Diagnosing and Treating Functional Neurological Disorder (FND)

Diagnostic Approach

The American Academy of Neurology recommends that Functional Neurological Disorder (FND) should be diagnosed using positive clinical signs and a comprehensive biopsychosocial assessment, followed by a treatment approach that combines education, physical rehabilitation, and psychological interventions tailored to the specific symptom presentation 1, 2
FND is diagnosed by a neurologist using positive clinical signs, not as a diagnosis of exclusion 3
Key diagnostic signs include Hoover's sign for functional weakness, distractibility of symptoms, entrainment of tremor, and variability in symptoms during functional tasks 3, 4
A comprehensive assessment should include symptom history and presentation, medical and psychological history, functional assessment, and social and occupational impact 1, 3, 5

The treatment approach should combine education, physical rehabilitation, and psychological interventions tailored to the specific symptom presentation 1, 2
Initial education and explanation should acknowledge that FND is a real, common, and disabling condition causing neurological symptoms outside the person's control, and explain that symptoms are caused by a potentially reversible miscommunication between brain and body 3
Physical rehabilitation should engage in tasks that promote normal movement patterns, good alignment, and even weight-bearing, and use distraction techniques during task performance to normalize movement 4
Psychological interventions should address contributing factors to symptoms such as anxiety, depression, and unhelpful coping behaviors, and implement strategies for cognitive symptoms by addressing contributing factors (fatigue, pain, anxiety, poor sleep) 4, 6

Outcome measurement should include multiple domains, such as core FND symptom change, life impact (quality of life, disability, general functioning), and health economics/cost-utility 1, 2, 3

Failing to make a positive diagnosis based on clinical signs, providing insufficient explanation of the diagnosis, using splinting or adaptive aids prematurely, neglecting to address psychological comorbidities, and overlooking the importance of the patient's understanding and agreement with the diagnosis should be avoided 3, 4, 6

Treatment is more likely to be successful when the patient has some degree of understanding and agreement with the diagnosis, has agreed to the referral, can identify rehabilitation goals and is motivated to make changes, and understands that the initial focus is to improve function 1, 5