How are functional neurological disorders treated?
The first step in the treatment is explaining exactly what condition the patient has. They may be under the impression that their symptoms are “in their head” or in some way made up or their fault. Explaining that this is absolutely not the case is the first step in treatment.
Then it is important to establish if there has been a stressor that may have started or exacerbated the particular symptom. This is not always the case. However if it is the case it is crucial that it is not overlooked. The stressor may be something quite recent or could be an adverse event from much earlier in life. If a stressor is identified then dealing with it is of paramount importance.
Regardless of the presence or absence of a stressor the treatment of a functional neurological disorder will likely be a combination of cognitive behavioural therapy (which is a form of psychotherapy), physiotherapy and medication.
Cognitive Behavioural Therapy (CBT): CBT is a well-known form of psychotherapy and is used for many different conditions. The basic idea is to help patients “become aware of, examine and if appropriate revise the way they think, respond emotionally and behave in response to symptoms”. CBT emphasises the interaction of cognitive, behavioural, emotional and physiological factors in perpetuating symptoms. It helps patients become aware of their dysfunctional thoughts and help improve function of the nervous system maximise function by practising new ways to think about their symptoms and learning new ways to respond to their symptoms. Even if you do not have an underlying stressor that has precipitated the functional disorder, psychological therapies can still help. There are different levels of CBT depending on how severe the functional illness is. CBT can be given in a general neurology clinic by the simple explanation of the symptoms and why they are occurring - in patients with milder forms of functional disorders this may set them on the right track to recovery. As mentioned above, part of the challenge for patients with these disorders is that they get the impression that their symptoms are not believed and therefore are not real. CBT can also be delivered in the form of a self-help manual with or without some guidance. Again, this is more appropriate for patients on the milder end of the spectrum. For more severe cases sessions with a psychotherapist trained in the delivery of CBT may be the most appropriate course of action.
Physiotherapy: The delivery of physiotherapy in a functional disorder is a bit different to when a patient has a structural disorder. However, the purpose is the same- improve function. In a structural disorder there may be an emphasis on focusing on the weak leg or arm. In a functional disorder the focus is actually away from the weak arm or leg. The challenge is for the physiotherapist to demonstrate normal movement in the context of a meaningful activity such as walking. The physiotherapist can help the patient regain control over their nervous system and voluntary movements. Again, it is of great importance that your physiotherapist understands what a functional illness is and what the goals of treatment and steps to get there are.
- Goals of the physiotherapist would be:
- Education- this could be a further explanation of what a functional illness is and how it can improve. This would hopefully follow on from a detailed explanation by your neurologist;
- Demonstration that normal movement can occur;
- Retraining movement with attention diverted away from the weakness or abnormal movements- more of a focus on goal directed movement such as walking;
- Helping you to change maladaptive behaviours that may have developed in response to having the weakness, abnormal movements or abnormal walking;
- Rehabilitation diary- this can be very useful, especially with the support of your physiotherapist, allowing you to reflect on, remember and reinforce the information provided during physiotherapy sessions.
It should be noted, however, that you are unlikely to benefit from physiotherapy if you do not believe you have the correct diagnosis.
Non-specific graded exercise is also considered part of rehabilitation programmes to address reduced exercise tolerance (that occurs from disuse of a limb), chronic pain, fatigue, anxiety and depressive traits.
Medication: Anti-depressants are frequently used in the treatment of functional neurological disorders. This will target any underlying anxiety or depressive symptoms that are present either as a cause or as a result of the functional illness. This is a very individual treatment. Not every patient will want this. However, it is certainly worth having a discussion with your neurologist as to whether or not it is a reasonable option to help you cope with your illness. This should be combined with the above therapies. Eventually if the above therapies work you will not need this medication in the longer term. It may however support you as you begin to engage with physiotherapy and psychological therapy. There are many different options and the one you choose should be based on a discussion with your neurologist.