unhelpful thoughts, beliefs, and behaviors
   • Use variability of symptoms positively in treatment
   • Integrate specific techniques into functional activities

3. Maintenance phase:

   • Complete relapse prevention planning
   • Develop ongoing self-management strategies
   • Gradually reduce clinical support

Important Considerations

• Avoid compensatory aids in acute phases: These may interrupt normal automatic movement patterns and cause maladaptive functioning 1

• Focus on activity-based rather than impairment-based goals: This helps redirect attention away from symptoms and toward function 1

• Involve significant others: Family education is important for reinforcing therapeutic approaches 1

• Address vocational needs: Support for work/study modifications and graded return plans is essential 1

Common Pitfalls to Avoid

1. Using splints or devices that immobilize joints: These can lead to muscle deconditioning, increased pain, and learned non-use 1, 3

2. Focusing solely on symptom reduction: Instead, prioritize functional improvement and quality of life

3. Delaying treatment: Early intervention is associated with better outcomes 4

4. Inconsistent communication: Be open and consistent in verbal and written communications with the patient and other healthcare professionals 1

The evidence strongly supports that education and rehabilitation within functional activity, delivered through a multidisciplinary approach that includes occupational therapy and psychological interventions, form the cornerstone of effective FND treatment.