Unraveling the Complexities of Functional Neurological Disorder: Insights from a Masterclass

Functional Neurological Disorder (FND) is a challenging condition that has gained increased attention in recent years, particularly during the COVID-19 pandemic. On March 23, 2024, I had the privilege of attending a masterclass titled “Working with Functional Neurological Disorder: Current Diagnostic and Treatment Approaches,” presented by Dr. Vance Locke, a clinical psychologist from the University of Western Australia, and Mr. Rowan Pearce, a senior physiotherapist and head of the Complex Care Clinic at Western Kids Health. The seminar, organized by the Australian Association for Cognitive and Behaviour Therapy, shed light on the latest developments in diagnosing and treating FND, providing valuable insights for practitioners working with individuals affected by this condition.

The Growing Importance of FND: Dr. Locke and Mr. Pearce began by discussing the increasing prevalence of FND, which has become more apparent during the COVID-19 pandemic. They highlighted potential links between FND and social media trends, such as the rise of “tic-like” behaviors on platforms like TikTok. The presenters also touched on the ongoing debate surrounding the relationship between long-COVID symptoms and FND. These observations underscore the need for healthcare providers to stay informed about the evolving landscape of FND and its various presentations.

Diagnostic Criteria and Common Comorbidities

The masterclass delved into the diagnostic criteria for FND, as outlined in the DSM-5 and ICD-11. The presenters emphasized the shift from viewing FND as a “diagnosis of exclusion” to a more inclusive approach that relies on identifying positive signs. This shift is crucial for providing patients with a clear and timely diagnosis, which can be a critical step in their journey towards recovery.

Dr. Locke and Mr. Pearce also discussed the common comorbidities associated with FND, such as anxiety, depression, autism spectrum disorder, and Ehlers-Danlos syndrome. Recognizing these comorbidities is essential for developing a comprehensive treatment plan that addresses the unique needs of each individual.

Models of FND: Understanding the Underlying Processes

To better understand the various presentations of FND, the presenters explored several models that attempt to explain the underlying processes. These models include:

1. Psychodynamic theories, which focus on the role of repressed emotions and experiences in the development of FND symptoms.
2. Stress and emotion models, which highlight the impact of emotional processing difficulties and heightened arousal on the manifestation of FND.
3. Automatic/controlled processes models, which suggest that FND symptoms arise when individuals attempt to consciously control automatic processes, leading to interference and dysfunction.
4. Predictive processing models, which propose that FND symptoms result from a mismatch between an individual’s expectations (or “priors”) and the actual sensory input they receive.

Understanding these models can help practitioners develop targeted treatment approaches that address the specific needs of each patient.

The Role of Positive Signs in Diagnosis

One of the key takeaways from the masterclass was the importance of identifying positive signs of FND during the diagnostic process. These signs, which demonstrate inconsistencies in the nervous system, can be observed by physiotherapists and other health clinicians. Examples of positive signs include:

• Hoover’s sign, which indicates weakness in one leg that resolves when attention is shifted to the opposite leg.
• Entrainment tests, which show how symptoms can be temporarily alleviated when attention is focused on an external stimulus, such as music or a specific task.
• Inconsistencies in sensory or visual symptoms that do not align with known neurological conditions.

By recognising these positive signs, practitioners can not only confirm the diagnosis of FND but also demonstrate to patients that their symptoms are not indicative of permanent damage or dysfunction. This understanding can be empowering for patients, as it highlights the potential for improvement and a return to normal function.

A Multifaceted Approach to Treatment

The masterclass showcased a range of treatment approaches for FND, emphasizing the importance of a multidisciplinary team in providing comprehensive care. Key aspects of treatment include:

1. Education and Explanation: Dr. Locke and Mr. Pearce stressed the significance of finding effective ways to explain the FND diagnosis to patients. Using analogies, such as comparing the brain to a computer with software glitches, can help patients better understand their condition and engage in the treatment process.
2. Psychological Interventions: Cognitive-behavioral therapy (CBT) and psychodynamic therapy (PDT) were discussed as valuable tools in addressing the psychological aspects of FND. These therapies can help patients develop coping strategies, process emotional distress, and challenge unhelpful thought patterns that may contribute to their symptoms.
3. Physiotherapy Techniques: Mr. Pearce highlighted the role of physiotherapy in “retraining” the brain and encouraging automatic movements. By using techniques such as distraction, external focus, and graded exposure, physiotherapists can help patients regain trust in their bodies and improve their overall function.
4. Occupational Therapy Strategies: Occupational therapists play a crucial role in helping patients with FND reintegrate into their daily lives. This includes setting achievable goals, developing pacing strategies, and providing support for returning to work or school.

Throughout the treatment process, collaboration and consistent communication among the multidisciplinary team members are essential. By creating an “airtight” environment where all team members share a common understanding of the patient’s formulation and treatment plan, practitioners can optimize outcomes and support patients in their journey towards recovery.

Conclusion

The “Working with Functional Neurological Disorder” masterclass provided a wealth of information on the current state of FND diagnosis and treatment. By understanding the growing importance of FND, recognizing common comorbidities, and appreciating the various models that explain the underlying processes, practitioners can better serve their patients. The identification of positive signs during diagnosis, combined with a multifaceted, collaborative approach to treatment, offers hope and support for individuals navigating the challenges of FND. As an occupational therapist, I am grateful for the insights gained from this masterclass and look forward to applying this knowledge in my practice to help patients achieve their goals and improve their quality of life.