Management of Functional Neurological Disorder with Non-Epileptic Seizures

Immediate Management During a Dissociative Episode

The American Academy of Neurology recommends moving the person to a safe space where they cannot injure themselves, then calmly informing them they are safe without providing constant reassurance, which paradoxically prolongs the episode 1, 2
Recognize that the patient may hear and understand you even if unable to respond, and advise caregivers to behave as they would during a panic attack 1, 2
Avoid physical restraint unless absolutely necessary for immediate safety, and do not pursue acute hospital admission, as these are usually unnecessary and highly distressing 1
Implement sensory grounding techniques immediately: guide them to notice five things they can see, four they can touch, three they can hear, and use word games or counting backwards to redirect attention 1

Create a written plan with the patient documenting their specific triggers, warning signs, and preferred grounding techniques to use when they feel an episode approaching 1, 2
Share this plan with all caregivers, family members, and treating clinicians so everyone responds consistently 1
Identify early warning signs when intervention strategies are most effective, as many patients initially report no memory of pre-episode events but recognize patterns after discussion 1, 2

Refer for occupational therapy and physical therapy as first-line treatment, focusing on retraining normal movement within functional activities and graded reintroduction to daily activities 3, 4, 5
Treatment should be based on a biopsychosocial framework addressing biological, psychological, and social factors contributing to symptoms 3, 4

Explain the physiological process of anxiety and the "fight or flight" response, particularly useful for patients who don't identify as feeling anxious 1
Implement breathing techniques, progressive muscle relaxation, visualization, and mindfulness practices to manage anxiety 1, 3
Address fatigue, pain, and poor sleep which exacerbate dissociative symptoms, and encourage structured daily routines to prevent cognitive overload 1, 2

Explain that FND is a positive diagnosis based on recognizable clinical signs, not a diagnosis of exclusion, and emphasize that symptoms are real and potentially reversible 3
Use understandable analogies such as "a software problem, not a hardware problem" to explain the disorder 3

Do not treat FND like other neurological conditions by focusing on impairment-based goals rather than functional goals 3
Avoid relying primarily on pharmacological approaches or providing compensatory devices (wheelchairs, walkers) prematurely, as this reinforces disability 3
Do not dismiss the diagnosis or suggest symptoms are "all in their head," as this increases stigma and reduces engagement 3, 4

Create a written relapse prevention plan collaboratively documenting learned management strategies and identifying triggers for symptom exacerbation 1
Establish graded goals for 3, 6, 9, and 12 months, preparing the patient for possible relapse with emphasis on self-management using learned techniques 1
Reestablish structure and routine in daily activities, as this is central to preventing symptom recurrence 4, 5

Multidisciplinary studies report improvements in physical function and quality of life immediately after treatment and at follow-up periods of 12-25 months with high patient acceptability 3, 4