In an adult woman with chronic stress and heightened anxiety related to recent health concerns, who has a normal neurological examination and unremarkable laboratory studies, could her burning and tingling sensations in the hands and feet be a functional (psychosomatic) manifestation?

Functional Neurological Disorder: Sensory Symptoms in the Context of Anxiety

Yes, the burning and tingling sensations in your patient's hands and feet can be functional (psychosomatic) manifestations, particularly given the context of chronic stress, heightened anxiety, normal neurological examination, and unremarkable laboratory studies—this presentation is consistent with Functional Neurological Disorder (FND).

Understanding the Clinical Picture

Your patient's presentation aligns with FND, where sensory symptoms including hypersensitivity, tingling, and burning are well-recognized manifestations. Many people with FND report hypersensitivity to touch, light, sound and movement, and these symptoms are not unique to FND but are also common in people with other diagnoses such as migraine, chronic pain and fatigue 1. Importantly, there is no single FND-specific outcome measure for functional sensory symptoms, reflecting the heterogeneity of this presentation 1.

The relationship between stress and FND is supported by a stress-diathesis model where biological susceptibility interacts with psychological stressors 2. However, it's critical to understand that:

• Anxiety is common in FND and may act as a symptom precipitating or perpetuating factor 1
• Some patients experience physiological and somatic consequences of anxiety (racing heart rate, tight chest, and notably sensory symptoms) without recognizing the experience emotionally—described as "panic without panic" or alexithymia 1
• The concept of a fight-or-flight response may be useful for patients who do not identify as feeling anxious 1

Key Diagnostic Considerations

Attention-related body sensations such as tingling can emerge due to simply focusing attention on a body part, and these sensations are more the result of top-down functions with weak connection to peripheral processes 3. This is particularly relevant in your patient with heightened anxiety and health concerns.

Research shows that hot-burning sensations can occur independently of nerve lesion or axonal damage of unmyelinated fibers 4, supporting the functional nature of these symptoms when neurological examination and bloodwork are normal.

Clinical Pitfalls to Avoid

• Do not dismiss these symptoms as "just psychological"—they are real, disabling symptoms that require validation and specific treatment 1
• Avoid constant reassurance, which can paradoxically maintain symptoms 1
• Hypersensitivity can become a maintaining factor, resulting in avoidant behaviors and limiting participation in functional activities 1

Management Approach

Address anxiety as a primary intervention target since it commonly precipitates and perpetuates FND symptoms 1:

• Educate the patient about the physiological process of anxiety and its physical impact on the body, including how the fight-or-flight response can manifest as sensory symptoms 1
• Implement anxiety management strategies including breathing techniques, progressive muscle relaxation, grounding strategies, visualization, distraction, thought reframing, mindfulness, and regular cardiovascular exercise 1
• Sensory grounding techniques can be particularly helpful: noticing detail in the environment (colors, textures, sounds), cognitive distractions (word games, counting backwards), and sensory-based distractors 1

Address the hypersensitivity directly to prevent it from becoming a maintaining factor 1:

• Use graded exposure to sensory stimuli
• Implement desensitization protocols adapted from chronic pain management 1

Evidence for Stress-Symptom Connection

The biological plausibility is supported by research showing that women reporting more stressful life events demonstrate enhanced central sensitization manifested by increased area of secondary hyperalgesia 5, suggesting that life stressors facilitate pain and sensory processing through neurobiological mechanisms.

A stress-diathesis model proposes that greater biological susceptibility to FND is associated with less severe stress exposure, while FND precipitated by more severe stress is associated with lower biological vulnerability 2. This explains the variable exposure to traumatic stress among people with FND.

Monitoring and Follow-up

Given that anxiety disorders occur quite frequently in patients with neurological conditions 6, ongoing screening for anxiety and depression is warranted. The Patient Health Questionnaire-15 (PHQ-15) can be useful for tracking somatic symptoms over time 1.