Functional neurological disorder: GP diagnosis and management

Functional neurological disorder (FND) — the contemporary name for what older classifications called conversion disorder, non-epileptic seizures, or psychogenic movement disorder — is one of the most common and most commonly mismanaged conditions crossing a GP desk. It accounts for roughly 16% of new neurology outpatient referrals, placing it second only to headache as the most frequent new diagnosis in that setting. Yet most patients wait years for a correct diagnosis, accumulate unnecessary investigations, and are often inadvertently harmed by antiepileptic drugs, opioids, or repeated negative workups that leave the underlying condition untreated.

The diagnostic revolution of the past 15 years is this: FND is now diagnosed on positive clinical signs, not by excluding everything else. The GP who can recognise Hoover’s sign, tremor entrainment, and the characteristic features of psychogenic non-epileptic seizures (PNES) — and who can deliver the diagnosis in a way that opens the door to physiotherapy and CBT — is providing genuinely disease-modifying care. The neurologist’s role is confirmatory and specialist-physiotherapy-initiating; ongoing management belongs in general practice.

A. Core clinical — the AU general-practice framework

Who presents with FND

FND occurs across the lifespan, though peak onset is in the second to fourth decades and it is about twice as common in women as in men. It frequently co-exists with, or follows, trauma (physical injury, abuse, adverse life events), and with anxiety, depression, chronic pain, and other functional somatic syndromes (fibromyalgia, chronic fatigue syndrome, irritable bowel syndrome). These co-morbidities are not the cause of FND — they are overlapping presentations that share neurobiological mechanisms of central sensitisation and interoceptive dysregulation.

The commonest presentations in general practice are:

• Psychogenic non-epileptic seizures (PNES): paroxysmal episodes resembling epilepsy but without ictal EEG correlate. Often prolonged (>2 minutes, unlike most tonic-clonic seizures), with pelvic thrusting, eye closure (ictal epilepsy typically produces eye opening), preserved consciousness with convulsive movements, rapid recovery. Up to 30% of patients attending epilepsy clinics have PNES rather than or in addition to epilepsy.
• Functional motor disorder: limb weakness, dragging gait, tremor, myoclonus, dystonia. Often fluctuating, with characteristic positive signs.
• Functional sensory disorder: hemisensory loss, visual disturbance, hearing symptoms.
• Functional cognitive disorder: subjective and objective cognitive complaints, common in middle-aged women, often with prominent attentional and memory symptoms disproportionate to objective neuropsychological testing.

Positive signs the GP can elicit

Hoover’s sign is the most diagnostically reliable positive test for functional leg weakness. The examination technique and its clinical interpretation are described in the FAQ section. Sensitivity approximately 63%, specificity approximately 100% for functional versus organic weakness when performed correctly. It requires only your hand under the heel and a cooperative patient.

Tremor entrainment: ask the patient to tap a rhythmic beat with the unaffected hand (e.g., tapping the knee at a regular pace) while observing the tremulous limb. In organic tremor (Parkinson’s, essential tremor), the amplitude of the affected limb tremor remains independent of the tapping task. In functional tremor, the tremor frequency entrains to the tapping rhythm — the affected limb “captures” the imposed rhythm. This phenomenon is measurable objectively with accelerometry but is visible clinically.

Dragging gait: in functional gait disorder, the affected leg is dragged in a way that is mechanically inconsistent with upper motor neurone weakness (which produces circumduction) and with lower motor neurone weakness (which produces steppage gait). The dragging pattern often changes with distraction, is absent during sitting transfers, and may dramatically normalise when walking backwards.

Variability and distractibility across the examination — more than in most organic conditions — is itself a positive finding when documented consistently.

B. Evidence base for treatment

FND physiotherapy (Physio4FMD model)

The Physio4FMD RCT (Nielsen et al., JNNP 2017) randomised 60 participants with functional motor disorder to physiotherapy using a specialised protocol versus no physiotherapy. At 12 months, the physiotherapy group showed significant improvement in mobility and global function. The physiotherapy protocol targets movement normalisation through attention retraining, symptom-specific exercises, and a movement-based rather than symptom-monitoring focus. This is distinct from general rehabilitation physiotherapy.

In Australia, FND-specialist physiotherapists are concentrated in major cities; telehealth delivery of the model has been piloted and is increasingly available. The GPCDMP allied health pathway (item 721/723, up to 5 allied health visits per year) is the practical access route.

CBT for PNES

The CODES trial (Goldstein et al., Lancet Psychiatry 2020) is the first adequately powered RCT for PNES — 368 participants across 27 centres in the UK. CBT plus standard care achieved ≥50% reduction in monthly seizure days in 55% of participants at 12 months, versus 8% with standard care alone. The CBT protocol addressed avoidance behaviour, triggers, interoceptive dysregulation, and trauma processing where indicated. Under Better Access (MHCP), 10 annual sessions with a trained psychologist or clinical social worker is the practical AU delivery vehicle.

What the evidence says about medications

No antiepileptic drug (AED) reduces PNES frequency in controlled trials; several (especially sodium valproate and benzodiazepines) worsen long-term recovery. The NPS MedicineWise framework for choosing medicines requires evidence of benefit — evidence is absent for AEDs in PNES. If co-existing anxiety or depression is present, SSRIs (sertraline first-line) are appropriate but treat the comorbidity, not the FND directly. Opioids worsen central sensitisation underlying functional pain syndromes; antipsychotics are not indicated and risk extrapyramidal worsening of functional movement disorders.

C. Delivering the diagnosis

The most important clinical skill in FND is how the diagnosis is communicated. Evidence shows that clear, positive, non-dismissive explanation of the mechanism is associated with better patient engagement, adherence to treatment, and outcomes. The neurosymptoms.org resource by Professor Jon Stone (University of Edinburgh) is the GP’s best adjunct here and is freely available for patient use.

A framework that works:

“The tests have come back normal — and that’s actually very useful information. It tells us the hardware of your brain and nervous system is intact. What we’re seeing is a problem with the software — the way your brain is sending and receiving signals to that part of the body. It’s a real problem; the brain can produce real symptoms without any structural damage, in the same way that a computer can crash without anything being physically wrong with the chip. The good news is that the software can be reprogrammed — that’s what specialised physiotherapy and psychological therapy are designed to do.”

Specific things to avoid:

• “There is nothing wrong with you” — factually wrong and dismissive
• “It is stress” — partial and unhelpfully vague; many patients have no identified psychosocial trigger
• “It is psychological” (as first framing) — most patients interpret this as “imaginary” or “weakness of character”
• Implying the diagnosis may change with more investigations — this undermines the treatment framing

Offer written resources at the appointment, specifically neurosymptoms.org, which has patient-facing explanations of each symptom type and treatment rationale.

D. Australian operations

Medicare pathways

Pathway	Item	Sessions	Access
Mental Health Treatment Plan (MHCP)	GP item 2713–2715	Up to 10/year individual Allied Health	Psychologist, social worker, OT
GP Chronic Disease Management Plan	Item 721	Up to 5 Allied Health visits	Physiotherapy, OT, psychology
NDIS	Nil specific item	Ongoing	Meets disability/functional criteria

To write an MHCP for FND/PNES: the diagnosis code is F44 (ICD-10), mental health disorder confirmed, functional impairment documented, evidence-based treatment (CBT) specified. There is no separate “PNES-specific” item number — it falls under the established F44 pathway.

The NDIS pathway is available when FND causes significant functional limitation that is permanent or likely to be permanent. GP documentation requires: confirmed diagnosis, description of daily activities impacted, estimate of ongoing support needs. The NDIS website lists functional capacity assessment guidelines.

ATAPS/headspace: for patients under 25, headspace centres provide psychology via referral without requiring a formal MHCP; waiting lists vary significantly by location.

Specialist referral

Neurology referral for diagnostic confirmation is appropriate for the first episode or when clinical features are atypical. Most ANZAN-affiliated neurologists are familiar with FND. Following diagnosis, the main specialists to engage are:

• FND-specialist physiotherapist (GPCDMP allied health)
• Psychologist trained in CBT for functional disorders (MHCP)
• Psychiatrist (if diagnostic uncertainty, severe comorbid psychiatric illness, or treatment-resistant FND)

RANZCP clinical practice guidelines cover FND co-morbidities including PTSD, anxiety, and depression treatment in this population.

E. Special populations

Trauma and PTSD co-morbidity

A significant proportion of FND — particularly PNES — occurs in patients with histories of trauma. Post-traumatic stress disorder (PTSD) does not cause FND but frequently co-exists. The Phoenix Australia PTSD guidelines provide the evidence-based framework for trauma-focused CBT (TF-CBT, EMDR) in this population. It is important not to require trauma processing as a prerequisite for FND physiotherapy — both can proceed in parallel.

First Nations patients with FND may have experienced systemic trauma and distrust of medical settings. Culturally safe history-taking requires time, ideally with an Aboriginal or Torres Strait Islander Liaison Officer. The diagnosis framing should acknowledge the limits of Western biomedical models and offer practical pathways to community-controlled health.

Children and adolescents

FND in young people (peak age 10–18) has a better prognosis than adult-onset FND, particularly when the diagnosis is delivered promptly and treatment initiated within weeks rather than months. School avoidance is common and a major driver of functional decline. The paediatric allied health pathway, school liaison letters, and early physiotherapy are priorities. PNES in adolescents is frequently misdiagnosed as epilepsy; the presence of eye closure during apparent convulsions and prolonged duration should prompt consideration.

Older adults

De novo FND in patients over 60 requires more thorough investigation to exclude structural disease. Neurodegenerative disorders (Parkinson’s disease) can present with mixed functional and organic features — this is the most complex diagnostic territory and usually warrants neurologist review. Lewy body dementia should be considered if cognitive features accompany the presentation.

Pregnancy

PNES occurring for the first time in pregnancy requires careful assessment — new-onset seizures must be distinguished from eclampsia, which is a life-threatening emergency. Confirmed FND in pregnancy: all AEDs should be deprescribed (evidence of no benefit, known teratogenicity of older agents). CBT is appropriate throughout pregnancy. Physiotherapy for functional motor disorder is safe and should continue.

When to escalate

Refer immediately (same-day or emergency) if:

• First seizure without prior diagnosis — requires acute assessment to exclude epilepsy and metabolic causes
• Consciousness not regained within 5 minutes during a witnessed event — cannot reliably distinguish from status epilepticus without monitoring
• New FND in older adults without prior assessment — structural disease must be excluded
• Rapid functional deterioration

Refer urgently (within 1–2 weeks) to neurology if:

• First presentation of functional motor disorder or sensory FND without imaging
• Diagnostic uncertainty after initial assessment
• PNES: video-EEG referral for diagnostic confirmation in treatment-resistant cases

Refer to psychiatry if:

• Severe co-existing psychiatric disorder (psychosis, severe PTSD with dissociation, active suicidality)
• Treatment-resistant FND after adequate trial of physiotherapy and CBT

What this article is and is not

This article summarises the evidence base and AU general-practice management framework for FND, drawing on RACGP, eTG, RANZCP, ANZAN, and peer-reviewed literature. It is a professional clinical reference and is not patient-facing medical advice. It does not constitute an AHPRA-regulated patient consultation, a specialist opinion, or a recommendation specific to any individual patient. Management decisions must account for the full clinical picture and patient values. The resources linked — particularly neurosymptoms.org and the Phoenix Australia PTSD guidelines — are excellent patient and clinician adjuncts.

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Sources cited

1. Goldstein LH et al. — Cognitive behavioural therapy for dissociative seizures (CODES trial), Lancet Psychiatry 2020 — https://doi.org/10.1016/S2215-0366(20)30128-0
2. Nielsen G et al. — Physiotherapy for functional motor disorder (Physio4FMD), JNNP 2017 — https://doi.org/10.1136/jnnp-2016-314816
3. Stone J et al. — Positive symptoms and signs in FND, JNNP 2010 — https://doi.org/10.1136/jnnp.2010.219006
4. Espay AJ et al. — FND Society diagnostic criteria update, Neurology 2018 — https://doi.org/10.1212/WNL.0000000000004817
5. RANZCP Clinical Practice Guidelines — https://www.ranzcp.org/clinical-guidelines-publications
6. neurosymptoms.org — Professor Jon Stone patient resource — https://www.neurosymptoms.org
7. Phoenix Australia — PTSD guidelines — https://www.phoenixaustralia.org/resources/ptsd-guidelines/
8. Better Access Initiative — https://www.health.gov.au/our-work/better-access-initiative
9. HealthDirect — Functional neurological disorder — https://www.healthdirect.gov.au/functional-neurological-disorder
10. Therapeutic Guidelines (eTG) — Neurological — https://tgldcdp.tg.org.au