What is the initial approach to managing a patient with Functional Neurological Disorder (FND) presenting with Parkinson's-like motor neuron symptoms?

Initial Management Approach for Functional Neurological Disorder with Parkinson's-like Motor Symptoms

The initial approach to managing a patient with Functional Neurological Disorder (FND) presenting with Parkinson's-like motor symptoms should focus on making a positive diagnosis, providing clear explanation of the condition, and implementing a multidisciplinary treatment plan that addresses both physical and psychological aspects of the disorder. 1

Diagnostic Approach

• Establish a positive diagnosis based on clinical features rather than treating FND as a diagnosis of exclusion 1
• Look for positive clinical signs specific to FND, such as:
  • Symptoms inconsistent with clinical examination findings (e.g., total or partial loss of function despite normal structure) 1
  • Internal inconsistency in symptoms (e.g., resolution or reduced severity when attention is diverted) 1
  • Inefficient and non-ergonomic movement patterns (e.g., excessive effort, struggle behaviors) 1
• Consider neuroimaging (MRI head without contrast) to rule out structural causes, especially when symptoms are atypical or rapidly progressive 1
• Document the presence of distractibility and variability of symptoms during functional activities 1

Explaining the Diagnosis

• Acknowledge that FND is a real, common, and disabling condition causing neurological symptoms that are outside the person's voluntary control 1
• Explain that FND is caused by a potentially reversible miscommunication between the brain and body (not structural damage) 1
• Use supportive and accessible metaphors to explain the condition:
  • "A software problem, not a hardware problem" 1
  • "Your muscles have the potential to work properly but the messages are having problems getting through" 1
• Discuss how self-directed attention can worsen symptoms while redirection of attention can temporarily reduce symptoms 1
• Provide written information and direct to resources such as www.neurosymptoms.org 1

Treatment Framework

Physical Rehabilitation

• Implement guided activity practice focusing on normal movement patterns 1
• Use distraction techniques during movement to demonstrate normal function:
  • Introduce additional activities to shift attention away from performance 1
  • Temporarily mask auditory feedback which may trigger self-conscious inhibition 1
• Establish a graded exercise program that gradually increases in complexity 1
• Focus on improving function rather than symptom reduction 1

Psychological Interventions

• Address cognitive features related to locus of control, abnormal illness beliefs, and hypervigilance 1
• Implement cognitive behavioral therapy strategies to identify and challenge:
  • Maladaptive beliefs and cognitions 1
  • Self-reported sensations 1
  • Avoidance behaviors 1
• Teach anxiety management techniques:
  • Breathing techniques and progressive muscle relaxation 1
  • Grounding strategies and visualization 1
  • Thought reframing and mindfulness 1

Managing Comorbidities

• Address common comorbidities that may exacerbate FND symptoms:
  • Fatigue (reported in 47-93% of FND patients) 2
  • Cognitive symptoms (reported in 80-85% of FND patients) 2
  • Anxiety and depression (reported in 40-100% of FND patients) 2
  • Pain syndromes (reported in about 50% of FND patients) 2
• Consider medication for specific symptoms:
  • SSRIs for anxiety and depression 1
  • Low-dose amitriptyline for pain and sleep disturbances 1

Multidisciplinary Approach

• Implement a coordinated team approach including:
  • Neurology for diagnosis and medication management 3
  • Occupational therapy for functional activities and daily living skills 1
  • Physical therapy for movement retraining 3
  • Speech and language therapy for communication difficulties 1
  • Psychology for addressing psychological factors 3

Important Considerations and Pitfalls

• Avoid reinforcing abnormal movement patterns or excessive focus on symptoms 1
• Be aware that FND can coexist with neurological disorders, including Parkinson's disease (reported in 7% of cases) 2, 4
• Recognize that early treatment is crucial, even when other FND symptoms are present 1
• Understand that patient acceptance of the diagnosis is important for treatment success, but some patients may only embrace the diagnosis during successful treatment 1
• Avoid excessive medical investigations once a positive diagnosis is established, as this can reinforce illness beliefs 1

Expected Outcomes

• Many patients show improvement or even elimination of symptoms during initial consultations 1
• Integrated multidisciplinary treatment has been associated with significant improvements in quality of life and function 3
• Treatment can lead to substantial improvements in work status and social participation 3