September 17, 2026 by Haley Hansen, PT, DPT
Steve Kerschke: With that though, we will go ahead and get started. So it’s nine o’clock. Those of you who are still joining will get going here, but we’re excited to bring a topic that’s been really top of mind for our team here. And even we’ve had some questions prior to this, so it sounds like it might be top of mind to our audience as well. So we’re going to be talking about functional neurological disorder today, and we’re really happy to invite Brad Dexter back to QLI. So if you didn’t know a sad day and a sad loss for QLI, Brad recently took a position over at the Nebraska Medical Center as an assistant professor, but our loss is for sure there again. He’s one of the best teachers that I know, and we’re really excited to have you back, Brad. And this is an interesting topic and I’m hoping to learn quite a bit today too, so expectations are high.
Brad Dexter: Oh boy. Thanks, Steve.
Steve Kerschke: Before we turn it to Brad, we’ll do a little bit of information sharing and housekeeping. So Brad, if you could just click to the QLI informational slide. Just a reminder, those of you who are regulars, welcome back. If you’re new to QLI, QLI is a post-acute rehab facility based in Omaha, Nebraska. We’re considered a center of excellence at the post-acute level. We also have a pretty unique telerehab program, but in either case, we serve individuals with traumatic brain injury, spinal cord injury, chronic pain, limb loss, and stroke. So we specialize in really anything neurological and complex, and we’re just fortunate to have grown our program over the last 35 years to include all of these diagnoses. Before we jump in, a little bit of housekeeping. We know that you want your CEUs, so just a reminder to get those. We just ask that you attend the majority of the presentation.
There will be a poll question at the very end. Please participate in that. And then upon leaving the webinar, you should have something that automatically pops up to fill out the. What’s the word that I’m looking for? Survey. The survey. And if you click submit, you should automatically get sent your CEUs and the slides. So that will be coming to you automatically upon leaving. We do have some folks who struggle through that for various reasons. A lot of times it’s firewalls and things like that. Just reach out to Don and I, we’ll get you set up. And then just a reminder, use the Q&A. Between Don and I, we will monitor the Q&A throughout the presentation and toss Brad questions as we see fit. Otherwise, at the end, there’s definitely going to be some time to answer those. So excited to hear what you have to say.
Brad, I’ll kick it over to you. All
Brad Dexter: Right, thank you. Thanks for the introduction. I’m going to give just a little bit more. So name is Brad Dexter. I usually like to start from a place of who am I? I’m a husband, I’m a father. This is my family. I have an eighth grade daughter. I have a daughter that’s in sixth grade and a son that’s in third grade, and we love to adventure. We love to be outdoors. We do have a little dog, a little Havanese. He does not always wear a bandana, but when he does, it’s pretty cute. It happens after haircuts typically. But just given age of my kids, you can probably guess that we’re pretty busy. We’re kind of in that phase of life where we are taxi cabs a lot of the time and it’s a lot of fun. It’s definitely fulfilling and we are enjoying it. As Steve mentioned, I’m a product of QLI, I would say that.
So I just have a few pictures here. I think one of the reasons that I wanted to talk on this topic today is because of a lot of the things that I learned as a clinician through QLI too. Functional neurological disorder, it requires a lot of empathy. It requires a high level of understanding. It requires a high level of collaboration between disciplines. And I really kind of grew up and came into my own as a clinician at QLI. I had lots of opportunities to work in collaboration with other clinical providers. We were always challenged to dream big for the patients that we had in front of us. And ultimately, like Steve said, I had an opportunity to come over to the academic side. I really want to try to instill those types of similar values into the students that I teach and influence them so that they can be excellent providers for hopefully some of your patients in the future as well.
So just a couple of things here before I advance the slide. The title of this presentation is Rebooting the System, and we’ll talk a little bit more about why that is in a bit here, but it’s understanding functional neurological disorder. And I’ll hit on a few of the learning objectives here in a moment, but if you could at least walk away from this webinar understanding just a hair more about functional neurological disorder than you did before you came into it, I think it’s a big win. I’m probably going to screw some things up. I’m probably going to slip over some of my words today. You might go to some of the websites or articles that I provided and be like, “What was Brad talking about?” That’s okay. I’ve moved the needle to some extent and I’ve at least developed a curiosity for you in functional neurological disorder.
I will use the acronym FND as shorthand for functional neurological disorder because that’s a mouthful. So just know that moving forward. And I have a few quick poll questions for you. These poll questions are not the ones that you’re getting credit for. That one’s coming at the end. These are really just to act as a warmup for us. So you guys, if you have your phone available, you can scan that QR code and it will take you to the survey or you can type in the pollev.com and fill out the survey that way. It’s six quick questions. They’re yes, no questions or true false if you want to think about it that way. But again, just going to act as a warmup. I’m going to sit on this slide for a moment as those keep coming in before I start to advance through. We could talk a little bit more about football if we need to, just to kill time.
Steve Kerschke: We could talk school starting because everyone’s life gets way easier when school starts.
Brad Dexter:
That’s true. You know what doesn’t get easier when school starts? Traffic. Traffic does
Steve Kerschke: Not. Yeah, traffic downside.
Brad Dexter: Those of you that are on your phones will probably not be able to participate in the survey, but it’s a small amount, so hang on for the educational ride.
Steve Kerschke: Brad, are your students back yet?
Brad Dexter: We have orientation for our new cohort this week and then classes start next week.
Steve Kerschke: Nice.
Brad Dexter: It is always nice when students get back onto campus. It feels quite a bit different. All right, so surveys are underway and they’re being completed. I’m going to start advancing through the slides just to see what you guys are thinking. All right, so first question here, FND is a diagnosis of exclusion. We have a bunch of yeses and we have a bunch of nos, a little over half in the yes. Okay, hold on to that. We’ll come back to it. Patients have either FND or another neurological disorder. We have a lot of nos here, so a lot of you are saying it’s exclusive. It’s either one or the other. It can’t be both.
FND is exclusively a psychological problem. Okay. Majority of you are saying false or no to that one. FND symptoms are voluntary. No. Okay. F and D is exclusively a psychological problem, and majority of you are saying no to that. And the treatment of FND is solely psychological. Again, majority of you are saying no. Hey, just looking at that, I think we have a pretty good start on our hands. We’ll address each of those things as we progress through the presentation here. So I said, if you could leave this webinar today, just understanding at a basic level what functional neurological disorder is and how you might identify that in some of the clients, patients that you’re working with, that’s a huge win. But beyond that, we’re going to talk about what FND is. We’ll differentiate that from other neurological conditions. We’re going to try to go through some of the common signs and symptoms that we might see with FND in clinical practice.
We’ll try to frame the treatment of it through a biopsychosocial framework and then hit on some key strategies that can be utilized in treating these patients as well. And real briefly, I’ll touch on just effective communication with some of these individuals, especially within the realm of collaborative care.
All right, so we’re going to start off with the history of functional neurological disorder. I didn’t have a poll question of how long you guys have known about this, but it is really interesting just to follow the path of functional neurological disorder, some of the different naming conventions. So it was formerly known as conversion disorder, and it’s really a condition at the intersection of neurology and psychiatry that’s characterized by neurological symptoms. So we can see weakness and movement disorders and seizures that happen, but they’re not really explained by structural disease. However, they are genuine and involuntary types of symptoms. The history of FND really reflects the evolving understanding of mind-body interaction and the stigma that can be associated with disorders that are lacking more visible pathology. So if we look at just this historical evolution of FND over time, if you go back into ancient medieval times types of literature, you can actually see some early descriptions that are linked to similar symptoms that we would describe within FND today.
You fast-forward into the 17th and the 18th centuries, and some of those early physicians were challenging more supernatural explanations like demons or gods that were possessing people, and they started to propose more nervous system disorders. In the 19th century, you had neurologists like Charcot that were distinguishing more functional symptoms from organic symptoms. And then there was a shift in the early 20th century that moved things in more of a psychological direction, and that’s from the influence of psychologists like Freud and Brewer who reframed symptoms of FND as more unresolved psychological conflict. Now, as we progressed through the 20th century, get into the mid 20th century, the disorder’s legitimacy started to be questioned because there were a lot of misdiagnoses, and you get into the late 20th century and moving into the day, and functional neurological disorder really started to resurge with more scientific validation and new diagnostic approaches.
The validation and the diagnostic approaches really came from technology evolving. So the dawn of functional MRI and EEG studies started to actually show that there was altered brain function in patients with FND. You could see abnormalities and attention in movement planning and emotional regulation through looking at the imaging in the brain itself. And there was more and more of a recognition of involuntary nature. So people weren’t faking these things, they weren’t faking symptoms. Instead, symptoms were arising from that brain dysfunction that was being identified in fMRI, and it also meant that some of those symptoms were potentially reversible and not due to some kind of damage. Within the medical realm in around 2013, we actually saw the DSM-5 rename conversion disorder to functional neurological symptom disorder. So they dropped the requirement for a psychological stressor there, and they started to emphasize that there were positive signs for diagnosis, meaning it wasn’t necessarily a diagnosis of exclusion, but it was a diagnosis of inclusion at that point.
So our current understanding is that F&D, present day here, is seen as a biopsychosocial disorder. It can be influenced by predisposing factors like trauma, anxiety, or illness, precipitating events like an injury of some kind, and perpetuating factors like reinforcement or avoidance. And collaborative types of treatment are really, the interdisciplinary care are really what’s accepted and favored with this population of individuals, neurologists, your physical therapists, PMR docs, psychologists, occupational therapists, speech therapists. There has to be some kind of collaboration that exists there.
Just to make sure that you understand that this is credible too, there’s an FND society that was founded in 2017 that is promoting research and advocacy and education around functional neurological disorder. But overall, if we think about the history, and just to wrap up this slide, F&D is mirroring broader themes in medicine, that mind-body divide, stigma around invisible illnesses, and the challenge of interdisciplinary care over time. We’ve gotten better and better at those things, even though some care can still be siloed. And today, F&D is understood as legitimate, common, and a treatable condition, but we have to recognize that past approaches continue to shape patient experiences and the way that we handle those patients within the clinic. So what is it exactly? FND is describing neurological symptoms. Let me say functional neurological disorder is describing neurological symptoms like limb weakness, tremor, numbness or blackouts that can be related to the movement and sensory parts of the nervous system.
Oftentimes, it’s caused by a problem with the functioning of the nervous system. And hold onto this next though here because we’re going to revisit it in a little bit. It’s a software issue of the brain, not a hardware issue of the brain. And I’ll explain what that means in a little bit here. They’re positive diagnostic features that are typical of F and D, and ultimately it’s going to cause day-to-day difficulties for the person who experiences them. Now, a person can be diagnosed with functional neurological disorder, but they can also have functional neurological symptoms, and those would be symptoms that you might start recognizing before they actually have a diagnosis of FND itself. And those functional neurological symptoms are just troublesome symptoms that someone wants to understand a little bit better without having that disorder. So those are what are called functional neurological symptoms.
David Perez is an MD that works a lot with this population. And again, he just describes it as a disorder of communication across a range of brain networks. And again, we’re going to get to that here in a little bit. So what FND is not? Let’s talk about that. FND is not feigning or malingering. The paper that I have highlighted on this slide, these authors kind of hit on these five bullets, and I’ll share a little bit more here, but they hit on the fact that it’s not a diagnosis of exclusion. It’s not purely psychiatric or requiring a psychiatric history or comorbidity. It is not malingering. It’s not just a throwaway type of diagnosis. We can’t figure out anything else, so it’s got to be this and it’s not feigning or faking. So just to speak a little bit more on those things from this article, some of the high points, they identify that there are distinctive features of functional neurological disorder, and those symptoms are clinically genuine.
They’re often going to fluctuate in severity and they’re not consistent with deliberate fabrication. So in other words, there’s not secondary motivation, financial or legal benefit motivation, and that’s something that distinguishes FND from malingering. There’s clinical and neuroimaging evidence. So we talked about fMRI being able to reveal altered brain function in very specific areas that we’ve been able to tie to FND over time as well. And those areas that are lighting up in the brain are fundamentally different patterns than we would see in conscious feigning from people. The patient experience. So people with FND are frequently going to seek medical attention and undergo tests. That is inconsistent with what malingering would be, where those symptoms are typically fabricated for gain and people don’t want the medical engagement, that’s usually minimized. Another thing, just thinking back to the history lesson that we had, there’s been historical and cross-cultural presence.
This isn’t just a new culture-bound phenomenon that’s happening. It’s been documented throughout history and across cultures in a consistent way. And the contemporary neuroscience models have changed over time as technology has evolved and as our understanding of the brain and the nervous system have evolved as well with the dawn of technology. And our current contemporary neuroscience models, like the dysfunction in the brain’s predictive processing, that type of a model, actually explain FND symptoms as involuntary disturbances in perception and movement, which again is fundamentally different from a consciously produced symptom that would be associated with faking or malingering. And the last piece here is there’s stigma and clinical implications. So distinguishing FND from malingering is crucial to avoid stigma, to promote appropriate diagnosis, and to deliver evidence-based care to affected patients. So overall, this is my little soapbox on, “Hey, let’s not get FND confused with something that it’s not, and let’s be able to identify what it is.
Why should we talk about it? Beyond the ideas of avoiding stigma and promoting appropriate diagnosis and delivering evidence-based care to affected patients, this Finkelstein study actually gives us some numbers on the prevalence of FND. So the minimum prevalence that they identified was estimated around 80 to 140 cases per 100,000 people. If we compare that to other types of neurological diagnoses, namely on this little line graph that we have here, MS or brain cancer or ALS, it’s significantly more prevalent than those types of neurological disorders and diseases. It’s one reason why I’ve kind of been stumping to get functional neurological disorder out of our psychosocial aspects of healthcare class and into our neurological neuromuscular classes where I teach, because it has a higher prevalence than MS and Parkinson’s disease, yet we’re not talking about it in the same way even in educational environments right now. It’s actually one of the top five reasons why people are seeking a neurology consult.
It’s affecting women more than men at a rate of three to one. It’s affecting people across a wide spectrum, pediatrics to elderly. Here’s one that might hit home. We’re spending $1.2 billion, that’s an estimated annual cost, on F&D care in the US alone. And the level of physical disability is equivalent to what we might see in a multiple sclerosis or epilepsy. So just let’s keep that in mind. One, we’re talking about it because we want to understand it better. We want to take care of our patients better, but two, there’s a massive financial cost with some of this. And if we’re getting people maybe into the right streams of care, perhaps we can get that cost down, and the prevalence of this is very, very high as well. All right. In the case that you haven’t seen something like this before, as we start to go into the clinical presentation and the diagnosis, I just want to show you a couple short clips.
So in this video, you’re going to see the before on the left, and you’re going to see the after on the right.
There’s no sound. Don’t worry about the sound. The video on the left is shorter than the one on the right. All right, so if I look at this just as a movement specialist, I look at the person on the left, I actually watched the way that she’s walking and I’m thinking, gosh, it doesn’t fit any of the movement buckets that I would typically think about. So if someone has ataxia or if they’ve had some kind of a cerebellar infarct or they have a disorder of the basal ganglia or they’ve had a stroke or a TBI, there are different synergies or patterns that we see people walk in, and I see something like that, it just doesn’t really fit. Now, what does that mean? It doesn’t mean that, hey, just because it looks wrong that it’s F and D. It’s really, for me as a clinician, I would look at that and say, “Gosh, maybe there’s something just a little bit more going on here that I need to make sure that I’m getting back to the physician, to the case manager, to other clinicians, just to identify maybe we’re seeing some functional neurological symptoms.
We don’t have that diagnosis yet, but maybe we’re having some symptoms and we might need to address those in a certain way.” Here’s another clinical presentation. These are, again, small sample size here, but I just want you to see a couple different presentations. This is one where a young individual is having a lot of functional seizures.
You see a drastic change in a relatively short period of time. I’m just going to play that one more time. 20 seizures per day, six-week transformation, motor control issues, POTS, migraine, chronic pain, lots of sensory motor control and autonomic practice. Significant change here, right? Okay, so again, those were just a couple short clips. It’s not all encompassing, but what kinds of symptoms are we seeing within a functional neurological disorder? There are a lot of them, right? We can see limb weakness, we can see seizures, sensory symptoms, dizziness, bladder issues, visual issues, tics, movement disorders, cognitive symptoms. There’s a lot going on. There’s a lot that can show up. How is this happening? The basic answer is that there’s a problem in the function of the nervous system itself, not a hardware issue, but a software issue. And so for symptoms like weakness or movement disorder, anything that’s motor related on this list here, there’s going to be some kind of a problem with the way that the brain is sending the messages to the body for movement.
For symptoms on here that are like numbness or pain, there’s going to be a problem with the way that the brain is receiving those messages from the body. For issues on here like functional seizures or dissociative symptoms, the brain can go into more of a trance-like state and it’s a bit like hypnosis. In reality, we’re just starting to understand the complexities of what goes wrong with the nervous system in these patients, and honestly, in related disorders like chronic pain. Chronic pain is another place where there’s maybe something weird going on with the wiring and the way that messages are being sent or perceived by those individuals. But remember, functional scans of the brain are going to help show which parts of the brain are active or underactive when a person has F and D. This is another way that we can visualize some of the symptom prevalence with this population.
The lines that are in blue are motor control related issues, and the lines that are in orange are non-motor related symptoms. And so even just looking at say the top five symptoms and prevalence here, we have two that are motor related, weakness and reduced balance, and three in the top five that are non-motor fatigue and more somatosensory issues, so sensation issues, and cognitive fog that can happen. So again, the functional neurological disorder might not show up like what we saw in those videos. They may be non-motor types of signs that are rearing their ugly head, especially early on. All right, we’re going to dive in a little bit more into what’s happening here, and I’ve said multiple times now that this is a software issue as opposed to a hardware issue. And again, there’s still much that isn’t known about what’s going wrong in the nervous system to cause FND, but it’s not a complete mystery right now.
I’m going to camp out here for a moment. Hopefully this is exciting information to you and I don’t bore you. It’s exciting to me. In a lot of other neurological conditions, we can see what the problem is. We can understand what the problem is really well. On a scan, you can look for lesions for multiple sclerosis, or you can find the lesion in the spinal cord, or you can see where the injury from a traumatic brain injury or from a stroke may be in individuals. Under a microscope, you can identify changes in cells and figure out what’s going on and appropriately diagnose something like a Parkinson’s disease. But patients with FND don’t have damage to their nervous systems. So again, that’s why I’m saying if the nervous system is the hardware, there’s not actually something that can be seen there. There’s not damage to the nervous system, so it’s not really surprising that we can’t see it on a typical scan.
Instead, it’s really just that the nervous system itself as a network isn’t functioning properly. So the software, it has a bug of some kind. So think about it this way. If you were a computer, it’s like having a software problem rather than a hardware problem. If you have that software bug in your computer, it might keep crashing on you, your computer might run really slowly, maybe you get a bunch of popups that show up, but you wouldn’t solve that type of a problem with your computer by opening up the hard drive and looking at the components. You’re not going to see anything if you do that or if you took an x-ray of the computer itself. You’d have to actually solve it by reprogramming the computer, working out the bugs in identifying where the bugs are at, and then working out those bugs in the specific programs where they’re causing the problems.
Now, let’s try to translate that to people. People are obviously more complicated than computers. Our thoughts Our behavior, our sensations, and our emotions are similar to those programs.
And there can be a bug that gets into some of those programs, and we have to identify which one of those programs is the one that the bug is in, and how do we appropriately address that to work the bug out of it. Hopefully, that helps just to understand the software, not a hardware type of issue. Now, I have this picture on here of brain networks. When we typically think about the brain, if you guys have been watching these webinars for a while, you’ve probably got to hear Dr. Snell talk about the brain, and it’s always fun to just listen to Dr. Snell talk about the brain. He’s so knowledgeable on it. The brain and how we identify the different areas of the brain is still thinking about it from a hardware perspective. So we might identify the frontal lobe, we might identify the parietal lobes or the temporal lobe or the occipital lobe, the cerebellum, the basal ganglia, the thalamus, the limbic system.
These are all different areas, and we might even be able to understand how information is traveling to and from those areas, just depending on your experience with it. But there are also brain networks that have been identified, especially as we’ve been able to use fMRI more and more in the past 15 plus years. And what these brain networks are, it’s really just identifying how the brain is intrinsically organized into distinct functional networks that can support complex mental processes. So if I want to generate movement, it’s not as simple as a message is generated from the frontal lobe of my brain and it travels to the spinal cord, which gets to a nerve that sends that information out to a muscle in my body. There are actually a lot of other factors within a system that would impact that. Namely, if we look at the dorsal attention network and the sensory motor network here and the frontoparietal network, the salience network, all of those can impact that one pathway to try to generate a movement in my body.
And so we have to acknowledge that these brain networks are present. It’s a way of describing how those hardware areas of our brain are communicating at a really high and fast level with one another and what the distinct features of each one of these networks are as well. I told you I’m going to camp out on this slide for a little while and I’m not done quite yet. I want to give you a way to maybe relate this information to something that you’ve maybe seen in a patient before or experienced in some way. You’ve probably heard about phantom limb pain or phantom limb syndrome for someone that undergoes an amputation. They have that amputation of the limb, but they feel like the limb is still there. Studies of phantom limb syndrome or phantom limb pain have often shown that what goes wrong is almost certainly that the map of the limb in the brain is what’s causing the issues.
We have maps within our motor strip and our sensory strip of our brain that represent different parts of our body. And that map of our body should change if there’s new information. So if you lose a limb, in this case, let’s say you lose a left leg, your brain should register that as, “Hey, we’ve got an update here. There’s no left leg anymore.” In phantom limb syndrome, pain, that updating process goes wrong. And neuroscientists think that the brain is actually just making a really strong prediction that the leg is there. And that prediction is so strong and it’s been doing it for so many years in that person that even the absence of the leg doesn’t stop it predicting the leg. And so if the brain predicts that a leg is there, then the person is going to feel that the leg is there, even though it’s not.
In FND, we think that there’s something similar that’s happening, but instead of a strong prediction that the leg is there for various reasons, the brain develops a prediction that the leg is not there. Again, the problem is that although the brain is getting messages that the leg is there, the prediction that it isn’t there is too strong and the brain doesn’t update just like in phantom limb. And so the person experiences the prediction, not the sensation. So you might even ask here, why would the brain decide to predict that a limb is not there? Well, there could be a lot of reasons, right? It could be because that limb has been painful and it’s trying to get rid of the sensation. It could be because there’s been a migraine or some other kind of strange neurological symptom that’s going on, which has sent the brain into fight or flight mode, and it’s trying to shut down that part of the body, or maybe it’s been used to shutting down parts of the body before in response to threatening events.
Okay, I’m done on this slide, but it was an exciting slide for me and I would love at some point to dive into these brain networks a little bit more. Honestly, Steve, I would love to hear Dr. Snell dive into these brain networks. I think he would do a phenomenal job describing them and talking about the influence of them.
Steve Kerschke: You and I are on the same wavelength. I’ve already put it down for a potential topic.
Brad Dexter: I’m joining that webinar. All right, so let’s talk a little bit more then about network dysfunction. And one of those poll questions early on in the webinar, I forget exactly what the question was, but it was like, “Hey, can FND exist with another neurological diagnosis?” And these next couple slides, I just want to make a case that yeah, it can. I think a lot of us responded, maybe it was close to half and half, maybe it was a lot of people that said, “No, that can’t happen. I don’t remember what the results were.” But what we know from evidence right now is that virtually every major neurological and psychiatric condition that has been studied with fMRI has shown some form of network dysfunction, even if the specific patterns vary. So you can see a number of different conditions on this slide, maybe a couple that aren’t there that I would add in are things like chronic pain, chronic fatigue syndrome, CRPS.
Those are also some neurological conditions that have demonstrated network dysfunction that can be associated with FND. So you may have someone that you’re working with that had, let’s say, a spinal cord injury, but maybe they also have a history of bipolar disorder or maybe they had a history of one of these other things that is on this list too, and they could develop some FND types of symptoms. Maybe it’s someone you’re working with that has a traumatic brain injury, but they’ve gotten back to a higher level of functioning, but they start demonstrating some symptoms that are more functional in nature. And just recognize that it may not be part of the original hardware injury that happens, but you can develop those software types of issues a little bit further down the line in someone’s rehabilitation process.
Just to connect that last slide and the brain network slide, let’s talk about a couple different types of neurological conditions here. So Alzheimer’s disease, there can be an original breakdown in some of the memory circuits within Alzheimer’s disease. Well, what happens in a network? So you might have a circuit, but in an entire network, if that circuit isn’t working very well, how is that going to influence the rest of the network? In this case, maybe it’s a default mode network. That breakdown in some of the memory circuits can start to impact how the rest of the default mode network is working. In Parkinson’s disease, there are motor network disruptions that cause movement issues, namely with the basal ganglia and the influence that the basal ganglia has on automatic types of movements. But if something starts to break down in the circuits within the basal ganglia that are connecting to some of our motor pathways, you can start to get disruptions in the frontoparietal network or in the sensory motor network as well.
Huntington’s disease, that’s another one. You guys may not work with Huntington’s disease as much if you’re more in the work comp space, but both motor and cognitive networks here can show signs of dysfunction in pre-manifest individuals even. So before they’re starting to develop some of the normal motor symptoms of Huntington’s disease, some of the cognitive networks can start to break down there. And just to show the influence of people with this neurological disorder also have a prevalence of FND within their condition, or people with FND also maybe have a higher prevalence of maybe pain that comes along with it too. This slide is kind of trying to show some of those connections. So autism, 17% of children with functional seizures have autism. 8% of adults with FND have autism, and 86.7% of participants with autism reported at least one FND symptom. So just there’s a connection here.
Ehler-Danlos syndrome, which is hypermobility of joints, 92% of these people with Ehlers-Danlos syndrome plus neuropathic pain had some kind of functional neurological symptom as well. And on the flip side, 74% of people that had a diagnosis of functional neurological disorder also met the criteria for hypermobility, even if they didn’t have that Ehler-Danlos syndrome diagnosis. And chronic pain, this one may be of more interest to some of you. Of people with chronic pain, 17% of them also had a diagnosis of functional neurological disorder. Of people that have a diagnosis of functional neurological disorder, 55% of them have pain with 22% of them meeting the criteria for chronic pain. So again, just a lot of overlap, a lot of connections. I have a few website resources for you guys at the end of the presentation, and one of those websites, neurosymptoms.org, is a really great place to go to get information.
And they show some pictures on that website even of how they’re kind of Venn diagram pictures of you might have chronic fatigue syndrome, you might also have F&D symptoms, and you might also have irritable bowel syndrome. So there’s just a lot of connectivity between some of these different conditions. So we’ve talked about the how. Let’s talk about the why now. Why is this happening? What are the potential reasons that lead to these changes in the networks, in the nervous system, in the software of the nervous system? Well, there’s really three potential reasons why an individual can become vulnerable to F&D. And my simple way of remembering them is what can happen before, during, and after. So number one, it’s kind of these predisposing factors. So the things that happened before the symptoms started, you can see here that they have a neurological condition like a migraine already or Parkinson’s disease or a TBI.
Have they had other functional types of disorders like chronic fatigue syndrome or irritable bowel syndrome, CRPS? Do they have a history of anxiety, depression, or other stressful events in their lives? Those are the before types of things. And then you have the during, so the precipitating or triggering factors. These are things that happened at the time that the symptoms started. So was there some kind of injury? Was there a panic attack? Was there a migraine, neurological illness, dissociative event, drug side effect, minor head injury, like a concussion of some kind that could influence this? Things that happen during or at the time that the symptoms started. And then we have to understand any comorbidities that can play into that as well. So they have any sleep issues or dissociation ahead of time, depression, anxiety.
But the third factor is this perpetuating factor, what happens after the symptoms start? Are they feeling like they’re faking it? Are they feeling like they’re disbelieved? Are they getting a ton of different diagnoses leading to medical uncertainty? Are they on medications, getting put on medications that cause a little more sedation? Are they getting those opioids? Are they starting to have unnecessary surgeries that are influencing how they feel about some of these symptoms as well? And all of these factors can be biological, psychological, or social. So they can have some kind of genetic vulnerability to it from a biological standpoint. From a psychological standpoint, if they’re constantly worrying that a headache might be due to a brain tumor, it can make the headache worse. From a social aspect, if they don’t enjoy their job or their boss is mean to them, they might tend to feel worse.
If they don’t have that support system in place, they might tend to feel worse. So this is that biopsychosocial model of illness that we all probably know pretty well at this point, and it doesn’t just apply to F and D. We know that all illness really has that psychological and social dimension to it. But just think that person maybe that’s going back to work after a TBI, mild TBI, concussion, spinal cord injury, whatever it might be, they go back and they feel miserable or they have a lot of debt that’s going to tend to make them experience worse symptoms than someone who is not unhappy and has no other life stresses. So along the lines of the why part here, models of why people are getting F and D, even though we’re starting to understand it better, they’re still incomplete. Many of these factors that seem to be relevant at least are also relevant for lots of other symptoms too.
We just have to acknowledge that.
And so it’s still unclear why someone with these vulnerabilities that I named before, during, and after should, for example, just become weak down one side or start to develop those movement disorders, tremors out of nowhere. But this picture that I was kind of going through at least shows us some of the factors that can be relevant in the development of the functional symptoms. And so when you look at this, just remember that people might vary tremendously in how many of these factors are relevant. For some people, a lot of those are relevant and for others, maybe one or two of them are. But again, even just thinking back to some of the poll questions I had you answer, let’s remember, and you guys did a good job on these, let’s remember they don’t have to just be stressed, depressed, or anxious to develop FND, and they don’t have to have experienced an adverse childhood event to develop FND either.
So it’s not just those aspects. There’s a lot that can go on in causing the why behind this.
All right, so we’ve taken some time to really understand, hey, what do we see? How does that happen? Why is it happening? Let’s dive into some of the diagnostic points of this. So we’ve talked around the fact that fMRI is really helpful. That type of imaging can be helpful to understand what’s going on from maybe a misfiring in the nervous system perspective. But I also want to name here again that FND is not a diagnosis of exclusion, it is a positive diagnosis, and these are some of our key rule-in signs here. We’ve established that FND is not a diagnosis of exclusion, and the rule-in signs for FND are really specific clinical features on examination that can positively support the diagnosis rather than diagnosing FND just by excluding other conditions. So some of our best established rule-in signs here, if you look under the functional limb weakness part there, it’s Hoover sign and a hip abduction sign.
So in Hoover sign, you can maybe see from that photo what happens in a case of functional leg weakness, say that person has left-sided weakness in their leg that kind of came out of nowhere, is that there’s involuntary activation of the weak leg when testing the opposite leg can suggest that the motor system is intact and the weakness is functional. So in other words, in that first photo, you can see they’re just maybe resisting the left leg and the weakness shows up there, but if they actually resist both legs and push it on both of the legs, the functionally weak leg is actually going to respond to that. And there’s another way to test the Hoover sign in a supine position lying down too.
The hip abduction sign, again, is kind of a similar thing. So if you push on the leg, it might show weakness, but if you push on both legs, all of a sudden it’s strong. Under the functional movement disorders part, I just want to name that tremor entrainment test, so it’s the bottom one there. And in that tremor and treatment test, if a tremor changes or disappears when the person is performing another kind of rhythmic movement, it suggests that it’s more of a functional tremor. So true tremors don’t just disappear. We probably know that you have to introduce some kind of a medication to help with that, but a functional tremor can actually disappear or entrain when you add in some kind of a different, more automatic rhythmic movement. Now, some other general rule-in types of features of FND are that clinical findings can be inconsistent or incompatible with recognized neurological or medical diseases.
So back to those videos that I showed you earlier, like I said, those were really, really hard or really, really different types of signs that we were seeing when that person was walking, so it’s kind of inconsistent.
There’s a distractibility of symptoms that can improve them. So if you distract the person, you might actually see the symptoms go away. And if we look in that functional dissociative seizures column there, features like a prolonged duration or a fluctuating course or a lack of typical risks that can be seen in epileptic seizures would be a general rule in feature for this population. I promise I have five minutes left and then we can get to some questions here for you guys, okay? So treatment, I’m going to move through this a little bit more quickly, but try to give you some resources along the way too. I wouldn’t be here if I didn’t believe in the collaborative interdisciplinary aspect of treatment. It takes a village, not just a single person, and there’s really no slow fixes for F&D, but if we have all of these people, all these different disciplines on the same page, it can be really, really helpful.
There’s an article by Adams listed in some of the references at the end of the presentation. It’s titled, You’ve Made the Diagnosis of Functional Neurological Disorder. Now what? Now what do you do? And it goes through a lot of different conversation points that could actually be helpful to physicians, to other types of providers that are making these diagnoses or caring for these individuals to help give conversation starters or even just frame out what those conversations can look like. And another key aspect of treatment for F&D is helping the person understand their diagnosis at a pretty high level. Steve knows that I’ve talked about this for a long time. He and I have talked about this a long time too, but just how do you demystify something for someone so that they can start to buy into the treatment that’s happening? And it’s not just the individual, it’s friends and family, it’s employers, it’s schools, because the person and those people around them need to understand that what they have is common.
It’s not a weird thing that it’s genuine, they’re not imagining it, that the symptoms are potentially reversible and it’s not their fault that they have the symptoms, but ultimately there are no passive approaches to it. There’s only really active participant types of treatments, and they’re going to have to put in some work in order to get better. Much of this slide just comes back to the fact that we have to understand this well to be able to educate well as providers, especially as case managers, we have to be able to do that. I do want to hit on some high points here with OT and psych and speech therapy and physical therapy before I wrap things up. But I would just say for OT especially, I would be cautious about aids and adaptations. We want to encourage independence and normal movement as much as possible.
And our OTs can be really, really great at the sensory aspects of caring for someone that has F&D as well. We also want to reduce the reliance on caregivers and help influence these individuals with just understanding that their daily activities in and of themselves can be part of their rehabilitation. Psychology can be a difficult thing for people to get into sometimes. It can feel vulnerable, but there’s a lot that can happen in this space to work through, whether it’s just identifying and treating coexisting mental health issues that are going on or addressing unhelpful behaviors, providing a space for education on F&D, problem solving other life stressors that can just cause a person to be overwhelmed and can influence some of the maybe physical rehab that they’re doing as well. But something I would really state here for a psychologist is you need this person to be highly, highly integrated into a collective team and not just doing something off on their own and not communicating with the other rehab professionals because the magic is really going to happen when they’re able to communicate some of their strategies to the other rehab professionals so those can be utilized together in congruence with the patient themselves.
Our speechies, for those folks that maybe develop a swallowing or communication issue, a tic issue, they’re going to be a phenomenal resource to help move back toward normal speech swallowing or facial movements. And then for physical therapy, activity pacing and rated activity programs are going to be incredibly important here. One of the things that can happen on a regular basis is people just try to do too much too fast and they get really overwhelmed and it influences their symptoms. And so a lot of time has to be spent on education, on grading exercises to slowly move someone back toward this sense of normal. So I want to move on to, I have two cases here, but I’m just going to show this one and then I’ll wrap up. Okay? So this is a 24-year-old nurse who presented with an abrupt onset of tremor, full body spasms, gait disorder, and falls.
She had a neuropsychiatric evaluation that revealed longstanding symptoms of anxiety, depression, post-traumatic stress, and affect dysregulation with self-harm. So let me play this. You’ll see baseline, you’ll see some of the changes. There wasn’t really a trigger that was identified before these symptoms started, and you’ll see some of the tremors that she has, you’ll see some of the gait disruption that she has. But what the rehab professionals learned was that dance was an area of healthy pride for her. It was more of a rhythmic, implicit type of movement pattern that she knew really well. And so they tapped into that. They created a motor retraining program that was based on ballet exercises that she knew really, really well. And they also targeted some of the emotional dysregulation that she was experiencing. And so her motor symptoms actually improved gradually. You can see six sessions, right? Those motor symptoms improved gradually in parallel with an observed return of confidence and agency.
And those are two things that can’t be understated. So developing confidence, developing agency were a key part of this. And that just goes to show you that it’s the influence of several different brain networks that are being impacted here too. All right, I need to wrap up. I was really excited about this next case too, but I got long-winded probably on that one slide. So there’s a poll question for you guys. Steve’s going to pop that up here.
Steve Kerschke: Your favorite slide of the day. Here’s the poll question. This is the poll question for your CEUs. While we are doing this, we’ll take some questions and if there’s some extra time, Brad, you can do that other case study, so I’ll go ahead and launch the poll question. We do have a question about what causes FND. I’ll take that or I’ll let Brad take that. And then the second part is it common in work comp? Honestly, you all on this in the audience are probably better to answer this one than we are. We certainly see individuals on our telerehab side of things. This is typically where these individuals land because we often see it associated with some sort of mild TBI. If you go back to the slide where Brad mentioned what happens before, during, and after, we’re usually seeing it where there’s been some sort of incident and then it’s kind of associated with that, whether it be aspects of FND where it’s maybe not formally diagnosed or a formal diagnosis.
We’ve kind of seen both. So I’m hesitant to say that we see FND all the time because we don’t often get it where it’s actually diagnosed. So Brad, anything to add on?
Brad Dexter: Well, I would say, so what you’re probably seeing are those functional neurological symptoms, right? And in that case, you maybe recognize that as a team and you start to treat it in some of the ways that we just identified, and you can actually see some of those changes over time. So to the what causes FND, I think you hit on that too, Steve, in the before, during, and after. So what are some of those predisposing factors? What are some of the factors that during an event at the time of event can cause that? So I can think of a case in my mind where an individual had originally had an injury at work, but that injury actually unlocked a variety of other things that were predisposing factors in her life that I think started to reveal more functional neurological symptoms that we began to treat as a team to help influence some of those symptoms as well.
Now, if you get that diagnosis, does it actually help? It can. It can help because it starts to target and train and focus the area of rehab and everyone’s kind of on the same page with that. But again, back to the beginning of the presentation, stigma and past practice around something like this can make it hard for people to get the right kind of care that they need as well.
Steve Kerschke: So Brad, there’s a few other questions. I’ll take one real quick one. Elizabeth, your question on can you share the presentation? Yes, we will have this available on our YouTube probably by the end of the day. Usually it takes a little bit to get it chopped up and uploaded, but to Brad’s point around education, I think this is a terrific opportunity to educate. And then I would encourage you to look at some of the resources that Brad has included. There’s some really great resources that I think could be helpful with the injured worker and the treating physicians. As we’re getting down, we are already over, but Brad, I think you have a hard stop today, Brad, too, don’t you?
Brad Dexter: I can stay on to answer a few
Steve Kerschke: Questions. I don’t know if you want to look through some of the questions that are up and hit some of the high points. You can see those, correct?
Brad Dexter: I don’t know that I can see them.
Steve Kerschke: Okay. So there’s a question on eye movement and seesaw nystagmus. Do you have anything to comment related to that?
Brad Dexter: Has the person seen a vestibular therapist at all?
Steve Kerschke: Good question. I mean, my take on the eye movement is typically we’re doing a pretty full vision assessment. Our OTs typically handle that, but our PTs are pretty involved and we’re trying to determine the presence of vision issues, whether they’re central or peripheral, as well as how that leads into any sort of vestibular or balance issues. So Elizabeth, I’m not exactly sure the context of that question, but just trying to connect a few dots. That would be the direction that we would look at it. Brad, I don’t know if you have anything to add to that.
Brad Dexter: Yeah, so there are specific patterns that you can see in the eyes with a vestibular system, if it’s a peripheral vestibular issue, there are different rotational aspects or even nystagmus types of movements that are related to different semicircular canals in the vestibular system. If it’s more central, you can see issues of just either vertical or even horizontal nystagmus. There are some strange patterns. I didn’t show any videos of this, but you could probably look some of them up on YouTube even. There are some just strange patterns in the eyes that can develop in the same way that I said, “Hey, that walking motion, it just doesn’t fit in the right bucket for me as a movement specialist.” I know enough to be dangerous as a vestibular therapist, but I’m not as good as many other people that are out there. And so I may not have the right bucket for what you’re trying to describe, but a seesaw type of movement doesn’t really fit what I have seen or what I know of vestibular types of issues either.
So that can be one of those functional signs or symptoms that develop for an individual.
Steve Kerschke: And then thank you. Last one, curious on the relation of IBS and the predisposing factor. Any comment on what makes IBS a predisposing factor for this particular diagnosis?
Brad Dexter: So right now,
How we would understand fibromyalgia or polymyalgia or chronic fatigue syndrome, IBS, many of those are autoimmune oriented types of conditions. And it’s more that they’ve been able to link some of those conditions to patients that also develop FND or patients that have an FND diagnosis that then consequently have some of those same comorbidities. So is it causal? We don’t really know that at this time, but in the same way I showed, I think it was autism and Ehler-Danlos syndrome and chronic pain on that slide and just the associations across the board there, some of those same things are shown for chronic fatigue syndrome, some of those autoimmune types of issues too. So I don’t know the answer to that. It’s just that there’s some association right now.
Steve Kerschke: Great. Well, Brad, thank you so much for the information. If you can’t see some of these comments, already some rave reviews, one of them being from Dr. Snell, so he’s already volunteered for the network’s presentation, so we’ll get to go. We’ll get working. I’m sure he already has it pretty much. Yeah,
Brad Dexter: I’m showing up for that. Working on it right now.
Steve Kerschke: He just did it off the top of his head probably. But at any rate, really great information today. Great to see you, and thanks to our listeners for joining, and we’ll see you all next month.
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