Care Guide for Hospital and ED Staff: Functional Neurological Disorder (FND)

Understanding FND

• Functional Neurological Disorder (FND) is a real, disabling neurological condition involving changes in how the brain sends and receives signals.
  
  

• Symptoms are not fabricated, faked, or consciously produced.
  
  

• FND is a disorder of brain function, without detectable structural brain damage.
  
  

• Global leaders including Dr. Jon Stone (University of Edinburgh), Dr. W. Curt LaFrance (Brown University), and Professor Mark Edwards (St George’s University Hospitals) stress that early recognition, validation, and appropriate management are critical for recovery.
  
  

Key Clinical Considerations

1. Communication Issues

• Common symptoms:
  
  

  • Stuttering, slurred speech, mutism
    
    

  • Word-finding difficulty
    
    

  • Brain fog (slow or confused thinking)
    
    

• Staff actions:
  
  

  • Allow extra time for responses.
    
    

  • Use written communication or yes/no signaling if necessary.
    
    

  • Offer reassurance that communication challenges are understood.
    
    

2. Sensory and Temperature Regulation Changes

• Sensory anomalies may include:
  
  

  • Lack of normal sensation (touch, temperature, pain).
    
    

  • Dysregulated temperature perception (feeling too hot or cold without environmental cause).
    
    

• Staff actions:
  
  

  • Monitor for thermal injury risks.
    
    

  • Adjust patient environment as needed.
    
    

3. Mobility and Paralysis Concerns

• Symptoms may involve:
  
  

  • Weakness, tremor, dystonia, gait disturbance, or complete paralysis.
    
    

• If paralysis is present:
  
  

  • Urgently rule out stroke, spinal cord compression, multiple sclerosis, or Guillain-Barré syndrome with:
    
    

    • MRI brain and spine
      
      

    • Neurological examination
      
      

    • Reflex testing
      
      

    • EMG/Nerve conduction studies if indicated
      
      

• Staff actions:
  
  

  • Early physiotherapy referral is essential.
    
    

  • Encourage achievable movement to reinforce functional improvement.
    
    

  • Be aware that while many recover quickly, some may experience prolonged disability if untreated.
    
    

4. Urinary and Gastrointestinal Considerations

• Potential symptoms:
  
  

  • Urinary retention or incontinence
    
    

  • Vomiting, leading to aspiration risk
    
    

• Staff actions:
  
  

  • Monitor urinary function; use bladder scans.
    
    

  • Attend to vomiting quickly and reposition immobile patients to prevent injury and aspiration.
    
    

5. Vestibular and Inner Ear Issues

• Balance disturbances and vertigo are common.
  
  

• Staff actions:
  
  

  • Refer to vestibular physiotherapy.
    
    

  • Rule out mechanical vestibular disorders like BPPV.
    
    

6. Seizure-like Episodes

• Dissociative (non-epileptic) seizures frequently occur in FND.
  
  

• Staff actions:
  
  

  • Follow standard seizure precautions.
    
    

  • Obtain neurology consultation to differentiate from epileptic seizures.
    
    

  • EEG may assist but can be normal outside of events.
    
    

7. Medication and Drug-Seeking Considerations

• Pain, distress, and anxiety are common; some patients may seek medication for relief.
  
  

• Important distinction:
  
  

  • Most FND patients are not drug-seeking.
    
    

  • Repeated aggressive demands for controlled substances should prompt a psychological assessment.
    
    

• Staff actions:
  
  

  • Respond to medication requests with empathy and clinical judgment.
    
    

  • Document symptoms factually without stigmatizing language.
    
    

  • Refer to pain services or psychiatry when needed for complex management.
    
    

Principles for Management

• Validate the patient's symptoms as real and distressing.
  
  

• Communicate simply and clearly, allowing extra processing time.
  
  

• Rule out urgent organic causes early.
  
  

• Encourage early mobilization under physiotherapy guidance.
  
  

• Prevent secondary complications such as pressure ulcers and aspiration pneumonia.
  
  

• Promote multidisciplinary care: Neurology, Physiotherapy, Occupational Therapy, Psychiatry, and Pain Services involvement is ideal.
  
  

Summary Table

Clinical Concern

Action to Take

Communication difficulty

Allow time, use alternative communication

Temperature dysregulation

Adjust environment, monitor for risks

Suspected paralysis

Imaging, neuro exam, early mobilization

Urinary or vomiting concerns

Bladder scanning, airway protection, repositioning

Vestibular/balance disturbance

Vestibular therapy referral

Seizure-like activity

Seizure precautions, neurology input

Medication concerns

Empathic assessment, psych referral if necessary

In Summary

• FND is a genuine, diagnosable, and treatable disorder.
  
  

• Early validation, symptom management, and multidisciplinary rehabilitation are the keys to maximizing recovery.
  
  

• Avoiding stigma and focusing on functional improvement leads to better outcomes.
  
  

References

1. Stone J, Carson A, Duncan R, Roberts R, Warlow C, Hibberd C, Murray G, Pelosi A, Cull R, Sharpe M. "Symptoms 'unexplained by organic disease' in 1144 new neurology outpatients: how often does the diagnosis change at follow-up?" Brain, 2009;132(10):2878-88.
   
   

2. LaFrance WC Jr, Baker GA. "Dissociation, conversion, and somatization: The diagnosis and management of functional neurological disorders." Handbook of Clinical Neurology, 2017;139:407-420.
   
   

3. Edwards MJ, Adams RA, Brown H, Parees I, Friston KJ. "A Bayesian account of 'hysteria'." Brain, 2012;135(11):3495–3512.
   
   

4. Nielsen G, Stone J, Matthews A, Brown M, Sparkes C, Farmer R, David AS, Edwards MJ. "Physiotherapy for functional motor disorders: A consensus recommendation." Journal of Neurology, Neurosurgery & Psychiatry, 2015;86(10):1113-1119.
   
   

5. LaFrance WC Jr, Wincze JP. "The Treatment of Nonepileptic Seizures: Cognitive Behavioral Therapy and Standard Medical Care." Epilepsy & Behavior, 2015;47:70–77.
   
   

6. Stone J, Hallett M, Carson A (Eds.). "Functional Neurologic Disorders." Handbook of Clinical Neurology, Vol. 139, Elsevier, 2016.

UPDATED APRIL 2025

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BELOW IS A QUICK REFERENCE GUIDE DESIGNED TO BE EASILY PRINTED OR PASSED ON.

🏥 Quick Reference: Functional Neurological Disorder (FND) – Hospital & ED Care Guide

What is FND?

• A real neurological disorder of brain network dysfunction, not structural brain injury.
  
  

• Symptoms are not faked or consciously produced.
  
  

• Recognized by neurology experts worldwide:
  Dr. Jon Stone, Dr. W. Curt LaFrance, Prof. Mark Edwards, and others.
  
  

Common Presentations

Symptom

Key Features

Speech difficulties

Stuttering, slurred speech, mutism, word-finding issues

Sensory changes

Altered or absent touch, pain, temperature sensation

Motor symptoms

Weakness, tremor, dystonia, paralysis

Seizure-like episodes

Dissociative seizures (non-epileptic)

Balance problems

Vertigo, unsteady gait

Autonomic symptoms

Heat/cold dysregulation, bladder dysfunction, vomiting

Priority Actions for Staff

🩺 Validate:

• Communicate clearly: "We believe you; your symptoms are real."
  
  

🧠 Rule Out Organic Disease:

• Stroke, spinal cord compression, MS, Guillain-Barré, epilepsy, among others.
  
  

• Tests:
  
  

  • MRI Brain and Spine
    
    

  • Neurological Exam
    
    

  • Reflex Testing
    
    

  • EEG if seizures suspected
    
    

  • Vestibular assessment for balance complaints
    
    

🤝 Support Communication:

• Allow extra time.
  
  

• Offer writing tools or yes/no signals.
  
  

• Avoid forcing speech or movement under stress.
  
  

🏃 Early Physiotherapy:

• Start light functional movement as soon as safe.
  
  

• Positive reinforcement: celebrate small movement successes.
  
  

• Physiotherapy is evidence-based best practice (Nielsen et al., 2015).
  
  

🚽 Manage Urinary and GI Concerns:

• Bladder scanning if urinary retention suspected.
  
  

• Reposition immobile patients to prevent aspiration and pressure sores.
  
  

• Attend vomiting risks urgently.
  
  

🧊 Temperature Safety:

• Monitor for burns or hypothermia if sensation is altered.
  
  

• Adjust room environment based on patient feedback.
  
  

💊 Medication & Drug-Seeking Behavior:

• Most patients are not drug-seeking.
  
  

• Repeated demanding behavior may warrant psychological evaluation, NOT assumptions.
  
  

• Offer pain management compassionately.
  
  

🧠 Multidisciplinary Care Essential:

• Involve: Neurology, Physiotherapy, Psychiatry/Psychology, Pain Teams, Occupational Therapy.
  
  

If Paralysis is a Concern:

🔎 Urgent Tests to Rule Out Serious Conditions:

• MRI
  
  

• Full Neuro Exam
  
  

• Nerve Conduction Studies / EMG if indicated
  
  

⚙️ Mobility Support:

• Initiate gentle physio even if paralysis persists.
  
  

• Recognize risk for permanent disability if immobility continues too long.
  
  

Fast Communication Tips

• Avoid phrases like: "It's all in your head" or "Just try harder."
  
  

• Use phrases like:
  
  
  "Your brain is having trouble sending the right signals to your body — we're here to help it recover."
  
  
  

Key Principles

✔️ Symptoms are real and involuntary.
✔️ Early rehabilitation improves recovery rates.
✔️ Kind, validating communication makes a major difference.
✔️ A multidisciplinary team approach achieves the best outcomes.

📚 References

1. Stone J, Carson A, Duncan R, et al. "Symptoms 'unexplained by organic disease'..." Brain, 2009;132(10):2878-88.
   
   

2. LaFrance WC Jr, Baker GA. "Dissociation, conversion, and somatization..." Handbook of Clinical Neurology, 2017;139:407-420.
   
   

3. Edwards MJ, et al. "A Bayesian account of 'hysteria'." Brain, 2012;135(11):3495–3512.
   
   

4. Nielsen G, et al. "Physiotherapy for functional motor disorders: A consensus recommendation." JNNP, 2015;86(10):1113-1119.
   
   

5. LaFrance WC Jr, Wincze JP. "The Treatment of Nonepileptic Seizures..." Epilepsy & Behavior, 2015;47:70–77.
   
   

6. Stone J, Hallett M, Carson A (Eds.). "Functional Neurologic Disorders." Handbook of Clinical Neurology, 2016.
   
   

✅ This version is structured to be laminated, pinned to a hospital station, or uploaded to staff intranet for rapid access.