Damian Sendler: Comorbid psychopathology (e.g., anxiety, depression, PTSD, somatic symptom and pain syndromes, and dissociative and personality disorders) is common in people with functional neurological disorder (FND). Many patients’ conditions can deteriorate to the point of chronicity, making it difficult to find work or receive benefits. An important role is played by psychological and social factors in the onset and persistence of symptoms. This is why treating functional seizures with psychotherapy is a good idea for anyone with FND, regardless of the specific symptoms they present with (FS). The use of CBT, third-wave approaches, and psychodynamic psychotherapies as well as group therapeutics and psychoeducational interventions have all been used to treat FND. Prolonged exposure therapy, a CBT-based treatment, has been implemented for patients with FS and PTSD. Specific elements (e.g., theoretical foundations, tools, goals, and definitions of success) of the main psychotherapeutic approaches used in patients with FND will be described and analyzed in this manuscript Our premise is that there will be significant overlap between these modalities. We’ll wrap up by talking about how discrete differences can make them more suitable for subgroups of patients with FND or for patients at different stages of recovery.
Damian Jacob Sendler: Symptoms of functional neurological disorder (FND) are disruptive and disabling because they don’t fit in with the known pathophysiology of neurological disease. Comorbid psychopathology frequently occurs with FND and can lead to chronic illness, unemployment, and disability for many patients [2–3]. In the onset and perpetuation of symptoms, psychosocial factors play an important role [4]. FND can have a wide range of symptoms, either alone or in combination. PNES, dissociative and functional seizures, gait difficulties, abnormal movements, sensory deficits, and cognitive complaints are among the most common phenotypes.
Dr. Sendler: A large number of patients with FND have reported experiencing adversity and trauma in their lives. There is a wide range in the frequency of FS risk factors, with reports ranging from 9 to 100% [6]. Comorbid psychiatric diagnoses (such as anxiety, depression, PTSD, somatic symptom and pain syndromes, and dissociative and personality disorders) are also common in patients with FND [7], [8].
Psychotherapy is therefore recommended for FNDs and is the primary treatment modality for patients with FS [9]. “The informed and intentional application of clinical methods and interpersonal stances derived from established psychological principles for the purpose of assisting people to modify their behaviors, cognitions, emotions and/or other personal characteristics in directions that the participants deem desirable,” is how the American Psychological Association defines psychotherapy [10]. In 2017, Carlson and Perry [11] conducted a meta-analysis of 13 FS studies and found that 82% of patients who completed psychological treatment saw a 50% or greater reduction in seizures. Numerous controlled and uncontrolled clinical trials show that psychotherapy can reduce seizure frequency, improve mental health, quality of life (QoL), and reduce medical service utilization [12, 13, 14, 15, 16]. Other FND phenotypes have been shown to benefit from psychotherapy in reducing symptom burden or severity [16].
CBT, third-wave approaches that incorporate mindfulness, and psychodynamic psychotherapies have all been used in the treatment of FNDs [12], [15], [17], [18] as well as group therapeutic and psychoeducational interventions. A CBT-based treatment for the treatment of PTSD, prolonged exposure therapy, has been used in the treatment of FS and PTSD.
Several etiological, predisposing and perpetuating factors are involved in the development of FND [24, 25]. To meet the needs of all patients, a standardized psychological intervention is needed. To illustrate this, Rusch et al. [26] noted that the clinical presentations of patients with FS are so diverse that psychotherapeutic treatments must be tailored to the patient’s specific needs.
Meta-analytic reviews [11] describe the most common psychotherapeutic approaches used with FND patients, and this manuscript aims to summarize those findings. The vast majority of the available information pertains to a single FND subtype, namely, FS. Treatments have shown improvements in specific outcomes (e.g, physical symptoms including seizure frequency, mental health, QOL, work and social function and resource use) but reporting on sustained remission of symptoms has been inconsistent.. We’ll talk about how discrete differences may make these modalities more appropriate for specific subgroups of patients with FND or for patients at different stages of their recovery. A patient-centered theory of psychotherapy, rather than a 20th-century psychotherapeutic partisanship, is consistent with the latter. There are some who argue that multimodal approaches in the treatment of children have been around longer, but this is not the case [28].
The CODES study by Goldstein et al. [14], [15] and the LaFrance et al. [12] approach are the two most detailed models of CBT for FS patients that have been described in the literature.
In general, CBT views functional symptoms as the result of maladaptive learned patterns of behavior caused by unhelpful or distorted ways of thinking. In order to get better, patients must first learn to recognize their symptoms and distorted thinking, then identify unhealthy responses (such as avoidance), and finally, adopt new ways of solving problems and coping with stress.
According to LaFrance and co-workers, CBT-ip is based on modifications from an epilepsy therapy workbook that emphasizes mood, cognition, and environment, relaxation techniques, healthy communication, and identifying internal and external triggers. Seizure frequency was reduced significantly in both the CBT-ip and the combined (CBT-ip and sertraline) arms of a multicenter pilot study, which randomized participants across four treatment arms. The treatment as usual and sertraline-only arms did not show a significant decrease in seizure frequency.
In the Goldstein et al. [29] model, “panic without panic” is a symptom of fear avoidance, despite the fact that the person may not be aware of their fear (i.e., “panic in the absence of panic”). An initial physiological trigger sets off a chain reaction of avoidant behavior that is fueled by cognitive and attributional factors. Factors such as these all contribute to the maintenance of stable emotional states in people with frontal lobe dysfunction (FS). For the first time, a clinical trial for a FND has randomized 368 patients to either standard medical treatment (SMT) or cognitive behavioral therapy (CBT) and SMT. The primary outcome measure of seizure frequency was not significantly different between groups at 12 months of follow-up. When it came to overall health-related quality of life (QOL), impairment in psychosocial functioning, overall psychological distress, and somatic symptoms, the CBT plus SMT group scored higher [15].
There were three groups of patients with functional movement disorder (FMD) that were randomized into: CBT alone, CBT and physical therapy, or a control group. [30] Treatment with CBT focused on the identification of thoughts/beliefs that maintain functional movement symptoms and on somatic misinterpretations. The functional movement disorder scale, depression and anxiety scores of patients in the active treatment groups improved.
Functional tremors were treated using the CBT-informed psychotherapy protocol mentioned above in an uncontrolled study. A key component of this protocol was identifying and correcting mental distortions, which was accomplished through regular thought tracking. Thought distortions that lead to symptoms worsening have been mapped out between sessions. Tremor severity was significantly reduced after 12 weeks of cognitive behavioral therapy (CBT) in patients with functional movement disorder (FMD) [16].
Patients with various phenotypes of FND were randomly assigned to either a CBT-based guided self-help (GSH) group or a treatment as usual (TAU) group by Sharpe et al [31]. For those in the GSH group, symptoms improved significantly at 3 and 6 months, while the TAU group’s symptoms worsened.
“Paying attention in a particular way: intentionally, in the present moment, and non-judgmentally” is what MBT refers to when used broadly to describe psychotherapies rooted in mindfulness practice. The “third wave” of behavioral therapies includes these mindfulness-based approaches as well as classical behavioral therapy (the “first” wave) and Beckian cognitive behavioral therapy (the “second” wave). For MBT, the goal is not to change the content of thoughts, but to accept them as they are, without judging them.
Seizure frequency and intensity were reduced significantly by the end of a 12-session manualized MBT protocol for FS, as well as an improvement in quality of life. Seizure frequency was reduced by at least 50% among most participants at the end of the treatment, and many of them reported that they had completely eliminated their symptoms of FFS. Seizure frequency was found to be significantly lower than it had been at the beginning of treatment six months later [17].
There are three main goals of brief psychodynamic therapy: reducing the suffering of the patient, strengthening the ego and increasing self-awareness, and permanently altering his or her personality. Starting with rapport and engagement and then focusing on illness perception, Psychodynamic Interpersonal Therapy (PIT) aims to improve self-care, control symptoms and enhance symptom control. Treatment promotes the processing of emotions and psychological trauma that are thought to be the source of the symptoms you’re experiencing today.
PDT for FND [32, [33], [34] is based on the premise that patients’ symptoms are a result of early-life patterns and dysfunctional interpersonal relationships. PIT uses trauma-specific interventions and focuses on unresolved trauma as part of the treatment. Interpersonal psychotherapy is based on psychodynamic interpersonal therapy, but also incorporates elements of cognitive behavioral therapy. And somatic trauma therapy was one of these components, which involves close family members in the healing process. There were significant improvements in well-being and mental health symptoms, general health and quality of life, and severity of somatic symptoms in a pilot uncontrolled study. Improvements were maintained over the course of six months, and about half of the patients showed improvement in at least one measure.
The frequency and severity of seizures were reduced in another study using a brief PIT. Over time, these gains were maintained. From the baseline to the follow-up, there was a decrease in health care use [35].
FMD patients have had varying degrees of success with psychodynamic psychotherapy. Patients with FMD were randomized to receive short-term weekly psychodynamic psychotherapy either immediately after diagnosis or three months after diagnosis, and Kompoliti et al examined the effects of this treatment. When it comes to functional symptom severity, there was no significant difference between the two allocation groups at 3 and 6 months after diagnosis.
A single-blind, uncontrolled study of short-term psychodynamic psychotherapy in FMD was conducted by Hinson et al. In addition to improvements in depression, anxiety, and functioning, a functional movement rating scale was significantly improved at the conclusion of treatment [37].
As a clinical approach to neurophysiological regulation, therapeutic communication and exploration, somatic psychotherapy encompasses body-oriented or somatic psychotherapy. Therapies like sensorimotor psychotherapy, somatic experience, acupoint tapping, and healing/therapeutic touch are examples of structured modalities. Sensory (rather than cognitive) resources, such as interoception, proprioception, and kinesthesis, have been shown to reduce psychological distress through neurophysiological regulation techniques [38, 39] [40, 41]. Many of these therapies are based primarily on the body’s autonomic, arousal and limbic systems as therapeutic mediators rather than verbal cognitive approaches [39]. In addition to traditional ‘top-down’ methods, these “bottom-up” methods could be seen as complementary [40]. Depression, anxiety, PTSD, and somatic distress (including pain) may benefit from these treatments, but the evidence supporting their efficacy is still limited [38].
Damian Jacob Markiewicz Sendler: The treatment of FS in children that has been described in the medical literature has emphasized a focus on the body. A two-week mind–body program designed to help children identify and manage changes in their physical state and increase their physical resilience was studied by Kozlowska et al. A year later, 75 percent of the 60 participants had returned to school full-time, with full control of FS or only brief relapses, and 75 percent had regained normal function [41]. For pediatric patients with FS, Sawchuck et al. described a step-by-step approach that included various therapeutic components. A psychophysiology assessment and subsequent biofeedback training (1–3 sessions) were two of these ingredients. It’s hard to say how much the body-oriented training contributed to the positive outcomes, which included FS remission in more than half of the participants by treatment’s end [42], because this stepped care program had so many other therapeutic components.
CBT and mindfulness-based approaches have joined traditional group psychotherapy’s eclectic approach since its inception in the 1940s [43], when it was known primarily for its psychodynamic foundations. In addition to providing didactic information about a particular health condition or illness, psychoeducational groups also offer emotional support and practical resources [44].
At the conclusion of an uncontrolled trial, one of the first investigations into psychoeducational group interventions found significant reductions in posttraumatic and dissociative symptoms as well as improved coping mechanisms [19]. Recent studies have found a positive effect on work and social adjustment, as well as decreased emergency room visits for seizure-related reasons, in those who received an active psychoeducational intervention for three months [21]. Seizure frequency and intensity improved in neither study.
Psychopathology and depression scores improved significantly after a trial of psychodynamic group therapy. Seizure frequency was reduced in the majority of patients [20].
Patients in a DBT-ST group for FS saw a significant decrease in seizure frequency [22].
Patients with FS and other FND phenotypes were only shown to benefit from a CBT-based group intervention that focused on specific subscales on a quality-of-life measure. There was no improvement in overall quality of life or depression and anxiety scores, but a clinical global impression indicated a moderate to substantial improvement [45].
Children with FS may benefit from ReACT, a cognitive behavioral therapy based on cognitive restructuring (CBT). By focusing on the catastrophic and symptom expectations and the low control over symptoms, ReACT retrains classically-conditioned, involuntary FS. The “Integrated Etiological Summary Model” describes FS as the result of catastrophic symptom expectations and/or classically conditioned responses in this treatment modality’s explanation of FS. [48]. When compared to patients who received supportive therapy as a control, the results seven days after treatment completion were exceptional, with 100 percent of patients reporting no FS. More than eighty-two percent of patients remained seizure-free 60 days after the end of their treatment. Section 2.1.4 describes other pediatric approaches that use body-centered psychotherapies.
Epilepsy patients are often recommended psychological interventions to improve their mood, anxiety, and self-management skills. Psychoeducation and mindfulness-based approaches have shown positive results in reducing the frequency of seizures [49].
Drug-resistant temporal lobe epilepsy and FS were treated with an 8-session CBT group program, and the patients’ QOL improved, their depression and anxiety levels decreased, and their seizure frequency dropped significantly [50].
Identifying triggers and pre-seizure auras, learning relaxation techniques, identifying and managing life stressors, and recognizing internal and interpersonal conflicts, as well as isolation, are all topics covered in the sessions. Teachers emphasize confronting negative states, accepting oneself, and cultivating a healthy lifestyle. A one-on-one session dedicated to medication issues is a standout feature.
An intensive 12-session CBT program designed by Goldstein et al. can be completed in 4–5 months. Important components include: psychoeducation; treatment participation; reinforcement of independence; distraction, relaxation, and refocusing techniques when an episode is imminent; gradual exposure to avoided situations; cognitive restructuring; and prevention of relapse [15]..
A CBT professional can provide patients with guided self-help for FND in the form of four half-hour sessions over the course of three months, either in person or over the phone [31]. Cognitive restructuring and psychological education are key components of GSH.
An eight-session program called ReACT is used in the treatment. Each patient receives an individualized treatment plan that teaches them how to deal with their symptoms in ways that aren’t compatible with their FS diagnosis, as well as a family response to FS that includes monitoring the patient for safety while still allowing the patient to follow their treatment plan [48].
In Cognitive Behavioral Therapy (CBT), relaxation techniques are taught and practiced by patients in order to lower their arousal level and help them overcome their fear-based behaviors. Behavioral and cognitive factors that perpetuate symptoms can be lessened by identifying and challenging ingrained beliefs and assumptions.
Session content includes instruction in self-awareness and self-awareness training, as well as instruction in contextual and value-based factors.
Damien Sendler: Through the practice of mindfulness, this treatment aims to improve one’s psychological flexibility. In the beginning, the emphasis is on discovering one’s values in order to aid in making behavioral choices. By increasing awareness and acceptance of internal states (e.g., thoughts, emotions, and physical sensations), patients are encouraged to engage in values-based behavior, while automatic processes that lead to FS are reduced. Reducing baseline arousal levels through relaxation training is similar to other CBT methods. Instead of identifying and changing thoughts and behaviors, the focus of mindfulness shifts from this to identifying and changing one’s relationship to these internal processes.
Understanding hypotheses, linking hypotheses, and explanatory hypotheses are all used to help patients better understand their symptoms and the underlying causes of them. “Understanding hypotheses” help patients gain a better understanding of their feelings and emotions both inside and outside of therapy.
A two-hour semi-structured interview is the first step in treatment, followed by a series of nineteen 50-minute sessions (weekly or biweekly). The goal of the first session is to generate a patient commitment to therapy and a personalized case formulation, modify illness perceptions through a psychological formulation based on predisposing, precipitating, perpetuating factors, and triggers, and provide symptom control techniques. Patients’ self-care skills are further developed in subsequent sessions, as are their relationships with family and friends, as well as their ability to cope with stressful situations [33].
[37] Hinson et al’s 12-week psychodynamically-based treatment for FMD consisted of weekly 1-hour sessions. There were many links between childhood experiences and current life experiences, as well as a person’s personality traits, in the intervention. By making unconscious phenomena conscious and resolving underlying conflicts, the intervention studied by Kompoliti et al. was aimed at helping patients develop insight into unconscious phenomena or to improve alexithymia deficits.In general, psychodynamic modalities believe that problematic emotions and symptoms can be triggered and perpetuated by a person’s past interpersonal experiences and dynamics. As a result of this, the patient can work through early traumas and develop better emotional regulation abilities.
First, the child and his/her family are assessed in Kozlowska’s et al approach (2018). Individual assessments begin with a session of slow-breathing training that matches the patient’s breathing rate to a picture of his or her lungs and reduces it to the rate that corresponds to the greatest heart rate variability. Another assessment task is for patients to draw their symptoms on an outline of their own body to document their physical condition. Using this body map, doctors can look for warning signs of impending FS, as well as monitor clinical progress. Patients and their loved ones are then given an explanation of the diagnosis. Then comes a two-week inpatient Mind-Body program. There is a daily individual therapy component, as well as a hospital school component and a physical therapy exercise component, in this program, which helps patients learn about managing their FS, as well as a reintegration back into school. The Mind-Body program’s outpatient therapy continues after discharge to help patients deal with stressors in the community [41].
There was one psychoeducational group intervention that included 10 lectures in which participants learned about FS and triggers, as well as anger/assertiveness and psychological trauma and comorbid psychiatric symptoms. First, a lecture was given to the group about FS, with subsequent sessions focusing on specific themes (such as how physical manifestations can have underlying emotional causes and patient empowerment) A 32-week pilot study on group psychodynamic therapy covered a wide range of topics. [20]. Three modules of distress tolerance, emotion regulation, and interpersonal effectiveness, each lasting 8–10 weeks, comprised a DBT-ST group modality for FS [22].
FND (including FS) was treated with CBT in a group consisting of four or five one-hour sessions, depending on the diagnosis of FS (five). Behavioral strategies to control symptoms were developed through psychoeducation, which involved exploring the patients’ thoughts, feelings, physical sensations, and actions in relation to their symptoms [45].
The prevalence of epilepsy in patients with FS ranges from 9.4% to 50% [52]. Many studies that evaluate treatments for FS do not include comorbid epilepsy, so the evidence for treating comorbid FS and epilepsy is limited. Epilepsy management may benefit from some effective FS interventions. There are many examples of this, such as the CBT-ip manual used to treat FS [12] which was adapted from an original treatment protocol developed for epilepsy [53].
Psychotherapy models for FS were used in an intervention for patients with epilepsy and FS [50]. (CBT, PIT, MBT). There were eight sessions in total, including an introduction to the group, identification of cognitive and emotional distortions, epileptic seizures, and FS, relaxation techniques, body monitoring, stress assessment, and “preparation for life” at the end of treatment, among other things. The proper recognition of the type of paroxysmal event is critical to the treatment of comorbid FS and epilepsy. Patients and their families/caregivers must be educated. Measurements such as videos for review can help distinguish between different types of events.
Damian Sendler
CBT primarily focuses on functional neurological symptoms, interpersonal issues, negative thoughts, and behavior (socialization, well-being, and avoidance) [12]. Abuse and family dysfunction are explicitly allowed in Goldstein et al’s [15] modality. People with post-traumatic stress disorder (PTSD) can benefit greatly from psychoeducation (PE). Emotional dysregulation and distorted views of the world and self are also addressed by this treatment [55].
Seizures and other functional neurological symptoms can be treated by enhancing awareness of the contexts and vulnerable states that promote them. Personal values and how they influence behavior choices are the focus of this treatment [17].
The unconscious is the focus of both brief psychodynamic therapy and traditional psychoanalysis. It is the goal of PIT to identify and address the unhelpful patterns of interpersonal relations, emotional processing and psychological trauma. To make emotional distress conscious and verbally expressed, psychodynamic group approaches aim to identify symptomatic primary and secondary gains, focus on anger and assertiveness as well as to identify current seizure triggers and significant past events [20]. Similarly,
Distress tolerance, emotion regulation, and interpersonal effectiveness are all goals of a DBT-ST group for FS. In purely psychoeducational groups, the goal is to raise awareness of FND and foster a sense of camaraderie among the members of the group [22].
“Catastrophic symptoms expectations and perceived control over symptoms” were the focus of ReACT, a CBT-based treatment that was piloted in a pediatric FS population. [48]
All forms of psychotherapy include psychoeducation and a rationale for the treatment. Information about the targeted symptoms and treatment rationale, hypothesized etiological mechanisms, expectations, and a roadmap for recovery are all provided by psychoeducation [51].
The first session of CBT modalities is devoted to psychoeducation and the rationale for treatment. “Taking control of your seizures” is a stated objective of CBT-ip [46]. The first session of MBT for FS is devoted to psychoeducation. The first three sessions of PE are devoted to educating the patient about trauma and the benefits of exposure therapy. The fact that psychoeducational groups educate people about FS is not surprising [52]. Patients were taught about FS risk factors, comorbidities, and healthy behaviors by Zaroff et al [18]. There was an initial “psychoeducational focus” in the pilot group of Barry et al. [19]. [21] The DBT-ST groups are psychoeducational. Traditional psychoeducation was only used in the brief psychodynamic interpersonal model [36].
A symptom log, relaxation training, or distraction techniques, self-care tools, handouts, and homework are required for all CBT-based and similar approaches. The use of thought recording to detect negative thinking styles and thinking errors, such as incorrect attributions, is commonplace these days.. [12], [53] Some treatment modalities use patient workbooks [12], [53], trigger charts, goal-setting exercises, medication logs, the use of a support person, and a relapse prevention plan. PE is unique in that it utilizes both in-vivo and out-of-body exposures for the duration of the treatment.
Workbooks for depression and anxiety were created for FND using existing CBT-based self-help manuals. There were techniques for self-management and explanations of functional symptoms (e.g. anatomical structure, physiology, and psychology) and diagnosis included [31]. CBT and adjunctive physical activity and distraction techniques were used to treat FMD patients [30].
Damian Jacob Sendler
Among MBT’s unique features are its use of behavior chain analysis, exercises for identifying values, mindfulness, and emotion recognition logs, as well as methods for identifying behavioral tendencies and associated cognition and for determining behavioral choice [17].
Multi-modal tools in PIT make it particularly eclectic. In the therapist’s toolbox, there are life charts, sensory focusing, emotional freedom technique (or tapping), eye movement desensitization and reprogramming (EMDR), and emotional diaries.
DBT diary cards and mindfulness training [22] and scheduled naps [21] are just some of the unique tools used in some group modalities [20]. People who participated in both group psychotherapies were urged to continue receiving individual psychotherapy at the same time.
The primary definition of success in these treatments is a decrease in functional neurological symptoms, with the exception of a few modalities [21]. There are a number of secondary indicators of success that include reduced symptom burden, and unnecessary use of medical resources, as well as improved psychosocial functioning [12], [23], decreased health anxiety, greater satisfaction with care [12], [15], and a positive change in quality of life [17]. In the MBT model, success is defined as engaging in value-based activities. Finally, PIT aims to “improve identification and change of unhealthy interpersonal patterns and to achieve more effective processing of emotions” [33]. Many psychodynamic therapies aim to reshape “the patient’s intrapsychic structure” in order for the patient to be able to express his or her emotions verbally rather than through somatic means[20], [37].
Treatment outcome studies for FNDs have grown in number and quality in recent years. When it comes to treating the same disorder with different approaches based on differing theoretical underpinnings and treatment rationales and tools, there appears to be some overlap.
FND psychotherapies almost universally incorporate psychoeducation and a rationale for treatment. Many similar tools are used regardless of treatment orientation (e.g., a symptom record to increase the patients’ understanding of triggers, emotional dysregulation and symptom expression). Most people also use techniques like relaxation training, grounding, and distraction to help manage symptoms and lessen the vulnerable states that come along with them. Psychological trauma, emotional dysregulation, distorted thoughts and unhelpful concepts of self and others, and dysfunctional behaviors (avoidance, isolation) are all relevant targets in most treatment modalities. Regardless of treatment approach, it is common to make explicit recommendations for self-care (such as good sleep habits, regular physical activity, and downtime).
Some treatment modalities have unique features, such as the use of negative reinforcements in pediatric treatment [48]. In addition, some modalities employ unique tools, such as DBT diary cards (22), medication logs (12), self-hypnosis (20), prolonged exposure (46), prescribed physical activity (30), mindfulness training (17), (22), life charts (33), emotional diaries (17), (33), behavior chain analysis and values identification exercises (17), (17), and massage, touch, or tapping (38). Many different treatment modalities have been tested on different subpopulations of FND patients, including those with FS, FMS, and epilepsy/FS [50], as well as those with both FS and post-traumatic stress disorder (PTSD) [23], [57].
What remains to be determined is which treatment is most appropriate for which patient. If the patient accepts the diagnosis of FND, it is likely that treatment rationale will assist in determining the best course of action.. There are patients that may find it easier to relate to their symptoms as being caused by concrete cognitive and behavioral factors (such as a trigger that leads to distorted thinking/emotion that in turn causes maladaptive behavior), and a present focus may be more understandable than past trauma and emotional/interpersonal conflicts [58]. Alternately, a patient who prefers MBT may be receptive to explanations that suggest that a rise in self-awareness and acceptance of internal states leads to the development of values-based behavior rather than rote behavior (such as in FS). Patients who have difficulty comprehending verbal concepts, such as children, may benefit from body-centered therapies. In addition, a patient who meets the criteria for PTSD and FS may be eligible for treatment that combines a trauma-based approach with treatment that focuses on both disorders. Most patients are likely to benefit from psychoeducational groups, which can help them understand their condition and treatment options, as reliable information on FNDs is difficult to come by.
It’s possible that some new and unique tools could be added to some of the treatment approaches discussed above, enhancing their effectiveness (e.g., inclusion of significant others or adjunctive mindfulness training). Based on how therapeutic the clinician believes the incorporation of these unique tools will be, he or she may choose a specific approach. Trauma-specific tools and interventions should be offered as soon as possible to patients with unresolved trauma.
Finally, clinical formulations that focus on a wide range of biopsychosocial predisposing, precipitating, and perpetuating factors [29], [30] or to consider different modalities at different points in the patient’s recovery path may be useful in choosing psychotherapeutic approaches [29] and [30]. CBT for fear avoidance and distorted cognitions, for example, may be used to help a patient begin the process of recovery. By increasing tolerance for difficult thoughts and feelings and promoting intentional and value-based behavior, mindfulness-based skills can further assist. A more in-depth treatment (i.e. psychodynamic) focusing on interpersonal issues and long-standing trauma may be offered to the same patient. To address the various aspects of FND, the patient can make use of a variety of currently available resources, including those that have been shown to be effective in the treatment of symptoms and the improvement of mental health.
The availability of evidence-based, effective psychotherapy treatments for a clinical population in desperate need has increased as a result of research in FND. Increasing the likelihood of clinical success may be achieved by drawing on complementary treatment modalities and conceptualizing treatment plans that incorporate specific interventions at various stages of the patient’s care. For patients receiving treatment in naturalistic settings, this may be particularly relevant.
