What is the prognosis of functional neurological disorder?

Prognosis of Functional Neurological Disorder

The prognosis of functional neurological disorder (FND) is generally unfavorable when untreated, with the majority of patients experiencing persistent or worsening symptoms at follow-up; however, early diagnosis and treatment—particularly multidisciplinary rehabilitation combining physical therapy and psychological interventions—can lead to significant improvement in 60-96% of patients, especially when symptoms are of shorter duration. 1, 2

Natural History Without Treatment

The untreated course of FND tends toward chronicity and disability:

• Most patients remain the same or worsen when followed longitudinally without intervention, with functional motor symptoms and psychogenic nonepileptic attacks persisting in the majority 1
• Quality of life measures and work status are often poor at long-term follow-up in untreated cohorts 1
• The misdiagnosis rate at follow-up is low (comparable to other neurologic disorders), confirming that FND is a valid and stable diagnosis 1

Outcomes With Treatment

Treatment substantially alters the prognosis, with evidence from randomized controlled trials and observational studies showing:

• 60-96% of patients report improvement after intervention in the majority of treatment studies 2
• Patient-rated and clinician-rated Clinical Global Impression-Improvement scores typically fall in the minimally to much improved range post-treatment 2
• Even in severe, chronic cases (mean symptom duration 9.7 years), most patients (43/52, or 83%) showed global improvement with intensive inpatient multidisciplinary rehabilitation 3
• Measurable improvements occur across multiple domains including mobility, depression, quality of life, and patients experience symptoms as more understandable and less distressing after treatment 3

Prognostic Factors

Negative Predictors (Worse Prognosis)

• Long symptom duration is the most consistent negative predictor across studies 1, 4
• Delayed diagnosis contributes to worse outcomes, as the majority of patients are diagnosed after considerable delays 4
• Litigation and state benefits were negative predictors in some (but not all) studies 1

Positive Predictors (Better Prognosis)

• Early diagnosis is associated with better outcomes 1, 4
• Younger age predicts favorable prognosis 1
• Patient confidence in treatment at admission is predictive of eventual clinical outcome 3
• Patient understanding and agreement with the diagnosis, motivation to make changes, and ability to identify rehabilitation goals predict treatment success 5

Inconsistent Predictors

• Emotional disorders (anxiety, depression) and personality disorders show inconsistent associations with outcome across studies 1
• While clinically relevant levels of depression, anxiety, and depersonalization-derealization are common at presentation, their presence does not necessarily predict poor outcome with appropriate treatment 3

Key Outcome Domains

Prognosis should be assessed across multiple domains rather than symptom change alone:

• Core FND symptom change (seizure frequency, movement disorder severity, weakness) 2
• Life impact measures including quality of life, disability, and general functioning 2
• Additional physical and psychological symptoms (pain, fatigue, depression, anxiety) 2
• Healthcare resource utilization and cost-effectiveness 2

Clinical Implications

The prognosis of FND is fundamentally linked to timely diagnosis and access to evidence-based treatment:

• Without intervention, the natural history is one of chronicity and disability 1
• With appropriate multidisciplinary treatment combining physical rehabilitation and psychological interventions, the majority of patients can achieve meaningful improvement even when symptoms are severe and chronic 2, 3
• The window for optimal outcomes narrows with symptom duration, making early diagnosis and treatment initiation critical 1, 4