Functional Neurological Disorder, or FND, is a condition that can be difficult to understand, not only for patients and their families, but sometimes for the people around them.
A person may experience seizures, weakness, tremor, abnormal movements, numbness or difficulty walking, yet conventional brain scans may show no obvious structural abnormality. This can understandably leave people asking: if nothing appears to be damaged, what is actually causing the symptoms?
The answer lies in the way the brain is functioning.
What is FND?
FND is a genuine neurological condition in which there is a problem with how the brain’s networks function and communicate, rather than visible structural damage to the brain or nervous system.
The brain is still sending and receiving signals, but the way those signals are processed can become disrupted. This can affect movement, sensation, speech, vision, memory and awareness.
The word “functional” is sometimes misunderstood. It does not mean imaginary, and it does not mean that symptoms are simply psychological. The symptoms are real and, for some people, can be profoundly disabling.
One way of thinking about it is that the physical structures of the nervous system may appear intact, but the way those systems are working together has become disrupted. Conventional scans are primarily designed to identify structural abnormalities, so they may look normal in someone with FND.
Our understanding of FND has developed considerably in recent years. We are increasingly recognising the role of brain networks involved in movement, attention, emotion, prediction and sensory processing. It is a complex condition, however, and there is no single mechanism that explains every person’s symptoms.
How is FND diagnosed?
An important point about FND is that it should not simply be diagnosed because a brain scan or another investigation is normal.
FND is a clinical diagnosis. Neurologists look for positive clinical signs that demonstrate that the nervous system is functioning differently from what would be expected in a structural neurological disorder.
For example, someone with functional weakness may demonstrate different levels of strength depending on how a movement is tested. A functional tremor may change or reduce when someone performs another movement or follows a different rhythm.
There are also clinical features that can help distinguish functional seizures from epileptic seizures. In some cases, video EEG monitoring can provide additional support for the diagnosis. Patients deserve to understand why FND is being diagnosed. It should be based on what the person is demonstrating clinically, rather than simply on what has not been found on a scan.
Why can FND be mistaken for epilepsy or other neurological conditions?
FND can resemble a number of other neurological disorders, including epilepsy, multiple sclerosis, Parkinson’s disease, dystonia, stroke and other movement disorders.
Functional seizures are particularly likely to be confused with epilepsy because the two can look remarkably similar.
Historically, FND was often treated as a diagnosis of exclusion. In other words, doctors would rule out conditions such as epilepsy or multiple sclerosis and, if investigations were inconclusive, eventually arrive at FND.
Our approach has changed. We now understand that there are positive clinical signs that can support an FND diagnosis, rather than simply relying on the absence of another explanation.
It is still important to assess each person carefully. FND can present in many different ways, and it is also possible to have FND alongside another neurological condition, such as epilepsy, migraine or multiple sclerosis.
FND is not “all in the mind”
Perhaps one of the most damaging misconceptions about FND is that it means someone’s symptoms are imaginary or that they are consciously producing them.
They are not.
FND is a neurological disorder. The symptoms are generated by the nervous system and can be extremely disabling.
Psychological factors such as stress, anxiety or previous trauma can contribute to FND in some people, but they are not universal and should not automatically be assumed to be the cause.
It is more accurate to think of FND as a disorder of nervous system functioning, where biological, psychological and psychosocial factors may contribute in different ways.
Another reason FND can be difficult for other people to understand is that symptoms can fluctuate. Someone may struggle to walk at one point and appear to walk relatively normally later. A tremor may change depending on what the person is doing. A seizure may occur in one situation but not another.
From the outside, this can appear contradictory. For the person experiencing it, the symptoms are very real.
How we communicate the diagnosis therefore matters enormously. Patients need to understand that FND is a recognised neurological condition, that their symptoms are real and that treatment can help.
Why can symptoms change so dramatically?
Fluctuation is a characteristic feature of FND and can be one of the most frustrating aspects of the condition.
The brain is constantly integrating information from the body with attention, movement, emotion, the environment and our expectations. In FND, these processes can become disrupted, meaning that symptoms can change depending on the demands being placed on the nervous system.
Fatigue, poor sleep, pain, illness, stress and sensory overload can all make symptoms worse. For some people, focusing intensely on a particular movement or symptom can also increase it.
Again, this does not mean the symptoms are voluntary.
It reflects the complex relationship between attention and the brain networks involved in neurological function.
For someone living with FND, this unpredictability can have a significant impact on everyday life. Work, driving, relationships, independence and social activities can all be affected. A person may be able to walk reasonably well one morning and struggle significantly later that day.
That uncertainty can be particularly difficult to live with.
Why are we hearing more about FND?
FND is not a new condition. What has changed is our understanding of it.
Historically, neurological disorders were often divided into those where there was an identifiable structural abnormality and those where there was not. This made conditions such as FND much harder to explain and, unfortunately, sometimes contributed to patients feeling dismissed.
We now have a much better understanding of the brain as a network. The brain does not simply depend on its physical structures. Its function also depends on how different areas and networks communicate and process information.
This has helped FND become much more firmly established within modern neurology.
Doctors are also becoming more familiar with the clinical signs that can support a diagnosis, meaning that FND can increasingly be diagnosed positively rather than only after every other possibility has been excluded.
It is therefore likely that increased awareness is contributing to more diagnoses. At the same time, it is difficult to know how much this represents a genuine increase in the number of people developing FND and how much reflects cases that were previously missed or diagnosed differently.
What is clear is that FND is common, can be profoundly disabling and is now better recognised and understood.
Can FND be treated?
The treatment of FND is usually tailored to the individual and may involve neurological rehabilitation, physiotherapy and psychological therapies, depending on the person’s symptoms and circumstances.
A new specialist approach is also being explored for some people with FND at Re:Cognition Health, using Intensive Short-Term Dynamic Psychotherapy (ISTDP).
ISTDP is a focused form of therapy that explores how unconscious emotional responses, physical anxiety and patterns of emotional avoidance may contribute to the nervous system remaining in a state of heightened threat.
Importantly, this approach does not suggest that FND symptoms are psychological or imagined. The starting point remains that the neurological symptoms are real. The aim is to explore whether emotional processing and nervous system dysregulation may be contributing to the persistence or severity of symptoms in some individuals.
This may be particularly relevant in complex cases where there appears to be a relationship between symptoms, stress, emotional processing and the way the nervous system responds to perceived threat.
The goal is not simply to help someone manage their symptoms, but, where possible, to address factors that may be helping to maintain them and support more lasting improvement.
Understanding the person behind the symptoms
Perhaps the most important thing to recognise about FND is that there is a person behind every diagnosis.
For someone who has suddenly developed seizures, weakness, abnormal movements or difficulty walking, being told that their scans are normal can be confusing and frightening. If they are then made to feel that their symptoms are imaginary, the experience can become even more distressing.
FND gives us a different way of understanding these symptoms.
The nervous system does not have to show obvious structural damage for its function to be disrupted. As our understanding of the brain continues to develop, we are increasingly able to recognise the complex ways in which different brain networks interact to produce movement, sensation and awareness.
For patients, that understanding can be an important first step. A diagnosis of FND should not mean being told that nothing is wrong. It should mean being given an explanation for what is happening, a treatment plan and appropriate support.
FND is real. Its symptoms are real. And for many people, understanding what is happening in their nervous system can be the beginning of finding a way forward.
For consultations and enquiries about Intensive Short-Term Dynamic Psychotherapy treatment, please contact 020 3355 2526 or visit https://www.recognitionhealth.com/private-service/neurology-clinics/
Read the article in Daily Mail:
https://www.dailymail.com/health/article-16156845/Jo-seizures-epilepsy-little-known-brain-condition-affecting-thousands.html
