The core to treatment is to understand that the biopsychology of FND has many layers. On the most surface layer, one part of the brain is doing something without the permission of the other part of the brain. We think that most activity is intentional (volitional) but in reality the majority of our thoughts, movements, and behaviors are going on without our awareness. If you had to consider every muscle movement during the course of a short walk, it would be awkward and painful. Surely, we do control a lot, and we can train those automated systems with effort. This is like an athlete, honing their skill. On the most surface layer of FND, there is loss of ability to intervene on those automated activities. 

Layer two could be considered a system of triggered responses. It's more complex than Pavlov’s dogs, but most of us have a pretty stable set of habits that are triggered. See someone you like and it triggers a smile. See a piece of chocolate and it triggers you to reach out and grab it. Triggers also exist for panic attacks, fainting spells, and even seizures. These can be simple connections in the brain or they can involve many different layers including changes in hormone production or even changes to the way our cells use our DNA. Finding what triggers an FND event can be complex and therapeutic techniques used in different disciplines can be utilized. Chain analysis is a common process in looking for the earliest trigger to certain behaviors, most commonly as part of DBT therapy. 

Layer three could be considered the overall allostatic load. If the FND symptom or spell is a misbehaving network in the brain, then why is it misbehaving now? It is best to consider other brain network problems like seizure, migraine, or depression. All brain network problems get worse when the body is under increased stress. Whether it is sleep quality, diet, an infection, or an emotional stressor, the body can only process so much stress before it starts to malfunction. Whether it is toxic food or toxic people, exposure to too much stress has a myriad of effects on the body and brain that affect its ability to perform a set of very delicate balancing acts called our homeostatic mechanisms. This is easy to study with individual hormones and measures like blood pressure, but the complexity of our mood and behavior regulating homeostatic mechanisms are similarly vulnerable. It results in a functional disconnection in various brain networks, best studied with complex functional brain imaging called resting state fMRI. Certain areas of the brain move together in a healthy patient, but they have reduced coordination in various disorders. Unfortunately, it isn’t as easy as analyzing triggers. In periods of extreme stress, there may be no symptoms at all. It is after the stress has passed and the brain and body are “trying to recover” that the symptoms develop. 

It is within layer four that we begin to branch towards the psychological processes, and away from well understood neuroanatomy. Layer four is best understood in the metaphors used in the psychology literature to explain the data around early childhood trauma and the development of various personality traits and behavior patterns. The modern way of studying this has connected early trauma with the development of many medical illnesses, from heart disease to poor immune system functioning to even the development of diabetes. It is called the Adverse Childhood Events score (ACES) that simply identifies the correlation between early traumas and the development of disease. Causation is difficult to prove, but the correlation is clearly there. Older methods included a more subjective but richer analysis of individual cases, where it was clear that the early traumas not only determined the risk of developing psychological illness, but often seemed to have bearing on their manifestation. There were certain patterns of psychological distress and maladaptive behavioral patterns associated with the age of the trauma as well as the type. Sexual trauma led to certain types of conditions while neglect led to others. 

Layer five could be seen as a bridging between the different components, seeing the symptom as a normal and natural defense against underlying psychological mechanisms. There is something hardwired into the human brain that drives us to develop relationships, seek out similar struggles over and over, sabotage our own goals, and even to desire death. These drives often have two poles, both seeking help and rejecting it, both living in a state of hope and despair. There is no clear understanding of how these mechanisms work in the brain, but for those who study depth psychology the patterns are just as clear as any brain scan. 

When starting treatment for Functional Neurologic Disorders, one of the first questions that should be asked is which layer of this process should be the focus of treatment. If someone is young and still developing, often the first couple of layers is sufficient. Basic behavioral treatments or Cognitive Behavioral Therapies can not only resolve the symptom quickly, but natural mechanisms can kick in to keep the symptoms from coming back. This is why standard treatments are extraordinarily effective in very young people. As people age and develop complex stressors on the body, focusing on layer one or layer two is insufficient, because the symptom will just return or a new FND will develop within a short time. This leads to a lot of distrust in the treatment because it is seen as a failure. However, a focus on removing global stressors on the body and optimizing overall health along with basic CBT and other techniques can often give lasting relief as long as overall health remains a focus long term. 

As we age, or in states where the psychological mechanisms have certain deep and well developed patterns, the deeper layers must be addressed. If, for example, someone has developed very strong defense mechanisms that have kept them going, as is seen in the most successful individuals, but this comes into conflict with other deeply rooted psychological drives, the surface layer treatment will have only minimal (or very transient) benefit. If someone’s entire psychological structure demands they are a very successful hard worker, and that they must be an amazing father or mother, and their situation begins to cause one or both of these to be impossible, then those deep structures of the person’s psychology must be addressed. The psychological dissonance caused by the demand that someone fulfill an unachievable goal is difficult to reconcile. This deep conflict of two forces is very closely connected to a unique depression syndrome in the brain that sometimes manifests as a physical symptom (like FND) or a melancholic or catatonic depression state. Resolving it requires a deeper psychotherapeutic model along with medications that help speed the process along. 

After a patient and their therapist determine which levels to focus on, usually with a discussion about the patient’s goals and preferences and the therapists training and methodologies, many different options are usually available from standard CBT to a mixed approach or a primary dynamic approach. For a consult to learn more, contact us today.