What Happens When You Have FND and No Clear Path Forward

Most people who arrive at my practice carrying a diagnosis of FND, or functional neurological disorder, have been through something similar. The process begins with a symptom that is real and often frightening: a limb that stops working, a seizure with no epileptic cause, a voice that disappears, a gait that suddenly changes. The investigations that follow are thorough, sometimes exhausting, and ultimately return with a result that feels like a non-answer: everything is normal.

The diagnosis of FND is then given, sometimes carefully, sometimes poorly. It is explained as a disorder of function rather than structure, as the brain sending incorrect signals, as something neurological but not neurodegenerative. Some clinicians add, with varying degrees of care, that psychological factors may be involved. Others do not mention this at all. What is rarely offered, in the immediate aftermath of the neurological workup, is a clear treatment pathway.

This is the gap that this article addresses.

The Scale of the Problem

FND is not rare. It is, according to most estimates, the second most common reason for attendance at neurology clinics, after headache and migraine (Stone et al., 2020). Approximately one in six neurology outpatients presents with symptoms that are functional in nature, meaning that they arise from a disturbance in the functioning of the nervous system rather than from identifiable structural damage (Carson et al., 2012). In absolute numbers, this is a very large group of people.

What is striking is the contrast between the scale of the population affected and the scarcity of adequately resourced treatment. In most Australian public health settings, a person who receives an FND diagnosis will be referred back to their GP, offered a brief explanation of the diagnosis, and perhaps placed on a waiting list for a psychology service that may or may not have clinicians experienced with FND presentations. In some cases they will be offered a short course of CBT-based psychological input through a hospital program. In many cases, they are effectively discharged from the specialist system with the diagnosis in hand and no treatment plan behind it.

The research on outcomes without adequate treatment is sobering. Gelauff and colleagues, in a systematic review of long-term prognosis for functional motor disorder, found that a substantial proportion of patients continue to experience significant symptoms at follow-up periods of two to seven years, with many reporting deterioration or persistent disability rather than spontaneous recovery (Gelauff et al., 2014). The absence of treatment is not a neutral position. For many people with FND, the passage of time without adequate psychological input produces entrenchment rather than resolution.

The Experience of the Diagnostic Odyssey

Before the FND diagnosis, many people have spent months or years in a state of clinical uncertainty. The journey typically begins with a presentation to a GP or emergency department, followed by referral to neurology, followed by investigations: MRI scans, EEGs, nerve conduction studies, blood panels, sometimes lumbar puncture. Each investigation returns normal, and each normal result produces a particular kind of disorientation. The symptom is clearly present. The body is clearly doing something. But the tools designed to detect what is wrong are consistently finding nothing.

This period is often experienced as a form of not being believed, even when the clinicians involved are careful and compassionate. The repeated experience of investigations that find nothing can generate, in the person carrying the symptom, a particular internal pressure: a sense that they must somehow be responsible for producing a result that will finally confirm what they already know. Some people begin to research their symptoms obsessively, seeking the investigation that has not yet been ordered. Others begin to internalise the implicit message that nothing is wrong, experiencing shame or self-doubt alongside the physical symptoms.

When the FND diagnosis is finally given, it often comes with ambivalence. There is relief at having a name for the experience, at no longer being in the position of the unexplained. But the relief is complicated. FND is not a diagnosis that opens a clear treatment pathway in the way that, for instance, an epilepsy diagnosis does. It is a diagnosis that names an absence: the absence of structural pathology. What it does not yet say, in most clinical contexts, is what the symptoms are doing, what might be maintaining them, or what kind of treatment is likely to help.

What the Dominant Treatment Model Offers

The current evidence-based approach to FND treatment involves a multidisciplinary program combining psychoeducation about the diagnosis, specialist physiotherapy, and a course of CBT-based psychological input. The most robust evidence for this model comes from physiotherapy research, where Nielsen and colleagues demonstrated meaningful improvement in functional motor symptoms following a structured physiotherapy program (Nielsen et al., 2015). The model is well-intentioned and, for some people, genuinely helpful.

Its limitations become apparent at specific points. Psychoeducation about FND, while necessary, addresses the cognitive representation of the symptom without addressing the processes that produced it. Understanding that the brain is sending incorrect signals, or that the symptom is related to a disruption in predictive processing, gives the person a framework for making sense of their diagnosis. It does not, in itself, change what is generating the signals.

The CBT-based components of standard programs are similarly bounded. CBT addresses the relationship between thoughts, feelings, and behaviours, and has value for the management of associated anxiety and depression, which are common in FND presentations. What it does not reach is the question of what the symptom is carrying: the history, the relational context, the thing that could not be said and has found its way instead into the body. This is not a failure of CBT. It is a description of what CBT is designed to do and what lies outside its scope.

Kozlowska and colleagues, in a review of assessment and treatment approaches for functional neurological symptom disorder, note that a subset of patients fail to respond to first-line multidisciplinary treatment, and that this group tends to have more complex psychosocial histories, higher rates of prior trauma, and presentations that involve significant dissociative features (Kozlowska et al., 2015). This is the population for whom a different approach is most clearly indicated.

What Psychoanalysis Addresses That Other Approaches Cannot

The psychoanalytic understanding of FND begins from a different premise than the neurological model. Where the neurological model asks what is wrong with the system, psychoanalysis asks what the symptom is saying, and to whom.

This is not a dismissal of the neurology. The symptoms of FND are real. They are not imagined, not fabricated, and not under voluntary control. Psychoanalysis has never disputed this. What it adds is a second question, one the neurological frame cannot reach: what has this particular symptom, in this particular person, at this particular moment in their life, been organised to carry?

Freud and Breuer’s foundational observation, published in the Studies on Hysteria in 1895, was that what they called conversion symptoms, the transformation of psychical material into somatic form, were not arbitrary. They had a logic. The symptom was a formation, a compromise between what needed to be expressed and what could not yet be expressed directly (Freud and Breuer, 1895). The body took on what speech had failed to carry. Anna O., the first case in that volume, did not have a paralysis that happened to coincide with an unbearable situation. The paralysis was organised around that situation, and it spoke about it, in a form that could not yet be spoken directly.

This observation is a century old, and it remains clinically precise. The person whose leg stops working at a particular moment in their life, in a particular relational context, against the background of a particular history, is not randomly afflicted. Something is being staged in the body. The analytic question is what it is staging, and what speech it is standing in for.

McDougall’s account of what she calls the psychosomatosis, bodies that have been used to resolve what cannot be resolved symbolically, extends this framework usefully. She argues that somatic presentations are not simply conversions of specific psychological content but speak to a more fundamental difficulty with symbolisation: an incapacity, built over time and in relation to specific early experiences, to hold certain kinds of experience in thought at all (McDougall, 1989). The body becomes, in her formulation, a theatre: the site where dramas that cannot be staged in thought or speech are performed instead.

Verhaeghe, drawing on Lacan, makes a related point about the function of the symptom in the subject’s economy. The symptom, however distressing, always serves a function. It organises something. It makes a particular position possible. This is not a moral claim: the person with FND is not choosing their symptoms. It is a structural claim: the symptom is not separable from the subject’s history and their relation to the Other, and treatment that proceeds as though it is will tend to manage the symptom temporarily without addressing what generated it (Verhaeghe, 2004).

What Actually Happens in Psychoanalytic Treatment for FND

Psychoanalytic work with FND does not begin with the symptom. It begins with the person. The preliminary sessions are a space for the person to speak about what has brought them to treatment, without an agenda imposed in advance. This is not unusual in therapy, but the absence of agenda in psychoanalytic work is more thoroughgoing than it is in most other approaches: there is no homework, no structured exercise, no psychoeducational module to complete. There is speech, and what emerges from it.

Over time, in an analytic space that holds itself open, things become available that could not be said immediately. Connections emerge that were not previously apparent. The history that preceded the symptom’s onset begins to take shape. The relational context in which the symptom appears and disappears becomes clearer. What could not be spoken begins, slowly, to find words.

This does not mean that the symptom disappears as soon as its meaning is articulated. The relationship between the psychical and the somatic is not a simple code to be decoded. Working-through takes time. The unconscious processes that have organised the symptom are not immediately accessible to speech, and they do not simply dissolve when they are named. What changes, in successful analytic work, is the subject’s relationship to what they are carrying. The symptom may persist, change, transform, or resolve. What tends to shift, more reliably, is the position the person occupies in relation to it: from helpless victim of an inexplicable body to a subject who is beginning to find words for what their body has been holding.

For some people, this shift is itself significant enough to make a substantial difference to how the symptoms affect their life, even before any reduction in their severity. The sense that what is happening in the body is connected to something that can be understood and, eventually, spoken about, provides a different relationship to the symptom than the experience of being at its mercy.

On Dissociation and FND

A substantial proportion of people with FND also experience dissociative symptoms: episodes of depersonalisation or derealisation, periods of amnesia, a sense of observing oneself from outside, or the collapse of continuity in consciousness that is sometimes described as losing time. This co-occurrence is not coincidental.

Both FND and dissociation can be understood as responses to experience that exceeded the subject’s capacity to process it symbolically. When what has happened cannot be held in thought, cannot be put into words, cannot be integrated into a continuous account of one’s own history, it does not disappear. It persists in the body and in the gaps in consciousness. The FND symptom and the dissociative episode are, from a psychoanalytic perspective, close relatives: both are formations that speak to what speech has failed to carry.

Demartini and colleagues found that a significant proportion of FND patients report symptom onset in the context of acute emotional stress, and that many have histories of adverse life events and psychological trauma (Demartini et al., 2014). This does not mean that FND is simply the result of trauma, or that all FND presentations have an obvious traumatic origin. It means that the history that preceded the symptom is clinically significant, and that approaches that attend to that history, rather than to the symptom in isolation, are likely to reach further.

Psychoanalytic work is specifically suited to presentations involving dissociation because it does not require the person to arrive with a coherent account of their history, or with access to the experiences that may be relevant. Free association, the invitation to speak whatever comes to mind without editorial selection, creates conditions under which material that is not consciously available can begin to emerge. The gaps, the contradictions, the things that are said without being intended: these are where the analytic work often finds its most significant purchase.

A Note on What This Practice Offers

I work with FND and conversion presentations from a psychoanalytic orientation, and I also collaborate with Revive Neuro Physiotherapy for the bodily dimension of treatment. The analytic and physiotherapeutic registers are not alternatives. They address different dimensions of the same presentation, and I have found that the combination of a sustained analytic engagement and specialist physiotherapy offers something that neither alone provides.

I do not require a person to have completed a hospital program before beginning analytic work, and I do not require a formal FND diagnosis if neurological investigations are still underway. What I do require, which is itself often a product of the preliminary sessions rather than a precondition for them, is some openness to the possibility that what the body is doing may be connected to something in the person’s history and inner life.

That openness does not need to arrive as a conviction. It can arrive as a question.

Sessions are available in person at 53 Erin Street, Richmond, and via Telehealth across Victoria and nationally. I am a registered Clinical Psychologist and Medicare rebates are available with a Mental Health Care Plan from your GP. Neurologist, GP, and psychiatrist referrals are welcome. A free fifteen-minute phone consultation is available to anyone wanting to explore whether this is the right fit for their situation.

About Myles Medwell

Myles Medwell is a Clinical Psychologist and Lacanian psychoanalyst based in Richmond, Melbourne. He holds a Master of Psychology (Clinical) from Federation University and is registered with AHPRA. He is a member of the Australian Clinical Psychology Association and undertakes ongoing psychoanalytic formation at the Freudian School of Melbourne.

He works with adults and older adolescents across a wide range of presentations, with a particular interest in FND and conversion disorder, complex trauma, dissociation, personality disorders, and identity-related difficulties. Psychological assessment and psychoanalytic clinical supervision are also available. Referrals welcome from neurologists, GPs, psychiatrists, and allied health professionals.

53 Erin Street, Richmond Melbourne VIC 3121  |  www.mylesmedwell.com.au  |  0466 509 179

References

Carson, A., Stone, J., Hibberd, C., Murray, G., Duncan, R., Coleman, R., Warlow, C., Roberts, R., Pelosi, A., Cavanagh, J., Matthews, K., Goldbeck, R., Walker, J., and Sharpe, M. Disability, distress and unemployment in neurology outpatients with symptoms unexplained by organic disease. Journal of Neurology, Neurosurgery and Psychiatry, 83(11), 1068-1074. (2012)

Demartini, B., Batla, A., Petrochilos, P., Fisher, L., Edwards, M. J., and Joyce, E. Multidisciplinary treatment for functional neurological symptoms: A prospective study. Journal of Neurology, 261(12), 2370-2377. (2014)

Freud, S., and Breuer, J. Studies on Hysteria. In J. Strachey (Ed. and Trans.), The Standard Edition of the Complete Psychological Works of Sigmund Freud, Vol. II. London: Hogarth Press. (Original work published 1895; SE 1955)

Freud, S. Fragment of an Analysis of a Case of Hysteria (Dora). In J. Strachey (Ed. and Trans.), The Standard Edition, Vol. VII, pp. 1-122. London: Hogarth Press. (Original work published 1905; SE 1953)

Gelauff, J. M., Stone, J., Edwards, M., and Carson, A. The prognosis of functional (psychogenic) motor symptoms: A systematic review. Journal of Neurology, Neurosurgery and Psychiatry, 85(2), 220-226. (2014)

Kozlowska, K., Scher, S., and Helgeland, H. Functional Somatic Symptoms in Children and Adolescents: A Stress-System Approach to Assessment and Treatment. London: Palgrave Macmillan. (2020)

Lacan, J. Ecrits: The First Complete Edition in English. Translated by B. Fink. New York: Norton. (Original works 1953-1966; English translation 2006)

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Nielsen, G., Stone, J., Matthews, A., Brown, R., Davie, C., Greenwood, R., Howlett, S., Mann, A., Reuber, M., Nicholson, T. R., Goldstein, L. H., and Edwards, M. J. Physiotherapy for functional motor disorder: A consensus recommendation. Journal of Neurology, Neurosurgery and Psychiatry, 86(12), 1281-1287. (2015)

Stone, J., Carson, A., Duncan, R., Roberts, R., Warlow, C., Hibberd, C., Coleman, R., Cull, R., Murray, G., Pelosi, A., Cavanagh, J., Matthews, K., and Sharpe, M. Who is referred to neurology clinics? The diagnoses made in 3781 new patients. Clinical Neurology and Neurosurgery, 112(9), 747-751. (2010) [see also Stone et al. (2020) Functional neurological disorder. Practical Neurology, 20(5), 386-395]

Verhaeghe, P. On Being Normal and Other Disorders: A Manual for Clinical Psychodiagnostics. New York: Other Press. (2004)

Webster, J. Conversion Disorder: Listening to the Body in Psychoanalysis. New York: Columbia University Press. (2018)