What is the recommended treatment plan for a patient with a functional neurological disorder after discharge?

Post-Discharge Treatment Plan for Functional Neurological Disorder

Refer immediately to outpatient occupational therapy and physical therapy as first-line treatment, with therapy sessions focused on retraining normal movement within functional daily activities rather than isolated exercises, using a biopsychosocial framework that addresses anxiety, sleep, pain, and fatigue as perpetuating factors. 1, 2

Core Treatment Framework

Your patient requires multidisciplinary rehabilitation centered on functional retraining, not impairment-based interventions. 2, 3 The evidence strongly supports this approach, with 60-96% of patients reporting improvement after intervention, with gains maintained at 12-25 month follow-up. 2, 3

Immediate Referrals Required

• Occupational therapy for functional retraining in activities of daily living (dressing, cooking, household management), vocational rehabilitation with graded return-to-work planning, and self-management strategy development. 1, 3
• Physical therapy for movement retraining integrated into functional tasks, not isolated strengthening exercises. 2, 3
• Psychology/psychiatry if significant anxiety, depression, or dissociative symptoms are present, as these perpetuate functional symptoms. 1, 2

Patient Education (Therapeutic in Itself)

Deliver this education now, as explaining the diagnosis correctly has direct therapeutic value and is the critical first step for treatment engagement. 2

• Tell the patient their symptoms are real, disabling, and involuntary—not "in their head" or deliberately produced. 2
• Explain FND is a positive diagnosis based on recognizable clinical signs (internal inconsistency, variability, distractibility), not a diagnosis of exclusion. 2
• Use the analogy: "This is a software problem, not a hardware problem"—the brain's wiring is intact, but the signals are getting crossed. 2
• Emphasize potential reversibility: the miscommunication between brain and body can improve with appropriate treatment, distinguishing FND from degenerative conditions like ALS or Parkinson's. 2
• Provide written materials and direct them to reputable online resources (neurosymptoms.org). 2

Specific Treatment Components

For Motor Symptoms (Weakness, Tremor, Gait Disturbance)

• Therapy must focus on activity-based goals ("return to cooking meals") rather than impairment-based goals ("increase grip strength"). 1, 3
• Demonstrate symptom variability during therapy sessions to show the patient their capacity for normal function—use this positively in treatment. 1, 3
• Avoid compensatory devices (wheelchairs, walkers, splints) during active rehabilitation, as these reinforce disability rather than promoting recovery. 1, 3
• Integrate specific techniques directly into functional tasks like dressing, cooking, or returning to work, not isolated exercises. 3

For Dissociative (Non-Epileptic) Seizures

If your patient has functional seizures, create a written episode management plan documenting: 1, 4

• Triggers and warning signs: Many patients initially report no memory but recognize patterns after discussion. 1, 4
• Sensory grounding techniques to use when warning signs appear: notice five things they can see, four they can touch, three they can hear; use word games or counting backwards. 1, 4
• Instructions for caregivers: Move to safe space, calmly inform them they are safe without constant reassurance (which paradoxically prolongs episodes), avoid physical restraint, behave as during a panic attack. 1, 4
• Recognize the patient may hear and understand even if unable to respond. 1, 4

For Cognitive Symptoms (Mental Fatigue, Memory Problems, Concentration Difficulties)

• Address contributing factors first: fatigue, pain, anxiety, and poor sleep—these exacerbate cognitive symptoms. 1, 2
• Implement structured daily routines with written daily plans to prevent cognitive overload. 1, 2
• Schedule regular rest breaks and time for relaxation to minimize stress. 1
• Use calendars and phone alarms normally but avoid dependence on them. 1
• Teach that overly attending to the problem (trying hard to remember) is unhelpful—most people remember forgotten names once they stop trying. 1

For Anxiety (Common Perpetuating Factor)

Many patients experience physiological anxiety (racing heart, tight chest) without recognizing it emotionally—described as "panic without panic." 1, 2

• Explain the fight-or-flight response and how anxiety physically impacts the body. 1, 4
• Teach anxiety management techniques: breathing exercises, progressive muscle relaxation, grounding strategies, visualization, distraction, thought reframing, mindfulness. 1, 2, 4
• Integrate these techniques directly into functional activities when anxiety triggers symptoms. 3

Self-Management and Relapse Prevention

Teaching self-management is central to intervention and must begin now. 1, 2

• Reestablish structure and routine: consistent sleep-wake schedules, predictable daily activities, regular meal times. 1, 2
• Create a written relapse prevention plan documenting learned management strategies and identifying triggers for symptom exacerbation. 1, 4
• Set graded goals for 3,6,9, and 12 months, preparing the patient for possible symptom fluctuation with emphasis on using learned techniques. 4
• Recovery follows a pattern of remission and exacerbation, not linear improvement—set this expectation now. 2

Vocational Rehabilitation

If your patient is employed or seeking employment, address this early—do not defer until "full recovery," as meaningful occupation is therapeutic. 2

• Refer for vocational rehabilitation with graded return-to-work planning, workplace accommodation recommendations, and flexible scheduling. 2, 3
• Target jobs with predictable routines, structured schedules, and flexible arrangements (remote work, hybrid models) to accommodate fatigue and anxiety. 2
• Initially choose roles with minimal physical demands if motor symptoms predominate, avoiding sustained standing or repetitive movements until movement retraining is consolidated. 2
• Work with occupational health departments to identify reasonable adjustments and teach self-management strategies applicable to the workplace. 2

Critical Pitfalls to Avoid

• Do not treat FND like other neurological conditions by focusing on impairment rather than function. 2, 4
• Do not rely on pharmacological approaches as primary treatment—rehabilitation is first-line. 2
• Do not provide compensatory devices prematurely—this reinforces disability. 1, 2, 3
• Do not dismiss symptoms or suggest they are "all in their head"—this increases stigma and reduces engagement. 4
• Avoid constant reassurance during episodes—this paradoxically prolongs them. 4

Follow-Up and Monitoring

• Book a follow-up appointment to review progress, troubleshoot issues, and reset goals as needed. 1
• Consider peer support organizations as an adjunct, especially for patients with ongoing symptoms. 1
• Involve family members and caregivers in education and treatment to facilitate support and carry-over of strategies. 3
• Address facilitatory care rather than passive care—encourage the patient to problem-solve and perform tasks independently with guidance. 3

Expected Outcomes and Prognosis

• Two-thirds of patients rate their health as "better" or "much better" at discharge, with improvement maintained over the following year. 5
• Multidisciplinary studies demonstrate improvements in physical function, quality of life, mood, anxiety, and return to meaningful activities including work. 2, 5
• Early diagnosis and treatment are critical for optimal outcomes. 2
• Patient confidence in treatment, understanding of the diagnosis, and motivation to make changes predict treatment success. 2