What is the impact of functional neurological disorder on lifespan and what are the treatment options?

Functional Neurological Disorder Does Not Shorten Lifespan

Functional neurological disorder (FND) does not cause death, shorten lifespan, or lead to permanent structural damage to the nervous system—it is not a degenerative or life-threatening condition, with mortality rates no higher than the general population. 1, 2

Impact on Lifespan and Mortality

• FND symptoms arise from a potentially reversible miscommunication between the brain and body, not from structural neurological disease that would affect survival 1, 3
• The disorder does not inherently reduce life expectancy because it does not cause progressive neurological degeneration 1
• The primary impact is on quality of life, not longevity—patients frequently experience high levels of distress, disability, unemployment, and reduced quality of life, but these reflect symptom burden and stigma rather than a life-threatening disease process 1, 2

Important Caveats About Secondary Complications

While FND itself doesn't affect lifespan, prolonged illness can create secondary problems:

• Prolonged immobility or reduced activity can lead to deconditioning and muscle atrophy, which become progressively more difficult to reverse over time 1
• Maladaptive movement patterns and premature use of assistive devices can create new musculoskeletal problems including secondary pain syndromes 1
• These secondary complications emphasize why early diagnosis and treatment are critical for optimal outcomes 1

Treatment Options and Expected Outcomes

First-Line Treatment Approach

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 as per American Academy of Neurology recommendations 1, 3

Core Treatment Components

Physical and occupational therapy are the treatments of choice for functional motor symptoms, with key principles including:

• Retraining normal movement within functional activities (not isolated exercises) 1, 3
• Using distraction techniques during task performance to normalize movement 3
• Graded reintroduction to daily activities with activity-based goals 1
• Avoiding compensatory devices prematurely, which can reinforce abnormal patterns 1, 3

Patient education must include:

• Acknowledging that FND is real, common, and disabling with symptoms outside the person's control 3
• Explaining that symptoms are caused by potentially reversible miscommunication between brain and body 1, 3
• Demonstrating clinical signs during consultation, which can be a positive experience 1
• Using understandable analogies such as "a software problem, not a hardware problem" 1

Self-management strategies are central and must include:

• Anxiety management techniques: breathing techniques, progressive muscle relaxation, grounding strategies, visualization, distraction, reframing thoughts, mindfulness 1
• Reestablishment of structure and routine 1
• Completion of a relapse prevention plan for long-term symptom control 1

Psychological interventions should address:

• Contributing factors such as anxiety, depression, and unhelpful coping behaviors 3
• For cognitive symptoms, address fatigue, pain, anxiety, and sleep deficiency 1, 3

Treatment Intensity and Setting

• Intensive therapy with several sessions per week may be more successful in helping patients recover normal function 1
• Treatment should be delivered across the continuum: hospital settings for acute presentations, rehabilitation wards for intensive therapy, and community settings for ongoing management 1

Expected Treatment Outcomes

60-96% of patients report improvement after intervention, with Clinical Global Impression-Improvement scores typically falling in the minimally to much improved range 4, 2

Measurable improvements occur across multiple domains:

• Mobility, depression, and quality of life show significant improvement 2, 5
• Symptoms become more understandable and less distressing after treatment 2, 5
• Realistic timelines for improvement are 12-25 months with multidisciplinary intervention 1, 2

Predictors of Treatment Success

Patient confidence in treatment is the key predictor of clinical outcomes 5

Additional positive predictors include:

• Patient understanding and agreement with the diagnosis 3, 2
• Motivation to make changes and ability to identify rehabilitation goals 3, 2
• Early diagnosis and younger age 6

Long duration of symptoms is the most distinct negative predictor 6

Critical Errors to Avoid

• Do not treat FND like other neurological conditions or rely primarily on pharmacological approaches 1
• Do not use splinting or adaptive aids prematurely, as this reinforces abnormal movement patterns 1, 3
• Do not focus on impairment-based goals rather than functional goals 1
• Do not fail to address psychological comorbidities including depression, anxiety, and depersonalization-derealization 3, 5
• Do not provide insufficient explanation of the diagnosis or fail to make a positive diagnosis based on clinical signs 3

Prognosis Considerations

Recovery often follows a pattern of symptom remission and exacerbation rather than linear improvement 1

Even in chronic and severe cases (mean symptom duration 9.7 years), most patients (43/52 in one cohort) showed global improvement with inpatient rehabilitation 5

However, without treatment, prognosis is generally unfavorable—in most studies, functional motor symptoms and psychogenic nonepileptic attacks remain the same or worse in the majority of patients at follow-up 6