Functional neurologic and somatic symptom disorders

2nd line – brief rehabilitation intervention

Back

1st line –

patient education

Education and explanation of the diagnosis is the first step of management. The diagnosis should be made and explained by a neurologist, a neuropsychiatrist, and/or another clinician with expertise in neurologic examination.[3]

The aims are to:[66][74]

Demonstrate positive clinical signs to illustrate underlying mechanisms involved

Validate patients' symptoms

Offer a confident diagnosis that negates the need to seek an alternative medical opinion

Develop a sense of partnership between patient and clinician

Outline likely next steps in management (including rationale for psychological treatment).

Back

2nd line –

brief rehabilitation intervention

If problematic symptoms persist following explanation and demonstration of diagnosis, the next step is usually a brief rehabilitation intervention, guided by the specific subtype of functional neurologic disorder, such as:

Physical therapy; for those with motor or gait disturbance[103][105][106][107][108]

Speech and language therapy; for those with speech and swallowing disturbance[92][103]

Occupational therapy; this may be more generally applicable for improving function.[104]

The evidence base for rehabilitation treatments for functional neurologic disorder is growing, particularly for physical therapy for motor symptoms.[103][105][106][107][108] Successful programs incorporate treatment delivered by a practitioner with experience of functional neurologic disorders, delivered within a psychologically informed framework. Counterproductive thinking styles and behaviors are addressed, such as avoidance of particular movements in an attempt to avoid damage.[74][105]

Plus – psychological therapy

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Plus –

psychological therapy

Treatment recommended for ALL patients in selected patient group

Psychological therapy typically incorporates elements of cognitive behavioral therapy (CBT).[74] In practice, eclectic psychotherapeutic approaches are often used. This includes a combination of CBT, mindfulness, interpersonal psychotherapy, and general psychotherapy. CBT for this group involves psychoeducation about mind-body connection and attribution of psychiatric or psychological causes rather than purely neurologic or medical causes for symptoms; learning to identify mood-cognition-environment connections, automatic thoughts, catastrophic thinking, and somatic misinterpretations; recognizing triggers associated with physical symptoms; training in healthy communication and support seeking; recognizing emotions and ways to cope with them; relaxation training; coping with external life stresses; and coping with internal stress and conflict.[114][157][159][160]

Consider – hypnosis

Back

Consider –

hypnosis

Treatment recommended for SOME patients in selected patient group

Patients with functional neurologic disorder may benefit from learning self-hypnosis as one tool to control symptoms.[125][126]

3rd line – further psychological therapy

Back

3rd line –

further psychological therapy

Patients who do not respond to initial therapies may benefit from further psychological therapy, including psychodynamic psychotherapy; family therapy (recognizing unspeakable dilemmas and interrupting spousal reinforcement of illness behaviors); group therapy; dialectical behavioral therapy (particularly with comorbid borderline personality disorder or trauma); paradoxical intention therapy (encourages the patient to deliberately engage in the unwanted behavior); and eye-movement desensitization-reprocessing (particularly with comorbid post-traumatic stress disorder).[128][129] Alternatively, there is some evidence for the benefit of drug interviews to facilitate abreaction in treatment-resistant functional neurologic disorder.[161]

4th line – intensive multidisciplinary therapy

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Consider –

biofeedback training

Treatment recommended for SOME patients in selected patient group

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. Unlikely to cure patients of functional neurologic disorder symptoms if other treatment modalities are not used conjunctively.

Back

4th line –

intensive multidisciplinary therapy

Patients with complex and treatment-refractory functional neurologic disorder may benefit from specialized multidisciplinary therapy conducted in an outpatient or inpatient setting. This approach has shown positive results in single-center studies.[130][131][132][133][134]

with comorbid anxiety or depressive disorder

Back

1st line –

patient education

The aims are to:[66][74]

Demonstrate positive clinical signs to illustrate underlying mechanisms involved

Validate patients' symptoms

Offer a confident diagnosis that negates the need to seek an alternative medical opinion

Develop a sense of partnership between patient and clinician

Outline likely next steps in management (including rationale for psychological treatment).

Back

Plus –

antidepressant

Treatment recommended for ALL patients in selected patient group

Specialist input is typically required (e.g., from a medical psychologist or psychiatry attending).

Pharmacologic options for comorbid depression or anxiety include selective serotonin-reuptake inhibitors (SSRIs), particularly for anxiety disorders; serotonin-norepinephrine reuptake inhibitors (SNRIs), particularly for coexistent pain syndromes; tricyclic antidepressants (TCAs); mirtazapine; or bupropion.

SSRIs include sertraline, citalopram, fluoxetine, paroxetine, escitalopram, and fluvoxamine.

SNRIs include venlafaxine, desvenlafaxine, and duloxetine.

TCAs include nortriptyline, amitriptyline, desipramine, imipramine, and doxepin.

Doses should be started low and increased gradually according to response.

2nd line – brief rehabilitation intervention

Back

2nd line –

brief rehabilitation intervention

Physical therapy; for those with motor or gait disturbance[103][105][106][107][108]

Speech and language therapy; for those with speech and swallowing disturbance[92][103]

Occupational therapy; this may be more generally applicable for improving function.[104]

Back

Plus –

antidepressant

Treatment recommended for ALL patients in selected patient group

Specialist input is typically required (e.g., from a medical psychologist or psychiatry attending).

SSRIs include sertraline, citalopram, fluoxetine, paroxetine, escitalopram, and fluvoxamine.

SNRIs include venlafaxine, desvenlafaxine, and duloxetine.

TCAs include nortriptyline, amitriptyline, desipramine, imipramine, and doxepin.

Doses should be started low and increased gradually according to response.

Plus – psychological therapy

Back

Plus –

psychological therapy

Treatment recommended for ALL patients in selected patient group

Consider – hypnosis

Back

Consider –

hypnosis

Treatment recommended for SOME patients in selected patient group

Patients with functional neurologic disorder may benefit from learning self-hypnosis as one tool to control symptoms.[125][126]

3rd line – further psychological therapy

Back

3rd line –

further psychological therapy

Back

Plus –

antidepressant

Treatment recommended for ALL patients in selected patient group

Specialist input is typically required (e.g., from a medical psychologist or psychiatry attending).

SSRIs include sertraline, citalopram, fluoxetine, paroxetine, escitalopram, and fluvoxamine.

SNRIs include venlafaxine, desvenlafaxine, and duloxetine.

TCAs include nortriptyline, amitriptyline, desipramine, imipramine, and doxepin.

Doses should be started low and increased gradually according to response.

4th line – intensive multidisciplinary therapy

Back

Consider –

biofeedback training

Treatment recommended for SOME patients in selected patient group

Back

4th line –

intensive multidisciplinary therapy

Back

Plus –

antidepressant

Treatment recommended for ALL patients in selected patient group

Specialist input is typically required (e.g., from a medical psychologist or psychiatry attending).

SSRIs include sertraline, citalopram, fluoxetine, paroxetine, escitalopram, and fluvoxamine.

SNRIs include venlafaxine, desvenlafaxine, and duloxetine.

TCAs include nortriptyline, amitriptyline, desipramine, imipramine, and doxepin.

Doses should be started low and increased gradually according to response.

5th line – atypical antipsychotic

Back

5th line –

atypical antipsychotic

May be used by a specialist if psychotherapeutic and antidepressant measures are not effective. If insomnia is prominent, a more sedating agent such as quetiapine at bedtime may be selected. If weight gain is a concern, aripiprazole or ziprasidone may be preferred.

Doses should be started low and increased gradually according to response.

Primary options

aripiprazole: 2 mg orally once daily initially, increase according to response, maximum 15 mg/day

ziprasidone: 20 mg orally twice daily initially, increase according to response, maximum 160 mg/day

quetiapine: 25 mg orally (immediate-release) once daily initially, increase according to response, maximum 400 mg/day given in 1-3 divided doses

Secondary options

olanzapine: 2.5 mg orally once daily initially, increase according to response, maximum 10 mg/day

risperidone: 0.5 mg orally once daily initially, increase according to response, maximum 4 mg/day given in 1-2 divided doses

6th line – electroconvulsive therapy (ECT) or repetitive transcranial magnetic stimulation (rTMS)

Back

6th line –

electroconvulsive therapy (ECT) or repetitive transcranial magnetic stimulation (rTMS)

If augmentation strategies are not effective, ECT or rTMS may be considered. Evidence supporting the use of ECT or rTMS for functional neurologic disorder is limited.[139][140][141][142][143][144][145]

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

2nd line – psychological therapy

Back

1st line –

patient education

Education and explanation of the diagnosis is the first step of management.

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.[147]

Before delivering the diagnosis, explore what the patient thinks is wrong, and tailor the explanation accordingly.[146]

Explain that there is no evidence of a serious or life-threatening illness, and emphasize 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."

Evidence on treatment is limited, but a practical approach to the primary care consultation includes the following:[98][146][147][148]

Exploring symptoms, including patients' thoughts and emotions in response

Exploring impact on functioning

Conducting brief physical exams focusing on areas of discomfort at each visit

Establishing a therapeutic alliance

Acknowledging that symptoms are real

Limiting tests and referrals unless symptoms change

Communicating with any specialists involved

Gradually discontinuing unnecessary medications

Psychoeducation, explaining that the body may generate symptoms in the absence of disease

Developing mutually agreed realistic and incremental goals for improvement of functioning.

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. Acknowledge this uncertainty to avoid offering facile reassurance, which may exacerbate fears. Advise patients to report any changing, worsening, or new symptoms, as they may warrant reassessment.[149]

Back

2nd line –

psychological therapy

May include a combination of cognitive behavioral therapy (CBT), mindfulness, and/or short-term dynamic psychotherapy, interpersonal psychotherapy, reattribution training, and general psychotherapy.[113][119][150][151] CBT for this group involves reducing physiologic 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; and reducing spousal reinforcement of illness behavior.

Discussion with a psychiatrist may be warranted to review initial management and verify the diagnosis. 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."

Consider – graded physical exercise (GET)

Back

Consider –

graded physical exercise (GET)

Treatment recommended for SOME patients in selected patient group

Patients are gently introduced to exercise by 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 attempt to increase the amount of exercise with the goal of increasing tolerance and capacity for exercise. Any patient may potentially benefit.[152][153]

Note that the rationale for offering GET is based on its use in other conditions with overlapping symptoms, such as myalgic encephalomyelitis/chronic fatigue (ME/CFS). There have been serious concerns expressed regarding the potential for iatrogenic harm with graded exercise 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.[154] However, it is important to acknowledge that this is a topic of polarized discussion; the current evidence base concerning the possibility of iatrogenic harm with GET is hindered by methodologic shortcomings, and there a lack of widespread consensus among experts regarding the balance between its risks and benefits.

3rd line – referral to a psychiatrist

Back

Consider –

biofeedback training

Treatment recommended for SOME patients in selected patient group

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 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.

Back

3rd line –

referral to a psychiatrist

For patients whose symptoms have not responded adequately to previous measures, psychiatric referral is indicated, with continuing regular primary care input. Even a single visit with a psychiatrist may improve outcomes.[151] A sensitive explanation of the rationale for psychiatric input is key. It can be helpful to emphasize that you will continue to care for the patient, but that you are seeking input from a colleague to better help you do this.

Consider – antidepressant

Back

Consider –

antidepressant

Treatment recommended for SOME patients in selected patient group

Evidence on pharmacologic treatment is limited, low-quality, and often indirect.[155][156][157][158]

A specialist (e.g., a psychiatrist experienced in managing complex and treatment-refractory somatic symptom disorder) may consider offering antidepressant therapy to selected patients independently of the presence of depressive symptoms, particularly in cases of pain syndromes or cyclic vomiting.[156]

Serotonin-norepinephrine reuptake inhibitors (SNRIs), nortriptyline, and amitriptyline are used as first line in order to target chronic pain symptoms.

Selective serotonin-reuptake inhibitors (SSRIs) include sertraline, citalopram, fluoxetine, paroxetine, escitalopram, and fluvoxamine.

SNRIs include venlafaxine, desvenlafaxine, and duloxetine.

Tricyclic antidepressants (TCAs) include nortriptyline, amitriptyline, desipramine, imipramine, and doxepin.

Doses should be started low and increased gradually according to response.

4th line – further psychotherapy

Back

4th line –

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 (recognizing unspeakable dilemmas and interrupting spousal reinforcement of illness behaviors); group therapy; dialectical behavioral therapy (particularly with comorbid borderline personality disorder or trauma); paradoxical intention therapy (encourages the patient to deliberately engage in the unwanted behavior); and eye-movement desensitization-reprocessing (particularly with comorbid post-traumatic stress disorder).[128][129]

with comorbid anxiety or depressive disorder

Back

1st line –

patient education

Education and explanation of the diagnosis is the first step of management.

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.[147]

Before delivering the diagnosis, explore what the patient thinks is wrong, and tailor the explanation accordingly.[146]

Evidence on treatment is limited, but a practical approach to the primary care consultation includes the following:[98][146][147][148]

Exploring symptoms, including patients' thoughts and emotions in response

Exploring impact on functioning

Conducting brief physical exams focusing on areas of discomfort at each visit

Establishing a therapeutic alliance

Acknowledging that symptoms are real

Limiting tests and referrals unless symptoms change

Communicating with any specialists involved

Gradually discontinuing unnecessary medications

Psychoeducation, explaining that the body may generate symptoms in the absence of disease

Developing mutually agreed realistic and incremental goals for improvement of functioning.

Back

Plus –

antidepressant

Treatment recommended for ALL patients in selected patient group

Specialist input is typically required (e.g., from a psychiatry attending).[149]

SSRIs include sertraline, citalopram, fluoxetine, paroxetine, fluvoxamine, and escitalopram.

SNRIs include venlafaxine, desvenlafaxine, and duloxetine.

TCAs include nortriptyline, amitriptyline, desipramine, imipramine, and doxepin.

Doses should be started low and increased gradually according to response.

2nd line – psychological therapy

Back

2nd line –

psychological therapy

Back

Plus –

antidepressant

Treatment recommended for ALL patients in selected patient group

Specialist input is typically required (e.g., from a psychiatry attending).[149]

SSRIs include sertraline, citalopram, fluoxetine, paroxetine, fluvoxamine, and escitalopram.

SNRIs include venlafaxine, desvenlafaxine, and duloxetine.

TCAs include nortriptyline, amitriptyline, desipramine, imipramine, and doxepin.

Doses should be started low and increased gradually according to response.

Consider – graded physical exercise

Back

Consider –

graded physical exercise

Treatment recommended for SOME patients in selected patient group

Note that the rationale for offering graded exercise is based on its use in other conditions with overlapping symptoms, such as myalgic encephalomyelitis/chronic fatigue (ME/CFS). There have been serious concerns expressed regarding the potential for iatrogenic harm with graded exercise 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.[154]

3rd line – referral to a psychiatrist

Back

Consider –

biofeedback training

Treatment recommended for SOME patients in selected patient group

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 complaints who will learn to relax those organ systems. There is added benefit for patients with anxiety or depression in helping to control anxiety symptoms or insomnia. The rationale for considering biofeedback is based on its use in pain syndromes and other mind-body disorders.

Back

3rd line –

referral to a psychiatrist

For patients whose symptoms have not responded adequately to previous measures, psychiatric referral is indicated (if not received already), with continuing regular primary care input. Even a single visit with a psychiatrist may improve outcomes.[151] A sensitive explanation of the rationale for psychiatric input is key. It can be helpful to emphasize that you will continue to care for the patient, but that you are seeking input from a colleague to better help you do this.

Back

Plus –

antidepressant

Treatment recommended for ALL patients in selected patient group

Specialist input is typically required (e.g., from a psychiatry attending).[149]

SSRIs include sertraline, citalopram, fluoxetine, paroxetine, fluvoxamine, and escitalopram.

SNRIs include venlafaxine, desvenlafaxine, and duloxetine.

TCAs include nortriptyline, amitriptyline, desipramine, imipramine, and doxepin.

Doses should be started low and increased gradually according to response.

4th line – further psychotherapy

Back

4th line –

further psychotherapy

Back

Plus –

antidepressant

Treatment recommended for ALL patients in selected patient group

Specialist input is typically required (e.g., from a psychiatry attending).[149]

SSRIs include sertraline, citalopram, fluoxetine, paroxetine, and fluvoxamine.

SNRIs include venlafaxine and duloxetine.

TCAs include nortriptyline, amitriptyline, desipramine, imipramine, and doxepin.

Doses should be started low and increased gradually according to response.