Functional Neurologic Disorder Series - Part 5

In part five of this seven-part series on FND, Dr. Jon Stone and Dr. Gabriela Gilmour discuss treatment options.

Show citation:

Gilmour, G.S., Nielsen, G., Teodoro, T. et al. Management of functional neurological disorder. J Neurol 267, 2164–2172 (2020). https://doi.org/10.1007/s00415-020-09772-w

Gilmour GS, Langer LK, Bhatt H, MacGillivray L, Lidstone SC. Factors Influencing Triage to Rehabilitation in Functional Movement Disorder. Mov Disord Clin Pract. 2024;11(5):515-525. doi:10.1002/mdc3.14007

Stone J, Carson A. Multidisciplinary Treatment for Functional Movement Disorder. Continuum (Minneap Minn). 2025;31(4):1182-1196. doi:10.1212/cont.0000000000001606

Tolchin B, Goldstein LH, Reuber M, et al. Management of Functional Seizures Practice Guideline Executive Summary: Report of the AAN Guidelines Subcommittee. Neurology. 2026;106(1):e214466. doi:10.1212/WNL.0000000000214466

Show transcript:

Dr. Jon Stone:

Hello, this is Jon Stone with the Neurology Minute. Gabriela Gilmour and I are back to continue with part five of our seven-part series on FND. Today we'll be discussing treatment. Gabriela, talk us through what the rehabilitation or therapy approaches exist for FND now.

Dr. Gabriela Gilmour:

I would start actually even before jumping into rehabilitation and therapy to again emphasize something that we talked about in the last episode, which is that rehabilitation very much starts at our first visits with our patients when we examine for positive signs and show these to our patients and explain what they mean. So education about FND is really a fundamental treatment step, and I think we as neurologists have so much to offer to our patients in these visits.

Next, when we're thinking about rehabilitation for FND, this often includes some combination of physical rehabilitation and psychological therapy and really should be individualized to each patient. So multidisciplinary or integrated therapy approaches are the gold standard and treatment strategies with these are really guided by our evolving understanding of the mechanisms of FND.

So for example, this means using strategies like distraction, motor visualization, relaxation and mindfulness to target that underlying mechanism of FND. And then we use psychological therapies to also address perpetuating factors. So as we have discussed in this series, patients often experience many symptoms. So we also want to think about those other symptoms in our treatment plan, whether that be chronic pain or sleep disturbance or treating comorbid psychiatric or neurological illness.

When we think about the subtypes of FND, there is some research into specific strategies for each. So psychotherapy, in particular, cognitive behavioral therapy is the focus for functional dissociative seizures with strategies aimed at attack prevention. Whereas for functional movement disorder, motor retraining physiotherapy has the most evidence. One big thing that I want to emphasize though is that rehabilitation for FND really relies on patient self-management and patient engagement. So I often explain to my patients that I can't retrain their brain, but I can help support them in this process and doing this for themselves.

Dr. Jon Stone:

So when you meet a patient with FND, how do you decide whether therapy is going to be helpful for them? I think people often have a tendency to say, "Oh, it's FND right off you go to psychotherapy or physiotherapy," but is that always the right option? How should we try and help our patients to decide if it's the right time for them to do these treatments?

Dr. Gabriela Gilmour:

Yeah, I think that that's something that's really maybe not unique, but something that's really important to FND and to treatment planning and FND. When we're supporting our patients as they embark on a treatment pathway, we really want to set them up for success. And so this really does rely on a robust triage process. So unlike other neurological conditions where you have X disease, therefore, why is the treatment? For FND, we've got a host of different types of treatments, and we want to individualize that and we want to time it right.

Fundamentally, we really want to select the right treatment for our patients, and that relies on us understanding what symptoms are most bothersome to our patients, and we want to then provide that treatment at the right time. And I think right time is really what I would emphasize as being so, so important. So this means that patients are ready for active participation and rehabilitation, they're enthusiastically opted in. They think that treatment's going to help, and there aren't major barriers that are going to impact their ability to participate fully, so things like severe pain that could get in the way.

And this is a conversation that I have really openly with my patients, and I really try to let them guide the timing. They will let me know, "Hey, I'm a teacher, and I'm in school right now. Now is not the right time for me to embark on this, but what about in June or July?" And then we revisit and regroup at that time. So really I do let my patients guide this process, but I would say that there are a subset of patients that don't need these more advanced rehabilitation type programs. Maybe are spontaneously improved or are able to implement some of their own self-management strategies on their own and have a significant improvement in symptoms already.

Dr. Jon Stone:

We need to make it easy for our patients to tell us when it's not the right time, but also, there's no one-size-fits-all, basically.

Dr. Gabriela Gilmour:

Absolutely.

Dr. Jon Stone:

So we'll be back for more Neurology Minute to continue our discussion on FND. We'll be talking about prognosis. Thanks for listening.