Emotional processing in functional neurological disorder: A review, biopsychosocial model and research agenda
Open accessAbstract
Functional neurological disorder (FND) is a common and highly disabling disorder, but its aetiology remains enigmatic. Conceptually, there has been reduced emphasis on the role of psychosocial stressors in recent years, with a corresponding increase in neurobiological explanations. However, a wealth of evidence supports the role of psychosocial adversities (eg, stressful life events, interpersonal difficulties) as important risk factors for FND. Therefore, there is a need to integrate psychosocial (environmental) and neurobiological factors (eg, sensorimotor and cognitive functions) in contemporary models of FND. Altered emotional processing may represent a key link between psychosocial risk factors and core features of FND. Here, we summarise and critically appraise experimental studies of emotional processing in FND using behavioural, psychophysiological and/or neuroimaging measures in conjunction with affective processing tasks. We propose that enhanced preconscious (implicit) processing of emotionally salient stimuli, associated with elevated limbic reactivity (eg, amygdala), may contribute to the initiation of basic affective/defensive responses via hypothalamic and brainstem pathways (eg, periaqueductal grey). In parallel, affect-related brain areas may simultaneously exert a disruptive influence on neurocircuits involved in voluntary motor control, awareness and emotional regulation (eg, sensorimotor, salience, central executive networks). Limbic-paralimbic disturbances in patients with FND may represent one of several neurobiological adaptations linked to early, severe and/or prolonged psychosocial adversity. This perspective integrates neurobiological and psychosocial factors in FND and proposes a research agenda, highlighting the need for replication of existing findings, multimodal sampling across emotional response domains and further examination of emotional influences on sensorimotor and cognitive functions in FND populations.
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A central issue in contemporary discussions of functional neurological disorder has been the extent to which emotions play a mechanistic and aetiological role.
“A central issue in contemporary discussions has revolved around questioning the extent to which emotions play a mechanistic and aetiological role in FND.23,28,30,31”
From A new science of emotion: implications for functional neurological disorder (2022) · cites this paper as [28]
Other proposed emotion processing mechanisms for FND are not incorrect, but rather incomplete, with a constructionist perspective addressing an important gap.
“Furthermore, we think that other proposed emotion processing mechanisms for FND are not incorrect, but rather incomplete-with a constructionist perspective addressing an important gap.27,28”
From A new science of emotion: implications for functional neurological disorder (2022) · cites this paper as [28]
Such miscalculations could predispose to chronic negative affect and altered predictions, which offers an explanatory framework for behavioural and physiological findings of altered responses to 'emotional' stimuli in people with FND.
“Such 'miscalculations' could predispose to chronic negative affect and altered predictions, which offers an explanatory framework for behavioural and physiological findings of altered responses to 'emotional' stimuli in people with FND.27,28,44”
From A new science of emotion: implications for functional neurological disorder (2022) · cites this paper as [28]
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“The procedures were identical to those described in a previous study (Pick et al., 2018).”
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“Various bio-psycho-social models have been hypothesised and suggest FND results from dysfunction of higher-order motor and limbic processes in complex interaction with early life adversity, stress, bodily experiences and expectations [34].”
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Stager, L., Morriss, S., McKibben, L., Grant, M., Szaflarski, J. P., & Fobian, A. D. (2022) · Seizure · doi:10.1016/j.seizure.2022.03.021 · Cited by 21 · see citing works
Psychogenic non-epileptic seizures in children – psychophysiology & dissociative characteristics
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Kozlowska, K., Schollar-Root, O., Savage, B., Hawkes, C., Chudleigh, C., Raghunandan, J., Scher, S., & Helgeland, H. (2023) · Children · doi:10.3390/children10111724 · Cited by 14 · see citing works
- Authors
- Pick, S., Goldstein, L. H., Perez, D. L., & Nicholson, T. R.
- Affiliations
- King's College London (GB)
- Harvard University (US)
- Corresponding author
- Pick, Susannah
- Venue
- Journal of Neurology, Neurosurgery & Psychiatry
- Publisher
- BMJ
- Published
- 2018-11-19
- Volume
- 90
- Issue
- 6
- Pages
- 704-711
- ISSN
- 0022-3050 (ISSN-L)
- 1468-330X
- PMC
- PMC6525039
- OpenAlex
- W2901870388
- Semantic Scholar
- d16ec4fcf73c2d012b9671d6244731a9a1643ec7
- Cited by
- 296
- References
- 94
- Citations by year
- 2026: 41 · 2025: 50 · 2024: 42 · 2023: 34 · 2022: 32 · 2021: 36 · 2020: 41 · 2019: 19 · 2017: 1
- FWCI
- 3.65
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Journal of Neurology Neurosurgery & Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Research Portal (King's College London) (submittedVersion, other-oa)
- HighWire Press Open Archive (submittedVersion)
- Funders
- National Institute for Health Research (CS-2014-14-016)
- National Institute of Mental Health (1K23MH111983-01A1)
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Psychosomatic Disorders and Their Treatments
- Health Sciences › Medicine › Psychiatry and Mental health › Fibromyalgia and Chronic Fatigue Syndrome Research
- Social Sciences › Psychology › Experimental and Cognitive Psychology › Anxiety, Depression, Psychometrics, Treatment, Cognitive Processes
- Keywords
- conversion disorder, emotional processing, psychosocial adversity, biopsychosocial model, amygdala, periaqueductal gray, sensorimotor network, salience network, frontoparietal network, emotion regulation, stress, etiology
- MeSH terms
- Conversion Disorder, Emotions, Humans, Models, Theoretical, Nervous System Diseases, Psychology, Biomedical Research
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Registry, retraction, Cites and statistics results are computed, not judged, with one exception: a printed reference that no index lists is read once by a model before it counts as a citation error. Claims are extracted by a model and kept only when their quote appears verbatim in the text; each cited source is then checked, with a model’s help, for whether it says what the claim relies on. Those verdicts can be wrong — read the claim’s quote and the cited source before relying on one.
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