Functional Neurologic Disorder (FND)

🎧 Functional Neurologic Disorder (FND) — deep-dive podcast

📋 Key Information Summary

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Functional Neurologic Disorder (FND) is a genuine neurological condition characteruated by neurological symptoms not explained by another disease, diagnosed using positive clinical signs — not by exclusion alone.
Prevalence in Australian outpatient neurology clinics is estimated at 10–15% of referrals, making FND the second most common reason for neurological outpatient consultation after headache.
Use the DSM-5 and ICD-11 criteria: positive signs of inconsistency (variability over time) and incompatibility with recognised neurological disease are required for diagnosis.
The Hoover sign (involuntary hip extension during contralateral flexion against resistance) is the most widely validated positive sign for functional weakness; perform and document systematically.
The diagnosis must be communicated as a real, diagnosable condition — never as a diagnosis of exclusion, and never framed as "all in your head" or "medically unexplained."
Physiotherapy tailored to FND (task-based motor retraining, distraction techniques) is the first-line treatment with the strongest evidence base.
Psychotherapy — particularly cognitive-behavioural therapy (CBT) — addresses comorbid anxiety, depression, and maladaptive illness beliefs but is not the sole treatment.
Multidisciplinary FND clinics (available in several Australian tertiary centres) provide integrated neurological, physiotherapy, psychology, and occupational therapy input.
Avoid iatrogenic harm: unnecessary investigations, conflicting diagnoses, dismissive language, and prolonged medical uncertainty all worsen prognosis.
Pharmacotherapy has a limited role; treat comorbid mood disorders with SSRIs (e.g., sertraline) and manage associated pain, but no medication treats FND symptoms directly.
Aboriginal and Torres Strait Islander Australians may experience FND in the context of intergenerational trauma and cultural distress — culturally safe engagement and local community health worker involvement are essential.
Children and adolescents with FND require family-based approaches and school liaison; prognosis is generally better than in adults when early intervention is provided.

🎬 Functional Neurologic Disorder (FND) — clinical explainer

Introduction & Australian Epidemiology

Functional Neurologic Disorder (FND), historically termed conversion disorder or functional neurological symptom disorder, is a condition in which patients experience genuine neurological symptoms — weakness, abnormal movements, gait disturbance, sensory loss, seizure-like episodes, or cognitive difficulties — that are not fully explained by a recognised neurological or medical disease. Crucially, modern understanding frames FND as a disorder of nervous system function rather than structure, diagnosed through the presence of positive clinical signs rather than the absence of organic pathology.

The transition from a purely exclusionary diagnosis to a positive, rule-in approach represents one of the most significant conceptual shifts in neurology over the past two decades. The DSM-5 (2013) and ICD-11 (2022) both now require positive evidence of inconsistency and incompatibility for diagnosis, moving FND away from the problematic "diagnosis of exclusion" paradigm.

Australian Epidemiology

Australian data are consistent with international estimates:

FND accounts for approximately 10–15% of new referrals to Australian outpatient neurology clinics, placing it as the second most common diagnosis after headache disorders.
Incidence of functional seizures (psychogenic non-epileptic seizures, PNES) in Australian epilepsy monitoring units is 20–30% of patients referred for refractory "epilepsy."
The Australian Institute of Health and Welfare (AIHW) reports significant healthcare utilisation by FND patients — multiple ED presentations, repeated investigations, and serial specialist referrals — prior to correct diagnosis, with a median diagnostic delay of 2–7 years.
FND is more common in women (2:1 to 3:1 ratio overall), though functional motor disorder in men is increasingly recognised, particularly in older populations.
Paediatric FND accounts for a significant proportion of referrals to Australian tertiary paediatric neurology services, with peak incidence in early adolescence (10–14 years) and a female predominance.

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Diagnostic delay harms patients: Australian studies show that prolonged diagnostic uncertainty — often arising from repeated normal investigations without clear diagnosis — is associated with increased disability, psychological distress, iatrogenic harm, and escalating healthcare costs. Early, confident diagnosis with positive signs is essential.

Functional Neurologic Disorder (FND) clinical infographic — pathophysiology, clinical clues, diagnosis, imaging, and management — Tap or click image to enlarge — Functional Neurologic Disorder (FND): pathophysiology, clinical clues, diagnosis, imaging, and management.

Recognizing FND — Positive Signs and Rule-In Approach

The diagnosis of FND rests on positive clinical signs that demonstrate inconsistency and incompatibility with recognised neurological disease. A thorough neurological examination remains the cornerstone of diagnosis — advanced imaging and neurophysiology are supportive but cannot replace clinical assessment.

DSM-5 Diagnostic Criteria (Functional Neurological Symptom Disorder)

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One or more symptoms of altered voluntary motor or sensory function.
Clinical findings provide positive evidence of incompatibility between the symptom and recognised neurological or medical conditions.
The symptom or deficit is not better explained by another medical or mental disorder.
The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

ICD-11 Classification

In the ICD-11, FND is classified under 6B60 — Functional neurological symptom disorder, with subdivisions for presentations with weakness (6B60.0), movement disorder (6B60.1), seizure-like episodes (6B60.2), sensory disturbance (6B60.3), and mixed presentations (6B60.Y). This classification explicitly places FND within neurology, not psychiatry.

Positive Clinical Signs for Functional Weakness

Sign	Technique	Positive Result	Evidence Level
Hoover sign	Ask the patient to flex the weak hip against resistance. Then, without telling them, test extension of the contralateral (normal) hip against resistance.	Involuntary hip extension of the weak leg is generated ("positive Hoover") — demonstrates that full voluntary power is physiologically possible.	High — sensitivity 63–100%, specificity 86–100%
Drift without pronation	Ask the patient to hold both arms outstretched with eyes closed for 20–30 seconds.	Functional arm drift tends to move without pronation and may show non-organic trajectory patterns (e.g., wild flapping, slow wandering).	Moderate
Dragging gait	Observe gait. Ask patient to walk normally, then on heels, then on toes.	A leg dragged behind like a "dead weight," often with trunk sway disproportionate to weakness. Contrasts with the circumduction pattern of a true UMN hemiparesis.	Moderate — high specificity when classical pattern present
Tremor entrainment	Ask the patient to perform rhythmic tapping with the unaffected limb at a specified frequency.	Functional tremor shifts to match the entrainment frequency, stops, or dramatically changes character — organic tremors do not entrain.	High — one of the most reliable signs for functional movement disorder
Knee-drop test	Patient supine, legs flexed at hip and knee. Ask patient to let both legs fall to one side.	The "weak" leg falls faster and with less control than the "strong" leg — this contradicts genuine pyramidal weakness where tone differences would be expected.	Moderate
Tubular (non-dermatomal) sensory loss	Map the boundaries of sensory loss. Test with cotton wool and pinprick across a limb circumferentially.	Sensory loss that stops sharply at a geometric boundary (e.g., the wrist all the way around the limb) rather than following dermatomal or peripheral nerve distribution.	High specificity

Positive Signs for Functional Seizures (PNES)

Feature	Functional Seizures (PNES)	Epileptic Seizures
Duration	Usually >2 minutes, often prolonged (minutes to hours)	Typically <2 minutes (tonic-clonic)
Eyes	Often closed during event; resistance to eye opening	Usually open during and after event
Movements	Asynchronous, thrashing, side-to-side head movement, pelvic thrusting, waxing/waning intensity	Rhythmic, synchronous, stereotyped
Postictal state	Rapid recovery, often with minimal confusion; tearfulness or distress	Prolonged confusion, Todd's paresis, drowsiness
EEG during event	Normal background rhythm preserved (video-EEG gold standard)	Ictal epileptiform discharges

Inconsistency and Incompatibility — The Two Pillars

Inconsistency

Symptoms vary in a way that organic disease does not explain — e.g., leg weakness that resolves when distracted, tremor that changes frequency between tasks, or Hoover sign positive on one day but not another.

Incompatibility

Clinical findings do not correspond to recognised neuroanatomical or neurophysiological patterns — e.g., give-way weakness, non-dermatomal sensory loss, or seizure-like events without EEG correlate.

Investigations — When and How

FND is a clinical diagnosis. Investigations are used to exclude dangerous mimics — not to "prove" FND. The clinician must avoid the trap of endless investigation, which reinforces diagnostic uncertainty and worsens outcomes.

Essential Detailed neurological examination Including systematic positive sign testing (Hoover, entrainment, sensory mapping). Document findings explicitly as positive signs for FND.

Essential MRI Brain (with contrast if indicated) To exclude structural lesion. MBS Item 63003/63007. Usually performed once at initial workup — not repeated unless new focal signs emerge.

Essential Routine bloods — FBC, EUC, LFT, TFT, B12, folate, glucose, CRP To exclude metabolic, inflammatory, or nutritional causes. MBS Item 66816/66835.

Available Video-EEG monitoring Gold standard for differentiating functional seizures (PNES) from epileptic seizures. Requires specialist epilepsy unit admission (typically 3–5 days). MBS Item 11022. Available at Royal Melbourne, RPA, Royal Brisbane, Royal Adelaide, and other major centres.

Available Nerve conduction studies / EMG To exclude peripheral neuropathy or myopathy when clinical features are ambiguous. MBS Item 11000 series.

Referral Movement disorder neurologist assessment For functional tremor, dystonia, gait disorder — specialist examination with expertise in positive signs. Refer to movement disorder clinic at tertiary centre.

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Do not diagnose FND by exclusion alone. Saying "your tests are normal, so it must be functional" is both diagnostically incorrect and harmful. The diagnosis requires positive evidence: positive clinical signs demonstrating inconsistency and incompatibility with organic disease. Always communicate the diagnosis in terms of what you found — not what you did not find.

Communicating the Diagnosis

How the diagnosis of FND is communicated is one of the most critical steps in management. Poor communication is a major cause of treatment failure, persistent disability, and patient disengagement. Research from Australian and international centres demonstrates that the diagnostic conversation itself can be therapeutic — when done well, it shifts the patient's explanatory model and opens the door to rehabilitation.

Principles of Effective Communication

Validate the reality of symptoms

Begin by affirming that the patient's symptoms are real, not imagined or feigned. "You have a real neurological condition that I can explain and that has a name." Avoid any language suggesting malingering or exaggeration.

Demonstrate positive signs

Show the patient what you found. "When I tested your weak leg, I found something important — your leg was able to generate power when you weren't thinking about it. This tells me that the wiring in your spinal cord and muscles is intact. The problem is in how the brain is sending its signals." Demonstrate Hoover sign if positive. This provides tangible evidence and builds diagnostic credibility.

Explain the mechanism

Use the analogy of a software problem rather than a hardware problem. "Your nervous system is like a computer — the hardware (brain, spinal cord, nerves) is intact, but the software (how the brain controls movement and sensation) is not working properly." Avoid terms like "medically unexplained," "it's all in your head," or "there's nothing wrong."

Name the condition

Use the term Functional Neurologic Disorder or functional neurological disorder. Give it a name — unnamed conditions are harder for patients to process and for clinicians to manage. Explain that it is well-recognised, common, and treatable.

Outline a management plan

Provide hope grounded in evidence: "This condition can improve with specific physiotherapy and, for many people, psychological support. It is not a life sentence." Provide a clear next step — referral to physiotherapy, FND clinic, or psychology. Avoid saying "there's nothing more we can do."

Language to Use and Language to Avoid

✔ Use This Language	✘ Avoid This Language
"You have a functional neurological disorder — a real and recognised condition."	"Your tests are all normal, so there's nothing wrong."
"The problem is in how the brain is functioning — not in damage to the brain itself."	"It's all in your head."
"Your symptoms are real and can improve with targeted treatment."	"It's psychosomatic" or "You're imagining it."
"I found positive signs on examination that explain your symptoms."	"We couldn't find anything serious."
"This is common — I see this regularly in my practice."	"I've never seen anything like this before."
"Physiotherapy specifically designed for functional symptoms can help you regain function."	"You need to see a psychiatrist."

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Writing the diagnosis in the clinical letter: Explicitly write "Functional Neurologic Disorder" as the diagnosis — not "medically unexplained symptoms." Document the positive signs found (e.g., "positive Hoover sign, tubular sensory loss, tremor entrainment"). This is critical for other clinicians who will see the patient and prevents the cycle of repeated exclusionary workups.

Functional Neurologic Disorder (FND) visual summary infographic — 🖼️ Functional Neurologic Disorder (FND) — visual summary

Management Pathways

FND management is fundamentally multidisciplinary. There is no single "drug cure" for FND — treatment centres on targeted physiotherapy, psychological therapy for comorbidities and illness beliefs, occupational therapy, and the avoidance of iatrogenic harm. Australian tertiary FND clinics provide integrated care models, but the majority of FND management occurs in primary care and community settings.

First-Line: Physiotherapy for FND

Physiotherapy has the strongest evidence base for functional motor symptoms. It should be delivered by a physiotherapist with training or experience in FND — general neurological physiotherapy techniques (e.g., standard stroke rehabilitation exercises) are not appropriate and may worsen symptoms.

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Key physiotherapy principles for FND:

Task-specific motor retraining: Focus on automatic and semi-automatic movements (e.g., walking while talking, reaching for objects with distraction) rather than isolated muscle strengthening.
Distraction techniques: Encourage the patient to focus attention on a task while performing a movement — this exploits the hallmark of FND (symptoms improve when attention is diverted).
Motor relearning hierarchy: Start with movements the patient can perform in clinic, progressively increase complexity, and transition from clinic to home and community settings.
Avoid excessive focus on impairment: Do not repeatedly test the "weak" limb in isolation — this reinforces symptom-focused attention. Shift to functional, goal-based activities.
Frequency: Intensive blocks of physiotherapy (2–3 sessions per week for 4–6 weeks) are more effective than sporadic sessions. Consider telehealth physiotherapy follow-up for rural and remote Australian patients.

Second-Line: Psychotherapy

Psychotherapy addresses comorbid conditions (anxiety, depression, PTSD) and maladaptive illness beliefs, but is not a substitute for physiotherapy in motor presentations. It should be framed as part of the multidisciplinary approach, not as a suggestion that the symptoms are "psychological."

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Cognitive-Behavioural Therapy (CBT)

First-line psychotherapy for FND

Evidence Moderate evidence from RCTs (CODES trial for PNES). Targets illness beliefs, symptom monitoring, avoidance behaviours, and comorbid anxiety/depression.

Frequency Weekly sessions × 12–16 weeks (8–12 sessions minimum)

Availability Clinical psychologists with FND experience (Medicare rebated under Better Access — MBS Item 80110). Limited specialist FND-experienced psychologists in regional Australia.

PBS status ✔ Medicare rebate (not PBS)

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Psychodynamic Therapy / Trauma-Focused Therapy

Adjunctive for patients with significant trauma history

Evidence Limited RCT evidence but supported by observational data. EMDR or prolonged exposure for patients with PTSD contributing to FND onset or maintenance.

Frequency Weekly sessions × 12–20 weeks

Note Should not be the initial focus unless the patient has identified trauma as a significant factor. Premature trauma work may be destabilising.

PBS status ✔ Medicare rebate (not PBS)

Pharmacotherapy — Limited Role

No medication has been shown to treat the core symptoms of FND. Pharmacotherapy is reserved for comorbid conditions:

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Sertraline

Zoloft® · SSRI · For comorbid anxiety/depression

Adult dose 50 mg PO daily, titrate to 100–200 mg daily over 4–6 weeks

Paediatric dose ≥12 years: 25–50 mg PO daily, max 200 mg daily

Renal adjustment Not required for mild–moderate impairment; use with caution in severe impairment (CrCl <10 mL/min)

Key caution Hyponatraemia risk in elderly. Monitor sodium at 2 and 4 weeks.

PBS status ✔ PBS General Benefit

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Duloxetine

Cymbalta® · SNRI · For comorbid depression with pain

Adult dose 30 mg PO daily for 1 week, then 60 mg PO daily; max 120 mg daily

Renal adjustment Avoid if CrCl <30 mL/min

Key caution Discontinuation syndrome on abrupt cessation. Taper over 2–4 weeks.

PBS status ✔ PBS General Benefit (depression); Authority Required (neuropathic pain)

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Pregabalin

Lyrica® · For comorbid chronic pain/anxiety

Adult dose 75 mg PO BD, titrate to 150–300 mg PO BD over 1–2 weeks

Renal adjustment eGFR 30–60: 25–75 mg BD; eGFR 15–30: 25–50 mg OD; eGFR <15: 25 mg OD

Key caution Dizziness, sedation, weight gain. Schedule 4 — monitor for misuse potential.

PBS status ✔ PBS Authority Required (refractory neuropathic pain)

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Do not prescribe benzodiazepines or antiepileptics for functional seizures (PNES). These medications are ineffective for PNES and carry significant harm (dependence, sedation, falls). Valproate and levetiracetam have no evidence for functional seizures and should not be continued when PNES is confirmed — this requires clear communication with the patient and careful tapering under specialist guidance.

Multidisciplinary FND Clinics in Australia

Several Australian tertiary centres have established dedicated FND clinics providing integrated neurological, physiotherapy, psychology, and occupational therapy services:

Neurology / Movement Disorder Clinics: Royal Melbourne Hospital, Royal Prince Alfred Hospital (Sydney), Royal Brisbane and Women's Hospital, Royal Adelaide Hospital, Alfred Hospital (Melbourne).
Epilepsy Monitoring Units (for PNES): Comprehensive video-EEG services at most tertiary hospitals for definitive functional seizure diagnosis.
Paediatric FND Services: The Royal Children's Hospital (Melbourne), Children's Hospital at Westmead (Sydney), Queensland Children's Hospital — these offer multidisciplinary assessment with family-centred models.
Telehealth FND services: Increasing availability through state-funded neurology telehealth networks, particularly important for patients in regional and remote Australia.

Avoiding Iatrogenic Harm

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Iatrogenic harm is a major driver of poor outcomes in FND. Common iatrogenic pitfalls include:

Conflicting diagnoses: One clinician says "it's functional," another says "it might be MS." Inconsistent messaging from the medical team undermines the diagnosis and delays recovery.
Unnecessary investigations: Repeated MRIs, lumbar punctures, and EMGs in the absence of new clinical findings reinforce the patient's belief that something serious has been missed.
Inappropriate prescriptions: Continuing antiepileptics after a confirmed diagnosis of PNES; prescribing opioids for functional pain; escalating benzodiazepines for functional seizures.
Dismissive communication: Telling patients "there's nothing wrong" or "it's stress" without providing a positive diagnosis framework.
Prolonged diagnostic uncertainty: Refusing to name the diagnosis because the clinician is uncomfortable with FND. A named, explained diagnosis — even if it requires a difficult conversation — is always better than indefinite uncertainty.

Monitoring and Follow-Up

Week 0–2 Diagnostic communication. Initiate physiotherapy and psychology referrals. Ensure patient has a written summary of diagnosis and management plan. GP follow-up within 1–2 weeks.

Week 2–6 Intensive physiotherapy block (2–3 sessions/week). Commence CBT if indicated. Review comorbid mood disorder and initiate SSRI if needed. GP review of medication and function.

Week 6–12 Reassess functional status. Transition from intensive physiotherapy to home programme and community activity. Ongoing CBT. Neurologist review if plateau or new symptoms.

Month 3–6 Graduated return to work/school. Occupational therapy for functional goals. Reduce frequency of allied health appointments. GP-led ongoing care.

Month 6–12 Long-term follow-up. Address relapse early. Consider booster physiotherapy or psychology sessions. Annual neurology review if stable. Ongoing GP support for comorbidities.

Special Populations

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Paediatrics

Epidemiology FND is common in children and adolescents, with peak onset aged 10–14 years. Functional gait disorder and limb weakness are the most common presentations. Girls are affected more frequently (3:1).

Diagnosis Positive signs apply in children but may be more difficult to elicit. Diagnosis should be made by a paediatric neurologist. Video documentation of episodes is invaluable.

Management Family-based approach is essential. Parents must understand the diagnosis and support the rehabilitation plan. School liaison is critical — a letter to the school explaining FND and the expected recovery trajectory prevents excessive accommodation and supports reintegration. Avoid school exemption where possible.

Prognosis Generally better than in adults. Early diagnosis and intensive physiotherapy within 3 months of onset yields the best outcomes. Relapse is common during transitions (e.g., moving from primary to secondary school).

Medication Pharmacotherapy has minimal role. If comorbid anxiety is significant: sertraline 25 mg PO daily, titrate to 50–100 mg PO daily (≥12 years). Refer to CAMHS if available.

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Pregnancy

Considerations FND symptoms may fluctuate during pregnancy. Functional seizures (PNES) must be clearly differentiated from eclamptic seizures — video-EEG is valuable. Physiotherapy can continue safely in pregnancy.

Medication Sertraline is the preferred SSRI in pregnancy (Category B1). Avoid paroxetine (cardiac malformation risk). Duloxetine should be avoided. Pregabalin — avoid (Category B3). Liaise with perinatal mental health services for complex cases.

Delivery planning Ensure the obstetric team understands the FND diagnosis. Functional weakness may impact mobility during labour. Functional seizures should not trigger emergency caesarean section — ensure a clear management plan is in the birth plan.

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Elderly

Diagnostic challenge FND in the elderly is under-recognised. It frequently coexists with genuine neurological disease (e.g., stroke with disproportionate functional overlay). Careful application of positive signs is essential to delineate the functional component.

Medication Start SSRIs at half the usual dose (e.g., sertraline 25 mg PO daily). Monitor for hyponatraemia at 2 and 4 weeks (serum sodium). Avoid pregabalin if falls risk is high. Be aware of polypharmacy and drug interactions.

Physiotherapy Focus on falls prevention and maintaining independence. Coordinate with existing geriatric rehabilitation services. Home physiotherapy may be necessary if mobility is severely restricted.

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Renal Impairment

Sertraline No dose adjustment for mild–moderate impairment. Use with caution in severe impairment (CrCl <10 mL/min).

Duloxetine Avoid if CrCl <30 mL/min (accumulation of metabolites).

Pregabalin Dose reduction required: eGFR 30–60: max 75 mg BD; eGFR 15–30: max 50 mg BD; eGFR <15: max 25 mg OD.

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Hepatic Impairment

Sertraline Use with caution in Child-Pugh B–C; reduce dose or increase dosing interval. Monitor LFTs.

Duloxetine Contraindicated in hepatic impairment (Child-Pugh B or C).

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Immunocompromised

Special consideration Immunocompromised patients with new neurological symptoms require a lower threshold for investigation to exclude opportunistic CNS infections and malignancy before attributing symptoms to FND. Ensure HIV testing, CSF analysis, and enhanced MRI are considered when clinically appropriate.

Aboriginal and Torres Strait Islander Health

Cultural context of distress

Functional neurological symptoms in Aboriginal and Torres Strait Islander Australians must be understood within the broader context of cultural distress, intergenerational trauma, and social determinants of health. The concept of "functional" symptoms may map onto culturally understood expressions of distress, including somatic presentations linked to sorry business (bereavement), family disruption, and community grief. Clinicians must engage with cultural understanding and avoid imposing Western biomedical frameworks without dialogue.

Language and communication

The term "functional" may not translate meaningfully into Aboriginal English or traditional languages. Use plain language, involve Aboriginal and Torres Strait Islander health workers or liaison officers, and allow adequate time for the diagnostic conversation. Avoid rushed or formulaic explanations. Use visual aids and concrete demonstrations (e.g., showing Hoover sign) where helpful.

Access to specialist services

Aboriginal and Torres Strait Islander Australians in remote and very remote areas have severely limited access to neurology, physiotherapy, and psychology services. FND clinics are concentrated in major urban centres. Telehealth neurology and physiotherapy services through the Medical Specialist Outreach Assistance Program (MSOAP) and state-based telehealth platforms are critical. Patient-assisted travel schemes (PATS) must be utilised.

Stigma and diagnostic framing

FND carries significant stigma in all populations but may be particularly harmful if perceived as a "mental health" label in communities where mental health stigma is pronounced. Frame the diagnosis as a brain-body connection problem — not a psychiatric condition. Emphasise that the nervous system is physically healthy but not functioning correctly.

Community-controlled health services

Wherever possible, FND management should be coordinated through Aboriginal Community Controlled Health Organisations (ACCHOs). These services provide culturally safe, holistic care that integrates physical, social, emotional, and cultural wellbeing. Referral letters should be co-addressed to the ACCHO and the specialist service to ensure continuity.

Social determinants

Housing instability, food insecurity, family violence, incarceration, and substance use are highly prevalent and directly impact FND outcomes. Management plans must address these factors in partnership with social work, housing services, and community organisations. Failure to address social determinants renders neurological rehabilitation ineffective.

📊 Functional Neurologic Disorder (FND) — slide deck

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📚 References

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