What is the approach to diagnosing and treating functional neurological disorder?

Diagnosing and Treating Functional Neurological Disorder (FND)

Functional Neurological Disorder (FND) should be diagnosed using positive clinical signs and a comprehensive biopsychosocial assessment, followed by a treatment approach that combines education, physical rehabilitation, and psychological interventions tailored to the specific symptom presentation. 1

Diagnostic Approach

Positive Clinical Signs for Diagnosis

• FND is diagnosed by a neurologist using positive clinical signs, not as a diagnosis of exclusion 1
• Key diagnostic signs include:
  • Hoover's sign (for functional weakness)
  • Distractibility of symptoms
  • Entrainment of tremor
  • Variability in symptoms during functional tasks 1

Comprehensive Assessment Components

1. Symptom History and Presentation

   • Document when and how symptoms started
   • Create a detailed list of current symptoms, including exacerbating/easing factors, variability, and severity 1
   • Note the impact of symptoms on daily functioning 1

2. Medical and Psychological History

   • Inquire about other health problems and medical history
   • Assess psychological health and comorbidities 1
   • Explore potential triggering events that may be relevant 1

3. Functional Assessment

   • Observe daily activities to establish impact of symptoms
   • Note distractibility and variability of symptoms during tasks 1
   • Document 24-hour routine to identify symptom perpetuating factors (e.g., poor sleep hygiene, boom-bust activity patterns) 1

4. Social and Occupational Impact

   • Take detailed social history exploring roles, responsibilities, and meaningful activities
   • Assess impact on work/education and any resulting disability 1

Treatment Approach

Initial Education and Explanation

• Acknowledge that FND is a real, common, and disabling condition causing neurological symptoms outside the person's control 1
• Explain that symptoms are caused by a potentially reversible miscommunication between brain and body 1
• Discuss how self-directed attention can worsen symptoms while redirection of attention can temporarily reduce symptoms 1
• Explain how the body's stress response can influence nervous system functioning 1

Physical Rehabilitation

• Engage in tasks that promote normal movement patterns, good alignment, and even weight-bearing 1
• Use distraction techniques during task performance to normalize movement 1
• Video recording interventions (with consent) can demonstrate changeability and highlight successes 1
• Avoid splinting and adaptive aids when possible as they may prevent restoration of normal movement 1

Psychological Interventions

• Address contributing factors to symptoms such as anxiety, depression, and unhelpful coping behaviors 1
• Implement strategies for cognitive symptoms by addressing contributing factors (fatigue, pain, anxiety, poor sleep) 1
• Support development of an internal locus of control rather than placing control in hands of clinicians or family members 1

Goal Setting and Self-Management

• Take a flexible approach to goal setting, with goals set by the person with FND in their own words 1
• Support self-management through understanding the diagnosis, rationale for interventions, and importance of independent practice 1
• Use interactive workbooks or therapy journals as tools to support self-management 1

Outcome Measurement

• Currently, there are few well-validated FND-specific outcome measures 1
• Assessment should include multiple domains:
  • Core FND symptom change
  • Additional physical and psychological symptoms
  • Life impact (quality of life, disability, general functioning)
  • Health economics/cost-utility 1

Common Pitfalls to Avoid

• Failing to make a positive diagnosis based on clinical signs (treating FND as a diagnosis of exclusion) 1
• Providing insufficient explanation of the diagnosis, which can prevent understanding and lead to inappropriate treatments 2
• Using splinting or adaptive aids prematurely, which may worsen symptoms 1
• Neglecting to address psychological comorbidities that may perpetuate symptoms 1
• Overlooking the importance of the patient's understanding and agreement with the diagnosis 1

Suitability for Treatment

Treatment is more likely to be successful when the patient:

• Has some degree of understanding and agreement with the diagnosis
• Has agreed to the referral
• Can identify rehabilitation goals and is motivated to make changes
• Understands that the initial focus is to improve function 1

When there is strong disagreement about the diagnosis, therapy is much less likely to be helpful, though focusing on function rather than symptoms may still be beneficial 1.