What medications are used to treat Functional Neurological Disorder (FND)?

Medications for Functional Neurological Disorder (FND)

There are no FDA-approved medications specifically for FND, but selective serotonin reuptake inhibitors (SSRIs) and low-dose amitriptyline are recommended for certain FND symptoms, particularly functional dysphagia with globus sensation. 1

Medication Approaches by FND Symptom Type

For Functional Dysphagia/Globus Pharyngeus

• First-line options:
  • SSRIs (e.g., paroxetine, citalopram, escitalopram) 1
  • Low-dose amitriptyline (starting at 10-25mg at night) 1

For Comorbid Anxiety/Depression in FND

• SSRIs are preferred due to better tolerability compared to tricyclic antidepressants 1
• Evidence suggests escitalopram may provide pain relief in some patients with neuropathic symptoms 1

For FND with Sleep Disturbances

• For REM sleep behavior disorder symptoms:
  • Immediate-release melatonin (starting at 3mg, increasing by 3mg increments to 15mg) 1
  • Clonazepam (starting at 0.25-0.5mg at bedtime) - use with caution in elderly patients 1

Important Medication Considerations

Dosing and Administration

• Start at low doses and titrate slowly to minimize side effects
• For amitriptyline: Begin at 10-25mg at night and increase gradually if needed
• For SSRIs: Standard starting doses with gradual titration based on response

Monitoring

• Assess for improvement in target symptoms (dysphagia, anxiety, depression)
• Monitor for common side effects:
  • SSRIs: Nausea, headache, sexual dysfunction
  • Amitriptyline: Sedation, dry mouth, constipation, urinary retention

Cautions

• Benzodiazepines (including clonazepam) should be used cautiously due to:
  • Risk of falls, especially in elderly patients
  • Cognitive impairment
  • Potential for dependence
  • Listed on American Geriatrics Society Beers Criteria as potentially inappropriate in older adults 1

Non-Pharmacological Approaches

While medications may help manage specific symptoms, they are not the primary treatment for FND. The evidence strongly supports:

1. Cognitive Behavioral Therapy (CBT) - Medium-sized benefits for physical symptoms, mental health, and function 2

2. Physical and Occupational Therapy - First-line treatment for functional motor symptoms 1, 3

   • Focus on retraining normal movement patterns
   • Engage in tasks promoting normal alignment and weight-bearing
   • Employ anxiety management and distraction techniques during tasks

3. Psychodynamic Therapy - Shows potential benefit similar to CBT 2

Treatment Algorithm

1. Identify specific FND symptom pattern
2. For functional dysphagia/globus sensation:
   • Start SSRI or low-dose amitriptyline
   • Provide education about acid reflux management if relevant
3. For other FND symptoms:
   • Prioritize appropriate non-pharmacological therapy (CBT, physical therapy)
   • Consider medication only for specific target symptoms (anxiety, depression, sleep)
4. For all patients:
   • Provide clear explanation of the diagnosis
   • Emphasize that symptoms are real and treatable
   • Focus on function rather than symptom elimination

Pitfalls to Avoid

• Prescribing multiple medications simultaneously
• Using medications as the primary treatment without appropriate non-pharmacological therapies
• Overlooking the importance of a clear diagnostic explanation to the patient
• Using high doses of sedating medications in elderly patients or those with subtle neurological deficits
• Failing to address comorbid conditions that may exacerbate FND symptoms

The evidence for medication use in FND is limited, and treatment should focus primarily on appropriate rehabilitative and psychological approaches, with medications used as adjuncts for specific symptoms rather than as primary treatment.