What is the recommended medical treatment for functional neurological syndrome disorder?

Medical Treatment for Functional Neurological Syndrome 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

Diagnostic Education and Communication

Education is a critical first step in FND treatment:

• Explain that FND is a real, common, and disabling condition causing neurological symptoms outside the patient's control
• Clarify that symptoms result from a potentially reversible miscommunication between brain and body
• Use positive framing that emphasizes the diagnosis is based on specific clinical signs, not just the absence of other conditions
• Establish therapeutic rapport to enhance engagement and treatment outcomes

Rehabilitation Approaches

Physical and Occupational Therapy

• Focus on gross rather than fine movements for retraining function 1
• Engage patients in tasks that promote normal movement patterns and even weight distribution 2
• Implement strategies to reduce muscle overactivity, pain, and fatigue
• Avoid compensatory aids in acute phases as they may interrupt normal automatic movement patterns 1
• Avoid splinting as it may lead to muscle deconditioning, increased pain, and learned non-use 2, 1

Speech and Language Therapy (for communication/swallowing FND)

• Help patients regain voluntary control over speech and swallowing 2
• Extend automatic activities into graded, functionally relevant tasks 2
• Use positive and negative practice between old and new patterns 2

Psychological Interventions

Both cognitive behavioral therapy (CBT) and psychodynamic therapy (PDT) show medium-sized benefits for physical symptoms, mental health, and function 3:

Cognitive Behavioral Therapy

• Help patients notice and challenge unhelpful thoughts 2
• Address catastrophizing (e.g., "If I stutter at work I'll lose my job") 2
• Plan behavioral experiments to address fear and avoidance of specific activities 2
• Implement sensory grounding techniques to prevent dissociation 2

For Dissociative Seizures

• Develop a seizure management plan 2
• Identify triggers and warning signs
• Teach sensory grounding techniques (e.g., noticing environmental details, cognitive distractions) 2

Addressing Cognitive Symptoms

• Manage contributing factors: fatigue, pain, anxiety, poor sleep 2
• Encourage structure and routine
• Create daily plans to prevent activity and cognitive overload
• Incorporate relaxation techniques to minimize stress 2

Treatment Phases

1. Initial Phase:

   • Deliver comprehensive education about FND
   • Establish therapeutic rapport
   • Agree on treatment parameters
   • Introduce self-management concepts 1

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 1

3. Maintenance Phase:

   • Complete relapse prevention planning
   • Develop ongoing self-management strategies
   • Gradually reduce clinical support 1

Common Pitfalls to Avoid

• Focusing solely on symptom reduction rather than functional improvement and quality of life 1
• Using splints or immobilizing devices which can lead to muscle deconditioning 2, 1
• Inconsistent communication between healthcare professionals 1
• Overreliance on compensatory aids which may prevent restoration of normal movement 2
• Neglecting psychological factors that may contribute to symptom maintenance 4
• Failing to address vocational needs and work/study modifications 1

Treatment Outcomes

Research shows that both CBT and PDT appear to provide medium-sized benefits for physical symptoms, mental health, well-being, function, and resource use 3. However, there is a lack of high-quality controlled trials for PDT and limited long-term follow-up data for CBT interventions 3.

The heterogeneity in treatment responses underscores the need for more research to develop individualized approaches and novel interventions for those who do not respond to currently available treatments 5.