What are the diagnosis and treatment options for functional neurological disorder (FND)?

Diagnosis and Treatment of Functional Neurological Disorder

Diagnostic Approach

FND must be diagnosed as a rule-in condition based on positive clinical signs during neurological examination, not as a diagnosis of exclusion. 1, 2

Key Diagnostic Signs

• For functional weakness: Hoover's sign demonstrates incompatibility between voluntary effort and automatic movement patterns 1, 3
• For functional tremor: Entrainment (tremor changes frequency when patient taps at a different rhythm) and distractibility (tremor diminishes or disappears when attention is diverted) 1, 3
• For functional movement disorders: Variability in symptoms during functional tasks and inconsistency with recognized neurological patterns 1, 4
• These clinical signs have specificities ranging from 64-100% 2

Comprehensive Assessment Components

• Document symptom history including onset pattern (sudden onset is typical), time course (intermittent is common), and variability over time 5
• Obtain medical and psychological history, including childhood trauma and other somatic symptoms 5
• Assess functional impact on daily activities, social relationships, and occupational functioning 1, 4
• Note that anxiety and depression are common but not universal or necessarily more prevalent than in the general population 4, 5

Treatment Framework

Multidisciplinary rehabilitation combining physical/occupational therapy with patient education and psychological interventions represents first-line treatment, grounded in a biopsychosocial framework. 1, 4, 3

Initial Education and Explanation (Therapeutic in Itself)

• Acknowledge that FND is a real, common, and disabling condition causing neurological symptoms outside the person's control 1, 3
• Explain 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" 4, 3
• Demonstrate clinical signs during consultation, which can be a positive experience for patients 4
• Provide written materials and links to resources 4
• Emphasize this is a positive diagnosis based on specific clinical findings, not exclusion of other diseases 4, 3

Physical Rehabilitation (Treatment of Choice for Motor Symptoms)

Occupational therapy and physical therapy are the primary treatments for functional motor symptoms. 4, 2

Core Rehabilitation Principles

• Retrain normal movement patterns within functional activities (not isolated exercises) 6, 1, 4
• Engage patients in tasks promoting normal movement patterns, good alignment, and even weight-bearing 1, 3
• Use distraction techniques during task performance to normalize movement—avoid having patients focus on the affected body part 1, 3
• Implement graded reintroduction to daily activities with activity-based goals 4
• Intensive therapy with several sessions per week may be more successful than sporadic treatment 4

Critical Pitfalls to Avoid in Rehabilitation

• Do not use splinting, adaptive aids, or compensatory devices prematurely—these interrupt normal automatic movement patterns and cause maladaptive functioning 1, 3
• Do not treat FND like other neurological conditions with impairment-based approaches 4
• Avoid relying primarily on pharmacological approaches 4

Psychological Interventions

Cognitive-behavioral therapy is the psychological treatment of choice, particularly for dissociative seizures and when anxiety/depression perpetuate symptoms. 3, 2

Anxiety Management Techniques

• Educate about the physiological process of anxiety using the fight-or-flight concept for those who don't identify as feeling anxious 3
• Teach breathing techniques, progressive muscle relaxation, grounding strategies, visualization, distraction, thought reframing, and mindfulness 4, 3
• Integrate pleasant activities into daily routine 4

Sensory Grounding for Dissociative Episodes

• Notice environmental details (colors, textures, sounds) 3
• Use cognitive distractions (word games, counting backwards) 3
• Apply sensory-based distractors (flicking a rubber band on wrist) 3
• Avoid constant reassurance, physical contact, or restraint during dissociative episodes 3

Management of Cognitive Symptoms

• Address contributing factors: fatigue, pain, anxiety, and poor sleep 1, 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

Self-Management Strategies (Central to Long-Term Success)

• Reestablish structure and routine in daily activities 6, 4
• Complete a relapse prevention plan identifying early warning signs 4
• Develop an ongoing self-management plan for long-term symptom control 4
• Implement activity pacing to prevent boom-bust cycles 4

Treatment Sequencing Algorithm

1. Acute phase (hospital/initial presentation): Neurologist makes positive diagnosis, provides initial education, avoids premature use of aids 1, 4
2. Intensive rehabilitation phase: Physical/occupational therapy several times per week in rehabilitation ward or outpatient setting 4
3. Psychological intervention phase: Can occur concurrently or sequentially depending on patient readiness and symptom profile 7
4. Community maintenance phase: Ongoing self-management with periodic therapy check-ins 4

Multidisciplinary Team Composition

• Neurologist (diagnosis and medical oversight) 4
• Physical therapist (motor symptom rehabilitation) 4, 2
• Occupational therapist (functional activity retraining) 6, 4
• Psychologist/psychiatrist (psychological interventions, comorbidity management) 4
• Speech and language therapist (for speech/swallowing symptoms) 7

Patient Suitability for Treatment

Treatment is more likely to succeed when the patient has some understanding and agreement with the diagnosis, has agreed to the referral, can identify rehabilitation goals, is motivated to make changes, and understands the initial focus is improving function. 1

Expected Outcomes

• Multidisciplinary studies report improvements in physical function and quality of life immediately after treatment and at 12-25 month follow-up 6, 4
• High levels of patient acceptability have been demonstrated 6
• Heterogeneity in treatment responses exists, with some patients not responding to currently available interventions 2
• Early diagnosis and shorter symptom duration are linked to better prognosis 5

Common Diagnostic and Management Pitfalls

• Failing to make a positive diagnosis based on clinical signs and instead using diagnosis of exclusion 1
• Providing insufficient explanation of the diagnosis 1
• Neglecting to address psychological comorbidities 1
• Overlooking the importance of the patient's understanding and agreement with the diagnosis 1
• Focusing on impairment-based rather than functional goals 4