Occupational therapy consensus recommendations for functional neurological disorder

Occupational therapists have an integral role in the treatment of people with functional neurological disorder, yet there is evidence of variable implementation of occupational therapy in community settings. This study explored the barriers and enablers to delivering community-based occupational therapy to people with functional neurological disorder in the United Kingdom. Community-based neurological occupational therapists (n = 10) with experience in functional neurological disorder were invited to complete semi-structured qualitative interviews. The interview schedule and analysis were based on the Theoretical Domains Framework, a behavioural science tool for investigating barriers and enablers to clinical practice. Data were analysed using a combined content and framework analysis approach. Important barriers to treatment included limited published information to guide practice, lack of professional role clarity and restricted multidisciplinary team working. Enablers included occupational therapists' dual training in physical and mental health and focus on activity engagement. Service provision, quality and access varied across geographical locations. Occupational therapists are uniquely placed to help people with functional neurological disorder; however, findings suggest that existing community service structures in many regions in the United Kingdom are inadequate and limit the quality of treatment that can be provided. Additional resources are required to support occupational therapy service provision in community settings.

Sensory Processing Difficulties in Patients with Functional Neurological Disorder: Occupational Therapy Management Strategies and Two Cases

The emergence of acute-onset functional neurological symptoms, the focus of this study, is one of three stress responses related to immunisation. This case-control study documents the experience of 61 young people with past or current functional neurological disorder (FND) in relation to the COVID-19 vaccination program in Australia. Information about the young person's/parent's choice and response pertaining to COVID-19 vaccination was collected as part of routine clinical care or FND research program follow-up. 61 young people treated for FND (47 females, mean age = 16.22 years) and 46 healthy controls (34 females, mean age = 16.37 years) were included in the study. Vaccination rates were high: 58/61 (95.1%) in the FND group and 45/46 (97.8%) in the control group. In the FND group, 2 young people (2/61, 3.3%) presented with new-onset FND following COVID-19 vaccination; two young people with resolved FND reported an FND relapse (2/36, 5.56%); and two young people with unresolved FND (2/20, 10.0%) reported an FND exacerbation. In the control group no FND symptoms were reported. Acute-onset FND symptoms following COVID-19 vaccination are uncommon in the general population. In young people prone to FND, COVID-19 vaccination can sometimes trigger new-onset FND, FND relapse, or FND exacerbation.

To describe the presenting symptoms and short-term outcomes of children diagnosed with functional neurologic symptom disorder and to compare the demographic and clinical characteristics of children who received neurodiagnostic testing to those who did not. Single center, retrospective review of 222 children who presented to the emergency department of a children's hospital, and diagnosed with functional neurologic symptom disorder, between 2010 and 2015. Out of 222 visits (females = 156, African Americans = 130, mean age = 13.9 years), neurodiagnostic tests were performed in 102/222 (46%) visits. The most commonly performed investigations were magnetic resonance imaging (MRI) of brain (n = 37) and electroencephalogram (EEG) (n = 56) and were noted to be unremarkable in all instances. Neurodiagnostic tests were more likely to be performed in patients who (1) were non-African American (54% vs 40%; P = .03), (2) presented with new-onset symptoms (55% vs 31%; P < .01), (3) underwent hospitalization (61% vs 17%; P < .01), and (4) were evaluated by a neurologist (59% vs 9%; P < .01) or a psychiatrist (58% vs 28%; P < .01). Common clinical presentations included seizurelike or strokelike symptoms. Short-term follow-up was possible in 20%, with an alternate diagnosis of syncope, noted in only 1 child. Most children who presented with a functional neurologic symptom disorder in our study were noted to have seizurelike or strokelike presentations and were adolescent females. Caucasians were more likely to undergo neurodiagnostic investigations. Radiologic and neurophysiological tests were more commonly performed when neurology and psychiatry consultations were sought. Such investigations had low diagnostic utility.

Objectives/Aims Functional neurological disorders (FND) account for 20% of patients in neurology clinics and can lead to functional impairment, multiple re-attendances and significant cost. However, diagnosing FND remains challenging; identifying associated factors could aid earlier diagnosis. We aimed to determine the value of self-reported multi-allergies as predictor for FND. Methods We retrospectively reviewed records of consecutive patients from two clinics (General Neurology and FND), St George’s Hospital, January 2015–June 2018. A logistic regression model was used in conditional fashion; statistically significant variables in univariate analysis were included. Results Of 720 patients with definitive diagnosis, 243 (33.8%) had FND and 477 (66.3%) another neurological disorder. Mean age was 43 years (range 16–93), 63.9% (453) were female. 81 patients with FND (33%) had Non-epileptic attack disorder (NEAD). In multivariate analysis, factors associated with FND were female sex (Odds Ratio [95% Confidence Intervals], OR=0.49 [0.33, 0.73], p Increased number of allergies increased the probability of FND: one allergy OR=4.53 [3.08, 6.65, p Conclusions Previous studies highlighted the increased prevalence of allergies in NEAD compared to epilepsy. Our study expand this to all FND, as only 1 in 3 FND patients had NEAD. Presence of allergies, particularly to multiple agents, should raise the suspicion of FND.

Attachment styles, identification of feelings and psychiatric symptoms in functional neurological disorders

Functional neurological disorder (FND) is a neuropsychiatric condition that is framed as a multi-network brain problem. Despite this conceptualization, studies have generally focused on specific regions or connectivity features, under-characterizing the complex and nuanced role of resting-state networks in FND pathophysiology. This study employed three complementary graph theory analyses to delineate the functional network architecture in FND. Specifically, we investigated whole-brain weighted-degree, isocortical integration and isocortical segregation extracted from resting-state functional MRI data prospectively collected from 178 participants: 61 individuals with mixed FND; 58 psychiatric controls matched on age, sex, depression, anxiety and post-traumatic stress disorder severity; and 59 age- and sex-matched healthy controls. All analyses were adjusted for age, sex and antidepressant use and focused on differences between FND versus psychiatric controls, with individual-subject maps normalized to healthy controls. Compared to psychiatric controls, patients with mixed FND exhibited increased weighted-degree in the right dorsal anterior cingulate and superior frontal gyrus and the left inferior frontal gyrus and supplementary motor area. Isocortical integration analyses revealed increased between-network connectivity for somatomotor network areas, with widespread heightened connections to regions of the default mode, frontoparietal and salience networks. Isocortical segregation analyses revealed increased within-network connectivity for the frontoparietal network. Secondary analyses of functional motor disorder (n = 46) and functional seizure (n = 23) subtypes (versus psychiatric controls) revealed both shared and unique patterns of altered connectivity across subtypes, including increased weighted-degree and integrated connectivity in the left posterior insula and anterior/mid-cingulate in functional motor disorder and increased segregated connectivity in the right angular gyrus for functional seizures. In post hoc between-group analyses, findings remained significant adjusting for depression, anxiety and post-traumatic stress disorder severity, as well as for childhood maltreatment. Post hoc correlations revealed significant relationships between connectivity metrics in several of these regions and somatic symptom severity across FND and psychiatric control participants. Notably, individual connectivity values were predominantly within the range of healthy controls (with patients with FND generally showing tendencies for increased connectivity and psychiatric controls showing tendencies towards decreased connectivity), indicating subtle shifts in the network architecture rather than gross abnormalities. This study provides novel mechanistic insights (i.e. increased somatomotor integration) and specificity regarding the neurobiology of FND, highlighting both shared mechanisms across subtypes and subtype-specific patterns. The results support the notion that FND involves aberrant within- and between-network communication, setting the stage for biologically informed treatment development and large-scale replication.

Functional neurological disorder (FND) is a common and often disabling condition. Limited access to services for FND poses challenges both for patients and their health care providers. This survey explored the attitudes, experiences, support needs and training needs of health care professionals (HCPs) who provide care to individuals with FND in Ireland. A broad range of HCPs working with patients with FND in Ireland partook in an anonymous online 12-item survey. Participants were recruited via professional bodies and snowball convenience sampling utilising social media and email invitation. Descriptive and inferential statistics were employed to analyze data. A total of 314 HCPs working in Ireland completed the survey. 80% were female and over half worked in their current role for more than 10 years. 75% of the sample encountered three or less individuals with FND per month. Identified service-related challenges to effective patient care included insufficient clinic time, lack of confidence explaining the diagnosis, and the need for greater access to specialist support. Data revealed persisting negative attitudes toward FND patients among a proportion of respondents. The majority of respondents did not feel they received adequate education on FND, with the exception of neurologists, of whom 65% felt adequately trained. The majority of respondents (85%) also felt that people with FND did not have access to appropriate FND services in Ireland. This study indicates that there is a significant need to improve FND education among HCPs in Ireland, in addition to developing appropriately resourced, integrated, multidisciplinary care pathways for the FND patient group.

Patients with functional neurological symptom disorder (FNSD) report high rates of traumatization and have high levels of posttraumatic stress disorder (PTSD) symptoms. Psychotherapy is a mainstay of treatment for persons with FNSD. In this study, the investigators explored changes in PTSD symptoms and health-related quality of life after psychotherapy among persons with FNSD and examined factors contributing to these changes. Data were prospectively collected for patients with FNSD attending a specialist outpatient psychotherapy service in the United Kingdom (N=210) as part of an ongoing routine service evaluation. Pre- and posttherapy questionnaires included self-report measures of PTSD symptoms (Posttraumatic Stress Disorder Checklist-Civilian version), depressive symptoms (Patient Health Questionnaire-9), anxiety symptoms (General Anxiety Disorder-7 scale), somatic symptoms (Patient Health Questionnaire-15), health-related quality of life (Short-Form Health Survey-36), and social functioning (Work and Social Adjustment Scale). Independent contributions to psychotherapy-related changes in PTSD symptoms and health-related quality of life were explored through multivariate analyses. All outcome measures revealed improvements after psychotherapy (p<0.001). Psychotherapy-related changes in depression and somatic symptoms and employment status at baseline explained 51% of the variance in PTSD symptom changes. Changes in PTSD symptoms, depressive symptoms, and somatic symptoms made independent contributions to improvements in health-related quality of life (R2=0.54). Improvements were unrelated to FNSD subtype (dissociative seizures or other FNSD), age, marital status, or number of sessions attended. Reductions in self-reported PTSD, depressive, anxiety, and somatic symptoms, as well as improved health-related quality of life, were observed among patients who received one or more sessions of psychotherapy. Randomized controlled trials of psychotherapy for patients with FNSD are warranted.

Objectives/Aims Self-report studies of alexithymic traits in individuals with Functional Neurological Symptom Disorder (FND), suggest that emotion dysregulation in this population is characterised by an impaired ability to detect and identify their own emotions (identification impairments).1 This regulatory deficit might be particularly problematic for a patient group with an increased incidence of stressful life events relative to healthy controls,2 for whom the ability to regulate emotions might therefore be more crucial. Examining sensitivity to changes in physiological cues associated with emotional experience (interoception) is a way of assessing one aspect of participants’ capacity to identify their own emotions. However, no studies have yet experimentally investigated how stress might interact with interoception in this population. Therefore, the aim of this study was to investigate patients’ interoceptive sensitivity both at baseline and under stress. Methods Twenty-six patients with FND and twenty-seven healthy controls performed the Heartbeat Detection Task (HBDT) pre- and post- stress-induction with the Cold Pressor Test. The HBDT is a behavioural paradigm, measuring participants’ sensitivity to a physiological cue associated with emotional experience - the heartbeat. Participants also completed a self-report measure of emotion dysregulation (The Emotional Processing Scale-25) which includes a subscale capturing ‘a detached experience of one’s emotions due to poor emotional insight’, and a measure of Major Depressive symptomology (The PHQ-9). Results Relative to healthy controls, patients with FND performed more poorly on the HBDT both at baseline and following stress-induction (p=0.032). Patients also reported greater impairments across all domains of the EPS-25 and higher scores on the PHQ-9 than healthy controls (both p Conclusions Impaired HBDT performance suggests that patients with FND lack sensitivity to their heartbeat, both under ‘normal’ conditions and following stress-induction. Physiological cues (like the heartbeat) are an important source of interoceptive information for emotional experience, for example during stress. Our findings therefore represent a form of identification impairment that may contribute to stress-vulnerability in this population. Raised levels of self- reported ‘impoverished emotional experience’ corroborate the suggestion that patients with FND have difficulty identifying and understanding their emotions. These findings have direct implications for understanding and treating emotion dysregulation in FND. References Williams IA, Levita L, Reuber M. Emotion dysregulation in patients with psychogenic nonepileptic seizures: A systematic review based on the extended process model. Epilepsy & Behavior. 2018;86:37–48. Ludwig L, Pasman JA, Nicholson T, Aybek S, David AS, Tuck S, et al. Stressful life events and maltreatment in conversion (functional neurological) disorder: systematic review and meta-analysis of case-control studies. The Lancet Psychiatry. 2018;5(4):307–20.

Functional neurological disorder (FND) is a common and disabling neuropsychiatric condition in which women comprise approximately 75% of cases. This paper examines whether the gender imbalance seen in FND is unique among neurological and psychiatric conditions and explores the biological, psychological, and social contributors to this disparity. A narrative review was conducted using MEDLINE, PsycINFO, and Web of Science. Gender ratios were compared across depression, anxiety, post-traumatic stress disorder, schizophrenia, eating disorders, Parkinson's disease, and multiple sclerosis. Evidence regarding sex hormones, early life trauma, gender-based social determinants, and diagnostic biases were synthesized thematically. Amongst the psychiatric and neurological conditions reviewed, FND shows a pronounced female predominance (approximately 3:1), placing it amongst the most gender imbalanced disorders in our sample, with only eating disorders showing a larger female predominance. Biological factors (particularly the influence of estrogen and progesterone on stress reactivity, neuronal excitability, and agency), may heighten female vulnerability. Social determinants (increased exposure to trauma, socioeconomic inequality, and gender norms) further contribute to this risk. FND shares clinical and demographic similarities with other internalizing disorders and conditions linked to dissociation and trauma. The literature suggests FND emerges from a bidirectional interaction between gonadal hormones and psychosocial stressors. The marked gender imbalance in FND arises from the interplay of biological vulnerability and gendered social adversity. Understanding these intersecting influences is essential for reducing stigma and guiding future research, diagnosis, and treatment. The findings support the need for a gender-sensitive, biopsychosocial approach to FND care, and investigation.

Multiple sclerosis (MS) and functional neurological disorder (FND) are both diagnostically challenging conditions which can present with similar symptoms. We systematically reviewed the literature to identify patients with MS who were misdiagnosed with FND, patients with FND who were misdiagnosed with MS, and reports of patients with both conditions. In addition to FND, we included studies of patients with other functional and psychiatric disorders where these caused symptoms leading to investigation for or a diagnosis of MS, which in a different context would likely have been labeled as FND. Our review suggests that MS is one of the most common causes of misdiagnosis of FND and vice versa. We discuss the clinical errors that appear to result in misdiagnoses, such as over-reliance on psychiatric comorbidity when making a diagnosis of FND or over-reliance on neuroimaging for the diagnosis of MS, and practical ways to avoid them. Comorbidity between these two conditions is also likely common, has been poorly studied, and adds complexity to diagnosis and treatment in patients with both MS and FND. Misdiagnosis and comorbidity in a landscape of emerging evidence-based treatments for both MS and FND are issues not only of clinical importance to the care of these patients, but also to treatment trials, especially of MS, where FND could be a hidden confounder.

SummaryBackgroundAdverse life events and other stressors were central to historical ‘Freudian’ models of functional neurological disorder (FND), which have been increasingly replaced by more nuanced biopsychosocial models. Studies of the aetiological relevance of stressors have been limited by small sample sizes.MethodsRetrospective cohort analyses using a large international electronic health records network (TriNetX), including ICD-10 codes, were performed. Between 2015 and 2025, 147,595 individuals were diagnosed with FND. The rates of adverse life events and psychosocial stressors were compared to matched cohorts with migraine and generalised anxiety disorder (GAD) diagnoses. We also investigated associations between FND and the presence of stressors, including the stressor type and whether it occurred in childhood or adulthood.FindingsRates of abuse or neglect (1·33%), assault (2·42%), and psychosocial and socioeconomic difficulties (10·63%) were significantly higher in FND compared to migraine (0·42%/0·93%/3·43%, respectively) and GAD (0·75%/1·29%/7·69%, respectively) (p < ·0001 for all comparisons). A history of physical and sexual abuse was more prevalent in FND than in comparison groups. Psychological abuse was more common in FND than in migraine, but not when compared to GAD. FND cases with recorded stressors were younger, more often female, and more frequently diagnosed with functional/dissociative seizures than those without stressors. Further, these stressors were associated with an increased prevalence of psychiatric comorbidities, pain, and fatigue. Different stressor types had distinct influences on clinical presentations. Adult-onset adversity was associated with higher rates of psychiatric comorbidities, pain and fatigue.InterpretationA record of adversities was at least 2·5 times more common in FND than in migraine, and about 1·5 times more common than in GAD, varying by stressor type. Psychosocial stressors were particularly common. The presence of stressors, as well as their type, shapes the presentation of FND. Life history should therefore be considered when assessing individuals with FND.FundingNone.

Functional neurological disorder (FND) is a common condition, associated with high disability and healthcare costs, and poor treatment access. This qualitative study aimed to explore participants' experiences of being diagnosed with functional neurological disorder (FND), accessing treatment, and navigating life after diagnosis. Participants were drawn from a randomised feasibility study of eye movement desensitisation and reprocessing therapy for people with FND (MODIFI, Trial Registration: NCT05455450 (www.clinicaltrials.gov)). Reflexive thematic analysis was used to analyse the data from eighteen semi-structured interviews with participants diagnosed with FND. Six main themes were identified: (1) the process of seeking a diagnosis and initial relief from the physical struggles, (2) receiving a diagnosis of FND, (3) treatment for FND, (4) the burden of FND in day-to-day life, (5) the need to assert agency and return to normal, and (6) hopes for the future. The findings emphasize the need for personalised and compassionate care for individuals suffering from FND, underpinned by increased service provision within the healthcare system.

&lt;sec&gt;&lt;st&gt;Objective&lt;/st&gt; Functional neurological disorder (FND) is a common presentation in both primary and secondary care, and contributes to around 30% of initial presentations to neurology. Depersonalisation is commonly associated with FND and is particularly associated with more severe and debilitating presentations. Another factor that has been found to contribute to both FND and depersonalisation is a history of childhood sexual abuse (CSA). We designed a study to test the hypothesis that a history of CSA would result in increased severity of depersonalisation and other dissociative symptoms in FND patients compared to those with no experience of sexual abuse. &lt;/sec&gt; &lt;sec&gt;&lt;st&gt;Method&lt;/st&gt; Questionnaires were administered to 38 participants (13 men and 25 women), all of whom were patients with a diagnosis of FND who attended a neuropsychiatry outpatient clinic at the Princess Royal Hospital. These included the STAI Trait Anxiety Scale, the Rosenberg Self Esteem Scale (RSES), the Beck Depression Inventory (BDI), the Cambridge Depersonalization Scale (CDS), and the Dissociative Experiences Scale (DES-II). The results of these were then compared for patients with (CSA(+)) and without (CSA(-)) a CSA history. It is part of standard clinical practice to discuss any history of childhood trauma (including CSA) with patients in this clinic, and it was therefore possible to ascertain this information from patients’ notes. CSA in this case was considered to be any experience of undesired sexual behaviour or contact below the age of 16. &lt;/sec&gt; &lt;sec&gt;&lt;st&gt;Results&lt;/st&gt; CSA(+) FND patients scored higher on the CDS (p&lt;0.015), and particularly on the subscales for Emotional Numbing (p&lt;0.05) and Alienation From Surroundings” (p&lt;0.005). CSA(+) patients also scored lower on the RSES (p=0.005), and higher on the BDI (p=0.023). We also divided the cohort into patients with non-epileptic attack disorder (NEAD) (n=29) and those with other functional neurological symptoms (FNS) (n=9) and found that NEAD patients scored higher on the CDS Emotional Numbing subscale (p&lt;0.043). Within the NEAD subgroup, CSA(+) patients scored higher on the Alienation From Surroundings CDS subscale (p&lt;0.003), and lower on the RSES (p&lt;0.044). &lt;/sec&gt; &lt;sec&gt;&lt;st&gt;Conclusion&lt;/st&gt; CSA is associated with higher levels of depersonalization in FND patients, as well as greater levels of depression and lower self-esteem. NEAD patients are more susceptible to experiencing “emotional numbing” than other FND patients, and within the subgroup of NEAD patients a CSA history is associated with increased “alienation from surroundings” and lower self-esteem. From these findings, it appears that CSA is associated with depersonalization in FND patients. &lt;/sec&gt;