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Functional neurological disorder
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Research question: What is functional neurological disorder? How is it best diagnosed and managed?
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- Contents
Functional neurological disorder …………………………………………………………………………………… 1
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Contents ………………………………………………………………………………………………………….. 1
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Summary …………………………………………………………………………………………………………. 2
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Previous TAPIB research …………………………………………………………………………………… 2
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Functional neurological disorder………………………………………………………………………….. 3
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Epidemiology ……………………………………………………………………………………………………. 3
5.1 In Australia ………………………………………………………………………………………………… 3
- Diagnosis ………………………………………………………………………………………………………… 4
6.1 Diagnosis requires positive evidence of symptoms ………………………………………….. 4
6.2 Assessment ……………………………………………………………………………………………….. 4
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6.3 Diagnosing clinician ……………………………………………………………………………………. 5
6.4 DSM-5 diagnostic criteria …………………………………………………………………………….. 5
6.5 ICD-11 diagnostic criteria …………………………………………………………………………….. 6
- Presentation …………………………………………………………………………………………………….. 6
7.1 Symptoms …………………………………………………………………………………………………. 6
7.2 Functional impact ……………………………………………………………………………………….. 7
- Management ……………………………………………………………………………………………………. 8
8.1 Recommendations ……………………………………………………………………………………… 8
8.2 Treatment outcomes …………………………………………………………………………………… 9
8.3 Evidence of efficacy of management strategies …………………………………………….. 10
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References …………………………………………………………………………………………………….. 10
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Summary
Functional neurological disorder is a psychiatric condition in which neurological symptoms are present but inconsistent with any known medical condition. People with the condition often present with a diverse range of motor, sensory or cognitive symptoms that can significantly affect their quality of life and daily functioning.
Accurate estimates of incidence and prevalence are difficult to find, though recent estimates suggest global incidence of 10 – 22 per 100,000 people and prevalence of 80 – 140 per 100,000 people.
Diagnosis of functional neurological disorder can be made on the basis of diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders or the International Classification of Diseases.
Most treatment and management guidelines recommend a multidisciplinary approach with individualised treatment strategies to address specific symptoms. However, limitations in the literature mean further evidence is required in some areas.
- Previous TAPIB research
This paper incorporates content from previous versions of RES 018 Functional neurological seizure disorder.
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- Functional neurological disorder
Functional neurological disorder is a psychiatric condition in which neurological symptoms (especially motor or sensory symptoms) are present but inconsistent with any medical condition (World Health Organisation, 2024; APA, 2022).
The American Psychological Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) classifies functional neurological disorder as a somatic symptom related disorder under the label functional neurological symptom disorder. Somatic symptom related disorders are psychiatric conditions which present with physical or bodily symptoms (e.g. vision loss, seizures, limb weakness or paralysis, speech articulation issues etc.) (APA, 2022).
The World Health Organisation’s International Classification of Diseases (ICD-11) classifies functional neurological disorder as a dissociative disorder under the label dissociative neurological symptom disorder. Under this classification, functional neurological disorder is an impairment (“disruption or discontinuity”) to the integration of behavioural or psychological functions (e.g. sensations, perceptions, voluntary control of bodily movements, thoughts) (World Health Organisation, 2024).
Functional neurological disorder was previously known as conversion disorder. This term was used in past editions of the DSM. It refers to a psychoanalytic theory regarding the unconscious origins of the physical symptoms of functional neurological disorder. Conversion disorder is still used in some of the clinical and research literature, though this is no longer the official terminology (FND SIG, 2024; APA, 2022).
- Epidemiology
Accurate estimates of frequency of functional neurological disorder are difficult to find due to misdiagnosis and changing diagnostic criteria (6. Diagnosis) as well as wide variability in the presentation of the condition (7. Presentation). Women are more likely to be diagnosed with functional neurological disorder, making up around 65-70% of the patient population (FND SIG, 2024).
Estimates from a recent systematic review of incidence and prevalence studies (Finkelstein et al, 2024) include:
incidence (adults and children) at 10 – 22 per 100,000
incidence (children) at 1 – 18 per 100,000
Prevalence at 80 – 140 per 100,000 (range 50 – 1600).
5.1 In Australia
There are few prevalence or incidence studies of functional neurological disorder in Australia. An early study offered an incidence estimate for paediatric functional neurological disorder at 2 – 2.6 per 100,000 people (Finkelstein et al, 2024). In a 2016 Australian study, 15% of all the
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new presentations to an outpatient neurology clinic were diagnosed with functional neurological disorder (Ahmad & Ahmad, 2016). A 2024 study identified 16 specialist clinics with expertise in functional neurological disorder across Australia and New Zealand (Connors et al, 2024).
Applying estimates of global prevalence from Finkelstein et al (2024) to Australia’s current population (26 million) there may be at least 20,800 – 36,400 people with functional neurological disorder in Australia.
- Diagnosis
Diagnosis of functional neurological disorder can be made on the basis of diagnostic criteria from the DSM-5 or the ICD-11.
Patients may wait years between initial symptoms and a correct diagnosis (Medina et al, 2021; Edwards, 2020) and often have a history of negative experiences of healthcare (Bennet et al, 2021).
For some people with functional neurological disorder, an accurate diagnosis can itself lead to reduction or cessation of symptoms (Edwards, 2020). For others, discussing the symptoms may exacerbate them (FND SIG, 2024).
6.1 Diagnosis requires positive evidence of symptoms
Diagnosis should not be made because some symptoms cannot be explained, are out-of-the- ordinary, or do not fit with another condition (Mavroudis et al, 2024; APA, 2022; Bennet et al, 2021; Edwards, 2020). Although other medical conditions must be ruled out as possible explanations for the symptoms, functional neurological disorder is not a diagnosis of exclusion. Instead, diagnosis requires positive evidence of somatic symptoms demonstrating “inconsistency between impaired voluntary movement and intact automatic movement” or “incongruency with structural neurological disease” (FND SIG, 2024, p.14; Mavroudis et al, 2024; World Health Organisation, 2024; APA, 2022). This can include evidence of inconsistency between clinical tests, that is, evidence that symptoms present on one method of examination are not detected on another. For example, for those showing weakness of hip extension or thigh abduction, a clinician might observe a return to normal strength with contralateral hip abduction against resistance (APA, 2022).
6.2 Assessment
Diagnosis should be made by evaluating the overall clinical picture rather than relying on one or two observations or tests. Gaining an overall clinical picture should include:
examination of the full list of symptoms (and not just the major somatic symptoms) patient history, including previous diagnoses and healthcare interactions
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the patient’s opinion about their symptoms or diagnoses (FND SIG, 2024; APA,
2022; Edwards, 2020).
Some symptoms or features of the patient’s history may support a diagnosis by filling out the overall clinical picture though they are not diagnostic criteria proper and should not be relied upon too heavily. These include:
a history of other functional somatic symptoms or disorders, particularly including
pain and fatigue significant stress or trauma around the time of symptom onset a lack of concern about the symptom, even if serious (APA, 2022).
Other medical conditions should be ruled out as explanations for the symptoms. However, people with other neurological conditions, such as multiple sclerosis or epilepsy, might also be diagnosed with functional neurological disorder provided that there is also evidence of symptom inconsistency or incongruity (FND SIG, 2024, p.14; World Health Organisation, 2024; APA, 2022).
6.3 Diagnosing clinician
Diagnosis of functional neurological disorder should be made by a healthcare professional with experience diagnosing neurological conditions. Because symptoms are physical, people with functional neurological disorder usually present to other clinicians before a neurologist or psychiatrist (APA, 2022). Queensland’s Functional Neurological Disorder Special Interest Group recommends diagnosis be made by a neurologist. Where access to a neurologist is not possible, another specialist with subject matter knowledge may make the diagnosis, such as a psychiatrist or rehabilitation specialist. This position is endorsed by Functional Neurological Disorder Australia (FND SIG, 2024).
6.4 DSM-5 diagnostic criteria
The diagnostic criteria for functional neurological symptom disorder are:
A. One or more symptoms of altered voluntary motor or sensory function.
B. Clinical findings provide evidence of incompatibility between the symptom and
recognised neurological or medical conditions.
C. The symptom or deficit is not better explained by another medical or mental
disorder.
D. The symptom or deficit causes clinically significant distress or impairment in social,
occupational, or other important areas of functioning and warrants medical
evaluation (APA, 2022).
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6.5 ICD-11 diagnostic criteria
The diagnostic criteria for dissociative neurological symptom disorder are:
Involuntary disruption or discontinuity in the normal integration of motor, sensory, or
cognitive functions, lasting at least several hours. Clinical findings are not consistent with a recognized Disease of the Nervous
System (e.g., a stroke) or another medical condition (e.g., a head injury). The symptoms do not occur exclusively during episodes of Trance Disorder,
Possession Trance Disorder, Dissociative Identity Disorder, or Partial Dissociative
Identity Disorder. The symptoms are not due to the effects of a substance or medication on the central
nervous system, including withdrawal effects, do not occur exclusively during
hypnagogic or hypnopompic states, and are not due to a Sleep-Wake disorder (e.g.,
Sleep-Related Rhythmic Movement Disorder, Recurrent isolated sleep paralysis). The symptoms are not better accounted for by another mental disorder (e.g.,
Schizophrenia or Other Primary Psychotic Disorder, Post-Traumatic Stress
Disorder). The symptoms result in significant impairment in personal, family, social,
educational, occupational or other important areas of functioning (World Health
Organisation, 2024).
- Presentation
7.1 Symptoms
Most people with functional neurological disorder present with multiple symptoms (FND SIG, 2024; Edwards, 2020). In a large international survey study of people diagnosed with functional neurological disorder, the authors found less than 1% of respondents reported a single symptom, while over 50% reported 10 or more symptoms (FND SIG, 2024).
The most common groups of symptoms are dissociative or functional seizures, movement disorders and sensory disorders (refer to Table 1 Common symptoms of functional neurological disorder). Other symptoms can include brain fog, difficulty concentrating, fatigue, dizziness, sleep dysfunction, dysphagia, incontinence and urinary retention (FND SIG, 2024; Mavroudis et al, 2024; World Health Organisation, 2024; APA, 2022; Bennet et al, 2021; Edwards, 2020).
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Table 1 – Common symptoms of functional neurological disorder (Source: FND SIG, 2024; Mavroudis et al, 2024; World Health Organisation, 2024; APA, 2022)
Functional seizures Movement disorders Sensory disorders
seizure-like movements limb weakness pain
black outs or altered paralysis sensory loss (vision or consciousness hearing
feeling of lack of motor gait disorder tingling, numbness, pins control and needles
reduced or absent tremor tinnitus speech volume
dysarthria dystonia
vocalisations tics, jerks and spasms
Memory loss
7.2 Functional impact
Presence of significant distress or functional impairment is required for a diagnosis of functional neurological disorder (World Health Organisation, 2024; APA, 2022; Pick et al, 2020). If changes in motor, sensory, or cognitive function are transient and do not cause significant functional impairment, this does not meet criteria for diagnosis (World Health Organisation, 2024).
Functional impairment associated with functional neurological disorder can be as significant as other neurological conditions (Saunders et al, 2024; Bennet et al, 2021). In severe cases, affected people may be unable to get out of bed or depend on a wheelchair for all mobility (Saunders et al, 2024). However, it is difficult to generalise about the functional impact of symptoms as the presentation of functional neurological disorder varies widely according to the presence or absence of symptoms and their duration, chronicity, rate of progression and severity (Mavroudis et al, 2024; World Health Organisation, 2024; APA, 2022). In addition, current understanding of outcomes is usually based on low certainty evidence from small, mostly hospital or clinic observational studies (Saunders et al, 2024) (refer to 8.2 Treatment Outcomes).
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- Management
8.1 Recommendations
Most recommendations suggest a management by a multidisciplinary team which may include a general practitioner, psychiatrist, neurologist and allied health practitioners such as physiotherapist, occupational therapist, speech therapist, psychologist and social worker (FND SIG, 2024; Molero-Mateoa & Molina-Rueda, 2024; Petrie et al, 2023; Pepper et al, 2022; Gilmour et al, 2020; Nicholson et al, 2020). Individualised management strategies are necessary due to the heterogenous presentation of symptoms and functional impairments (Gilmour et al, 2020).
8.1.1 Functional Neurological Disorder Special Interest Group
Queensland’s Functional Neurological Disorder Special Interest Group published practice guidelines including recommendations for diagnosis, assessment and management of functional neurological disorder. Strength of their recommendations is rated from A to D in descending order of confidence based on quality of studies that informed the recommendation. Where research evidence was not available, the authors identified what they considered good clinical practice (identified as Clinical Opinion in the list below).
[Clinical Opinion] The patient’s GP is informed of the diagnosis and provided
information on how to best support the patient in ongoing management. [Clinical Opinion] The GP-patient relationship is recognised as pivotal as a way of
providing care in the longer term. They should have access to specialist advice and
be given opportunity for continuing professional development in the management of
FND. [Clinical Opinion] The neurological assessment can be seen as the start of the
treatment in FND, not just a prelude to diagnosis. [B] Effective explanation of a diagnosis of FND can alter key beliefs in patients and
foster helpful behavioural changes [Clinical Opinion] Neurologists have a role in triaging to different types of evidence-
based treatment. [A] Physiotherapy management should include facilitating normal movement,
retraining normal movement, addressing secondary changes and education
(including role of physiotherapy, activity pacing and long-term self-management of
symptoms) [Clinical Opinion] Patients with FND often have problems coping with daily life, and
therefore, occupational therapy could be seen as a natural fit for treatment.
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[A] Cognitive Behaviour Therapy (CBT) alone compared to standard medical care
has proven to be beneficial in the treatment for FND. [B] Provide evidence-based psychological therapy for the driver of the problem
and/or comorbid psychological condition - e.g., Dialectical Behaviour Therapy for
Borderline Personality Disorder, trauma-focused psychotherapy for PTSD. [Clinical Opinion] Consider a referral to a psychiatrist for additional diagnostics and
treatment of psychiatric comorbidities in patients with FND. [C] Social workers can provide transferrable practice skills which can be utilized to
promote better health outcomes for FND clients and their supporting networks. [Clinical Opinion] Patients’ cultural backgrounds should be considered in
management, with good communication being a cornerstone of management. [Clinical Opinion] The use of subacute rehabilitation services to manage patients
with FND should be considered on a case-by-case basis. [B] The use of telehealth as delivery mode for Cognitive Behavioural Therapy (CBT)
is helpful in managing dissociative events. [C] The use of telehealth to delivery physiotherapy and psychiatry to promote self-
management and for movement retraining.
8.2 Treatment outcomes
Treatment response varies widely between individuals with functional neurological disorder (Mavroudis et al, 2024; World Health Organisation, 2024; APA, 2022).
Current evidence suggests short duration of symptoms, early diagnosis and agreement with the diagnosis are associated with better outcomes, whereas maladaptive personality traits, comorbid physical disease, reluctance to participate in the full treatment program, inability to identify therapy goals and receipt of disability benefits are correlated with worse outcomes (FND SIG, 2024; APA, 2022). Severe and persist pain is a poor prognostic factor and often the symptom causing the greatest functional impact (FND SIG, 2024). Fatigue, sleep difficulties and cognitive symptoms such as difficulty concentrating may have more of an impact on function and quality of life than motor symptoms associated with functional neurological disorder (Bennet et al, 2021; Edwards, 2020).
One study suggests symptoms worsened after 7 years in 40% of people, with 20% of people achieving remission (Petrie et al, 2023; Hallet et al, 2021). Other studies suggest up to two thirds of patients achieve better outcomes (Gilmour et al, 2024; Gilmour et al, 2020). For people experiencing functional seizures, recovery rates are estimated to be between 30% and 50% overall and 70% for children (FND SIG, 2024; Hallet et al, 2021).
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8.3 Evidence of efficacy of management strategies
Molero-Mateoa & Molina-Rueda (2024) identified moderate quality evidence that physiotherapy improves motor symptoms, activity, perceived health, and quality of life in people showing motor symptoms of functional neurological disorder.
Gutkin et al (2021) found that cognitive behavioural therapy and psychodynamic therapy could improve physical symptoms, mental health, well-being, function and resource use for people. Although they note the low quality of the studies included and identify the need for further research to identify benefits of psychotherapy.
A systematic review of neurostimulation protocols has identified need for better quality studies with consistent protocols to confidently assess the effectiveness of the treatment for people with functional neurological disorder (Gonsalvez et al, 2021).
- References
Ahmad, O., & Ahmad, K. E. (2016). Functional neurological disorders in outpatient practice: An Australian cohort. Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia, 28, 93–96. https://doi.org/10.1016/j.jocn.2015.11.020
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Bennett, K., Diamond, C., Hoeritzauer, I., Gardiner, P., McWhirter, L., Carson, A., & Stone, J. (2021). A practical review of functional neurological disorder (FND) for the general physician. Clinical medicine (London, England), 21(1), 28–36. https://doi.org/10.7861/clinmed.2020-0987
Boylan, K. A., Dworetzky, B. A., Baslet, G., Polich, G., Angela O’Neal, M., & Reinsberger, C. (2024). Functional neurological disorder, physical activity and exercise: What we know and what we can learn from comorbid disorders. Epilepsy & behavior reports, 27, 100682. https://doi.org/10.1016/j.ebr.2024.100682
Connors, M. H., Kinder, J., Swift, E., Kanaan, R. A., Sachdev, P. S., & Mohan, A. (2024). Functional neurological disorder clinics in Australasia: A binational survey. Journal of Clinical Neuroscience, 126, 80-85. https://doi.org/10.1016/j.jocn.2024.05.043
Finkelstein, S. A., Diamond, C., Carson, A., & Stone, J. (2024). Incidence and prevalence of functional neurological disorder: a systematic review. Journal of Neurology, Neurosurgery & Psychiatry. https://doi.org/10.1136/jnnp-2024-334767
Gilmour, G. S., Nielsen, G., Teodoro, T., Yogarajah, M., Coebergh, J. A., Dilley, M. D., Martino, D., & Edwards, M. J. (2020). Management of functional neurological disorder. Journal of neurology, 267(7), 2164–2172. https://doi.org/10.1007/s00415-020-09772-w
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Gilmour, G. S., Langer, L. K., Bhatt, H., MacGillivray, L., & Lidstone, S. C. (2024). Factors Influencing Triage to Rehabilitation in Functional Movement Disorder. Movement disorders clinical practice, 11(5), 515–525. https://doi.org/10.1002/mdc3.14007
Gonsalvez, I., Spagnolo, P., Dworetzky, B., & Baslet, G. (2021). Neurostimulation for the treatment of functional neurological disorder: A systematic review. Epilepsy & behavior reports, 16, 100501. https://doi.org/10.1016/j.ebr.2021.100501
Hallett, M., Aybek, S., Dworetzky, B. A., McWhirter, L., Staab, J. P., & Stone, J. (2022). Functional neurological disorder: new subtypes and shared mechanisms. The Lancet. Neurology, 21(6), 537–550. https://doi.org/10.1016/S1474-4422(21)00422-1
Mark V. W. (2024). Biomarkers and Rehabilitation for Functional Neurological Disorder. Journal of personalized medicine, 14(9), 948. https://doi.org/10.3390/jpm14090948
Mavroudis, I., Kazis, D., Kamal, F. Z., Gurzu, I. L., Ciobica, A., Pădurariu, M., Novac, B., & Iordache, A. (2024). Understanding Functional Neurological Disorder: Recent Insights and Diagnostic Challenges. International journal of molecular sciences, 25(8), 4470. https://doi.org/10.3390/ijms25084470
McLoughlin, C., Hoeritzauer, I., Cabreira, V., Aybek, S., Adams, C., Alty, J., Ball, H. A., Baker, J., Bullock, K., Burness, C., Dworetzky, B. A., Finkelstein, S., Garcin, B., Gelauff, J., Goldstein, L. H., Jordbru, A., Huys, A. M., Laffan, A., Lidstone, S. C., Linden, S. C., … McWhirter, L. (2023). Functional neurological disorder is a feminist issue. Journal of neurology, neurosurgery, and psychiatry, 94(10), 855–862. https://doi.org/10.1136/jnnp- 2022-330192
Medina, M., Giambarberi, L., Lazarow, S. S., Lockman, J., Faridi, N., Hooshmad, F., Karasov, A., & Bajestan, S. N. (2021). Using patient centred clinical neuroscience to deliver the diagnosis of functional neurological disorder (FND): Results from an innovative educational workshop. Academic Psychiatry, 45, 185-189. https://doi.org/10.1007/s40596-020-01324-8
Molero-Mateo, P., & Molina-Rueda, F. (2024). Physiotherapy for patients with functional movement disorder: a systematic review. Neurologia, 39(6), 505–514. https://doi.org/10.1016/j.nrleng.2022.01.008
Nicholson, C., Edwards, M. J., Carson, A. J., Gardiner, P., Golder, D., Hayward, K., Humblestone, S., Jinadu, H., Lumsden, C., MacLean, J., Main, L., Macgregor, L., Nielsen, G., Oakley, L., Price, J., Ranford, J., Ranu, J., Sum, E., & Stone, J. (2020). Occupational therapy consensus recommendations for functional neurological disorder. Journal of neurology, neurosurgery, and psychiatry, 91(10), 1037–1045. https://doi.org/10.1136/jnnp-2019-322281
Pepper, E., Mohan, A., Butcher, K., Parsons, M., & Curtis, J. (2022). Functional neurological disorders: an Australian interdisciplinary perspective. The Medical journal of Australia, 216(10), 501–503. https://doi.org/10.5694/mja2.51543
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Petrie, D., Lehn, A., Barratt, J., Hughes, A., Roberts, K., Fitzhenry, S., & Gane, E. (2023). How Is Functional Neurological Disorder Managed in Australian Hospitals? A Multi-Site Study Conducted on Acute Inpatient and Inpatient Rehabilitation Wards. Movement disorders clinical practice, 10(5), 774–782. https://doi.org/10.1002/mdc3.13718
Pick, S., Anderson, D. G., Asadi-Pooya, A. A., Aybek, S., Baslet, G., Bloem, B. R., Bradley- Westguard, A., Brown, R. J., Carson, A. J., Chalder, T., Damianova, M., David, A. S., Edwards, M. J., Epstein, S. A., Espay, A. J., Garcin, B., Goldstein, L. H., Hallett, M., Jankovic, J., Joyce, E. M., … Nicholson, T. R. (2020). Outcome measurement in functional neurological disorder: a systematic review and recommendations. Journal of neurology, neurosurgery, and psychiatry, 91(6), 638–649. https://doi.org/10.1136/jnnp- 2019-322180
Queensland Functional Neurological Disorder Special Interest Group. (2024). Managing Functional Neurological Disorders - A State-wide Recommendation for an FND Clinical Pathway. https://fndaustralia.com.au/resources/FND-treatment-recommnedations- FINAL-20-May-2024.pdf
Saunders, C., Bawa, H., Aslanyan, D., Coleman, F., Jinadu, H., Sigala, N., & Medford, N. (2024). Treatment outcomes in the inpatient management of severe functional neurological disorder: a retrospective cohort study. BMJ neurology open, 6(2), e000675. https://doi.org/10.1136/bmjno-2024-000675
Steinruecke, M., Mason, I., Keen, M., McWhirter, L., Carson, A. J., Stone, J., & Hoeritzauer, I. (2024). Pain and functional neurological disorder: a systematic review and meta- analysis. Journal of neurology, neurosurgery, and psychiatry, 95(9), 874–885. https://doi.org/10.1136/jnnp-2023-332810
Szasz, A., Korner, A., & McLean, L. (2025). Qualitative systematic review on the lived experience of functional neurological disorder. BMJ neurology open, 7(1), e000694. https://doi.org/10.1136/bmjno-2024-000694
World Health Organisation. (2024). International classification of diseases for mortality and morbidity statistics (11th ed.). 6B60 Dissociative neurological symptom disorder. https://icd.who.int/browse/2024-01/mms/en#1069443471
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