Psychology
Due to the marked heterogeneity of patients with functional neurological disorders and the different combination of precipitating and perpetuating factors, it is very difficult to speak of a standardised psychological treatment. Also, relatively few studies have been done examining the efficacy of different therapeutic modalities on FND symptoms. Individual therapeutic modalities have been shown to be effective for individual symptoms, but none of the therapeutic modalities led to 100% remission of symptoms (Lorna et al, 2021). Nevertheless, psychological therapies are recommended as part of multidisciplinary treatment for all FND subtypes.
The purpose of psychological treatment
Psychological treatment is not about attributing neurological symptoms to psychological causes, but about putting them in context, allowing both the psychologist and the patient to understand the risk factors, triggers and maintenance of the disorder. It is also crucial to treat comorbid psychiatric disorders (e.g., anxiety, panic attacks, depression, PTSD) if present (Bennet et al., 2021).
Psychological treatment is particularly important in patients with functional seizures, where cognitive behavioural therapy is primarily used. This uses similar principles to those used in the treatment of panic attacks:
earthing techniques,
exposure,
identifying safe and avoidant behaviour, etc (Bennet et al., 2021).
Psychological treatment in the context of multidisciplinary treatment is crucial, so below we will briefly present the different psychological modalities that have been studied so far.
Whichever therapeutic modality is chosen, individualised treatment of the patient is essential and may require a broad knowledge of different therapeutic schools.
Cognitive Behavioural Therapy (CBT)
Cognitive Behavioural Therapy is the most common form of therapy used with patients with FND and explores 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). In the course of CBT therapy, patients with FND can gain the opportunity to actively explore their own automatic negative thoughts about themselves, the world and the future, enabling them to identify them and also change them. Learning relaxation skills, distraction and other problem-solving techniques can help them to mitigate the impact of misinterpretations of body signals, disorder beliefs, emotional responses and automatic negative thoughts they have about FND.
For more information on the use of CBT in the treatment of patients with FND click here.
The work of the CBT focuses on exploring the way in content of the patient's thinking, which can be divided into three levels of cognition:
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Core beliefs or schemas are learned very early in life and refer to deep-seated and absolute beliefs about oneself, others and the world (Fenn and Byrne, 2013).
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Dysfunctional assumptions refer to the rigid and often unrealistic and inflexible "rules of life" that people accept. For example, someone may accept the rule: "I am responsible for what others feel and experience. If I say 'no', no one will like me."
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Negative automatic thoughts are thoughts that are unconsciously activated when we are faced with a situation. For example, you want to start a new hobby or business and immediately think: "Eh, why bother, I'm not going to succeed anyway!"
Dialectical Behavioural Therapy (DBT)
Dialectical Behavioural Therapy is a CBT-based therapy that was originally developed for the treatment of patients with borderline personality disorder, but has also been shown to be effective in the treatment of other mental disorders. It is based on acceptance as well as on changing thoughts, feelings and behaviours. The goals of the therapy are improved levels of mindfulness, better coping with stress, emotional regulation and improved interpersonal skills (Finkelstein et al., 2022).
For more information on the use of DBT in the treatment of patients with FND click here.
Mindfulness-based cognitive therapy( MBCT)
Mindfulness-based therapy is based on the practice of mindfulness, which requires the client to be aware and non-judgementally accepting of the present moment. MBCT incorporates many elements of contemplative practices such as various meditation and breathing techniques, yoga, body scanning and mindfulness walking. The primary aim is not to change the mind, as in CBT, but to change one's relationship to the mind.
MBCT works through the following mechanisms:
a shift in perception, leading to the development of tolerance, acceptance of somatic pain and/or maladaptive cognitive and emotional processing,
exposure to and encouragement to experience all emotions and thoughts leads to a reduction in anxiety,
developing self-awareness (metacognition) leads to better psychosocial coping strategies,
reduced autonomic arousal, leading to greater levels of relaxation, and,
actual changes in body systems (neuroendocrine and neurobiological changes; Felver et al., 2014; Lakhan and Schofield, 2013).
For more information on the use of MBCT in the treatment of patients with FND click here.
Acceptance and Commitment therapy( ACT)
Acceptance and Commitment Therapy is a science-based therapy that uses mindfulness approaches and behavioural strategies to increase psychological flexibility.
The core principles of ACT relate to:
Cognitive defusion: Learning methods by which individuals become observers of their inner experiences and no longer identify with them.
Acceptance: Acceptance of subjective inner experiences (all thoughts, feelings, sensations) and understanding of their transitivity.
The present moment: Learning to intentionally focus attention on the present moment with openness, curiosity and without judgement.
Me as context: Understanding the continuity of awareness and that we are observers of our inner experiences.
Values: Identifying and developing our own value system; checking whether our actions are in line with our values.
Committed behaviour: Learning how to set goals in line with your values and taking responsibility for your own life.
For more information on the use of ACT in the treatment of patients with FND click here.
EMDR (Eye Movement Desensitisation and Reprocessing)
EMDR( eye movement desensitisation and reprocessing) is an effective therapy for relieving symptoms of trauma (especially post-traumatic stress disorder), the positive effects of which have been scientifically validated in a number of well-controlled studies. EMDR therapy was founded in 1987 by Francis Shapiro. During the therapy, bilateral stimulation is used, which means that the patient has to make horizontal eye movements during the therapy while recalling traumatic memories. Tactile or auditory stimulation are also used as types of bilateral stimulation.
For more information on using EMDR to treat patients with FND click here.
The psychodynamic aspect
The psychodynamic perspective includes a wide range of theoretical knowledge and techniques that attempt to explain human psychological functioning in the broadest possible sense (e.g. the structure and defence mechanisms of personality).
Psychoanalysis is a form of therapy based on the process of working on oneself. It differs from other therapies in that the patient does most of the talking while the therapist does most of the directing. It lasts for several years rather than a few months like CBT. The patient sits and/or lies on a couch while the therapist is facing away from him/her. Psychoanalysis is based on the assumption that the interpretation of past events and internalised experiences from early childhood (e.g. attitudes, core beliefs about life, people, relationships, etc.) determine the patient's present reactions to the world (e.g. beliefs, thoughts, emotions). The aim is to understand the individual's functioning, personality structure, internal conflicts, defence mechanisms and psychic causality. It is based on the relationship that develops between the client and the psychotherapist.
For more information on using a psychodynamic approach to treat patients with FND click here.
What is common to all forms of psychological treatment for patients with FND?
Psychoeducation and interpretation are the primary commonalities in all psychological modalities, both FND and in the treatment of this type of disorder.
They address and take into account similar themes in treatment:
psychological trauma,
inadequate emotion regulation,
distorted automatic thoughts,
dysfunctional behaviours (avoidance, isolation)
In most cases, psychotherapists or clinical (neuro)psychologists also discuss with patients other aspects that contribute to mental health, such as: good quality sleep, pain and fatigue management, adequate nutrition, etc.
Similar techniques are also used:
Understanding the symptoms, the contexts and the triggers that set them off
Emotional regulation techniques
Relaxation techniques, mindfulness techniques
Distraction techniques
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Gutkin, M., McLean, L., Brown, R., and Kanaan, R. A. (2021). Systematic review of psychotherapy for adults with functional neurological disorder. Journal of Neurology, Neurosurgery & Psychiatry, 92(1), 36-44.
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..
Fobian, A. D., and Szaflarski, J. P. (2021). Identifying and evaluating novel treatment targets for the development of evidence-based interventions for functional neurological disorder. Epilepsy & Behavior Reports, 16, 100479.
Myers, L., Sarudiansky, M., Korman, G., in Baslet, G. (2021). Using evidence-based psychotherapy to tailor treatment for patients with functional neurological disorders. Epilepsy & Behavior Reports, 16, 100478.
Pun, P., Frater, J., Broughton, M., Dob, R., and Lehn, A. (2020). Psychological profiles and clinical clusters of patients diagnosed with functional neurological disorder. Frontiers in Neurology, 11, 580267.