Behavioral Health

Conversion disorder (functional neurological symptom)

Clinical Overview and When to Suspect Conversion Disorder

— One or more symptoms of altered voluntary motor or sensory function

— Clinical findings show incompatibility between symptom and recognized neurologic/medical conditions (positive signs, not just absence of disease)

— Not better explained by another medical/mental disorder

— Causes distress or functional impairment

— Women > men (2–3:1); peak onset adolescence to middle age

— ~5% of neurology outpatient referrals; very common in EDs

— Frequent comorbidity: depression, anxiety, PTSD, personality disorders, prior abuse, migraine

— Acute neurologic deficit after psychosocial stressor (assault, deployment, bereavement, conflict)

— Symptoms fluctuate, distract away, or are inconsistent on serial exam

— Normal imaging/EEG/labs despite dramatic presentation

— History of multiple unexplained somatic complaints, prior "spells," frequent ED visits

Board pearl: A preceding stressor is supportive but not required by DSM-5-TR — it was removed as a mandatory criterion. Don't fall for the distractor that says "no identifiable stressor rules out conversion disorder."

Key distinction: Conversion disorder = unintentional. Factitious disorder = intentional production for sick role. Malingering = intentional production for external gain (disability, drugs, avoiding work/jail). All three can mimic each other; intent and incentive structure differentiate them.

Definition: Functional neurological symptom disorder (FND) — neurological symptoms (motor, sensory, seizure-like, speech) that are incompatible with recognized neurological disease, causing distress or impairment.

DSM-5-TR criteria:

Epidemiology:

When to suspect on Step 3:

Diagnostic shift: Modern FND is a rule-in diagnosis based on positive signs (Hoover, tremor entrainment, tubular vision), NOT a diagnosis of exclusion. Avoid endless workup.

Terminology to use with patients: "Functional neurological disorder" — software (not hardware) problem. Avoid "psychogenic," "pseudo-," or "it's all in your head."

Presentation Patterns and Key History

— Functional weakness/paralysis: hemiparesis, monoparesis, paraparesis with give-way weakness

— Functional movement disorder: tremor, dystonia, myoclonus, gait disorder ("astasia-abasia")

— Functional (dissociative/non-epileptic) seizures: previously PNES — convulsive episodes without EEG correlate

— Functional sensory loss: numbness in non-dermatomal distribution, often splitting midline exactly

— Functional speech: dysphonia, stuttering, foreign accent

— Functional visual: tunnel/tubular vision, monocular diplopia, "blindness" with preserved menace

— Sudden onset at moment of stress or minor injury

— Variability — symptom changes with attention, distraction, observation

— Patient reports symptom worsens when watched, improves when alone

— Model — family member or coworker with similar symptoms (e.g., epileptic relative → non-epileptic spells)

— Multiple prior functional episodes

— Trauma history (childhood abuse strongest risk factor for FND seizures)

— Recent stressors: bereavement, divorce, deployment, job loss, litigation

— Medication and substance use (to exclude toxidromes and withdrawal)

— Prior workups — avoid duplicating and exposing to repeat radiation/LPs

Step 3 management: Take a collaborative, non-confrontational history. Ask explicitly: "Has anything especially stressful happened recently?" but reassure the patient you are not implying the symptoms are fake. Document mental status, suicide risk, and prior psychiatric history at the index visit — this affects disposition decisions you'll be tested on.

Board pearl: Onset after physical injury (whiplash, sprain) is common in functional movement disorders — the trigger need not be psychological.

Common functional phenotypes:

History red flags pointing toward FND:

Always ask:

La belle indifférence — classic but unreliable; many FND patients are genuinely distressed. Its presence or absence does NOT rule in or out.

Secondary gain is common but not diagnostic — many organic diseases also have secondary gain.

Physical Exam Findings — Positive Rule-In Signs

— Hoover sign: weak hip extension on affected side normalizes when patient flexes the contralateral hip against resistance (involuntary recruitment)

— Hip abductor sign: weak abduction normalizes with contralateral abduction against resistance

— Give-way (collapsing) weakness: sudden ratchety give vs. smooth pyramidal weakness

— Drift without pronation: arm drifts down without pronation typical of pyramidal lesion

— Co-contraction of agonist/antagonist

— Entrainment test: ask patient to tap a rhythm with the unaffected hand — functional tremor entrains to that frequency or stops; organic tremor does not

— Distractibility, variability in frequency/amplitude

— Ballistic movement task disrupts tremor

— Prolonged duration (>2 min), waxing/waning

— Eyes forcefully closed during event (open in epilepsy)

— Side-to-side head shaking, pelvic thrusting, opisthotonic posturing

— Preserved awareness during bilateral motor activity

— No postictal confusion, no tongue lateral biting, no incontinence (though all can occur)

— Recall of ictal events; ictal crying

— Exact midline splitting of vibration (tuning fork on sternum/skull) — true sensory loss splits ~1 cm off midline because of overlapping innervation

— Non-anatomic distribution (sock/glove not respecting nerve territories)

— Tubular ("gun-barrel") fields that don't expand with distance

— Intact OKN response despite reported blindness

— Preserved pupillary light reflex

Board pearl: Hoover sign and tremor entrainment are the two most testable positive signs on Step 3. Memorize the mechanics.

Key distinction: Positive signs rule in FND; they are not "tricking" the patient. Demonstrate them at the bedside to the patient to anchor the diagnosis — this is therapeutic, not adversarial.

Functional weakness — positive signs:

Functional tremor — positive signs:

Functional seizures vs. epileptic:

Functional sensory loss:

Functional visual:

Diagnostic Workup — Initial Studies

— CBC, CMP (glucose, Na, Ca, Mg, BUN/Cr, LFTs)

— TSH (hypo/hyperthyroidism causes weakness, tremor, anxiety)

— Vitamin B12, folate (myelopathy, neuropathy mimics)

— Urine pregnancy test (women of childbearing age — affects imaging/meds)

— Urine toxicology if altered mental status, new "seizures," or movement disorder

— Functional seizure → EEG (ideally video-EEG capturing typical event is gold standard); routine interictal EEG often normal in epilepsy too, so a normal EEG alone does NOT diagnose FND

— Functional weakness/numbness → MRI brain and/or spinal cord with contrast if focal deficit; rule out stroke (in ED, head CT first to exclude bleed if acute)

— Functional movement disorder → MRI brain; consider ceruloplasmin/24-hr urine copper if young patient with movement disorder (Wilson)

— Functional visual loss → ophthalmology, VEP if needed

Step 3 management: When a patient presents with new "stroke-like" symptoms, the CCS-correct sequence is: ABCs → glucose → NIH stroke scale → non-contrast head CT → labs (CBC, BMP, coags, troponin) → consider tPA window. Only after structural disease is excluded and positive functional signs are demonstrated do you label FND.

Board pearl: A normal MRI does not diagnose FND. The diagnosis requires positive clinical signs of incompatibility.

General principle: Targeted workup to exclude mimics, stop when reasonable. Over-testing reinforces illness behavior and exposes patients to harm.

Baseline labs (most patients):

By presentation:

ECG: if syncope is on the differential for "seizure-like" episodes — rule out long QT, arrhythmic syncope, vasovagal

Glucose at bedside for any acute neurologic event — never miss hypoglycemia

Acute stroke pathway: If presentation is hyperacute focal deficit, activate stroke protocol — do not anchor on functional diagnosis until imaging and exam excludes stroke. Hoover sign cannot be relied on in the first hour when stroke is on the table.

Diagnostic Workup — Advanced and Confirmatory Studies

— Gold standard for distinguishing epileptic from functional (dissociative) seizures

— Inpatient or epilepsy monitoring unit admission for 3–7 days

— Captures a habitual event with simultaneous EEG → no epileptiform correlate confirms functional seizures

— Indicated when: diagnosis unclear, refractory "epilepsy" on multiple AEDs, atypical semiology, frequent events

— ~10–20% of patients in epilepsy monitoring units have functional seizures; another subset has both epilepsy and functional seizures (dual diagnosis ~10%)

— MRI with contrast if MS, tumor, or inflammatory demyelination suspected

— MRA/CTA for vascular causes of acute deficit

— DAT scan for parkinsonism vs. functional parkinsonism (DAT normal in functional)

— EMG/NCS to exclude neuropathy, myasthenia, ALS in functional weakness

— Tremor analysis with accelerometry can document entrainment objectively

— Standardized screening: PHQ-9, GAD-7, PCL-5 (PTSD), trauma history

— Personality assessment when relevant

— Suicide risk screen — comorbid depression is common

Key distinction: Anti-NMDA receptor encephalitis classically presents with prodromal viral illness → psychiatric symptoms → dyskinesias, autonomic instability, seizures in young women, often with ovarian teratoma. Always send anti-NMDA Ab and consider pelvic imaging before labeling a young woman with new bizarre neuro-psychiatric symptoms as "conversion."

Board pearl: vEEG capturing a typical event without epileptiform discharge is the single most diagnostic test for functional seizures and should be ordered for any patient with refractory or atypical seizures.

Video-EEG monitoring (vEEG):

Advanced neuroimaging:

Neurophysiology:

CSF analysis: reserved for suspected infection, inflammation, autoimmune encephalitis (anti-NMDA receptor encephalitis can mimic functional/psychiatric disease — don't miss this in young women with new psychiatric and movement symptoms)

Autoimmune/paraneoplastic panel: consider in subacute presentations with refractory features

Psychiatric assessment:

Risk Stratification and First-Line Management Logic

— Tell the patient explicitly: "You have functional neurological disorder. It is real, common, and treatable."

— Demonstrate the positive signs at the bedside (Hoover, entrainment) so the patient sees what you see

— Use the "software, not hardware" metaphor: the brain's structure is intact, but the way it sends signals is misfiring

— Avoid: "We didn't find anything," "It's stress," "It's all in your head" — these worsen outcomes

— neurosymptoms.org (commonly recommended)

— Explain that ongoing tests reinforce the wrong frame

— Functional motor symptoms / gait / weakness → specialized physiotherapy (1st line, strongest evidence)

— Functional seizures → CBT (1st line, strongest evidence — including CBT-informed psychotherapy)

— Functional speech → speech-language pathology

— Mixed/complex → multidisciplinary FND clinic

— Depression, anxiety, PTSD, insomnia, chronic pain — these worsen FND and respond to standard treatment

— SSRIs/SNRIs are NOT primary FND treatment but help comorbid mood/anxiety

— Short duration of symptoms, early diagnosis and explanation, acceptance of diagnosis, no pending litigation/disability claim, absence of personality disorder, good premorbid functioning

— Long duration, ongoing litigation, severe psychiatric comorbidity, history of childhood abuse, polypharmacy, repeated negative workups

Step 3 management: The single highest-yield intervention is a clear, validating explanation of the diagnosis. Outcomes improve substantially when patients understand and accept the diagnosis. This is on the test.

Board pearl: Refer first-line to physical therapy for functional motor symptoms and CBT for functional seizures — match the modality to the phenotype.

Step 1 — Establish and communicate the diagnosis clearly:

Step 2 — Provide written/online resources:

Step 3 — Multidisciplinary referral, tailored to phenotype:

Step 4 — Treat comorbidities:

Prognostic factors — good:

Prognostic factors — poor:

Pharmacotherapy — Targeted Use

— SSRIs (sertraline 50–200 mg, escitalopram 10–20 mg) — first line

— SNRIs (venlafaxine, duloxetine) — particularly if chronic pain or fibromyalgia overlap

— Start low, titrate; reassess at 4–6 weeks; full effect 8–12 weeks

— Screen for bipolar disorder before starting antidepressants — manic switch risk

— Sertraline or paroxetine (FDA-approved)

— Prazosin for nightmares

— Trauma-focused psychotherapy (PE, CPT, EMDR) is first-line overall

— Sleep hygiene, CBT-I preferred

— Trazodone or low-dose mirtazapine if comorbid depression

— Avoid chronic benzodiazepines — worsen FND and risk dependence

— Amitriptyline, topiramate, propranolol, duloxetine — pick by comorbidity

— Avoid opioids

— Antiepileptic drugs in pure functional seizures — taper carefully under neurology; abrupt withdrawal of long-standing AED can provoke real seizures

— Opioids and benzodiazepines — reinforce illness, cause cognitive blunting

— Anticholinergics for "functional dystonia" without clear benefit

— Reassurance, reduce stimulation, breathing techniques first

— Avoid IV pushes that reinforce sick-role behavior

— Lorazepam only if true status epilepticus cannot be excluded

Key distinction: A patient with refractory "epilepsy" on three AEDs whose video-EEG confirms functional seizures should have AEDs gradually tapered — not stopped overnight — and CBT initiated. The taper itself can be therapeutic by removing side effects.

Step 3 management: Choose SSRI based on side-effect profile and comorbidities; escitalopram is a high-yield default for mixed depression/anxiety with FND.

No medication treats conversion disorder directly. Pharmacotherapy targets comorbidities and reinforces the multidisciplinary plan.

Depression / anxiety comorbidity (very common):

PTSD:

Sleep disturbance:

Migraine / chronic pain (frequent overlap):

Medications to STOP / DEPRESCRIBE:

Acute agitation during a functional episode in ED:

Non-Pharmacologic and Procedural Interventions

— Specialized FND-informed PT (e.g., Nielsen protocol)

— Focus on automatic, distraction-based movement rather than effortful attempted movement

— Goals: retrain normal movement patterns, redirect attention, build graded exposure to function

— Typical course: 5 days intensive or 8–12 weekly outpatient sessions

— CODES trial and others show benefit for seizure frequency, quality of life

— 12 sessions typical; addresses triggers, dissociation, avoidance, catastrophizing

— Psychoeducation about diagnosis is integrated

— Psychodynamic psychotherapy — particularly with trauma background

— Mindfulness-based therapies

— Trauma-focused therapy (EMDR, prolonged exposure) when PTSD comorbid

— For severe, disabling FND with multiple symptoms

— Combines PT, OT, SLP, psychology, psychiatry, neurology

— Avoid invasive procedures (DBS, botulinum toxin) for functional tremor/dystonia — diagnostically and therapeutically counterproductive

— Avoid repeated imaging once diagnosis is established

— Avoid disability paperwork early — reinforces chronic illness identity; encourage return to work/function

Board pearl: The CODES trial established CBT as the first-line treatment for functional (dissociative) seizures. Match the high-yield trial to the high-yield phenotype.

Step 3 management: For an outpatient with new functional gait disorder, the correct referral is physical therapy with FND expertise, not neurology re-imaging or psychiatry alone. Bundle the explanation, PT referral, and treatment of comorbid depression in the index visit.

Physical therapy for functional motor symptoms (gold standard, level A evidence):

Cognitive behavioral therapy (CBT) — first-line for functional seizures:

Other psychotherapies with evidence:

Multidisciplinary inpatient or day-program rehabilitation:

Speech-language pathology: functional dysphonia, foreign accent, stuttering

Occupational therapy: functional limb symptoms affecting ADLs/work

TMS (transcranial magnetic stimulation): emerging evidence for functional motor symptoms — not standard of care; testable as "experimental"

What NOT to do:

Special Populations — Elderly and Renal/Hepatic Impairment

— FND can present at any age, but new neurologic symptoms in an elderly patient should be considered organic until proven otherwise

— Higher pretest probability of stroke, subdural hematoma, NPH, Parkinson disease, dementia, delirium, drug toxicity

— Lower threshold for imaging and metabolic workup

— Be particularly cautious about labeling a first-ever "spell" in someone over 60 as functional — get vEEG, cardiac workup, and consider TIA/seizure

— Reconcile medications carefully — anticholinergics, benzodiazepines, opioids, and antiepileptics can produce tremor, weakness, confusion mimicking FND

— Beers criteria — avoid benzodiazepines for "spells" in older adults

— Adjust SSRIs/SNRIs cautiously

— Avoid duloxetine if CrCl <30 mL/min

— Citalopram >20 mg associated with QT prolongation — use escitalopram or sertraline preferentially in elderly with renal disease

— Be cautious with gabapentin (often inherited from prior workups) — dose-reduce by CrCl

— Sertraline preferred among SSRIs; reduce dose

— Avoid duloxetine in hepatic disease or heavy alcohol use

— Hepatic encephalopathy can mimic functional movement disorder — check ammonia, MELD, asterixis

— Functional cognitive disorder (FCD) is increasingly recognized — patients with subjective memory complaints, internally inconsistent on testing, often with anxiety/depression

— Key distinction: FCD vs. early dementia — FCD patients usually present themselves with complaints and remember details well; dementia patients are typically brought in by family and confabulate

Board pearl: Always exclude organic disease aggressively in new-onset symptoms after age 60 before assigning a functional label — base-rate of organic disease is much higher in this population, and a missed posterior stroke or normal-pressure hydrocephalus is a board-classic trap.

Step 3 management: Geriatric "functional" presentations warrant medication reconciliation, B12/TSH/folate, glucose, head imaging, and orthostatic vitals before psychiatric framing.

Older adults with possible FND:

Polypharmacy considerations:

Renal impairment:

Hepatic impairment:

Cognitive considerations:

Special Populations — Pregnancy, Pediatrics, Military/Trauma

— Increasingly recognized; girls > boys, adolescence peak

— Common phenotypes: functional seizures, gait disorder, tics, abdominal pain

— School absence, bullying, family conflict, academic pressure, abuse are frequent triggers

— Outcomes generally better in children than adults — earlier intervention is key

— Treatment: school reintegration plan, family therapy, CBT, PT

— Mandatory reporting: if abuse is identified or suspected, file a CPS report — this is testable

— Hormonal/psychosocial shifts can unmask FND

— Imaging: MRI without gadolinium preferred over CT for new neurologic symptoms

— SSRIs: sertraline is generally preferred in pregnancy; avoid paroxetine (cardiac malformations risk)

— Avoid valproate, topiramate, benzodiazepines if possible

— Coordinate with OB and psychiatry; screen for IPV (intimate partner violence)

— Differentiate FND from postpartum depression, postpartum psychosis, autoimmune encephalitis (anti-NMDA)

— Postpartum new psychiatric symptoms — rule out anti-NMDA receptor encephalitis in young women with movement disorder + psychiatric features

— Functional seizures and functional movement disorders are common in combat veterans with PTSD and mild TBI

— Integrate trauma-focused therapy

— Outbreaks in schools/workplaces — manage by separating affected individuals, ruling out toxic exposure, transparent communication

Key distinction: Postpartum psychosis = psychiatric emergency requiring hospitalization and treatment (often with antipsychotics + mood stabilizer); FND does not cause hallucinations or grossly disorganized thought. Don't confuse them.

Board pearl: In a child with new "seizures" plus school refusal after bullying, the answer involves CBT, family therapy, school reintegration, AND a CPS evaluation if abuse is suspected — not escalation of antiepileptic drugs.

Pediatric FND:

Pregnancy:

Postpartum:

Military/veterans:

Mass psychogenic illness / cultural presentations:

Complications and Adverse Outcomes

— Repeated imaging with radiation exposure (CT)

— Lumbar punctures, EMG, invasive monitoring

— Polypharmacy: AEDs, opioids, benzodiazepines with side effects (sedation, falls, dependence, hepatotoxicity)

— Inappropriate tPA for "stroke mimic" — risk of intracranial hemorrhage; estimated 1–2% of tPA administrations are to FND mimics, with low but real hemorrhage risk

— Unnecessary surgeries, biopsies

— Intubation for prolonged functional seizures misdiagnosed as status epilepticus

— Deconditioning, muscle atrophy, contractures from chronic functional weakness

— Falls and fractures

— Pressure ulcers in chronic functional paralysis

— DVT from immobility

— Aspiration in functional dysphagia

— Job loss, financial strain, social withdrawal

— Worsening depression, anxiety

— Elevated suicide risk — comparable to or exceeding many neurologic diseases

— Substance use disorder, especially from prescribed opioids/benzodiazepines

— Chronic illness identity formation

— Missed organic disease: ~4% of FND diagnoses are revised to an organic cause over follow-up (lower than older estimates but not zero)

— Delayed diagnosis of MS, autoimmune encephalitis, ALS, dystonia, complex partial seizures

— Dual diagnosis: ~10% of patients have both epilepsy AND functional seizures — managing one without the other fails

— Caregiver burden, family conflict, school/work disruption

Step 3 management: Periodic rediagnosis review is reasonable — if features change or response is atypical, reconsider organic disease without abandoning the functional framework.

Board pearl: The most testable adverse outcome is inappropriate tPA administration for functional stroke mimic — this question tests whether you can use positive signs (Hoover, midline splitting) AND imaging together to avoid harm.

Iatrogenic complications (a major theme in FND):

Functional/physical complications:

Psychiatric complications:

Diagnostic complications:

Family/system impact:

When to Escalate — ICU, Consult, Inpatient

— Any first-ever acute focal deficit → stroke protocol regardless of suspicion for FND

— Status epilepticus appearance → treat as status until proven otherwise (benzodiazepine, glucose, labs); if no response and exam suggests functional, consider video-EEG urgently before escalating to intubation/anesthetic infusion

— Severe agitation, suicidality, or psychosis → psychiatry consult, possible inpatient psychiatric admission

— Rarely needed for pure FND — but if intubated for "status," extubate promptly once functional seizures confirmed

— Avoid escalating sedation when exam is inconsistent with status epilepticus

— Diagnostic uncertainty requiring vEEG

— Severe motor symptoms requiring intensive inpatient rehab

— Refractory functional seizures with frequent ED visits

— Active suicidality

— Severe comorbid depression or psychosis

— Inability to function safely at home

— Neurology — confirms diagnosis, demonstrates positive signs, communicates plan

— Psychiatry — addresses comorbidity, supports diagnosis acceptance, coordinates therapy

— PT/OT/SLP — phenotype-specific

— Social work — disability, school/work, abuse screening, housing

— Case management — coordinate outpatient FND clinic referral, reduce ED bouncebacks

— Patient understands and accepts the diagnosis (or at least is open to it)

— Clear written plan with named follow-up appointments

— Comorbidities addressed

— Suicide risk assessed and mitigated

CCS pearl: For a suspected functional seizure in the ED that has lasted "30 minutes," the correct CCS sequence is: ABCs → bedside glucose → IV lorazepam → labs → continuous EEG → call neurology. Do NOT jump to intubation and propofol drip until EEG and exam confirm true status. Document Hoover sign, eyes-closed semiology, response to verbal redirection.

Acute ED / inpatient triage:

ICU triage:

Inpatient neurology admission criteria:

Inpatient psychiatry admission criteria:

Consults to obtain:

Discharge criteria:

Key Differentials — Other Functional/Somatic Conditions

— One or more somatic symptoms (pain, fatigue, GI) with excessive thoughts, feelings, behaviors about them

— Symptoms may have a medical basis; the pathology is the disproportionate response

— Key contrast: SSD focuses on symptom-related distress; FND requires neurological symptom with incompatibility

— Preoccupation with having or acquiring a serious illness

— Few or no actual somatic symptoms

— Excessive health-related behaviors or maladaptive avoidance

— Intentional falsification of physical/psychological symptoms

— Motivation: assume sick role; no external reward

— May induce illness (insulin injection, contamination of wounds)

— Factitious disorder imposed on another (Munchausen by proxy) — mandatory reporting if child/dependent involved

— Intentional symptom production for external reward (disability, narcotics, avoiding work/military/legal consequences)

— Not a mental disorder per DSM-5 — a V/Z code

— Suspected when: medico-legal context, marked discrepancy between distress and findings, poor cooperation with evaluation, antisocial personality features

— Dissociative amnesia, depersonalization/derealization, dissociative identity disorder

— Overlap with FND particularly for functional seizures (often called "dissociative seizures")

— Panic attacks can mimic functional sensory symptoms (paresthesias, derealization, weakness)

Key distinction: Intent and incentive separate the somatic family:

— FND/SSD/IAD — symptoms are unintentional

— Factitious — intentional, internal motivation (sick role)

— Malingering — intentional, external motivation (gain)

Board pearl: A soldier with sudden paralysis the day before deployment who refuses examination and exaggerates findings → malingering suspicion, not conversion. Look for incentive structure in the stem.

Somatic symptom disorder (SSD):

Illness anxiety disorder (formerly hypochondriasis):

Factitious disorder:

Malingering:

Dissociative disorders:

Body dysmorphic disorder, conversion vs. anxiety panic:

Key Differentials — Organic Mimics to Rule Out

— Posterior circulation strokes, lacunar syndromes, and small cortical strokes can mimic functional weakness

— Always image acutely; Hoover can be falsely positive in early stroke

— Young woman with episodic neurologic symptoms — order MRI brain/spine; INO, optic neuritis, Lhermitte sign favor MS

— Fatigable weakness, ptosis, diplopia, bulbar symptoms; ice-pack test, acetylcholine receptor antibodies, EMG with decrement

— Ascending weakness with areflexia — never call this functional; LP shows albuminocytologic dissociation

— Wilson disease (young + tremor + psychiatric + Kayser-Fleischer rings) — ceruloplasmin, 24-h urine copper

— Huntington (chorea + family history + psychiatric)

— Tourette, paroxysmal dyskinesias

— Stiff-person syndrome (anti-GAD)

— Frontal lobe seizures can have bizarre semiology mimicking functional seizures — vEEG required

— Anti-NMDA, anti-LGI1, anti-Hu — psychiatric symptoms + movement disorder + seizures

— Hypoglycemia, hyponatremia, hepatic encephalopathy, uremia

— Drug intoxication (lithium, anticonvulsant toxicity, serotonin syndrome)

— Patients with epilepsy can develop functional seizures

— Patients with Parkinson can develop functional overlay

— Don't binary-classify; treat both

Board pearl: In a young woman with subacute psychiatric symptoms, dyskinesias, autonomic instability, and seizures → anti-NMDA receptor encephalitis until proven otherwise. Check CSF NMDA-R antibodies and image pelvis for ovarian teratoma.

Key distinction: Areflexia, sensory level, fasciculations, true cranial nerve palsies, and persistent objective signs across distractors are NOT explained by FND — re-investigate.

Acute stroke / TIA:

Multiple sclerosis:

Myasthenia gravis:

Guillain-Barré syndrome:

Movement disorders:

Epilepsy:

Autoimmune encephalitis:

Metabolic / toxic:

Functional + organic overlap (mixed disease):

Secondary Prevention / Discharge Planning / Long-Term Plan

— Continue SSRIs/SNRIs for comorbid depression/anxiety; document indication

— Taper unnecessary AEDs if pure functional seizures confirmed — typically over weeks, coordinated with neurology

— Discontinue chronic opioids and benzodiazepines safely (slow taper, taper plan documented)

— Avoid starting new "neurologic" medications

— Diagnosis stated clearly in problem list: "Functional neurological disorder, [phenotype]"

— Positive signs documented in the chart so future clinicians don't re-investigate

— Written patient education materials provided

— Named follow-up: neurology, psychiatry, PT, primary care

— Continue CBT or psychotherapy course to completion

— Continue PT/OT until functional goals met

— Treat comorbid sleep, pain, mood

— Stress management training, lifestyle (exercise, sleep, alcohol reduction)

— Address ongoing stressors: workplace accommodation, school plan, family therapy

— Gradual graded return is generally preferred over indefinite disability

— Indefinite disability paperwork reinforces sick-role identity and worsens prognosis

— Workplace accommodations may be appropriate short-term

— Symptom diary identifying triggers

— Online resources (neurosymptoms.org)

— Support groups (FND Hope, FND Action)

— Establish a care plan accessible across the system: "Patient has known FND; reassure, exam, avoid repeat imaging unless new objective deficit"

— Shared decision-making with the patient about ED use

Step 3 management: A consistent, documented care plan in the EMR (sometimes called a "high-utilizer care plan") reduces ED visits, costs, and iatrogenic harm. This is value-based-care language that Step 3 likes.

Board pearl: Do NOT fill out long-term disability paperwork in the first months of diagnosis — push for functional recovery first; this is testable.

Discharge medications:

Discharge documentation:

Secondary prevention of relapse / chronicity:

Return-to-work / return-to-school plan:

Patient self-management:

Reduce ED bouncebacks:

Follow-Up, Monitoring, and Rehab/Counseling

— Primary care: 2–4 weeks after diagnosis, then monthly until stable

— Neurology: 1–3 months after diagnosis to confirm trajectory; longer interval thereafter

— Psychiatry: every 2–4 weeks initially when titrating meds or actively in CBT

— PT: 1–3 times weekly for 6–12 weeks, then taper

— Symptom severity (validated scales: SF-MPQ, FSS, PHQ-9, GAD-7, seizure frequency diary)

— Functional status: return to work, return to school, ADLs

— Medication adherence and side effects

— Suicide risk at each visit

— ED utilization

— Reduction in event frequency, increased awareness of triggers, reduced avoidance behaviors

— Improvement in quality-of-life measures

— Reduced AED burden

— Gait speed, independence in transfers, return of automatic movement during dual-task activities

— Improvement on distraction-based tasks before effortful ones

— Reinforce the diagnostic explanation at every visit — many patients oscillate between accepting and rejecting it

— Validate the realness of symptoms while maintaining the functional framework

— Address frustration with slow recovery; set realistic expectations (months, not days)

— Identify and treat lapses early

— Regular sleep schedule, exercise, alcohol moderation, caffeine reduction (for tremor), mindfulness practice

— Avoid reinforcing sick-role behaviors (e.g., excessive caregiving for capable patients)

— Encourage normal activities

Step 3 management: At the 6-week follow-up, expect partial improvement at best; full recovery often takes 6–12 months. Plan accordingly so the patient is not disappointed prematurely.

Board pearl: Validated tools — PHQ-9 ≥10 indicates moderate depression warranting treatment; document at baseline and at each follow-up to demonstrate response.

Follow-up cadence:

Monitoring parameters:

CBT progress markers (for functional seizures):

PT progress markers (for motor symptoms):

Counseling content:

Lifestyle measures:

Family/caregiver education:

Ethical, Legal, and Patient Safety Considerations

— Patients have a right to know their diagnosis clearly and honestly

— Avoid euphemistic vagueness ("we don't know what's wrong") — this prolongs distress and prompts doctor-shopping

— Communicate diagnosis with empathy and validation — bad delivery is the most common ethical lapse

— Explain that PT and CBT are evidence-based for FND

— Discuss risks/benefits/alternatives, including the option of no treatment

— For SSRI/SNRI: discuss black-box warning of suicidality in <25 yr olds; document explicit discussion

— FND patients retain decision-making capacity; respect refusals after full information

— If a patient refuses to engage and remains severely disabled, ongoing supportive care without coercion is appropriate

— Trauma history (abuse, assault) frequently emerges — handle with explicit confidentiality discussion

— Document sensitively

— Suspected child abuse uncovered during FND evaluation → file with CPS

— Suspected elder abuse / dependent adult abuse → mandated state reporting

— Factitious disorder imposed on another (Munchausen by proxy) → CPS immediately; consider child safety planning

— Intimate partner violence is NOT mandatorily reportable in most states (varies) — provide resources, document, do not force disclosure

— Avoid premature long-term disability certification — it worsens prognosis

— Be honest in disability forms; balance patient advocacy with accuracy

— Communicate diagnosis explicitly in discharge summary and in cross-coverage notes

— Without documentation, the next ED visit triggers redundant CT, LP, tPA risk

— A standardized care plan in the EMR is a patient-safety intervention

— Use "functional" not "psychogenic" or "pseudo-"

— Train staff to validate symptoms

Step 3 management: A patient with known functional seizures returns to ED on Saturday night with another event. The shift physician doesn't know the diagnosis and orders CT + lorazepam + neurology. The root-cause analysis answer is failure of care-plan documentation in the EMR — a transition-of-care patient safety failure.

Board pearl: Munchausen-by-proxy → CPS report is non-negotiable.

Truth-telling and the diagnosis:

Informed consent for treatment:

Capacity and refusal of care:

Confidentiality:

Mandatory reporting:

Disability and gatekeeper role:

Transitions-of-care risk (highly testable Step 3):

Stigma and language:

High-Yield Associations and Rapid-Fire Clinical Facts

— Female sex (2–3:1)

— Childhood adversity / abuse (esp. for functional seizures)

— Recent stressful life event

— Comorbid anxiety, depression, PTSD

— Personality disorder (Cluster B/C overlap)

— Prior functional symptoms; modeling from family

— Mild traumatic brain injury, whiplash, peripheral injury (motor FND)

— Hoover sign — functional leg weakness

— Hip abductor sign — functional leg weakness

— Tremor entrainment — functional tremor

— Eyes closed during seizure — functional seizures

— Midline splitting of vibration — functional sensory loss

— Tubular visual fields — functional visual loss

— Co-contraction, give-way weakness

— Drift without pronation

— CODES trial — CBT for functional seizures

— Nielsen protocol — specialized PT for motor FND

— Anti-NMDA receptor encephalitis — must rule out in young women with new psychiatric + neuro signs

— ~10–20% of EMU patients have functional seizures

— ~10% have both epilepsy and functional seizures

— Rate of misdiagnosis (organic disease later found) ~4%

— Motor → PT

— Seizures → CBT

— Speech → SLP

— All → explain diagnosis, treat comorbidities

— Removed requirement for psychological stressor

— Removed requirement to exclude feigning

— Added positive clinical findings as criterion

— Better in children, with short duration, early diagnosis, no litigation

— Worse with long duration, ongoing litigation, severe psychiatric comorbidity, polypharmacy

Board pearl: "Eyes forcefully closed during convulsion" → functional seizure; "eyes open with deviation" → epilepsy. This is one of the most testable single findings.

Key distinction: Positive rule-in signs > absence of disease. Modern FND is positively diagnosed.

Risk factors:

High-yield signs (memorize):

High-yield trials/facts:

Treatment first-line by phenotype:

DSM-5-TR changes:

Prognosis pearls:

Avoid: opioids, chronic benzodiazepines, unnecessary AEDs, repeat imaging, premature disability paperwork

Board Question Stem Patterns

— 32-year-old woman after argument with spouse develops sudden left leg weakness. Strength 1/5 on direct testing; when asked to extend the right leg against resistance, left hip extension is 5/5. MRI brain and spine normal. Diagnosis? → Conversion disorder / FND with weakness

— 28-year-old with new right-hand tremor 4 weeks after MVC; tremor stops when patient taps a rhythm with left hand. → Functional tremor

— Young woman with frequent "seizures" refractory to 3 AEDs; events feature side-to-side head shaking, eyes closed, pelvic thrusting, no postictal confusion; routine EEG normal. Next step? → Inpatient video-EEG monitoring

— Young woman with new psychiatric symptoms, orofacial dyskinesias, autonomic instability, seizures. Don't pick conversion — pick anti-NMDA receptor encephalitis; order CSF antibodies and pelvic imaging for teratoma

— Soldier days before deployment with sudden paralysis, refuses exam, exaggerates findings → malingering (external incentive)

— Healthcare worker with recurrent unexplained hypoglycemia, found with insulin syringes → factitious disorder

— Patient newly diagnosed with FND asks "what now?" → Clear diagnostic explanation + referral to physical therapy (motor) or CBT (seizures) + treat comorbid mood disorder

— Adolescent with new functional seizures, missed school, signs of abuse → CBT + family therapy + CPS report

— Repeated ED visits, repeat CTs and AED doses for known FND — root cause = failure to document care plan

Step 3 management: When the stem gives you positive functional signs PLUS normal imaging PLUS recent stressor → answer is functional/conversion. When the stem gives external incentive → malingering. When sick-role only → factitious.

Board pearl: The "next best step" after diagnosis is almost always explain the diagnosis and refer to PT or CBT, not more imaging.

Stem pattern 1 — Hoover sign:

Stem pattern 2 — Tremor entrainment:

Stem pattern 3 — Functional seizures:

Stem pattern 4 — Anti-NMDA mimic (the trap):

Stem pattern 5 — Malingering vs. conversion:

Stem pattern 6 — Factitious disorder:

Stem pattern 7 — Best initial management of FND:

Stem pattern 8 — Pediatric FND with abuse:

Stem pattern 9 — Care transition failure:

One-Line Recap

Conversion disorder (functional neurological symptom disorder) is a positively diagnosed neurologic illness — identified by rule-in signs of incompatibility (Hoover, tremor entrainment, eyes-closed seizures, midline splitting) — that is managed by a clear validating explanation, phenotype-matched therapy (PT for motor, CBT for seizures), and treatment of psychiatric comorbidities, while avoiding iatrogenic harm and premature disability certification.

Board pearl: The two most testable positive signs are Hoover sign (functional leg weakness) and tremor entrainment (functional tremor); the most testable management decisions are PT first-line for motor FND and CBT first-line for functional seizures (CODES trial).

Key distinction: Conversion = unintentional; factitious = intentional for sick role; malingering = intentional for external gain. Intent + incentive separates the trio on every Step 3 vignette.

Step 3 management: Index visit deliverables — name the diagnosis, demonstrate the positive sign, hand over written resources, refer to PT/CBT, treat comorbid mood, schedule named follow-up, document the care plan to prevent ED bouncebacks. That bundle is the answer the test wants.

Diagnosis = positive signs + neurologic symptom + incompatibility with disease; stressor not required.

First-line treatment = clear empathic explanation + PT (motor) or CBT (functional seizures) + SSRI for comorbid depression/anxiety.

Don't miss mimics = anti-NMDA encephalitis in young women, stroke in acute focal deficits, autoimmune encephalitis, Wilson disease, MS, frontal lobe seizures; ~4% revised to organic later.

Avoid harm = no chronic opioids/benzodiazepines, no unnecessary AEDs, no premature disability paperwork, document the diagnosis in the EMR to prevent transition-of-care failures and repeat imaging.