What is the treatment approach for conversion disorder (functional neurological symptom disorder)?

Treatment Approach for Conversion Disorder (Functional Neurological Disorder)

Treatment of conversion disorder requires a structured multidisciplinary approach combining patient education about the diagnosis, physical rehabilitation focused on normalizing movement patterns through distraction techniques, and psychological interventions targeting anxiety and other perpetuating factors. 1, 2

Core Treatment Components

1. Patient Education and Explanation

The foundation of treatment begins with proper explanation of the diagnosis, which itself has therapeutic value 1, 2:

• Acknowledge that FND is a real, common, and disabling condition causing neurological symptoms outside the person's control 3, 1
• Explain that symptoms result from a potentially reversible miscommunication between brain and body—use analogies like "a software problem, not a hardware problem" or "the train is off the tracks" 3, 2
• Emphasize that FND is diagnosed using positive clinical signs (Hoover's sign, distractibility, entrainment of tremor, symptom variability during function), not as a diagnosis of exclusion 3, 1
• Demonstrate clinical signs during consultation when possible, as this can be a positive experience for patients 2
• Discuss how self-directed attention worsens symptoms while redirecting attention (distraction) can temporarily reduce them 3

2. Physical Rehabilitation Through Occupational and Physical Therapy

Rehabilitation should focus on retraining normal movement patterns within functional activities 3, 1:

• Engage patients in tasks that promote normal movement patterns, good alignment, and even weight-bearing 1
• Use distraction techniques during task performance to normalize movement—avoid having patients focus on the affected body part 1
• Implement graded reintroduction to daily activities with a 24-hour approach, integrating rehabilitation strategies throughout the daily routine 3
• Encourage structure and routine: write out daily plans to prevent activity and cognitive overload, schedule time for relaxation to minimize stress 3
• Intensive therapy with several sessions per week may be more successful in helping patients recover normal function 2

3. Management of Contributing Factors

Address perpetuating factors that maintain symptoms 3, 2:

For Anxiety Management:

• Educate patients about the physiological process of anxiety and its physical impact, using the concept of fight-or-flight response for those who don't identify as feeling anxious 3
• Implement breathing techniques, progressive muscle relaxation, grounding strategies, visualization, distraction, thought reframing, mindfulness, and integration of enjoyable activities 3, 2

For Cognitive Symptoms:

• Address contributing factors including fatigue, pain, anxiety, and poor sleep—either within therapy or by encouraging patients to seek help from their general practitioner (e.g., to reduce sedating medications) 3, 2
• Explain that cognitive skills are likely intact but multiple factors compete for cognitive resources 3
• Encourage normal use of (but not dependence on) calendars and alarm functions in mobile phones 3

4. Psychological Interventions

Cognitive-behavioral therapy is the psychological treatment of choice, though more definitive data are still awaited 4:

• Address contributing factors such as anxiety, depression, and unhelpful coping behaviors 1
• For dissociative (non-epileptic) seizures specifically, psychological therapy delivered by specially trained clinicians is the main evidence-based treatment 3
• Implement sensory grounding techniques to keep patients present and prevent dissociation: noticing environmental details (colors, textures, sounds), cognitive distractions (word games, counting backwards), and sensory-based distractors (flicking a rubber band on wrist) 3

5. Vocational Rehabilitation

Support patients in managing their condition in the context of work or study 3:

• Help employers and educators understand that symptoms are genuine and may vary in severity with periods of remission and exacerbation 3
• Work with occupational health departments to identify reasonable adjustments: role modifications, reduced hours, regular rest breaks, flexible working options 3
• Develop a graded return to work/study following sick leave 3

Treatment Suitability Criteria

Treatment is more likely to be successful when 1:

• The patient has some degree of understanding and agreement with the diagnosis
• The patient has agreed to the referral
• The patient can identify rehabilitation goals and is motivated to make changes
• The patient understands that the initial focus is to improve function

Critical Pitfalls to Avoid

Avoid these common errors that can impede recovery 1:

• Minimize use of aids and adaptive equipment, especially in the acute phase—these can interrupt normal automatic movement patterns and cause maladaptive functioning 3, 1
• If aids are necessary (e.g., for safe hospital discharge), consider them short-term solutions with a plan to progress toward independence 3
• Avoid constant reassurance, physical contact, or restraint during dissociative episodes 3
• Do not delay treatment waiting for psychological factors to be identified—symptom longevity can negatively influence outcome 4
• Avoid overly attending to cognitive problems (e.g., trying hard to remember)—this is unhelpful, similar to how a forgotten name is remembered once you stop trying 3

Prognosis Considerations

Duration of symptoms correlates with treatment duration—there is a strong positive correlation between how long conversion symptoms have been present and the time required to eradicate them 5. Early intervention is therefore critical, as symptom longevity can influence outcome 4.