A list of physiotherapy, CBT, comorbidity treatment, and follow-up can sound complete in an FND short-answer response. But if the stem gives only a diagnosis, motivation, and ongoing symptoms, it may not tell you which symptoms are present or how they limit daily life. The exam task is to match each intervention to a clear target—and mark what depends on missing information.
Build the plan from symptoms and function
Start with the symptom pattern, baseline, and functional impact. Is the main difficulty weakness or gait, another movement problem, speech or communication, functional seizures, or a mixture? What could the person do before symptoms began, what can they do now, and which activities matter most to them? Ask about treatment history, access to rehabilitation, relevant medications, and co-occurring symptoms when the case allows.
A brief stem may not supply these details. Don’t invent motor symptoms just because physiotherapy appears in a familiar FND answer, or assume that depression, anxiety, or trauma is present. Use conditional wording where treatment depends on the phenotype.
| Target in the case | Management to consider | Boundary to state |
|---|---|---|
| Functional motor symptoms | Refer for physiotherapy informed by FND, with movement retraining, attention redirection, and goals linked to function. Consider occupational therapy when daily activities are affected. | This is not a routine referral for every FND presentation; tailor rehabilitation to symptoms and abilities. |
| Functional speech or communication symptoms | Consider speech-language therapy when those symptoms are present; use occupational therapy when the main difficulty is participation in daily tasks. | Don’t select a therapy for a symptom the stem has not described. |
| Functional seizures | Explain the diagnosis, use shared treatment planning, and consider referral for functional-seizure-specific psychological treatment when appropriate and desired. Assess for co-occurring epilepsy and psychiatric disorders. | Don’t assume all seizure-like events are functional or that epilepsy cannot coexist. Don’t prescribe benzodiazepines or antiseizure medication for functional seizures without another indication. |
| Distress, avoidance, symptom-related beliefs, or a co-occurring psychiatric disorder | Offer FND-informed psychological therapy, such as CBT, when it fits the person’s needs and goals. Assess for depression, anxiety, or trauma-related symptoms and treat them when supported by the history. | Psychological treatment does not mean symptoms are imagined or require a presumed traumatic cause. |
When the diagnosis has just been explained, build on that conversation: check what the patient understood, acknowledge that symptoms are genuine, invite questions, and agree on a practical goal. A goal might concern mobility, communication, or a valued daily activity; it should reflect the person’s own priorities rather than promise complete symptom resolution.
Explain the purpose of treatment without psychologizing
CBT is not a test of whether symptoms are “really psychological.” Depending on the presentation, therapy may address symptom-focused attention, fear or avoidance, coping, or beliefs that make it harder to engage in rehabilitation. A co-occurring anxiety or depressive disorder is a separate assessment and treatment target—not a prerequisite for an FND diagnosis.
Likewise, a physiotherapy referral should name its purpose. For motor symptoms, FND-informed rehabilitation can work on regaining more automatic movement and practicing functional activity; it is not simply a generic strengthening plan. If the stem does not describe motor symptoms, say that physiotherapy is indicated if they are present, rather than treating it as a universal step.
For functional seizures, psychological treatment is a symptom-specific option, not evidence that the seizures are consciously produced or necessarily caused by trauma. The care plan should also account for whether epilepsy or another condition is present.
Keep follow-up active, but avoid false closure
A diagnosis of FND should not mean either endless repeat investigation or a promise never to investigate again. Coordinate care, agree who will follow progress, and review symptoms, function, and whether the plan is workable. Avoid routine duplication without a new clinical indication; reassess a changed presentation or new findings on their merits.
Review medications in the same individualized way. Don’t start benzodiazepines or opioids solely as treatment for FND symptoms. For functional seizures, don’t prescribe benzodiazepines or antiseizure medication without co-occurring epilepsy or another indication. If a medication is already prescribed, check its indication, benefits, and risks; a medication used for another condition needs its own plan, and any change or taper should be coordinated rather than assumed to be abrupt.
The evidence supports a measured answer, not a guaranteed cure. In the large pragmatic Physio4FMD trial, specialist physiotherapy did not significantly outperform treatment as usual—which included local neurological physiotherapy—on the primary physical-function outcome at 12 months, although some secondary self-reported outcomes favored the specialist group. A separate small, single-center randomized trial enrolled 40 adults to combined physiotherapy and CBT or supportive psychotherapy; it found a significant between-group improvement in the physical component of quality of life at five months, but no significant between-group difference in the mental component. These findings support offering appropriate care while avoiding claims that one protocol works for everyone.
A 12-minute retrieval exercise for this SAQ
Close your notes. Minutes 1–3: write what the stem establishes and what it leaves unknown: symptom type, baseline, functional impact, comorbidity, and current medication. This prevents the common reasoning error of filling gaps with a memorized case.
Minutes 4–7: draft a short management answer from memory. For every intervention, add its target: for example, “FND-informed physiotherapy if motor symptoms are present,” or “assess and treat depression or anxiety if supported by the history.” Include a patient-defined functional goal and planned follow-up.
Minutes 8–10: label each statement supported by the stem, conditional, or assumption. Delete unsupported assumptions, especially a presumed psychological cause or an unstated motor presentation. Minutes 11–12: check your notes and revise one vague referral so it names both the intended target and the follow-up plan.
This is retrieval practice because you produce the answer before looking at the source. The audit then targets the reasoning errors most likely in this question: turning a treatment menu into a universal protocol, psychologizing the diagnosis, or treating “avoid unnecessary tests” as “never reassess.”
Practical takeaways
- Match rehabilitation to the symptom pattern and functional need; don’t assume every FND presentation calls for the same referral.
- For functional seizures, consider appropriate psychological treatment and continuity of care, while checking for co-occurring epilepsy or another indication for medication.
- Offer psychological therapy in a way that supports symptom-focused goals without implying that symptoms are imagined or trauma-caused.
- Assess and treat co-occurring disorders when present; don’t infer them from FND alone.
- Coordinate follow-up, review medication indications, and reassess new or changed features rather than repeating tests automatically or ruling them out forever.
