Functional Neurological Disorder (FND) is one of the most common presenting problems in neurology clinics and is associated with high economic burden (O’Mahoney et al., 2023). FND is a condition in which people experience real, disabling neurological symptoms—such as seizures, weakness, movement abnormalities, sensory changes, dizziness, or cognitive problems—that arise from abnormal functioning rather than damage to the nervous system (Espay et al., 2018; Hallett et al., 2022). These symptoms follow recognizable clinical patterns and show internal inconsistency on examination, such as tremor that changes with externally-cued rhythms. They are now diagnosed on the basis of such positive signs rather than exclusion of other diseases (Espay et al., 2018; Varley et al., 2023).
FND often coexists with, or is precipitated by, organic neurological or medical conditions (Espay et al., 2018; Hallett et al., 2022). As a result, people with FND often initially present to physicians, particularly in emergency and neurology settings. Physicians conduct a thorough biomedical workup to exclude acute or life‑threatening causes before arriving at a diagnosis of FND (Hallett et al., 2022; Varley et al., 2023). At this point, care shifts from potential organic causes to understanding mechanisms and triggers. As many patients have relevant psychological factors—such as trauma history, anxiety, depression, or unhelpful illness beliefs —that can predispose, precipitate, or perpetuate functional symptoms, psychological formulation and therapy are important parts of treatment (Espay et al., 2018; Hallett et al., 2022). Unfortunately, most patients experience a complicated series of tests and mixed messages before receiving a clear, mechanism-based explanation. Consequently, many patients with FND are left feeling as if they were referred to mental health “after everything else was ruled out” (Espay et al., 2018; Varley et al., 2023).
Providers and patients alike are gridlocked in how to address FND. Patients are unaware of the impetus for their symptoms. Providers feel ill-equipped in either time or resources to treat them. Treating FND like a neurological problem (e.g., antiepileptic drugs for psychogenic nonepileptic seizures [PNES]) does not work, and at times, may cause more harm than good (Hallett et al., 2022; LaFrance and Wincze, 2015).
Current Treatments
Current evidence indicates that treatments for FNDs produce modest but clinically meaningful benefits for a substantial subset of patients, while many continue to experience significant symptoms and disability despite care (Aybek & Perez, 2022; Gutkin et al., 2021; Varley et al., 2023). First-line approaches emphasize a clear, empathic diagnostic explanation plus psychologically-informed rehabilitation. Treatments have included specialist physiotherapy focused on motor retraining and diverted attention, (Aybek & Perez, 2022; Varley et al., 2023), cognitive-behavioral therapy (CBT) and related psychotherapies, (Aybek & Perez, 2022; Gutkin et al., 2021), antidepressants, and neuromodulatory or pharmacologic strategies (Aybek & Perez, 2022; Varley et al., 2023) but evidence is variable regarding efficacy. The best outcomes that consistently report improvements in function and quality of life tend to occur in multidisciplinary programs. Currently, there is no single universally effective therapy for FND (Aybek & Perez, 2022; Gutkin et al., 2021; Varley et al., 2023).
A New Approach: “Treating FNDs”
Using LaFrance and Wincze’s (2015) transtheoretical psychotherapy for treating PNES as framework, these authors created an 8-session psychotherapy protocol intended to apply to any form of FND while still targeting distressing symptoms. In addition to broadening the treatment scope, tenets of brain health as well as values-based living are implemented to encourage a holistic approach.
While LaFrance and Wincze’s (2015) therapy is based on Lethem and colleagues (1983) and LaFrance and Bjønæs’s (2010) fear avoidance model (as cited in LaFrance & Wincze, 2015), the model underpinning “Treating FNDs” is slightly different when it comes to breaking the cycle of the functional system. In their model, LaFrance and Wincze (2015) break the cycle with no longer fearing the symptom, followed by confrontation and recovery. In “Treating FNDs”, confrontation precedes no longer being afraid because confronting the symptom builds confidence to alleviate fear. This model also supports the two-factor theory (Schachter & Singer, 1962) that an emotion is derived from cognitive appraisal of a physiological response (a reinforcing pathway). This helps the patient to dissect their FND symptom using functional behavior analysis, starting with FND symptoms and assessing what they were feeling physically, emotionally, and experiencing environmentally. This method was intentionally chosen over the Beck (2011) cognitive model because FND involves lack of insight into beliefs tied to the functional symptom(s). Instead, this model allows for variability in whichever area the patient is able to identify stimuli first.
Session Structure of "Treating FNDs"
| Session | Topic | Activity | Homework | Theory |
|---|---|---|---|---|
| 1 | FND and biopsychosocial approach | Identifying situations/thoughts/Identifying ituations/thoughts/ emotions/sensations with the Feelings Wheel | Taking the Wheel exercise for locus of control; event log 1 | Psychoeducation, DBT, CBT |
| 2 | Setting the foundation for heathy living: nutrition, exercise, sleep hygiene | Commitment to change statement | Identifying areas of improvement in healthy living; event log 2 | Psychoeducation, ACT |
| 3 | Medications and Diagnosis | Review medication safety | Managing medications and talking to your prescriber; event log 3 | Biomedical, Motivational Interviewing |
| 4 | Values and Goals | My values worksheet; SMART goals | My first SMART goal; event log 4 | ACT |
| 5 | Healthy communication and setting boundaries | How to be assertive; How to set boundaries | Communication SMART goal; event log 5 | DBT |
| 6 | ABCs of human experience and FND feedback loop | Building insight into your loop | Cyclic sighing; Big Wave log 1 | CBT; Mindfulness |
| 7 | Stopping the cycle of FND | Thought challenging | Stop the Cycle worksheet using your “biggest wave” from log 1; Big Wave log 2 | CBT; values-based living |
| 8 | Recap of Treating FND | Review of what was helpful in taking control away from FND | Applying skills in daily life post-treatment | Skills review |
Symptom Monitoring
At the end of each session, the patient is assigned a homework activity in addition to weekly FND symptom tracking on an event log. The event log allows for each symptom event to be tracked, emphasizing what happened to the patient physically (i.e., FND symptom and severity), cognitively, and emotionally, precursors and triggers, any improvement, as well as impact to their day and others around them. During session 6, the event log is truncated into tracking the most impairing symptom per day (“big wave” of the day). This directs the patient to recognize there is an association between stimulus intensity and response severity.
Overarching Barriers to Successful Treatment
Barriers to successful treatment of FND regarding accountability arise on both provider and patient sides, and frequently reinforce one another (Aybek & Perez, 2022; Varley et al., 2023). Provider-related problems include delayed or unclear diagnosis, inconsistent or stigmatizing communication (e.g., framing symptoms as “not real” or implying malingering), limited FND-specific training, and fragmented services with poor interdisciplinary coordination. These reduce patient trust, undermine therapeutic alliance, and negatively impact patient engagement. Patients’ barriers commonly include understanding/accepting an FND diagnosis (especially when prior clinicians emphasized ruling out “organic” disease), ambivalence about psychological or rehabilitative explanations, low referral follow‑through, high non‑attendance rates, and the impact of prior negative healthcare experiences. Together, these can manifest as limited adherence, early dropout, or resistance to behavior change even when appropriate care is available (Aybek & Perez, 2022; Varley et al., 2023).
Patient Barriers to Successful Treatment
Treating FND requires a minimum level of psychological flexibility and openness to the idea that the mind is the origin of symptoms rather than a physiological mechanism. This therapy is not designed to challenge the “reality” of patients’ symptoms. Ideally, it is the etiology that is challenged through building insight. The treatment target is to improve emotional functioning and overall quality of life while indirectly decreasing symptom frequency and severity. By building awareness that functional symptoms change as emotional functioning and quality of life improve, acceptance that symptoms are psychologically rather than neurologically driven will increase. Though insight and acceptance will increase over time, this therapy necessitates the patient’s initial buy-in that psychotherapy can affect their symptoms. As such, patients with a history of treatment dropout or noncompliance in other CBT-based psychotherapies are likely inappropriate candidates for FND therapy.
Provider Barriers to Treatment
Mental health professionals may find themselves hesitant to treat FND because of the neurologically-presenting symptoms, complex comorbidities, and often traumatic psychosocial histories. However, the psychoeducation and skills included in this protocol are evidence-based practices used in many other psychotherapies and not reserved for FND. An understanding of functional symptoms as an expression of psychogenic stress and a solution-focused CBT approach is all that is required. Providers may be concerned about how to react when FND symptoms occur in session. This protocol encourages remaining calm during the episode, confirming safety afterward, and continuing as planned, modeling that FND episodes need not impede daily life.
How Psychologists Can Help
Neuropsychologists play a distinctive role in the treatment of FND as neuropsychology includes the intersection of brain–behavior science, assessment, and psychotherapy, allowing integration into a coherent, individualized treatment other disciplines lack (Aybek & Perez, 2022; Varley et al., 2023). Guided by neuropsychological assessment, neuropsychologists can develop an integrated biopsychosocial formulation that links cognitive style, emotional processing, life events, and symptom patterns, and deliver cognitive‑behavioral interventions that normalize symptoms, enhance diagnostic acceptance, and reduce avoidance and maladaptive safety behaviors known to maintain FND (Aybek & Perez, 2022; Varley et al., 2023). “Treating FNDs” is particularly useful when recent neuropsychological results can be directly referenced in session so treatment, symptom tracking, and skills application are tailored to testing findings, maximizing impact.
Current models suggest that FND is best addressed in a multidisciplinary format (Aybek & Perez, 2022; Varley et al., 2023). Clinical and health psychologists’ specialty areas, including psychological approaches to medical conditions to treatments for psychological stressors/traumas, add value to the FND treatment protocol as treatment emphasizes the importance of behavioral responses to symptoms. Especially considering between 40-100% of patients meet diagnostic criteria for a psychiatric disorder (Carle-Toulemonde et al., 2023). Trauma history, especially childhood maltreatment, has also been identified in up to 75% of FND patients. Clinical and health psychologists are uniquely suited to use this protocol as a precursor to trauma-focused psychotherapy: clinicians can harness the pre-established therapeutic alliance and buy-in built during “Treating FNDs” and smoothly transition to trauma treatment for further addressing symptoms.
References
Aybek, S., & Perez, D. L. (2022). Diagnosis and management of functional neurological disorder. BMJ (Clinical research ed.), 376, o64. https://doi.org/10.1136/bmj.o64
Beck, J. S. (2011). Cognitive behavior therapy: Basics and beyond (2nd ed.). The Guilford Press.
Espay, A. J., Aybek, S., Carson, A., Edwards, M. J., Goldstein, L. H., Hallett, M., LaFaver, K, LaFrance J, W. C., Lang, A. E., Nicholson, T., Nielsen, G., Reuber, M., Voon, V., Stone, J., & Morgante, F. (2018). Current concepts in diagnosis and treatment of functional neurological disorders. JAMA Neurology, 75(9), 1132-1141. doi:10.1001/jamaneurol.2018.1264
Gutkin, M., McLean, L., Brown, R., & Kanaan, R. A. (2021). Systematic review of psychotherapy for adults with functional neurological disorder. Journal of Neurology, Neurosurgery & Psychiatry, 92(1), 36-44. http://dx.doi.org/10.1136/jnnp-2019-321926
Hallett, M., Aybek, S., Dworetzky, B. A., McWhirter, L., Staab, J. P., & Stone, J. (2022). Functional neurological disorder: new subtypes and shared mechanisms. The Lancet Neurology, 21(6), 537-550. doi:10.1016/S1474-4422(21)00422-1
LaFrance Jr, W. C., & Bjønæs, H. (2010). Designing treatment plans based on etiology of psychogenic nonepileptic seizures. In S. C. Schachter & W. C. LaFrance Jr. (Eds.), Gates and Rowan’s Nonepileptic Seizures, (pp. 271, 3rd ed.). Cambridge University Press.
LaFrance Jr, W. C., & Wincze, J. P. (2015). Treating nonepileptic seizures: Therapist guide. Oxford University Press. https://doi.org/10.1093/med:psych/9780199307173.001.0001
Lethem, J., Slade, P. D., Troup, J. D. G., & Bentley, G. (1983). Outline of a fear-avoidance model of exaggerated pain perception—I. Behaviour Research and Therapy, 21(4), 401-408. https://doi.org/10.1016/0005-7967(83)90009-8
O’Mahony, B., Nielsen, G., Baxendale, S., Edwards, M. J., & Yogarajah, M. (2023). Economic cost of functional neurologic disorders: A systematic review. Neurology, 101(2), e202-e214. https://doi.org/10.1212/WNL.0000000000207388
Carle-Toulemond, G., Goutte, J., Do-Quan-Cantagrel, N., Mouchabac, S. Joly, C., & Garcin, B. (2023). Overall comorbidities in functional neurological disorder: A narrative review. L’Encephale. 49(4), S24-S32. https://doi.org/10.1016/j.encep.2023.06.004
Schachter, S., & Singer, J. (1962). Cognitive, social, and physiological determinants of emotional state. Psychological Review, 69(5), 379–399. https://doi.org/10.1037/h0046234
Varley, D., Sweetman, J., Brabyn, S., Lagos, D., & van der Feltz-Cornelis, C. (2023). The clinical management of functional neurological disorder: A scoping review of the literature. Journal of Psychosomatic Research, 165, 111121. https://doi.org/10.1016/j.jpsychores.2022.111121
Meredith A. Pollock, PsyD
Correspondence: mpollockpsyd@gmail.com
Jennifer A. Mathis, PhD, ABPP
Board Certified in Clinical Neuropsychology
