Youth with functional neurological symptom disorder (FNSD) commonly present for medical evaluation with puzzling and often dramatic neurologic impairments, contributing to distress in both patients and their caregivers. Diagnosing FNSD is clinically challenging, as it often demands greater time and broader diagnostic consideration to effectively characterize the evolution of symptoms and their relationship with contextual factors.1 Functional neurologic symptoms may be unusual in quality but can mimic other common dangerous conditions that warrant immediate intervention (Table 1), adding to the complexity of clinical management.
Differential Diagnostic Considerations for Functional Neurological Symptom Disorder
FNSD and other related somatic disorders are frequently seen in youth, and it is diagnosed using the same criteria as for adults. Refinements to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5),2 remove etiologic assumptions by eliminating the requirement for identifying a precipitating stressor or proving that symptoms are involuntary. Evidence for malingering should warrant a separate diagnosis, yet this distinction is less helpful for youth, who may lack more sophisticated methods to adaptively communicate distress. The essential diagnostic features of FNSD are now neurologic in nature and require positive findings of neuromuscular or sensory impairments incompatible with neurologic pathophysiology. Symptoms are further clustered into specified phenotypes of functional neurologic impairments (eg, nonepileptic seizures [NES]). When identified, the presence of a precipitating stressor should be specified, as well as whether symptoms have persisted for more than 6 months. Comorbidity with other neurologic or medical illness is possible and often adds to the complexity of both symptom assessment and management.
The diagnostic focus on functional impairment requires consideration for not only brain function but behavioral function as well. The assessment should, therefore, engage both the patient and family's perspectives of function, including their own recovery goals, concerns, and expectations. Because symptoms are nonorganic in nature, they have the potential to resolve quickly when effectively addressed. With careful assessment, providers can reassure families of the diagnostic accuracy of FNSD, and the revised language in DSM-52 facilitates open communication of the diagnosis, a process known to facilitate recovery.3 Even so, resistance to embracing a psychological explanation of symptoms is common. Patients diagnosed with conversion disorder are significantly less likely than their family members to endorse the possibility of an emotional component to their symptoms, and compared to neurology patients with known organic disease, they are only half as likely to identify emotional factors as contributing to their distress.4
Despite this resistance, there are multiple lines of evidence demonstrating how neurophysiologic functioning is intimately related to emotional functioning. Providing a list of approachable examples can broaden the perspective of patients and families regarding the importance of supporting emotional processing (Table 2). Families, however, can be extremely reluctant to believe that the disabling or frightening symptoms do not warrant further investigation, often advocating for their child's well-being by insisting on further tests that lack clinical utility. Yet, many of the effective treatment interventions for conversion disorder (particularly in youth) rely on extending their impact by incorporating behavioral interventions in the home. Behavioral therapy approaches may be essential to support parents in providing their children the naturalistic environment to best foster their independent capabilities. Families may require multiple primary care visits or even specialist consultations before they are willing to embrace a multimodal treatment. Often, one of the biggest challenges they face is to learn to resist their tendency to engage in reinforcing accommodations, which are often reflexively elicited by increased symptomatology in their child.
Examples Demonstrating How the Functions of Mind and Body Are Interconnected
The prevalence of FNSD is thought to increase with advancing age throughout development,5 peaking in adulthood. Despite a similar frequency in childhood, female prevalence is much greater than male prevalence during adolescence. Diagnosis is also correlated with rural regions and lower economic status, although culturally sanctioned expressions of illness should not be included. Stressors are often related to somatic symptom expression, and common triggers should be screened for during assessment (Table 3). Despite this association, one study of outpatients with FNSD showed no differences on psychological questionnaires compared to patients with other movement disorders,6 whereas another study of medically admitted inpatients with somatoform disorders found that they did not exhibit increased rates of trauma compared to controls.7 However, when present, a positive trauma history is associated with significantly greater psychiatric comorbidity. Although psychiatric consultation may not be universally warranted for youth with FNSD, additional concerns for clinical depression or anxiety should prompt a referral, even if functional symptoms remit. Expression of symptoms can also be affected by community tragedies, including terrorism, as documented by Guerriero et al.8 Notably, they found that neurologic impairments commonly emerged after some delay, suggesting the need for ongoing attunement to the emotional needs of youth presenting with physical complaints in the context of stressful life events.
Common Stressors that May Heighten Functional Symptoms
Although the prognosis of FNSD is quite good for children,9 and impairments typically resolve within 3 months from diagnosis,10 many untreated patients will experience chronic and often disabling symptoms, occasionally into adulthood.11 Prognosis is improved when there is an identifiable stressor, high premorbid functioning, and no psychiatric comorbidity. Patients with NES are thought to have a slightly worse prognosis than other phenotypes. Recurrence of functional symptoms is also relatively common, and patients may benefit from prescheduled appointments at regular intervals to monitor treatment progress and review treatment strategies.
Pediatricians can be essential to the management of somatic symptoms in youth. Children with FNSD and their families often present to primary care providers at the onset of their symptoms and may require follow-up for emergency visits prompted by symptom exacerbation. It is important to evaluate the symptoms and their relevance to a broad differential diagnosis of medical and psychiatric etiologies (Table 1). Patients with unexplained symptoms often complain of feeling unwanted, abandoned, or blamed for feigning illness, so it is essential to validate the distress these symptoms must be creating, allowing patients and their families to feel comfortable communicating their concerns. Functional symptoms have historically been thought to be physical expressions of emotional distress, and children with conversion tend to practice a more solitary style of emotional coping.12 Therefore, encouraging patients to verbally express their perspectives and feelings around their impairments can be valuable not only to better understand the etiology of their complaints, but also to facilitate the patient's practice of adaptive expression of his or her emotions. Assessments should include a detailed chronologic functional analysis of symptoms and their context, identifying precipitating factors as well as environmental responses.
Despite its categorization within somatic symptom and other disorders, medically unexplained symptoms are not sufficient for diagnosis of FNSD, which requires positive neurologic findings inconsistent with recognized medical conditions. Yet, even without a formal neurologic evaluation, the presenting history may offer diagnostic clues. Functional neurologic impairments tend to be abrupt, often overnight, and may exhibit profound changes in severity with a variable, episodic course. Ordering further tests may be important when considering differential processes, but if FNSD is suspected, conservative approaches are indicated.
The neurologic examination is the primary diagnostic tool for FNSD and offers a rich opportunity to provide valuable insight and feedback to the patient and their family. Although psychiatrists may have more familiarity discussing the diagnosis of conversion disorder and the relationship between physical and emotional symptoms, a neurologist may be better positioned than anyone to shift fundamental misconceptions. They often possess the medical authority to speak to neurologic interpretation of the symptoms, their relative safety, and the importance of using a neuropsychiatric treatment approach. Functional symptoms, including NES, are thought to comprise between 5% and 30% of visits to neurology clinics and almost 10% of inpatient neurology admissions.13,14 These figures are thought to be lower in pediatric populations, but with recent diagnostic refinements, the overall prevalence of FNSD is likely to increase, particularly in neurology clinics.
Prior to the examination, providers should encourage open communication of concerns so they can be appropriately addressed. Several examination findings have been validated in the neurologic assessment of functional movement disorders, and demonstration of symptom reversibility using clinical techniques, such as Hoover's sign (in which a patient with one paretic leg is able to extend the healthy leg at the hip, which requires intact extensor strength from the affected leg), can have a powerful influence on improving the way patients and families understand the nature of the impairments.15,16 Other functional signs may include increased severity with attention to the affected area, decreased symptom severity with distraction, abnormal slowness, or pain escalation during evaluations or benign interventions. Although inconsistencies in patient performance may be diagnostically relevant, examiners should maintain an empathic reflective manner that conveys genuine curiosity and concern.
Importantly, providers are encouraged to discuss the positive inconsistencies with patients and families while reaffirming them as real and treatable. Directly conveying the diagnosis of FNSD and instilling an expectation of rapid recovery can have dramatic effects on symptom resolution.17 Providers may also need to acknowledge the possibility that previous findings may have accounted for early symptoms but may no longer be the primary etiology for ongoing impairments. Successful consultation is considered the beginning of treatment and can steer interventions away from excessive tests, redundant visits, and unnecessary medications.
Treatment of Youth with FNSD
When FNSD is diagnosed, treatment is aimed at bolstering the youth's self-efficacy by both fostering abilities that support adaptive functioning while reducing the environmental reinforcements for their symptoms. Although treatment data are limited, findings show effectiveness for cognitive-behavioral therapy (CBT) approaches in adults with functional disorders. The goals of CBT treatment include building awareness of signals for emerging symptoms, learning skills to improve emotion regulation, fostering reengagement in previous activities, and challenging unhelpful negative cognitions. CBT trials have shown that additional benefits can be realized by targeting dissociative features,18 implementing mindfulness training,19 and through augmenting treatment with guided self-help.20
The limited data evaluating pharmacotherapy for NES suggest mild benefit, and only when combined with CBT approaches.21 Medications may also be more likely to induce adverse effects in somatically focused patients. Expertise in the psychiatric management of somatic symptoms in general is thought to be quite limited and variable, yet therapeutic treatments have recently shown promise in adults. Therefore, engaging youth with FNSD with mental health providers should be a priority despite the challenges.22 Educating youth and families on the importance and potential of retraining brain circuitry, and teaching skills in using distraction and emotion modulation, can normalize the use of effective modalities aimed at regaining functional independence. Although not applicable to all clinical presentations, occupational and physical therapy, biofeedback, mindfulness exercises, and use of emotion regulation skills have been shown to be effective treatment interventions.23
Despite the clinical urgency to incorporate immediate therapeutic treatment, FNSD patient engagement may initially benefit most from nondirective motivational interviewing approaches, which serve to enhance the patient's own drive for change. Providers should encourage patients to be active in designing their goals for recovery, which then can be used to reinforce engagement and to measure and monitor progress. Therapeutically, in youth, targeting emotion regulation by simply practicing emotion identification can serve as an important foundation for expressing emotional needs more adaptively.
Treatment requires a coordinated multidisciplinary approach outlining mutual goals toward a rapid recovery. This should include measurable steps toward recovery milestones, a clear emphasis on self-efficacy, and incorporation of clinical expertise to facilitate this process. As such, a rehabilitative intervention partnering with psychiatric and neurologic consultation is often most valuable to guide youth and their families along an attainable direct path toward full recovery.18 Depending on the specific neuromuscular or sensory impairment, a rehabilitative model for FNSD may include tailored occupational or physical therapy programs aimed at retraining specific motor patterns required for functional goals. Physiotherapists may consider adjusting their traditional approaches by using a more reflective style, gradually building self-initiative while limiting hands-on treatment and assistive devices, and minimizing focus on impairments or personal effort.24 Retraining motor patterns with diverted attention using rhythmical, unfamiliar, or unpredictable movements helps reduce the sense of feeling overwhelmed, especially for youth. Nevertheless, setbacks are common as demands for self-efficacy are increased, so families should be cautioned not to abandon rehabilitative treatment efforts if symptoms worsen temporarily. Treatment is designed to continually enhance patient insight into symptom evolution and to help develop strategies to manage their functional impairments independently.
Familial and Environmental Treatment Opportunities
Meeting separately with their caregivers provides an important opportunity to incorporate the family's goals and encourages communication of their concerns without fracturing a unified treatment approach. Parents may have their own biases, including occasionally believing their child may be faking neurologic impairments that were not present during sleep or at other times of distraction. Providers are, therefore, encouraged to explain the importance of validating symptoms as real to the patient. This is a requirement of both diagnosis of FNSD and appropriate treatment, and is supported by neurophysiologic evidence.25 When identifying differences in perspectives, clinicians can be a valuable model for adaptive interpersonal communication and conflict resolution, as studies have revealed the impact of family conflict on functional symptom expression.
Comprehensive treatment must additionally address ongoing environmental contingencies at home that shape functional impairments and their improvement. Educating parents to praise functional improvements and empower self-efficacy while identifying inadvertent reinforcements for symptoms, such as providing excessive attention or granting special privileges, can be critical to meaningful change. Families should implement goals of quickly reestablishing normative tasks, including walking, communicating, and performing basic independent tasks, such as bathing and eating. For children, this would also include attending school, following common household rules, and participating in previous social activities. Functional recovery often demands that parents are able to provide emotional support and validation while also holding firm on these expectations. Supporting parents in this effort can facilitate functional recovery, often quite rapidly.
Refractory or severe cases may call for further coordination with other important settings, including schools, which are often underequipped to manage complex symptom presentations. Prearranged nursing visits, with specified limits on time away from class, may be helpful to shift the reinforcement of symptom expression. Athletic coaches should also be aware of symptoms in youth with FNSD and respond in an empathic but nonemergent fashion to support self-efficacy as tolerated when symptoms escalate.
Even when seen for severe symptoms, patients with FNSD have the greatest opportunity for recovery in a naturalistic and safe environment so that they may quickly reengage in normative activities. However, should an adolescent patient continue to exhibit severe impairments despite efforts to provide treatment in their home environment, the hospital may be the only suitable forum to address their ongoing dysfunction. Inpatient observation allows for more robust assessment of symptom patterns and insight into potential reinforcing factors, away from the accommodations in the home environment. Access to trained clinicians and emergency management in the hospital setting may also be necessary before families feel comfortable implementing home-based treatment approaches. However, hospitalization itself can be highly reinforcing by fulfilling essential needs of being taken care of, feeling valued, and feeling safe. Inpatient care for functional disorders, therefore, requires enhanced coordination to prevent splitting treatment approaches so that providers, patients, and family members can all coalesce around the common goal of a rapid return to home. At times, this may call for reduced active intervention for FNSD as compared to the community (or cultural) standard of care. This may be even more challenging during emergency evaluations; however, emergency department providers are capable of reliably diagnosing functional disorders,26 and symptomatic youth may benefit most if the clinician creates an early expectancy of improvement using conservative approaches before their impairments become more chronic and disabling.
Diagnostic refinements for FNSD create new opportunities for engaging youth and their families in a more integrated neuropsychiatric formulation of functional impairments. FNSD is a challenging disorder to manage clinically and requires a time-intensive, highly coordinated and, at times, an atypical interdisciplinary treatment approach designed to enhance self-efficacy. Engaging youth in multimodal treatment with specialty providers using a rehabilitative model of care that supports both emotional and sensorimotor brain networks is the ideal way to effectively restore functional recovery.
- Stone J, Smyth R, Carson A, et al. Systematic review of misdiagnosis of conversion symptoms and “hysteria.”BMJ. 2005;331(7523):989. doi:10.1136/bmj.38628.466898.55 [CrossRef]
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013.
- Edwards MJ, Stone J, Lang AE. From psychogenic movement disorder to functional movement disorder: it's time to change the name. Mov Disord. 2014;29(7):849–852. doi:10.1002/mds.25562 [CrossRef]
- Whitehead K, Stone J, Norman P, Sharpe M, Reuber M. Differences in relatives' and patients' illness perceptions in functional neurological symptom disorders compared with neurological diseases. Epilepsy Behav. 2015;42:159–164. doi:10.1016/j.yebeh.2014.10.031 [CrossRef]
- Kotagal P, Costa M, Wyllie E, Wolgamuth B. Paroxysmal nonepileptic events in children and adolescents. Pediatrics. 2002;110(4):e46. doi:10.1542/peds.110.4.e46 [CrossRef]
- van der Hoeven RM, Broersma M, Pijnenborg GH, et al. Functional (psychogenic) movement disorders associated with normal scores in psychological questionnaires: a case control study. J Psychosom Res. 2015;79(3):190–194. doi:10.1016/j.jpsychores.2015.06.002 [CrossRef]
- Thomson K, Randall E, Ibeziako P, Bujoreanu IS. Somatoform disorders and trauma in medically-admitted children, adolescents, and young adults: prevalence rates and psychosocial characteristics. Psychosomatics. 2014;55(6):630–639. doi:10.1016/j.psym.2014.05.006 [CrossRef]
- Guerriero RM, Pier DB, de Gusmão CM, et al. Increased pediatric functional neurological symptom disorders after the Boston marathon bombings: a case series. Pediatr Neurol. 2014;51(5):619–623. doi:10.1016/j.pediatrneurol.2014.07.011 [CrossRef]
- Ibeziako P, Bujoreanu S. Approach to psychosomatic illness in adolescents. Curr Opin Pediatr. 2011;23(4):384–389. doi:10.1097/MOP.0b013e3283483f1c [CrossRef]
- Fritz GK, Fritsch S, Hagino O. Somatoform disorders in children and adolescents: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry. 1997;36(10):1329–1338. doi:10.1097/00004583-199710000-00014 [CrossRef]
- Gelauff J, Stone J, Edwards M, Carson A. The prognosis of functional (psychogenic) motor symptoms: a systematic review. J Neurol Neurosurg Psychiatry. 2014;85(2):220–226. doi:10.1136/jnnp-2013-305321 [CrossRef]
- Plioplys S, Doss J, Siddarth P, et al. A multisite controlled study of risk factors in pediatric psychogenic nonepileptic seizures. Epilepsia. 2014;55(11):1739–1747. doi:10.1111/epi.12773 [CrossRef]
- Carson A, Stone J, Hibberd C, et al. Disability, distress and unemployment in neurology outpatients with symptoms “unexplained by organic disease”. J Neurol Neurosurg Psychiatry. 2011;82(7):810–813. doi:10.1136/jnnp.2010.220640 [CrossRef]
- Edwards MJ, Bhatia KP. Functional (psychogenic) movement disorders: merging mind and brain. Lancet Neurol. 2012;11(3):250–260. doi:10.1016/S1474-4422(11)70310-6 [CrossRef]
- Daum C, Hubschmid M, Aybek S. The value of ‘positive’ clinical signs for weakness, sensory and gait disorders in conversion disorder: a systematic and narrative review. J Neurol Neurosurg Psychiatry. 2014;85(2):180–190. doi:10.1136/jnnp-2012-304607 [CrossRef]
- Tremolizzo L, Susani E, Riva MA, Cesana G, Ferrarese C, Appollonio I. Positive signs of functional weakness. J Neurol Sci. 2014;340(1–2):13–18. doi:10.1016/j.jns.2014.03.003 [CrossRef]
- Stone J. Functional neurological disorders: the neurological assessment as treatment. Neurophysiol Clin. 2014;44(4):363–373. doi:10.1016/j.neucli.2014.01.002 [CrossRef]
- Hubschmid M, Aybek S, Maccaferri GE, et al. Efficacy of brief interdisciplinary psychotherapeutic intervention for motor conversion disorder and nonepileptic attacks. Gen Hosp Psychiatry. 2015;37(5):448–455. doi:10.1016/j.genhosppsych.2015.05.007 [CrossRef]
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- Sharpe M, Walker J, Williams C, et al. Guided self-help for functional (psychogenic) symptoms: a randomized controlled efficacy trial. Neurology. 2011;77(6):564–572. doi:10.1212/WNL.0b013e318228c0c7 [CrossRef]
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- Yam A, Rickards T, Pawlowski CA, Harris O, Karandikar N, Yutsis MV. Interdisciplinary rehabilitation approach for functional neurological symptom (conversion) disorder: a case study. Rehabil Psychol. 2016;61(1):102–111. doi:10.1037/rep0000063 [CrossRef]
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Differential Diagnostic Considerations for Functional Neurological Symptom Disorder
|Medical Differential Diagnosis
||Psychiatric Differential Diagnosis
||Posttraumatic stress disorder, dissociative disorder
||Culturally sanctioned response
||Major depressive episode
|Systemic lupus erythematosus
||Factitious disorder, malingering
|Spinal cord injury
||Illness anxiety disorder
||Somatic symptom disorder
||Separation anxiety disorder
Examples Demonstrating How the Functions of Mind and Body Are Interconnected
If we stub our toe and happen to be feeling tired or angry, it tends to be much more upsetting and painful
The brain connects extensively to the gut; both use similar transmitters and connect through integrated networks, giving the experience of having “butterflies in your stomach” when nervous
Just like the rest of the body, the brain requires challenges to maintain health and grow; if we just lie in bed, our muscles will atrophy, and if we don't identify and communicate our emotions, our brain will lose that that skill as well
Breathing is an automatic process that uses muscles without even thinking, but it is also influenced by voluntary intent or emotional intensity, leading to your voice cracking or more labored breathing
If we try to be extremely precise, we often get shaky and make more errors. During high-pressure situations, professional sports players often miss putts or can't throw strikes despite practicing the same movements thousands of times
Supporting emotional regulation can, therefore, help allow brain networks to reestablish their effective motor patterns, supporting the circuits to enable breathing and moving more easily and smoothly
Common Stressors that May Heighten Functional Symptoms
School-related difficulties (academic pressures, bullying, school avoidance)
Family conflict (emotion invalidation, parental discord or separation, changes in authority)
Interpersonal conflict (peer rejection, cyber-bullying, recent break-ups)
Changes in the home (moves, new caregivers or children around, different sleeping arrangements)
Distress in others (parental illness, illness in relatives, witness to dramatic symptoms)
Familial pressure (excessive pressure to be compliant or successful)
Physical injury (surgery, invasive or disabling wounds, illness, pain sensitivity)
Internalizing symptoms (depression, anxiety, dissociation, traumatic reexperiencing, concern for safety)