What is the Best Treatment for Functional Neurological Disorder (FND)?

Summary: While the complex nature of the disorder means there is no single best treatment for functional neurological disorder (FND), experts agree that an integrated approach is the best framework for treating FND.

Key Points:

• Some patients report symptom relief after receiving basic education and communication about the core features of FND and the existence of the disorder.
• In most cases, however, patients require/benefit from treatment with psychotherapy and/or individual, family, or group counseling.
• Physical therapy may help patients with movement-related and/or motor symptoms of FND.
• For patients with co-occurring mental health diagnoses, treatment for those disorders can improve outcomes for people with FND.
• Emerging treatments under review include mindfulness, hypnotherapy, exposure therapy, and hypnosis.

What is Functional Neurological Disorder (FND)?

The National Institute of Neurological Disorders and Stroke (NINDS) define functional neurological disorder as follows:

“Functional neurologic disorder (FND) refers to a neurological condition caused by changes in how brain networks work, rather than changes in the structure of the brain itself, as seen in many other neurological disorders. Physical symptoms of FND are genuine but cannot be explained by changes in the brain structure. The exact cause of FND is unknown.”

The latest data on functional neurological disorder shows the following prevalence:

• General estimate:
  • 10-22 per 100,000 people, or between 0.01% and 0.022%
• Minimum estimate:
  • 80-140 per 100,000 people, or between 0.08% and 0.014%
• Possible estimated range, based on latest information on misdiagnosis/missed diagnosis/inaccurate diagnoses:
  • 50-1600 per 100,000 people, or between 0.05% and 1.6%
• Estimate among children:
  • 1-18 per 100,000 people, or between 0.001% and 0.018%

Among patients in the hospital – excluding those receiving inpatient mental health treatment for primary mental health diagnoses or crises – rates of FND are much higher:

• 20-25% of hospital patients report FND symptoms
• 5% of patients report symptoms that meet clinical threshold for diagnosis

Research also shows a connection between FND and mental health and behavioral disorders. The most common mental health/behavioral disorders among people with FND include:

• Anxiety disorders
• Depressive disorders
• Alcohol use disorder (AUD)
• Substance use disorder (SUD)

Because of the high rate of comorbidity associated with conversion disorder, and the complexity of the disorder itself, productive, successful treatment requires:

1. An accurate diagnosis by an experienced treatment team that understands conversion disorder, comorbid mental health disorders, and co-occurring alcohol/substance use disorder
2. An effective treatment plan that addresses all potential contributing factors, meaning the plan should be comprehensive, patient-centered, and integrated.

We’ll return to our main topic – the best treatment for functional neurologic disorder – in a moment. First, we’ll share more basic and essential information about FND.

Functional Neurologic Disorder: Symptoms, Causes, Diagnosis

The most common symptoms of functional neurologic disorder include, but are not limited to:

• Seizures or incidents that resemble seizures
• Movement issues such as tremors, problems with walking, involuntary jerking/twitches, and unplanned/unconscious movements that feel beyond voluntary control.
• Cognitive issues, such as difficulty concentrating, sustaining focus, and memory, sometimes generally called brain fog
• Dizziness and/or feelings of unsteadiness/lack of balance, atypical sense of swaying or rocking
• Difficulty with speech, including new/sudden stuttering, or having problems forming words
• Sensory changes/difficulties, such as problems seeing and/or hearing, including sensations of numbness or loss of ability to sense touch/experience tactile physical feedback from body
• Unexplained pain, such as aches, burning sensations, sharp stabbing sensations, migraine headaches

Those are the primary symptoms associated with FND. One reason this disorder causes distress among people with symptoms is that they feel real and are real, but have no identifiable physiological causes, but are instead associated with changes in brain function. That’s a change in the function but not the structure of the brain, with the physical symptoms – dizziness, headaches, seizures – showing no typical, known, or identifiable origin.

But what causes FND?

The exact cause of FND is currently unknown. However, experts identify several common events or circumstances that can trigger the onset of functional neurologic disorder (FND), including:

• Physical injuries
• Migraine headaches
• Infections
• Traumatic experiences
• Extreme stress
• Emotional or psychological distress

While the cause or causes is/are elusive, experts identify the following risk factors:

• Hospitalization
• Chronic pain
• Chronic stress
• Adverse childhood experiences
• Presence of mental health diagnosis, such as depression or anxiety

Since the causes are not well known, assigning a comprehensive set of risk factors for FND is difficult. A person with FND may have some or none of the risk factors listed above.

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) indicates there are four (4) primary criteria for clinical diagnosis of FND:

Criterion A:

“One or more symptoms of altered voluntary motor or sensory function.”

Criterion B:

“Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions.”

Criterion C:

“The symptom or deficit is not better explained by another medical or mental (health) disorder.”

Criterion D:

“The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.”

When a person meets all four criterion, they may receive a diagnosis of FND, with additional specifier that describe, for instance, the specific motor dysfunction present – seizures, problems walking, others – and the nature of the social and occupational disruption. In addition, experts from the National Institute of Neurological Disorders and Stroke NIND note the following:

“There is no single test or biomarker (biological sign of disease) to confirm the diagnosis of FND. Diagnosis of FND is made based on the person’s history, symptoms, and a physical exam.”

Physicians assessing possible FND may recommend a series of tests to rule out known and established causes for symptoms that overlap with disorders, conditions, or diseases with well-established origins. These tests may include:

• Electroencephalography (EEG): monitors/records electrical activity in the brain
• Electromyography (EMG): monitors/records the electrical activity in muscles

That’s the current state of knowledge on the symptoms, possible causes, risk factors, and diagnosis of functional neurologic disorder.

Next, we’ll review the best treatments available for functional neurologic disorder (FND).

Treatment for Functional Neurologic Disorder (FND)

The diversity and complexity of the symptoms of the disorder means the best treatment for functional neurologic disorder (FND) depends on three things:

1. Early and accurate diagnosis
2. Acceptance and understanding of the diagnosis
3. Access to and full utilization of multidisciplinary care

Experts agree that effective treatment for FND starts with understanding and a full awareness of what’s going on:

“Strong, two-way communication between the healthcare provider and the patient is important for effective treatment of FND. This will help improve the patient’s understanding of the disorder and involve them actively in their own treatment.”

Here’s how an effective, multidisciplinary treatment plan may work:

• Providers agree that clear and open communication – which includes evidence-based psychoeducation – is the best first step.
• The second step depends on various factors. For patients with movement symptoms, physiotherapy or physical therapy may closely follow clear/open communication and education about the disorder. At the same, experts indicate psychotherapy may begin concurrently, particularly for people without movement symptoms. Evidence-based modes of psychotherapy that help people with FND include:
  • Cognitive behavioral therapy (CBT)
  • Acceptance and commitment therapy (ACT)
  • Psychodynamic psychotherapy
  • Dialectical behavior therapy (DBT)
  • Prolonged exposure therapy (PET)
• After education and targeted therapy determined by individual symptom profile, medication can help improve outcomes:
  • Analgesic medication for patients experiencing pain
  • Psychiatric medication for patients with co-occurring mental health disorders
• Treatments that may offer relief, but are in process of review for FND, include:
  • Mindfulness-based CBT
  • Stress reduction techniques, such as progressive relaxation and mindful meditation
  • Hypnotherapy
  • Transcranial magnetic stimulation (TMS)
  • Transcutaneous electrical stimulation (TENS), for patients with significant pain

We’ll also offer this insight regarding medication from the publication “Diagnosis and Management of Functional Neurological Disorder,” which we also link to above:

“Selective serotonin reuptake inhibitors (SSRIs), serotonin norepinephrine reuptake inhibitors (SNRIs), or other indicted psychotropic medications, are used to manage concurrent mental health symptoms, but are not themselves indicated for the direct treatment of FND.”

We’ll discuss this information further, below.

Understanding the Diagnosis, Recognizing the Benefits of Treatment

A common thread unites the existing peer-reviewed literature that helps us identify the best treatment for functional neurologic disorder (FND): understanding the diagnosis and committing to an individualized, multidisciplinary treatment plan guided by specific symptoms and patient needs yields the most reliable and consistent improvement and symptom relief.

People diagnosed with FND should understand these two facts:

• Patients can achieve significant symptom relief after receiving evidence-based treatment and intervention.
• Early diagnosis and access to a multidisciplinary care team improves outcomes.

In other words, patients who receive a diagnosis for FND after a thorough assessment from qualified professionals can benefit from beginning FND-specific treatment as early as possible. Evidence shows that deferring treatment, or FND that goes untreated for a year or more, results in a far less favorable long-term prognosis than beginning FND-specific treatment within six months of diagnosis or earlier.

We would never discourage anyone from getting a second opinion: that’s a well-established, and well-respected practice in healthcare, especially for people with complex conditions or people whose subjective experience doesn’t align with what they hear from their provider(s).

Any good provider will support a patient who wants a second opinion and will even offer resources to help them find another qualified provider to offer that opinion.

With that said, it’s also important to remember that the earlier a person with clinically diagnosed FND gets the treatment they need, the better the outcome: that’s a fact supported by an extensive evidence base.