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Review
Decade of progress in motor functional neurological disorder: continuing the momentum
  1. David L Perez1,
  2. Mark J Edwards2,
  3. Glenn Nielsen2,
  4. Kasia Kozlowska3,
  5. Mark Hallett4,
  6. W Curt LaFrance, Jr5
  1. 1Neurology and Psychiatry, Massachusetts General Hospital, Boston, Massachusetts, USA
  2. 2Neuroscience Research Centre, St George's University of London, London, UK
  3. 3Westmead Institute of Medical Research, The Children's Hospital at Westmead, Sydney Medical School, Westmead, New South Wales, Australia
  4. 4NIH, NINDS, Bethesda, Maryland, USA
  5. 5Psychiatry and Neurology, Rhode Island Hospital, Providence, Rhode Island, USA
  1. Correspondence to Dr W Curt LaFrance, Jr, Psychiatry and Neurology, Rhode Island Hospital, Providence, RI 2903, USA; william_lafrance_jr{at}brown.edu

Abstract

Functional neurological disorder (FND) is a prevalent, disabling and costly condition at the neurology–psychiatry intersection. After being marginalised in the late 20th century, there has been renewed interest in this field. In this article, we review advances that have occurred over the past decade (2011–2020) across diagnosis, mechanisms, aetiologies, treatments and stigma in patients with motor FND (mFND, that is, functional movement disorder and functional limb weakness). In each content area, we also discuss the implications of recent advances and suggest future directions that will help continue the momentum of the past decade. In diagnosis, a major advance has been the emphasis on rule-in physical signs that are specific for hyperkinetic and hypokinetic functional motor symptoms. Mechanistically, greater importance has been given to determining ‘how’ functional neurological symptoms develop, highlighting roles for misdirected attention, expectation and self-agency, as well as abnormal influences of emotion/threat processing brain areas on motor control circuits. Aetiologically, while roles for adverse life experiences remain of interest in mFND, there is recognition of other aetiologic contributors, and efforts are needed to investigate links between aetiological factors and mechanisms. This decade has seen the first randomised controlled trials for physiotherapy, multidisciplinary rehabilitation and psychotherapy performed in the field, with consensus recommendations for physiotherapy, occupational therapy and outcome measures also published. Across patients, clinicians, healthcare systems and society, stigma remains a major concern. While challenges persist, a patient-centred integrated clinical neuroscience approach is primed to carry forward the momentum of the past decade into the future.

  • functional neurological disorder
  • conversion disorder
  • neuropsychiatry

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Footnotes

  • Contributors All authors contributed to the planning, literature review, drafting and editing of the manuscript.

  • Funding DLP was funded by the National Institute of Mental Health (NIMH) Grant K23MH111983-04 and the Sidney R. Baer Jr. Foundation. MH was supported by the National Institute of Neurological Disorders and Stroke (NINDS) Intramural Programme. GN receives research funding from the National Institute for Health Research.

  • Competing interests DLP has received honoraria for continuing medical education lectures in functional neurological disorder and is on the editorial board of Epilepsy & Behavior. MH is an inventor of patents held by National Institutes of Health (NIH) for an immunotoxin for the treatment of focal movement disorders and the H-coil for magnetic stimulation; in relation to the latter, he has received license fee payments from the NIH (from Brainsway). He is on the medical advisory boards of Cala Health and Brainsway. He has research grants from Allergan for studies of methods to inject botulinum toxins, Medtronic, Inc. for a study of deep brain stimulation (DBS) for dystonia and Cala Health for studies of a device to suppress tremor. WCL receives editor’s royalties from the publication of Gates and Rowan’s Nonepileptic Seizures, 3rd edition (Cambridge University Press, 2010) and 4th edition (2018) and author’s royalties for Taking Control of Your Seizures: Workbook and Therapist Guide (Oxford University Press, 2015) and receives research support from the Department of Defense (DoD W81XWH-17-0169).

  • Patient consent for publication Not required.

  • Provenance and peer review Commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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