Functional neurological disorder

Functional neurological disorder is a newer and broader term that includes what some people call conversion disorder, which feature nervous system (neurological) symptoms that can’t be explained by a neurological disease or other medical condition ¹. However, the symptoms are real and cause significant distress or problems functioning.

Functional neurological disorder signs and symptoms vary, depending on the type of functional neurological disorder and may include specific patterns. Typically these disorders affect your movement or your senses, such as the ability to walk, swallow, see or hear. Symptoms can vary in severity and may come and go or be persistent. However, you can’t intentionally produce or control your symptoms.

Functional neurological disorder is characterized by unexplained neurological symptoms, including movement, seizures or sensory symptoms that are unrelated to an underlying neurological or medical disorder ². It has been proposed that excessive negative affect and anxiety can exacerbate a deficient top-down regulatory system, leading to psychogenic or ‘functional’ neurological symptoms ³. There is a relatively high prevalence of these unexplained neurological symptoms in neurology outpatient clinics ⁴.

The exact prevalence of functional neurological disorder is unknown. However, research suggests functional neurological disorder is the second most common reason for a neurological outpatient visit after headache/migraine; accounting for one sixth of diagnoses. This means functional neurological disorder is as common as multiple sclerosis or Parkinson’s disease.

Functional neurological disorder can affect anyone, at any time, although it is uncommon in children under 10. Functional neurological disorder is more likely to affect women than men for most symptoms, although when patients present over the age of 50 then it occurs equally in both groups.

The cause of functional neurological disorders is unknown. The condition may be triggered by a neurological disorder or by a reaction to stress or psychological or physical trauma, but that’s not always the case. Functional neurological disorders are related to how the brain functions, rather than damage to the brain’s structure (such as from a stroke, multiple sclerosis, infection or injury).

Early diagnosis and treatment, especially education about the condition, can help with recovery. Encouraging studies support the potential reversibility of functional neurological disorder with specifically tailored treatments. New scientific findings are influencing how patients are diagnosed and treated which is creating an overall change in attitude towards people with functional neurological disorder.

Functional neurological disorder can be hard to understand and most people haven’t heard of it. Treatment should start with a clear and supportive explanation of the positive clinical features that have allowed the diagnosis to be made, even though scans and other laboratory tests may be normal.

When it goes well, understanding the diagnosis enables the patient to see that they have a genuine and relatively common condition which has the potential for improvement over time. This creates a foundation for treatment to build upon. Written information, like that available at https://fndhope.org or http://neurosymptoms.org may help individuals comprehend this complex and difficult to understand disorder.

Evidence is now emerging for the efficacy of certain treatments, especially physiotherapy for motor symptoms and a type of psychological therapy called cognitive behavioral therapy (CBT) for attacks or seizures. Specialized types of physiotherapy and cognitive behavioral therapy (CBT) have been developed for functional neurological disorder. Other therapies such as speech therapy and occupational therapy may also have a role depending on the symptoms.

Is conversion disorder the same as functional neurological disorder?

Yes and No.

Yes, both are listed as the same illness in the American Psychiatric Association diagnostic manual known as the DSM-5 ⁵ and both are typically used interchangeably with one another.

No, conversion disorder and functional neurological disorder are theoretically different concepts ⁶. Conversion disorder is the theory that symptoms are the result of suppressed psychological trauma converting to physical symptoms. Studies have found many do not have a history of major emotional traumatic events, or major depression/anxiety. Even if a patient does have mental health issues, now or in their past, there is no quantifiable way to confirm a correlation to symptoms. The change in criterion now makes it easier for physicians to use the conversion disorder or functional neurological disorder diagnosis, where in the past they couldn’t when they found their patient did not meet the criterion standard and there was no “converting” of symptoms taking place. Because there is sometimes no identifiable mental health issues, the need to identify one was removed. However, there are some patients who do identify with the conversion disorder theory.

What are the treatment options besides CBT?

Physical therapy or physiotherapy specific to functional neurological disorder has been shown to have the greatest results. Also, patients find grounding techniques and meditation to be helpful. This is sometimes achieved through biofeedback. Biofeedback teaches you how to turn down over excited senses, which may be making symptoms worse.

Is there a window of opportunity for best results?

Yes, the sooner a patient can receive treatment the better. Many patients see improved results in movement soon after receiving proper physical/physiotherapy training. The goal is to retrain the brain, and not let atypical movement become a “habitual”or a relearned way to move.

Should I push through symptoms?

It is recommended that patients get out of the “boom and bust” pattern. The goal should be aimed at becoming balanced. Separating your physical, social, and cognitive activities and then micro balancing the time you spend doing activities in each of the day to day activities is a vital part in improving symptoms.

What if I had an organic illness diagnosed then received an functional neurological disorder diagnosis?

It is not uncommon for patients to have functional symptoms in conjunction with other illness.

Which should be treated if I have both?

Doctors should always err on the side of medical caution. An functional neurological disorder diagnosis should never take precedence over a diagnosed organic illness, and most certainly should not impede treatment for a known illness at any time.

Is functional neurological disorder genetic?

There are not any standard research papers confirming or denying a genetic link. It is likely, that it is genetic for some, but is by no means going to be genetic just because it has in the past or because you now have functional neurological disorder. They know so little about functional symptoms and what they have thought in the past caused functional neurological disorder (suppressed trauma) wouldn’t necessarily be passed down. New researchers are starting to acknowledge a pattern some families are seeing and looking into more genetic links. Please note genetic or not does not lend any weight on whether or not the illness has a psychological component or not –many mental health illnesses are genetic.

How will I know when something is functional neurological disorder and not something else?

Over time you will learn what is normal for your body. Finding a balance is a very common struggle for everyone involved. On the one hand there are those (patients, caregivers and doctors) that suggest everything is functional neurological disorder or conversion disorder and never have issues properly looked at, then there are those that rush to the emergency room with every new or altered symptom. You may consider discussing with those around you when to take you to hospital and what to watch out for. In the end this will have to be your decision, but ‘when in doubt check it out’.

Do I need to be on medication?

This is why you need a specific doctor to coordinate your ongoing care and monitor medications. This could be your primary caregiver working with a neurologist and psychologist. As a team, the goal should be to take the least amount of prescription drugs as possible to relieve symptoms. With every medication comes a list of side effects. If a medication is not helping significantly then discuss discontinuing it. NEVER start or stop a medication without a doctors’ supervision. Many medications are just as harmful coming off as they are starting. Always use caution and check for drug interactions with over-the-counter medicines and natural herbs and supplements. If a new symptom does develop always look into medication to be a possible catalyst.

Why does my doctor insist on sending me to a psychologist when I don’t feel I need one?

This is probably one of the most confusing aspects of this disorder. Some sort of therapy is part of the standard treatment plan regardless of which doctor you see. The key issue is the absence of pathophysiological understanding of this disorder. Your doctor is trying to use the tools available for these types of disorder. Who knows what will work best for you, and it is best to leave no stone unturned. You owe it to yourself to give it a fair shot. The most common treatment that is offered is Cognitive Behavioral Therapy, which some people have found to be helpful. Whether it does improve your physical symptoms or not, CBT may help you find ways to cope with the symptoms and with some of the new challenges you may face. You may be one of the 13% that does benefit. However, do not feel discouraged if you give it your all, but are not cured or see little improvement in your physical symptoms. Your new coping tools can be very helpful.

Can I drive?

You are responsible for what happens when you are behind the wheel. This is something you must discuss with your physician and others in your home. The laws vary in each country and you are responsible to obey the laws of the land where you reside. Be advised that you may be required to report some symptoms, i.e. seizures, to your insurance company. Regardless, it is your responsibility to be honest with yourself if you are well enough to operate a vehicle. The safety of yourself and others should never be compromised.

Functional neurological disorder causes

The exact cause of functional neurological disorders is unknown, although ongoing research is starting to provide suggestions as to how and why it develops. Theories regarding what happens in the brain to result in symptoms are complex and involve multiple mechanisms that may differ, depending on the type of functional neurological disorder.

Basically, parts of the brain that control the functioning of your muscles and senses may be involved, even though no disease or abnormality exists. Neurobiological models suggest that conversion disorder results from changes in higher-order cortical processing. The general, broad hypothesis is that frontal and subcortical areas of the brain may be activated by emotional stress, which then leads to input to inhibitory basal ganglia-thalamocortical circuits when then reduces conscious sensory or motor processing. There is not currently an abundance of studies looking at the neural mechanisms of conversion disorder with large sample sizes. Functional neuroimaging has helped shed some light on these mechanisms and will be a crucial tool in future studies. One study conducted by Spence et al. ⁷ compared three patients with weakness secondary to conversion disorder with both normal controls and controls that researchers asked to feign weakness. The patients were asked to move a joystick while undergoing PET comparison. The patients with conversion disorder demonstrated decreased left dorsolateral prefrontal cortical activity when they attempted to move the affected limb. This study suggests that patients with conversion disorder are distinct from those that are feigning symptoms. The left dorsolateral prefrontal cortex has a role in volition and willed action. Another study conducted by Voon et al. ² looked at the relationship between emotion and symptom production in patients with conversion disorder. Researchers asked the patients to perform an emotional task, and functional MRI showed an abnormal correlation between activation of the amygdala and the supplementary motor area ⁸.

There are two major models or hypotheses for functional neurological disorder ⁹:

• Psychodynamic models. These models suggest that somatic symptoms of conversion disorder are a product of emotional conflict. This emotional conflict becomes repressed into the unconscious mind and converted into a symptom. The postulation is that this scenario is a type of defense mechanism against negative feelings that would be induced by the emotional conflict. Other psychodynamic models focus on the development of inadequate coping mechanisms and negative interpersonal relationships that develop earlier in a patient’s life. Later in life, if the patient encounters another traumatic event, these coping mechanisms or behaviors may recur.
• Cognitive-behavioral models. One well-studied model suggests that exposure to information related to a specific symptom can lead to the creation of representation in memory. Conversion disorder then occurs when this representation is “activated” by an individual worrying excessively about or looking for signs of the symptom. This activation passes a specific threshold in the mind, where it overrides sensory input and becomes an actual symptom. An example would be an individual seeing someone have a seizure in a movie and creating a memory or a representation of this event in their mind. Later, they encounter anxiety, light-headedness, or dizziness, and fear that they may be experiencing symptoms preceding a seizure. They worry about having a seizure, and this activates the representation or memory of a seizure previously created. This activated pathway causes them to have a psychogenic non-epileptic seizure. Cognitive-behavioral models hypothesize that behavioral and perceptual processing occurs automatically and outside of an individual’s awareness. They state that symptoms of conversion disorder may result from psychological influences at lower levels of processing.

Many different predisposing factors can make patients more susceptible to functional neurological disorder such as having another neurological condition, experiencing chronic pain, fatigue or stress. However, some people with functional neurological disorder have none of these risk factors.

Symptoms of functional neurological disorders may appear suddenly after a stressful event, or with emotional or physical trauma. Other triggers may include changes or disruptions in how the brain functions at the structural, cellular or metabolic level. But the trigger for symptoms can’t always be identified.

At the time functional neurological disorder begins, studies have shown that there may be triggering factors like a physical injury, infectious illness, panic attack or migraine which can give someone the first experience of the symptoms. These symptoms normally settle down on their own. However, in functional neurological disorder the symptoms become ‘stuck’ in a ‘pattern’ in the nervous system. That ‘pattern’ is reflected in altered brain functioning. The result is a genuine and disabling problem, which the patient cannot control. The aim of treatment is to ‘retrain the brain’, for example by unlearning abnormal and dysfunctional movement patterns that have developed and relearning normal movement.

One way of thinking about functional neurological disorder is looking at it as a bit like a ‘software’ problem on a computer. The ‘hardware’ is not damaged but there is a problem with the ‘software’ and so the computer doesn’t work doesn’t work properly. Conventional structural MRI brain scans are usually normal in functional neurological disorder unless the person has another neurological condition. Functional’ brain scans (fMRI) are starting to provide early evidence for how the brain goes wrong in functional neurological disorder. fMRI scans show changes in patients with functional neurological disorder which look different from healthy patients without these symptoms as well as healthy people ‘pretending’ to have these symptoms. Functional imaging is still a research tool and is not developed enough to be used in the diagnosis of functional neurological disorder. Scans support what patients and researchers already know – these are genuine disorders in which there is a change in brain functioning, which is out with the control of the person with functional neurological disorder.

Historically, functional neurological disorder has traditionally been viewed as an entirely psychological disorder in which repressed psychological stress or trauma gets ‘converted’ into a physical symptom. This is where the term ‘conversion disorder’ comes from. Psychological disorders and stressful life events, both recent and in childhood, may be risk factors for developing the condition in some patients, but they rarely provide a full explanation for the cause of the condition and are absent in many patients. Patients do not have to be depressed, anxious or the survivor of adverse childhood experience to develop functional neurological disorder.

Modern theories propose that functional neurological disorder has many causes, which vary from patient to patient. One comparison is to think about heart disease. There are lots of causes of heart disease – smoking, genetic factors, diet and even stress-related / psychological factors such as depression. Smoking may be a factor in heart disease in many people, but it is not in everyone. The same analogy can be made for functional neurological disorder. In some psychological factors such as past trauma or stress at the time of symptom onset in functional neurological disorder are important in understanding how the brain has gone wrong. In others the presence of a problem like migraine or a physical injury may be the most important thing.

Risk factors for developing functional neurological disorder

Factors that may increase your risk of functional neurological disorders include:

• Having a neurological disease or disorder, such as epilepsy, migraines or a movement disorder
• Recent significant stress or emotional or physical trauma
• Having a mental health condition, such as a mood or anxiety disorder, dissociative disorder or certain personality disorders
• Having a family member with a functional neurological disorder
• Possibly, having a history of physical or sexual abuse or neglect in childhood

Women may be more likely than men to develop functional neurological disorders.

Related disorders

It is common for functional neurological disorder to co-exist with other illnesses. functional neurological disorder can have similar symptoms to most other types of condition seen in neurological practice such as multiple sclerosis, stroke and epilepsy. Some patients have both a neurological disease diagnosis such as stroke and functional neurological disorder. A neurologist is normally required to assess which symptoms relate to functional neurological disorder and to monitor where required for any new symptoms.

Anxiety and depression can sometimes cause physical symptoms which overlap with functional neurological disorder symptoms. For example, panic attacks can present with symptoms such as pins and needles in the fingers or mouth and depression often causes poor concentration or fatigue. Anxiety and depression are common in patients with functional neurological disorder but many patients do not have such problems.

Chronic pain is also common in patients with functional neurological disorder including fibromyalgia, which is also related to disturbed nervous system functioning. Pain disorders are also usually associated with fatigue, sleep disturbance, and poor concentration. Migraine and chronic headaches are also common.

Other functional disorders including irritable bowel syndrome, or overactive bladder syndrome are more common in patients with functional neurological disorder.

It is important that new symptoms not automatically be considered functional and other causes are considered and investigated as appropriate.

Functional neurological disorder symptoms

Functional neurological disorder patients can experience a wide range and combination of symptoms that are physical, sensory and/or cognitive, depending on the type of functional neurological disorder, and they’re significant enough to cause impairment and warrant medical evaluation. Symptoms can affect body movement and function and the senses.

Signs and symptoms that affect body movement and function may include:

• Functional limb weakness/paralysis. Weakness is a common presenting symptom with conversion disorder. When paralysis occurs, it is usually confined to one half of the patient’s body or a single limb. It does not follow any specific anatomical pattern. When paraplegia occurs, normal deep tendon reflexes will still be present, and the Babinski sign will be absent. The most apparent sign of psychogenic weakness is inconsistency. It is essential that the examiner observes the patient carefully during both examinations and when they engage in other actions, such as entering or leaving the room. Common tests/signs used to identify psychogenic weakness are as follows:
  • Hoover’s sign – This simple test has its basis on the fact that patients extend their hip when our contralateral hip flexes against resistance. This test is useful for patients with functional weakness in the lower extremities; the examiner has the patient lay supine and places one hand under the affected heel and asks the patient to lift their unaffected leg against resistance. Patients with functional weakness will have downward pressure on the affected heel.
  • Co-contraction sign – Co-contraction is the contraction of an antagonist muscle (such as the triceps) when the agonist muscle contracts (such as the biceps). This test is possible in any agonist/antagonist muscle group to detect the absence of true weakness.
  • Arm-drop test – In this test, the examiner holds the patient’s outstretched arm in front of them and then releases it. Jerky or slow descent of the arm onto the patient’s lap is typical of functional weakness.
  • Sternocleidomastoid test – Patients with conversion disorder will often exhibit weakness when asked to rotate their head towards the affected side, whereas patients with organic disease will not.
  • Collapsing weakness – This phenomenon can be elicited by asking a patient to hold one of their limbs in a specific position; the examiner then applies light force to the limb, and it appears to “collapse” suddenly.
• Functional movement disorders: Abnormal movement, such as tremors, spasms (dystonia), jerky movements (myoclonus) and problems walking (gait disorder)
  • Functional tremors are often present at rest and with action. They usually fluctuate in frequency. Organic tremors are present either with rest or action and have a rhythmic consistency. Functional tremors tend to be abrupt in onset (whereas organic tremors are more gradual), often triggered by an emotional or traumatic experience. Upon onset, functional tremors are typical of maximum severity and may start unilaterally. If weights are applied to the affected limb, patients with a functional tremor will generally exhibit an increase in tremor amplitude; patients with organic tremors will show a decrease in tremor amplitude. An examiner can also ask a patient to make a rhythmic movement with their unaffected limb. The unaffected limb tends to take on the frequency/rhythm of the affected limb, or the patient is unable to keep a steady rhythm; this is called entrainment.
  • Gait disorder – Functional gait disorder is characterized by a gait that does not adhere to typical patterns seen in neurologic/organic disorders. Patients with unilateral weakness of one leg tend to drag their leg behind them and to maintain their hip in internal or external rotation, which causes the affected foot to point outwards or inwards. Several other features are commonly seen in functional gait disorder. The first is sudden knee-buckling, with prevention from an actual fall. Another feature is a “walking on ice” pattern, where the patient acts as if they are walking on a slippery surface, with stiff knees and ankles, broad and slow gait, and arms sometimes abducted. Patients with functional gait disorder may also exhibit excessively slow gait initiation and the appearance of their feet sticking to the ground. They may also engage in pseudoataxia, with a very unsteady gait, crossed legs, and/or sudden side-stepping. Examination of these patients will likely reveal uneconomic postures that displace the natural center of gravity.
  • Dystonia – Features seen in functional dystonia include severe pain of the affected limb, adult-onset, fixed posture (present even during sleep), a clenched fist, or an inverted foot. There are often inconsistent movements and multiple somatic complaints associated. Patients with functional dystonia will often have complete remission of symptoms after the placebo, suggestion, or administration of general anesthesia.
  • Myoclonus – Organic myoclonus is characterized by jerking or spastic movements caused by sudden muscle contractions or a decrease in muscle tone. Functional myoclonus will be inconsistent in frequency or amplitude. It may also resolve with placebo treatment or suggestion. Patients with functional myoclonus can be very stimuli sensitive, though unlike a typical response to an abrupt stimulus, they will exhibit a long and variable latency.
• Loss of balance
• Difficulty swallowing or feeling “a lump in the throat”. Patients with swallowing symptoms typically describe the sensation of a lump or tightness in their throats, which is referred to as globus sensation or globus pharyngeus. This functional esophageal disorder has no apparent physiologic cause, including no underlying structural abnormality, gastroesophageal reflux disease, or motility disorder. It is also seen in patients without conversion disorder, though these patients often have a comorbid psychiatric condition. Other features of globus pharyngeus include occurrence in between meals, and the absence of odynophagia or dysphagia.
• Psychogenic nonepileptic seizures or episodes of shaking and apparent loss of consciousness (nonepileptic seizures)
  • This is the most common subtype of conversion disorder. Psychogenic nonepileptic seizures characteristically demonstrate features such as generalized limb shaking, hip thrusting, and lack of postictal confusion. They may be longer in duration than an actual seizure, with a waxing and waning course, and these patients typically do not lose control of bowel or bladder function or endure injury (such as tongue-biting). They will have no paroxysmal activity on an electroencephalogram. They often do not respond to antiepileptic medications, or exhibit worsening of seizure-like activity with attempted treatment. One feature that may present on physical exam is forced eye closure; an examiner will encounter resistance when trying to open the patient’s eyes, which is not characteristic of an epileptic seizure.
• Episodes of unresponsiveness

Signs and symptoms that affect the senses may include:

• Functional sensory disturbance includes altered sensation; e.g. numbness, tingling or pain in the face, torso or limbs. This often occurs on one side of the body
• Anesthesia or sensory loss – Functional sensory loss is a less specific manifestation of conversion disorder. Often, the sensory loss does not follow typical dermatomal patterns or patterns indicative of neurologic disorders. Patients may report a sharp demarcation of their sensory loss, which is often a joint or at the end of their extremity, shoulder, or groin. Other patients may exhibit a “hemisensory syndrome,” with sensory loss of an entire side of their body; this can be accompanied by a sensation of feeling “cut in half” or ipsilateral hearing/vision issues. One test that is possible with midline splitting involves placing a tuning fork over the left and right side of the sternum or the frontal bone. Patients should feel the vibrations equally despite their supposed sensory loss, as these bones should vibrate as a single unit. However, patients with functional sensory loss often do not feel the vibration on the affected side.
• Functional speech symptoms, such as inability to speak, whispering speech (dysphonia), slurred or stuttering speech. The most common symptom is functional dysphonia (hoarseness or whispering), but other symptoms include slurred speech, articulatory issues, stuttering, foreign accent syndrome, and mutism. The examiner can ask patients with symptoms of functional dysphonia to cough or sing during lung exam; often, they will be able to perform these functions, whereas patients with true dysphonia have difficulty doing so. The inspection of the vocal cords will be normal.
• Functional visual symptoms; including loss of vision (blindness) or double vision. In general, visual disturbances are very common in conversion disorder. If a patient exhibits complete blindness, they are more likely to have factitious symptoms. In conversion disorder, the patient’s pupillary reflex is present. Expect a recent diagnosis of true blindness to result in the patient having some difficulty maneuvering, and perhaps increased incidence of injury, with superficial bruising/wounds; this is not present in conversion disorder. The following tests can aid in proper diagnosis:
  • Mirror test – This test involves holding a mirror in front of the patient, with their eyes open. The examiner moves the mirror from side-to-side, and the test is positive if the patient tracks themselves in the mirror, indicating that they are not truly blind.
  • Fingertip test – In this test, the patient is asked to bring the tips of their index fingers together. Patients with conversion disorder usually exhibit difficulty with this task, whereas truly blind patients use proprioception to complete the test appropriately.
  • Signature test – This simple test involves asking the patient to write their signature on a piece of paper. Patients with conversion disorder will often be unable to complete this test, but truly blind patients can write their signatures without difficulty.
  • Optokinetic test – This test involves placing a large rotating drum, which has black and white vertical stripes on it, in front of the patient’s eyes. If one observes optokinetic nystagmus, this indicates that the patient’s brain can detect the stripes.
  • Menace reflex – The menace reflex is tested by presenting a threat to the patient’s vision. An example would be quickly bringing the examiner’s hand close to the patient’s face as if they were to strike the patient. Patients with conversion disorder will typically blink or flinch, whereas blind patients will not.
  • Tearing reflex – The tearing reflex is tested by placing a strong light in front of the patient’s eyes. If their vision is intact, as is the case with conversion disorder, the patient will start to tear up.
• Hearing problems or deafness. Olfactory or hearing disturbances are less common than visual disturbances. Patients with conversion disorder typically report anosmia or deafness. Patients with anosmia can take a taste test, in which they will usually indicate a normal sense of taste. In true cases of anosmia, patients have a decreased sense of taste or exhibit some signs of nutritional deficiency/malnourishment. In patients with symptoms of deafness, the examiner can attempt to confront the patient with a loud sound, which will usually elicit a blink or some form of the startle response.

Symptoms often fluctuate and may vary from day to day or be present all the time. Some patients with functional neurological disorder may experience substantial or even complete remission followed by sudden relapses of symptoms.

Other physical and psychological symptoms are commonly experienced by patients with functional neurological disorder but may not be present. These include: chronic pains, fatigue, sleep problems, memory symptoms, bowel and bladder symptoms, anxiety and depression.

Functional neurological disorder complications

Some symptoms of functional neurological disorders, particularly if not treated, can result in substantial disability and poor quality of life, similar to that caused by medical conditions or disease.

The complications of functional neurological disorder include permanent disability and impaired quality of life. Some patients become lost to follow-up, and other patients do not complete treatment as advised. One study found that disability rates and impairment of quality of life were similar in patients with functional movement symptoms when compared to Parkinson disease. Another study found that patients with symptoms of paralysis had rates of disability similar to patients with multiple sclerosis. Overall, patients with psychogenic symptoms have comparable rates of physical disability and higher rates of psychological disability than patients with actual neurologic disorders.

Functional neurological disorder diagnosis

There are no standard tests for functional neurological disorders. Diagnosis usually requires a neurologist or a doctor familiar with neurological diagnosis and involves assessment of existing symptoms and ruling out any neurological or other medical condition that could cause the symptoms.

Functional neurological disorders are diagnosed based on what is present, such as specific patterns of signs and symptoms, and not just by what is absent, such as a lack of structural changes on an MRI or abnormalities on an EEG.

Testing and diagnosis usually involves a neurologist, but may include a psychiatrist or other mental health professional. Your doctor may use any of these terms: functional neurological disorders, functional neurological symptom disorder or conversion disorder.

One advantage to using the term “functional neurological disorders” is that it can be used to specify the type of functional neurological symptoms you have. For example, if your symptoms include problems walking, your doctor may refer to functional gait disorder or functional weakness.

Evaluation may include:

• Physical exam. Your doctor examines you and asks in-depth questions about your health and your signs and symptoms. Certain tests may eliminate medical disorders or neurological disease as the cause of your symptoms. Which tests you’ll have depends on your signs and symptoms.
• Psychiatric exam. If appropriate, your neurologist may refer you to a mental health professional. He or she asks questions about your thoughts, feelings and behavior and discusses your symptoms. With your permission, information from family members or others may be helpful.
• Diagnostic criteria in the DSM-5. Your doctor may compare your symptoms to the criteria for diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association.

Functional neurological disorder is diagnosed on the basis of positive physical signs, some examples of these signs are:

• Hoover’s test is for of functional leg weakness – the patient may have difficulty pushing their “bad” leg down (hip extension), but when they are asked to lift up their “good” leg, movement in the “bad” leg returns transiently to normal.
• Tremor entrainment test for functional tremor – this is when the shaking of an arm or leg becomes momentarily better when the person concentrates on copying a movement that the examiner makes.
• Psychogenic nonepileptic seizures or dissociative (non-epileptic) seizures can often be recognized by a trained health professional using a combination of typical features such as: an episode of violent limb thrashing in which the eyes remain closed, side-to-side head movements, or an event lasting longer than 5 minutes where the eyes are closed, hyperventilation during a shaking attack or tearfulness on recovery.

DSM-5 lists these diagnostic criteria for Conversion Disorder (Functional Neurological Symptom Disorder) ⁵:

• A. One or more symptoms of altered voluntary motor or sensory function.
• B. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions.
• C. The symptom or deficit is not better explained by another medical or mental disorder.
• D. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

Functional neurological disorder treatment

Treatment will depend on your type of functional neurological disorder and your particular signs and symptoms. For some people, a multispecialty team approach that includes a neurologist; psychiatrist or other mental health professional; speech, physical and occupational therapists; or others may be appropriate.

Learning about functional neurological disorders

Understanding what functional neurological disorders are, that the symptoms are real and that improvement is possible can help you with treatment choices and recovery. Symptoms may get better after an explanation of the condition and reassurance from your doctor that symptoms aren’t caused by a serious underlying neurological or medical problem.

For some people, education and reassurance that they don’t have a serious medical problem is the most effective treatment. For others, additional treatments may be beneficial. Involving loved ones can be helpful so that they can understand and support you.

Medical disorder treatment

Your medical team provides treatment of any medical or neurological disease you may have that might be a trigger for your symptoms.

Therapies

Depending on your needs, therapies may include:

• Physical or occupational therapy. Working with a physical or occupational therapist may improve movement symptoms and prevent complications. For example, regular movement of arms or legs may ward off muscle tightness and weakness if you have paralysis or loss of mobility. Gradual increases in exercise may improve your ability to function.
• Speech therapy. If your symptoms include problems with speech or swallowing, working with a speech therapist (speech-language pathologist) may help.
• Stress reduction or distraction techniques. Stress reduction techniques can include methods such as progressive muscle relaxation, breathing exercises, physical activity and exercise. Distraction techniques can include music, talking to another person, or deliberately changing the way you walk or move.

Mental health options

Even though functional neurological symptoms are not “all in your head,” emotions and the way you think about things can have an impact on your symptoms and your recovery. Psychiatric treatment options may include:

• Cognitive behavioral therapy (CBT). A type of psychotherapy, CBT helps you become aware of inaccurate or negative thinking so that you can view situations more clearly and respond to them in a more effective way. CBT can also help you learn how to better manage stressful life situations and symptoms. This may be particularly beneficial if your symptoms include nonepileptic seizures. Other types of psychotherapy may be helpful if you have interpersonal problems or a history of trauma or abuse.
• Treating other mental health conditions. Anxiety, depression or other mental health disorders can worsen symptoms of functional neurological disorders. Treating mental health conditions along with functional neurological disorders can help recovery.
• Hypnosis. When done by a trained professional who is familiar with functional neurological disorders, people who are receptive to suggestions during hypnosis may benefit if they have symptoms of a functional neurological disorder that involve, for example, the loss of sensations or speech problems.

Medications

Medications are not effective for functional neurological disorders, and no drugs are approved by the Food and Drug Administration (FDA) specifically as a treatment. However, medications such as antidepressants may be helpful if you also have depression or other mood disorders, or you’re having pain or insomnia.

Regular follow-up

Regular follow-up with your medical team is important to monitor your recovery and make changes to your treatment plan as needed.

Functional neurological disorder recovery

Most do not get completely cured. However, many can get better by physical and cognitive management ⁶.

When can I get back to work?

That is a question to discuss with your physician and your employer. Safety should always be of the utmost consideration. Some find that because the brain is not sending and receiving messages like it once did that some changes maybe needed. It may be that your old job is just not conducive to your new situation or it may be that a more flexible schedule or an environment with less sensory overload will be more manageable. For some people, working is not an option until they find ways or treatment to manage the disorder. This is a decision to be carefully weighed because the overall goal is to get back into normal healthy living as soon as you can, if you can.

Functional neurological disorder prognosis

The general prognosis for functional neurological disorder is generally poor; however, this is dependent on multiple factors. Factors that promote a good prognosis include sudden onset, early diagnosis, short duration of symptoms, lack of comorbid psychiatric disorders (especially personality disorders), identifiable stressors, and a positive patient-clinician relationship. Patients with a greater number of physical symptoms of poor physical functioning prior to diagnosis have an increased chance of a poor outcome.

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