Functional Neurological Disorder (FND)

Question 1

Definition of FND

Answer 1

Disorders significantly altered by attention and occurring in a dysfunctional neurobiological system but still able to function normally

Underlined by several pathophysiological abnormalities in the CNS

(Edwards et al., 2012; Morgante et al., 2018)

• Functional Motor diseases FMD, FMD with excess of movement (dystonia, tremor, jerks), FMD with poverty of movement (weakness, slowness), Functional GAIT and Balance disorders.
• Functional cognitive disorders
• Functional Sensory Disorders
• Paroxysmal Non-Epileptic Seizures (PNES)

Question 2

Risk Factors for FND

Answer 2

• Genetic risk factors
• Psychological (life stressors) risk factors
• social environment risk factors
• psychiatric diseases
• other neurological disease

Epidemiology

• 4-12/100000 per year
• Age of onset = 37-50 but may occur in childhood
• Female are more frequently affected (61-87%)

(Stone et al., 2010)

Question 3

Describe clinical features of FND

Answer 3

Motor Symptoms:

Weakness or paralysis, abnormal movements (tremor, dystonia or chorea), gait disorders, and functional seizures or attacks that resemble epilepsy but are not associated with the typical electric brain activity seen in epileptic seizures

Sensory Symptoms:

Patients can experience altered sensations like numbness, tingling or a sensation of electricity which can localise or widespread

Functional Seizures:

Non-epileptic seizures, these are episodes that can look like epileptic fits but as mentioned are not accompanied by the characteristic of electrical changes in the brain. They can include a variety of movements and levels of consciousness

Persistent Perceptual Postural Dizziness (PPPD):

This is a condition where the patient experiences persistent sensations of swaying or rocking that are not due to any underlying vestibular disorders

Cognitive Symptoms:

These can include difficulties with concentration, memory and executive functions without distinct neurological pathologies.

(Stone et al., 2009)

Question 4

Understand the main treatment options

Answer 4

1. Education and Psychoeducation:

• Education about the disorder forms the cornerstone of FND treatment, helping patients understand their symptoms and the mind-body connections. It is crucial for reducing fears about the symptoms and setting the stage for further investigations.

2. Physical Therapy:

• Central for FND with motor symptoms such as weakness and abnormal movements. It involves retraining movement patterns and focusing on normalising function

3. CBT:

• Address maladaptive thought patterns and behaviour that contribute to the maintenance of FND symptoms. It can also help manage associated anxiety and depression.

4. Pharmacological Management:

• Medication plays a limited role in directly treating FND but may be used to address comorbid conditions such as depression, anxiety or pain syndromes that often co-occur with FND

5. Multidisciplinary Care:

• A comprehensive treatment plan may involve neurologists, neuropsychiatrists, psychologists, physical therapists, occupational therapists, speech and language therapists, specialist nurses and social workers

(Espay et al., 2018)

Question 5

Understand the rationale for physical rehabilitation

Answer 5

The rationale for physical rehabilitation in FND is grounded in the understanding that although the brain’s structure may be intact, its function, how it sends and receive signals is altered. Physical rehabilitation seeks to capitalise on the brain’s neuroplasticity, its ability to learn and reorganise itself by forming new neural connections

1. Neuroplasticity:

• Leverage the concept of neuroplasticity to help retrain the brain to produce normal movements and reduce symptoms. Through repetitive practice and training, patients can develop new, more functional neural pathways, potentially leading to improved motor function and reduction in disability.

2. Redirection of Attention:

• Motor symptoms in FND can be exacerbated by self-focused attention. Physical rehabilitation helps patients shift their focus away from the dysfunction, using strategies such as distraction and concentration on external tasks which can normalise movement

3. Addressing Learned Abnormal Movement Patterns:

• Physical therapy is structured to help unlearn maladaptive movement patterns, Patients with FND may develop certain patterns of movement, or lack thereof, that become ingrained. Rehabilitation works to correct these patterns by teaching the body to move in more functional ways.

4. Symptom Management:

5. Empowerment and Self-management

(Espay et al., 2018)

(Nielsen et al., 2015)