What is the recommended workup and first‑line treatment for a patient with conversion disorder (functional neurological symptom disorder)?

Conversion Disorder (Functional Neurological Disorder): Workup and First-Line Treatment

Recommended Workup

The workup for conversion disorder must establish the diagnosis through positive clinical signs demonstrating internal inconsistency, not merely by excluding organic disease. 1, 2

Essential Diagnostic Elements

Positive clinical signs to identify:

• Internal inconsistency: Symptoms that lessen or resolve during spontaneous conversation, when attention is diverted, or during automatic functions like walking 2
• Suggestibility: Symptoms become more pronounced when the patient discusses them or during examination 2
• Inefficient movement patterns: Speech/swallowing fatigue, over-mouth movements, excessive eye blinking, facial contortions, exaggerated effort 2
• Hoover's sign (for functional limb weakness) and tremor entrainment (for functional tremor) 3
• Distractibility: Symptoms improve with attention redirection 1

Clinical History Components

Obtain specific details about:

• Symptom onset: Acute onset is common, often following injury, illness, upper respiratory infection, voice overuse, or traumatic head injury 4
• Temporal pattern: Waxing and waning course with spontaneous remissions is characteristic 3
• Precipitating events: Surgery, anesthesia, physical injury 5, 3
• 24-hour routine: Sleep hygiene, boom-bust activity patterns, lack of structure 4
• Functional impact: Specific activities affected (personal care, meal preparation, work, social engagement) 4
• Comorbid symptoms: Fatigue, persistent pain, anxiety, depression 1, 3

Neurological Exclusion (Rule-Out Organic Disease)

Must exclude these specific conditions:

• Guillain-Barré syndrome and variants 2
• Multiple sclerosis and demyelinating disorders 2
• Myasthenia gravis 2
• Stroke or vascular events 2
• Metabolic disorders 2
• Inflammatory or infectious CNS conditions 2

Neuroimaging (MRI preferred over CT) should be performed when:

• Neurologic symptoms are present to exclude structural abnormalities 4
• Brain imaging may show no abnormalities or incidental findings that do not explain the functional symptoms 1

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First-Line Treatment

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. 1

Step 1: Diagnostic Explanation (Therapeutic in Itself)

The explanation must include:

• Acknowledge symptoms are real, involuntary, and disabling—not "in the patient's head" 1, 2
• Name the diagnosis clearly: Use "functional neurological disorder" or "conversion disorder" 4
• Explain what it IS, not what it is NOT: "A software problem, not a hardware problem" or "the train is off the tracks" 1
• Emphasize reversibility: Symptoms arise from potentially reversible miscommunication between brain and body, not structural damage 1, 2
• Demonstrate clinical signs during consultation: Show the patient the internal inconsistency (e.g., Hoover's sign) 1, 2
• Provide written materials and links to resources 1

Step 2: Core Rehabilitation (Physical and Occupational Therapy)

Key rehabilitation principles:

• Retraining normal movement within functional activities—not impairment-based exercises 1
• Graded reintroduction to daily activities with activity-based goals 1
• Intensive therapy schedule: Several sessions per week is more effective than weekly sessions 1, 2
• Avoid compensatory devices prematurely: Aids reinforce sick role and are generally unhelpful 4, 6
• Focus on function, not symptom elimination: Return to meaningful activities (work, self-care, social engagement) drives rehabilitation 1

Specific techniques:

• Attention redirection during movement 1
• Rhythm modification and entrainment for functional tremor 6
• Demonstration of symptom variability during automatic functions 2

Step 3: Psychotherapy (Cognitive Behavioral Therapy)

CBT is the evidence-based first-line psychotherapeutic approach. 2, 6, 7

CBT structure:

• 12-22 weekly sessions 2
• Core components: Psychoeducation and formulation, exposure with response prevention or behavioral experiments, relapse prevention 2
• Motivational interviewing at the start to increase engagement 2

Psychological interventions to integrate:

• Anxiety management: Breathing techniques, progressive muscle relaxation, grounding strategies, visualization, distraction, reframing thoughts, mindfulness 1
• Address cognitive features: Locus of control, executive function, abnormal illness beliefs, hypervigilance to bodily functions 4
• Cognitive Behavioral Therapy strategies: Identify and challenge maladaptive beliefs ("I will choke"), self-reported sensations ("My throat feels tight"), avoidance behaviors, self-directed attention 4

Step 4: Self-Management Strategies

Teach patients:

• Reestablishment of structure and routine: Consistent sleep-wake schedules, structured daily activities 4, 1
• Activity pacing: Avoid boom-bust patterns 1
• Relapse prevention plan: Written plan for managing symptom exacerbations 1
• Anxiety management techniques applicable to daily life 1

Step 5: Vocational Rehabilitation (When Appropriate)

Support return to work or study with:

• Graded increases in activity: Start with reduced hours, flexible scheduling, remote work options 1
• Workplace accommodations: Regular rest breaks, role modifications, hybrid arrangements 1
• Employer education: Clear explanation of diagnosis and expected symptom variability 1

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Role of Medication

Psychotherapy and rehabilitation, not medication, are first-line treatment for conversion disorder. 2, 6

Pharmacotherapy has no evidence for treating functional symptoms directly. 2, 6

Medication should be limited to:

• Treating comorbid psychiatric conditions: SSRIs or low-dose amitriptyline for comorbid anxiety, depression, or globus 4, 2
• Not targeting conversion symptoms themselves 6

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Expected Outcomes and Prognosis

60-96% of patients report improvement after intervention, with Clinical Global Impression-Improvement scores in the minimally to much improved range. 1

Recovery pattern:

• Symptom remission and exacerbation rather than linear improvement 1
• Early symptom improvement during initial consultation is common but does not guarantee complete resolution 2
• Improvements in physical function and quality of life at 12-25 month follow-up 1

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Critical Pitfalls to Avoid

Do not:

• Treat FND like other neurological conditions with compensatory devices or impairment-based therapy 1
• Rely primarily on pharmacological approaches for functional symptoms 1, 6
• Use compensatory devices prematurely: This reinforces sick role 4, 6
• Focus on impairment-based rather than functional goals 1
• Take a dismissive approach that fails to acknowledge involuntary nature of symptoms 2, 6
• Reinforce illness behavior through excessive focus on symptoms 2, 6

Do:

• Emphasize that symptoms are real but potentially reversible 1, 2
• Demonstrate symptom reversibility during therapy sessions 1
• Begin vocational rehabilitation early, not deferred until "full recovery" 1