Functional neurological disorder (FND) represents a complex condition where individuals experience neurological symptoms, such as weakness, abnormal movements, or non-epileptic seizures, that are inconsistent with recognised neurological diseases. Despite often resembling conditions like epilepsy or stroke, FND is not explained by structural neurological damage but rather by a functional problem with how the brain sends and receives signals. It is considered a disorder lying at the intersection of neurology and psychiatry, highlighting the need for integrated approaches in its understanding and care.
FND can manifest in a variety of ways, impacting motor, sensory, or cognitive abilities, and the symptoms can cause considerable functional impairment and distress. Crucially, these symptoms are not ‘faked’ or under voluntary control; they are involuntary and real to the person experiencing them. Recent advances in FND research suggest that issues such as abnormal attention, beliefs about symptoms, and altered sense of agency play a key role in the development and maintenance of the disorder.
The underlying causes of FND are thought to be multifactorial, involving a combination of biological, psychological, and social factors. Some individuals may have a history of trauma or psychiatric conditions like anxiety or depression, whereas for others, FND arises without any clear precipitating event. Mental health therefore plays a critical role both in the aetiology and in the management of FND, underscoring the interconnected pathways between emotional wellbeing and neurological function.
Diagnosis of FND has evolved significantly over the years, shifting away from being a diagnosis of exclusion to one based on positive clinical signs, such as inconsistency of symptoms or specific patterns of movement abnormalities. This positive diagnostic approach, recommended by modern clinical guidelines, helps reduce the stigma historically associated with the disorder and opens the door for earlier and more effective intervention with treatment options including psychotherapy.
Understanding FND in this biopsychosocial framework allows healthcare professionals to better tailor treatment strategies, empowering patients to regain function and improve their quality of life. Psychotherapeutic interventions, especially cognitive behavioural therapy (CBT), play a central role in treatment, often alongside physiotherapy and occupational therapy, reflecting the consensus that an interdisciplinary approach is essential for effective management.
Psychotherapeutic approaches for FND management
Psychotherapy, particularly cognitive behavioural therapy (CBT), is widely regarded as a cornerstone treatment option for individuals with FND. CBT focuses on identifying and addressing patterns of thoughts, beliefs, and behaviours that may contribute to the onset or persistence of functional symptoms. Patients are supported in understanding how psychological factors, such as heightened bodily attention or maladaptive coping strategies, can influence neurological function. Through CBT, individuals are guided to develop healthier ways of interpreting and responding to bodily sensations, reducing symptom-related distress and promoting improved functioning.
Another psychotherapeutic approach used in FND management is psychodynamic therapy, which explores underlying emotional conflicts and past experiences that might unconsciously contribute to symptom development. By fostering insight into emotional processes and relational patterns, psychodynamic therapy can help patients make sense of their symptoms and support more adaptive emotional regulation. Some patients benefit from trauma-focused therapies, such as eye movement desensitisation and reprocessing (EMDR), particularly when there is a history of adverse experiences that may be linked to the onset of FND symptoms.
Mindfulness-based interventions are increasingly being integrated into the treatment landscape for FND. Techniques such as mindfulness-based stress reduction (MBSR) aim to cultivate present-moment awareness and decrease experiential avoidance, which can be pivotal in breaking the cycle of symptom amplification and fear. Mindfulness practices also contribute to improvements in emotional regulation and overall mental health, both of which are critical in managing FND.
Multidisciplinary approaches combining psychotherapy with physiotherapy, occupational therapy, and speech and language therapy have shown particular promise. In such models, psychological treatment is not isolated but integrated with physical rehabilitation, ensuring that patients receive holistic care addressing both the mind and body. Goal-focused, time-limited interventions help patients enhance their functional abilities while simultaneously working on emotional and cognitive aspects that underpin their symptoms.
Importantly, psychoeducation forms a vital part of psychotherapeutic interventions for FND. Helping individuals understand the nature of FND, validate their experiences, and reduce feelings of blame or misunderstanding can itself be profoundly therapeutic. Clear communication about the diagnosis and treatment options empowers patients and fosters a collaborative partnership in their recovery journey.
Ultimately, tailoring psychotherapeutic approaches to the individual’s needs, preferences, and symptom patterns is essential to achieving the best outcomes. A flexible, patient-centred approach, grounded in empathy and validation, lays the foundation for effective treatment and improved quality of life for those living with FND.
Evidence supporting psychotherapy in FND treatment
A growing body of research underlines the effectiveness of psychotherapy, particularly cognitive behavioural therapy (CBT), as a treatment option for individuals with FND. Randomised controlled trials (RCTs) have demonstrated that CBT can significantly reduce symptom severity and improve functional outcomes for patients, addressing both the neurological symptoms themselves and the psychological factors that sustain them. These findings reinforce current clinical practices that recommend psychotherapy as a first-line intervention for FND.
One notable study, the CODES trial (Cognitive Behavioural Therapy versus Standardised Medical Care for Adults with Dissociative Non-Epileptic Seizures), highlighted that individuals receiving CBT alongside standard medical care exhibited improved seizure frequency, reduction in distress, and better overall mental health compared to those receiving medical care alone. The results from CODES support the broader application of CBT strategies in managing FND symptoms, including motor and sensory presentations beyond non-epileptic attacks.
In addition to CBT, research has explored the benefits of other psychotherapeutic modalities, such as psychodynamic therapy and mindfulness-based interventions. Outcome studies suggest that integrating mindfulness principles into treatment can enhance emotional regulation and decrease symptom-related anxiety, which are crucial components in the management of FND. These interventions help patients disengage from maladaptive patterns of bodily monitoring and catastrophic thinking, thus supporting better symptom control and improving quality of life.
Psychotherapy’s positive impact extends beyond symptom reduction, often resulting in better engagement with physical rehabilitation programmes and other treatment options. This is particularly significant given the high levels of disability frequently associated with FND. Therapeutic work that builds patients’ understanding of the disorder and fosters confidence in their ability to manage symptoms empowers individuals, promoting autonomy and restoring a sense of agency, both key psychological goals in FND care.
Meta-analyses and systematic reviews further affirm the value of psychotherapeutic approaches, with many studies noting sustained improvements at follow-up periods, suggesting lasting effects of treatment. Importantly, the therapeutic relationship itself plays a critical role; factors such as empathy, validation, and collaborative goal-setting are frequently associated with better outcomes, regardless of the specific modality of psychotherapy employed.
While evidence supports psychotherapy broadly, there is recognition that individual differences, including comorbid mental health conditions and personal psychosocial histories, can influence treatment response. Tailored interventions that address both the functional symptoms and coexisting psychological factors yield the most promising results, highlighting the need for flexible, patient-centred therapeutic frameworks in FND management.
Challenges and considerations in psychotherapy for FND
Delivering effective psychotherapy for FND presents a range of unique challenges that necessitate careful consideration. One major difficulty is the stigma still attached to FND among both patients and healthcare professionals. Misconceptions that the symptoms are ‘imagined’ or under voluntary control can undermine trust in the treatment process and negatively affect patient engagement. For psychotherapy to succeed, establishing a validating, non-judgemental therapeutic relationship is vital, helping patients to feel understood and respected rather than dismissed.
Diagnosis itself can be a barrier to effective intervention. Some patients have experienced long periods of uncertainty or been subjected to extensive investigation before receiving a diagnosis of FND, which can contribute to feelings of frustration, mistrust, and ambivalence about mental health treatment options. A clear, positive diagnostic explanation, delivered with empathy, lays an important foundation for future psychological work.
Tailoring psychotherapy to individual needs is crucial, yet complex. FND often coexists with other mental health conditions such as anxiety, depression, or post-traumatic stress disorder, requiring therapists to integrate treatment for comorbidities alongside interventions targeting functional symptoms. The heterogeneity of symptom presentation in FND also necessitates flexible approaches, as patients may be dealing with diverse challenges ranging from motor weakness to dissociative episodes, each requiring nuanced therapeutic strategies.
Another significant consideration is patients’ readiness for psychological intervention. Some individuals may initially resist engaging with psychotherapy, particularly if they perceive their condition as purely physical. Educating patients about the biopsychosocial model of FND and the relevance of CBT or other therapeutic modalities to their symptoms can foster greater openness and motivation for psychological work. Psychoeducation should emphasise that psychotherapy does not negate the reality of symptoms, but rather offers tools for regaining control and improving quality of life.
Practical challenges also abound, including limited access to trained professionals familiar with FND, particularly outside specialist centres. Many standard mental health services lack specific expertise in managing FND, meaning that patients might not receive evidence-based interventions tailored to their complex needs. Building capacity within mental health services, offering specialist training, and improving interdisciplinary collaboration are essential steps towards addressing these gaps in care.
Lastly, the duration and intensity of treatment needed can vary considerably. Some patients benefit from brief, focused interventions, while others require longer-term therapy to address ingrained psychological patterns and complex trauma histories contributing to their functional symptoms. Balancing the demand for brief, cost-effective therapies with the often multifaceted needs of FND patients presents an ongoing tension within service provision and treatment planning.
Despite these challenges, psychotherapy remains a critical component of holistic FND management. A patient-centred approach that acknowledges barriers, adapts flexibly to individual circumstances, and emphasises compassionate care is key to maximising the benefits of psychotherapeutic treatment options for those living with functional neurological disorder.
Future directions in psychotherapeutic care for FND
Advancements in the psychotherapeutic care of FND are increasingly centred around refining and personalising treatment options to better meet the diverse needs of patients. One promising direction involves the development of stepped-care models, where individuals are provided with interventions tailored to the severity and complexity of their symptoms. For example, patients with milder presentations might benefit from brief psychoeducation and self-help CBT programmes, while those with more complex needs may require intensive, multidisciplinary input, combining psychotherapy, physiotherapy, and neurological care in an integrated framework.
Technological innovations hold substantial potential for expanding access to psychotherapeutic care for FND. Online-based CBT platforms, telepsychology services, and mobile health applications are being explored to provide flexible, scalable solutions that overcome geographical and logistical barriers. Digital tools could offer psychoeducation modules, symptom monitoring, and guided self-help exercises, empowering patients to engage actively in their own recovery process while maintaining access to clinician support when necessary. As research into digital mental health interventions progresses, it is essential to ensure that adaptations for FND are evidence-based and sensitive to the unique challenges faced by this patient group.
Another important future direction involves enhancing the training of healthcare professionals in recognising and managing FND. Integration of FND-specific education into the curricula of psychology, psychiatry, neurology, and physiotherapy programmes can help disseminate understanding of the condition and its psychotherapeutic treatment options more widely. Better-informed clinicians are more likely to deliver early, accurate diagnoses and make timely referrals to appropriate therapies, significantly impacting patient outcomes.
Research into novel psychotherapeutic modalities is also underway. Compassion-focused therapy (CFT), acceptance and commitment therapy (ACT), and somatic therapies are being studied for their potential applicability to FND. These approaches, which focus on self-compassion, cognitive flexibility, and mind-body connection respectively, may offer additional tools for addressing the complex emotional and embodied experiences of patients with FND. Tailored intervention strategies that incorporate these modalities could further enrich the therapeutic landscape, particularly for individuals who do not respond fully to traditional CBT approaches.
Personalised medicine principles are beginning to shape the future vision for FND care. The goal is to identify specific psychological, biological, and social predictors of treatment response, using these insights to match patients with the most appropriate and effective interventions. For instance, individuals with prominent trauma histories may be better suited to trauma-focused therapies, while those with predominant anxiety patterns might benefit most from structured CBT-based programmes. Continued investment in clinical trials and longitudinal studies will be critical to advancing these predictive models and enhancing treatment precision.
Closer collaboration between researchers, clinicians, and patients is another crucial element for the evolution of psychotherapeutic care in FND. Patient-centred research initiatives that prioritise the lived experiences and preferences of individuals with FND can uncover unmet needs and guide the development of more responsive, accessible services. Co-production in therapy design and delivery helps ensure that treatment options resonate with patients’ realities, promoting better engagement and adherence.
Ultimately, the future of psychotherapy for FND lies in embracing innovation while maintaining a strong foundation of empathetic, evidence-based practice. By leveraging technological tools, broadening therapeutic repertoires, enhancing education, and personalising care pathways, the next generation of psychotherapeutic interventions has the potential to transform outcomes for people living with this complex and often misunderstood condition.
