A psychological perspective
Cognitive Behavioural Therapy is the most common form of therapy used for treating FND patients, exploring the link between emotions, thoughts and behaviour.
It is a highly structured, directive and time-limited approach aimed at alleviating distress and helping people to develop their own mental insight and more adaptive behaviour. It is the most researched and empirically supported psychotherapeutic method used to treat a variety of mental disorders(Fenn and Byrne, 2013; Frankelstein et al., 2022).
CBT is particularly useful for the treatment of psychogenic non-epileptic seizures, as patients have developed many maladaptive illness beliefs and negative somatic behaviours. They also have a higher prevalence of dissociative and psychopathological symptoms (La France et al., 2009).
In the context of FND, CBT primarily focuses on reducing the severity and/or intensity of symptoms through exploring, identifying and actively changing maladaptive beliefs, thoughts, feelings and negative behaviour patterns (e.g. avoidant behaviour developed as a consequence of the disorder) that are linked to the severity of FND symptoms.
Symptomatic improvement is based on the assumption that abnormal symptoms are related to a specific non-functional core belief. When patients succeed in identifying the non-functional belief and transforming it into a more functional one, symptomatic improvement occurs.
The CBT for treating FND focuses on:
diverting attention
changing negative automatic thoughts, beliefs and putting situations into context
taking control of your body's physiology
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Context
Social situation
Thoughts:
"I can't." "I'm scared." "What will others think of my symptoms? "Everyone will look at me and talk about me." "What if they think I'm faking?"
Perceived social risk:
Fear of negative judgement and being rejected by others.
High and abnormal attention to symptoms:
Being overwhelmed by the severity of symptoms and other people's opinions. Attention is overly focused on the internal perception of the social situation and on the search for 'protective behaviours' to cope successfully with the social situation.
Symptoms:
Anxiety, sweating, worsening of FND symptoms, sleep problems, muscle tension, etc.
Protective Behaviours:
Dissociation, exacerbation of FND symptoms to 'avoid' social situations; avoiding social situations altogether, suppressing anxiety and coping internally with stress, etc.
Some techniques and strategies to help:
Mindfulness techniques (keeping attention on the present moment)
Identifying and transforming dysfunctional beliefs about 'judgement' and 'social standards'
Changing perspective ("What would you think if your best friend was in your shoes? Would you judge his symptoms?")
Systematic desensitisation ( prolonged exposure to social situations)
Behavioural experiments that help to abandon protective behaviours.
A catastrophic misinterpretation
The CBT models of functional neurological disorders are much closer to the CBT models of anxiety and panic disorders than to the CBT models of depression. Catastrophic misinterpretation of bodily symptoms plays a central role in the CBT model of anxiety. CBT leads to dysfunctional beliefs about the severity of illness/disorder, health and physiological sensations, which are further exacerbated when symptoms are unexplained (Bailey et al., 2015; Barsky et al., 1993).
Catastrophic misinterpretation is the process by which an individual interprets a stimulus as an impending catastrophe (e.g. an individual with functional seizures may experience a rapid heartbeat as a sign that he or she is about to experience a severe seizure). This results in an active exchange in the interpretation of the situation, making catastrophic misinterpretation a cognitive process rather than a stand-alone thought (Ohst and Tuschen-Caffier; 2018).
Research on FND also reports the impact of beliefs and expectations on functional neurological symptoms. Edwards et al. (2013) explain this using the theory of active interference, whereby the brain predicts and interprets sensory input based on past experience. FND patients are thought to be characterised by a 'jumping to conclusions' bias, as research suggests that FND patients require less information to make a decision, compared to the control population. They also change their decision more quickly when conflicting evidence is added, which may be a risk factor for inappropriate updating of the past model in the brain.
Edwards et al., (2013) also report discrepancies between subjective and objective reporting of the frequency of daily functional tremor. While patients reported experiencing functional tremor from 80%-90% of the whole day, objective measures showed that they only experience it for 30 minutes per day. This suggests that patients with FND have impairments in 'top-down' inference and time perception, compared to individuals with organic tremor, where subjective and objective tremor frequencies are more closely matched.
Self-regulation model for executive functions
The premise of the model is that the problem is more about the maladaptive beliefs that individuals hold about thinking than the maladaptive beliefs that individuals hold about illness/disorder/illness/health/symptoms.
Negative thought "Nobody knows what's wrong with me. What if I never get better?" can trigger a cascade of negative thoughts such as rumination, worry and focusing on the threat in anxiety-prone individuals. Collectively, these responses are referred to as Cognitive Attentional Syn drome (CAS). These responses can persist at:
individuals with positive metacognitive beliefs
(" Concerns about health problems can help me to strengthen in time")
individuals with negative metacognitive beliefs
(" I can't control my health")
Positive metacognitive beliefs perpetuate a cascade of negative thinking, while negative metacognitive beliefs lead to reduced mental control and other dysfunctional forms of thinking. Both forms perpetuate health anxiety and lead to increased experience of stress (Bailey et al., 2015).
La France et al. (2009) developed Beckian-based CBT, a time-limited and present-oriented psychotherapy that addresses distorted cognition and behavioural changes in patients with psychogenic non-epileptic seizures. The aim is to achieve control over psychogenic non-epileptic seizures.
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Bailey, R., and Wells, A. (2015). Metacognitive beliefs moderate the relationship between catastrophic misinterpretation and health anxiety. Journal of Anxiety Disorders, 34, 8-14. doi:10.1016/j.janxdis.2015.05.005
Barsky, A. J., Goodson, J. D., Lane, R. S., and Cleary, P. D. (1988). The amplification of somatic symptoms. Psychosomatic Medicine, 50(5), 510-519.
Edwards, M. J., Fotopoulou, A., and Pareés, I. (2013). Neurobiology of functional (psychogenic) movement disorders. Current opinion in neurology, 26(4), 442-447.
Finkelstein, S. A., Adams, C., Tuttle, M., Saxena, A., and Perez, D. L. (2022, April). Neuropsychiatric treatment approaches for functional neurological disorder: a how to guide. In Seminars in Neurology (Vol. 42, No. 02, pp. 204-224). Thieme Medical Publishers, Inc..
Fobian, A. D., and Elliott, L. (2019). A review of functional neurological symptom disorder etiology and the integrated etiological summary model. Journal of Psychiatry & Neuroscience, 44(1), 8-18. doi:10.1503/jpn.170190
LaFrance, W. C., Miller, I. W., Ryan, C. E., Blum, A. S., Solomon, D. A., Kelley, J. E., & Keitner, G. I. (2009). Cognitive behavioral therapy for psychogenic nonepileptic seizures. Epilepsy & Behavior, 14(4), 591-596. doi:10.1016/j.yebeh.2009.02.016
Ohst, B., and Tuschen-Caffier, B. (2018). Catastrophic misinterpretation of bodily sensations and external events in panic disorder, other anxiety disorders, and healthy subjects: A systematic review and meta-analysis. PLOS ONE, 13(3), e0194493. doi:10.1371/journal.pone.0194493