A psychological perspective
Before the psychological treatment of the FND patient itself, it is important to consider the following points:
Does the patient have a confirmed positive diagnosis of FND?
Before the psychological treatment itself, it is important that a positive diagnosis of a functional neurological disorder has been made and clearly explained to the patient. Any ambiguity about the diagnosis itself may lead to the belief that there is still a potential possibility of an organic cause of the disorder, which may impair the patient's acceptance of the psychological impact of the presenting symptoms.
Has the patient been diagnosed with any other psychological disorder and/or illness?
FND is characterised by high comorbidity, which makes interdisciplinary management (e.g. neurologists, physiotherapists, epileptologists, etc.) important. Obtaining information on medical history is crucial, as it provides information on previous experiences with health professionals, understanding and acceptance of psychological models of treatment, as well as historical triggers of the functional neurological disorder. Based on this information, a risk assessment can be made.
Is there a possibility that the patient has been a victim of systemic re-travmatisation?
The phenomenon of systemic re-travmatisation is common in the FND population. Patients often report that medical staff did not believe them and even accused them of simulating their symptoms because they could not find an organic cause. As a result, many patients perceive a referral to a psychologist as a threat and as confirmation that the medical staff are convinced that everything is 'in their head'. It is precisely because of these negative experiences that it is crucial to establish a therapeutic relationship and to actively listen and empathically accept their previous experiences.
Does the patient understand the importance of psychological treatment for functional neurological disorder?
Psychological treatment is still stigmatised and many patients have misconceptions about psychological therapy, especially in the context of FND. It is therefore crucial that the patient is equipped with the correct information about psychology before starting treatment. You can prepare a document with the most common myths and truths about psychological treatment.
ASSESSMENT
Open questions
Your questions should be as open as possible, given the complexity and wide range of symptoms that characterise FND. This will also help to satisfy the patient's need to be heard and to discover what their understanding of the diagnosis is.
In your own words, please explain to me what symptoms you are experiencing?
Which symptoms are currently the most disruptive to your daily functioning?
The nature of the FND: variability and complexity
A key characteristic of FND is the variability and fluctuation of symptoms. It is very important to keep in mind all types of FND symptoms = motor, sensory, dissociative seizures and functional cognitive symptoms. We should also bear in mind that symptomatic substitution can occur (e.g. the patient initially has only dissociative seizures, but with chronic progression of the disorder develops motor type FND symptoms; e.g. weakness of a limb).
Risk assessment
Risk assessment is important for all subtypes of FND patients, but especially for those who experience hours of violent dissociative episodes. Sometimes dissociative episodes can also result in unintentional self-harm, which in some cases is difficult to distinguish from intentional self-harm. The risk is particularly high in patients who experience both epileptic and dissociative seizures at the same time.
Medications
FND patients often take many different medications that can have counter-productive effects on cognition and even cause certain cognitive symptoms, although the relationship between cognition and medications is quite complex.
Associated symptoms
In addition to the primary symptoms, patients with FND experience a number of associated or secondary symptoms, such as pain and fatigue (Nielson et al., 2017). It is important to thoroughly explore these symptoms (their causes, triggers, etc.) with the patient and to teach them specific techniques to help them manage them.
Assessment of the 'ignition' profile by PC model
Ignition in the PC model refers to the critical events that are most likely to have contributed to the development of FND symptoms. In general, we can speak of three different profiles:
Profile 1: before-and-after
This profile is characterised by the development of FND following a critical event, which may be either a stressful or traumatic life event (e.g. divorce, accident, death, assault) or a previous illness and/or medical intervention (e.g. surgery). Traumatic childhood experiences and/or the development of inappropriate coping strategies are also common (but not necessary!) for this profile, as are negative interpersonal dynamics in the family at the time of the development of the first symptoms.
Profile 2: Sudden development
Some patients also report a sudden onset of panic attacks. This profile is strongly associated with anxiety manifestations and often results in non-epileptic or dissociative episodes.
Profile 3: Progressive development
Some patients are also characterised by a long period of various abusive behaviours (e.g. violence, toxic relationships) which may make them even more vulnerable to developing FND. On the other hand, there are also patients who experience stress (e.g. from work) for long periods of time in the absence of useful coping strategies and who, after a certain period of time, reach a point where the body reacts with illness.
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Finkelstein, S. A., Adams, C., Tuttle, M., Saxena, A., and Perez, D. L. (2022). 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..
Perez, D. L., Aybek, S., Popkirov, S., Kozlowska, K., Stephen, C. D., Anderson, J., ... and American Neuropsychiatric Association Committee for Research. (2021). A review and expert opinion on the neuropsychiatric assessment of motor functional neurological disorders. The Journal of neuropsychiatry and clinical neurosciences, 33(1), 14-26.
van der Hulst, E. J. (2023). A Clinician's Guide to Functional Neurological Disorder: A Practical Neuropsychological Approach. Routledge.