A psychological perspective
Emotional regulation techniques
Exercise 1: Reflection
Every evening (and especially in stressful situations), you can take 10-15 minutes to write down the answers to the following questions;
What situation have I faced today? (Awareness)
What emotions did I experience in this situation? (Identifying and recognising emotions)
Can I identify unconscious beliefs, thoughts or values behind emotions? (Identifying unconscious beliefs)
What do I know about myself now, based on this experience? (Personality Change Planning)
What do I need to accept about myself as a result of this experience? (Forgiveness and self-love)
Exercise 2: Non-judgemental observer
Find a place where you'll be alone and no one will disturb you for five minutes. You can sit or lie on the bed. Close your eyes and focus on your breathing. Take three deep breaths in and out at your own rhythm. Then stay alert- waiting for thoughts, sensations in your body, emotions... to arise. When they arise, don't judge them or try to change them. Treat them like clouds in the sky- let them come, then let them go.
Exercise 3: Spot the thieves
Set an alarm for any time of the day (e.g. 4.28 p.m.). When the alarm rings, focus on your thoughts. Try to summarise what you have been thinking about for the last 5 minutes and how you have been feeling. This can help you catch the 'thieves' at work - the negative thoughts that can trigger negative feelings. Sometimes just being aware of negative thoughts and feelings is enough.
You can also make the exercise more interesting by asking a family member or partner to call out to you "See, a thief!" when you are not expecting it, and then do the same as in the previous example.
Tips on meditation
Grounding techniques
Exercise 1: Textures (Howlett and Reuber, 2009)
Find something rough or with a lot of texture in your immediate surroundings and feel it, focusing fully on the sensations. After you have been groping for a while (e.g. a piece of cloth), feel the solid ground under your feet. If you are not cold and uncomfortable, take off your socks and feel the coolness of the floor. If you are sitting or lying down, try to feel the full contact between your body and the surface you are sitting/lying on.
It is recommended to practise the technique when you feel good and relaxed, so that you know exactly what to do in an unpleasant situation. You can also choose an object in advance that you will always feel when such a situation arises. This could be a piece of cloth, a toy, balls with a rough surface, etc.
Exercise 2: Sounds and shapes (Howlett and Reuber, 2009)
The following exercise is very similar to the previous one, except that this time you focus first on the things you see in your surroundings. Observe very carefully and describe what you see in your mind or out loud. When you have finished, shift your attention to the sounds in your environment. Focus first on the most immediate sounds (e.g. the sound of a clock, the radio, footsteps) and then on increasingly more distant sounds (e.g. the sound of birds, the sound of cars, the sound of a neighbour, etc.).
Exercise 3: Ice water (Finkelstein et al., 2022)
The exercise is primarily intended for patients who are experiencing functional seizures and have been able to identify the warning signs and/or symptoms that lead to a dissociative seizure. Their task is to dip their hand in ice water at the first warning signs of a seizure and to hold it in the ice water even if the water is uncomfortably cold (be careful to remind them that the water should not be cold to the point of having negative side effects on their health). They hold their hand in the cold water until they feel that they are in the present moment and that the warning signs have stopped. They can also combine the exercise with mindful breathing, counting to 100, repeating a phrase/mantra, focusing on environmental sounds, etc.
Stress management techniques
Exercise 1: Breathing technique for energy and focus
Purpose: To increase energy levels and focus, to teach the body and mind how to cope in stressful situations.
Procedure: you can sit or lie on a bed or comfortable surface. Take a deep breath in through your nose, followed immediately by a deep breath out through your mouth. Do 25-30 repetitions, then exhale until the lungs empty and hold the breath for 30 sec-1 min. Do 2-3 repetitions.
Important: Do not use this technique near water and/or while driving. Also, do not do this technique if you are experiencing anxiety, depression or panic attacks.
Exercise 2: Physiological sigh
Purpose: Acute stress relief, relaxation and improved well-being
Procedure: you can sit or lie on a bed or comfortable surface. Take two breaths through your nose, the first longer and deeper, the second shorter and sharper. Then exhale through your mouth until your lungs are completely empty. You can repeat this process for 5 minutes in a cyclic pattern.
Interesting fact: The 3 physiological sighs can also help alleviate cramping when exercising on the right side of the ribs, as this specific cramping is related to the malfunctioning of the phrenic nerve. If you have a cramp on the left side, breathing will not relieve it, as it is related to an excessive amount of fluid or air in the stomach.
Exercise 3: The 'box' technique
Purpose: Acute relief and better control of stress, improved well-being
Procedure: sit up straight and slowly exhale all the air out of your mouth.
Step 1: Slowly and deeply inhale through your nose while counting to 4.
Step 2: Then hold your breath and count to 4 again in your mind.
Step 3: Exhale through the mouth with the same slow count to four and
Step 4: Hold your breath again with the same slow count to 4.
Step 5: Repeat the process.
Breathing
Tips for regulating sleep hygiene
Pain management techniques
Exercise 1: Applying cognitive reinterpretation and redirection techniques
Redirecting attention can be a good coping strategy. Encourage the patient to write down a list of enjoyable activities that relax him and that he likes to do. It can be as creative as possible, but the activities written down should be realistic to carry out. When he is in pain, ask him to read the list and choose one activity that he finds easiest to do at that moment. Doing the activity will distract the person from the experience of pain, and at the same time he or she will feel positive emotions while doing the activity (Lawrence et al., 2011).
You can encourage the patient to keep a pain diary to help them identify:
Negative beliefs and thoughts about pain
Catastrophising
Triggers of pain (e.g. overexertion, stress, coping with difficult experiences)
When identifying negative thoughts, he or she can apply the Socratic method of evaluating thoughts (Clark and Egan, 2015):
What is the evidence that this thought is true? (Try to list as many as you can)
What is the evidence that this thought is not true? (Try to list as many as you can)
What is the consequence of believing this thought? How does it affect my thoughts, feelings, behaviour?
Is there an alternative and more appropriate explanation?
What is the consequence if I change my belief?
How can I change my beliefs?
Fatigue management techniques
Exercise 1: Planning your rest day and setting priorities
Fatigue in some FND patients is often caused by too much activity during the day. The patient should write down a list of daily activities to be done the next day and then rate their importance on a scale of 0-5. If he/she places a high importance on almost all activities, ask him/her about the alignment of these activities with his/her values, short-term and long-term goals. The aim is for him/her to identify 1-2 activities that he/she needs to do in the next day.
Patients often plan activities that make them feel productive, while neglecting to plan their rest during the day. You can encourage the patient to plan daily rest periods according to their needs, lifestyle and abilities. They can plan several short breaks during the day (e.g. 10 minute intervals) or one longer one (1 hour to 2 hours).
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Clark, G. I., and Egan, S. J. (2015). The Socratic method in cognitive behavioural therapy: A narrative review. Cognitive Therapy and Research, 39, 863-879.
Morley, S., Williams, A., and Hussain, S. (2008). Estimating the clinical effectiveness of cognitive behavioural therapy in the clinic: Evaluation of a CBT informed pain management programme. Pain, 137(3), 670-680. doi:10.1016/j.pain.2008.02.025