Functional Neurological Symptom Disorder (Conversion Disorder)

Treatment Approaches

1. Building Trust and Explaining the Diagnosis: The treatment of functional neurological symptom disorder starts with establishing a strong, supportive therapeutic relationshipmerckmanuals.com. Our psychiatric providers approach FNSD patients with validation and compassion. In initial telepsychiatry sessions, we take the time to listen to the patient’s full story of their symptoms – how they developed, what medical evaluations have been done – and we acknowledge that what they are experiencing is real and debilitating. A critical step is providing a clear and non-judgmental explanation of the diagnosis. For example, we might explain, “Your nervous system is functioning, but it seems to be misprocessing signals because of underlying stress factors – it’s like a software issue, not a hardware issue, in the brain.” We often use analogies (like a computer that freezes not due to a broken part but due to an overload of commands) to help patients and families understand that symptoms can occur without structural damage. We assure them that recovery is possible, which many haven’t heard because they’ve only been doing tests to find something wrong. We also make sure to screen for and discuss any potential psychological stressors. Sometimes patients will readily identify a trigger (“Yes, this started after I lost my job” or “after I experienced a traumatic incident”), and sometimes they won’t see a connection or may even say “I don’t feel stressed.” We accept that and don’t force a narrative – sometimes the link is not obvious, or the stress is subconscious. Instead, we focus on the present: “Regardless of cause, let’s work on getting you better.” Importantly, we involve family early if the patient agrees, because family members might be skeptical or might inadvertently reinforce symptoms (for instance, a well-meaning spouse doing all activities for a patient with functional weakness could unintentionally maintain the sick role). In a telehealth session, we might educate the family: “These symptoms are real but not caused by damage – the brain is ‘stuck in gear,’ and our plan is to help it reset.” We encourage a team mindset: patient, family, and providers working together. Often, just this initial phase – forming a trusting relationship and giving a framework for understanding the disorder – can start the healing processmerckmanuals.com. Some studies and clinical experience show that when a patient feels believed and has a logical explanation (e.g., their legs stopped working due to the brain’s protective response to stress), symptoms can begin to improve even before formal therapy starts, because anxiety about “what’s wrong with me?” decreases.

2. Psychotherapy (especially CBT and Trauma-Focused Therapies): The mainstay treatment for FNSD is psychotherapy, particularly approaches like cognitive-behavioral therapy (CBT) that are tailored to functional symptoms. Our clinic provides therapy via telehealth, which is effective for FNSD because it reduces the barrier of travel (some patients may have mobility issues or seizures that make it hard to come in person). In CBT for conversion disorder, we work on several levels:

• Identifying and addressing stressors or conflicts: If a clear precipitant is identified (say, symptoms began after a traumatic event or during overwhelming life stress), therapy will focus on processing that. This could involve elements of trauma-focused therapy (like EMDR or cognitive processing therapy) if there was trauma. For example, a patient with psychogenic seizures after a sexual assault may benefit from gradually processing the trauma memories; as the trauma is resolved, the need for the subconscious mind to “escape” via seizures often diminishes.
• Re-framing beliefs about the symptoms: We explore the patient’s thoughts about their symptoms. Often, fears and misconceptions can amplify the symptoms (for instance, “I’m terrified I’ll go blind forever” or “What if I have a seizure in public and everyone thinks I’m crazy?”). We gently correct any erroneous beliefs (using the medical evidence they’ve gathered: “Multiple doctors have confirmed your eyes are healthy – that’s a good sign that we can restore your vision”), and we replace catastrophic thinking with hopeful, realistic thinking (“These symptoms often improve with therapy, and we’re already starting that. You recovered some speech last week, remember? That means improvement is possible.”).
• Symptom management techniques: For functional movement symptoms or seizures, we often incorporate techniques from physical therapy and occupational therapy. For PNES (non-epileptic seizures), we teach grounding techniques – recognizing early warning signs and using breathing exercises or sensory grounding (e.g., holding ice) to prevent or shorten episodes. For functional gait or weakness, a technique called graded motor imagery or other physiotherapy exercises under a therapist’s guidance is used – basically retraining the brain to move the limb step by step without provoking the “system glitch.” In therapy sessions, we set small goals like standing for a few seconds longer, taking one step with support – emphasizing successes to rebuild confidence. Over video, a patient might even show us their attempt at a movement so we can coach them (“Great, I saw you move your foot a bit – let’s build on that”). We coordinate with any in-person rehab: for instance, if a neurologist has them in physical therapy, we align our coaching with what PT is doing, and use therapy time to reinforce and emotionally support that process.
• Stress reduction and emotional expression: Many patients with FNSD have difficulty expressing emotions or have been under excessive pressure to “stay strong.” Therapy provides a safe space to express fears, anger, sadness – which might be indirectly manifesting as physical symptoms. We often train patients in relaxation techniques (which can reduce symptom frequency). For example, a functional seizure patient could use a breathing relaxation exercise daily, which may lower overall stress arousal that triggers episodes. Hypnotherapy is another tool (some providers use clinical hypnosis especially for conversion symptoms like psychogenic blindness or mutism) – under hypnosis, patients sometimes recover function, which demonstrates to them that the ability is still there; then suggestions are made to carry that recovery into the waking state.
• Behavioral reinforcement: We utilize the concept of not reinforcing illness behaviors. This doesn’t mean ignoring the patient, but rather encouraging and praising attempts at normal function. For instance, if a patient manages to walk a few steps, we lavish praise and attention on that effort, whereas we avoid giving excessive attention to time spent bedridden (not as a punishment, but to subtly encourage the mind-body to move toward healthful behaviors). Families are coached similarly: respond to well behaviors warmly (“I’m so happy to see you sitting up for lunch with us!”) and avoid inadvertently rewarding sick behaviors (like doing everything for the patient or providing excessive sympathy that might subconsciously encourage remaining ill).
• Group therapy or peer support: Sometimes we involve patients in groups (if available, perhaps virtually) of others with functional disorders. Seeing others improve and discussing openly can help reduce stigma and isolation. Family therapy can also be useful to address any family dynamics contributing to stress (for example, a child’s conversion symptoms sometimes relate to family conflicts – a family session to improve communication can alleviate the child’s need to express distress through the body).

3. Physical Rehabilitation and Multidisciplinary Approach: Treatment is often multidisciplinary, meaning we involve neurologists, physical/occupational therapists, and sometimes speech therapists (for functional speech or swallowing issues). As psychiatric providers, we coordinate with these professionals – often through phone calls or tele-meetings. For example, if a patient has functional limb paralysis, a neurologist might have confirmed no stroke. We then get a physical therapist on board who starts gentle exercise of that limb. We’ll talk to the PT about the patient’s progress and any psychological barriers (maybe the patient has a fear that moving will cause harm). We then address that fear in therapy, and the PT continues exercises. Over time, this tandem approach can lead to substantial recoverymerckmanuals.com. In telehealth follow-ups, the NP/psychiatrist will also monitor if any medications are needed: while there’s no specific drug for conversion disorder, some patients benefit from medications that treat underlying issues like anxiety or depression which may be perpetuating symptoms. For instance, an SSRI might reduce overall anxiety levels, indirectly decreasing the frequency of non-epileptic seizures. Or short-term use of a benzodiazepine might be considered in a crisis (though careful because it could also, for example, reduce inhibition and sometimes PNES episodes could increase – so typically we prefer non-drug approaches first). If insomnia is present, treating it with melatonin or a non-addictive sleep aid can improve resilience. Essentially, we treat co-morbid conditions: many conversion patients have a history of trauma or anxiety – so we might treat PTSD with appropriate medication if needed, or use beta-blockers to help a patient with psychogenic tremors who also has panic symptoms.

4. Telepsychiatry-Specific Advantages and Considerations: Our use of telepsychiatry for FNSD offers some special advantages. Patients often feel more at ease at home, which might actually allow some function to return spontaneously – for instance, a patient who couldn’t walk in the neurologist’s office might actually ambulate at home when nobody’s watching, and we can catch glimpses of that in tele sessions (with their consent, perhaps a family member might show us a video of them walking when they didn’t realize it). We can then gently point out these successes: “You see, your legs are capable of supporting you for a few steps – this is great news!” Additionally, telehealth removes geographic barriers, so we can treat patients who may not have local specialists for conversion disorder. We must also prepare for managing sessions if symptoms occur: e.g., if a patient has a psychogenic seizure during a video call, our providers are trained to ensure their safety (we might ask a family member ahead of time to be on call in the next room, and have an emergency protocol). We usually schedule sessions when someone else is home, or ensure the patient has a way to quickly contact help if needed, just in case of severe episodes. Fortunately, as therapy progresses, such incidents often reduce in frequency.

We emphasize gradualism: functional symptoms that took months or years to develop may take time to resolve. There might be ups and downs – maybe a symptom shifts (someone’s paralysis improves but they start having headaches, a phenomenon of “symptom substitution” that sometimes happens). We treat that with a positive frame: it means the emotional conflict is looking for a way out and we’re closing in on it, so we keep working. We also focus on reintegration into normal life. As symptoms improve, patients may have fears (“What if people think I was faking now that I’m better?”). We provide support, possibly doing a family session to validate the journey: “No, you weren’t faking – you were ill, and now you’re recovering thanks to your hard work.” We might strategize return to work or school in a graded fashion if they had left due to symptoms.

Finally, our approach includes relapse prevention. Functional symptoms can recur under new stress. So we equip patients with a plan: for example, if their leg gets weak again when stressed, rather than panicking, they should recognize it as a signal to use their coping skills or call us for a booster session. We ensure they leave therapy with an understanding of their triggers and tools (like continuing a regular stress-reduction practice, or journaling feelings so they don’t build up unconsciously).

In summary, treating Functional Neurological Symptom Disorder is a careful blend of medical rule-out, patient education, trust-building, therapy (especially CBT with a trauma/stress focus), physical rehabilitation techniques, and family involvement. By leveraging telepsychiatry and a compassionate, team-based strategy, we often see patients gradually reclaim functions they thought were lost. For instance, we’ve had patients go from wheelchair-bound with functional leg paralysis to walking independently after a combination of psychotherapy and PT – outcomes that are incredibly rewarding. We always remind patients that improvement is a process, and even if symptoms don’t vanish overnight, reductions in severity (a shorter seizure, a partial return of sensation) are significant wins to build onmerckmanuals.com. With patience, support, and proper treatment, many individuals with FNSD can achieve full or substantial recovery of function and learn healthier ways to cope with the stresses that underlie their condition.