Historically diagnosed as “conversion disorder” or “hysteria”, Functional Neurological Disorder (FND) is a condition of disabling neurological symptoms for which there are no structural brain abnormalities. FND is primarily characterised by a disturbance of nervous system function rather than underlying pathophysiological disease. The disorder produces a heterogenous (unique) range of symptoms for each person including altered, reduced, or absent sensory function, motor abnormalities (paralysis, tremors, weakness, dystonia, gait imbalance), and cognitive impairments (non-epileptic seizures, speech impediments, difficulties swallowing), as well as altered awareness such as dissociation and vertigo. The distress, disability, and impact on daily functioning associated with FND is comparable to chronic neurological conditions such as stroke and multiple sclerosis.

Occurring across the age span, FND commonly presents with significant comorbidities and psychological stressors, although a minority of patients do not present with these features. A range of biopsychosocial factors appear to influence the onset and maintenance of FND. Predisposing factors include adverse life experiences such as pain, medical trauma, emotional neglect, family problems, child sexual abuse, parental divorce, and looking after parents/siblings as a child. Precipitating factors commonly involve physical exertion, sleep disturbance, bereavement, fatigue, and life stressors (emotional, interpersonal, or work-related). Perpetuating factors include heightened somatosensory attention, alexithymia, dissociation, anxiety, depression, and maladaptive illness perceptions. The interplay of significant biopsychosocial influences reflects the complexity and individuality of FND presentations and can impact how individuals engage with their diagnosis and treatment. Hence, improvement in psychosocial functioning (rather than reduction in symptom severity) is often the target of psychological treatment.

Psychological factors often contribute to the initial rejection or denial of distress and FND diagnosis, particularly in individuals with alexithymia, dissociation, or repressed emotional expression. Dissociative symptoms are transdiagnostically associated with greater symptom severity and functional impairment across psychiatric disorders and may predict reduced responsiveness to psychological treatment. Prognostic FND studies have identified better outcomes in patients who accept their diagnosis, have shorter symptom duration, and fewer comorbidities, however these factors do not necessarily predict outcomes at the individual level. Individual differences in psychological functioning and diagnostic acceptance occur alongside systemic challenges in the recognition and management of FND within healthcare settings.

FND is under-recognised in medical systems largely due to diagnostic uncertainty, insufficient assessment time, misconceptions of malingering, and the historical separation of hospital neurology and psychiatry departments. This persists despite Australian hospital data indicating high admission rates and substantial service utilisation costs for patients presenting with functional neurological symptoms. A 2023 Australian survey identified 14 metropolitan FND clinics, most with multidisciplinary teams, yet highlighted variability in referral pathways, service demand exceeding capacity, and wait times longer than 3-months (Connors et al., 2024). Another national survey reported underfunding and workforce fragility as barriers to providing specialised FND care, while service advocacy and multidisciplinary teams were identified as key enablers (Pearce et al., 2024). Diagnostic challenges and fragmented care pathways contribute to iatrogenic harm and poorer outcomes for FND patients. This ultimately increases the health service burden and underscores the need for a stepped care model to support more efficient FND interventions. In response to the identified health service gap, multidisciplinary FND group interventions continue to be established through hospitals to offer accessible care for FND outpatients, while generating clinical data to inform treatment development and support more efficient service utilisation. However, eligibility criteria, including residing in hospital catchment areas, can be a barrier to accessing FND outpatient treatment.

Contemporary health models support the conceptualisation of FND through a biopsychosocial lens with patient-centred interdisciplinary treatment planning, however the optimal setting for delivery remains unclear. FND group interventions offer an efficient and potentially cost-effective format, with preliminary findings suggesting positive results on functioning. In addition, telehealth delivery has emerged as a promising model for increasing access to specialists, particularly for those facing barriers to attending in-person care. One study reported remote delivery of an individually tailored stepped model of Cognitive Behavioural Therapy (CBT) for FND clients was feasible (Lin & Espay, 2021). While another study reported 12 sessions of psychotherapy delivered via telehealth resulted in a 46% reduction in seizures across 32 patients (LaFrance Jr. et al., 2020). While research continues to support clinical practice in the development and delivery of effective treatment protocols, what appears to be the most important factors for recovery at present is early diagnosis and access to multidisciplinary treatment in areas such as neurology, psychology and physiotherapy.

** There is currently a petition circulating for signatures to request parliament provide FND patients with access to a Medicare FND Care Plan including at least 60 annual Medicare funded allied health outpatient sessions.

Please read the petition and sign if you’re in agreement – www.aph.gov.au/e-petitions/petition/EN9549