What is the initial approach to treating functional neurological disorder?

Initial Treatment Approach for Functional Neurological Disorder

The initial approach to treating FND requires three simultaneous components: delivering a clear diagnostic explanation that frames FND as a real neurological condition caused by reversible brain-body miscommunication, immediately initiating physical rehabilitation focused on normalizing movement patterns through distraction techniques, and addressing psychological perpetuating factors such as anxiety and depression. 1, 2, 3

Step 1: Deliver the Diagnostic Explanation (First Visit)

The diagnostic conversation is itself therapeutic and must occur before any other intervention. 1, 2

• Explicitly state that FND is a real, common, and disabling neurological condition causing symptoms outside the person's voluntary control. 1, 2, 3
• Frame the problem as "a software problem, not a hardware problem" or explain it as "the train is off the tracks"—the brain and body are structurally intact but miscommunicating. 2, 3
• Emphasize that the diagnosis was made using positive clinical signs (Hoover's sign for weakness, distractibility of symptoms, entrainment of tremor, symptom variability during functional tasks), not as a diagnosis of exclusion. 1, 3
• Explain how self-directed attention worsens symptoms while redirection of attention can temporarily reduce them—this provides the rationale for distraction-based rehabilitation. 2

Step 2: Initiate Physical Rehabilitation Immediately

Physical rehabilitation is the primary treatment for functional motor symptoms and should begin as soon as the diagnosis is delivered. 3, 4

Core Rehabilitation Principles:

• Engage patients in tasks that promote normal movement patterns, good alignment, and even weight-bearing. 1, 3
• Use distraction techniques during task performance—introduce additional activities (counting backwards, word games, environmental observation) to shift attention away from the affected body part. 1, 2, 3
• Implement a graded exercise program that gradually increases in complexity, focusing on improving function rather than symptom reduction. 2
• Many patients show improvement or even elimination of symptoms during initial consultations when these techniques are applied. 2

Critical Pitfall to Avoid:

• Do not use splinting, adaptive aids, or assistive devices in the acute phase—these interrupt normal automatic movement patterns and cause maladaptive functioning. 3

Step 3: Address Psychological Perpetuating Factors

Psychological interventions should run parallel to physical rehabilitation, not sequentially. 1, 3, 5

Anxiety Management (Most Common Target):

• Educate patients about the physiological process of anxiety using the fight-or-flight response concept, particularly for those who don't identify as feeling anxious. 3
• Implement breathing techniques, progressive muscle relaxation, grounding strategies (noticing environmental details, cognitive distractions, sensory-based distractors like flicking a rubber band), visualization, and mindfulness. 3

Cognitive-Behavioral Therapy:

• CBT is the psychological treatment of choice for FND, targeting abnormal illness beliefs, hypervigilance, and maladaptive cognitions. 2, 3
• Address contributing factors such as depression and unhelpful coping behaviors. 1, 3

Medication Considerations:

• Consider SSRIs for comorbid anxiety and depression. 2
• Consider low-dose amitriptyline for pain and sleep disturbances. 2

Step 4: Establish Treatment Suitability and Goals

Treatment success depends on specific patient factors that should be assessed upfront. 1

Favorable Prognostic Indicators:

• Patient has some degree of understanding and agreement with the diagnosis (though full acceptance may only come during successful treatment). 1, 2
• Patient has agreed to the referral and can identify rehabilitation goals. 1
• Patient is motivated to make changes and understands that the initial focus is improving function, not eliminating symptoms. 1

Step 5: Coordinate Multidisciplinary Care

A coordinated team approach is essential for optimal outcomes. 2, 5

• Include occupational therapy for functional activities and daily living skills. 2
• Include speech and language therapy for communication difficulties when present. 2
• Avoid excessive medical investigations once a positive diagnosis is established, as this reinforces illness beliefs. 2

Common Pitfalls Beyond Those Already Mentioned:

• Do not provide constant reassurance, physical contact, or restraint during dissociative episodes—this reinforces symptom behavior. 3
• Do not have patients overly attend to cognitive problems (e.g., trying hard to remember)—similar to how a forgotten name is remembered once you stop trying. 3
• Failing to provide sufficient explanation of the diagnosis undermines all subsequent treatment efforts. 1
• Neglecting to address psychological comorbidities significantly reduces treatment success. 1

Outcome Monitoring

Track multiple domains to assess treatment response comprehensively. 6, 1

• Core FND symptom change (seizure frequency for functional seizures, clinician-rated scales like PMDRS for movement disorders, patient-rated symptom severity). 6
• Life impact measures including quality of life (SF-36), disability, and general functioning (WSAS, GAF). 6, 1
• Clinical Global Impression–Improvement (CGI-I) scale, which shows 60-96% of patients reporting improvement after intervention in most studies. 6