Functional Movement Disorders
One of the first thoroughly studied functional neurologic disorders was found in veterans returning from war. While Charcot was discovering the benefits of hypnosis, some of his students were identifying what exam findings predicted a “structural problem” of the brain or spinal cord, and what exam findings were more common in those who could improve with psychiatric treatments. Babinski, for example, found a particular reflex in the foot that occurred when someone had damage to the spinal cord or brain, but wasn’t present in weak patients that responded to Hypnosis. Others were discovering techniques to trick the brain into using a weak limb, or finding features of someone’s gait (how they walk) that predicted outcomes with different treatments.
There are some fascinating videos of patients who had returned from World War I with extreme difficulty walking, typically showing them walking normally after the hypnosis treatments. As we have discussed, hypnosis can give a quick benefit but the symptoms inevitably return within days to weeks. These World War I veterans had a form of PTSD called shell shock. This is a very different form of PTSD than most modern veterans. While the modern veteran has long periods of quiet with a sudden and explosive trauma, World War I survivors had spent months in a trench with a constant barrage of explosions above and around them. More modern veterans return with head trauma or the loss of a limb because of high quality battlefield medical care, but so many returned from World War I with internal scars.
The symptoms don’t usually arise during or right after the traumatic experience, but they wait until after the dust settles. These patients often denied any active anxiety or depression, but now we know that the weakness or balance difficulties were their brain’s version of anxiety and depression. The same networks were involved, and many of the same therapeutic treatments helped. Unfortunately, there was even more stigma at that time regarding mental health, and so patients treated their symptoms by isolating, withdrawing, and drinking.
What does treatment actually look like? It often begins with physical therapy to see if practicing different movements can rewire the brain networks that are misbehaving. This is often sufficient treatment, and young people and children respond very quickly. If physical therapy alone doesn’t give much relief, the next step is to identify any psychiatric comorbidities and to treat them with the standard model. This is usually counseling, medications, or a combination of the two. Common diagnoses are PTSD, Substance Use Disorder, Generalized Anxiety Disorder, Panic Disorder, Major Depressive Disorder, or Bipolar Disorder. If there was also early life trauma, personality disorders like Borderline Personality Disorder, Antisocial Personality Disorder, Histrionic Personality Disorder, and Dependent Personality Disorder are also common. Those personality disorders typically require longer courses of psychotherapy, and respond less well to medication trials.
If those treatments don’t resolve the problem, or if a patient wants to deal with them later and address the movement disorder first, focused psychotherapeutic models can be very helpful. It is important to understand that this method of avoiding the underlying psychiatric condition has a downside, since many patients will have relief for a year or two and then the symptom will return, or a different symptom will arise to take its place. The oldest approach to this was the depth psychology treatments mostly studied back when it was called “Conversion Disorder”. They often do a deep dive into internal conflicts associated with the trauma or the symptom, revealing connections. By simply helping patients to process these connections, symptoms would often resolve. Modern research has focused primarily on a combination of Cognitive Behavioral Therapies with or without input from models like DBT, ACT, IFS, and others. In combination with simple medications, these therapeutic models can often give quick relief. It may not be permanent, but if the goal is to get back to work or school, structured therapies like this can be the best option.
I typically recommend a strong relationship remain with the neurologist who diagnosed the functional movement disorder, often having exams every six months to confirm no new symptoms or disorders have developed. If this relationship doesn’t continue, patients will often have a slow return of the fear that something is being missed. In an ideal world, the neurologist is in communication with the therapist so that questions can be answered and the goals of treatment are clear. If a therapist also develops a fear that something else is being missed, that fear can be felt by the patient and may stop or delay progress.
Therapists use the same tools to treat FND that they use to treat panic attacks, depressive episodes, and PTSD associated dissociative spells. However, there is an issue with familiarity. When a patient has a panic attack in the room, the therapist knows exactly what to do. When a patient has a seizure or develops difficulty walking in the room, they may have their own fear response or even call 911. That is why having a therapist who is familiar with FND is so vital, to keep calm during the event so that treatment can continue.
If you or a loved one is suffering from functional weakness, please request a consult today.
