Rebecca Puchkors; Jeanne Saunders; David Sharp

Learning Objectives

By the end of this section, you will be able to:

Discuss the DSM-5-TR diagnosis relative to functional neurological disorder
Identify risk factors for functional neurological disorder
Give examples of client behaviors associated with functional neurological disorder
Describe stress responses reported by clients due to functional neurological disorder
Plan nursing and collaborative care for clients in treatment for functional neurological disorder

When clients present with puzzling neurological symptoms that defy traditional medical explanations, intricate connections between the mind and body may be the cause. Nurses encounter individuals experiencing a wide range of symptoms, from unexplained paralysis and tremors to sensory abnormalities and gait disturbances. The hidden connection may be that these symptoms often emerge in response to psychological stress or trauma. The intricacies of functional neurological disorder call for exploration of the complex relationship between emotions, the brain, and physical health.

Medical Diagnosis

Also known as conversion disorder, functional neurological disorder (FND) is a condition where a person experiences neurological symptoms in the form of one or more altered motor or sensory symptoms that cannot be attributed to a specific medical or neurological condition (APA, 2022). In formulating a medical diagnosis of FND, there may or may not be compatibility of the symptoms with a known neurological diagnosis, but clinical findings (lab work, EEG, imaging) are incompatible. Medical evaluations and diagnostic tests may not reveal any underlying medical or neurological cause for the symptoms, and the symptoms experienced by the person may or may not follow typical patterns of known neurological disorders. It is thought that FND symptoms may occur because of a psychological conflict. It is important to note that clients are not intentionally producing symptoms; rather, the production of symptoms is involuntary and unconscious.

It is also important to note that FND can be present in clients with physical illness. Clients with epileptic seizures may also have nonepileptic seizures. And clients with significant and life-threatening physical illnesses may also present with dissociative symptoms and FND symptoms.

Link to Learning

Though research is ongoing regarding effective therapies, this article tells of a twenty-six-year-old male client who experienced severe neurological symptoms after an assault and how he was ultimately diagnosed with functional neurological disorder.

Risk Factors

Neurologic illness, such as epilepsy, stroke, or migraine, can increase the risk of symptoms of FND (Peeling & Muzio, 2023). Symptoms usually begin suddenly after a stressful experience. Other risk factors for FND include medical illness, dissociative disorder, and personality disorders.

Psychosocial Risk Factors

Psychosocial risk factors can contribute to the development and manifestation of FND. While the exact causes of FND are not fully understood, several psychosocial factors have been associated with an increased risk.

Individuals with a history of traumatic experiences, such as physical or sexual abuse, accidents, or witnessing violence, and those with post-traumatic stress disorder (PTSD) are more likely to develop FND because these conditions can overwhelm an individual’s coping mechanisms. High levels of emotional distress, such as anxiety, depression, or unresolved conflicts, increase the vulnerability to FND. Individuals who have difficulty expressing or managing their emotions may unconsciously convert their emotional distress into physical symptoms as a way of coping or communicating their distress. Stressful life events, such as financial difficulties, relationship problems, or major life transitions, can contribute to the development of FND. The experience of acute or chronic stress and the inability to cope effectively with stressors can manifest as physical symptoms.

Certain personality traits or characteristics may increase the risk of FND. Individuals with a high level of neuroticism, perfectionism, or a tendency to internalize stress may be more prone to developing other symptoms affecting thoughts, physical movement, or sensory function. Poor coping strategies, such as avoidance or suppression of emotions, can contribute to the development of FND. Inadequate coping mechanisms may lead to the conversion of emotional distress into physical symptoms as a way of managing internal conflicts or stressors.

One’s environment can play a large role in the risk of development of FND in the form of cultural and family systems. Dysfunctional family relationships, high levels of family conflict, or a history of childhood adversity can increase the risk, as can the presence of family members who inadvertently reinforce or encourage the symptoms. Additionally, cultural beliefs about illness, social expectations, and stigma associated with mental health can influence the expression of FND symptoms and can influence how a client perceives, interprets, and addresses symptoms within a particular cultural context (Canna & Seligman, 2020).

Behavioral Risk Factors

Behavioral risk factors for FND can both trigger the onset of the disorder and reinforce the cycle of its continuation. Seeking and receiving reassurance from others, especially regarding physical symptoms, may reinforce the belief that physical symptoms are the only way to gain attention or support, contributing to the maintenance or exacerbation of FND symptoms.

As with SSD, secondary gains associated with assuming the “sick role” can perpetuate FND symptoms. This may include receiving increased attention, sympathy, or support when experiencing physical symptoms, which may be more acceptable than emotional distress. If individuals receive attention or support primarily when they exhibit physical symptoms, they may be more likely to continue expressing those symptoms. This support can unintentionally strengthen the association between emotional distress and physical symptoms.

Maladaptive behaviors and poor coping mechanisms can increase the likelihood of FND symptoms. If individuals lack effective strategies for emotion regulation, they may unconsciously convert psychological distress into physical symptoms as a coping mechanism. This can present in multiple ways, from a client consciously engaging in maladaptive behaviors to a client experiencing trauma and not having the coping skills to respond to the trauma.

It is important to approach the understanding of behavioral risk factors cautiously, as the relationship between behavior and FND is complex, and not all individuals with FND exhibit the same behavioral patterns.

Behaviors and Symptoms Associated with FND

The symptoms associated with FND can be quite complex because they manifest as neurological symptoms that take the form of either altered motor symptoms or sensory symptoms. See the following lists for examples of the most common symptoms (NHS Inform, 2024).

Altered motor symptoms:

Weakness or paralysis: Partial or complete loss of muscle strength or control in specific body parts, such as an arm or leg
Abnormal movements: Involuntary movements, such as tremors, jerking, or dystonia (sustained muscle contractions causing abnormal postures)
Abnormal gait: Difficulty walking or an unusual manner of walking
Speech difficulties: Trouble speaking or slurred speech
Swallowing difficulties: Difficulty swallowing or a sensation of a lump in the throat, called globus
Nonepileptic seizures: Also known as pseudoseizures, which are seizure-like episodes without the characteristic electrical abnormalities observed in epilepsy on an electroencephalogram (EEG)

Sensory symptoms:

Numbness or loss of sensation: Decreased or absent sensation in a specific body area
Vision problems: Blurred vision, tunnel vision, or double vision
Hearing loss or deafness: Partial or complete loss of hearing without any detectable organic cause
Loss of touch or pain sensation: Reduced or absent ability to feel touch or pain

Other common behavioral symptoms include:

a debilitating symptom that begins suddenly
a history of a psychological problem that gets better after the symptom appears
a lack of concern that usually occurs with a severe symptom

Stress Responses Reported by Clients

FND carries a wide range of neurological symptoms that can be distressing and debilitating, leading to limitations in mobility, self-care, and overall physical functioning. They may also interfere with activities of daily living and work or school attendance. For this and other reasons, living with FND can be emotionally challenging. Individuals may experience anxiety, depression, frustration, or a sense of loss due to the effect of symptoms on their daily lives.

The uncertainty surrounding the symptoms and the difficulty obtaining a clear medical explanation can contribute to heightened anxiety and distress. Clients can also experience distress when getting results from medical tests, especially if the medical tests do not validate their physical symptoms. FND can lead to a sense of self-doubt and identity issues for clients. They may question the legitimacy of their symptoms, feel invalidated by others, or struggle with the dichotomy between physical symptoms and the absence of an identifiable medical cause. This can have a profound impact on self-esteem, self-image, and overall identity. Also, the stigma associated with functional disorders can further exacerbate emotional distress.

FND can strain personal relationships because loved ones may struggle to understand or accept the nature of the symptoms. The unpredictable nature of symptoms can lead to frustration, confusion, or feelings of helplessness among family members and friends. This may result in social isolation, as individuals with FND may withdraw from social activities due to embarrassment, fear of judgment, or limitations imposed by their symptoms.

FND symptoms can interfere with work or educational activities, leading to absenteeism, reduced productivity, or the need for accommodations. The impact on occupational functioning can result in financial difficulties, loss of employment opportunities, and diminished career prospects. Similarly, students with FND may face challenges in attending classes, completing assignments, and maintaining academic progress.

Individuals with FND often seek medical care from multiple health-care providers in an attempt to find an explanation or treatment for their symptoms. This can result in a long, expensive, and frustrating diagnostic journey, with frequent medical appointments, tests, and treatments. The fragmented nature of health care and the lack of awareness about FND among some health-care professionals can lead to stressful delays from appropriate diagnosis and treatment.

Nursing Care for Functional Neurological Disorder

FND is a medical condition classified by the DSM-5. As with other somatic symptom–related disorders, nursing care for FND begins with a caring and nonjudgmental approach to establish trust and rapport. The nurse should provide the client with accurate information about FND to help them understand the nature of their condition. Explain that FND is a real illness, that the client is not intentionally producing symptoms, and that they are not under the client’s conscious control. Providing emotional support and reassurance to the individual is important because FND can be a chronic and debilitating condition.

Nurses should advocate for clients’ needs and assist them in accessing appropriate resources and support groups. Work together with the individual to set realistic goals for their care. Involve them in decision-making processes and encourage their active participation in their treatment plan for best outcomes. Nurses can also help ensure continuity of care by maintaining regular communication with the individual and the health-care team. Monitor their progress, adjust the care plan as needed, and provide ongoing support throughout their journey.

Real RN Stories

Nurse: Jamila, RN
Years in Practice: Five
Clinical Setting: Charge nurse on a neurology floor at a large tertiary care hospital
Geographic Location: Major metropolitan area

Our neurology floor is large, and we care for a diverse population. We have a special epilepsy monitoring unit, which consists of eight client rooms with special equipment used for monitoring clients for seizures. These clients are planned admissions. They come in and stay for several days, attached to a continuous EEG that is monitored by clinicians who can interpret the client’s brain activity. Clients are also monitored visually by camera around the clock for their own safety. If they are on any seizure medications, they are usually discontinued in advance of their stay, and we do not give them any while they’re in the hospital unless there is an emergency and the clinician orders something.

Clients with confirmed epilepsy are sometimes admitted and their EEG studied in order to adjust their seizure medications to provide better control over their illness. Many of the clients in our epilepsy monitoring unit are admitted, however, because of suspected functional neurological disorder, or having psychogenic nonepileptic seizures (PNES). These seizures don’t result from electrical activity in the brain but instead from psychological distress. So, when the client has one of these seizures, it will not register on the EEG like an epileptic seizure.

One afternoon I was called to a client’s room and told they wanted to speak to the charge nurse. The client was a thirty-six-year-old female who had been on the epilepsy monitoring unit for four days and, based on her clinical assessments and testing, she appeared to be having nonepileptic seizures. She was tearful and angry when I entered the room. She informed me that she had heard two employees talking in the hallway right outside her door. One of the employees mentioned to the other that the client was not having “real” seizures and was, instead, “faking” them to get attention. The client was hurt and offended and felt like nursing staff did not believe her. She felt like she could no longer trust nursing staff with her care. I assured the client that we did care about her and as a unit were invested in providing her with accepting and nonjudgmental care. I told her that her nonepileptic seizures did not mean she was “faking it” and told her that I would provide her with some client education regarding functional neurological disorder. I also told her that I would educate all of the nurses on the floor to ensure they were providing understanding, supportive, and nonjudgmental care.

The client was still hurt but thanked me for listening to her. I spoke with both staff members who were involved individually. I provided them with information on FND and educated them on why clients are not “faking it.” Both staff members chose to apologize to the client, which she appreciated. I also made sure to lead staff huddles each shift for the rest of the week to provide the staff with education on FND and to ensure that they were not talking about clients in the hallway. FND is a psychiatric disorder and nurses will not encounter it in everyday medical client care; they should be educated on its signs and symptoms and how to educate clients and staff on how to manage it.

Nursing Assessment

The nurse should approach the assessment of the FND client with a comprehensive and compassionate mindset. Perform a thorough physical and psychological assessment to understand the client’s symptoms, their impact on daily functioning, and any underlying emotional or psychological factors contributing to the symptoms. Evaluate the client’s mental health status, including any history of anxiety, depression, or trauma. Assess their emotional well-being, coping strategies, and levels of stress.

Obtain a detailed history of the client’s symptoms, including their onset, duration, and any potential triggers or stressors. Ask the client about their perception of their symptoms and any previous medical evaluations or treatments they have undergone. Assess the specific neurological symptoms experienced by the client, such as motor abnormalities, sensory disturbances, or nonepileptic seizures. Perform a thorough physical examination to rule out any organic causes of the client’s symptoms. Pay close attention to neurological findings, reflexes, and coordination. Observe and document the characteristics of these symptoms, including their frequency, duration, and any pattern or association with emotional or psychological factors.

Some assessment tools used within the interdisciplinary team may include observation of specific body regions and functions, or interviews with the client to evaluate improvements, such as the Simplified Functional Movement Disorders Rating Scale (S-FMDRS), and the Clinical Global Impression (CGI) scale (Keatley & Molton, 2022).

Assess the impact of FND on the client’s daily functioning, relationships, and overall quality of life. Explore any occupational, social, or personal difficulties they may be experiencing as a result of their symptoms. This assessment helps guide the development of individualized care plans. Observe boundaries within the therapeutic relationship so as not to reinforce behaviors.

Approaches to Treating Functional Neurological Disorder

Managing FND is complex. As with many somatic disorders, individuals may face challenges in receiving an accurate diagnosis, finding appropriate health-care providers who understand the condition, and accessing effective treatments (Keatley & Molton, 2022). Education helps clients understand the nature of their symptoms, the mind-body connection, and the absence of an underlying organic pathology. By increasing clients’ knowledge and understanding, nurses can empower them to participate in their treatment and self-management.

CBT is an evidence-based psychological therapy used in the treatment of FND. It aims to address maladaptive thoughts, emotions, and behaviors associated with FND. By targeting anxiety, fear, and avoidance behaviors, CBT can help clients regain control over their symptoms and improve overall functioning.

Physical therapy plays a crucial role in the treatment of FND. It focuses on improving physical functioning and minimizing functional limitations caused by FND symptoms. Rehabilitation programs also emphasize functional restoration and quality of life. And while medications are not typically used as the primary treatment for FND, they may work to address comorbid psychiatric conditions, such as anxiety or depression.

Importantly, collaboration among health-care professionals, including nurses, physicians and advance practice providers, psychologists, physical therapists, and occupational therapists, is vital in managing FND. A coordinated and integrated approach centered around the client ensures a holistic treatment plan tailored to the needs of the individual. Regular communication, joint treatment planning, and shared decision-making help optimize outcomes and promote continuity of care.

21.2 Functional Neurological Disorder