Functional Neurological Disorder (FND)

Learning guide
 Written by:
Phuong Nhan, Registered Nurse
Vincent Cheah, Registered Nurse
Reviewed by:
Dr Alexander Lehn, Neurologist
Dr Megan Broughton, Neuropsychologist
Dr Rian Dob, Neuropsychologist
Dharsha Navaratnam, Physiotherapist

Our Mission
In the spirit of the Sisters of Mercy, the
Mater Hospital offers compassionate service
to the sick and needy, promotes an holistic
approach to healthcare in response to
changing community needs and fosters
high standards in health-related education
and research. Following the example of
Christ the healer, we commit ourselves
to offering these services to all without
discrimination.

Our Values
Mercy: The spirit of responding to
one another
Dignity: The spirit of humanity,
respecting the worth of
each person
Care: The spirit of compassion
Commitment: The spirit of integrity
Quality: The spirit of professionalism

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Contents

Functional Neurological Disorder learning guide 4

Aim ......................................................................................................... 4
Guide outline........................................................................................... 4
Introduction to FND 5
What is FND?........................................................................................... 5
A brief history of FND............................................................................... 5
Glossary of key terminologies 6
Who is at risk? 7
Symptoms of FND 8
Functional motor disorders ...................................................................... 8
Dissociative attacks................................................................................... 8
Assessment for FND patients 9
Barriers to effective assessment................................................................. 9
Obtaining patient’s history........................................................................ 9
Assessment for specific symptoms ......................................................... 10
DSM-5.................................................................................................... 11
Are patients making it up? ..................................................................... 12
FND under Imaging 13
Caring for patients with FND 14
Explanation of diagnosis......................................................................... 14
Allied health........................................................................................... 15
Medications............................................................................................ 15
Psychiatry/psychology............................................................................. 15
Other treatments.................................................................................... 17
Aids and appliances................................................................................ 17
Disability benefits................................................................................... 17
The nursing role in FND 18
Transference........................................................................................... 21
Countertransference............................................................................... 21
When the patient does not get better 23
Additional resources 24
References 25
Appendices 26
Appendix 1: Answers to difficult questions for FND patients................... 26

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Functional Neurological Disorder learning guide

Aim
The aim of this guide is to provide new nursing staff and graduates an understanding of
functional neurological disorder (FND). The guide breaks down the symptoms, assessment
progress and treatment for FND.

Guide outline
• Introduction to FND

• Key terminologies

• Risk factors

• Symptoms of FND

• Assessment of patients with FND

• Caring for FND patients

• Transference and countertransference

• Important contacts and FND resources

• References

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Introduction to FND

What is FND?
Functional neurological disorders (FND) comprise of somatic symptoms such as blackouts,
paralysis and abnormal movements that suggest the presence of an underlying neurological
condition but none of the symptoms are explained by diseases. FND is caused by a complex
combination of biological, psychological and social factors on the brain [6,10].

A brief history of FND

Symptoms of FND date back to the 18th century, neurologists were perplexed as it became
clear that functional symptoms had no detectable neuropathology. This gave rise to assimilating
FND with ‘feigning’ or deducing that FND was a by-product from mental disorders. The terms
‘conversion disorder’ or ‘hysteria’ were therefore coined to describe this transition [7].
FND is still described as a ‘crisis’ among neurologists today. Some authors have interpreted FND
as a primitive iconic language in which different symptoms have particular meanings. Others have
argued that it would be better to conceptualise functional disorders with different symptoms as a
single functional somatic syndrome [7,11].
Due to the complexity in understanding and diagnosis, neurologists are beginning to integrate
positive signs of FND in presenting clinical symptoms and the patient’s psychological background
upon assessment.
Neurology is associated closely to psychology and psychiatry. All three specialties focus on the
functions and disorders of a single organ, the brain. The notion that many of us in neurology
have—that only a small subset of neurological disorders has a significant psychological/psychiatric
dimension—is false. A neurological examination involving sensory and motor processes should
therefore take into account of psychological, behavioural and social factors to be considered
adequate. Psychosocial involvement among patients with disorders of the central nervous system
is a rule, not an exception [1].
Patients with FND often come from complex psychological backgrounds, so it is important for
healthcare workers to be aware of the correlation between these disciplines. The physical and
psychological symptoms of disease can be related in the following ways [1]:
• Physical symptoms come to light by way of complex psychological processes.

• Psychological upset can manifest itself as physical symptoms.

• Physical disease commonly causes a secondary psychological reaction.

• Physical diseases affecting the brain can give rise, more or less directly, to psychological
manifestations.
Despite not being well understood by many, FND is exceptionally prevalent. One third of
presentations in neurology clinics, both outpatients and inpatients, are patients suffering from
FND. Female patients are three times more common than male. FND is also common in young
children and adolescents (two-fold more common in female), representing between 2-10% of
patients seen in paediatric clinics [2,13].

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Glossary of key terminologies

• Functional: Implies the problem culminates from a change in function (in the
context of FND—the nervous system) rather than structure.
• Hysteria: An ancient term that describes a complex neurosis where psychological
conflicts manifests into physical symptoms.
• Dissociative disorders: Indicates dissociation as the main mechanism in
symptom manifestation. Dissociation has numerous definitions, but in the context
of FND refers to two particular phenomena that will be explored in further detail
later: derealisation and depersonalisation.
• Psychogenic: Suggests that symptoms are psychologically influenced.

• Conversion disorder: Proposition based on the idea of conversion from mental

distress to physical symptoms.
• Health Anxiety/Hypochondriasis: Excessive anxiety about the possibility of
a serious disease and stressing over minor symptoms. Patients typically seek
reassurance from medical professionals but the effects are short lived.
• Factitious disorder: When patients intentionally fabricate symptoms for
obtaining medical care.
• Malingering: Making up symptoms for material gain (healthcare, benefits, fraud).

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Who is at risk?

No single mechanism has been identified as sufficient to explain the onset of FND but rather
several interacting factors. Predisposing factors increase the patient’s vulnerability to FND.
Precipitating factors include historical and immediate precipitants. Perpetuating factors maintain
or exacerbate the problem. Table 1 lists some of the possible factors that contribute to the
development of FND [10,11].

Factors Biological Psychological Social

Factors acting • ‘Organic’ diseases • Emotional disorder • Socio-economic/

at all stages deprivation
• Female gender • Personality disorder
• Life events and
• History of previous
difficulties
functional symptoms

Predisposition • Genetic factors • Perception of • Childhood

(Vulnerabilities) affecting personality childhood experience neglect/abuse
as adverse
• Biological • Poor family
vulnerabilities in the • Personality traits functioning
nervous system
• Poor attachment/ • Symptom modelling
coping style of others

Precipitants • Abnormal • Perception of life • Bereavement

(Triggers) physiological event event as negative/
(drug side effect, unexpected
hyperventilation,
• Acute dissociative
sleep deprivation)
episode/panic attacks
• Physical injury/pain

Maintaining • Plasticity in CNS • Illness beliefs • Social benefits

Factors motor and sensory of being ill
• Perception of
pathways leading to
symptoms as being • Availability of legal
habitual abnormal
irreversible compensation
movements
• Not feeling believed • Ongoing medical
• Deconditioning
investigations and
• Perception that
• Neuroendocrine uncertainty
movement will
and immunological
cause damage • Excessive reliance on
abnormalities similar
sources of information
to those seen in • Avoidance of
or group affiliation
depression/anxiety symptom provocation
which reinforce beliefs
• Fear of falling that symptoms are
• Hypochondriasis irreversible and purely
physical in nature

Table 1: Potential aetiological factors in patients with FND [10,11]

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Symptoms of FND

Despite having no physical explanations for the symptoms, patients are not imagining or feigning
their disorder. Currently, the two most common subgroups of FND are:

Functional motor disorders

Patients display a range of debilitating physical symptoms including:
• Limb weakness

• Dysphagia

• Chronic pain

• Sensory symptoms

–– Visual disturbances

–– Cognitive symptoms

• Tremor

• Dystonia

• Gait disorders

• Fatigue

These symptoms are unexplained by any organic disorders [6,13,15].

Dissociative attacks
Often referred to as non-epileptic seizures/attacks, these episodes involve altered movements,
sensations or experiences that closely resemble epileptic seizures but are not associated with ictal
electrical discharges in the brain. The most common semiology are excessive moments of limbs,
trunk and head that loosely portray tonic-clonic seizures; stiffening, tremor, atonia and loss of
responsiveness may also occur [10,11].
The driving force behind these attacks is dissociation. This is frequently a behavioural
response to mental, physical (including sensory overload) or social stress characterised by
depersonalisation and derealisation. Depersonalisation refers to the feeling of disconnection
from the body of thoughts; derealisation is the disconnection from the surrounding; and
dissociation is the blanket term [12].

It is inadvisable to refer to dissociative attacks as ‘non-epileptic’ or ‘seizures’ as this may

give the impression of epilepsy for FND patients. This will stem the belief that anti-epileptic
medications will alleviate their symptoms when this is not the case.

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Assessment for FND patients

Incongruities can arise with physical examinations as they often appear normal or inconsistently
abnormal. Neurological assessments therefore should be thorough and not be regarded as
prelude to treatment but rather the first stage of treatment itself. Assessment is not only
for obtaining information but also aims to enable the patient to feel unburdened and gain
confidence in their treatment team [14].

Barriers to effective assessment

Patients with FND have often had bad experiences when seeking help, common reasons include [14]:
• Not getting the chance to describe their symptoms, cause and discussion of potential
treatment.
• Feeling that symptoms were dismissed or disbelieved.

• Perception that the doctor was adamant on finding a psychological problem to pin their
symptoms on.
• Not being given enough time.

Obtaining patient’s history

Keeping potential unpleasant previous experiences for the patient in mind, some therapeutic
suggestions for obtaining history include [12,13,14,15]:
• Cover all symptoms: Ask about fatigue, pain, sleep and concentration. The more
symptoms the patient has, the more likely it is that the primary symptoms will not be due to
a recognised disease.
• Ask about dissociation: Dissociative symptoms are common in panic attacks and persistent
fatigue but can be experienced in isolation. They are especially common in patients with
dissociative attacks and patients with sudden onset functional motor symptoms. Patients are
rarely able/willing to describe these symptoms spontaneously, partly because they do not know
which words to use but also the fear that the clinician will think that they are mad. Therefore,
it may be necessary to ask direct questions to reveal these symptoms. A patient discussing
dizziness or spinning may actually be describing dissociative symptoms.
• Ask what the patient think may be wrong and what should be done: Does the patient
have any thoughts on why they have their symptoms? What does the family/friend think?
Does the patient think they have epilepsy or Lyme disease? Take note if you are aware of this
to tailor your explanation for later. The discussion becomes therapeutic when the patient or
family experiences relief by getting their worst fears and concerns out into the open. Find
out if the patient actually wants to try to get better or did they only present because their GP
referred them? What do they think will help? It is difficult to treat patients who do not want
or who are not motivated to improve.
• What happened on previous experiences: If the patient tells you their previous doctor
told them that the symptoms were ‘all in their mind’, it is an indicator that the patient may
be sensitive to psychological questions.

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• Be mindful of ‘psychological’ questions: It may be tempting to dive into questions about
depression, anxiety or stress, however it is not always necessary. Questions about prior
psychological trauma such as physical or sexual abuse may be unnecessarily intrusive on the
first assessment unless the patient specifically wants to discuss it. If these things are required to
be discussed, it is best to wait until the patient has gained confidence in their treatment team.

Assessment for specific symptoms

Assessment for specific functional neurological symptoms is a complex task and is most
commonly performed by neurologists. There are many tests for functional motor disorders due to
its broad nature. One example is the Hoover’s sign which tests for functional lower limb weakness
(Figure 1) [6,14].

Test hip extension hip extension is weak Test contralateral hip flexion against resistance—
hip extension has become strong

Figure 1: Hoover’s sign is one of many tests to examine functional motor symptoms [6]
In terms of dissociative attacks, video-encephalogram (VEEG) is the gold standard diagnostic
tool. Approximately 50% of patients will experience an attack during a short monitoring session,
especially those who have ‘medical settings’ as a trigger. However, a normal surface ictal EEG
during a dissociative event does not exclude epilepsy [5,13,14].
There have been cases where prolonged dissociative attacks were mistaken for status epilepticus
(life-threatening persistent epileptic seizures) and the patient was wrongly hospitalised to receive
unnecessary and potentially life-threatening interventions. It is therefore imperative that the two
are clearly distinguished (Table 2) [13].

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Distinguishing features Dissociative events Epileptic seizures

Duration over 5 minutes Common Rare

Gradual onset Common Rare

Eyes and mouth closed Common Rare

Resisting eye opening Common Very rare

Post ictal weeping/upset Occasional Rare

Side-to-side head movements Common Rare

Respiration Often fast Ceases

Grunting sound Occasional Common

Recall for period of

Common Very rare
unresponsiveness

Aura Common Common

Attacks rising from sleep

Occasional Common

Table 2: Dissociative attacks versus epileptic seizures [14]

DSM-5
The most recent model of the diagnostic and statistical manual of mental disorders (DSM-5)
removed both the requirement for a ‘recent psychological stressor’ as well as ‘the need to exclude
feigning’ when it comes to diagnosing FND [8].

DSM-5 criteria for functional neurological disorder

1. One or more symptoms of altered voluntary motor or sensory function.

2. Clinical findings provide evidence of incompatibility between the symptom and recognised
neurological or medical conditions.

3. The symptom or deficit is not better explained by another medical or mental disorder.

4. The symptom or deficit causes clinically significant distress or impairment in social,

occupational, or other important areas of functioning or warrants medical evaluation.

Table 3: DSM criteria for FND [14]

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 Are patients making it up?
Unfortunately, patients who stimulate symptoms solely to obtain medical care do exist but
they only account for some 5% of hospital presentations in the FND cohort. The main clues in
recognising malingering or factitious disorders are [13]:
• Inconsistency in the history on different hospital admission (between patient, doctors or
relatives).
• An admission from the patient who has been dishonest in the past.

• Deliberate avoidance of tests.

• A direct confession.

• Evidence of gross inconsistency between proclaimed symptoms and covert surveillance

(a patient with bilateral lower limb weakness seen running).
• Stimulation of symptoms that mimic disease very closely (displaying head aversion and tonic
clonic movements in a dissociative attack) or mimicking the symptoms of other patients.

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FND under Imaging

Progress has been made in understanding the mechanisms of FND. Several recent imaging studies
have attempted to gain a better understanding of the neural basis of FND [4].
A recent study has detected a pattern of activation involving basal ganglia and the cerebellum
in patients with functional dystonia in contrast to ‘organic’ dystonia where the activation lies in
the primary motor cortex. Furthermore, patients with functional dystonia may share features with
a right parietal lobe syndrome named ‘xenomelia’, where healthy individual actively seek limb
amputations. Magnetoencephalography studies have revealed reduced activation of the right
superior parietal lobule during sensory stimulation of the affected limb, a brain region associated
with body image and out-of-body experiences [4].
A functional MRI study showed greater activity in limbic structures (right amygdala, left anterior
insula and bilateral posterior cingulate area) and decreased activity in the left supplementary motor
area (SMA) during a motor preparation task in FND patients compared to a healthy control group.
This indicates a possible mechanism of abnormal emotional process that is actively interfering with
normal motor planning. Additionally, the left SMA had lower functional connectivity with bilateral
dorsolateral prefrontal cortex regions during internally versus externally generated movements,
providing evidence for impaired top-down regulation of action selection [4,8].
Other subsequent studies have supported this functional connectivity between the SMA and the
amygdala. One functional MRI study in particular using emotional stimuli to induce stress found
enhanced activity in the amygdala in FND patients compared to healthy control group [8].

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 Caring for patients with FND

Explanation of diagnosis
The first step to successful management of functional symptoms is the appropriate explanation
from healthcare professionals. Current expert opinions stress the importance developing good
rapport with the patients. This means communicating the diagnosis in clear terms and providing a
disease model that enables the patient to clearly comprehend their symptoms [6,13].
Most patients will want to know the cause of their symptoms. Explaining the diagnosis in a
transparent, rational and non-offensive manner is crucial. This can be adequate in producing
improvements in patients.
There is no “one size fits all” solution. Nevertheless, common pointers towards a successful
explanation are listed below [6,12,13,14]:
• Explain what they do have: “You have a functional weakness.” It is advisable to emphasise
on the mechanism of the symptoms rather than the cause. For example: “Your nervous system
is not damaged but it also isn’t working properly (functional weakness)” or “You are going
into a trance-like state, like being hypnotised (dissociative attacks)”
• Metaphors and comparisons can be helpful: “Imagine the hardware of a computer is
intact but there is a software problem”; “It’s like a piano that is out of tune”; “Something
similar to a short circuit on your nervous system (dissociative attacks)”; “It is the total opposite
to phantom limb where they can feel a limb that is not there, you cannot feel one that is
(functional weakness).”
• Indicate that you believe them: The key concern for patient with FND is often that their
treating team do not believe them or think they are mad/imagining/feigning their symptoms.
If this is noted, something as simple as “I do not think you are imagining or putting on the
symptoms” can be very effective in building rapport.

This is especially important as there is good evidence suggesting patients with FND often
feel disbelieved by their therapists and are understandably angry when their symptoms
are not taken seriously. Many will then look elsewhere for a diagnosis, thus, consuming
further resources in second opinions and unnecessary investigations.

• Explain what they do not have: Emphasise the disorders that the patient does not have to
alleviate health anxiety. For example: “You do not have epilepsy, stroke, etc.”
• Emphasise that it is common: “I see lot of patients with similar problem” is often enough to
reduce the sense of alienation.
• Emphasise reversibility: For example: “Because there is no damage, you have the potential
to get better.”
• Emphasise self-help: Encourage the patient to feel the sense of empowerment over their
symptoms. For example: “This is not your fault and there are things you can do to help you
get better.”
• Use supporting information: Give the patient some written information or direct them to
other resources (figures 1-3, page 23).

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• Explore the psychiatric spectrum: Use your clinical judgement to assess whether this will
be helpful or not, especially at an early stage. Explain to the patient that psychiatric disorders
(depression/anxiety/stress) can worsen the condition. Patients who do not show signs of
responding to treatment may benefit from psychological/psychiatric involvement.
• Talk to family and friends: Explain and reinforce the diagnosis with the patient’s family and
friend to enhance understanding.
Appendix 1 (page 24) is a template on how to answer difficult questions from FND patients by a
psychologist at the Mater with clinical interest in FND.
For patients with mild FND symptoms, explanation, reassurance and encouragement to reengage
in their normal daily activities may be sufficient to facilitating good recovery.
Unfortunately, there will be patients who will present with more persistent symptoms and will
require more extensive treatments.

Allied health
Patients with physical symptoms (gait disturbance, weakness, paralysis, dystonia, etc.) will often
need physical treatment. Allied health professionals including: speech pathologist, occupational
therapists and physiotherapists then becomes integral to the patient’s recovery process [6].
Neuro-physiotherapists can offer education, movement retraining and self-management
strategies. Recent research has demonstrated marked improvements in functional motor
symptoms in patients who work closely with physiotherapists [5,6,8,9].
Occupational therapists are able to build good rapport with patients and help them with self-
explorations to understand what they can/can’t do, as well as, determining and addressing the
specific blockages for their normal everyday functioning. This is done through a wide range of
activities and relaxation techniques. Appendix 2 (page 26) explores the occupational therapy
aspect in FND treatment from one of the Mater occupational therapists [6].

Medications
Generally, pharmacological therapy for FND is avoided when possible. In the clinical practice, their
use may not be welcomed by many patients due to:
• Psychiatric stigma

• Perception of addictive and harmful properties

• Side effects

Nevertheless, antidepressants have demonstrated benefits even in those who do not have
comorbid mental disorders. Tricyclics are helpful in those with insomnia and pain. Serotonin
reuptake inhibitors are good for hypersomnia but not so good in pain management. Neuropathic
analgesia such as gabapentin or pregabalin are used in chronic pain. Patients are often explained
to that they can get better without the tablets but they are worth trying for those who are
looking to explore every therapeutic avenue [12,13,15].

Psychiatry/psychology
Around one third of patients with FND have a comorbid psychiatric condition. Some patients
experience depression and anxiety as a result of having their functional symptoms. For others,
a history of trauma or adverse childhood experiences can make them vulnerable to developing

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 FND. Psychologists and psychiatrists can assist in the management of comorbid mental health
conditions and in the treatment of FND.
Cognitive behavioural therapy (CBT) is an evidenced based psychological approach for treating
FND. This can include exploring the symptoms and identifying behaviours and cognitions
(thoughts) that maintain or exacerbate the symptoms to increase the patient’s awareness of their
symptoms. A range of CBT strategies can be taught to the patient to assist them manage their
FND and mood symptoms to maximise their everyday function. (Table 3) [1,6,8,13,15].

Dissociative attacks Functional weakness

Old thought “Oh no! What is happening to me? “Do I have multiple sclerosis? I’m
Do I have epilepsy? Am I going to die going to end up in a wheelchair!”
during one of these attacks?”

Old behaviour Avoid social interactions, tendency Seeing many specialists, not doing
to succumb to attacks as a way of much just in case symptoms are
getting rid of warning symptoms. exacerbated.

New thought “I’m having something that is similar “It’s a strange diagnosis but seems
to a panic attack” like I have the potential to get better.”

New behaviour Tries distraction techniques during Gradually exercises, learn to expect
warning signs to negate attacks. relapses, good days and bad days.

Table 3: Example of changes in thoughts and behaviours of FND patients accompanied

by good understanding of their symptoms [13]
Studies have shown that CBT has been especially effective in helping patients with dissociative
attack. In the United Kingdom, guidelines have been developed for CBT aimed at patients with
dissociative attacks, these involve [8]:
• Techniques for interrupting behavioural/psychological/cognitive warning signs at
the start of an attack.
• Enabling patients to engage in the activities they were avoiding.

• Tackling unhelpful thoughts which may have influence on attack control, self-
esteem, mood and anxiety.
Psychiatrists/psychologists can also assist in recovery by [13,15]:
• Spending longer on specific techniques to deal with anxiety and panic symptoms.

• Reinforce explanation about FND symptoms.

• Discuss how previous life events/personality traits may help explain the patient’s
vulnerability to symptoms.
• Monitor medication treatments.

• Detect and treat other comorbid psychiatric disorders (bipolar, depression, post-
traumatic stress disorder, etc.).
• Involve another pertinent professional—community psychiatric nurse,
psychotherapist, etc.

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Other treatments
A variety of other physical treatments have been gaining traction in their potential to help the
treatment of FND.
Hypnosis and light sedation can transiently or sometimes permanently improve the posture of a
dystonic limb or help regain function of a paralysed limb. The procedure is video recorded and
played back to the patient to help them believe their condition can be reversed [8].
Transcranial magnetic stimulation (TMS) has been a recent interest in the treatment for functional
movement disorders. Applied at supra-motor-threshold intensities to the contralateral motor
cortex, TMS can produce jerky movements in the functionally weak, dystonic or tremulous limb.
Despite its mechanism in functional movement disorders remain uncertain; TMS has shown
promising results in clinical trials [8].
Transcutaneous electrical nerve stimulation (TENS) was also trailed with some promise, producing
stimulation intensity sufficient to produce a ‘tingling sensation’ without muscle twitching or pain.
It is primarily focused on patients with sensory symptoms such as numbness or allodynia [8].
Biofeedback treatment for functional tremors use tactile and auditory external cueing for real
time visual feedback to help retrain the patient’s tremor frequency has also been trialled with
promising results [8].

Aids and appliances

These can be helpful in providing independence and bolstering confidence. However, negative
effects such as increased dependence on them and decreased activity have been observed. They
can also pose a barrier to recovery and should be considered last resort [13,15].

Disability benefits
Similar to aids and appliances, disability benefits are also exquisite barriers to recovery. Such
benefits can be so substantial that they are more than the patient’s previous earnings, leading to
a situation where the patient will lose money when they recover. Many controversies still revolve
around this topic and it may be useful to discuss openly with the patient. Remember that there is
evidence to suggest that secondary gain is a greater factor in patients with FND [13,15].

15
 The nursing role in FND

Nurses can play a critical role in FND patient care especially inpatients. By providing round
the clock care for these patient they are able to help monitor patient progression outside of
therapeutic sessions provided by the multi-disciplinary team. Nurses are also able to help reinforce
positive behaviours and strategies taught to FND patients by guiding patients through the
reflective practice model. A strong multi-disciplinary team must include nurses in care planning to
ensure that every profession is well informed of the goals of treatment.

Nursing responsibilities
• Provide around the clock hands on patient care

• Observe and monitor patient conditions

• Recording and maintaining communication with the multidisciplinary team

• Emotional support to patient and families

• Educational support

Nursing responsibilities for FND patients are no different from any other type of patient. However
the way that you interact with FND patients can make a big difference in the outcomes of their
inpatient care.
Nurses are around 24/7 and often deal with scenarios when the doctor or allied health profession
are not there. Creating a positive environment for FND patients is key so that they are able to
approach nurses with issues when members of the MDT are not available.
It is important to make a point of introducing yourself to the patient at the start of the shift and
let them know that you are there to provide them with support and help.
FND patients will have treatment plans devised by physiotherapists, psychologists and
occupational therapists. Nurses need to help facilitate and promote these plans to help maximise
patient progress.
When patients are not following the treatment plan or are not engaging, nurses are in an ideal
position to find out why this is happening. Some of these issues may be able to be solved with
some extra support from nurses on the ward. If the issue is not able to be solved it needs to be
documented for the appropriate members of the MDT to help.
Nurses must be mindful about disclosing sensitive patient information. Choosing where and when
you disclose information (even to other nurses) can have a big impact on patient care. Before
discussing anything consider if the language you would like to use appropriate?
Using the correct terminology when speaking to FND patient and their families is important for all
professions treating FND patients. You should not be afraid to correct terminology with patients and
their families. It may take time for their language behaviours to change, however if nurses can help
to reinforce proper terminology it may help patients and families to understand their diagnosis.
Diagram 1 displays the reflective cycle model. This is an extremely useful tool that nurses and
other professions can use when a FND patients is suffering from an episode.

16
 Description
What happened?

Action plan Feelings

If it arose again What were you
what would thinking and
you do? feeling?

Evaluation
Conclusion What was good
What else could and bad about the
you have done? experience?

Analysis
What sense can
you make of the
situation?

Diagram 1: Reflective cycle model (Gibbs 1988) [17]

17
 Below is an example of how the reflective model can be used:

Mr X is a 35 year old male who suffers from functional lower limb weakness. He has been
given a diagnosis of FND by the neurologist and has been seen by physiotherapy who
have given him some exercises and coping strategies. He has notified a nurse that he is
experiencing an episode of weakness.
Nurse: Hi Mr X, can you (DESCRIBE) to me what is happening?
Mr X: My legs suddenly felt really weak and I can’t walk.
Nurse: Mr X were you thinking of anything or (FEELING) anything at the time
your legs started feeling weak.
Mr X: I remember being very anxious about my next appointment with the
occupational therapist and all of a sudden I felt weak in the legs.
Nurse: What do you feel was good or bad about the experience? (EVALUATE)
Mr X: I feel that it was good that I could call you for help. I think it was bad
that my legs felt weak after worrying about my next appointment.
Nurse: What can you make sense of the situation? (ANALYSIS)
Mr X: I think that the weakness was caused by the anxiety I felt when
I thought about my next therapy appointment.
Nurse: Was there anything else you could have done? (CONCLUSION)
Mr X: I did call for help, but the physiotherapist did teach me some
breathing exercises. Next time I will try that first before calling for
help and see if it helps.
Nurse: If that feeling happened again what would you do differently?
(ACTION PLAN)
Mr X: Next time if I feel anxious I will try some deep breathing to try and
calm my thoughts before calling for help to see if I can stop my limbs
from becoming weak before it happens.

This example is an optimal outcome for the patient however not all patients respond in a
cooperative and polite manner. Nurses need to understand that the reflective model takes time
for patients to practice and nurses can help guide them through the steps with the goal that
patients will eventually begin to perform the steps of the reflective model independently to help
themselves begin to identify their triggers and self-manage symptoms independently.

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Transference and Countertransference

Transference
Transference is a phenomenon where the feelings, desires and expectations of an individual is
redirected and applied to another person. In a clinical context, the person in therapy applies
certain feelings and expectations towards the therapist [16].
Transference can be either positive or negative. The type can depend on the person’s social
background or mental health. It is established that patients with FND often come from a complex
social or psychological background thus it is important that the clinician is aware of how the
patient projects themselves towards them.
A complex background may often result in negative transference. For example, an adolescent
with history of childhood abuse may appear reserved and disconnected from an older neurologist;
a person with history of domestic abuse from their partner may be defiant of healthcare worker
of their partner’s gender; a patient who felt disbelieved by a previous doctor may harbour disdain
for neurologists [16].
However, positive transference is also common. Patients may see healthcare workers as kind,
helpful, experts in their symptoms and in charge of their recovery. This is especially seen in those
who are vulnerable and are genuinely seeking help for their symptoms.
When transference occurs, the clinician may be able to come to a better understanding of the
individual based on the feelings projected, and thus, help the person in therapy to achieve goals
in recovery. If correctly deployed, transference is an excellent therapeutic tool in understanding
the patient’s conscious and repressed feelings. Once well understood, recovery is much more
likely to be successful if these underlying issues are exposed and addressed [16].

Countertransference
Often as a direct result to transference, countertransference is when the therapist transfers
emotions to the person in therapy. As with transference, it can also be helpful or problematic [3].
Good countertransference is beneficial to the recovery process and helps to build the patient to
clinician rapport. A therapist may meet a person who has difficulty initiating conversations. The
therapist may begin conversations and lead them to provide additional prompts to the patient
and encourage discussion. Clinicians who have experienced the same issues as their patients may
also be able to empathise with them more deeply.
Some cases of countertransference can be negative. For example, an adolescent with a history of
childhood abuse is defiant of a therapist. The therapist therefore becomes more controlling as if
they were disciplining their own child. Another example could be a patient who felt disbelieved by
a previous neurologist encountering a neurologist who just had experience with a patient feigning
their FND symptoms. The situation leads to a total breakdown in communication as both party
became increasingly cynical towards one another. Therefore, if negative countertransference is not
appropriately recognised, it could negatively impact the relationship and perpetuate unhealthy
patterns in the patient. This can even become harmful if the therapist uses the person in therapy to
meet their personal psychological needs [3]. It is therefore important for healthcare workers to make
the distinction between helpful and unhelpful countertransference. Having a good level of self-
awareness, developing a healthy professional boundary and be aware of the threats that negative
countertransference poses to the therapeutic relationship is recommended [3].

19
 When the patient does not get better

Despite having ‘no’ disease, it is unreasonable to expect that every patient with FND will respond
well to treatment. A substantial number of FND patients cannot understand or refuse to accept
their diagnosis and do not benefit from treatment [13,14,15].
Common features pertaining to patients whom treatment fails include [14]:
• Inability to repeat back anything regarding their diagnosis despite receiving thorough
explanation of their condition from the neurologist.
• Personality disorders.

• Very fixated views on an alternative diagnosis.

• The presence of a legal case or benefits.

• Long-standing or disabling symptoms.

It is important to recognise that there are a group of FND patients who understand their diagnosis
and comply with treatment but do not see much improvements.
It is important for health professionals to recognise when treatment has not helped. It will be
futile to ask both patient and therapists to continue treatment that will probably fail, demoralising
both parties.
Therefore, clinicians should be at times willing to accept that they are unable to help underlying
symptoms as with many other neurological conditions. These situations would warrant the use of
aids such as wheelchairs or house adaptions as appropriate [13,14,15].
Financial benefits for disability can also be considered even though they form a large barrier
to recovery. These things can be discussed explicitly with the neurologist. Ongoing surveillance
should be put in place to monitor any treatable comorbid conditions (depression, anxiety) and
reviews should be made if any new treatment options arise [14,15].

20
Additional resources

Free online self-help information has been developed in recent years for patients with FND symptoms.

Figure 1: The site www.neurosymptoms.org was

developed in Edinburgh in 2009 by Jon Stone
(consultant neurologist and honorary senior lecturer in
Edinburgh with specialty interest in FND) and contains a
wide range of information for patients with FND.

Figure 2: Another site www.nonepilepticattacks.info is

developed to provide information specifically for patients
suffering from non-epileptic attacks in 2011 by Sheffield
hospital in the United Kingdom.

Figure 3: Additionally, in 2012, the site

www.fndhope.org was established. Contents of the
website were written by patients, caregivers and doctors/
researchers with the common goal of promoting
understanding and better care for patients with FND.

21
 References

1. Butler, C., Zeman, A. Z. J. (2005). Neurological symptoms which can be mistaken for psychiatric
conditions. J Neurol Neurosurg Psychiatry 2005;76(Suppl I):i32-i38. Doi: 10.1136/jnnp.2004.060459

2. Columbia University Medical Center. (2013). Functional neurological disorders in children and young
people. Development Medicine and Child Neurology, 55:3-4. Doi: 10.111/dmcn.12058

3. Countertransference. (2017). GoodTherapy.org. Retrieved from: https://www.goodtherapy.org/blog/

psychpedia/countertransference

4. Czarnecki, K., Hallet, M. (2012). Functional (psychogenic) movement disorders. Neurol, 25(4):507-512.
Doi: 10.1097/WCO.0b013e3283551bc1

5. Demartini, B., Balta, A., Petrochilos, P., Fisher, L., Edwards, J. A., Joyce, E. (2014). Multidisciplinary
treatment for functional neurological symptoms: a prospective study. J Neurol, 261:2370-2377. Doi:
10.1007/s00415-014-7495-4

6. Hallett, M., (2012). Stepped care for functional neurological symptoms. Healthcare Improvement Scotland.

7. Kanaan, R. A., Armstrong, D., Wessely, S. C. (2011). Neurologists’ understanding and management of
conversion disorder. J Neurol Neurosurg Psychiatry 2011:82:961-966. Doi: 10.1136/jnnp.2010.233114

8. Lehn, A., Gelauff, J., Hoerizauer, I., Ludwig, L., McWhirter, L., Williams, S., Gardiner, P., et al. (2015).
Functional neurological disorders: mechanism and treatment. J Neurol. Doi:10.
10007/s00415-015-7893-2

9. Nielsen, G., Stone, J., Matthews, A., Brown, M., Sparkes, C., Farmer, R., Masterton, L., et al. (2014).
Physiotherapy for functional motor disorders: a consensus recommendation. J Neurol Neurosurg
Psychiatry, 2015;86:1113-1119. Doi:10.1136/jnnp-2014-309255

10. Reuber, M. (2009). The etiology of psychogenic non-epileptic seizures: towards a biopsychosocial model.
Neurol Clin 27, 2009:909-924. Doi: 10.1016/j.ncl-2009-06-004

11. Reuber, M., Howlett, S., Khan, A., Grünewald, A. R. (2007). Non-epileptic seizures and other functional
neurological symptoms: predisposing, precipitation and perpetuating factors. Psychomatics, 48:3:230-238.

12. Stone, J. (2006). Dissociation: What is it and why is it important. Practical Neurology 2006, 6:308-313.
Doi: 10.1136/jnnp.2006.101287

13. Stone. J. (2009). Functional symptoms in neurology. Neurology in practice. 2009;9:179-189. Doi:
10.1136/jnnp.2009.177204

14. Stone. J. (2015). Functional neurological disorders: the neurological assessment as treatment. Pract
Neurol 2016;16;7-17. Doi:10.1136/practneurol-2015-001241

15. Stone, J., Carson, A., Sharp, M. (2005). Functional symptoms in neurology: management. J Neurol
Neurosurg Psychiatry. 2005;76(Suppl I):i13-i21. Doi: 10.1136/jnnp.2004.061663

16. Jones, A. C. (2004). Transference and countertransference. Perspectives in psychiatric care, 40(1), 13-19.

17. Gibbs, G. (1988). Learning by Doing: A Guide to Teaching and Learning Methods. Oxford: Oxford Further
Education Unit.

22
Appendices

Appendix 1: Answers to difficult questions for FND patients

When the patient has new symptoms, or worsening of symptoms:

I’m sorry that you are having this problem. If the problem is not at all like to your previous
symptoms, you should tell your doctor, but if it is similar to symptoms you have had in the past, it
is part of your Functional Neurological Symptoms Disorder. The best treatment is to keep working
with your therapists to help you to recover.

When the patient is upset or angry about the treatment they are given:
I’m sorry that you are upset. It must be very frustrating for you that your problems are not going
away quickly. We know that it is hard, but the best treatment is to keep working with your
therapists to help you to recover.

When the patient reports that they cannot do a rehabilitation task:

Even if the progress is very slow, every rehabilitation exercise is helping your brain and nerves to
learn how to work normally again. The best treatment is to keep working with your therapists to
help you to recover.

When the patient asks for an explanation of their condition:

You have Functional Neurological Symptoms Disorder which means that your brain and nerves
are not working the way they usually do due to an unintentional error in how they communicate
with your body. This is like a software problem on a computer, rather than a hardware problem.
The treatment is to keep practicing until you relearn how to move normally, while getting help to
deal with the frustration and strong emotions that the problems have caused you, so they don’t
delay your recovery.

When the patient asks if their symptoms will get better:

The symptoms of FND almost always get at least a bit better when the person engages in
rehabilitation combined with psychotherapy and 60% of patients recover completely. Sometimes
movement, pain and fatigue get worse before getting better, like when a person has a limp after
going to the gym, but gradually gets stronger and fitter. Symptoms often come and go, but will
improve over time. Without rehabilitation, spending a long time in a chair or bed will always lead
to deterioration.

23
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