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Functional Neurological Disorder Explained: Symptoms, Causes, and Treatment

Functional Neurological Disorder (FND) presents a significant challenge within neurological healthcare, giving rise to a range of symptoms such as limb weakness and seizures without a clear structural disease process. It is not only a common cause of neurological disability but also ranks as the second most common reason for outpatient neurological consultations, following headaches and migraines.

As a brain network disorder, FND impacts the functionality of the nervous system, leading to miscommunication between the brain and the body. This can have a profound effect on daily functions and quality of life without necessarily resulting in significant structural brain damage.

Encouraging research suggests the potential reversibility of FND symptoms through specifically tailored treatment strategies, highlighting the importance of early diagnosis for effective rehabilitation. Given the significant disruption that FND can cause to individuals' functioning and ability to cope with daily life, understanding the approaches for case management, including rehabilitation and immediate needs assessment, becomes crucial for both clients and healthcare providers. This aims at fostering a better quality of life for those affected.

Signs and Symptoms of FND

Triggered by factors like physical illness, stress, or injury, FND symptoms are varied and fluctuating in nature, presenting a complex challenge for diagnosis and treatment and significantly impacting daily life. Broadly, symptoms can be categorised into three main areas:

Movement and Motor Symptoms:

  • Weakness or paralysis affecting daily mobility and tasks.
  • Abnormal movements including tremors, difficulty walking, and loss of balance that complicate routine activities.
  • Functional limb weakness, problems walking, functional seizures, tremors, dystonia, gait disorder, facial spasms, tics, jerks, twitches, and drop attacks, presenting a wide range of motor challenges.

Sensory and Perceptual Symptoms:

  • Numbness or loss of touch sensation that alter the interaction with the physical environment.
  • Vision and hearing impairments, including double vision, blindness, or deafness impact the ability to navigate and communicate effectively.
  • Persistent postural perceptual dizziness (PPPD) exacerbates difficulties in crowded or moving environments.

Cognitive and Psychological Symptoms:

  • Cognitive difficulties with memory and concentration, impacting work and home life.
  • Speech and swallowing difficulties, leading to communication barriers and nutritional concerns.
  • Episodes of altered awareness and dissociative symptoms, challenging the perception of self and surroundings.

These symptoms are involuntary, with patients having no control over their appearance, emphasising the real and physical nature of FND despite its functional origin. Recognising the wide spectrum of symptoms, from movement and sensory issues to cognitive and psychological challenges, is crucial for comprehensive care and management strategies.

Diagnosing FND

Diagnosing FND involves a comprehensive assessment process, focusing on identifying specific patterns of symptoms rather than relying solely on the absence of structural abnormalities. This multidisciplinary approach often requires the expertise of neurologists and mental health professionals:

Initial Evaluation:

  • Neurological examination conducted to observe signs that align with FND, looking for positive neurological signs specific to the disorder, such as Hoover’s Sign for limb weakness.
  • Psychiatric assessment discusses thoughts, feelings, and behaviours to understand the psychological aspects that may influence FND symptoms.

Diagnostic Criteria:

  • Utilises the DSM-5 criteria for conversion disorder, which includes symptoms affecting movement or senses that cannot be explained by another medical condition, causing significant distress or functional impairment.
  • Diagnosis is not made through exclusion but based on positive clinical features observed during the assessment.

Further Investigations:

  • While no standard tests exist specifically for FND, investigations may be conducted to rule out other neurological conditions and identify any comorbidities.
  • A diagnosis must be made from positive signs/tests rather than as a diagnosis of exclusion or categorised as medically unexplained symptoms (MUS).

Fiona Kenny, Head of Case Management & Rehabilitation at Bush & Co, indicates the challenges in diagnosing FND:

“Functional neurological disorder is a condition that we are seeing more frequently within our client population. The symptoms and clinical presentation of FND is varied and extensive and because of that it can be challenging to diagnose, with the medical teams eliminating other conditions and diseases before making a final diagnosis.”

Understanding and accepting the diagnosis is crucial for both the individual and the healthcare provider, as it sets the stage for an effective treatment plan tailored to the client's needs. Misdiagnosis should be avoided at all costs, given the significant impact it can have on the patient's treatment and quality of life.

Treatment and Management Strategies

Early intervention and a personalised approach are crucial in the treatment and management of FND, and treatment strategies should focus on addressing both the physical and psychological aspects of the disorder to ensure a comprehensive pathway to recovery.

Fiona Kenny goes on to say “Treatment and rehabilitation can manage and improve FND, and the implementation of comprehensive and goal focussed rehabilitation plans offers the best outcomes for clients” when describing the approach the team at Bush & Co. adopt when working with FND clients.

Rehabilitative and Psychological Interventions:

  • Rehabilitative interventions, such as physical and occupational therapy, are primary treatments for functional motor symptoms and can aid in the recovery of movement and daily functioning.
  • Psychotherapy is an evidence-based treatment across FND subtypes and begins the treatment process for many, focusing on developing skills for better symptom control.
  • Medication is considered mainly when symptoms of depression or anxiety accompany FND, aiming to alleviate these conditions.

Multidisciplinary Approach:

  • Neurology Psychotherapy Service offers a comprehensive treatment regime including stabilisation, psychoeducation, 1-2-1 psychotherapy, and multidisciplinary teamwork.
  • Alternative therapies, including CBT, NLP, S&L therapy, and mindfulness are among the therapies that may complement the treatment plan and help to alleviate symptoms.

Self-Management Techniques:

  • Keeping a diary to note activities and emotions before symptom onset can identify triggers and reveal patterns, aiding in symptom management.
  • Sensory grounding and distraction techniques such as the 1-2-3-Safe method, counting backwards, and 4-8 breathing can help manage acute symptoms by focusing attention away or restoring bodily balance.

Treatment for FND is highly individualised, requiring a combination of physical and psychological rehabilitation tailored to each individual's unique needs and symptoms. Case managers ensure treatment plans are continually reviewed to monitor progress and adjust the treatment plan as necessary.

Living with FND

Among the biggest barriers to successful rehabilitation is a client’s understanding of FND and readiness to engage with case managers and therapies. Living with FND encompasses more than managing symptoms; it is about adapting life strategies to maintain quality and purpose. Understanding the origins of symptoms is crucial for individuals to live better and move forward with their lives. Some key strategies for living with FND include:

Engage in Life:

  • Not putting life on hold and gradually reintegrating activities to maintain structure, purpose, and routine, can improve symptoms and overall well-being.
  • Delegating and learning to manage responsibilities while allowing time for rest and relaxation is crucial.

Community and Support:

  • Avoid isolation by discussing feelings, which can prevent loneliness and depression.
  • Leverage support from friends and family to encourage independence, accept feelings, alleviate some pressure, practice management techniques, and seek additional resources.
  • Engage with FND Friends, a charity offering information, resources, and support groups to connect with others facing similar challenges.

Manage Stress and Comorbidities:

  • Utilise tips from the Mental Health Foundation to manage stress effectively.
  • Regular investigations to identify comorbid neurological conditions, as they are a strong risk factor for FND, ensuring comprehensive care.

These strategies underscore the importance of a balanced approach to living with FND, focusing on both symptom management and enhancing life quality through active engagement, support, and stress management.

The role of case managers

FND is more common than many people realise, yet it often goes undiagnosed or misunderstood. Studies have shown that FND is prevalent across diverse populations and can affect individuals of all ages, genders, and backgrounds. While specific prevalence rates may vary, it is clear that FND has a significant impact on the lives of many individuals and their families.

The role of a case manager in working with clients affected by FND is pivotal in providing comprehensive and personalised support and serves as a central point of contact offering guidance, advocacy, and coordination of care to ensure that individuals receive the necessary resources and assistance.

Playing a crucial role in facilitating communication among healthcare providers, specialists, and support services, case managers ensure that client needs are understood and addressed and work closely with the individual and their family to develop tailored care plans that encompass both the physical and psychological aspects of FND.

Perhaps above all else, the role of a case manager is to help educate their clients on FND to promote better understanding. Setting achievable goals from the outset and maintaining positive reinforcement can go a long way to dictating how engaged an individual will be with their treatment and how successful their rehabilitation is.

In addition, case managers provide invaluable support in navigating the healthcare system, assisting with appointments, referrals, and access to the correct therapies and interventions. They also serve as a source of emotional support, helping clients and their families cope with the challenges of living with FND and providing guidance on community resources and support networks.