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

First-Line Treatment for Functional Neurological Disorder (FND)

The first-line treatment for functional neurological disorder is a multidisciplinary rehabilitation approach focused on education about the diagnosis, functional activity, and self-management strategies. 1

Diagnostic Education as Initial Treatment

Education about the diagnosis is the critical first step in FND treatment and has therapeutic value in itself:

• Acknowledge that FND is a real, common, and disabling condition causing neurological symptoms outside the person's control 2, 1
• Explain that symptoms result from a potentially reversible miscommunication between brain and body 2, 1
• Emphasize that FND is diagnosed by positive clinical signs (not a diagnosis of exclusion) 2
• Explain how self-directed attention can worsen symptoms while redirection of attention can temporarily reduce symptoms 2
• Provide education on how stress responses can influence nervous system functioning 2

Core Rehabilitation Components

Following education, treatment should include:

1. Physical and Occupational Therapy

• Retraining normal movement patterns within functional activities 1
• Graded reintroduction to daily activities 1
• Guided activity practice with focus on function rather than symptoms 2
• Avoiding aids and equipment when possible to prevent maladaptive movement patterns 2

2. Speech and Language Therapy (for communication/swallowing disorders)

• Addressing inconsistent symptoms through attention redirection 2
• Working on inefficient movement patterns during speech and swallowing 2

3. Psychological Support

• Addressing unhelpful thoughts, beliefs, and behaviors 1
• Managing contributing factors like anxiety, depression, and trauma 2, 1
• Teaching relaxation techniques and stress management 1

Symptom-Specific Approaches

Treatment should be tailored to specific FND manifestations:

• For functional movement disorders: Encourage "slow" movement activities like yoga or tai chi 1
• For functional dystonia: Promote optimal postural alignment and even weight distribution 1
• For functional weakness: Engage in bilateral tasks requiring use of affected limbs 1
• For functional cognitive impairment: Address contributing factors like pain, fatigue, and poor sleep 1

Self-Management Strategies

Supporting self-management is particularly important in FND treatment:

• Develop an internal locus of control rather than dependency on clinicians 2
• Use interactive workbooks or therapy journals to track progress 2
• Implement a 24-hour approach to therapy (applying strategies throughout daily routines) 2
• Practice distraction techniques and attention redirection 1

Treatment Phases

FND treatment typically progresses through three phases:

1. Initial phase: Deliver comprehensive education, establish rapport, agree on treatment parameters 1
2. Active rehabilitation phase: Implement interventions focused on function, address unhelpful thoughts 1
3. Maintenance phase: Complete relapse prevention planning, develop ongoing self-management strategies 1

Common Pitfalls to Avoid

• Avoiding splinting or immobilizing devices that can lead to muscle deconditioning 1
• Preventing excessive reliance on adaptive equipment 2
• Avoiding inconsistent communication between healthcare providers 1
• Not setting overly rigid time-dependent goals, as FND often follows a pattern of remission and exacerbation 2

By following this structured approach that begins with education and incorporates multidisciplinary rehabilitation focused on function rather than symptoms, patients with FND have the best chance for improved quality of life and functional outcomes.