Decade of progress in motor functional neurological disorder: Continuing the momentum
Open accessAbstract
Functional neurological disorder (FND) is a prevalent, disabling and costly condition at the neurology–psychiatry intersection. After being marginalised in the late 20th century, there has been renewed interest in this field. In this article, we review advances that have occurred over the past decade (2011–2020) across diagnosis, mechanisms, aetiologies, treatments and stigma in patients with motor FND (mFND, that is, functional movement disorder and functional limb weakness). In each content area, we also discuss the implications of recent advances and suggest future directions that will help continue the momentum of the past decade. In diagnosis, a major advance has been the emphasis on rule-in physical signs that are specific for hyperkinetic and hypokinetic functional motor symptoms. Mechanistically, greater importance has been given to determining ‘how’ functional neurological symptoms develop, highlighting roles for misdirected attention, expectation and self-agency, as well as abnormal influences of emotion/threat processing brain areas on motor control circuits. Aetiologically, while roles for adverse life experiences remain of interest in mFND, there is recognition of other aetiologic contributors, and efforts are needed to investigate links between aetiological factors and mechanisms. This decade has seen the first randomised controlled trials for physiotherapy, multidisciplinary rehabilitation and psychotherapy performed in the field, with consensus recommendations for physiotherapy, occupational therapy and outcome measures also published. Across patients, clinicians, healthcare systems and society, stigma remains a major concern. While challenges persist, a patient-centred integrated clinical neuroscience approach is primed to carry forward the momentum of the past decade into the future.
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Taken together, these data suggest that ACEs are broad ranging and that activation and priming of the stress system-leading to subsequent vulnerability to FND-take place across the lifespan.
“Taken together, these data suggest that ACEs are broad ranging and that activation and priming of the stress system—leading to subsequent vulnerability to FND—take place across the lifespan [37,38,41,43,119].”
From Illness-Promoting Psychological Processes in Children and Adolescents with Functional Neurological Disorder (2023) · cites this paper as [119]
The Etiological Factors—New Developments section links childhood abuse and other adverse experiences to vulnerability to motor FND and discusses stress-diathesis and neurodevelopmental perspectives (page unavailable). It does not establish that stress-system activation and priming occur across the lifespan; the Etiological Factors—Future Directions section instead identifies developmental trajectories as needing further study. (LLM, conf=0.84)
Experimental — accuracy not yet measuredThey are hypothesized to activate and prime the stress system-including brain stress systems that underpin salience detection, arousal, pain, and emotional states-and to reflect the biological embedding of experience that makes the child's brain, body, and mind more likely to respond to future stress with an amplified response.
“They are hypothesized to activate and prime the stress system—including brain stress systems that underpin salience detection, arousal, pain, and emotional states—and to reflect the biological embedding of experience that makes the child’s brain, body, and mind more likely to respond to future stress with an amplified response [37,38,41,119].”
From Illness-Promoting Psychological Processes in Children and Adolescents with Functional Neurological Disorder (2023) · cites this paper as [119]
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Functional neurological disorder: new subtypes and shared mechanisms
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“Motor FND includes symptoms such as paralysis or weakness, gait disorders, tremor, myoclonus, tics (jerky movements) and dystonia [21].”
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“For example, the term “patient label avoidance” refers to patients’ efforts to distance themselves from a label, i.e., a diagnosis, because it can be perceived as being socially unacceptable [45].”
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- Authors
- Perez, D. L., Edwards, M. J., Nielsen, G., Kozlowska, K., Hallett, M., & LaFrance, Jr.
- Affiliations
- Massachusetts General Hospital (US)
- St George's, University of London (GB)
- Children's Hospital at Westmead (AU)
- National Institutes of Health (US)
- Venue
- Journal of Neurology, Neurosurgery & Psychiatry
- Publisher
- BMJ
- Published
- 2021-03-15
- Volume
- 92
- Issue
- 6
- Pages
- 668-677
- ISSN
- 0022-3050 (ISSN-L)
- 1468-330X
- PMC
- PMC8440656
- OpenAlex
- W3138102800
- Cited by
- 149
- References
- 53
- Citations by year
- 2026: 23 · 2025: 29 · 2024: 32 · 2023: 31 · 2022: 21 · 2021: 13
- FWCI
- 4.33
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- Journal of Neurology Neurosurgery & Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- St George's Online Research Archive (St George's University of London) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- Sidney R. Baer, Jr. Foundation (No funding number available)
- National Institute of Mental Health (K23MH111983-04)
- National Institute of Neurological Disorders and Stroke (NINDS) Intramural Program (No funding number available)
- National Institute for Health Research (No funding number available)
- Topics
- Health Sciences › Medicine › Psychiatry and Mental health › Psychosomatic Disorders and Their Treatments
- Health Sciences › Medicine › Neurology › Neurological disorders and treatments
- Health Sciences › Medicine › Psychiatry and Mental health › Fibromyalgia and Chronic Fatigue Syndrome Research
- Keywords
- functional movement disorders, diagnosis, expectations, self-agency, etiology, life events, physiotherapy, multidisciplinary rehabilitation, psychotherapy, stigma, outcome measures
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