What is the treatment approach for a patient with functional neurological disorder?

Treatment Approach for Functional Neurological Disorder

Multidisciplinary rehabilitation centered on physical therapy and occupational therapy, grounded in a biopsychosocial framework with patient education and self-management strategies, represents the first-line treatment for FND, with 60-96% of patients reporting improvement after intervention. 1

Critical First Step: Diagnostic Communication

The explanation of the diagnosis has direct therapeutic value and is essential for treatment engagement 1. This communication must include:

• Taking the problem seriously and naming the diagnosis clearly (e.g., "Functional Neurological Disorder"), emphasizing that symptoms are real, disabling, and involuntary—not "in the patient's head" 1
• Explaining what FND IS rather than what it is NOT: describe it as a potentially reversible miscommunication between the brain and body, using analogies like "a software problem, not a hardware problem" or "the train is off the tracks" 1
• Demonstrating clinical signs during the consultation (e.g., Hoover's sign for weakness, entrainment for tremor) to show internal inconsistency, which can be a positive experience for patients 1
• Providing written materials and links to resources for ongoing education 1
• Emphasizing reversibility: FND does not cause permanent structural damage to the nervous system, and symptoms can improve with appropriate treatment 1

Core Treatment Components

Physical and Occupational Therapy (First-Line for Motor Symptoms)

Physical and occupational therapy are the treatments of choice for functional motor symptoms 1, 2. Key rehabilitation principles include:

• Retraining normal movement within functional activities rather than isolated exercises 1
• Activity-based (functional) goals rather than impairment-based goals: integrate specific treatment techniques into daily function 1
• Graded reintroduction to daily activities with structured progression 1
• Intensive therapy with several sessions per week may be more successful in helping patients recover normal function 1

Self-Management Strategies (Central to Intervention)

Teaching self-management is essential and must include 1:

• Reestablishment of structure and routine through written daily plans to prevent activity and cognitive overload 1
• Anxiety management techniques: breathing techniques, progressive muscle relaxation, grounding strategies, visualization, distraction, reframing thoughts, mindfulness, and integration of pleasant activities 1
• Completion of a relapse prevention plan for long-term symptom control 1
• Addressing contributing factors such as fatigue, pain, anxiety, and sleep deficiency, particularly for cognitive symptoms 1
• A "24-hour approach to therapy" that includes consistent sleep-wake schedules as part of structured daily routines 1

Psychotherapy (Emerging Evidence-Based Treatment)

Psychotherapy is an emerging evidence-based treatment across FND subtypes 2. While the guidelines emphasize rehabilitation as first-line, psychological interventions should be integrated into the multidisciplinary approach to address:

• Psychological comorbidity including anxiety, depression, and dissociation, which are associated with symptom severity and diminished quality of life 1
• Perpetuating factors such as hypervigilance, self-monitoring, and fear-avoidance behaviors 3

Critical Pitfalls to Avoid

Do not treat FND like other neurological conditions 1. Specific errors include:

• Avoiding compensatory aids and devices prematurely (e.g., wheelchairs, walkers, splints) in the acute phase or during active rehabilitation, as these can reinforce maladaptive patterns 1
• Not relying primarily on pharmacological approaches, as medications are not the primary treatment for FND 1
• Avoiding immobilization devices that restrict function, which can lead to secondary complications like deconditioning, muscle atrophy, and new musculoskeletal problems 1
• Not focusing on impairment-based goals when functional goals are more appropriate 1

Multidisciplinary Team Structure

A multidisciplinary team is necessary for comprehensive management 1, involving:

• Neurologists (for diagnosis and ongoing neurological assessment)
• Physical therapists (for motor retraining)
• Occupational therapists (for functional activity integration)
• Psychiatrists or psychologists (for psychological comorbidity and perpetuating factors)
• Speech therapists (for functional dysphonia or speech disorders, if present) 1, 3
• Caregivers (for education and support) 1

Open and consistent communication among team members is essential 1.

Treatment Setting and Intensity

Treatment should be delivered across the continuum of care 1:

• Hospital settings for acute presentations requiring cardiorespiratory monitoring (e.g., functional seizures with potential respiratory compromise) or altered sensorium 1
• Rehabilitation wards for intensive therapy when severe disability requires concentrated intervention 1
• Community/outpatient settings for ongoing management, with vocational rehabilitation to support return to work or study with graded increases in activity 1

Expected Outcomes and Prognostic Factors

60-96% of patients report improvement after intervention, with Clinical Global Impression-Improvement scores typically falling in the minimally to much improved range 1. Multidisciplinary studies demonstrate improvements in physical function and quality of life immediately after treatment and at follow-up periods of 12-25 months 1.

Positive Prognostic Factors:

• Patient understanding and agreement with the diagnosis 1
• Motivation and agreement to treatment 1
• Patient confidence in treatment 1
• Ability to identify rehabilitation goals 1

Guarded Prognostic Factors:

• Transient, unpredictable, or highly variable symptoms across settings 1
• Resolution of symptoms leading to return to an unsafe or futile work environment 1

Follow-Up and Long-Term Management

Schedule follow-up appointments to review progress, troubleshoot issues, and reset goals 1. Recovery often follows a pattern of symptom remission and exacerbation rather than linear improvement 1, so ongoing support and adjustment of the self-management plan are necessary.

Early diagnosis and treatment are critical for optimal outcomes, as prolonged immobility can lead to secondary complications that become more difficult to reverse 1.