LEARNING OBJECTIVES
After reading this article you will be able to:
-
reach a positive diagnosis of adult FND and co-manage the disorder as a liaison psychiatrist in an acute hospital
-
provide psychoeducation to patients, carers and families, and appreciate its importance
-
appreciate the patient perspective, which should inform clinical practice.
Functional neurological disorder (FND) is a clinically significant and prevalent condition, which often represents around 15–20% of new neurology out-patient clinic appointments (Stone Reference Stone, Carson and Duncan2010) and can lead to functional disability with a profound impact on patients’ quality of life (Carson Reference Carson, Stone and Hibberd2011). Alterations in the functioning of brain networks rather than abnormalities in its structure are behind the condition’s pathophysiology, as its name suggests (Hallett Reference Hallett, Aybek and Dworetzky2022). The two medical specialties that are usually involved in the diagnosis and management of the condition in an in-patient setting are neurology and psychiatry.
In ICD-11 (World Health Organization 2022), FND is listed as ‘dissociative neurological symptom disorder’, under ‘Mental, behavioural and neurodevelopmental disorders’ (Chapter 6) (Box 1). The ICD-10 coding of ‘Somatoform disorders’ has been replaced by ‘Bodily distress disorder’ (6C20) for the diagnosis of other functional conditions, excluding dissociative disorders (6B60.0–6B60.Z).
Classification of functional neurological disorder in ICD-11 and DSM-5-TR
ICD-11 – 6B60 ‘Dissociative neurological symptom disorder’ (Chapter 6, under ‘Mental, behavioural and neurodevelopmental disorders’) (World Health Organization 2022)
‘Dissociative neurological symptom disorder is characterised by the presentation of motor, sensory, or cognitive symptoms that imply an involuntary discontinuity in the normal integration of motor, sensory, or cognitive functions and are not consistent with a recognised disease of the nervous system, other mental or behavioural disorder, or other medical condition. The symptoms do not occur exclusively during another dissociative disorder and are not due to the effects of a substance or medication on the central nervous system, including withdrawal effects, or a Sleep-Wake disorder.
Exclusions: Factitious disorders (6D50-6D5Z)’
Symptom specifiers – sections/codes in this section (6B60.0-6B60.Z)
Dissociative neurological symptom disorder with:
-
visual disturbance (6B60.0)
-
auditory disturbance (6B60.1)
-
vertigo or dizziness (6B60.2)
-
other sensory disturbance (6B60.3)
-
non-epileptic seizures (6B60.4)
-
speech disturbance (6B60.5)
-
paresis or weakness (6B60.6)
-
gait disturbance (6B60.7)
-
movement disturbance (6B60.8)
-
cognitive symptoms (6B60.9)
-
other specified symptoms (6B60.Y)
-
unspecified symptoms (6B60.Z)
DSM-5-TR – 360 ‘Functional neurological symptom disorder’ (American Psychiatric Association 2022)
‘Diagnostic criteria:
-
A. One or more symptoms of altered voluntary motor or sensory function.
-
B. Clinical findings provide evidence of incompatibility between the symptom and recognised neurological or medical conditions.
-
C. The symptom or deficit is not better explained by another medical or mental disorder.
-
D. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.’
In DSM-5-TR (American Psychiatric Association 2022), FND is coded as ‘functional neurological symptom disorder (conversion disorder)’ (360), and it no longer requires the presence of clear psychological factors, similar to ICD 11 (Box 1).
In this article, we give an overview of the condition and discuss how liaison psychiatrists could approach it in an acute hospital.
Types of functional neurological disorder
Several subtypes of FND are identified in the literature and observed clinically (Hallett Reference Hallett, Aybek and Dworetzky2022), although these can manifest in a variety of often overlapping ways:
-
functional seizures can be with or without movement and manifest differently from epileptic seizures;
-
functional movement disorders include functional limb weakness, functional tremor, functional dystonia, functional gait disorder and functional myoclonus;
-
functional sensory disorders may present with altered or loss of sensation or with a variety of visual symptoms;
-
functional communication, swallowing and cough disorders present with a sense of loss of voluntary control of functions related to swallowing, language, voice, speech, breathing or cough (Baker Reference Baker, Barnett and Cavalli2021);
-
in functional cognitive disorders, cognitive symptoms tend to cause distress and are not better explained by other conditions;
-
functional dizziness (persistent postural-perceptual dizziness) describes non-spinning vertigo and unsteadiness, and is exacerbated by motion or exposure to moving visual stimuli.
The two most common on this list are functional seizures and functional movement disorders (National Institute of Neurological Disorders and Stroke 2024).
Policy and guidance
Healthcare policy documents in recent years often use the broader and older term of medically unexplained symptoms (MUS) and link the topic to long-term physical health conditions (Naylor Reference Naylor, Galea and Parsonage2012). The No Health Without Mental Health report identified that this group of disorders was costing the National Health Service (NHS) in England £3 billion every year and called for access to psychological therapies, as well as identification of comorbid depression and anxiety (HM Government 2011).
National Institute for Health and Care Excellence (NICE) guidance on the identification of neurological disorders describes several functional neurological conditions and suggests that people who suffer with them might benefit from an understanding that their symptoms are likely to fluctuate and evolve over time and that acceptance of this may reduce the overall load on clinical services (NICE 2019). NICE quality standards note that patients should be supported to manage symptoms of the disorder in non-specialist care (NICE 2021). NICE has produced scenario guidance on how to manage FND in primary care that also suggests useful phrases to explain the condition (NICE 2024).
In 2023, the National Neurosciences Advisory Group (NNAG), a working group of specialist clinicians, allied health professionals and charity representatives, attempted to identify the optimum clinical pathway for adults with FND (NNAG 2023). The group described specific clinical challenges for this highly heterogeneous cohort of patients and – contrary to the NICE quality standards – advocated for regional centres providing specialist FND care. They emphasised the need for a positive, ‘swift and well-explained diagnosis’ (NNAG 2023: p. 4) and a fully integrated pathway that relies on a good understanding of the condition as well as on efficiency and expertise.
Assessing FND as a liaison psychiatrist in an acute hospital
Patients with a suspected or confirmed diagnosis of FND who are referred to an acute hospital’s mental health liaison team have often already seen a number of professionals from various disciplines and specialties. The liaison team’s role is multifaceted and key for the patient, but also for the treating team on the ward. Their involvement is usually subsequent to that of the neurologist, the specialist who commonly makes the formal diagnosis, which should be based on positive criteria from history and examination (NNAG 2023). Sharing expertise between the two disciplines is encouraged for the achievement of a good outcome (McKee Reference McKee, Glass and Adams2018). In light of common service provision challenges in the NHS, however, other physicians with a professional interest and experience in FND care may offer a diagnosis with confidence.
Pre-consultation
Before the consultation, a thorough review of the patient’s notes and preceding investigations is essential. The patient’s consent for the assessment should be obtained as an important first step, and sufficient uninterrupted time to complete the assessment should be allocated, maintaining confidentiality. Ambiguity regarding the rationale for the liaison psychiatrist’s involvement is not uncommon, in our experience. Explaining that a psychiatric assessment is essential for a holistic approach, and not because of a direct link between the patient’s symptoms and their mental health, is important and will form the basis for a good therapeutic relationship. Acknowledging the impact their symptoms may have on their mental health may also add to their understanding of the liaison psychiatrist’s role.
The assessment
History taking and clinical evaluation
A holistic and trauma-informed assessment that is attuned to the bodily, psychosocial, spiritual and cultural aspects of the patient’s experience should take place. Within the history of the presenting complaint, the assessor should begin with a comprehensive exploration of the presenting symptoms (Gilmour Reference Gilmour, Nielsen and Teodoro2020) before moving on to a standard psychiatric and risk assessment. Symptom characteristics such as internal inconsistency will support a diagnosis of FND (Mavroudis Reference Mavroudis, Kazis and Kamal2024), which during a subsequent physical examination may also be complemented by positive clinical signs (see ‘Positive clinical signs’ below). In addition, skilfully differentiating features of FND from other psychiatric pathology is an important task for the liaison psychiatrist (e.g. identifying somatic hallucinations as a symptom of psychosis).
The liaison psychiatrist has expertise in identifying possible precipitating psychosocial factors that will require clinical attention both in the context of FND and in terms of significant psychiatric comorbidity, alongside or preceding the diagnosis of FND. Common comorbid psychiatric conditions predominantly include anxiety, depression, personality disorders and post-traumatic stress disorder (PTSD) (Patron Reference Patron, Rustomji and Yip2022).
During the consultation, certain personality traits, behaviour patterns, a specific history of trauma or significant adverse events may emerge. Although these should subsequently be considered for the broader clinical formulation and the corresponding multidisciplinary personalised treatment plan, in our experience, detailed exploration of possible underlying psychological trauma is not helpful at this stage, unless voluntarily offered by the patient. Patients’ explanatory models lean towards somatic causation and hence, in our view, clinicians’ validation, acceptance and recognition that the individual’s symptoms are real is important at this stage and a foundation for therapeutic alliance.
Neurodevelopmental considerations
Neurodevelopmental factors have also been explored in relation to FND. Individuals with autism spectrum disorder (ASD) report a significantly higher prevalence of functional neurological symptoms, and tactile hypersensitivity has been identified as a risk factor for functional weakness and paraesthesia (Nisticò Reference Nisticò, Goeta and Iacono2022). Conversely, emerging evidence suggests that around 10% of individuals with FND also meet criteria for ASD, with overlapping features in sensory processing, motor control and emotion regulation (Gonzalez-Herrero Reference Gonzalez-Herrero, Happé and Nicholson2024). Although this association appears clinically significant, further research is needed to establish causality and inform tailored interventions. Attention-deficit hyperactivity disorder (ADHD) has also been linked to functional tics and seizures, although the evidence remains largely qualitative and prevalence data are limited (Staunton Reference Staunton, Rudrappa and Rathnaiah2024). Although inconclusive, these findings underscore the importance of considering neurodevelopmental comorbidities in the assessment and management of FND.
Investigations
Besides the neurological clinical evaluation and the identification of the positive clinical signs of FND, only a few types of investigation have been proven to be of clinical use. These include the use of electroencephalogram (EEG) and video EEG assessments to differentiate between functional seizures and epilepsy (Varley Reference Varley, Sweetman and Brabyn2023), with only the former being usually available in an acute hospital. Time-locked electromyography (EMG) may be a useful tool in identifying cortical myoclonus if a temporal relationship between an EEG discharge and a muscle jerk is shown (Tassinari Reference Tassinari, Rubboli and Shibasaki1998). Newer diagnostic tools and research biomarkers that have been suggested, include the use of smartphone video (with consent and solely for diagnostic purposes), wristwatch accelerometers and post-ictal plasma proteins to identify functional seizures (Hallett Reference Hallett, Aybek and Dworetzky2022).
The patient’s understanding, hopes and expectations
For some individuals their interaction with the healthcare system has been extensive, negative or even traumatic. The impact of their symptomatology on their functioning, personal relationships and family lives may have also been substantial. The liaison psychiatrist is often the first person to offer adequate space for their anguish to be voiced and to expertly help them understand and navigate their challenging circumstances.
After completing the assessment, bearing in mind the limitations of an acute hospital setting, the assessor should focus on the patient’s understanding of their condition and offer a clear explanation of the diagnosis. As they reach a formulation, the assessor should also aim to discuss the patient’s hopes and expectations of achieving a better quality of life. These are essential aspects of the assessment that are often overlooked in a hospital setting – hence, the wealth of experience and skill a liaison psychiatrist can bring is noteworthy.
Key takeaways on the assessment process
-
Review all available notes carefully.
-
Give sufficient time for the consultation.
-
Take a comprehensive history of the symptoms, focusing on positive signs of FND.
-
Do not rush into the exploration of a possible trauma in the personal history.
-
Explore the patient’s understanding, hopes and expectations.
-
Validate through the acceptance and recognition of the reality of the somatic nature of the complaints and corresponding explanatory model.
Specific clinical features
The overlap between FND and organic conditions: diagnostic challenges
Recent research highlights the convoluted relationship between FND and organic conditions, emphasising the risk of misdiagnosis in both directions. The rate of misdiagnosing an underlying neurological disease as FND is commonly cited as approximately 4% (Stone Reference Stone, Smyth and Carson2005), which may reassure clinicians about missing an organic condition. Conversely, misdiagnosing FND as another neurological disorder has been cited as occurring at a lower rate, around 0.4% (Walzl Reference Walzl, Carson and Stone2019).
The findings from a state-of-the-art literature review conducted by Aybek & Perez (Reference Aybek and Perez2022) point towards the ‘possibility that the patient has both FND and another neurological condition’.
Multiple sclerosis is particularly notable in this diagnostic overlap, as it is one of the most frequently mistaken conditions in both directions. In one study, FND accounted for 11% of 110 patients who were initially misdiagnosed with multiple sclerosis. These individuals not only received unnecessary disease-modifying therapy, but also experienced avoidable morbidity, and four were even enrolled in a clinical trial (Solomon Reference Solomon, Bourdette and Cross2016). Beyond the risks associated with misdiagnosing multiple sclerosis, this bidirectional diagnostic challenge can also contribute to delays in the appropriate recognition and management of FND itself (Walzl Reference Walzl, Solomon and Stone2021).
Similarly, FND is a well-recognised stroke mimic, accounting for approximately 8% of suspected stroke cases in recent studies (Popkirov Reference Popkirov, Stone and Buchan2020). Given the proven safety of thrombolysis in stroke mimics, it is reasonable to withhold the intervention only if there is high certainty of a functional stroke mimic, based on clear clinical signs and normal imaging. If uncertainty remains and ischaemic stroke is possible, stroke treatment should proceed because of the limited therapeutic window, while still acknowledging the potential for a functional disorder (Popkirov Reference Popkirov, Stone and Buchan2020).
Functional seizures (also known as non-epileptic or dissociative seizures) are the most frequently misdiagnosed paroxysmal events in epilepsy, profoundly affecting patients’ quality of life and functional outcomes (Baslet Reference Baslet, Seshadri and Bermeo-Ovalle2016). The diagnostic approach has shifted from exclusion of epilepsy to the recognition of distinct clinical features of FND, with emerging technologies such as artificial intelligence showing promise for improving diagnostic accuracy (Vijay Reference Vijay and Reuber2024). Current research conceptualises non-epileptic seizures as a disorder involving dysfunctional brain network interactions, accounting for the heterogeneity in clinical presentation and associated psychopathology. The biopsychosocial model is increasingly emphasised, with evidence linking non-epileptic seizures to heightened physiological arousal and impaired cognitive processing (Reuber Reference Reuber and Mayor2012). The high prevalence of psychiatric and medical comorbidities, alongside increased mortality risk, underscores the necessity of a multidisciplinary, integrative approach to management (Vijay Reference Vijay and Reuber2024).
Advances in neuroimaging and a deeper understanding of FND’s multifaceted nature may improve diagnosis and treatment (Mavroudis Reference Mavroudis, Kazis and Kamal2024). However, liaison psychiatrists must remain vigilant in the differential diagnosis of FND, as the condition imposes significant healthcare costs, comparable with hard-to-treat neurological diseases. Enhancing clinical skills and following updated diagnostic criteria are essential for reducing misdiagnosis rates. Also, clinicians should be mindful that patients may have both FND and another neurological disorder, as observed in both Parkinson’s disease (Wissel Reference Wissel, Dwivedi and Merola2018) and multiple sclerosis (Walzl Reference Walzl, Solomon and Stone2021).
Positive clinical signs
Although bedside neurological examination is not routinely included in mental health assessments, it can be valuable to be aware of the clinical signs associated with FND and how to distinguish it from organic neurological conditions (Box 2). These features have been studied for their diagnostic utility, demonstrating high specificity (92–100%) but variable sensitivity (8–100%) in distinguishing FND from organic disorders (Aybek Reference Aybek and Perez2022). The wide range of values suggests it would be a diagnostic pitfall to rely on a single clinical sign to diagnose FND (Box 3). Instead, multiple positive signs should be considered together to increase diagnostic confidence. Further research could assess the benefits of creating a diagnostic score, but we would be wary of diminishing the role of clinical history and over-relying on numerical values.
Positive clinical signs of functional neurological disorder
Functional weakness:
-
Hoover’s sign: involuntary movement of the weak leg when testing the opposite leg
-
inconsistencies in weakness on formal versus spontaneous movement
-
give-way weakness (sudden collapse of muscle resistance).
Functional movement disorder:
-
tremor entrainment (tremor changes with distraction or rhythmic tasks)
-
inconsistency between voluntary and automatic movements.
Functional seizures:
-
lack of post-ictal confusion in functional seizures
-
asynchronous limb movements, side-to-side head shaking
-
eye closure during seizures (uncommon in epilepsy).
Functional sensory loss:
-
non-anatomical sensory loss (does not follow dermatomal distribution).
Functional visual loss:
-
tubular vision rather than the normal conical vision – this means that the width of the visual field remains the same at different distances (e.g. the field at 150 cm is the same as at 50 cm), which defies the expected increase in field diameter with distance according to the laws of physics;
-
‘spiralling’ visual fields may be observed during Goldmann perimetry – this phenomenon occurs when the visual field becomes progressively more constricted as the test continues, leading to a narrowing pattern.
(Adapted from Stone Reference Stone, Burton and Carson2020)
Diagnostic pitfalls in functional neurological disorder (FND)
Common reasons for misdiagnosis:
-
overemphasis on psychological comorbidity rather than positive clinical signs
-
misjudging symptoms (e.g. gait disturbances, episodes) as ‘bizarre’ instead of recognising typical FND patterns
-
relying on single signs instead of assessing collections of features
-
assuming that it is FND if laboratory or imaging results are normal or that it is not FND if results are abnormal.
Common reasons for missed diagnosis:
-
assuming FND cannot be present without a trauma, psychological comorbidity or prior functional disorders
-
overlooking FND in patients who do not fit stereotypes (e.g. male, older, employed).
Key takeaway:
FND should be diagnosed positively, based on characteristic clinical features, rather than by exclusion.
(Adapted from Stone Reference Stone, Burton and Carson2020)
Notably, the requirement for a preceding psychological stressor or the presence of associated psychological factors has been removed from both the ICD-11 and DSM-5-TR diagnostic criteria for FND. However, it is still important to be aware that studies have found that people with FND report significantly more adverse life experiences compared with those with organic neurological disorders (Karatzias Reference Karatzias, Howard and Power2017).
Differentiating FND from other mental disorders or malingering
Functional neurological disorder is defined by involuntary symptoms that resemble neurological deficits despite the absence of identifiable structural pathology. In contrast, ICD-11 bodily distress disorder (DSM-5-TR somatic symptom disorder) also involves unintentional physical symptoms, but presents more broadly rather than as neurological deficits, often involving various somatic symptoms that cause preoccupation.
Hypochondriasis, on the other hand, is characterised by a preoccupation with the fear of having a serious illness. Psychosis, PTSD and anxiety/panic disorders can also present with features that may require differentiating those conditions from FND.
Factitious disorder involves deliberately producing symptoms without external incentives, whereas malingering, which is not a mental illness, is symptom fabrication for secondary gain, such as financial compensation. It is very important that the differentiation of FND from symptom feigning happens early on, to support improved outcomes, pathways and attitudes, both in clinical settings and in research (Edwards Reference Edwards, Yogarajah and Stone2023).
Managing FND as a liaison psychiatrist in an acute hospital
In our experience, the hallmark of good FND management, and what patients appreciate the most, is a well-coordinated multidisciplinary and individualised approach (Röhricht Reference Röhricht, Green and Filippidou2024) provided by clinicians who are adequately trained and experienced. The potential long-lasting benefits of specialised multidisciplinary team (MDT) in-patient programmes in tertiary centres are recognised (Demartini Reference Demartini, Batla and Petrochilos2014), and our clinical experience in an acute hospital’s less specialised setting shows the same. A concerted effort to reassure the patient that clinical experts are working together, utilising all available resources, is crucial for the individual’s recovery.
Formulation and management of psychiatric comorbidity
A comprehensive assessment of the patient’s symptoms, followed by a biopsychosocial formulation, explanation of the diagnosis and psychoeducation, are considered to be best practice for the management of FND (Aybek Reference Aybek and Perez2022). Attention should also be paid to symptoms that may be considered secondary (e.g. pain, fatigue or sleep disturbance) or comorbid to FND, including symptoms of mental illness (Gilmour Reference Gilmour, Nielsen and Teodoro2020). If comorbid mental illness has been identified, liaison mental health teams can offer both pharmacological and psychological treatment in the acute hospital, as well as form a plan for robust risk management and further support by mental health services in the community.
Utilisation of resources
The resources available for FND vary between hospitals, and whatever is available should be utilised appropriately and carefully.
Both cognitive–behavioural therapy (CBT) and psychodynamic psychotherapy can potentially benefit people with FND, primarily for secondary clinical outcomes (Goldstein Reference Goldstein, Robinson and Mellers2020), although studies of higher quality are needed (Gutkin Reference Gutkin, McLean and Brown2021). CBT can be introduced in an acute hospital, especially when liaison services have psychologists or therapists in their workforce. However, it is imperative to maintain a body-oriented approach, as focusing on holistic symptom management rather than an implied direct psychological causality will enable the patient to better understand and approach their condition (Röhricht Reference Röhricht, Green and Filippidou2024).
Evidence supports the use of occupational therapy and physiotherapy as part of the MDT approach to the management of functional movement disorders (Gardiner Reference Gardiner, MacGregor and Carson2018). Speech and language therapy can also be offered in an acute hospital if impaired swallowing or speech are prominent symptoms of FND. The importance of ultimately also developing a self-management plan is highlighted (Gilmour Reference Gilmour, Nielsen and Teodoro2020).
Discharge planning
The liaison psychiatrist should highlight the importance of careful discharge planning, which addresses common post-diagnosis pitfalls for the individual and the services. Key components include medication adjustments, adequate multidisciplinary follow-up (e.g. follow-up in the neurology clinic and by community occupational and physical therapists as an integral part of rehabilitation) attending to the patient’s social care needs, and good coordination of care post-discharge. Additionally, providing space for the individual to process the information and ask important questions is crucial (McKee Reference McKee, Glass and Adams2018). Careful signposting to specialist mental health services may also be required, where appropriate.
Iatrogenic harm
A review by Mcloughlin et al (Reference Mcloughlin, Lee and Carson2025) examined eight potential sources of iatrogenic harm in FND. These were: unnecessary medical treatment due to misdiagnosing FND as another condition; the psychosocial harm that follows from changing the diagnosis; delayed access to treatment and support due to a delayed diagnosis; direct harm and assault in medical settings; psychological harm due to stigma and disbelief of symptoms; misuse of the concept/diagnosis of FND; diagnostic overshadowing; and misdiagnosis of other conditions as FND and overdiagnosis of FND. These potential sources of harm are all important to consider in an acute hospital setting, and liaison psychiatrists are often best placed to be the patient’s advocates and identify any staff training needs.
Key takeaways on managing FND
-
A well-coordinated MDT approach is absolutely essential for the management of FND.
-
Clear explanation of the diagnosis, psychoeducation and management of comorbidity are key.
-
Utilise all available resources/disciplines in the acute hospital.
-
Be the patient’s advocate where needed.
-
Ensure that a holistic, body-oriented, person-centred approach is maintained.
-
Engage in comprehensive discharge planning, involving family and carers.
-
Avoid common sources of iatrogenic harm.
Psychoeducation
Psychoeducation in FND benefits patients, carers and families by providing a clear, compassionate and evidence-based approach. The goal is to help everyone understand the condition, encourage engagement with treatment and reduce fear. The initial step is a clear and appropriate explanation. When people understand why they are experiencing their symptoms, the experience can be less frightening. It is important to be mindful of how stigma may affect an individual’s perception of FND explanations (Staton Reference Staton, Dawson and Merdian2024).
Building a strong therapeutic rapport, conveying the diagnosis in simple terms and offering a disease model can help. It is important to validate the person’s experiences and assure them that their symptoms are real and not imagined.
Explain FND in simple terms
Functional neurological disorder develops when the brain has trouble sending and receiving signals properly, even though there is no structural damage such as in a stroke or multiple sclerosis. It is a real and common condition that affects how the body moves, feels and functions, and is related to an information processing difficulty in the brain. Treatment focuses on teaching how to retrain the brain – helping to bring movements, speech, thinking or other neurological symptoms back to normal function.
An easy analogy: the software versus hardware problem
In conditions like stroke and multiple sclerosis, there is ‘hardware’ (tissue/structural) damage. In FND, the ‘hardware’ (brain structure) is fine, but the ‘software’ (brain function and signalling) is glitching (Nhan Reference Nhan and Cheah2025). This can cause symptoms like weakness, tremors, seizures or numbness.
Explain the role of stress and past experiences
FND can develop after physical injuries, infections or emotional stress, but there may also be no clear trigger. Not all cases are related to psychological trauma, but understanding stress responses and the possible effect of thoughts, feelings and life experiences can be helpful.
Involve family and caregivers
Educating family members and caregivers is important so that they provide support without reinforcing disability. Discuss encouraging activity rather than avoidance and help them understand that FND is not voluntary or feigned.
Provide resources
Offer videos, brochures, internet links and support groups for further learning. Plan follow-up to reinforce education and address concerns over time.
Points to emphasise
The following points are gathered from neurologist Jon Stone’s website at neurosymptoms.org/en/symptoms/.
-
FND is real – it is not imagined or ‘all in your head’.
-
The symptoms are potentially reversible: the brain may be able to ‘retrain’ itself with the right treatment.
-
It is not the individual’s fault: symptoms are involuntary.
-
Why does this happen? The brain sometimes goes into ‘safe mode’ owing to stress, injury or unknown reasons, causing it to misfire signals.
-
There is good news: retraining the brain with physiotherapy, relaxation and movement techniques can help restore normal function and re-establish an equilibrium between mind and body.
Key takeaways on psychoeducation
-
Acknowledge the impact of the symptoms and distress these may cause, while avoiding dismissive language.
-
Reinforce that FND is a real, treatable condition affecting the central nervous system’s information processing.
-
Symptoms arise from functional changes, not structural damage.
-
Recovery is possible with support and treatment, including therapy and physical rehabilitation.
A journey with FND
This section has been written by someone with lived experience of FND. They wish to remain anonymous, but have given written consent to share their story.
The beginning
I have functional neurological disorder (FND). The day I was diagnosed was the first day I had ever heard of this condition. My first symptom started in August 2022, when on my way home from work, my chin began to move and twitch on its own. At the time, COVID was still lingering and using a facemask to disguise this unusual symptom from others was acceptable. When I returned home, I called the NHS 111 helpline for medical assistance. I was told that it could be stress and if it persisted to contact my GP [general practitioner]. For the next 2 weeks, I was on holiday from work and had no symptoms during this time. However, on my return to work, after 2 weeks the symptoms began again. First in my chin, then in my fingers. I contacted my GP, who planned to seek advice from a neurologist, but unfortunately in the days that I waited to hear the outcome of this discussion, the symptoms eventually spread to my entire body. For the next 4 months I was constantly in and out of involuntary movements, which shifted inconsistently around my body. It was a scary and uncertain time – I was unable to work and one of my main concerns was if I would ever work again. I had lost control of my body, it seemed my body and mind had disconnected from each other and I started to feel grief for the person that I was before this happened. I was off work for 6 months, while I tried to navigate this new world where I was ill. During this time, family would take care of me, which was an unfamiliar place, being dependent on others again. This was not just scary for me, but also for my family, who wanted to protect me.
Local hospital experience
In October 2022, my symptoms began to spread and I took myself to my local emergency department (ED). When I arrived, I was given an urgent red card and was told to go to the department’s waiting area. While I waited, my symptoms gradually spread to all different areas of my body, legs, arms, head, neck, tongue! I remained calm, until my symptoms moved to my head and neck, and I began to rattle the connecting chairs, along with the other patients sitting on them. I began to cry, the realisation that something might be wrong with me was setting in. I was aware that people were staring. A family member advocated for me to the nursing team and at this point, I was put in a wheelchair and taken for blood tests. I remember being asked more than three times if I had taken recreational drugs or antipsychotic medication. I remember how uncomfortable I felt when I had been asked this question so many times and after responding with ‘no’ twice, on the third occasion, a nurse responded for me.
I waited for 10 h to be seen that day, I can remember sitting on the examination bed with the curtain open, my family around me and the doctors and nurses not very far away at the nurse’s station, talking. I could hear staff talk about me, but when the symptoms worsened, no one came over. My symptoms were fast, faster than I would have voluntarily be able to move, if I had control. It wasn’t until my symptoms subsided that I was given an injection of medication for Parkinson’s disease. I was told that this hospital was unable to help me and that I needed to see a neurologist. I was told that the symptoms I was experiencing can be a side-effect of antipsychotic medication and that I could go home. I did not find this experience helpful, so I decided to video my symptoms in case I came across a professional in the medical field that could help me in the future.
How I got support
The Sunday after the trip to my local hospital, my symptoms began again, with violent tremors and erratic involuntary movements. I had also developed extreme fatigue and struggled to walk very far without feeling physically and cognitively exhausted. I could feel sensations such as pins and needles and numbness in my face and hands and the vibration from how fast my body would move. Prior to this, I looked up the top neurology hospitals in the UK, with the plan that when my symptoms worsened again, I would get in a taxi and go to the ED connected to one of these hospitals. This ended up being the best decision I ever made. By the time I got to ED, I was having trouble walking and a family member carried me into the reception. Staff rallied around, put me in a wheelchair and took me straight through to be seen. All steps were explained to me, even why they were asking the question about recreational drugs. The approach and care given in this ED and the rest of my journey in this hospital made me feel at ease and hopeful. Within 2 days, I was given a diagnosis by a neurologist and within 3 months I was on a 5-week out-patient rehabilitation programme for functional movement disorder. My postcode may have played a role in securing this level of support, as such input is not typically available. I was supported by a multidisciplinary team of professionals, such as a neuropsychiatrist, physiotherapist, occupational therapist, cognitive–behavioural therapist and support worker. I was finally being heard, seen and believed.
Box 4 summarises what I think is helpful and unhelpful in dealing with FND.
A patient’s perspective on what is helpful and unhelpful in functional neurological disorder (FND)
Helpful
-
Being heard and seen by professionals
-
Being understood and met with empathy
-
Being listened to
-
Remaining open minded to professionals’ suggestions for recovery
-
Pacing, prioritising and planning in recovery
-
Support in creating a relapse prevention plan
-
Being able to ask for FND support from the service in the future if needed
Unhelpful
-
Being told that it is all in your head and just a psychological issue
-
Staying in bed all day
-
Doing too much in one go without resting (boom and bust)
-
Being put in a group with those that have very different symptoms (e.g. seizures versus movement disorder) or whose symptoms are of a different severity
-
Professionals not listening or having time to hear what you have to say
-
Having to repeatedly explain your condition to professionals
Conclusion and future direction
Functional neurological disorder is a complex condition that bridges neurology and psychiatry, with ongoing challenges in diagnosis, multidisciplinary collaboration and stigma in acute hospital settings. Despite recent developments in care pathways via national guidance (NICE 2021; NNAG 2023), local variability in knowledge about FND and service accessibility remains a barrier to consistent care. Liaison psychiatrists play a key role in supporting patients, fostering teamwork and advocating for greater awareness and improved local care pathways.
A timely and early identification of FND comes from a thorough initial assessment (Gilmour Reference Gilmour, Nielsen and Teodoro2020) and recognising positive examination findings. Effective treatment begins with clear, compassionate communication, followed by early multidisciplinary involvement and smooth transition to community care. Prioritising local care ensures that individuals with long-term symptoms can access ongoing therapies, while preserving the viability of specialist services where there is diagnostic uncertainty, severe symptoms or poor response to the initial therapies offered locally.
Within hospitals, liaison psychiatry can drive targeted initiatives to improve patient flow from presentation to treatment. Embedding FND education into medical and allied health training is essential for improving recognition and reducing iatrogenic harm from misdiagnosis or dismissal.
Fostering a culture in which healthcare professionals readily recognise FND as a validated, treatable condition and equipping them with effective communication strategies can reduce patients’ distress and stigma and such things can make an ‘enormous difference’ to patient experience of healthcare systems and their trust in them (Cock Reference Cock and Edwards2018). Liaison psychiatry will remain important for identifying comorbid mental health conditions and facilitating communication among MDTs.
Early involvement of therapies like physiotherapy and speech therapy ensures they are well-integrated into the care pathway and easily accessible. A well-structured discharge plan can prevent unnecessary readmissions and ensure continuity of care through appropriate community referrals based on individual needs. In the long term, patients would benefit from a designated clinical contact, such as their GP, neurologist or care coordinator, for identifying relapses or new symptoms.
FND requires a nuanced, flexible approach, and there is no one-size-fits-all treatment plan (Gilmour Reference Gilmour, Nielsen and Teodoro2020). Liaison psychiatrists must advocate for improved clinical pathways, integrated care models and research into treatment strategies. With the right support, including self-help (Box 5), people with FND can achieve better symptom control and improved quality of life. It is the responsibility of policymakers, clinicians and researchers to ensure that FND care continues to advance in both policy and practice.
Online resources for patients, carers and families
-
FND Action: www.fndaction.org.uk
-
FND Dimensions: https://fnddimensions.org/
-
FND Guide: www.Neurosymptoms.org
-
FND Hope: www.fndhope.org
-
myFND app: https://myfnd.co.uk/
MCQs
Select the single best option for each question stem
-
1 The National Neurosciences Advisory Group identifies as one of its priorities:
-
a ensuring that an underlying trauma is identified in the patient’s history
-
b the need for a fully integrated pathway for FND
-
c that patients with FND should be seen by tertiary services only
-
d that FND should be considered a purely neurological disorder.
-
e none of the above.
-
-
2 Differential diagnosis in FND may include:
-
a stroke
-
b multiple sclerosis
-
c epilepsy
-
d factitious disorder
-
e all of the above.
-
-
3 From the patient’s perspective, it is helpful to:
-
a be told that FND is a psychological issue
-
b see professionals independently and not as part of an MDT
-
c know that the somatic nature of the complaints is validated
-
d be advised to forget about their previous life and stay in bed to recover
-
e none of the above.
-
-
4 Psychoeducation is about:
-
a telling the patient that it is ‘all in their head’
-
b helping the patient understand that their brain is damaged
-
c explaining FND in simple terms and in the context of the patient’s presentation and individual circumstances
-
d educating only carers
-
e explaining that FND is related to stress.
-
-
5 Positive clinical signs of FND include:
-
a Hoover’s sign in limb weakness
-
b tremor entrainment
-
c lack of post-ictal confusion
-
d tubular vision in visual loss
-
e all of the above.
-
MCQ answers
-
1 b
-
2 e
-
3 c
-
4 c
-
5 e
Data availability
Data availability is not applicable to this article as no new data were created or analysed in this study.
Author contributions
M.F. conceived the idea for this article. All authors contributed to the article’s design and content. M.M. also edited the article prior to submission and assisted M.F. with its first revision. F.R. also provided a senior overview of the article and a critical review for important intellectual content. All authors reviewed the article prior to submission.
Funding
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Declaration of interest
None.
eLetters
No eLetters have been published for this article.