What is the treatment for conversion disorder (functional neurological disorder)?

Treatment for Conversion Disorder (Functional Neurological Disorder)

Multidisciplinary rehabilitation centered on physical and occupational therapy, combined with cognitive-behavioral therapy and patient education about the diagnosis, represents the first-line treatment for conversion disorder, with 60-96% of patients reporting improvement after intervention. 1, 2

Core Treatment Framework

The treatment must be grounded in a biopsychosocial model that addresses biological, psychological, and social perpetuating factors simultaneously. 1, 2 This is not a sequential approach—all components should begin early and run in parallel. 2

Essential First Step: Diagnostic Explanation

Before any rehabilitation begins, explain the diagnosis using these specific elements: 1, 2

• Acknowledge reality: State explicitly that symptoms are real, disabling, and involuntary—not "in the patient's head" 1, 2
• Use concrete analogies: "This is a software problem, not a hardware problem" or "the train is off the tracks" 1
• Demonstrate positive signs: Show the patient Hoover's sign, distractibility, or tremor entrainment during the consultation to prove this is a positive diagnosis 1
• Emphasize reversibility: Explain that symptoms result from potentially reversible miscommunication between brain and body 1, 2
• Provide written materials: Give handouts and links to resources before the patient leaves 2

This explanation has direct therapeutic value and is critical for treatment engagement. 2

Physical and Occupational Therapy (Primary Treatment)

Core Rehabilitation Principles

Focus exclusively on retraining normal movement patterns within functional activities—not isolated exercises or impairment-based goals. 3, 1, 4

Specific techniques include: 1, 4

• Distraction-based retraining: Engage patients in tasks (dressing, cooking, walking while conversing) that promote normal movement without focusing attention on the affected body part 1, 4
• Functional goal setting: Target "return to cooking meals" rather than "increase grip strength" 4
• Graded activity progression: Systematically increase complexity and independence as skills improve 4
• Demonstrate variability: Use symptom fluctuation during examination positively—show the patient when they move normally to prove capacity for recovery 3, 4

Critical Equipment Restrictions

Avoid compensatory aids (wheelchairs, walkers, splints, braces) during acute phase and active rehabilitation—these interrupt automatic movement patterns and reinforce disability. 3, 1, 4 Only introduce adaptive equipment if rehabilitation fails after intensive therapy. 3

Treatment Intensity

Intensive therapy with several sessions per week is more successful than sporadic treatment. 2 Aim for daily therapy sessions initially if resources permit. 2

Psychological Interventions

Cognitive-Behavioral Therapy

CBT is the psychological treatment of choice, though it should run parallel to—not replace—physical rehabilitation. 1

Anxiety Management (Essential Component)

Even patients who don't identify as "anxious" require these interventions, as anxiety commonly perpetuates symptoms: 3, 1

• Breathing techniques and progressive muscle relaxation 3, 1
• Grounding strategies: Notice 5 things you see, 4 things you hear, 3 things you can touch, 2 things you smell, 1 thing you taste 1
• Sensory distractors: Flick a rubber band on wrist, hold ice cube, focus on environmental details 1
• Thought reframing and mindfulness 3, 1
• Integration of enjoyable activities 3, 1

Explain anxiety using the fight-or-flight response concept for patients who don't recognize psychological distress. 1

Addressing Dissociative Episodes

During dissociative episodes, avoid constant reassurance, physical contact, or restraint. 1 Instead, use sensory grounding techniques and cognitive distractions (word games, counting backwards). 1

Self-Management Training (Central to Long-Term Success)

Teaching self-management must begin at initial assessment, not after symptom improvement. 3, 4

Required components: 3, 4

• Reestablish structure and routine: Set consistent sleep-wake times, meal schedules, and daily activities 3, 4
• Activity pacing: Teach patients to balance activity with rest to prevent fatigue-related symptom exacerbation 4
• Relapse prevention plan: Create written plan identifying early warning signs and specific strategies to implement when symptoms worsen 3, 4
• Ongoing self-management strategies: Provide techniques patients can independently apply when symptoms fluctuate 4

Multidisciplinary Team Composition

The team should include: 2

• Neurologist (for diagnosis and medical oversight) 2
• Physical therapist 2
• Occupational therapist 2
• Psychologist or psychiatrist 2
• Speech therapist (if speech/swallowing symptoms present) 2

Maintain open and consistent communication across all team members and with the patient—mixed messages undermine treatment. 3

Vocational Rehabilitation

Begin vocational planning early in treatment, not after "full recovery," as meaningful occupation is therapeutic. 2

Specific workplace accommodations: 2

• Graded return-to-work: Start with reduced hours and incrementally increase 2
• Flexible scheduling: Allow remote work or hybrid arrangements 2
• Regular rest breaks throughout the workday 2
• Role modifications: Reduce physical or cognitive demands initially 2

Target jobs with predictable routines, structured schedules, and minimal physical demands if motor symptoms predominate. 2

Treatment Setting Algorithm

Outpatient multidisciplinary rehabilitation is first-line for most patients. 2

Hospital admission is indicated only for: 2

• Functional seizures with potential respiratory compromise requiring cardiorespiratory monitoring 2
• Altered sensorium requiring close neurologic observation 2

Otherwise, deliver treatment in community settings with intensive outpatient therapy. 2

Expected Outcomes and Timeline

• 60-96% of patients report improvement after intervention 1, 2
• Improvements in physical function and quality of life occur immediately after treatment and persist at 12-25 month follow-up 1, 2
• Recovery follows a pattern of remission and exacerbation, not linear improvement—prepare patients for symptom fluctuation 2

Critical Pitfalls to Avoid

1. Do not treat FND like other neurological conditions with passive modalities or pharmacological approaches as primary treatment 2
2. Do not focus on impairment-based goals ("increase strength") rather than functional goals ("return to work") 3, 4
3. Do not provide premature compensatory devices that reinforce sick role 4
4. Do not have patients focus attention on affected body parts during movement retraining 1
5. Do not defer vocational rehabilitation until symptoms fully resolve 2
6. Do not use constant reassurance during dissociative episodes 1

Factors Predicting Treatment Success

Positive predictors: 2

• Patient understanding and agreement with diagnosis 2
• Motivation to make changes 2
• Confidence in treatment 2

Guarded prognosis indicators: 2

• Transient, unpredictable, or highly variable symptoms across settings 2
• Return to unsafe or futile work environment after symptom resolution 2

Follow-Up and Long-Term Management

Book follow-up appointments to review progress, troubleshoot issues, and reset goals. 3 Peer support organizations can be important adjuncts, especially for patients with persistent symptoms. 3 Involve family members and caregivers in education and treatment to facilitate support and carry-over of strategies. 4