What is the management approach for a patient with Functional Neurological Disorder (FND) experiencing non-epileptic seizures?

Management of Functional Neurological Disorder with Non-Epileptic Seizures

For FND patients experiencing non-epileptic (dissociative) seizures, immediately implement sensory grounding techniques while ensuring the patient is in a safe space, avoid constant reassurance or physical restraint, and refer for multidisciplinary rehabilitation combining occupational therapy with psychological interventions as the primary treatment approach. 1, 2

Immediate Management During a Dissociative Episode

Acute intervention priorities:

• Move the person to a safe space where they cannot injure themselves, then calmly inform them they are safe without providing constant reassurance, which paradoxically prolongs the episode 1, 2
• Recognize that the patient may hear and understand you even if unable to respond, and advise caregivers to behave as they would during a panic attack 1, 2
• Avoid physical restraint unless absolutely necessary for immediate safety and do not pursue acute hospital admission, as these are usually unnecessary and highly distressing 1
• Implement sensory grounding techniques immediately: guide them to notice five things they can see, four they can touch, three they can hear, and use word games or counting backwards to redirect attention 1

Developing a Personalized Episode Management Plan

Before the next episode occurs:

• Create a written plan with the patient documenting their specific triggers, warning signs, and preferred grounding techniques to use when they feel an episode approaching 1, 2
• Share this plan with all caregivers, family members, and treating clinicians so everyone responds consistently 1
• Identify early warning signs when intervention strategies are most effective, as many patients initially report no memory of pre-episode events but recognize patterns after discussion 2, 1

Primary Treatment Framework

Multidisciplinary rehabilitation is the treatment of choice:

• Refer for occupational therapy and physical therapy as first-line treatment, focusing on retraining normal movement within functional activities and graded reintroduction to daily activities 3, 2
• Refer for psychological therapy (particularly cognitive behavioral therapy), which has emerging evidence as an effective treatment across FND subtypes including dissociative seizures 4, 5
• Treatment should be based on a biopsychosocial framework addressing biological, psychological, and social factors contributing to symptoms 2, 3

Addressing Underlying Perpetuating Factors

Target modifiable contributors:

• Explain the physiological process of anxiety and the "fight or flight" response, particularly useful for patients who don't identify as feeling anxious 1
• Implement breathing techniques, progressive muscle relaxation, visualization, and mindfulness practices to manage anxiety 1, 3
• Address fatigue, pain, and poor sleep which exacerbate dissociative symptoms, and encourage structured daily routines to prevent cognitive overload 1, 2
• Help patients notice and challenge catastrophizing and "all or nothing" thinking patterns that worsen symptoms 1

Diagnostic Communication and Education

The diagnostic discussion itself has therapeutic value:

• Explain that FND is a positive diagnosis based on recognizable clinical signs, not a diagnosis of exclusion, and emphasize that symptoms are real and potentially reversible 3, 5
• Use understandable analogies such as "a software problem, not a hardware problem" to explain the disorder 3
• Provide written materials and links to resources, and consider demonstrating clinical signs during consultation as this can be a positive experience 3

Critical Pitfalls to Avoid

Common management errors that worsen outcomes:

• Do not treat FND like other neurological conditions by focusing on impairment-based goals rather than functional goals 3
• Avoid relying primarily on pharmacological approaches or providing compensatory devices (wheelchairs, walkers) prematurely, as this reinforces disability 3
• Do not dismiss the diagnosis or suggest symptoms are "all in their head," as this increases stigma and reduces engagement 2, 3
• Avoid excessive medical investigations once the diagnosis is established, as this perpetuates diagnostic uncertainty 6

Long-Term Management and Relapse Prevention

Establish ongoing self-management:

• Create a written relapse prevention plan collaboratively documenting learned management strategies and identifying triggers for symptom exacerbation 1
• Establish graded goals for 3,6,9, and 12 months, preparing the patient for possible relapse with emphasis on self-management using learned techniques 1
• Reestablish structure and routine in daily activities, as this is central to preventing symptom recurrence 2

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 patient acceptability 2, 3
• However, treatment responses are heterogeneous, and not all patients respond to currently available treatments, underscoring the need for individualized approaches 5