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September 2018

Current Concepts in Diagnosis and Treatment of Functional Neurological Disorders

Author Affiliations
  • 1University of Cincinnati Gardner Neuroscience Institute, Gardner Family Center for Parkinson’s Disease and Movement Disorders, Department of Neurology, University of Cincinnati, Cincinnati, Ohio.
  • 2Department of Neurology, University Hospital Inselspital, Bern, Switzerland
  • 3Neuropsychiatry, Centre for Clinical Brain Studies, University of Edinburgh, Edinburgh, United Kingdom
  • 4Motor Control and Movement Disorders Group, Institute of Molecular and Clinical Sciences, St George's University of London, London, United Kingdom
  • 5Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
  • 6Human Motor Control Section, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
  • 7Department of Neurology, University of Louisville, Louisville, Kentucky
  • 8Department of Psychiatry, Alpert Medical School of Brown University, Providence, Rhode Island
  • 9Department of Neurology, Alpert Medical School of Brown University, Providence, Rhode Island
  • 10Morton and Gloria Shulman Movement Disorders Centre, Toronto Western Hospital and Edmond J. Safra Program in Parkinson Disease, University of Toronto, Toronto, Ontario, Canada
  • 11Section of Cognitive Neuropsychiatry, Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
  • 12Academic Neurology Unit, University of Sheffield, Royal Hallamshire Hospital, Sheffield, United Kingdom
  • 13Department of Psychiatry, University of Cambridge, Cambridge, United Kingdom
  • 14Centre for Clinical Brain Sciences, University of Edinburgh, Western General Hospital, Edinburgh, United Kingdom.
  • 15Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
JAMA Neurol. 2018;75(9):1132-1141. doi:10.1001/jamaneurol.2018.1264

Importance  Functional neurological disorders (FND) are common sources of disability in medicine. Patients have often been misdiagnosed, correctly diagnosed after lengthy delays, and/or subjected to poorly delivered diagnoses that prevent diagnostic understanding and lead to inappropriate treatments, iatrogenic harm, unnecessary and costly evaluations, and poor outcomes.

Observations  Functional Neurological Symptom Disorder/Conversion Disorder was adopted by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, replacing the term psychogenic with functional and removing the criterion of psychological stress as a prerequisite for FND. A diagnosis can now be made in an inclusionary manner by identifying neurological signs that are specific to FNDs without reliance on presence or absence of psychological stressors or suggestive historical clues. The new model highlights a wider range of past sensitizing events, such as physical trauma, medical illness, or physiological/psychophysiological events. In this model, strong ideas and expectations about these events correlate with abnormal predictions of sensory data and body-focused attention. Neurobiological abnormalities include hypoactivation of the supplementary motor area and relative disconnection with areas that select or inhibit movements and are associated with a sense of agency. Promising evidence has accumulated for the benefit of specific physical rehabilitation and psychological interventions alone or in combination, but clinical trial evidence remains limited.

Conclusions and Relevance  Functional neurological disorders are a neglected but potentially reversible source of disability. Further research is needed to determine the dose and duration of various interventions, the value of combination treatments and multidisciplinary therapy, and the therapeutic modality best suited for each patient.

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