Functional neurological disorder (FND)

Functional weakness can range from a limb feeling heavy to not being able to move it at all. It can come on suddenly.

Because the nerves themselves aren’t damaged, physiotherapy can help retrain movement.

Functional (also called dissociative) seizures can look like epileptic seizures, with shaking, falling or blanking out. But tests of brain electrical activity (EEG) are usually normal during them.

They are not put on and the person is not in control of them. Older terms like “pseudoseizures” are now discouraged because they wrongly suggest the seizures aren’t real.

Therapy can help people learn their warning signs and ways to reduce attacks. Worrying about the next seizure can sometimes make one more likely, so working on that fear is part of treatment.

FND can cause tremors, jerks, twitches, tics, unusual postures (dystonia) or problems with walking and balance.

A functional tremor often changes or settles when the person is distracted, or it may match the rhythm of a movement made by the other hand.

Functional sensory symptoms include numbness, tingling, double or tunnel vision, hearing loss, or changes in smell or taste.

These can be frightening. A careful check by a doctor helps make sure nothing else is going on, and an explanation of FND can bring real relief.

Some people with FND have brain fog, trouble finding words, poor attention or memory problems.

These often go along with fatigue, pain or low mood, and can improve when those are addressed too.

FND can affect speech (like stuttering or changes in voice), swallowing, and balance. Some people feel constantly unsteady or dizzy without a true spinning feeling.

Speech and language therapy can help with speech and swallowing symptoms.

Chronic fatigue or lack of energy is common in FND. Pain can range in severity, be long-lasting, or come and go.

FND frequently comes with chronic pain, sleep problems, fatigue and thinking difficulties. Treating these together helps.

• Infections
• Migraines
• Physical injuries
• Stressful or traumatic events

Sometimes there is no clear trigger at all. Sometimes the main stress is the symptoms themselves.

• Adverse childhood experiences, such as bullying, unhealthy family dynamics or abuse
• Another nervous system condition
• Chronic pain, fatigue or stress
• Mental health conditions such as depression or anxiety

You might have none of these and still develop FND.

Stress and past trauma can play a part for some people, but they are not always present. Many people develop FND without being stressed, and past trauma is not required.

If trauma is part of your story, it isn’t your fault, and it can be worked through. See the Healing from trauma guide.

In Hoover’s sign, a weak leg may push down normally when the person lifts their other leg, because that movement is automatic. Research shows it is a highly reliable sign of functional weakness.

When a person taps a rhythm with one hand, a functional tremor in the other hand may change to match it, or settle. Doctors call this entrainment, and it is a reliable positive sign.

Experts advise doctors to tell people what their diagnosis is, not just what it is not. A doctor’s attitude can be the deciding factor in whether someone accepts the diagnosis.

Understanding what FND is, that it is common, real, and can get better, is an important part of treatment. Care teams explain the condition in detail and reassure people that their symptoms are genuine.

Good communication between patient and doctor matters. A good relationship with your provider is one of the things linked to a better outlook.

FND-focused physiotherapy uses the fact that automatic movement often works better than movement you concentrate on. Instead of straining to move a weak leg, a physio might have you kick a ball or focus on a spot ahead while walking.

Distraction helps “open the door” to more natural movement, step by step. Rehabilitation is often the preferred approach for movement symptoms, and in a large trial, people who had FND-specific physiotherapy were more likely to report improvement.

Occupational therapists help people get back to everyday activities like dressing, cooking, work or school. Speech and language therapists help with speech and swallowing symptoms.

Talking therapy isn’t a sign that anyone thinks your symptoms are “in your mind”. It can help you understand FND, face activities you’ve been avoiding, work through worrying thoughts (like fear of the next seizure), and cope with the ups and downs of recovery.

Therapies like CBT and psychodynamic therapy have shown moderate benefit. A therapist can also check for anxiety, depression, panic or PTSD, which are common alongside FND and are treatable.

Exploring the past only happens when it is useful, and after the therapist has got to know you.

Biofeedback uses sensors to show your body’s stress responses, so you can learn to calm them.

Many people do too much on good days and then crash for days afterwards. This “boom and bust” pattern can feel like going back to square one.

How to pace

• Increase slowly, only when you are ready
• Keep a steady level of activity from day to day
• On bad days, aim for the basics, like getting up and dressed
• On good days, do a modest amount: less than your best, more than your worst

Activity may sometimes make symptoms worse for a while, but going slowly doesn’t cause further damage.

Symptoms may ease when you use distraction techniques. Music, a conversation or focusing on a point ahead can let automatic movement take over.

Changes at work, school and home are best made slowly. A phased return to work, agreed with your employer, can help.

Occupational therapists can help you plan a return to daily tasks.

Even if stress didn’t cause your FND, living with symptoms is stressful. Relaxation exercises like deep breathing and mindfulness can help calm the body.

Working closely with your healthcare team helps. Your care team can explain the condition and answer any questions you have.

FND symptoms are real. They involve the brain and body working differently, not imagination.

Asking whether symptoms are “in the mind” or “in the body” is the wrong question. The brain and mind are both involved, as they are in every illness.

Deliberately faking symptoms does happen, but it is rare. Symptoms that come and go, or change with distraction, are a normal part of FND and don’t mean someone is faking.

Being wrongly seen as faking or attention-seeking is hurtful and adds to the burden.

In FND, standard scans and blood tests are usually normal, because the problem is in how the brain is working, not its structure. Doctors diagnose it by finding positive signs, not just by ruling everything else out.

Stress and past trauma can play a part for some people, but they are not always present. FND can follow an injury, infection or migraine, or have no clear trigger.

FND is treatable with therapy and rehabilitation, and many people improve, especially with early care.

• Avoid doing everything for them. Gently support independence instead
• Believe them. Their symptoms are real, even if tests are normal
• Celebrate small steps forward, and be patient with setbacks
• Encourage them to stay active and connected, at their own pace
• Help with practical things, like getting to appointments
• Learn about FND, so you understand what they’re facing

• “It’s all in your head”
• “Just try harder”
• “You look fine to me”
• “You’re doing it for attention”

Trying harder can actually make functional symptoms worse, because movement often works better when it is automatic.

Family therapy helps loved ones understand FND and how to support recovery.

There are registered charities led by people with FND that offer information, support and a strong voice for the FND community. The neurosymptoms.org website keeps a list of them on its FND Links page.

Support groups can help you feel less alone and share what has helped others. Your doctor, hospital or local services may know of groups near you.

Online communities can help too. Just remember that what people share is personal experience, not medical advice.