What is the management approach for an individual with Functional Neurological Disorder (FND) who wakes up in a dissociative state?

Management of FND Patients Waking in Dissociative States

When an individual with FND wakes up in a dissociative state, immediately implement sensory grounding techniques to help them reconnect with the present moment, ensure they are in a safe space, and provide calm reassurance while avoiding excessive physical contact or repeated reassurance that may prolong the episode. 1

Immediate Acute Management

Creating a Safe Environment

• Move the person to a safe space where they are unlikely to injure themselves during the dissociative episode 1
• Maintain a calm, quiet environment to reduce stress and prevent symptom exacerbation 2
• Let them know they are safe, but avoid constant reassurance which can paradoxically prolong the episode 1
• Avoid physical contact or restraint unless absolutely necessary for safety 1

Communication During the Episode

• Speak calmly and recognize that the person may hear and understand what you say even if unable to respond 1
• Advise caregivers or family members to behave as they would if someone is having a panic attack 1
• Use clear, simple statements rather than asking multiple questions 1

Sensory Grounding Techniques (Primary Intervention)

The most effective immediate intervention is sensory grounding, which aims to keep the person present in the moment and focus attention to prevent further dissociation. 1

Environmental Awareness Techniques

• Guide them to notice details in their environment including colors, textures, and sounds 1
• Encourage them to identify five things they can see, four they can touch, three they can hear 1

Cognitive Distraction Methods

• Use word games or counting backwards to redirect attention 1
• Ask them to name categories of objects (e.g., types of animals, colors) 1

Sensory-Based Distractors

• Apply tactile stimulation such as flicking a rubber band on the wrist 1
• Have them feel textured items or hold ice cubes 1
• Use strong sensory inputs like peppermint or citrus scents 1

Developing a Personalized Dissociative Episode Plan

Essential Components

Ask the person how they wish to be supported during dissociative episodes, as they may have already devised a plan with other clinicians. 1

• Document specific triggers and warning signs that precede dissociative episodes 1
• Create a written plan that includes preferred grounding techniques 1
• Identify early warning signs when intervention strategies are most effective 1
• Share this plan with all caregivers and family members 1

Pattern Recognition

• Many patients initially report no memory of events prior to dissociative episodes, but after discussion begin to recognize patterns 1
• Work collaboratively to identify prodromal symptoms that signal an impending episode 1
• Teach strategies to avert episodes when warning signs are experienced 1

Addressing Underlying Anxiety

Anxiety commonly acts as both a precipitating and perpetuating factor for dissociative states in FND. 1

Education and Awareness

• Explain the physiological process of anxiety and its physical impact on the body 1
• Introduce the concept of "fight or flight" response, particularly useful for patients who don't identify as feeling anxious 1
• Address "panic without panic" or alexithymia—where patients experience physiological anxiety symptoms without recognizing the emotional component 1

Anxiety Management Strategies

• Implement breathing techniques and progressive muscle relaxation 1
• Use visualization and mindfulness practices 1
• Incorporate graded exposure to anxiety-provoking situations 1
• Encourage regular cardiovascular exercise 1
• Integrate activities of enjoyment into daily routine 1

Ongoing Treatment Framework

Cognitive-Behavioral Approaches

• Help patients notice and challenge unhelpful automatic thoughts such as catastrophizing 1
• Address "all or nothing" thinking patterns that may worsen dissociative symptoms 1
• Plan behavioral experiments to address fear and avoidance of specific activities 1

Addressing Contributing Factors

• Manage fatigue, pain, and poor sleep which can exacerbate dissociative symptoms 1
• Encourage structure and routine with daily planning to prevent cognitive overload 1
• Schedule regular relaxation time to minimize stress 1

Psychological Therapy

The main evidence-based treatment for dissociative episodes in FND involves psychological therapy delivered by specially trained clinicians. 1

• Consider referral to specialists trained in FND-specific psychotherapy 1, 3
• Cognitive-behavioral therapy has shown promising results for dissociative seizures and functional movement disorders 1

Important Pitfalls to Avoid

What NOT to Do

• Do not pursue acute hospital admissions for dissociative episodes, as they are usually unnecessary and can be highly distressing 1
• Avoid excessive reassurance during episodes, which can prolong the dissociative state 1
• Do not use physical restraint unless absolutely necessary for immediate safety 1
• Avoid overly attending to the problem or trying to force memory recall 1

Preventing Iatrogenic Harm

• Avoid repetitive medical investigations once FND diagnosis is established, as this reinforces illness beliefs 4, 2
• Do not frame dissociative episodes as "fake" or "not real"—they are genuine neurological symptoms outside voluntary control 4, 5
• Maintain consistent, respectful language when discussing symptoms 2

Relapse Prevention and Long-Term Management

Staying Well Plan

• Create a written relapse prevention plan collaboratively with the patient 1
• Document learned management strategies and identify triggers for symptom exacerbation 1
• Establish graded goals for 3,6,9, and 12 months 1
• Prepare the patient for possibility of relapse with emphasis on self-management using learned techniques 1

Multidisciplinary Coordination

• Ensure clear communication between all treating clinicians 6, 5
• Establish criteria for when future therapy should be sought 1
• Make further treatment available in case of relapse rather than permanently discharging 1