Functional neurological disorder: Practical management 2025 Dworetzky & Baslet

Abstract

Functional Neurological Disorder (FND) is a common and disabling condition seen by nearly every clinician in nearly every clinical setting. There are multiple subtypes with seizure and motor/movement being the most common. There is high health care utilization and costs, and many patients have a chronic course and remain disabled. It is clear from research over the past two decades that abnormalities in brain network activity are implicated in the pathophysiology of FND. Diagnosis requires positive criteria and knowing how to obtain a good history and avoid common pitfalls. There are evidence-based treatments and expert consensus recommendations. A multidisciplinary team knowledgeable about the disorder is important for the best outcomes but there is much more work to be done. This review will focus on the practical aspects of diagnosing and managing FND.

Open access

 

"FND is reported commonly after injury such as concussion [17] and frequently co-exist with other complaints including chronic pain, sleep, fatigue, and cognitive complaints [18], all of which are considered risk factors for FND. In children, family adversity and school challenges, including bullying, are more likely among the common predisposing risk factors to developing FND than sexual abuse, which is more common in adults [19–21]. In FND, as in many disorders, incorporating a biopsychosocial model with environmental factors contributing to and perpetuating the disorder is essential."


"A detailed review of symptoms may uncover migraine or other chronic pain disorder, cognitive complaints such as ‘brain fog’, fatigue, and other neurological symptoms commonly experienced by patients with FND that may need to be addressed before treatment which requires active participation to be helpful. Identifying the possibility of a functional cognitive disorder, a common mimic of Alzheimer's Disease, should be considered in those presenting mainly with memory/cognitive decline of abrupt onset, at young age and with shorter duration of symptoms. "


" Table 3 lists elements to be considered when delivering a diagnosis of FND, with a sample script for functional weakness.
...
5) Provide an individualized explanation of the disorder (mechanism and biopsychosocial formulation): “Functional neurological symptoms happen when our brain, for some reason, starts to misread signals from the body and then creates expectation of how a body part may move or feel. Like with all movements, you are not aware of this while it is happening. For example, in your case, after you injured your right knee and started to experience pain, the brain started to read signals from your right leg differently, with more alert than usual. You also told me that a year before you were undergoing problems with your marriage and were experiencing panic attacks, which probably influenced how sensitive your brain became at reading any signal of body discomfort. This may have created a ‘perfect’ storm for your functional leg weakness to develop. Additionally, you told me your sister had fibromyalgia and chronic fatigue syndrome when you were a teenager, and these disorders share some mechanisms with FND, so it is possible that there is some genetic predisposition.”

 

Another manual on more effective gaslighting, written by the abusers.

 

I wonder how many people with a FND diagnosis, like many people with ME/CFS learn to avoid doctors altogether or at least subsequently try to conceal the FND in medical consultations on other matters.

 

and thus, we get a sneak preview of where the FND dx fanclub will go, should any genetic predisposition for ME/CFs show up in Decode or be further elucidated via other studies

 

There is a subset of people who will hear this junk from a physician and think it could be plausible, mainly because it's very generic and, well, it's coming from a professional:

But most people will hear clearly that it's a bunch of bullshit and that apparently physicians have no shame lying to people about serious health problems. From LC forums, the vast majority clearly see through the BS for what it is. It's about as subtle as the same physician trying to get our noses.

Frankly, I think that people avoiding health care afterward is the main goal. Then they can write some fake concern about how health care avoidance for "real medical issues" is unfortunate, but it's the main goal. After all, health care utilization and costs are about the only metric they're interested in. Or the tiny subset of it that they can see happening in front of them anyway, since no one's actually looking at the big picture here, even less so counting the total balance.

 

My thought was even those that initially accept how their doctors define their FND diagnosis, they will after time learn they are not being offered much of practical value and learn to give up on medicine. Also I suspect they will over time become aware that any other condition is treated less seriously because of the prior FND diagnosis.

 

From the people I’ve met, a lot of them will internalise all the self help stuff and throw all the blame on themselves instead of the clinicians.

And when people try to explain to them that FND is a diagnosis made to psychologise etc, they will take that as an “insult” to their illness, and often turn to the likes of Stone and Carson, who paint themselves as “breaking the stigma” on FND.

 

It is hard because I don’t want to imply that people diagnosed with FND do not have an underlying condition that can seriously impact their lives, but I do suspect that in everyday medicine people so diagnosed are subject to same devaluing of their experience as encountered by people with ME/CFS. But is interesting that those identifying with the interpretation of their diagnosis provided by such as Stone and Carson double down on that interpretation when it is challenged.

 

This is what I see a lot of as well.

 

Yeah. The problem seems to be that these people are like us, desperate and searching for meaning for their flailing health. They finally find a neurologist who blabbels about software problems, promises them with hard work it’ll get better. Tells them they have FND.

Now they finally have a label to explain to friends and family who were doubting them. They finally have something to “do” to get better.

People will get really attached to the label as a sort of lifeline. So anything criticising the FND concept will be immediately recieved as an attack on them no matter how you hedge it.

(Obviously not everyone is like that, but that’s been my experience). I’m sure David Tuller could chime in as well he’s had some experience with this.

 

The irony is that this is what the BPS gang accuses us of doing as well.

 

Perhaps there needs to be better finesse in how we differentiate between labels and illnesses. Because in popular conception the label is the illness and so as we’ve seen on this forum, people might get quite offended when others critique the MCAS, hEDS, or even ME label.

 

I don’t know how to go about that. I got quite upset when someone here first told me that POTS is probably bogus. But when they explained that OI is real, it’s just that the POTS label is pretty meaningless, it made sense to me and I’ve since abandoned the POTS label.

But the only reason I understood it was because I was able to see through the studies. Most people don’t have the capacity, interest and/or know-how. I’m just lucky that my education covered a lot of the basics of science.

 

Yeah that’s the thing. That was my experience here at first with MCAS.

And mentioning S4ME in other support forums sometimes has others being like “eww noo that’s the place they don’t believe in [hEDS/POTS/MCAS…]”

 

Maybe Mr T is right to clip Harvard's wings a bit - they seem to be fairly strong on this sort of pseudo-medicine these days.