Written by Dr. Tim Nicholson (Maudsley Hospital and Institute of Psychiatry Psychology & Neuroscience, King’s College London, UK)
Psychological factors, and therefore psychological treatments, can be important to consider in FND. Traditional theories of FND propose that psychological factors (i.e. stressful life events either before symptom onset or in the more distant past) might be relevant to the development of FND. However, it has become clear that there are many patients for whom this is not the case – although psychological factors might still be relevant in such patients as they can develop significant distress, and even depression, as a result of living with severe and chronic disorder such as FND and in such cases this can be helped by psychological treatments. Furthermore, many patients can feel stigmatized by healthcare professionals because of their FND diagnosis as the condition is so poorly understood by many healthcare professionals – this lack of understanding can become a significant roadblock in their care. This experience can then become a form of ‘medical trauma’, taking on a life of its own, and potentially feed a cycle of symptoms and stress.
There is also growing evidence that emotions, and abnormalities of its processing, might be involved in causing FND, at least for some patients. Experiments looking at brain activity in FND (using ‘functional neuroimaging’ brain scans) suggest alterations in the activity of areas of the brain responsible for arousal and emotional processing, such as the amygdala (see Fig 1), and this might interfere with areas of the brain involved in initiating or planning movement such as the SMA (supplementary motor area)[1,2,3]. Furthermore, there is some evidence that these changes might be related to stressful life events in some people (see Fig 2). Such studies suggest that emotions might be able to influence the ability to initiate or control the motor system and result in symptoms such as weakness or tremor.
Fig 1: Brain scan showing increased activation in the amygdala of FND patients in response to negative emotional faces1
Fig 2: Brain scan showing amygdala – an area with increased functional connectivity to the SMA (supplementary motor area) in FND patients in response to remembering stressful events linked to the onset of symptoms.
Psychological treatments can be beneficial and they are typically worthwhile to try. These are also called ‘talking therapies’ and there are quite a few different types. The most commonly used type for FND is Cognitive Behavioural Therapy (CBT). Psychodynamic therapy (‘psychoanalysis’), Dialectical Behavioural Therapy (DBT) and hypnotherapy can also be used.
Cognitive Behavioral Therapy (CBT)
Written by Dr. Tim Nicholson, Dr John Mellers and Professor Laura Goldstein (Maudsley Hospital and Institute of Psychiatry Psychology & Neuroscience, King’s College London, UK)
Cognitive Behavioural Therapy (CBT) is the most commonly used psychological treatment for FND. CBT has been developed from a strong theoretical basis centered on research in both psychology and the broader neurosciences(1). It has been used in different forms to treat many psychological problems, particularly depression and anxiety disorders (e.g. phobias and panic attacks), which can co-exist with FND for a variety of reasons as mentioned in the introduction. In the context of FND, CBT focuses on identifying precipitants (‘triggers’) of physical symptoms (e.g. seizures) and finding ways to stop these symptoms occurring, such as using distraction or relaxation techniques. It also can be used to discuss how thoughts, feelings, bodily sensations and actions can be interconnected and how this might occur in the individual patient.
Key areas that may be addressed in treatment may include avoidance behaviors (i.e. what the person avoids doing because of their symptoms or concerns of experiencing symptoms), thoughts that relate to their condition and how emotions are dealt with. It, therefore, tends to focus on ‘the here and now’ rather than on issues from the past, although these can be incorporated into the treatment if relevant. It also tends to be quite brief in that the number weekly sessions (normally an hour each) normally run for around 10-14 weeks. Sometimes ‘booster’ sessions can be given after this initial course of therapy. Carers and/or family members may be included in therapy sessions although not in the context of formal family therapy. Illness models/beliefs can also be discussed along with the evidence supporting them in the individual.
Currently, this is the form of psychological therapy for which there is the most robust evidence to support its use in FND patients with seizures, in the form of randomized controlled trials (‘RCT’s) – the principle way to assess whether a treatment really does work or not. There have been two small (‘pilot’) RCTs investigating to test whether it is effective. These RCTs used somewhat different CBT approaches but both reported significant improvements in symptoms(2,3). A larger, multicentre, RCT is currently underway in the UK called the ‘CODES’ trial.
Self-help treatment packages have been developed are available both in computerized/online or book form. Click here for more information on CBT basics.
Dialectical Behavior Therapy (DBT)
Written by Dr. Kim Bullock, Stanford USA
Neuroimaging evidence in Functional Neurological Disorder suggests alterations in the areas of the brain responsible for arousal and emotional processing. A specific therapy called Dialectical Behavior Therapy (DBT) has been shown to normalize the part of the brain found to be dysregulated in FND patients called the amygdala. Although DBT is a powerful biological intervention it is delivered behaviorally thru skills training and psychotherapy. There are four categories of skills training; Mindfulness, Emotion Regulation, Distress Tolerance, and Interpersonal Effectiveness. Patients who acquire these skills are thought to improve their resiliency and better process emotions, bodily arousal systems, and stress responses.
Our lab is studying the effects of DBT on FND patients and preliminary evidence is promising. DBT is a type of therapy found and available in most mental health settings and is therefore accessible and affordable for most patients. If it is found useful, it could open doors of treatment that were previously closed for FND patients. DBT involves skills training groups, along with individual behavioral therapy, phone coaching, and weekly support groups for therapist to ensure maximum effectiveness and adherence to treatment principles. DBT has been found to be efficacious in a wide range of disorders including those with chronic suicidal ideation, bipolar disorder, chronic pain, drug addiction, and eating disorders. We are planning a randomized trial of DBT in FND to test its efficacy and will be looking at before and after brain, images to see if indeed the areas of the brain we expect to normalize do so.
Psychodynamic (‘psychoanalytic’) Therapy
Written by Dr. Tim Nicholson (Maudsley Hospital and Institute of Psychiatry, Psychology & Neuroscience, King’s College London, UK) and Stephanie Howlett (Sheffield University Hospitals, UK)
Psychodynamic approaches for FND try to make sense of the patient’s symptoms in the context of their life as a whole, looking at how past experiences and relationships may have shaped current patterns of relating to others and processing emotions in ways that may be unhelpful. The assumption is that functional symptoms may be a bodily expression of feelings that are ‘bottled up’ or not being accepted and dealt with at an emotional level. If severe traumas are found and thought relevant to the disorder, these can also be a focus of treatment. There are many brief models of psychodynamic therapy, or in some cases, longer-term work, lasting months or even years may be offered where this is felt to be helpful.
There have been no large controlled trials of psychodynamic therapy for FND but brief psychodynamic therapy has been demonstrated to be effective with other functional symptoms, and an uncontrolled study suggested that psychodynamic interpersonal therapy for seizures and FND may be cost-effective, and have immediate and long-term benefits in terms of symptom reduction and psychological functioning(1,2). There has recently been a small RCT of a very brief psychotherapeutic intervention (4-6 sessions) by a psychologist in the context of a multidisciplinary clinic with input from a neurologist and a psychiatrist(3). This was used for FND patients with both seizures and weakness and showed promising efficacy.
Written by Dr. Sepideh Bajestan, Stanford, USA
The Use of Hypnosis in Functional Movement Disorders
Hypnosis consists of three components; absorption, dissociation, and suggestibility (1). Absorption is the ability of the participant to focus (2). Dissociation is the state of mind that fragments perceptions from peripheral events. Finally, suggestibility is the ability to follow the hypnotherapist’s instructions. However, this does not mean that the hypnotized person loses the ability to exert control over what he thinks and does but the individual chooses to suspend the consideration of alternatives and to focus on the instructions (1, 3, 4).
Hypnotic ability alters over time with the highest level in late childhood and declines somewhat into adulthood and then stays relatively stable as a trait (with high and low hypnotizability traits) (4).
Neuroscience of Hypnosis:
Functional MRI studies have shown more functional connectivity in high hypnotizable individuals between left dorsolateral PFC (DLPFC); an executive control area of the brain, and the areas involved in salience network. Salience network includes dorsal anterior cingulate cortex (dACC), anterior insula, amygdala, and ventral striatum. This network is involved in detecting, integrating, and filtering relevant somatic, autonomic, and emotional information and plays an important role in different brain functions such as attention and subjective awareness (5-8).
Recent studies on functional movement disorders also show the importance of the DLPFC, ACC, orbitofrontal and temporal-parietal junction in this disorder (9- 12). Therefore it appears that there is a significant overlap in the physiological mechanisms seen in individuals with functional movement disorders and in the process of hypnosis, which makes the usefulness of this treatment more understandable (13).
Hypnosis in the Treatment of Functional Movement Disorders:
Hypnosis should be done by a licensed practitioner with ample training and experience with hypnosis and should be done in the context of a comprehensive treatment plan. Patients should be educated about the nature of the disorder and the hypnotic procedure itself.
The most common hypnotherapy approach for treatment of functional movement disorders is called “the split-screen technique”. In this model, the patient induces a typical event with the patient being able to start and terminate the movement dysfunction. Patients are also educated about the warning signs of their events and learn how to control the sequence of triggers that lead to functional movements or seizures. They learn to apply self-hypnosis as soon as possible in order to prevent or abort movement dysfunction (13-15).
Exploratory and expressive hypnosis approaches have also been used. Hypnosis can also be used as an adjunctive treatment in a combination of other psychotherapeutic treatments such as cognitive-behavioral therapy and psychodynamic psychotherapy (13, 16, 17).
Advertising hypnosis as a way of exerting control over a patient or bringing up past traumatic experiences without a patient’s consent is unethical and harmful. In contrary, self-control and empowerment are emphasized in this treatment.