Coping with relapses

If relapses are frequent, update the model of the maintenance factors of the disorder. Try to help the patient identify physical, psychological and social factors that he/she may not have been able to identify so far. Do not put pressure on the patient and give them a sense of belonging and unconditional acceptance, even when they are struggling with a relapse.

Keeping a diary can be an excellent strategy to identify triggers that either lead to relapse or to worsening of FND symptoms, which may result in a potential relapse.

The patient can identify, among other things:

• Catastrophic misinterpretation of symptoms (panic without panic) and identifies situations where he/she had similar symptoms but these did not result in a catastrophe.

• Triggers and learn to use mindfulness techniques

• Negative thoughts and feelings associated with FND

• Behaviours triggered by negative thoughts and feelings associated with FND

• Beliefs and assumptions held about the FND and the recovery

• Objectives;

  • The steps you need to take to reach your goal

  • Progress

• Check if the patient lacks social support

• Check if his/her needs for belonging/acceptance/love are not being met

• Check if his/her family/community does not create a safe psychological environment

Social benefits and losses of recovery:

Explore with the patient the social gains and losses on the road to recovery

• Some advantages

  • Gaining autonomy and independence

  • Self-discovery and identity development without FND

  • Developing better coping strategies

  • New hobbies and leisure activities

  • You can help other FND patients on the road to recovery

• Some disadvantages

  • Loss of closeness to a family member who cares for me

  • Who am I without  FND?

  • Losing the routine

  • Loss of membership of the FND community

  • Fear of regaining social functions and how other people will accept my recovery

  • Changing roles in the family

  • Will my family expect more from me now?

Patients with FND often have associated neurological or psychiatric disorders and/or associated symptoms. Inadequate management, diagnosis and treatment of these can lead to frequent relapses. It is important to refer the patient to an appropriate specialist if an additional diagnosis is suspected. A patient may develop either a neurological/psychiatric disorder or additional functional neurological symptoms some time after the initial diagnosis FND, which is why follow-up appointments are crucial and important on the road to recovery.

• Reassess the patient's associated disorders and/or symptoms

• If necessary, refer the patient to an appropriate specialist

• If the patient reports symptoms suggestive of an organic condition, refer them for appropriate investigations

• Is the patient experiencing sleep, cognition or pain/fatigue problems as a result of FND? How can you help him/her cope with associated symptoms due to FND?

Explore with the patient the emotions and cognitions that accompany relapse and the whole treatment process

• Feeling too slow to progress and overwhelmed by what the social environment will think?

• Does he experience feelings of guilt and shame when he relapses, and fear that people will again think he is simulating his symptoms?

• Do you have difficulty expressing and recognising emotions associated with FND?

• Has anything triggered and/or amplified the fear of recovery?

• Does the patient catastrophise the relapse? What are his beliefs about relapses? Can you identify the core beliefs that trigger them (e.g. "I never succeed at anything", "I'm not good enough", "If I don't do something perfectly, my sense of belonging/security/worth is threatened")?

• Is relapse triggered by a strong fear of relapse? Is the patient too focused on the physical symptoms, amplifying them?

• Can the patient identify the worst consequences of a 'future' relapse and compare them with the consequences of an actual relapse? Is there a large discrepancy between them? Does the fear of relapse trigger fear of something else, e.g. fear of rejection by a professional; fear of disappointing the physiotherapist, etc.?

• Is the patient experiencing a strong fear that he/she will never be cured and the symptoms will keep recurring? Can you help him to identify the worst case scenario? Can the patient radically accept at this point that he or she may never be completely symptom-free? Does radical acceptance remove the pressure of 'instant cure'?

Fear of recovery may be hidden or even subconscious, as it is associated with loss of social and/or psychological functions. It may seem paradoxical on the surface, as FND significantly impairs the patient's quality of life, but there are many factors that trigger it. It is important to be alert to the signs of fear of recovery and to address the fear empathetically in the face of frequent relapses:

• The patient has not progressed for a long time and is not achieving realistic goals

• Patient selectively chooses targets (e.g. targets that help to treat and/or resolve only one symptom of FND)

• The patient has positive assumptions about the eqquippment

• The patient oscillates between assisted and unassisted movement, which may symbolise an internal battle during recovery/non-recovery

• Consistent difficulties in identifying triggers

• Strong beliefs that they will never be cured

• Patient has difficulty identifying goals once cured

• The patient does not have strong social support

• The patient has developed a number of protective behaviours and is living well with adaptations

• Patient has a strong FND identity

• Patients' symptoms may be amplified by their social environment

Normalise the fear of recovery and praise the patient for being transparent enough to share their fear with you. Reassure the patient that you will not reject and/or judge them for experiencing this fear. Be patient and gradually discover the psychological and social functions of fear. Also explore your own fears that may be preventing the patient's recovery. Can you identify any social benefits or ways of amplifying the symptoms of FND in yourself?

Patients with FND (especially the motor subtype) often report a fear of falling. The risk of falls is maintained by physical, psychological and specific factors related to FND.

• Physical factors

  • History of falls

  • Pain

  • Balance problems

  • Lack of knowledge about aids

• Psychological factors

  • Psychological pressure (patient rushes because he/she feels others are waiting for him/her)

  • Feeling a lack of confidence when walking in public

  • Cognitive problems (problems with concentration, orientation, memory and 'fog in the head')

  • Lack of psychological safety and difficulty regulating emotions

  • Fear of recovery

  • External locus of control and/or feeling of lack of control

• Specific factors related to FND

  • Dissociative episodes

  • Functional visual symptoms

  • Fatigue and pain

Help the patient to identify and write a list of protective behaviours:

• No history of falls

• Correct walking and standing techniques

• Regular practice of techniques taught by the physiotherapist

• Managing your daily activity levels

• Good participation in psychological therapies that promote psychological safety

• Working on cognition and dissociative episodes

• Reducing the experience of pressure