What is functional neurological disorder and how is it managed?

Functional Neurological Disorder: Overview and Management

What is Functional Neurological Disorder?

Functional Neurological Disorder (FND) is a real, common, and disabling neurological condition characterized by altered voluntary motor, sensory, or cognitive function that is incompatible with recognized neurological diseases but causes genuine disability and distress. 1, 2

Core Characteristics

FND presents with diverse neurological symptoms that include: 1, 2

• Motor symptoms: weakness, tremor, jerks, dystonia, and abnormal gait patterns
• Sensory symptoms: numbness, tingling, or altered sensation
• Seizure-like events: dissociative or non-epileptic seizures
• Cognitive deficits: attention, memory, and processing difficulties
• Associated symptoms: fatigue, persistent pain, anxiety, and low mood are commonly experienced

The disorder causes high levels of distress, disability, unemployment, reduced quality of life, and significant social care utilization. 1

Diagnostic Approach

FND is diagnosed using positive clinical signs by a neurologist, not as a diagnosis of exclusion. 1, 3 Key diagnostic features include: 4, 3

• Hoover's sign for functional weakness
• Distractibility of symptoms during examination
• Entrainment of tremor to external rhythms
• Variability in symptoms during functional activities
• Internal inconsistency between symptoms and examination findings
• Inefficient movement patterns that don't match typical neurological disease

Studies report high specificities (64-100%) for these clinical signs. 3

Pathophysiological Understanding

The condition represents a potentially reversible miscommunication between the brain and body—a "software problem, not a hardware problem." 1, 4 This framework helps patients understand that: 1

• Symptoms are caused by altered nervous system functioning, not structural brain damage
• Self-directed attention worsens symptoms, while distraction can temporarily reduce them
• The body's stress response influences nervous system functioning and perpetuates FND
• Multiple neurobiological, psychological, and social factors contribute to symptom generation

Neuroimaging studies demonstrate hypoactivation of the contralateral primary motor cortex, decreased parietal lobe activity, aberrant amygdala activation, and altered functional connectivity between amygdala and motor areas. 5

Management of Functional Neurological Disorder

Biopsychosocial Treatment Framework

Multidisciplinary rehabilitation centered on occupational therapy and physical therapy, grounded in a biopsychosocial framework with patient education and self-management strategies, represents the recommended first-line treatment for FND. 2 This approach is endorsed by the American Academy of Neurology. 2

Essential First Step: Explaining the Diagnosis

Explaining the diagnosis has direct therapeutic value and is critical for treatment engagement and outcomes. 2, 6 The explanation must include: 1

1. Acknowledge legitimacy: State that FND is a real, common, and disabling condition causing neurological symptoms outside the person's voluntary control
2. Explain mechanism: Describe it as a potentially reversible miscommunication between brain and body
3. Emphasize positive diagnosis: Explain that diagnosis is based on positive clinical signs (demonstrate these during consultation when possible)
4. Discuss attention effects: Explain how self-directed attention worsens symptoms while redirecting attention can reduce them
5. Address stress response: Discuss how the body's stress response influences nervous system functioning
6. Provide resources: Give written materials and links to credible resources
7. Explain treatment role: Clarify that rehabilitation focuses on retraining normal function, not compensating for permanent damage

Core Treatment Components

Physical Rehabilitation (First-Line for Motor Symptoms)

Occupational therapy and physical therapy are the treatments of choice for functional motor symptoms. 2, 3 Key principles include: 1, 2

• Retraining normal movement within functional activities: Practice movements during actual daily tasks rather than isolated exercises
• Distraction techniques: Introduce additional activities during movement to shift attention away from symptom performance
• Graded activity reintroduction: Systematically increase complexity and duration of activities
• Focus on functional goals: Target activity-based outcomes (e.g., walking to the store) rather than impairment-based goals (e.g., increasing muscle strength)
• Intensive therapy schedule: Several sessions per week may be more successful for recovery 2

Self-Management Strategies (Central to All Interventions)

Supporting self-management is particularly important in FND and should be integrated throughout all aspects of treatment. 1 This includes: 1, 2

• Developing internal locus of control: Patients take ownership of rehabilitation rather than placing control in clinicians' hands
• 24-hour approach: Implementing rehabilitation strategies throughout daily routine, not just during therapy sessions
• Structure and routine: Establishing written daily plans to prevent activity and cognitive overload
• Relapse prevention planning: Creating strategies for managing symptom fluctuations
• Independent practice: Understanding that recovery requires consistent practice outside therapy sessions

Anxiety and Symptom Management

Specific techniques include: 2, 4

• Breathing techniques and progressive muscle relaxation
• Grounding strategies and visualization
• Distraction and reframing thoughts
• Mindfulness practices
• Integration of pleasant activities into daily routine

Psychological Interventions

Psychotherapy, particularly cognitive behavioral therapy (CBT), is an emerging evidence-based treatment across FND subtypes. 3 Psychological interventions should: 4

• Address cognitive features related to locus of control and abnormal illness beliefs
• Identify and challenge maladaptive beliefs and cognitions
• Address hypervigilance to bodily sensations
• Treat comorbid anxiety and depression

Vocational Rehabilitation

Occupational therapists have a key role in supporting return to work or study. 1 This involves: 1

• Helping employers understand that symptoms are genuine and may vary in severity
• Identifying and advocating for reasonable adjustments (role modifications, reduced hours, regular breaks, flexible working)
• Developing graded return to work/study following sick leave
• Working with occupational health departments

Goal Setting Approach

Goal setting in FND differs from typical neurorehabilitation because recovery follows a pattern of symptom remission and exacerbation. 1 Therefore: 1

• Goals are set by the person with FND in their own words
• Goals may not be time-dependent
• Flexible approach is taken, with regular review and adjustment
• Interactive workbooks or therapy journals support self-management

Treatment Sequencing by Setting

Treatment should be delivered across the continuum: 2

• Hospital settings: For acute presentations requiring monitoring (e.g., functional seizures with potential respiratory compromise)
• Rehabilitation wards: For intensive therapy programs
• Community settings: For ongoing management and maintenance

Medication Considerations

Pharmacological treatment is not first-line for FND but may address specific comorbidities. 4 Consider: 4

• SSRIs for comorbid anxiety and depression
• Low-dose amitriptyline for pain and sleep disturbances

Critical Pitfalls to Avoid

Several common errors significantly undermine FND treatment effectiveness: 2, 4

1. Do not treat FND like other neurological conditions: Standard neurorehabilitation strategies are not directly translatable 1
2. Avoid compensatory devices prematurely: Aids and equipment (crutches, wheelchairs, splints) can cause secondary problems (joint pain, muscle deconditioning) and reinforce disability 1, 2
3. Do not focus on impairment-based goals: Target functional outcomes, not isolated impairments 2
4. Avoid excessive medical investigations: Once positive diagnosis is established, further testing reinforces illness beliefs 4
5. Do not rely primarily on pharmacological approaches: Medication alone is insufficient 2
6. Avoid reinforcing abnormal movement patterns: Do not allow excessive focus on symptoms during therapy 4

Expected Outcomes

Multidisciplinary studies report improvements in physical function and quality of life immediately after treatment and at follow-up periods of 12-25 months, with high levels of patient acceptability. 1, 2 Many patients show improvement or even elimination of symptoms during initial consultations when diagnosis is explained effectively. 4

However, heterogeneity in treatment responses exists, and not all patients respond to currently available treatments. 3 Recovery often follows a pattern of symptom remission and exacerbation rather than linear improvement. 1

Multidisciplinary Team Composition

A coordinated multidisciplinary team is necessary for comprehensive management. 2, 7 The team typically includes: 2, 7

• Neurologists: Formulate and deliver diagnosis
• Occupational therapists: Address functional activities and daily living skills
• Physical therapists: Retrain normal movement patterns
• Psychologists/Psychiatrists: Provide psychotherapy and manage comorbidities
• Speech and language therapists: Address communication difficulties when present

Neurologists and neuropsychiatrists typically engage in diagnosis, while treatment is often administered by physiotherapists and psychologists. 7 Open and consistent communication between team members is essential. 2