From the Guidelines
Functional Neurological Disorder (FND) should be diagnosed by a neurologist using ‘positive clinical signs’ and treated with a multidisciplinary approach centered on education and rehabilitation, prioritizing physical therapy, cognitive behavioral therapy, and occupational therapy to improve functional recovery and quality of life. The diagnosis of FND is made by identifying positive clinical signs such as Hoover’s sign, distractibility, entrainment of tremor, and variability in symptoms during function, as noted in the study by 1. This approach emphasizes that FND is not a diagnosis of exclusion but rather one that can be made alongside other neurological conditions.
Key Components of Treatment
- Physical therapy focuses on retraining normal movement patterns
- Cognitive behavioral therapy helps address underlying psychological factors that may contribute to symptoms
- Occupational therapy assists patients in regaining daily function
- Medications, such as antidepressants (e.g., sertraline 50-200mg daily or duloxetine 30-60mg daily) for mood and anxiety, and anticonvulsants for functional seizures, may be used to address specific symptoms but are not the primary treatment
Importance of Early Diagnosis and Treatment
Early diagnosis and appropriate treatment of FND can lead to significant improvement in symptoms and quality of life, as highlighted by the occupational therapy consensus recommendations for FND 1. The prognosis varies among patients, but many show improvement when treated early and with a focus on functional recovery rather than just symptom management.
Multidisciplinary Approach
A multidisciplinary approach, including speech and language therapy for managing functional communication, swallowing, cough, and related disorders, as discussed in 1 and 1, is crucial for comprehensive care. This approach also incorporates principles from cognitive–behavioral therapy (CBT) to aid in the treatment of FND, helping patients notice and challenge unhelpful thoughts.
Outcome Measurement
Outcome measurement in FND is critical, and there is a need for well-validated FND-specific outcome measures, as noted in 1. Currently, existing outcome measures that are reliable, valid, and responsive in FND or closely related populations should be used to capture key outcome domains, facilitating comparison of treatment effects across different symptom types and treatment modalities.
From the Research
Diagnosis of Functional Neurological Disorder (FND)
- FND is characterized by neurological symptoms that are incompatible with any known structural disorder and best explained by a biopsychosocial model 2
- The diagnosis of FND should rest on clear positive evidence, typically from a combination of physical signs on examination or the nature of seizures 3
- Validated rule-in examination signs can guide diagnosis, with high specificities of clinical signs (64-100%) reported in studies on motor and seizure type symptoms 4
Treatment of FND
- Evidence-based treatments for FND are limited, with cognitive behavioral therapy (CBT) and physiotherapy being the most effective interventions 2
- Rehabilitative interventions (physical and occupational therapy) are treatments of choice for functional motor symptoms 4
- Psychotherapy is an emerging evidence-based treatment across FND subtypes, with approaches including CBT, third wave approaches, and psychodynamic psychotherapies 5
- A multidisciplinary and interdisciplinary team approach is beneficial in the treatment of FND, with clear communication of the diagnosis and involvement of specialists with expertise in neurological diagnosis 6, 3
- Novel treatments, such as non-invasive brain stimulation techniques (NIBS), may also represent an effective therapeutic option for patients with FND 2