Management of Functional Neurological Disorder (FND) Patients in Dissociative States

Introduction to FND Management

• The American Academy of Neurology recommends immediately implementing sensory grounding techniques to help FND patients reconnect with the present moment during dissociative episodes, ensuring they are in a safe space and providing calm reassurance while avoiding excessive physical contact or repeated reassurance that may prolong the episode 1

Immediate Acute Management

• Move the person to a safe space where they are unlikely to injure themselves during the dissociative episode, and let them know they are safe, but avoid constant reassurance which can paradoxically prolong the episode 1
• Speak calmly and recognize that the person may hear and understand what you say even if unable to respond, and advise caregivers or family members to behave as they would if someone is having a panic attack 1

Sensory Grounding Techniques

• Guide them to notice details in their environment including colors, textures, and sounds, and encourage them to identify five things they can see, four they can touch, three they can hear 1, 2
• Use word games or counting backwards to redirect attention, and ask them to name categories of objects (e.g., types of animals, colors) 1, 2

Developing a Personalized Dissociative Episode Plan

• Document specific triggers and warning signs that precede dissociative episodes, and create a written plan that includes preferred grounding techniques 1, 3
• Identify early warning signs when intervention strategies are most effective, and share this plan with all caregivers and family members 1, 3

Addressing Underlying Anxiety

• Explain the physiological process of anxiety and its physical impact on the body, and introduce the concept of "fight or flight" response, particularly useful for patients who don't identify as feeling anxious 2, 3
• Implement breathing techniques and progressive muscle relaxation, and use visualization and mindfulness practices 2, 3

Ongoing Treatment Framework

• Help patients notice and challenge unhelpful automatic thoughts such as catastrophizing, and address "all or nothing" thinking patterns that may worsen dissociative symptoms 4, 5
• Manage fatigue, pain, and poor sleep which can exacerbate dissociative symptoms, and encourage structure and routine with daily planning to prevent cognitive overload 6, 1

Important Pitfalls to Avoid

• Do not pursue acute hospital admissions for dissociative episodes, as they are usually unnecessary and can be highly distressing, and avoid excessive reassurance during episodes, which can prolong the dissociative state 1
• Avoid using physical restraint unless absolutely necessary for immediate safety, and do not use physical restraint unless absolutely necessary for immediate safety 1

Relapse Prevention and Long-Term Management

• Create a written relapse prevention plan collaboratively with the patient, and document learned management strategies and identify triggers for symptom exacerbation 8
• Establish graded goals for 3, 6, 9, and 12 months, and prepare the patient for possibility of relapse with emphasis on self-management using learned techniques 8, 5