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REVIEW
Towards an Outpatient Model of Care for Motor
Functional Neurological Disorders:
A Neuropsychiatric Perspective
This article was published in the following Dove Press journal:
Neuropsychiatric Disease and Treatment
Aneeta Saxena
1,2
Ellen Godena
1
Julie Maggio
1,3
David L Perez
1,4
1
Functional Neurological Disorder
Clinical and Research Program, Cognitive
Behavioral Neurology Unit, Department
of Neurology, Massachusetts General
Hospital, Harvard Medical School,
Boston, MA, USA;
2
Epilepsy Division,
Department of Neurology, Boston
Medical Center, Boston University School
of Medicine, Boston, MA, USA;
3
Department of Physical Therapy,
Massachusetts General Hospital, Boston,
MA, USA;
4
Division of Neuropsychiatry,
Massachusetts General Hospital, Harvard
Medical School, Boston, MA, USA
Abstract: Functional neurological disorder (FND), a condition at the intersection of neurol-
ogy and psychiatry, is a common and disabling outpatient referral to neurology and neurop-
sychiatry clinics. In this perspective article, we focus on the motor spectrum of FND
(mFND), including individuals with functional movement disorders (FND-movt), functional
limb weakness/paresis (FND-par) and functional [psychogenic non-epileptic/dissociative]
seizures (FND-seiz). Over the past several decades, there have been dedicated efforts within
the neurologic and psychiatric communities to create “rule-in” diagnostic criteria, as well as
thoughtful approaches to the clinical interview, delivery of the diagnosis and the develop-
ment of a patient-centered treatment plan. These advances allow the promotion of good
clinical practices in the outpatient assessment and management of mFND. Informed by the
literature and our prior clinical experiences, we provide suggestions on how to evaluate
individuals with suspected functional motor symptoms - including conducting sensitive
psychiatric and psychosocial screenings. Additional sections discuss common “rule-in”
neurological examination and semiologic signs of motor FND, as well as approaches to
deliver the diagnosis and formulate a treatment plan based on individual patient needs. To aid
the development of shared (partially overlapping) expertise that catalyzes an interdisciplinary
approach to mFND, the use of physiotherapy for therapeutic motor retraining and cognitive
behavioral therapy to examine relationships between symptoms, thoughts, behaviors and
emotions are also discussed. Additional clinical research is needed to further rene and
operationalize the assessment and management of mFND, across clinics, healthcare settings
and countries.
Keywords: functional movement disorder, dissociative seizures, conversion disorder,
psychogenic, treatment, neuropsychiatry
Introduction
Functional Neurological Disorder (FND), a condition at the intersection of neurol-
ogy and psychiatry, is common in outpatient neurology and neuropsychiatry
clinics.
1,2
With the changes made in the Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (DSM-5), positive examination signs and semiolo-
gical features enabled a “rule-in” FND diagnosis.
3
This article focuses on the
spectrum of motor FND (mFND), including functional movement disorders (FND-
movt), functional limb weakness/paresis (FND-par) and functional [psychogenic
non-epileptic/dissociative] seizures (FND-seiz).
4
A transdiagnostic approach across
functional motor disorders is supported by observations that many patients present
Correspondence: Aneeta Saxena
Massachusetts General Hospital,
Department of Neurology, 55 Fruit
Street, Boston, MA 02114, USA
Email asaxena7@mgh.harvard.edu
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with mixed symptoms or exhibit one symptom complex
initially and subsequently develop distinct symptoms dur-
ing their illness.
5,6
Patients can also experience disabling
pain, fatigue, and cognitive clouding, along with psychia-
tric comorbidities and psychosocial difculties that war-
rant consideration when developing a patient-centered
treatment plan.
7–10
For patients with FND-seiz, increased
diagnostic certainty can be obtained using video-
electroencephalography (EEG),
11,12
while challenging
FND-movt cases can potentially benet from adjunctive
electromyography (EMG) to aid detection of functional
motor features.
13,14
In parallel with a more uniform diag-
nostic approach is the emergence of evidence-based treat-
ments spanning motor rehabilitation and psychotherapy.
15–
18
These advances set the stage for the dissemination of
good clinical practices in the outpatient assessment and
management of mFND.
Our goal in this article is to provide a practical guide
for the neuropsychiatric approach to the outpatient
assessment and management of mFND.
12,14,19,20
We
have previously detailed our viewpoint on assessment
and management strategies in the acute hospital and
emergency department settings.
21,22
Here, we provide
a framework for the initial assessment and management
of mFND modeled in part after the example of the
Massachusetts General Hospital FND Clinic.
6,23–26
Using the approach detailed below, Glass et al pre-
viously reported in 81 consecutive patients with at
least one follow-up that 42% noted some degree of
clinical improvement at 7 months.
23
While emphasis
on neurological examination and semiological features
aids the neurologist’s role in diagnosis, a comprehensive
assessment guiding the development of a patient-
centered treatment plan benets from interdisciplinary
neurologic, psychiatric, allied mental health and rehabi-
litation perspectives.
14
Sections of this article outline the
neuropsychiatric history, physical examination, delivery
of the diagnosis, treatment planning, physical rehabilita-
tion, and psychological treatments. Lastly, we discuss
the physician’s role in longitudinal follow-up.
27,28
While recent publications have suggested that specia-
lized FND clinics should be integrated within neurology
departments to aid patient care (a sentiment we
support),
29
high prevalence rates suggest that both spe-
cialized tertiary care centers and community-based care
will be needed to meet the needs of this prevalent
patient population. As such, clinicians across the clinical
neurosciences should develop prociency in the
outpatient assessment and management of mFND.
30
The approach put further below is one example of
good outpatient practices, however, as research expands
optimal approaches will be further rened.
Framing the Encounter
It is rst important to operationalize the context for the
outpatient clinical encounter. The approach put forth here
is for patients that are referred by another physician
(typically a neurologist or other physician who has per-
formed an initial neurological evaluation) for a suspected
diagnosis of mFND. Thus, there is already an index of
suspicion for functional neurological symptoms. Within
this context, goals of the initial assessment would include
diagnostic conrmation, as well as performing
a neuropsychiatric interview (psychiatric and psychoso-
cial screenings) to inform discussions regarding delivery
of the diagnosis and treatment planning. Given that eval-
uating mFND patients can take more time than other
neurological consultations, consideration should be
given to setting aside at least 1 hour if possible. In our
clinical program, we aim for a 90-minute initial visit.
Given a variety of different time constraints (e.g., clinic
workows, healthcare policy, an FND-seiz event ect) it
may not be possible to complete the initial assessment in
one visit. As such, relevant information can be gathered
over a series of visits. Additionally, reviewing available
medical records beforehand can aid time efciency.
Lastly, our perspective cultivates an element of shared
(partially overlapping) expertise across neurology, psy-
chiatry and allied rehabilitation disciplines.
31
For
a suspected mFND referral, neurologists working at this
interface should develop increased prociency in psy-
chiatric and psychosocial screenings, while psychiatrists
should have increased neurological training to accurately
elicit neurological “rule-in” signs guiding an mFND
diagnosis.
Neuropsychiatric Interview
The interview of individuals suspected of mFND aids the
diagnostic assessment and can be therapeutic. The clinical
interview is an opportunity to understand the complexity and
natural history of the symptom complex, the patient’s illness
perception, and a range of other medical, neurologic, psychia-
tric, and psychosocial factors that inform treatment
planning.
12,14
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Chief Complaint and Other Physical
Symptoms
Unpacking the chief complaint starts with evaluating the
sensorimotor symptoms of concern: 1) timing and acuity
of events (e.g., sudden onset vs insidious onset); 2) debil-
itating at onset or slowly progressive; 3) evolution of
symptoms over time (e.g., spontaneous resolutions); 4)
range of symptoms experienced; and 5) chronic or
paroxysmal.
14
While the history is non-specic for
mFND, clues can include maximal severity in a short
time window and the presence of spontaneous
resolutions.
14
For those with paroxysmal symptoms,
inquiring about prodromal or warning symptoms (includ-
ing physiological panic without the accompanying nega-
tive affect (panic without panic)) will provide useful
information that may increase patient’s awareness of
such instances.
32
In our experience, warning or build-up
type symptoms are infrequently endorsed spontaneously
unless a specic inquiry is made. Similarly, asking about
triggers can also be helpful. There is increasing awareness
that physical injury (e.g., traumatic brain injury, peripheral
limb injury), in addition to emotionally-valenced events,
can be associated with mFND.
33,34
Inquiring about trig-
gers should not be limited to symptom onset, as patients
will commonly report that sensory experiences (bright
lights, loud sounds) may trigger or amplify symptoms
chronically.
35
The presentation of mixed symptoms is
common, underscoring that while the patient may primar-
ily report one neurological symptom (e.g., seizures) asking
about the range of possible neurological symptoms
(including cognitive symptoms) is important.
10,36,37
This
can also prevent questions about unaddressed symptoms at
the end of the visit.
19,20
Lastly, the clinician should also
listen for symptoms that potentially raise concern for other
neurological/medical conditions, particularly given that
neurological comorbidities are common in patients with
mFND. For example, 20% of patients with FND-seiz also
have concurrent epileptic seizures
38
and a subset of
patient’s with Parkinson disease also exhibit mFND
features.
39
Lastly it is important to consider how the
patient understands their symptoms. Illness beliefs such
as thoughts that symptoms will be permanent can be poor
predictors of outcome.
40
Other symptoms such as pain, fatigue, insomnia, bowel
and/or bladder difculties should also be screened for.
Asking about functional somatic diagnoses (e.g., bro-
myalgia, irritable bowel syndrome, ect) can be another
way of contextualizing bodily concerns. Understanding
patients medical and surgical histories, experiences with
healthcare professionals, medication use, allergies and
family history across medical/neurological/psychiatric
diagnoses is also helpful. For example, a greater number
of medication allergies/intolerances is more common in
mFND than other neurological populations and may be
a marker of somatic hypervigilance.
6,41
Once the clinician
feels that there is an initial good understanding of the
patient’s physical symptoms, they can transition to per-
forming psychiatric and psychosocial screenings. Focused
psychiatric and psychosocial screenings should be per-
formed early in the interview (prior to the physical exam-
ination) to avoid explicit connection to the delivery of the
diagnosis, which can prove invalidating and negatively
impact acceptance of the diagnosis.
42
Psychiatric Screening
High rates of psychiatric comorbidities (categorically and
dimensionally) are present in patients with mFND.
8,12,14,43–45
Assuming sufcient time to ask sensitively, the psychiatric
screen should include assessing current and past depression,
anxiety, trauma-related symptoms, self-injurious behaviors,
suicidality, past psychiatric hospitalizations, and prior mental
health treatment including psychotherapy such as cognitive
behavior therapy (CBT). It can be helpful to explicitly state:
“Let’s shift topics and talk about the emotional side of things.
Would that be okay?”. If the interviewer senses resistance or
concern from the patient you can reassure them by noting
“These are questions that we ask all patients that come through
our clinic and these questions may or may not be relevant to
you”. Within the context of inquiring about depression epi-
sodes (or chronic low-grade depression suggestive of dysthy-
mia), it is important to ask about dysphoric (negative) mood as
well as diminished pleasure in activities (anhedonia).
Similarly, the spectrum of anxiety and trauma-related disor-
ders should be assessed. This can be introduced by asking the
patient if they “are a worrier” or “struggle with worries”.
Exploring multi-content fears (including health anxiety) can
aid understanding if the patient has a generalized anxiety
disorder or an illness anxiety disorder.
46
Asking about panic
attacks should include whether events are triggered or untrig-
gered and the presence of agoraphobia. As noted above,
paroxysmal mFND features may overlap with some panic
attack symptoms. Inquiring sensitively about traumatic experi-
ences (including childhood maltreatment, as well as adverse
experiences as an adult) can facilitate an inquiry into lifetime
PTSD symptoms related to hypervigilance, intrusive traumatic
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recollections, nightmares, and dissociation.
47
It can be helpful
to tell the patient that “We do not need to unpackage the events
in any great detail” to aid sensitive discussions. While high
rates of lifetime PTSD symptoms are described in mFND,
many will not have active PTSD at the time of the assessment
but residual hypervigilance or avoidance tendencies may be
present.
44
Asking about estrangement or disconnection from
one’s body or surroundings can also evaluate dissociation.
48,49
Completing the psychiatric screen with open ended questions
regarding “How do you deal with life stress” and inquiring
about interpersonal relationships can also prove useful. Some
patients may have difculty answering questions about mood
or anxiety, even asking the interviewer “I’m not sure what you
mean by depression”. These may be clues suggesting alex-
ithymia (having difculty putting emotions into words).
50
When considering psychopathological traits, be mindful to
listen for obsessive-compulsive or neurotic tendencies.
50
Lastly, briey inquiring about eating disorders, mania/hypo-
mania, obsessions/compulsions and psychotic spectrum illness
help complete the interview. While it is rare for patients with
psychosis to have mFND, some with psychotic spectrum
disorders can be somatically preoccupied and this is important
to consider on the differential diagnosis. We have encountered
several young adults in the prodromal or early stages of
psychotic spectrum illness referred to the FND clinic that did
not meet criteria for FND but had signicant bodily (somatic)
concerns.
Psychosocial Screen
Psychosocial factors are important predisposing vulner-
abilities, acute precipitants and/or perpetuating factors for
mFND within the biopsychosocial model (See Table 1).
21
The clinician should decide based on the natural ow of
the encounter whether it makes more sense to rst conduct
the psychiatric screen or if it may be more benecial to
begin with the psychosocial history. We have found that
asking “What was life like for you growing up” as
a helpful way to begin this conversation. This can facilitate
a discussion about early home life and relationships with
family members. For some this can also be a natural
transition to discussing early-life adversity.
51
Education
and work histories are important, including whether the
patient is on or applying for disability and if there are any
nancial or legal concerns. Asking about interpersonal
relationships can also provide rich content, including any
marital difculties or other family tensions.
52
Cultural and
religious factors may also be relevant, including an over-
lap between paroxysmal mFND and “ataque de nervios”
described in some Latin American cultures.
53
Alcohol and
illicit drug misuse histories should also be screened for
either during the psychosocial or psychiatric screen.
Lastly, it is helpful to ask about how an individual spends
their weekdays as well as inquiring about hobbies and
social supports.
54,55
“Rule-in” Examination Signs
“Rule-in” neurological examination signs and semiologi-
cal features have been detailed in several authoritative
reviews, with high yield features outlined in Table 2.
56–61
Signs specic for functional limb weakness include
Hoover’s sign, hip abductor sign, collapsing/giveway
weakness and motor inconsistency among other signs.
58
When collapsing/giveway weakness is appreciated on
confrontation testing, asking about pain is important as
“pain limited weakness” should not be confused for func-
tional limb weakness. Hyperactivation of the platysma
with jaw deviation is a sign of functional facial
weakness.
62
For the range of FND-movt, familiarity
with the typical movement disorder presentations aids
diagnosis by noting features that are inconsistent and
incongruent with other movement disorders.
56
For func-
tional tremor, variability and distractibility are hallmark
features, with motor and cognitive tasks commonly used
for distraction. Tremor entrainment (the hijacking of the
functional tremor rhythm by volitional movements per-
formed elsewhere in the body) is another specic sign for
FND-movt. Functional gait disorders can present with
a range of features, including non-economical compensa-
tory movements (astasia-abasia), dragging monoplegic
gait, fear of falling gait, and sudden knee buckling
among other presentations.
60
Appreciating motor incon-
sistency in these various presentations aids diagnosis
(e.g., walking normally to go to the bathroom and yet
exhibiting a markedly impaired gait with non-economical
compensatory movements when attention is drawn to the
patient’s gait during examination); the chair test (maneu-
vering a rolling chair well from a seated position out of
proportion to apparent gait difculties) is another specic
functional motor sign.
63
Excellent teaching videos
demonstrating a range of functional motor signs have
been published and are high yield educational
resources.
60,64–66
When features suggestive of mFND
are appreciated, it can be helpful to show these to the
patient; the examiner can also refer back to these signs
during delivery of the diagnosis (see below).
67
Caution
should be taken to not mistakenly jump to conclusions in
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labeling bizarre never previously seen neurological pre-
sentations for functional, as well as confusing the dif-
cult to examine patient because of behavior/affect for
a mFND presentation.
68
Marginally positive functional
signs should also be interpreted with caution.
For FND-seiz, semiological features differentiating
functional vs epileptic seizures include tight eye closure
at event onset, ictal crying, asynchronous side to side head
or body movements, lack of post-ictal period and long
duration events among others.
59,69
Notably, urinary incon-
tinence and tongue biting are nonspecic, although tip of
the tongue biting events may be more suggestive of FND-
seiz while lateral tongue lacerations are consistent with
epileptic generalized tonic clonic seizures.
70
While the diagnosis of FND-movt and FND-par are made
by physical examination, review of semiological features can
be complemented by capturing a typical event(s) on video-
EEG to make a diagnosis of “documented” FND-seiz.
11
Notably, electromyography can aid the diagnosis of some
FND-movt presentations (e.g., identication of variable and
increased latencies in functional myoclonus; electrophysio-
logical evidence of tremor pause with contralateral
movements).
13,14
However, these procedures are limited by
their availability, as for example these tests are not currently
Table 1 The Biopsychosocial Model: Predisposing, Precipitating and Perpetuating Factors for the Development and Maintenance of
Motor Functional Neurological Disorders
Biological Psychological Psychosocial
Predisposing
Vulnerabilities
●Sex – female (except for military/veteran cohorts)
●Intellectual disability
●Comorbid neurological conditions
●Other nervous system vulnerabilities
●Co-morbid functional somatic disorders (i.e.,
bromyalgia, irritable bowel syndrome, other
chronic pain disorders)
●Sensory processing difculties
●Mood and anxiety disorders, PTSD, per-
sonality disorders
●Dissociation
●Alexithymia
●Insecure attachment
●Temperament and maladaptive person-
ality traits (i.e., obsessive-compulsive,
neuroticism)
●Family functioning
●Chronic illness in family
●Traumatic death in
family
●Adverse life experiences
●Financial status
●Inadequate social
support
Precipitating
Factors
●Abnormal physiological event(s), such as sleep
deprivation, hyperventilation, palpitations
●Acute physical pain
●Peripheral limb injury or head trauma
●Dizziness caused by vestibular event
●Surgical intervention
●Emotional reactions to physical injury
or other life events
●Acute dissociative event
●Panic attack (including dizziness as part
of panic)
●Loss of employment or
other occupational
difculty
●Divorce or marital
strain
●Traumatic death of
loved one
●Other relational stress
Perpetuating
Factors
●Physiological arousal
●Chronic pain
●Chronic fatigue
●Abnormal motor habit formation
●Deconditioning
●Other medical/neurological comorbidities limiting
treatment participation
●Negative expectation bias
●Negative attentional bias
●Illness beliefs including perception of
symptom irreversibility or attribution
to another cause
●Fear of falling
●“No pain no gain” philosophy to healing
●Avoidance of symptom exacerbation
●Hypervigilance and dissociation
●Identity linked to rigid concepts around
self-control, productivity, self-efcacy
●Provider diagnostic
uncertainty
●Social benets of being
ill (often out of
awareness)
●Pending litigation
●Workmen’s compensa-
tion/disability
●Poor care coordination
●Poor family buy in/sup-
port of diagnosis and
treatment plan
●Employer or patient
urgency to return to
work
Notes: The above list is not exhaustive but rather is representative of the commonly encountered factors that are relevant to consider in developing a patient-oriented
biopsychosocial formulation. A given factor may also cut across categories; for example, alexithymia can be both a predisposing vulnerability and a perpetuating factor.
Adapted from Psychosomatics. 59(4). McKee K, Glass S, Adams C, et al. The inpatient assessment and management of motor functional neurological disorders: an
interdisciplinary perspective. 358–368, copyright (2018), with permission from Elsevier.
21
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2123
available in our center. Lastly, while clinical neuroimaging is
not useful to “rule-in” an mFND diagnosis, FND can co-exist
with other neurological conditions; clinicians should have
a low threshold to acquire scans as otherwise appropriate. It
can also be helpful to discuss with patients prior to ordering
neuroimaging tests the potential identication of incidental
or nonspecic ndings that may not relate to their mFND
symptom complex, such as the identication of non-specic
T2 hyperintensities in patients with migraine headaches.
71
Additionally, for prominent physical comorbidities (e.g.,
pain, fatigue), these symptoms should be appropriately
(though not necessarily exhaustively) worked up to ensure
that there is not a readily identiable cause (e.g., obstructive
sleep apnea).
Table 2 Examples of “Rule-in” Neurological Examination Signs and Semiological Features Guiding the Diagnosis of Motor Functional
Neurological Disorders
Functional Neurological Sign Description
Functional Limb and Face Weakness
Hoover’s Sign Patient seated; place hand under paretic thigh and ask patient to push down — he/she cannot;
now ask patient to ex contralateral/normal leg up against resistance; test is positive if there is
now strong downward pressure in paretic leg. May also be performed in supine position.
Hip Abductor Sign In a seated position, ask patient to abduct weak leg verifying apparent weakness. Thereafter, test
bilateral hip abduction strength and if there is now good bilateral hip abduction strength, the test
is positive.
Collapsing/Give-way Weakness Full strength briey evident on exam, but limb collapses from normal position thereafter; strength
suddenly gives way to collapse during testing. Caution in interpreting this sign in the presence of
pain (which may be more suggestive of pain-limited weakness).
Motor Inconsistency Motor performance of a muscle or muscle group varies between two tests (e.g., unable to ex leg
on confrontation testing but readily able to left leg when putting themselves in bed or putting on
their shoes).
Hemifacial Overactivity Jaw deviation, platysma hyperactivation and/or orbicularis oculi contraction; supercially
resembles an upper motor neuron pattern for facial weakness.
Functional Movement Disorders
Tremor variability/distractibility Marked variability in frequency, rhythmicity and semiology of movements; improvement, pauses
or complete tremor resolution with distraction (can be a cognitive or motor tasks).
Tremor Entrainment Functional tremor adopts rhythmicity of paced volitional movements performed elsewhere in the
body (can be demonstrated via nger tapping or hand opening/closing).
Sudden Knee buckling Knees buckle with standing or ambulation, rarely leading to falls; sign can also be coupled with
motor inconsistency such as a lack of knee buckling on backward tandem gait.
Non-economical gait (Astasia-abasia) Markedly exaggerated compensatory and uneconomical movements, often with ailing arms or
trunk appearing to be unstable; however, compensatory maneuvers demonstrate signicant
preserved coordination.
Dragging Monoplegic Gait Patient with unilateral leg weakness drags leg behind them like inanimate object, often with
externally rotated foot.
Functional [Psychogenic Nonepileptic /
Dissociative] Seizures
Long duration Duration over 2 minutes. Use with caution, as alternative is status epilepticus.
Fluctuating course Intervening pauses, waxing/waning event tempo.
Specic ictal movements or characteristics Asynchronous or side-to-side movements, pelvic thrusting (can also be seen in frontal lobe
seizures), ictal crying.
Forced eye closure Often against resistance of examiner.
Increased ictal awareness Post-ictal recall of information presented ictally.
Post-ictal features Absence of post-seizure confusion.
Response to external stimuli Bystanders may be able to alleviate or intensify the ictal event.
Notes: Adapted from Psychosomatics. 59(4). McKee K, Glass S, Adams C, et al. The inpatient assessment and management of motor functional neurological disorders: an
interdisciplinary perspective. 358–368, copyright (2018), with permission from Elsevier.
21,69
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Delivering the Diagnosis and Next
Steps
Delivering the diagnosis of FND is the rst step in
treatment.
72
Understanding the diagnosis can in a small
minority lead to symptom resolution,
73
and acceptance of
the diagnosis is important in aiding treatment
engagement.
74
Successful delivery of the diagnosis relies
upon principles of validation, clarity regarding the ratio-
nale for the diagnosis, providing a diagnostic label, refer-
encing a conceptual model (software vs hardware
problem; mind-body overload), providing educational
materials and establishing plans for follow-up
appointments.
42,75
Pictorial illustrations demonstrating
useful approaches to the delivery of the diagnosis and
follow-up discussions have been published and are helpful
educational resources.
28,42
Naming the diagnosis can be perceived as challenging
by the neurologist given concerns of losing the patient’s
trust or harming the therapeutic alliance.
75,76
Similar to the
delivery of the diagnosis in other neurologic conditions,
rather than leading with discussion of normal test results
and comments regarding conditions that are not present,
the clinician can simply state “Based on your history and
exam (including those signs that I showed you earlier),
you have a Functional Neurological Disorder”. The speci-
c type of FND can also be introduced such as
a functional gait disorder or FND-seiz. Asking if the
patient has ever heard of this condition can be a natural
segue into providing educational materials on websites
such as www.neurosymptoms.org or www.fndhope.org.
In our program, we try to give patients a brief
2–3 minute “walk through” of www.neurosymptoms.org
as well as printed educational materials for the patient to
go home with. We emphasize that the patient learning
about FND and being curious about the diagnosis is an
important early treatment step. It is also important to
involve family members and other care providers to ensure
that they understand the rationale behind the diagnosis and
have an opportunity themselves to ask questions and raise
any concerns.
Validating the patient’s symptoms occurs by explain-
ing that FND is common, real and brain-based disorder,
and that the condition can be diagnosed by neurological
signs. A provider believing the disorder is brain-based (at
the intersection of neurology and psychiatry) and avoiding
subconscious biases that FND is “all psychological” are
important.
77–79
Unless the patient is already making the
connections explicitly for themselves, avoid creating
a direct relationship between “stress” and the diagnosis
of FND at the initial visit; connections between acute and
chronic stress have indirect (yet important) relationships
with FND that are nuanced.
51
It can also be helpful to
focus initially on “what” the diagnosis is based on exam-
ination and that the “why” is individualized and can be
explored through physical rehabilitation and psychologi-
cal treatments. In addition to framing the disorder as
a form of “mind-body overload” which is an approach
used in our clinic, other helpful and widely used
approaches include the software vs. hardware analogy
developed astutely by Stone and Carson.
19,20
Lastly, for
patients that have received a different diagnosis for their
motor symptoms, we encourage relying on the rule-in
physical examination signs and semiological features to
provide a non-judgmental opinion regarding the provi-
der’s rationale for why the patient’s symptom complex is
consistent with the mFND phenotype. Encouraging the
patient to learn more about the spectrum of mFND
through information available on www.neurosymptoms.
org can also be a useful aid in these challenging
discussions.
Once the diagnosis has been discussed (taking about
5–7 minutes), it is important to not continue to “talk at the
patient”, pausing to allow the patient to ask questions. For
patients who may look skeptical but are not asking ques-
tions, it can be helpful to encourage them to express any
concerns that they may have about the opinion provided. It
is at this juncture where the physician can reect on the
patient’s level of diagnostic acceptance and readiness to
discuss treatments. If the patient is expressing signicant
doubts, the recommendation may be for the patient to
explore printed and online materials and to return in fol-
low-up to continue the discussion and explore possible
treatment options at a later date. For a small minority of
patients, despite multiple follow-up visits and provider
discussions, some patients may continue to reject the diag-
nosis of mFND or request a continued (or repeat) medical/
neurological evaluation despite adequate workup and dis-
cussion of the diagnosis. In those limited cases, providers
can be encouraged to express nonjudgmentally the ratio-
nale for their diagnostic impressions (based on rule-in
signs), while also noting the patient is free to agree or
disagree. Such individuals can be offered a second opinion
(preferably with a clinician who has broad neurological
expertise including being up-to-date in the diagnostic
approach to mFND), with comments that the patient is
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2125
welcomed back in the future if they would like to revisit
mFND specic care. Despite the above important quali-
ers, many patients are receptive to the diagnosis, with the
conversation subsequently transitioning to discussing
treatment options.
There is growing evidence for two primary treatments:
motor retraining through physiotherapy (for FND-movt
and FND-par) and skills-based psychotherapy (generally
performed by a psychiatrist, psychologist or social worker-
psychotherapist), particularly CBT.
15–18
Based on indivi-
dual patient needs, we generally recommend CBT for most
patients that are interested in such treatment and motor
retraining based on the specics of the symptom complex.
Below are descriptions of motor retraining and psy-
chotherapy that will aid the development of shared exper-
tise across providers from different backgrounds. This is
important because the coordinating physician (typically
the neurologist or neuropsychiatrist making the diagnosis)
needs to be able to answer questions such as “How will
psychotherapy help me walk better?” or questions regard-
ing a physiotherapy referral when they have “already done
physiotherapy and it did not help.” While beyond the
scope of this article, occupational therapy and speech and
language therapy are also emerging rst-line treatments
discussed elsewhere.
80–83
Physiotherapy
A 2013 systematic review identied 29 studies performed
between 1970 and 2013 that looked at physiotherapy for
mFND and overall found a > 50% success rates.
84
Since
then, there have been additional studies supporting a role
for specialized physiotherapy,
85
and consensus recommen-
dations by Nielsen et al guiding physiotherapy treatment
were published in 2015 (including a long version with
guidance on specic physiotherapy interventions for the
various FND-par and FND-movt phenotypes).
15
There is
currently a large multicenter randomized controlled trial
underway in the United Kingdom.
86
Physiotherapy for mFND focuses on education, demon-
stration that normal movement can occur, changing unhelp-
ful behaviors, and retraining normal movements through
diverted attention.
7
Understanding the mechanisms behind
mFND helps guide rehabilitation, and physical therapists
should be aware that functional motor symptoms often wor-
sen when attention is directed toward them and improve with
distraction.
87
This provides the rationale for setting up phy-
siotherapy to maximize the role of distractors or other stra-
tegies that direct attention away from symptoms and towards
goal-oriented tasks.
24
Goal setting should be done collabora-
tively between patient and therapist from the beginning to set
realistic expectations and involve the patient as an active
participant in the care plan. In addition, the biopsychosocial
formulation can help to identify reasons why a patient may
not be making progress in treatment.
15
Core Physiotherapy Elements
Education
Education should be utilized throughout treatment. Early on
this includes discussing the patient’s diagnosis with them
and ensuring good understanding.
15
Education also includes
explaining that physiotherapy is working to maximize times
of typical movement patterns in order to minimize the
learned behaviors of their atypical movements.
Role of Attention
Rather than emphasizing isolated motor exercises (i.e.,
activating muscles in lower extremity during sit to
stand), physiotherapy for mFND should emphasize the
task as a whole while utilizing a distraction. For example,
a sit to stand while tossing a ball to the therapist brings
attention away from the affected limb(s) and towards the
dual task of tossing the ball. On a simpler level, this may
include having the patient shift focus to a non-involved
limb or asking them to use a cognitive challenge such as
counting backwards by 3’s. Some patients nd a sensory
distractor helpful, such as placing a stimulating object in
their hand during gait practice. Patients should actively
participate in selecting optimal strategies and the role for
distraction should be explained.
Home Exercise
Practice of techniques learned during physiotherapy ses-
sions are essential for patients with mFND, however, it is
often a challenge to create a home exercise program when
the focus is away from impairment-based treatment. We
have found that emphasizing daily practice of strategies to
maximize time spent performing more typical motor beha-
viors are a helpful home task. Movement retraining is
described as a balancing act, with every period of practice
adding to the side aiding typical movement attempts to
override atypical patterns. Additionally, patients are
encouraged to increase participation in the activities that
do not worsen symptoms and to gradually expand their
range of activities.
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Triaging Challenges
Beliefs that movements will worsen symptoms or prove
painful / dangerous can be perpetuating factors.
15
These
beliefs and accompanying avoidance behaviors contribute
to an anticipatory anxiety that can often amplify symptoms
and impede recovery. This can be addressed through var-
ious methods including education and challenging
thoughts through exposure to movement in a safe and
effective way. Often, performing the movement with
supervision and/or using distraction can result in different
movement patterns without negative consequences. As
individuals repeatedly perform the movement successfully
with support from a therapist, they will challenge their
own negative thoughts. This can also be applied to fear
of falling that often impacts patients with a functional gait
disorder. Principles of graded exposure apply here so that
the patient is safely able to challenge expectations about
movement.
88
Other common themes include the idea of
“boom or bust” activity that involves patients doing a large
amount of activity when feeling relatively good and sub-
sequently crashing with increased symptoms for several
days at a time.
89
Pointing this out to the patient (often in
collaboration with their psychotherapist) is essential. Here,
the goal can be to guide the patient in understanding that
often less is more and always pushing through symptoms
does not necessarily equal greater gains. These themes
highlight the close relationship between physical and psy-
chological treatments.
The presence of pain, fatigue, FND-seiz and other
symptoms can also present challenges in physiotherapy.
These symptoms should be addressed early to determine
appropriate next steps. With all of these additional symp-
toms, treatment with another discipline may need to be
prioritized prior to initiating physiotherapy. For example,
the patient with chronic pain whose primary complaint is
pain may benet rst from a multidisciplinary pain
program.
90
Similarly, those with substantial non-motor
bodily symptoms and/or comorbid FND-seiz may benet
from initiating psychotherapy rst. This tiered approach
may optimize engagement as the patient is not over-
whelmed by numerous parallel therapies. For those with
pain/fatigue in physiotherapy, treatment will also need to
be ramped up slowly and include pain science education.
Comorbid FND-seiz pose challenges as they can interrupt
sessions, and it can be helpful for physical therapists to
have some familiarity with FND-seiz and a plan for how to
address events if they occur during treatment sessions. If
the balance between seizure activity and other functional
movement difculties is heavily tipped towards FND-seiz,
that may warrant postponing physiotherapy temporarily.
Many with FND-seiz can participate fully in physiother-
apy as they become more aware of warning signs and are
able to prevent events or work with staff to safely manage
events.
Treatment Setting
Various treatment models and settings have been studied,
however, the optimal frequency and intensity for phy-
siotherapy in mFND has not yet been identied.
24
At our
center, we encourage patients to come in for one hour of
weekly outpatient physiotherapy treatment, establishing
the expectation that the desired minimum frequency is at
least every other week.
24
Some patients with severe motor
symptoms may require inpatient or more intensive out-
patient treatments that are currently being investigated.
91
Psychotherapy
CBT is a widely studied psychotherapy for mFND.
16–18,92–96
It should be noted upfront, however, that considerable more
work is needed to optimize and individualize psychotherapy
approaches in mFND.
93,97
The components of this time-
limited, structured treatment address psychological factors
perpetuating FND symptoms. Elements of the approach
include three main areas—thoughts, emotions and behavior
—that dynamically interact within a patient’s social context
and illness model. CBT interventions target unhelpful traits
that perpetuate symptoms in patients diagnosed with mFND
through the development of new skills. Available CBT treat-
ment manuals for FND include two evidence-based work-
books, Overcoming Functional Neurological Disorder: a 5
Areas Approach (a self-guided manual that we use as a guide
for individual psychotherapy)
89
and Taking Control of Your
Seizures, a workbook for treating FND-seiz.
98
Both manuals
provide patients with an enhanced “toolbox” of skills for
symptom management. In the near future, the CBT manual
based on Goldstein’s fear-avoidance treatment model for
FND-seiz is also expected to become available.
93
Patients with FND may demonstrate unhelpful cogni-
tions, health anxiety and/or xed illness beliefs that can
perpetuate symptoms and contribute to reduced stress
coping.
99
Cognitive restructuring helps identify and chal-
lenge inaccurate core beliefs, negative automatic thoughts
and the resulting emotional states that drive symptoms.
A core component of cognitive restructuring is the use of
the Socratic method,
100
which challenges the tendency to
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experience events negatively while supporting the patient
to identify alternative perspectives. This is achieved in
a stepped fashion beginning with the identication of
problematic categories of thinking (termed cognitive dis-
tortions), including tendencies to catastrophize, view
events through a negative lter, or make extreme state-
ments or rules. Patients learn to question the validity of
negative automatic thoughts and emotions stemming from
these appraisals. Finally, more adaptive perspectives and
strategies are generated to address problems.
Patients with mFND can display tendencies towards
behavioral and emotional avoidance.
26
This can manifest
as a progressive reduction of activity, greater dependency
on others, avoidance of certain emotional states, and/or
social isolation. Patients may also engage in boom-and-
bust patterns of activity or exhibit perfectionistic (and
obsessional) approaches to task completion that can be
self-defeating.
89
Addressing behavioral and emotional
avoidance and other perpetuating patterns through
improved recognition, while increasing self-efcacy are
points of treatment focus. Primary behavioral therapeutic
strategies include use of graded exposure and instruction
in distraction and refocusing techniques. Improving aware-
ness of the mind-body connection assists patients in learn-
ing to observe and then modulate their bodily stress
responses. The use of relaxation techniques to regulate
negative emotions and related arousal (ght or ight)
symptoms is an important component of psychotherapy
for mFND that helps patients detect bodily warning signs
of impending functional neurological episodes. Improved
awareness can be coupled with relaxation exercises (e.g.,
diaphragmatic breathing, progressive muscle relaxation) to
induce the relaxation response.
101
We still do not fully understand the role that CBT plays in
the treatment of mFND, as highlighted by the recent publica-
tion (2020) of the largest randomized controlled trial of CBT
for the treatment of FND-seiz.
93
368 patients recruited from
outpatient neurology clinics were randomized to CBT plus
standardized medical care vs standardized medical care
alone. Although no signicant difference in 4-week seizure
frequency (primary outcome) was observed between treat-
ment arms at 12-months, several secondary outcomes
favored CBT treatment (including longer period of seizure
freedom during the last 6 months of the study and improved
psychosocial functioning and health-related quality of life).
The lack of a statistically signicant difference in the primary
outcome suggests that more work is needed to fully under-
stand the role of CBT in the management of mFND,
including investigating if it may prove more efcacious to
use clinical formulations to guide psychotherapy treatment
modality selection.
97
In our experience, the biopsychosocial formulation can
be helpful in pairing appropriate psychotherapeutic inter-
ventions to patients given the considerable heterogeneity
within patients. For example, some with mFND will have
had prior extensive experience with mental health care,
while others may not have previously seen a mental health
provider. Additionally, we have found that the vast major-
ity of patients are appropriate for an initial skills-based
CBT approach, however, during treatment it may become
clear that other psychotherapeutic tools outside the pre-
scribed manuals may allow the treatment to be more
benecial. The CODES trial therapists themselves cited
the importance of the clinical formulation in orienting the
treatment for an individual patient.
102
Within the therapeutic setting it may become apparent
that an alternative treatment based on clinical formulation
(e.g., ongoing trauma-related symptoms and good insight
into the connection between mFND and PTSD) may be
warranted (See Table 3). Prolonged exposure therapy (PE),
a type of cognitive behavioral therapy rst developed as
a treatment for PTSD, is designed to address avoidance
strategies that arise as defensive reactions around trauma-
related symptoms. The approach utilizes imagined and in-
vivo exposure to trauma material.
103
A 2016 study of PE
in patients with FND-seiz and PTSD by Myers et al
reported cessation of seizures in 13 of 16 patients studied
and a decline in seizure frequency in the other 3 patients
by end of treatment.
104
Others may benet from mind-
fulness-based interventions, with a primary goal of devel-
oping non-judgmental awareness of present moment
experience through acceptance.
105
In a recent study of
a 12-session mindfulness-based therapy developed for
FND-seiz (n=26), 70% endorsed reduction of seizures by
at least 50% by the conclusion of treatment.
106
Dialectical
behavior therapy (DBT) is an evidence-based psychother-
apy that has been shown to be an effective intervention for
affect dysregulation that also incorporate elements of
mindfulness training.
107
DBT is a manualized treatment
consisting of 4 modules: core mindfulness, distress toler-
ance, emotion regulation, and interpersonal effectiveness.
In a 2015 pilot study, 17 patients diagnosed with FND-seiz
completed 20.5 weeks of group DBT treatment.
108
Mean
seizure frequency decreased by 66% and cessation of
seizures were experienced by 35% of the cohort by the
end of treatment. Other psychotherapies have been studied
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including psychodynamic psychotherapy, acceptance and
commitment psychotherapy and group psychotherapy that
are discussed elsewhere.
109–111
Longitudinal Management
Issues not yet addressed here include the management of
psychiatric comorbidities, team structure, longitudinal fol-
low-up, and collaborative approaches between commu-
nity-based clinicians and hospital-based FND clinical
programs. For many patients, we have found that it is
advisable to begin with education and ensure that there is
initial patient engagement in physiotherapy and CBT prior
to exploring potential use of psychotropic medications for
symptom management regarding affective symptoms. The
rationale for this is three-fold: 1) leading with
a medication may help perpetuate an external locus of
control (the physician and the pill are the primary treat-
ments), rather than encouraging the patient to consider
their own equally important role in recovery; 2) some
patients with mFND may be somatically hypervigilant, as
exemplied by associations between medication tolerances
and illness duration.
6
Thus, when psychotropic medica-
tions are introduced, it can be helpful to do so at low
doses and note that an early “air up” of functional neu-
rological symptoms with medication initiation does not
necessarily imply that the medication will not prove help-
ful in the intermediate term. 3) Psychotropic medications
are not directly treating mFND, but rather are addressing
affective disturbances that may be perpetuating functional
neurological symptoms. Additionally, there can be roles
for tapering medications that may not be indicated, such as
anti-epileptic drugs in patients with isolated FND-seiz or
high doses of pain medications with secondary side
effects. It is helpful to engage patients as partners in
these decisions, while also being clear about an inability
to increase medications that are not indicated.
With regards to team structure and longitudinal follow-
up, our general principle is shared (partially overlapping)
expertise across neurology, psychiatry, allied mental health
disciplines and rehabilitation specialties. In our opinion there
is no “one perfect team structure”, but it is clear that neuro-
logical expertise and psychiatric/psychological expertise are
core skills that are needed in the physician lead, which
alternatively can be accomplished by having several mem-
bers across the clinical neurosciences work together to co-
lead the clinical assessment and longitudinal management of
Table 3 Brief Description of the Psychotherapy Treatment Modalities with Emerging Evidence in Motor Functional Neurological
Disorders (mFND)
Psychotherapy Core Components Examples of
Supporting
Evidence
Cognitive Behavioral
Therapy (CBT)
CBT interventions focus on the interaction between thoughts, emotions and behaviors
and how these perpetuate functional neurological symptoms. Components include
education, cognitive restructuring, use of graded exposure, distraction techniques, and
relaxation skills training.
Sharpe et al
16*
LaFrance et al
17*,94
Goldstein et al
92*,93
O’Connell et al
96
Espay et al
18
Prolonged Exposure
Therapy (PE)
PE utilizes imaginal and in vivo exposure methods to address strategies of avoidance and
hyperarousal that arise as defensive reactions around trauma-related symptoms.
Myers et al
104
Dialectical Behavior
Therapy (DBT)
DBT is a manualized psychotherapy developed to treat affective dysregulation in a range of
psychiatric conditions. Treatment consists of 4 modules: core mindfulness, distress
tolerance, emotion regulation, and interpersonal effectiveness.
Bullock et at
108
Mindfulness-Based Therapy
(MBT)
MBT centers around the use of mindfulness techniques with a primary goal of developing
present moment awareness with acceptance.
Baslet et al
106
Acceptance and
Commitment Therapy
(ACT)
ACT is a therapeutic intervention aimed at increasing psychological exibility through the
use of acceptance and mindfulness strategies.
Barrett-Naylor et al
111
Psychodynamic
Interpersonal Therapy
(PIT)
A structured brief treatment based on psychodynamic principles, PIT treatments utilize
the patient-therapist relationship as the change-agent, allowing for an exploration of
unconscious internal processes through a focus on emotions in the present moment.
Kompoliti et al
110
Notes: *Indicates randomized CBT clinical trials that showed efcacy for the treatment of mFND based on primary outcome measures. More research is needed to
optimize psychotherapy treatments in mFND, including investigating the extent to which clinical formulations aid the pairing of patients to specic psychotherapy treatment
modalities.
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mFND. In our opinion, the physician “team” lead should
generally be a psychologically-minded neurologist or
a psychiatrist with additional neurological training (generally
a neuropsychiatrist). We would like to highlight that while
the neurologist or neuropsychiatrist member of the team may
not be performing psychotherapy, follow-up visits are primed
to catalyze psychological insights by helping the patient
make connections between neurological symptoms,
thoughts, behaviors, emotions and life factors.
27,28
When
such connections are uncovered, this can also be a nice
segue into asking the patient to follow-up with their psy-
chotherapist on these themes. To be clear, apart from referrals
to physiotherapy for motor retraining and a psychotherapist
for CBT, a physician lead must remain actively involved in
longitudinal care and collaborating with other members of
the treatment team to ensure consistent and coordinated care.
Collaborations between specialty mFND treatment
programs and community-based clinics are also impor-
tant points to discuss.
30
For the foreseeable future, there
are and will likely continue to be far too few specialized
treatment programs for all patients with mFND to
receive care within the bandwidth of such programs.
29
One approach is to empower community neurologists to
accurately diagnosis FND based on rule-in signs, pro-
vide education using websites such as www.neurosymp
toms.org and rely on the consensus recommendations
for physiotherapy (and occupational therapy) to guide
community-based rehabilitation (the recommendations
can be printed out in the clinic with instructions for
the patient to provide these to their assigned physical
therapist).
15,83
Recommending the self-guided CBT
workbook Overcoming Functional Neurological
Disorder: a 5 Areas Approach could complement
motor retraining,
16
and community-based psychiatric
consultation could be sought for those endorsing promi-
nent affective symptoms. For this approach to prove
feasible, educational efforts to increase awareness and
training in the assessment and management of mFND
need to be exponentially increased across the clinical
neurosciences and rehabilitation specialties. For patients
that are more neuropsychiatrically complex or those that
do not respond to initial treatments, such individuals
could then be referred onto a specialized program.
Additionally, hybrid models are likely a good option as
well (and frequently employed in our clinical program).
In such cases, individuals can continue to receive care
from community neurologists and mental health provi-
ders (aimed at primarily addressing the neurologic and
psychiatric comorbidities that are prevalent in this popu-
lation), while clinicians in the specialty mFND program
focus primarily on the assessment and management of
functional motor symptoms. In this latter approach,
good communication across treatment providers is
important – which can be achieved by having providers
send notes to one another, leveraging integrated electro-
nic medical record systems and intermittent telephone
(or video conference) calls.
Conclusions
In summary, this article details an approach to the out-
patient assessment and management of mFND based on
emerging evidence and our own experience initiating and
growing an interdisciplinary program for patients with
functional motor symptoms. More research is needed to
optimize the clinical approach and treatment pathways for
mFND. Our hope is that this perspective article will help
encourage increased enthusiasm by providers across the
clinical neurosciences and rehabilitation specialties to rise
to the challenge in caring for this prevalent and under-
served neuropsychiatric disorder.
Funding
D.L.P. and J.M. were funded by the Sidney R. Baer
Jr. Foundation. D.L.P. also received funding from the
Massachusetts General Hospital Physician-Scientist Career
Development Award.
Disclosure
D.L.P has received honoraria for continuing medical lec-
tures in functional neurological disorder from Harvard
Medical School. The authors report no other conicts of
interest in this work.
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