Functional neurological and somatic symptom disorders

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Primary care physicians should take a patient-centred and stepped-care treatment approach in the delivery of care, depending on the patient's risk profile.[97][98] Education and explanation of the diagnosis is the first step of management for both conditions. It is important to acknowledge the reality of the patient's symptoms and of their physical and emotional suffering. Take sufficient time, give the name of the condition, and provide further reading and support information.[99] An empathetic approach is key, but note that even when the diagnosis is presented with care, some people will respond with anger, humiliation, or distress. Follow-up explanations by other members of the multidisciplinary team in primary and secondary care may be useful.[71]

Functional neurological disorder and somatic symptom disorder management often involves referral to consultative liaison psychiatrists or psychotherapists; referral to physical, occupational, or speech therapists as needed; and, when indicated, judicious use of somatic, depressive, or anxiety treatments. An integrative, multidisciplinary approach is necessary for all patients. Regular brief visits with primary care physicians (for somatic symptom disorder) and neurologists (for functional neurological disorder) should be scheduled to assess progress, maintain therapeutic relationships, avoid abandonment, and prevent excessive tests/procedures. After the initial diagnosis, psychiatric consultation followed by weekly phone contact may also improve quality of life.[100] Although often ultimately the goal of treatment may be good management rather than cure, it may nonetheless be helpful to emphasise to patients from the offset that complete resolution of symptoms is possible.

Functional neurological disorder without comorbid anxiety and depression: stepped care management model

Step 1: Communication of the diagnosis and patient education

The diagnosis should be made and explained by a neurologist, a neuropsychiatrist, and/or another clinician with expertise in neurological examination.[3] They should demonstrate positive clinical signs to illustrate the underlying mechanisms involved.[101] The aim is to provide validation of the patient's symptoms, and to offer a confident diagnosis that negates the need to seek an alternative medical opinion.

Useful phrases to adapt may include:[71]

"Functional neurological disorder is a problem with the functioning of the nervous system. It's a problem with the software rather than the hardware."

If this explanation is not fully understood, an alternative may be: "It's like a piano that's out of tune; not broken, just not working properly."

A useful way to describe prognosis could be: "This is not an easy problem to put right, but it does have the potential to improve, and many people do make a good recovery."

Regarding the need for psychological or psychiatric input: "It's common in functional neurological disorder for people to have problems like anxiety and depression. For some, there are things that have happened which may explain why your brain is vulnerable to going wrong in this way and could be worth exploring. I think a psychiatric/psychological assessment could be helpful. What do you think?"

It is important to develop a sense of partnership between patient and clinician, and an understanding of the likely next steps in management (including psychological treatment).[74]

Internet resources to signpost to include:

Step 2: Brief rehabilitation plus psychological therapy

If problematic symptoms persist following explanation of the diagnosis, the next step is usually to offer a brief rehabilitation intervention directed towards specific symptoms, in combination with psychological therapy (e.g., cognitive behavioural therapy).

For example, those with motor or gait disturbance may benefit from physiotherapy, whereas speech and language therapy is recommended for those with speech and swallowing disturbance.[92][102] Occupational therapy may be more generally applicable for improving function and engagement with everyday activities.[103] For patients with functional seizures, general principles of management include helping the patient to recognise triggers and warning symptoms in order to avert episodes, and to learn and challenge safety or avoidance behaviours around episodes.[74]

The evidence base for rehabilitation treatments for functional neurological disorder is growing, and there is now good evidence (predominantly from randomised controlled trials) in particular for physiotherapy for motor symptoms.[102][104][105][106][107] Successful programmes incorporate physiotherapy delivered by a therapist with experience of functional neurological disorder, delivered within a psychologically informed framework (e.g., incorporating psychoeducation and stress reduction techniques). The aim is to focus on function and automatic movement rather than on individual components of the movement and symptoms (e.g., weakness). Counter-productive thinking styles and behaviours should be addressed during physiotherapy, such as avoidance of particular movements in an attempt to avoid damage.[74][104]

Psychological therapy (e.g., cognitive behavioural therapy [CBT]) is a key aspect of treatment for most patients, ideally delivered by a therapist with experience in managing functional neurological disorder.[108]

According to one Cochrane review there is insufficient evidence overall to recommend any particular psychological intervention for functional neurological disorder.[109] However, several other individual studies and systematic reviews suggest benefit with CBT, CBT-based guided self-help, CBT-group training, mindfulness therapy, short-term dynamic psychotherapy, re-attribution training, and augmented psychodynamic interpersonal psychotherapy.[108][110][111][112][113][114][115][116][117][118][119][120] [ ] [ ] In practice, eclectic psychotherapeutic approaches are often used, but evidence is limited and more randomised controlled trials of longer duration (>12 months) are needed.[121][122][123] Eclectic psychotherapy includes a combination of CBT, mindfulness, interpersonal psychotherapy, short-term dynamic psychotherapy, and general psychotherapy.

Patients with functional neurological disorder may benefit from learning self-hypnosis as one tool to control symptoms, and so hypnosis may be considered as an adjunctive treatment.[124][125]

Eclectic psychotherapy involves:

Insight into psychological mechanisms and patterns (e.g., between the physical and emotional; and between current or past relationships and symptoms)
Understanding and recognising problematic interpersonal relationships
Developing ways to express and process emotions effectively
Developing a new relationship with symptoms that involves acceptance, non-judgemental awareness of symptoms and symptom dynamics, and self-compassion, rather than trying to control the somatic symptoms
Creating strategies to recognise and resolve conflicts
Using cognitive and behavioural strategies such as changing maladaptive thinking, relaxation strategies, and managing symptoms (the type of CBT varies for each group).

Step 3: Further psychological therapy

Patients who do not respond to initial therapies (brief rehabilitation intervention in combination with psychological therapy [e.g., CBT]) may benefit from further psychological therapy.

Further psychological therapy involves:

Administering psychodynamic psychotherapy
Administering family therapy - recognising unspeakable dilemmas (the suppression of a conflict arising from family, social, or political events due to the belief that it must remain concealed from key persons involved), and interrupting spousal reinforcement of illness behaviours[126][127]
Administering group therapy
Administering dialectical behavioural therapy - using in vivo coaching, homework assignments, and skills groups to help patients cope with rapidly shifting emotions and problematic reactions to emotional stimuli (particularly with comorbid borderline personality disorder or trauma)[128]
Administering paradoxical intention therapy (encourages the patient to deliberately engage in the unwanted behaviour)
Administering eye-movement desensitisation-reprocessing (particularly with comorbid post-traumatic stress disorder).

Biofeedback training may be considered as an adjunct to further psychotherapy.[74] This helps patients influence automatic, involuntary bodily functions (e.g., brain waves, blood pressure, heart rate, muscle tension, skin temperature, sweat gland activity) and better understand the mind-body connection by measuring bodily functions, using information about how bodily functions contribute to bodily tension and stress, and incorporating relaxation training; it is unlikely to cure patients of functional neurological disorder if other treatment modalities are not used conjunctively.

Step 4: Specialised multidisciplinary therapy

Patients with problematic symptoms in spite of steps 1-3 (e.g., those with complex symptom presentations and/or high levels of disability) may benefit from specialised multidisciplinary therapy conducted in an outpatient or inpatient setting. This approach has shown positive results in single-centre studies.[129][130][131][132][133]

Functional neurological disorder with comorbid anxiety and depression: stepped care model

Steps 1-4: Usual management plus adjunctive pharmacotherapy

Management follows the same stepped care model as above, but with the addition of adjunctive pharmacological treatment directed towards symptoms of depression and anxiety.[74] Specialist input is typically required (e.g., from a medical psychologist or consultant liaison psychiatrist).

Pharmacological treatment options for comorbid depression or anxiety include selective serotonin-reuptake inhibitors (SSRIs), particularly for anxiety disorders; serotonin-noradrenaline reuptake (serotonin-norepinephrine reuptake) inhibitors (SNRIs), particularly for co-existent pain syndromes; tricyclic antidepressants; mirtazapine; or bupropion.

Patients who do not benefit from eclectic psychotherapy (including CBT) and antidepressant therapy may be treated with further psychological therapies.

Steps 5 and 6: Additional options

If the above management is not effective, atypical antipsychotics may be tried. If augmentation strategies are not effective, electroconvulsive therapy (ECT) or repetitive transcranial magnetic stimulation (rTMS) may be considered. Evidence supporting the use of atypical antipsychotics, ECT, or rTMS for functional neurological disorder is limited.[134][135][136][137][138][139][140][141][142][143][144] However, when mood or anxiety disorders are present these treatments may have added value for treating the comorbid condition.

Somatic symptom disorder without comorbid anxiety or depressive disorder: stepped care management model

Step 1: Communication of the diagnosis and patient education

Patient education including careful delivery of the diagnosis is the first step of management. Before delivering a diagnosis of somatic symptom disorder, carefully explore what the patient thinks is wrong, and tailor the explanation accordingly.[145] One approach to giving the diagnosis is to explain that there is no evidence of a serious or life-threatening illness, and to emphasise that this is positive news. The explanation may include: "You have a condition that is common but not yet fully understood, which we know to cause the group of symptoms you are experiencing."

Initial management usually takes place within primary care, with regular follow-up visits scheduled (e.g., every 4-8 weeks) that are not dependent on symptoms.[146] Evidence on treatment is limited, but a practical approach to initial primary care management based on expert opinion and several review articles includes:[97][145][146][147]

Exploration of symptoms, including patient's thoughts and emotions in response to these, including impact on functioning
Conducting brief physical examinations focusing on areas of discomfort at each visit
Establishing a therapeutic alliance, acknowledging that the patient's symptoms are real
Limiting tests and referrals unless symptoms change
Communication with specialists treating the patient
Gradual discontinuation of unnecessary medications
Psychoeducation (e.g., explaining that the body may generate symptoms in the absence of disease)
Mutually agreed realistic and incremental goals for improvement of functioning.

If no medical cause of symptoms has been identified, note that it is not possible to completely exclude the presence of an underlying medical condition via negative investigation results, although the probability of falsely reassuring results is low. By acknowledging this uncertainty to patients, clinicians can avoid offering facile reassurance, which may exacerbate fears. Advise patients to report any changing, worsening, or new symptoms, as they may warrant re-assessment.[148]

Step 2: Psychological therapy

Psychological therapy may be beneficial as the next step. Discussion with a psychiatrist may also be helpful to cover a review of initial management, to ensure this has been appropriate, and verification of the diagnosis. It is important to explain this sensitively, as patients may consider the involvement of psychiatric clinicians as evidence that their symptoms are believed to be 'all in their head'.

In practice, psychological therapy may include eclectic psychotherapy (including CBT, mindfulness, and/or short-term dynamic psychotherapy).[112][118][149][150]

CBT in this group involves:

Reducing physiological arousal through relaxation techniques
Enhancing activity regulation through increased exercise, and pleasurable and meaningful activities
Pacing activities
Increasing awareness of emotions
Modifying dysfunctional beliefs
Enhancing communication of thoughts and emotions
Reducing spousal reinforcement of illness behaviour.

Patients being treated with eclectic psychotherapy (including CBT) may also benefit from the following adjunctive treatments:

Graded physical exercise (GET): patients are gently introduced to exercise by only gradually increasing the amount of daily exertions; the aim is to begin with very short periods of exercise, such as walking or swimming, just to the point of toleration, and then each week to attempt to increase the amount of exercise with the goal of increasing tolerance and capacity for exercise.[151][152] The rationale for offering graded exercise is based on its use in other conditions with overlapping symptoms, such as myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS); note that there have been serious concerns expressed regarding the potential for iatrogenic harm with GET in ME/CFS, and its use is no longer recommended in ME/CFS by the National Institute for Health and Care Excellence (NICE) in the UK for this reason.[153] It is important to acknowledge that this is a topic of polarised discussion; the current evidence base concerning the possibility of iatrogenic harm with GET is hindered by methodological shortcomings, and there a lack of widespread consensus among experts regarding the balance between its risks and benefits.
Biofeedback training: the goal is to better understand the mind-body connection and to learn ways to use relaxation training; any patient may potentially benefit, especially those with genitourinary and/or gastrointestinal (GI) complaints who will learn to relax those organ systems. The rationale for considering biofeedback is based on its use in pain syndromes and other mind-body disorders.

Step 3: Referral to a psychiatrist

For patients whose symptoms have not responded adequately to steps 1-2, psychiatric referral is the next recommended step, with continued regular input in primary care. In order to avoid engendering feelings of abandonment, it can be helpful to emphasise that you will continue to help the patient, but that you are seeking input from a colleague to better help you do this. There is evidence that even a single visit with a psychiatrist may improve outcomes.[150]

Evidence on pharmacological treatment is limited, low-quality, and often indirect.[154][155][156][157] A specialist may consider offering antidepressant therapy (with tricyclic antidepressants, SNRIs, SSRIs, mirtazapine, or bupropion), particularly in cases of pain syndromes or cyclic vomiting.[155] Even if pain or cyclic vomiting are not the primary target symptoms, there is low-quality evidence for pharmacological therapies being effective compared with placebo in treating medically unexplained symptoms, with no one class of antidepressant or natural supplement being superior to another; benefits thus need to be weighed against their adverse effects.[154]

Step 4: Further psychotherapy

Patients who do not respond to initial therapies (eclectic psychotherapy and/or pharmacotherapy) may benefit from further psychotherapy, including psychodynamic psychotherapy; family therapy (recognising unspeakable dilemmas and interrupting spousal reinforcement of illness behaviours); group therapy; dialectical behavioural therapy (particularly with comorbid borderline personality disorder or trauma); paradoxical intention therapy (encourages the patient to deliberately engage in the unwanted behaviour); and eye-movement desensitisation-reprocessing (particularly with comorbid post-traumatic stress disorder).[127][128]

Somatic symptom disorder with comorbid depressive or anxiety disorder: stepped care model

Steps 1-4: Usual management plus adjunctive pharmacotherapy

Management follows the same stepped care model as above, but with the addition of adjunctive pharmacological treatment directed towards symptoms of depression and anxiety. Specialist input is typically required (e.g., from a consultant psychiatrist).[148]

Pharmacological treatment options for comorbid depression or anxiety include SSRIs (particularly for anxiety disorders); SNRIs (particularly with predominant pain); tricyclic antidepressants; mirtazapine; or bupropion.

Step 5: Atypical antipsychotic

Atypical antipsychotic medication can be offered by a specialist to patients who do not respond to further psychotherapy. When mood or anxiety disorders are present it may have added value for treating the comorbid condition. Consult a specialist for guidance on dose and choice of medication.

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