Functional Neurological Disorder: From Diagnosis of Exclusion to Rule-In Neurology

Introduction

Functional neurological disorder has moved from the margins of neurology toward a more precise and clinically useful framework. For decades, clinicians were often taught to consider conversion disorder only after structural, epileptic, vascular, inflammatory, metabolic, or toxic causes had been excluded. That approach contributed to delayed diagnosis, repeated testing, unnecessary treatment exposure, and explanations that could imply disbelief or dismissal.

The current approach is different. FND involves genuinely experienced neurologic symptoms associated with altered nervous system functioning. The symptoms are not voluntarily produced, and the diagnosis is not established merely by normal imaging or laboratory results. DSM-5-TR uses the term functional neurological symptom disorder, with conversion disorder retained parenthetically, and emphasizes clinical evidence that the symptom is incompatible with recognized neurologic or medical conditions rather than requiring a preceding psychological stressor. (American Psychiatric Association, 2022; Espay et al., 2018).

The diagnostic task is to identify a recognizable pattern of altered motor, sensory, cognitive, speech, gait, or seizure-like function supported by positive findings. These findings commonly involve internal inconsistency within the same task, variability across tasks or time, or incongruence with recognized neurologic disease patterns. Psychological stressors and psychiatric disorders may be relevant for some patients, but neither is required to make the diagnosis. (Hallett et al., 2022).

The phrase rule-in neurology captures this change in practice. FND may be supported by findings such as Hoover sign in functional limb weakness, tremor distractibility or entrainment, characteristic functional gait patterns, or semiologic and video-electroencephalographic findings in functional seizures. Rule-in diagnosis does not eliminate the need for diagnostic discipline. FND can coexist with epilepsy, migraine, stroke, multiple sclerosis, Parkinson disease, neuropathy, autoimmune disease, vestibular disorders, chronic pain, fatigue syndromes, and psychiatric conditions. A confident diagnosis therefore requires positive evidence for FND together with appropriate consideration of competing and coexisting diagnoses.

Why FND Matters Now

FND is sufficiently common that most clinicians who evaluate neurologic symptoms will encounter it. A 2025 systematic review estimated adult FND incidence at approximately 10 to 22 per 100,000 person-years and minimum prevalence at approximately 80 to 140 per 100,000. The investigators emphasized substantial heterogeneity among studies, methodological limitations, and probable underestimation. (Finkelstein et al., 2025).

Patients may present to emergency departments with stroke-like weakness, to epilepsy clinics with seizure-like episodes, to movement-disorders clinics with tremor or gait disturbance, or to general medical services with dizziness, dysphagia, fatigue, pain, cognitive symptoms, syncope-like events, or multisystem complaints. Neurologists remain central to diagnosis, but FND is not confined to neurology clinics.

The condition can be associated with substantial disability, impaired quality of life, fragmented care, repeated investigations, unnecessary medication exposure, occupational disruption, and stigma. A delayed or poorly communicated diagnosis may reinforce concern that clinicians have either missed another disorder or dismissed the symptoms. In contrast, an explanation that links the diagnosis to specific positive findings may improve understanding, treatment engagement, and transition from repeated exclusionary testing toward rehabilitation and comorbidity management. (Bennett et al., 2021; Dworetzky & Baslet, 2025).

A Rule-In Diagnosis, Not a Normal-Test Diagnosis

FND should not be diagnosed simply because magnetic resonance imaging, computed tomography, electroencephalography, electromyography, laboratory studies, or cardiac testing are unrevealing. Normal tests may contribute to the diagnostic context, but they do not establish FND. The stronger basis is a compatible clinical history together with positive signs.

In functional limb weakness, Hoover sign identifies a discrepancy between voluntary hip extension and hip extension generated during contralateral hip flexion against resistance. The finding supports functional weakness when interpreted within the full neurologic examination, but it should not be used in isolation or as evidence that every component of weakness is functional. (McWhirter et al., 2011).

Functional tremor may change frequency, diminish, pause, or entrain while the patient performs a rhythmic movement with another limb. Functional gait disorders may show marked impairment during standard walking but improved or differently expressed movement during distraction, altered tasks, or more automatic movement. Functional seizures may resemble epileptic seizures or syncope but show characteristic semiologic patterns. When feasible and clinically necessary, video-electroencephalographic capture of typical episodes can help distinguish functional seizures from epileptic seizures and identify mixed presentations. (Espay et al., 2018; Tolchin et al., 2026).

The clinical message is not that the patient is inconsistent in a moral or intentional sense. Positive signs are consistent with altered control across voluntary, attention-dependent, and more automatic processes. Demonstrating an appropriate sign may help show that capacity for a movement remains accessible under specific conditions, thereby providing a rationale for rehabilitation. Positive signs should be explained respectfully and should not be presented as definitive proof of a single pathophysiologic mechanism.

Table 1. Rule-In Features and Diagnostic Cautions

Presentation	Supportive features and diagnostic cautions
Functional limb weakness	Hoover sign, hip abductor sign, or preserved movement during automatic tasks may support the diagnosis. Evaluate for stroke, myelopathy, neuropathy, myopathy, multiple sclerosis, and structural lesions when clinically indicated.
Functional tremor	Variability, distractibility, and entrainment are supportive. Consider essential tremor, Parkinson disease, medication effects, hyperthyroidism, and other movement disorders.
Functional gait disorder	Variability, incongruent patterns, and improvement with distraction or task modification may be present. Assess falls and consider vestibular, cerebellar, parkinsonian, myelopathic, orthopedic, and sensory causes.
Functional seizures	Typical semiology, witness descriptions, smartphone video, and video-electroencephalography when feasible may support diagnosis. Evaluate for epilepsy, syncope, sleep-related events, metabolic disturbances, movement disorders, and mixed functional and epileptic seizures.
Functional speech or swallowing symptoms	Variable or incongruent voice, speech, cough, or swallowing patterns may be present. Evaluate for structural, neuromuscular, otolaryngologic, respiratory, and aspiration-related conditions when indicated.
Functional cognitive disorder	Look for positive internal inconsistency among reported symptoms, observed function, everyday abilities, and performance across tasks or contexts. Consider neurodegenerative disease, sleep disorders, medication effects, mood disorders, pain, and other contributors.

Functional cognitive disorder deserves particular caution. The diagnosis should not rest merely on severe subjective symptoms or a discrepancy between complaints and a single cognitive screening score. The more informative feature is internal inconsistency, such as a mismatch among reported disability, observed function, everyday abilities, and cognitive performance across contexts, provided that another neurologic, psychiatric, medical, or medication-related condition does not better explain the presentation. (Ball et al., 2020; Hallett et al., 2022).

Diagnostic Safety: Rule-In Diagnosis Still Requires Clinical Discipline

A rule-in diagnosis should be specific, documented, and revisited if the clinical picture changes. This is especially important in emergency and inpatient care. A patient with established FND can still develop stroke, epileptic seizure, pulmonary embolism, arrhythmia, spinal cord disease, autoimmune encephalitis, infection, medication toxicity, or another acute disorder.

Clinicians should document the positive findings supporting FND, the differential diagnosis considered, and the reason additional testing is or is not required. The relevant question is not whether every possible test has been performed. It is whether the history and examination provide positive evidence for FND and whether any feature warrants additional evaluation.

New focal deficits, progressive objective neurologic signs, systemic illness, unexplained loss of consciousness, significant trauma, cancer history, immunosuppression, new seizure-like events in a high-risk patient, or examination findings outside the established functional pattern should prompt reassessment. NICE guidance similarly advises that adults with diagnosed FND may be supported in non-specialist care for recognized symptoms but should undergo prompt neurologic assessment when new signs or symptoms arise.

FND and another neurologic disorder may coexist. Functional seizures may occur in a person with epilepsy. Functional tremor may coexist with Parkinson disease. Functional weakness may occur following stroke, injury, migraine, or acute medical illness. The diagnostic task is therefore not always either-or. Clinicians may need to identify which aspects of impairment are functional, which reflect another disorder, and how treatment should be coordinated.

Table 2. Practical Diagnostic Workflow

Step	Action and purpose
1. Identify the phenotype	Define whether the predominant presentation is weakness, tremor, gait dysfunction, seizure-like events, speech, swallowing, sensory, or cognitive symptoms. This determines which positive signs are most relevant.
2. Seek positive findings	Identify internally inconsistent, variable, distractible, entrainable, task-specific, or semiologically characteristic findings.
3. Screen for diagnostic warnings	Evaluate progressive deficits, objective signs, systemic illness, trauma, altered consciousness, or other high-risk features that require additional assessment.
4. Assess comorbidity	Consider epilepsy, migraine, pain, sleep disorders, psychiatric conditions, vestibular disease, autoimmune disease, medication effects, and other neurologic disorders.
5. Explain the diagnosis	Name FND, validate the symptoms, explain the positive findings, and avoid implying that symptoms are voluntary or fabricated.
6. Match treatment to impairment	Select physiotherapy, occupational therapy, speech and language therapy, psychological treatment, psychiatric care, primary care follow-up, or other specialty care according to phenotype and comorbidity.

Communication Is Part of Treatment

The diagnostic conversation is not a courtesy after the real workup. It is a clinical intervention. Statements limited to normal test results or stress are usually inadequate and may reinforce misunderstanding.

An effective explanation generally includes four elements. First, name the diagnosis clearly. Second, validate that the symptoms are real and potentially treatable. Third, explain that the examination indicates altered functioning rather than symptoms being consciously produced. Fourth, connect the explanation to the positive findings observed during examination.

For a patient with functional weakness, a clinician might explain that the examination suggests the symptom pattern is not fully accounted for by damage to a nerve or muscle and that the nervous system is having difficulty controlling the movement normally. The clinician may then demonstrate that the specific movement can be produced under another condition. This explanation should be individualized and should not imply that structural disease has been excluded when coexisting disease remains possible.

Language should avoid suggesting that the patient is faking, exaggerating, seeking attention, or simply anxious. Psychological stressors, trauma, mood disorders, pain, sleep disturbance, autonomic arousal, and illness-related beliefs may contribute in some patients, but they are not required for diagnosis. Conversely, avoiding discussion of psychiatric comorbidity may deprive patients of effective treatment for depression, anxiety disorders, post-traumatic stress disorder, substance use disorders, panic, or other clinically relevant conditions. (Espay et al., 2018; Lehn et al., 2025).

Functional Seizures: A Safety-Critical Phenotype

Functional seizures, also called dissociative seizures and historically described as psychogenic nonepileptic seizures, require particular attention because misdiagnosis can lead to prolonged antiseizure-medication exposure, repeated emergency benzodiazepine administration, intubation, inappropriate restrictions, and delayed access to appropriate treatment.

The differential includes epileptic seizures, syncope, sleep-related events, movement disorders, panic attacks, metabolic events, and mixed functional and epileptic seizure presentations. Historical and semiologic information should be obtained from the patient and witnesses whenever possible. Smartphone videos may provide clinically useful information. Video-electroencephalography of typical episodes may be obtained when diagnostic ambiguity remains or co-occurring epilepsy is possible. The 2026 AAN guideline specifically recommends assessment for co-occurring epilepsy and psychiatric disorders and emphasizes the use of history, semiology, witness information, smartphone recordings, and video-electroencephalography where feasible. (Tolchin et al., 2026).

Safety planning should address injury risk, loss of awareness, bathing and water safety, heights, machinery, occupational hazards, caregiver response, and emergency plans. Driving recommendations should be individualized according to episode characteristics and applicable jurisdictional requirements. Clinicians should avoid assuming that every prolonged or convulsive-appearing episode is functional when epileptic status, toxic-metabolic disease, or another acute neurologic emergency remains clinically possible.

Antiseizure medications do not directly treat functional seizures. The AAN guideline recommends against prescribing antiseizure medications to patients with functional seizures who do not have co-occurring epilepsy or another valid indication. For patients already taking an antiseizure medication without another indication, the guideline recommends tapering the medication to reduce unnecessary adverse effects. Tapering should be clinically supervised and individualized when epilepsy remains possible, the medication treats another disorder, or abrupt discontinuation could create withdrawal or rebound risk. (Tolchin et al., 2026).

Benzodiazepines should not be prescribed as acute abortive treatment for established functional seizures in patients without co-occurring epilepsy, an anxiety disorder, or another independent indication. Emergency treatment remains appropriate when epileptic status or another medical emergency has not been adequately excluded. The goal is to prevent reflexive administration after the event has been reasonably identified as functional, not to delay treatment of an undifferentiated emergency.

The AAN systematic review found that psychological interventions are possibly effective for increasing the likelihood of freedom from functional seizures, decreasing functional-seizure frequency, decreasing anxiety, and improving health-related quality of life and psychosocial functioning. These findings support referral of interested and clinically appropriate patients while preserving uncertainty about which intervention is most effective for a particular individual.

Treatment: Phenotype-Directed and Multidisciplinary

There is no single treatment for all forms of FND. Care should be directed by phenotype, functional impairment, comorbidities, access, patient goals, and readiness to engage in a particular intervention. A clear diagnostic explanation and continuity of care provide the foundation.

Functional Motor Symptoms

FND-informed physiotherapy focuses on retraining movement rather than strengthening a presumed damaged pathway. Strategies may include redirected attention, elicitation of more automatic movement, graded functional activity, modification of maladaptive movement patterns, education, self-management, and relapse planning. Consensus recommendations support a positive, nonjudgmental framework that integrates education and movement retraining. (Nielsen et al., 2015).

Evidence should not be overstated. In the phase 3 Physio4FMD trial, specialist physiotherapy was not superior to community neurological physiotherapy for the primary self-reported physical-function outcome at 12 months. Several secondary outcomes favored specialist physiotherapy, and both approaches appeared safe and valued by selected patients. The findings support physiotherapy as a potentially useful intervention while showing that specialist treatment does not improve every outcome or benefit every patient. (Nielsen et al., 2024).

Occupational Therapy

Occupational therapy can address activities of daily living, functional independence, sensory strategies, fatigue management, environmental adaptations, work or school participation, and return-to-role planning. Consensus recommendations emphasize education, rehabilitation within functional activities, and self-management strategies. The recommendations are expert consensus and a foundation for further research rather than proof that every intervention is effective for every patient. (Nicholson et al., 2020).

Speech and Language Therapy

Speech and language therapy may be appropriate for functional voice, speech, swallowing, cough, or related symptoms after clinically appropriate evaluation. Structural disease, neuromuscular disease, respiratory pathology, otolaryngologic disorders, and aspiration risk should be assessed when indicated. Consensus recommendations support education, symptom-focused retraining, reduction of excessive self-directed attention, and modification of abnormal movement patterns within a supportive therapeutic environment. (Baker et al., 2021).

Psychological Treatment

Psychological interventions may benefit selected patients with functional seizures and may be useful in other FND phenotypes when matched to the clinical formulation, comorbidities, and patient goals. Cognitive behavioral therapy and functional seizure-specific interventions have the most developed evidence base, while psychodynamic, mindfulness-based, motivational, and other approaches have more variable or limited support.

Psychological therapy should not be framed as evidence that FND is purely psychiatric. Depending on the patient and intervention, treatment may address arousal, avoidance, coping, panic, dissociation, mood symptoms, trauma-related symptoms, illness-related beliefs, attention, or behavioral responses. These treatment targets should not be assumed to explain symptom generation uniformly across all patients.

In the CODES randomized trial, cognitive behavioral therapy plus standardized medical care did not significantly reduce monthly dissociative-seizure frequency at 12 months compared with standardized medical care alone. However, several secondary outcomes favored cognitive behavioral therapy, including seizure bothersomeness, the longest seizure-free period, health-related quality of life, psychosocial functioning, psychological distress, and patient- and clinician-rated improvement. The trial therefore supports a nuanced interpretation rather than a blanket claim that cognitive behavioral therapy reliably eliminates functional seizures. (Goldstein et al., 2020).

Medication

No disease-specific pharmacologic treatment is established for FND itself. Medication may be appropriate for independently diagnosed depression, anxiety disorders, post-traumatic stress disorder, migraine, neuropathic pain, insomnia, epilepsy, or other comorbid conditions. Such treatment should not be described as disease-modifying therapy for FND.

Medication risks should be described by drug and indication rather than attributed uniformly across broad classes. Opioids and benzodiazepines may contribute to sedation, cognitive impairment, falls, respiratory depression, misuse, and physical dependence, depending on the drug, dose, duration, co-medications, and patient characteristics. Unnecessary antiseizure medications add adverse-effect burden without directly treating functional seizures.

In 2020, the FDA required boxed-warning updates for all benzodiazepines to address abuse, misuse, addiction, physical dependence, and withdrawal reactions. Abrupt discontinuation or excessively rapid dose reduction may produce serious withdrawal reactions, including potentially life-threatening seizures. The FDA advises gradual, individualized tapering with appropriate monitoring and particular caution when benzodiazepines are combined with opioids or other central nervous system depressants.

Table 3. Treatment Components and Evidence Limits

Clinical target	Practical approach and evidence or safety limits
Functional motor symptoms	FND-informed physiotherapy, movement retraining, redirected attention, graded functional activity, and relapse planning. Trial evidence is evolving, and not every patient benefits.
Functional seizures	Clear diagnosis, education, individualized safety planning, continuity of care, and referral for appropriate psychological treatment. Confirm whether epilepsy or another medication indication is present before changing therapy.
Functional speech or swallowing symptoms	Speech and language therapy following appropriate assessment. Evaluate aspiration risk and structural, neuromuscular, respiratory, or otolaryngologic disease when indicated.
Functional disability	Occupational therapy, graded return to activity, environmental modification, and return-to-work or school planning. Plans should account for pain, fatigue, cognition, safety, and social context.
Psychiatric comorbidity	Evidence-based psychotherapy, psychiatric care, and medication when independently indicated. Do not imply that symptoms are voluntary or exclusively psychological.
Pain, fatigue, and sleep disturbance	Multimodal management and treatment of identifiable comorbidities. Avoid escalation of opioids or sedatives without a clearly supported indication and monitoring plan.
Relapse prevention	Written plans, recognition of early warning signs, reinforcement of self-management strategies, and continuity of care. Recurrence does not necessarily imply a missed structural diagnosis, but new or changed findings require reassessment.

Implications for Internal Medicine Subspecialists

FND is not solely a neurology issue. Internal medicine specialists frequently encounter FND symptoms that overlap with conditions evaluated within their own fields. Cardiologists may assess syncope-like episodes, palpitations, or autonomic symptoms. Gastroenterologists may encounter functional dysphagia, nausea, pain, or disorders of gut-brain interaction. Rheumatologists may evaluate fatigue, pain, weakness, and suspected inflammatory disease. Endocrinologists may assess tremor, episodic symptoms, fatigue, or unexplained weakness. Pulmonologists and otolaryngologists may encounter functional cough, dyspnea, voice symptoms, or swallowing complaints. Hospitalists and emergency physicians may evaluate acute presentations resembling stroke, seizure, or neuromuscular disease.

The subspecialist should avoid two opposing errors. The first is continuing indefinite investigation after a well-supported rule-in diagnosis without a new clinical indication. The second is attributing every new symptom to FND without reconsidering neurologic or medical disease. Communication among clinicians should specify which findings support FND, which uncertainties remain, what comorbidities are present, and what changes should prompt reassessment.

Patient Selection and Referral

Specialist referral is appropriate when the diagnosis remains uncertain, neurologic findings are evolving, functional seizures require further characterization, coexisting neurologic disease is suspected, or disability is severe. Referral to FND-informed rehabilitation may be appropriate for persistent motor, gait, balance, occupational, speech, voice, cough, or swallowing impairment.

Psychological referral is particularly relevant for functional seizures and when anxiety, depression, panic, trauma-related symptoms, dissociation, avoidance, maladaptive coping, or adjustment difficulties are clinically important. Referral should be explained as part of integrated neurologic care rather than as evidence that the symptoms are imaginary.

Not every patient requires an intensive multidisciplinary program. Some improve after a clear diagnosis, education, self-management guidance, and follow-up. Others require coordinated rehabilitation and psychological care over months. Access remains a major limitation. NICE and contemporary treatment recommendations recognize that appropriately informed primary care, general neurology, rehabilitation, and mental health services may need to coordinate care when specialized FND programs are unavailable. (NICE, 2021; Lehn et al., 2025).

Limitations of the Evidence

The evidence base for FND is improving but remains uneven. Studies frequently involve small samples, heterogeneous populations, varying diagnostic definitions, different treatment intensities, and inconsistent outcome measures. Results from one phenotype should not be generalized automatically to another. Findings from functional motor disorder trials, for example, do not establish treatment efficacy for functional seizures, functional cognitive disorder, or functional speech symptoms.

A 2025 systematic review and meta-analysis found that longer symptom duration was associated with modestly smaller improvements in motor symptoms and physical health-related quality of life, although meaningful improvement remained possible in chronic FND. Interpretation remains limited by heterogeneity in interventions, phenotypes, study designs, and outcome measures. The findings support timely diagnosis and treatment without implying that chronic symptoms are untreatable. (Thomas et al., 2025).

The Physio4FMD and CODES trials illustrate the importance of distinguishing primary outcomes from secondary findings. Specialist physiotherapy did not improve the primary 12-month physical-function outcome compared with community neurological physiotherapy, despite benefits in several secondary outcomes. Cognitive behavioral therapy in CODES did not significantly reduce the primary monthly seizure-frequency outcome at 12 months, despite improvements in several secondary clinical and psychosocial outcomes. These findings support cautious, phenotype-specific treatment recommendations.

Biomarker research, including functional imaging and neurophysiology, has identified group-level associations and candidate mechanisms. These findings do not establish a single causal pathway and are not sufficiently validated to replace clinical diagnosis. Predictive-processing, attention, agency, arousal, and network-based models remain clinically useful frameworks, but they should be presented as evolving mechanistic models rather than proven explanations for every patient. (Hallett et al., 2022).

Future Directions

Priorities include improved diagnostic education, standardized outcome measures, broader access to informed rehabilitation, and trials that reflect the heterogeneity of real-world FND. Research should clarify which patients benefit most from particular forms of physiotherapy, psychological treatment, multidisciplinary care, digital interventions, group programs, and stepped-care models.

Additional work is needed in pediatric and geriatric populations, culturally and linguistically diverse communities, patients with coexisting neurologic disease, emergency and inpatient settings, and health systems without dedicated FND services. Implementation strategies may include multidisciplinary education, integration of FND care into general neurology and primary care, and appropriate use of telemedicine. These approaches require evaluation rather than assumption of benefit.

Artificial intelligence, wearable devices, and machine-learning systems may eventually assist with seizure classification, tremor characterization, rehabilitation monitoring, or activity measurement. These tools should remain investigational until validated in clinically representative populations with meaningful outcomes, transparent limitations, and safeguards against misclassification.

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