Abstracts
Orginial Research and Case Reports

Poster Session
Sunday, June 14, 2026
12:45 pm – 2:30 pm

 
1    THE ROLE AND BENEFITS OF PHYSICAL THERAPY IN A MULTIDISCIPLINARY FUNCTIONAL SEIZURE CLINIC (Treatment)
Dara Albert, DO, MEd, FAAN, FAES, Nationwide Children’s Hospital/The Ohio State University

Background: Functional seizures (FS), also referred to as psychogenic non-epileptic seizures (PNES), are the most common subtype of functional neurological disorder (FND) in youth. The interplay of autonomic, physical, sensory, and psychological factors are involved in the diagnosis and treatment of FS. Patients can experience a variety of symptoms and differing levels of disability. A multidisciplinary team approach can ensure the patient receives an appropriate diagnosis, education, and treatment tools.

Methods: The Functional Seizure Clinic at Nationwide Children’s Hospital, a tertiary referral center in Ohio, includes a team that aids in the evaluation and management of patients. In January 2025, a pediatric physical therapist (PT) joined the team. Patients are evaluated by PT during their first visit and if indicated, they are followed for targeted treatment in an outpatient setting. The PT evaluates functional impairments through a movement lens using the Functional Disability Inventory (FDI). The FDI is a self-reported outcome measure which assesses patients’ ability to participate in activities at home, school, and social settings. Scores above 12 indicate impactful functional impairment. During the PT evaluation, the PT also assesses potential fear avoidance behaviors, impaired proprioception, and functional movement disability. The PT engages patients in exercises that combine both upper and lower extremity movements, cross body coordination, dual tasking, and positional changes with the goal to reach an aerobic threshold.

Results: Twenty-six new patients have been seen by the full team. The average initial reported FDI score is 12.3 out of 60 with the maximal score of 41 and minimal score of 0. Twenty-seven percent of the patients reported moderate to severe functional impairment (score >21) [Figure 1]. At this time, limited data points exist for FDI scores from follow up clinic visits. Seven additional patients with FS engaged in outpatient PT and reported improvements in both functioning and decreased FS episodes. Three out of the seven, recorded pre-post FDI data and all reported a decrease in episode frequency. The average FDI score decreased by 11.3 points.

Conclusions: As clinical cases rise, the need for comprehensive treatment clinics for FS increases. Utilizing psychological interventions is widely used, and there is increasing evidence of the benefits of incorporating PT to address functional impairments. Our data emphasizes the presence of disability in this population and potential of utilizing a specialized physical therapist to help patients address functional impairments using movement and exercise. Early evidence suggests that a more comprehensive team approach consisting of providers from neurology, psychology, and physical therapy offers patients robust tools to address the interplay of both brain and body networks in FS management.

2    ARTIFICIAL INTELLIGENCE-DRIVEN KINEMATIC ANALYSIS FOR DIFFERENTIATING FUNCTIONAL FROM ORGANIC TREMORS: A PROSPECTIVE PILOT STUDY (Etiology/Pathophysiology)
Fouad Jameel Rashid Al-Zaidi, MD, Al-Farabi Kazakh National University

Background: Functional movement disorders, particularly tremors, present significant diagnostic challenges. Clinical differentiation from organic tremors relies on maneuvers like distractibility and entrainment, which may be subjective. Machine Learning (ML) can help with diagnosis in an objective, data-driven way [1]. This study evaluated the accuracy of a machine learning algorithm in distinguishing functional tremors from organic variants using wearable kinematic sensors.

Methods: A prospective pilot study was conducted with 50 participants, including 25 individuals with functional tremor and 25 with organic tremor. We used tri-axial accelerometers to get kinematic data while people were sitting, standing, and doing things. Feature extraction focused on changes in frequency, amplitude, and coherence. We created and tested a Random Forest classification model using a leave-one-out cross-validation method to see how accurate and sensitive it was for diagnosis.

Results: When it came to finding functional tremors, the ML model was 91.2% accurate, with a sensitivity of 89.6% and a specificity of 92.8%. Frequency variability was recognized as the most significant physiological marker, demonstrating a markedly greater prevalence in the functional group [table1]. This AI-based workflow cut the time it took to get a definitive diagnosis by 15% compared to just looking at the patient. The picture of the data makes it clear how functional and organic phenotypes are grouped together [figure1].

Conclusions: Machine learning-driven kinematic analysis is a robust and objective enhancement to clinical evaluation in Functional Neurological Disorder (FND) [2]. AI can help make diagnoses earlier and with more confidence by finding small patterns in how the body changes. This makes multidisciplinary triage more effective and lessens the need for costly long-term observation.

References: 
[1] Espay AJ, et al. Technology in the diagnosis and management of functional movement disorders. Nat Rev Neurol. 2023;19(11):674-688.
[2] Perez DL, et al. Artificial Intelligence and Machine Learning in Functional Neurological Disorder: A New Frontier in Clinical Care. Neurology: Clinical Practice. 2024;14(2):e200231.

3    CREATIVE ARTS THERAPIES INTERDISCIPLINARY TREATMENT: A CASE STUDY OF A WOMAN WITH FND ON INPATIENT REHABILITATION (Treatment)
Khyla Anderson, Inova Mount Vernon Hospital

Introduction:  This case study focuses on creative arts therapies (CATs) in an interdisciplinary approach to Functional Neurological Disorder (FND) treatment. CATs, such as music therapy and therapeutic reaction, uniquely target common treatment goals in FND such as increasing self-agency, distraction from symptoms, and increasing coping. Studies on CATs in the context of FND remain scarce. Evidence supports the integration of CATs with interdisciplinary modalities such as occupational therapy (OT), and physical therapy (PT), and psychology. CATs studies found improved patient outcomes for therapeutic goals, symptom management, and mood. The paucity of research in this area underscores a need for investigation into how CATs contribute to FND treatment.  

Case Presentation:  Ms. M is a 22-year-old woman who presented to inpatient rehabilitation with leg weakness and inability to ambulate. This patient had a recent surgery related to endometriosis, as well as co-occurring conditions of rheumatoid arthritis, gastroparesis, and POTS, depression and anxiety. The patient’s attending physicians did not find evidence of medical etiology for her leg weakness or loss of ambulation. Additionally, physical therapy and occupational therapy found inconsistencies in functional presentation. With an additional evaluation from a neuropsychologist, this patient was diagnosed with FND by her team. The patient endorsed medical challenges throughout childhood, leading to lack of self-agency and anxiety that paired with symptoms. An interdisciplinary team worked together to increase self-agency associated with symptoms. With the use of Neurologic Music Therapy (NMT) techniques, the patient benefited from Therapeutic Instrument Musical Performance (TIMP). Therapeutic recreation intervention included expressive arts, social movement groups, and pet therapy. 

Discussion: CATs are not often integrated into treatment for FND. However, this case study highlights the importance of these interventions. Evidence-based practices utilized in this case study include NMT and the Transformational Design Model (TDM), which evaluates the transferability of exercises to real-world functioning. CATs follow a patient-centered approach that tailors interventions to individual preferences, and in a patient with FND this added valuable improvement in self-agency and distraction from symptoms  

References:  
Hebb, C., Raynor, G., & Polich, G. (2022). The use of rhythmic auditory stimulation for functional gait disorder: A case report [Review of The use of rhythmic auditory stimulation for functional gait disorder: A case report]. Sage Pub, 50(2). https://journals.sagepub.com/doi/abs/10.3233/NRE-228005  
Yam, A., Rickards, T., Pawlowski, C. A., Harris, O., Karandikar, N., & Yutsis, M. V. (2016). Interdisciplinary rehabilitation approach for functional neurological symptom (conversion) disorder: A case study. Rehabilitation Psychology, 61(1), 102–111. https://doi.org/10.1037/rep000

4    RELATIONSHIPS BETWEEN BRAIN FUNCTIONAL CONNECTIVITY AND RESTING CARDIAC AUTONOMIC PROFILES IN FUNCTIONAL NEUROLOGICAL DISORDER: A PILOT STUDY (Etiology/Pathophysiology)
Cristina Bleier, MD, Mass General Brigham

Background: Functional neurological disorder (FND) is associated with alterations in functional brain networks, yet relationships between peripheral autonomic physiology and brain architecture remain poorly characterized. This pilot study examined associations between cardiac autonomic metrics and resting-state functionalconnectivity (rsFC) in FND.

Methods: Twenty females with FND and 23 age-matched female psychiatric controls (PCs) completed questionnaires, 10-min resting photoplethysmography recordings, and same-day resting-state fMRI. Interbeat interval (IBI) and heart rate variability (HRV) metrics were extracted. Whole-brain rsFC was quantified using weighted-degree [centrality]. Within-group analyses tested associations between cardiac autonomic metrics and weighted-degree rsFC separately in FND and PC cohorts, adjusting for age, head motion, and antidepressant/β-blocker use–while applying a cluster-wise correction.

Results: Cardiac (IBI and HRV) metrics did not differ between FND and PC cohorts, and these metrics did not correlate with FND symptom severity, somatic symptom burden, affective symptoms, or childhood trauma. In FND, shorter IBI (i.e., faster resting heart rate) correlated with increased weighted-degree rsFC in bilateral supplementary motor area (SMA) and right precentral/superior frontal regions, whereas higher HRV primarily correlated with decreased weighted-degree rsFC in the bilateral SMA, midcingulate cortex, and right amygdala, anterior insula, and lateral orbitofrontal cortex. In PCs, autonomic–rsFC associations were more spatially restricted to the anterior/midcingulate and SMA. 

Conclusion: In FND, individual differences in resting autonomic physiology related to the centrality of brain areas that are part of the central autonomic, salience, and allostatic-interoceptive networks. These findings suggest that the relationship between autonomic physiology and network architecture may be important in FND.

5    IMPROVING UNDERSTANDING AND ACCEPTANCE OF FUNCTIONAL NEUROLOGICAL DISORDER THROUGH AN ONLINE EDUCATIONAL MODULE: A FEASIBILITY STUDY (Treatment)
Marleen Bracke, PhD candidate, Amsterdam UMC

Background: In patients with a functional neurological disorder (FND), understanding and acceptance of the diagnosis are associated with better outcomes, yet are often insufficient due to inadequate explanation of the diagnosis. This study investigates whether the online educational module ‘Grip on FND’ is feasible, acceptable and can improve understanding and acceptance and support the translation from diagnosis to treatment.

Methods: This mixed-methods pilot study included patient-reported outcomes at baseline, one month, and two months, and focus group interviews. The intervention ‘Grip on FND’ is an online, non–therapist-guided educational module, intended to bridge the period between diagnosis and treatment. It consists of four chapters addressing FND symptoms, causes (including an explanation of the multifactorial aetiology and questions to develop a personalised diagnostic formulation) treatment, and coping. Primary outcomes were feasibility, acceptability, and understanding and acceptance of the diagnosis, measured using individual items from the Illness Perception Questionnaire-Revised (IPQ-R). Secondary outcomes included daily functioning, quality of life (QoL), self-reported neurological and psychological symptoms, perceived control over recovery and willingness to engage in treatment.

Results: Thirty-four participants with a recent FND diagnosis (<3 months) enrolled; 32 completed baseline questionnaires (84% female; median age 41). Thirty-one participants started the intervention, 71% completed all chapters and median usage time was 3 hours (IQR 2-4). Significant changes over time were observed for the IPQ-R items illness understanding (Cochran’s Q = 10.89, p = .004) and acceptance of the diagnosis (Cochran’s Q = 6.25, p = .044). Qualitative findings (n = 11) also indicated increased understanding and acceptance, primarily driven by (1) recognition and validation through detailed descriptions of FND symptoms and patient narratives, and (2) the process of constructing a personalised diagnostic formulation. Self-rated health status (EQ-VAS) showed a small but significant change over time (Friedman χ² = 7.29, p = 0.026). Other outcome measures showed no significant changes. At the final assessment, participants reported that the module had contributed to their willingness to engage in treatment (median 8/10, IQR 5–9). The likelihood of recommending the module to other patients was median 9/10 (IQR 8–10).

Conclusions: This study demonstrates that the module is feasible and valued by patients and may, through improved understanding and acceptance of the diagnosis, support readiness for treatment. No significant effects were observed on symptoms, functioning, or quality of life. Given that the study was not powered to detect changes in these outcomes, the module should not be considered a standalone treatment at this time, and further research is needed to evaluate its clinical impact.

6    STANDARDIZING CARE FOR FUNCTIONAL MOVEMENT DISORDERS THROUGH TEAM-BASED QUALITY IMPROVEMENT STRATEGIES (Treatment)
Laura Brown, PT, DPT, Ann & Robert H. Lurie Children's Hospital of Chicago

Patient presentation to pediatric Emergency Departments (ED) with a differential diagnosis of Functional Neurological Disorder (FND) is common (7.4-22%). While discharge to home from the ED is preferred, a certain percentage of individuals require an inpatient stay for further work-up, diagnosis and care coordination. Due to the heterogenous symptomatology of FND, the standardization of ED and subsequent inpatient care is challenging and results in variable treatment approaches. Therefore, classification for FND treatment is challenging with the potential for practice patterns to be most easily discerned when grouped by primary symptom presentation. Due to the rehabilitation focus of this project, the frequency of presentation and associated healthcare costs, movement-based presentations were highlighted as a first-step for care pathway creation and systemic coordination. 

A multidisciplinary team consisting of perspectives from Physical Therapy, Occupational Therapy, Psychology, Neurology, General Medicine, Emergency Medicine and Pain/Anesthesia met 1x/month to identified opportunities for quality improvement in the inpatient and ED management of patients with movement-based FND. Quality improvement tools (current state analysis; fishbone and key driver diagrams; value stream map; SMART goal development; creation of project timeline) were applied to organize, prioritize and create a mission and goals. A retrospective chart review was conducted to evaluate current processes and identify gaps in receiving diagnosis, consultation patterns, and discharge planning. A provider survey was performed to assess comfort in identifying and treating FND.  

A standardized clinical care pathway was developed with the goals of improving time to diagnosis, enhancing diagnostic education, promoting interdisciplinary communication, and streamlining inpatient and outpatient transitions. Two separate pathways were created with one for the ED and the other for individuals requiring admission.  Chart review confirmed perspectives regarding delayed time to care conferences, inconsistent rehabilitation consultations, reduced referrals to psychology, and limited access to outpatient rehabilitation resources and structured follow-up after discharge.  Needs for additional resources including provider education, systematic discharge, and decreased time to care conference were identified. Additionally, providers collaborated on educational resources for individuals, PCP and school communications and outpatient PT and OT resource lists were created.  

Implementation of a standardized ED and inpatient care pathways for movement-based FND aim to improve consistency of care, provider communication, and education. Future work will focus on pathway refinement, development of additional pathways focused on different presentations, ensuring appropriate diagnostic workup, and creation of on-going educational resources to support both diagnosis and longitudinal treatment.

7    PSILOCYBIN IN FUNCTIONAL NEUROLOGICAL DISORDER (PSIFUND) STUDY: FIRST-LOOK RESULTS (Treatment)
Matt Butler, Mres, MRCPsych, King's College London

Background: Recent research has indicated that psychedelics such as psilocybin may represent a safe and effective intervention in neuropsychiatric disorders. Literature from the ‘pre-prohibition’ period of research suggests tolerability and clinical response to psychedelics in functional neurological disorder (FND), and contemporary surveys indicate a high degree of patient interest. Modern studies are required to examine psychedelics in FND. 

Methods: In this open-label study (PsiFUND), which was not defined as a clinical trial, we aimed to investigate mechanistic changes induced by psilocybin in a diverse sample of people with treatment-resistant FND. Participants (target n = 20) with motor or seizure symptoms received a single dose of 25mg oral psilocybin alongside psychotherapeutic support in a controlled setting. Outcome data were collected in a pre-post design. Symptom burden was assessed via the Clinical Global Impression (CGI) severity and improvement subscales. Motor intentionality was assessed via the Libet Clock task, using W-M latency as a proxy for motor agency. Cardiac interoception was assessed via the Heartbeat Tracking Task. Expectancy was assessed via the Stanford Expectations of Treatment Scale (SETS). Suggestibility was measured via the Creative Imagination Scale (CIS). 

Results: At the time of writing, seventeen participants had been dosed; all were retained until final 3-month follow-up (70% female; mean age 43 years; mean symptom duration 6 years). The sample was broadly representative of pre-specified protected characteristics. There were no significant adverse events (AEs), although minor AEs such as headache, nausea, and tiredness were recorded. Qualitative assessments suggested a high degree of acceptability and tolerability, and FND-specific and winder psychological improvements were reported by many. Cardiac interoceptive accuracy, confidence, and metacognitive insight were not significantly different pre-post dose. There was no significant difference between average W-M latency pre-post dose. Mean CGI-S at enrolment was 4.4 (range 4-6), at one-week post-dose was 3.8 (2-6), and at 3-months post-dose was 3.5 (2-5); mean CGI-I at three months was 2.8 (1-4). SETS and CIS scores showed non-significant associations with GGI .

Conclusions: This study, the first in the modern era to report psychedelic administration in broad subtypes of FND, suggested psilocybin administration was safe, feasible, and well-tolerated. Psilocybin did not modify mechanistic markers such as cardiac interoception and motor agency. Conclusions cannot be made on clinical efficacy, although psilocybin administration was associated with sustained symptom improvement in some and limited symptom changes in others. No participants worsened. Further quantitative, fMRI, and qualitative analyses are to follow. This study suggests that future clinical trials examining psychedelics as treatments for FND may be warrant

8    FUNCTIONAL NEUROLOGICAL DISORDER AND MIGRAINE: A CROSS-SECTIONAL HEALTH-RELATED QUALITY OF LIFE STUDY (Phenomenology/Epidemiology, Etiology/Pathophysiology)
Verónica Cabreira, University of Porto/Sao Joao University Hospital

Background: Functional neurological disorder (FND) and migraine are prevalent and disabling neurological conditions with marked impairment in health-related quality of life (HRQoL). Emerging models suggest shared pathophysiological mechanisms involving altered predictive processing, heightened sensory gain, attentional and emotional dysregulation.1,2 Despite overlapping mechanisms, stigma, and comorbidities, direct comparisons of HRQoL between FND and migraine are lacking.

Methods: Single-centre cross-sectional study of adult patients with a diagnosis of FND or migraine without aura/chronic migraine followed in a tertiary neurology outpatient clinic. Demographic and clinical data were collected using self-administered online questionnaires and review of medical records. Psychological distress was assessed using the Hospital Anxiety and Depression Scale (HADS). Perceived treatment response was evaluated using the Patient Global Impression of Change (PGIC). The primary outcome measure, HRQoL, was assessed using the 36 Item Short Form Health Survey (SF-36). Multivariable linear regression models examined the independent association between diagnostic group (FND vs migraine) and HRQoL domains, adjusting for psychological distress, psychiatric comorbidity, and chronic pain.

Results: Sixty-eight patients (27 with FND and 41 with migraine; mean age of 44.2 years and 38.9 years, respectively) were included. Unadjusted analyses demonstrated significantly lower HRQoL in FND across all SF-36 domains, with moderate to large effect sizes. [table1] Patients with FND reported higher HADS scores and lower PGIC scores relative to migraine patients. Multivariable linear regression models accounting for psychological distress, fibromyalgia/chronic pain, and psychiatric comorbidities found that an FND diagnosis no longer independently predicted poorer HRQoL in most domains (vs migraine), apart from physical functioning, physical role limitations, and social functioning which remaining significantly associated with FND.[table2]

Conclusions: Although HRQoL impairment is more severe in FND than in migraine, this clinically meaningful difference appears largely attributable to transdiagnostic factors, particularly psychological distress, comorbid chronic pain and psychiatric disorders. Persistent impairments in physical and social functioning in the FND group, independent from psychiatric comorbidities, suggest additional disorder-specific mechanisms. These findings support integrative both mind-body and mechanism-informed treatment approaches addressing shared vulnerabilities across FND and pain-related disorders.

References:
1.Hallett M, Aybek S, Dworetzky BA, et al. Functional neurological disorder new subtypes and shared mechanisms. Lancet Neurol.2022;21:537-550.
2.Sedley W, Kumar S, Jones S, et al. Migraine as an allostatic reset triggered by unresolved interoceptive prediction errors. Neurosci Biobehav Rev.2024;157:105536.doi:10.1016/j.neubiorev.2024.105536

9    CLINIC-BASED ASSESSMENT AND TREATMENT STRATEGIES FOR FUNCTIONAL NEUROLOGIC DISORDERS (Treatment)
Ava Cicio, PT, DPT, re+active physical therapy and wellness

Background: Functional neurologic disorder (FND) is a common cause of disability and distress among people seen in outpatient neurology. FND is the second most common reason for people to consult outpatient neurology services, after headaches. Whereas evidence demonstrates the efficacy of interdisciplinary care in treating people with FND, access to programs remains limited, and the diagnosis and treatment process can be lengthy, ranging from months to years. There is an urgent need for neurologists to provide effective diagnosis, screening, treatment, and referral for people with FND. In this article, we provide a framework for tangible FND screening, FND treatment strategies, and resources to use in outpatient clinical visits.

An FND evaluation begins by confirming the diagnosis through positive clinical signs that lend themselves directly to treatment. The diagnostic process also includes screening for co-morbid conditions and identifying underlying and contributing factors. Contributing factors include motor control impairments, sensory processing differences, autonomic dysfunction, and lifestyle and psychosocial factors. By focusing on these contributing factors, neurologists can provide effective treatment within a clinical visit, and begin the referral process for additional rehabilitation support.

Conclusion: Neurologists play an important role in the diagnosis and management of FND. Providing clear diagnosis, treatment, and referral in the clinic visit will help expedite care and reduce disability for people with FND. An evidence-based framework for screening, treatment, and referral will assist neurologists as they seek to provide diagnostic clarity, identify and address comorbid conditions, and provide appropriate referrals and resources.

References:
1. Bennett K, Diamond C, Hoeritzauer I, et al. A practical review of functional neurological disorder (FND) for the general physician. Clin Med (Lond). 2021;21(1):28-36. doi:10.7861/clinmed.2020-0987
2. Stone J, Carson A, Duncan R, et al. Who is referred to neurology clinics? The diagnoses made in 3781 new patients. Clin Neurol Neurosurg. 2010;112(9):747-751. doi:10.1016/j.clineuro.2010.05.011
3. Stone J, Burton C, Carson A. Recognising and explaining functional neurological disorder. BMJ. 2020;371:m3745. doi:10.1136/bmj.m3745

10    OUTCOMES OF A MULTIDISCIPLINARY, COMMUNITY-BASED ONLINE MEMBERSHIP MODEL FOR INDIVIDUALS WITH FUNCTIONAL NEUROLOGICAL DISORDER (Phenomenology/Epidemiology)
Ava Cicio, PT, DPT, re+active physical therapy and wellness

Background: Functional Neurological Disorder (FND) is a complex condition requiring individualized, multidisciplinary care. While evidence supports education and mind–body approaches for FND, access to coordinated, ongoing care remains limited. Community-based models may address gaps in continuity, self-management, and social support. This abstract presents outcomes from an online FND membership program designed to support nervous system regulation, functional recovery, and patient empowerment through education, movement, and peer connection.

Case Presentation: re+active’s FND Membership is a structured program that includes weekly live education classes, weekly group classes: mind–body classes, exercise and pacing classes, and yoga. Members also participate in an online community that fosters peer support and shared problem-solving. Each member creates a personalized “pie chart” that allocates time and energy toward their highest-priority needs (e.g., sensory, autonomic, lifestyle, psychosocial, motor control and physical impairments).
Outcomes are tracked using two patient-reported measures: the Patient Global Impression of Change (PGIC) and the Patient-Specific Functional Scale (PSFS). Across the membership cohort, the average PGIC score was 5, corresponding to “moderately better,” with 73% of participants reporting meaningful improvement. On the PSFS, average functional scores improved from 28% to 51%, with a mean increase of 6.2 points.

Case 1 demonstrated substantial improvement in functional mobility, fatigue management, and confidence in daily activities over approximately two months of participation. Case 2 is a woman with functional seizures and weakness who improved from 14 hour seizures to seizure free over eight months in the membership,  alongside increased engagement in meaningful life roles. Both participants attributed improvements to consistent education, graded movement, nervous system regulation strategies, and community support.

Discussion: These cases and cohort outcomes suggest that a multidisciplinary, membership-based model may support clinically meaningful functional improvements for individuals with FND. The combination of education, movement, pacing, mind–body practices, and peer connection appears to facilitate sustained engagement and individualized self-management. The personalized “pie chart” framework may be particularly valuable in helping participants adapt care strategies as symptoms and capacity change. While limited by observational design and self-reported measures, these findings highlight the potential role of community-based programs as a complement to traditional FND care.

References:
Nielsen G, et al. Outcome measures in functional neurological disorder. J Neurol Neurosurg Psychiatry.
Stratford PW, et al. Assessing clinical change with the Patient-Specific Functional Scale. Phys Ther.

11    UTILITY OF LABORATORY-SUPPORTED TEST BATTERY IN EVALUATING FUNCTIONAL OVERLAY: CASE SERIES AND LITERATURE REVIEW (Phenomenology/Epidemiology)
Oday Halhouli, MD, NIH/NINDS

Background: Functional movement disorders are commonly encountered in routine clinical practice and may coexist with organic neurological disorders, a phenomenon referred to as functional overlay. Recognition of functional overlay is vital to avoid iatrogenic harm and to adequately manage affected patients. Neurophysiology can provide valuable insight in complex clinical scenarios. Laboratory-supported diagnostic criteria for functional tremor have been recently proposed using the 10-item Schwingenschuh test battery, in which a cut-off score of at least 3 out of 10 yielded a sensitivity of 89.5% and a specificity of 95.95%. However, this test battery has not been evaluated in complex cases involving functional overlay. Here, we present five cases in which we used this test battery to confirm the presence of coexistent functional tremor in patients with comorbid organic tremor. Surface electromyography (EMG) was recorded from the bilateral flexor carpi radialis and extensor carpi radialis muscles. Tremor was recorded with accelerometers attached to the dorsum of each hand. Tremor was recorded at rest, posture (with and without loading), and action, while performing tapping tasks (at 1, 3, and 5 Hz), and while performing ballistic movements with the less-affected hand.

Case Presentation: We describe five patients (2 women, 3 men) with suspected comorbid functional tremor who were referred for neurophysiological testing. Four patients had essential tremor (ET), and one patient had parkinsonian tremor. One ET patient was evaluated in the setting of presurgical assessment, and one ET patient was seen after DBS implantation in whom multiple programming attempts did not provide satisfactory benefit on one side. Three patients had functional overlay in both hands and two patients had functional overlay in one hand. The average score of the test battery in the hands affected by functional overlay was 4.75. 

Discussion: Neurophysiology can provide valuable insight into complex clinical movement disorders cases, and can aid diagnosis and guide management. Here, we present the utilization of this tool in five cases of coexistent functional tremor confirmed using a laboratory-supported test battery. 

References:
1. Schwingenschuh P, Saifee TA, Katschnig-Winter P, et al. Validation of "laboratory-supported" criteria for functional (psychogenic) tremor. Mov Disord. 2016;31(4):555-562. doi:10.1002/mds.26525
2. Chou CZ, Ahlskog JE, Klassen BT, Coon EA, Ali F, Bower JH, Savica R, Hassan A. Utility of routine surface electrophysiology to screen for functional tremor prior to surgical treatment of essential tremor. Clin Park Relat Disord. 2022 Jun 16;7:100149. doi: 10.1016/j.prdoa.2022.100149. PMID: 35928768; PMCID: PMC9344345.

12    CLINICAL OUTCOMES, COMORBIDITIES, AND SEIZURE TRIGGERS IN FUNCTIONAL SEIZURES FOLLOWING MINDFULNESS-BASED COGNITIVE THERAPY: A RETROSPECTIVE COHORT STUDY (Phenomenology/Epidemiology)
Sarah Hawkes, University of Oxford

Background: Functional (dissociative) seizures (FS) are associated with substantial clinical complexity, including high psychiatric and medical comorbidity and heterogeneous seizure triggers. Mindfulness-Based Cognitive Therapy (MBCT) is increasingly used within FND services, yet real-world data integrating outcomes with comorbidity and trigger profiles remain limited.

Methods: A retrospective chart review was conducted of all patients referred to MBCT for diagnosed or suspected functional seizures between 2013 and 2025 within a specialist neuropsychology service (N = 205). Electronic patient records were reviewed for seizure frequency pre- and post-MBCT, post-course symptom outcomes, course attendance, epilepsy status, psychiatric and neurodevelopmental diagnoses, medical comorbidities, and patient-reported seizure triggers. Medical comorbidities were coded by organ system and mechanism, and triggers were grouped into thematic categories. Quantitative analyses examined seizure frequency change, symptom outcomes, dose–response effects, and associations with clinical variables.

Results: MBCT participation was associated with a significant reduction in seizure frequency, with a mean decrease of approximately 200 seizures over a standardised six-month interval (p < .001). Most participants completing at least one full MBCT course reported reduced symptom burden, with more favourable outcomes among full compared with partial completers. A categorical dose–response relationship was observed for seizure reduction. Baseline seizure frequency was the only robust predictor of improvement; demographic variables, psychiatric comorbidity, neurodivergence, epilepsy status, and medical comorbidity burden were not associated with outcomes.
Comorbidity burden was high, with a mean of 6.6 comorbidities per patient across medical, psychiatric, and neurodevelopmental domains. Psychiatric conditions were present in 81.5% of the cohort, most commonly depression, anxiety, PTSD/CPTSD, and suicidal ideation or self-harm. Neurodevelopmental conditions were identified in 25.9% of patients, and 27.8% had co-occurring epilepsy. Seizure triggers were frequently multifactorial, most commonly emotional or psychological stress (56.6%), mood dysregulation (31.7%), systemic strain including illness, infection, or head trauma (25.9%), and fatigue or sleep disruption (13.7%).

Conclusions: In this large retrospective cohort, MBCT referral was associated with meaningful reductions in seizure frequency and symptom burden across a highly comorbid FS population. The extensive multimorbidity and diverse trigger profiles observed support a biopsychosocial framework for functional seizures and highlight the importance of integrated, multidisciplinary approaches to treatment.

References:
Baslet G, Ehlert A, Oser M, Dworetzky BA. Epilepsy & Behavior, 2020.
Brown RJ, Reuber M. Clinical Psychology Review, 2016.

13    EXPLORING COMMUNITY PERSPECTIVES ON FUNCTIONAL NEUROLOGICAL DISORDER AND REDUCING MENTAL HEALTH AND DISABILITY STIGMA IN UNDERSERVED INALND EMPIRE COMMUNITIES (Phenomenology/Epidemiology)
Andrew Helson, Arrowhead Regional Medical Center

Mental health and disability-related stigma remain pervasive barriers to care in underserved communities, particularly within the Inland Empire, where socioeconomic inequities and limited access to culturally responsive services disproportionately affect help-seeking behaviors. This exploratory qualitative study examines how community members, healthcare workers, and future healthcare professionals perceive stigma related to mental health and disability, with a specific focus on functional neurologic disorder (FND). By centering on community perspectives, the study aims to identify culturally embedded beliefs, structural barriers, and professional practices that influence the acceptance of diagnosis, disclosure, and treatment engagement. Findings will inform the development of culturally responsive, community-informed outreach, education, and support initiatives that align with the mission of the CUSM Center for Brain and Behavioral Health, promoting mental health equity.

This study employs a cross-sectional, mixed-methods exploratory design grounded in community-based research principles. Data is administered via self-administered, web-based surveys that include both structured quantitative items and open-ended qualitative questions. Surveys will be administered via SurveyMonkey across three participant groups: (1) adults from underserved Inland Empire communities, (2) healthcare workers (including nurses, CNAs, PT/OT professionals, and trainees), and (3) medical students at the California University of Science and Medicine (CUSM).

This survey-based mixed-methods approach is well-suited to capturing community perspectives, professional experiences, and sociocultural contexts related to stigma, diagnosis acceptance, and engagement in care, while minimizing participant burden and risk. Qualitative data will be derived exclusively from open-ended Survey responses.

References:
Woo, S., Perez, D. L., & Dworetzky, B. A. (2025).
Socioeconomic and cultural determinants of functional neurological disorder: Gaps and future directions. Epilepsy & Behavior Reports. Advance online publication. https://doi.org/10.1016/j.ebr.2024.100XXX
McLoughlin, R., McWilliams, S., & Stone, J. (2024).
Stigma, legitimacy, and functional neurological disorder: A systematic review. Journal of Psychosomatic Research, 176, 111586. https://doi.org/10.1016/j.jpsychores.2023.111586

14    WHAT WORKS? A LIVED-EXPERIENCE SURVEY OF THE MOST EFFECTIVE TREATMENT ELEMENTS FOR FUNCTIONAL SEIZURES (Treatment)
Lana Higson, Monash University/Alfred Hospital

Background: The value of incorporating lived experience into research is increasingly recognised, however, traditional functional seizure treatment studies assess treatment efficacy prior to ascertaining real-world effectiveness. This study aimed to gather firsthand accounts from individuals about their personal experiences with treatments for functional seizures, including therapies, tools, strategies, and interventions most helpful regardless of formal treatment engagement. 

Methods: We administered a brief survey to adults who self-reported a diagnosis of functional seizures from a medical professional. Participants were recruited internationally through an open access questionnaire via social media and patient groups over a month-long period. The survey was also administered to past and present patients of The Alfred Hospital’s functional seizures clinic. 

Results: Of 244 respondents, 64% had received treatment and 36% were untreated. The most prominent reason for non-treatment was non-referral for treatment (73%). In those who were treated, there were significant, moderate, positive associations between better or seizure-free status and those who were advised to engage in movement/exercise (p = .002, Cramer’s V = 0.26), cognitive behavioural therapy/cognitive reframing (p = .003, Cramer’s V = 0.24), or grounding/sensory strategies (p = .014, Cramer’s V = 0.20). Regardless of receiving formal treatment or not, the top four strategies deemed most helpful for managing functional seizures were grounding/sensory strategies (46%), practical changes to home/school/work life (41%), breathing/breath work (31%), and movement/exercise/physical activity (27%). 

Conclusions: Individuals with functional seizures who received treatment were more likely to have improvement or resolution of their seizures. Irrespective of treatment modality or provider, salient factors in recovery identified by those with lived experience can inform the design of functional seizure interventions.

15    FUNCTIONAL, FACTITIOUS, OR FAKE? UNTANGLING THE ORIGIN OF INCONGRUOUS SYMPTOMS IN THE CASE OF A YOUNG ADOLESCENT GIRL (Phenomenology/Epidemiology, Etiology/Pathophysiology)
Alison Wilkinson-Smith, PhD, Children's Medical Center Dallas

Introduction: FND in pediatrics is increasingly well-studied. An FND diagnosis requires symptoms incompatible with neurological disease (positive signs), but positive signs may be present for consciously produced symptoms. Factitious Disorder (FD) and malingering are not as well understood in pediatric populations. Features of these disorders in adults (e.g., financial incentives or healthcare background) may not be seen in pediatrics. Differentiating between FND, FD, and malingering is challenging in pediatrics. Symptoms may be consciously produced in patients who also have FND. These symptoms have different implications for treatment and prognosis. We present a case example of a 13-year-old girl to examine symptoms, highlight multidisciplinary collaboration, and discuss treatment options.

Case: A 13-year-old girl was admitted to the inpatient rehabilitation unit with multiple complaints. At admission, she had lost independence in most activities of daily living, including walking, toileting, and bathing. She had dissociative seizures, chronic pain, memory loss, behavioral regression, dysmenorrhea, and vision loss. Initially, all symptoms were thought to be FND and somatic disorders. She completed inpatient rehabilitation and was followed by multidisciplinary pediatric FND and pain clinics, psychiatry, and psychology. She participated in outpatient physical therapy and psychotherapy, enrolled in multiple psychiatric programs, and trialed many medications. Her presentation evolved. It became clear that some symptoms were consciously produced (e.g., she reported severe menorrhagia requiring excessive use of feminine hygiene supplies but was throwing them away unused and admitted she had not experienced menarche) with motivations of both primary and secondary gain. Two years later, symptoms related to FD and malingering are largely resolved. FND and somatic symptoms are improved but still present. The patient’s independence is greatly increased. 

Discussion: Our patient’s symptoms were first thought to be driven by unconscious processes. With monitoring and multidisciplinary collaboration, volitional production of symptoms was discovered and addressed. Reducing primary and secondary gain resulted in improvement and may have been overlooked if she had been viewed completely through a somatic lens. At the same time, established FND treatments were important to recovery, and thus a fully behavioral lens would have been equally unhelpful. We encourage those working with patients with FND to consider FD and malingering as alternatives or comorbidities.

References:
Ruppert, R. & Mao, KJ. The girl who cried wolf: A literature review and case report of pediatric factitious disorder. Clin. Child Psychol. Psychiatry. 2021; 26(3): 695-705. DOI: 10.1177/1359104521996742
Ernzen, JA, Gershan, SA, & Pergjika, A. A review of malingering within the child and adolescent psychiatric population. Psychiatr. Ann. 2025; 55(5): e121-e125. DOI: 10.3928/00485713-2

16    FUNCTIONAL MOVEMENT DISORDERS TREATMENT: PROGRAM DEVELOPMENT IN THE OUTPATIENT COMMUNITY SETTING (Treatment)
David Hinkle, MD, PhD, OhioHealth Neuroscience

Background: We developed a community health system-based outpatient functional movement disorder (FMD) treatment program combining simultaneous cognitive behavioral (CBT) and motor retraining therapies (MRT).1,2

Methods: Two movement disorders neurologists diagnosed and educated patients about FMDs and their treatment. In Phase 1 (year 1), patients were referred directly by the neurologists to the combined CBT/MRT treatment program. The program employed 2 CBT and 2 MRT sessions per week, each 1 hour in duration, for 4 weeks (8 total sessions of each treatment modality). Retention was not where we wanted it to be at the end of year 1, therefore, we updated our education and referral process. In Phase 2 (year 2), the same treatment program was used, but to improve referral retention we (i) required patients to take written FMD materials home for consideration prior to requesting referral by the neurologist to a CBT therapist, and (ii) required that each patient be cleared for “treatment readiness” by that therapist prior to referral to the combined CBT/MRT treatment program. For each phase we collected simplified FMD Rating Scale (sFMDRS) scores pre-treatment and within 2 months post-treatment. We also collected referral and retention data for each phase.
 
Results: In Phase 1, the post-treatment sFMDRS mean score was significantly lower (less FMD symptoms) than the pre-treatment mean: 3.8 ± 1.3 vs. 16.3 ± 1.9, respectively, p < 0.001 by paired-t test. In Phase 2, the post-treatment sFMDRS mean score was again significantly lower than the pre-treatment mean: 6.3 ± 1.0 vs. 20.2 ± 2.2, respectively, p < 0.001. In Phase 1, 59 patients were diagnosed with an FMD: 85% were referred to the treatment program, 37% started the program, and 17% completed the program. In Phase 2, 51 patients were diagnosed with an FMD: 78% were referred to the treatment program, 71% started the program, and 45% completed the program.

Conclusions: In each phase, sFMDRS scores were significantly lower post-treatment compared to pre-treatment, supporting clinical improvement in response to the treatment program. Our updated Phase 2 referral approach improved treatment program retention. We conclude that outpatient treatment of FMDs can be successful in a non-academic, community setting. Clinicians who are initially inexperienced with FMD treatment can use published guidelines, combined with their own experience, to successfully deliver therapy. Treatment program retention can be improved by pre-program focus on education-related “buy-in” and identification of, or treatment towards, greater psychological “readiness” for treatment. We identified and will discuss our own learned “clinical pearls” for CBT and MRT for FMD.   

References:
1Gutkin M et al. Systematic review of psychotherapy for adults with FND. J Neurol Neurosurg Psychiatry 2020
2Nielsen G et al. Physiotherapy for functional motor disorders: a consensus recommendation. J Neurol Neurosurg Psych 2015

17    DEVELOPMENT OF A DIGITAL PHYSIOTHERAPY WORKBOOK FOR FUNCTIONAL MOTOR DISORDER: PROTOTYPE DESIGN AND EARLY CLINICAL IMPLEMENTATION (Treatment)
Kate Holt, City St George’s, University of London

Background: Physiotherapy, as part of a multidisciplinary treatment approach, has a growing evidence base for Functional Motor Disorder (FMD), with some promising findings from our recent multi-centre randomised controlled trial of specialist physiotherapy [1]. In this trial, treatment was guided by a workbook designed to support patient engagement, promote active participation in rehabilitation, and facilitate self-management. The workbook also provided physiotherapists with a framework for delivering a specialist, structured, and collaborative intervention while maintaining individualisation. Previous qualitative research found that patients valued the workbook for providing direction, momentum, validation of diagnosis, and a sense of empowerment [2]. However, the workbook is currently paper-based, limiting accessibility and sustainability. We therefore aimed to develop a digital version that preserves its therapeutic value while improving usability and accessibility.

Methods: The original workbook was iteratively developed within clinical practice and refined through feasibility work and trial implementation. Building on this foundation, we partnered with a design company to create a digital workbook in an app-style format. The prototype was designed to retain the core therapeutic principles of the original version while enhancing usability and accessibility.
Key objectives included cross-platform compatibility (smartphone, tablet, and desktop), intuitive navigation, clear readability, and the ability to document physiotherapy treatment for the benefit of both patient and physiotherapist. 

Results: We have developed a working digital prototype that replicates the structure and therapeutic intent of the original workbook while enhancing portability. The platform allows sequential module completion, reflective documentation, charting of outcomes, and export of a consolidated summary of the rehabilitation journey. The prototype will be presented in this poster, with demonstration pages and live free to download access. 

Conclusions: The first digital prototype of our physiotherapy workbook for FMD has been completed and will be presented at this conference. The next phase will involve structured patient and clinician feedback and a collaborative co-design process to iteratively develop a Version 2.0 platform that is responsive to user experience and clinical need. Longer-term goals include adaptation of digital workbooks for multidisciplinary rehabilitation and overlapping conditions, development of appropriate versions for young people and adolescents, culturally responsive translation, and formal evaluation of clinical and implementation outcomes.

References:
1.Nielsen G, et al. Specialist physiotherapy for functional neurological disorder: a multi-centre randomised controlled trial. Lancet Neurol. 2024
2.Nielsen G, et al. The experience and meaning of rehabilitation in functional neurological disorder: a qualitative study Disabil Rehabil. 2019

18    NAVIGATING THE OVERLAP OF FND, POTS AND RUMINATION DISORDER: DIAGNOSTIC AND ETHICAL CHALLENGES (Phenomenology/Epidemiology)
Roberto Infante Rosado, MD, Johns Hopkins Hospital

Introduction: Functional symptoms in other body systems can occur alongside FND. Functional GI symptoms, particularly nausea and vomiting, have been characterized using the Rome criteria and DSM. Nausea and vomiting have also been associated with postural tachycardia syndrome (POTS) due to various etiologies. We present a patient with FND and POTS admitted to the hospital for worsening nausea and vomiting, highlighting the diagnostic challenges and ethical dilemmas that arose from her comorbid diagnoses.  

Case Presentation: BC is a 16-year-old-female with a history of FND with non-epileptic seizures and bilateral leg weakness, POTS, and hypermobility. BC was admitted to the hospital for acute-on-chronic nausea and vomiting. Nausea and vomiting of undigested food occurred about 10-15 minutes after every meal, resulting in weight loss and school absences.  

Despite a bowel cleanout and antiemetics trials, BC continued to regurgitate food. Upper GI endoscopy with biopsies was unremarkable. Nasogastric and nasojejunal tubes were placed repeatedly but were dislodged due to vomiting; thus, preventing adequate nutritional intake. Psychiatry was consulted to assist with diagnostic clarification and to address anxiety. Eating disorders were ruled out and close in-room observation excluded tube manipulation. 

The team ultimately diagnosed rumination syndrome with functional features. Psychology implemented diaphragmatic breathing after meals, but BC continued to fall short of her hydration and caloric goals. With weight loss, BC’s parents became focused on additional testing and feeding tube placement. BC began to describe worsening of FND-related leg weakness as hospitalization limited her ability to participate in therapy. Gastrojejunostomy (GJ) tube placement was performed on day 34 of hospitalization. Following the procedure, her oral intake improved and regurgitation decreased. BC was discharged home with the GJ tube and formula feeds on day 36 to follow-up with gastroenterology, psychiatry, psychology, neurology, and nutrition. 

Ethical dilemmas that arose included balancing the family’s autonomy with shared decision-making, advocating against over attribution to FND while minimizing iatrogenic harm from extraneous procedures or treatments, the risk of fragmented care that can occur with large multidisciplinary teams, and considerations of justice. 

Discussion: We believe this case highlights the interconnectedness of psychiatric, neurological, and GI symptoms and underscores the importance of a multidisciplinary approach. We also propose a framework for approaching management.  

References:
Mavroudis I, et al. Comorbidities Across Functional Neurological Disorder Subtypes: A Comprehensive Narrative Synthesis. Life (Basel). 2025;15(8):1322. Published 2025 Aug 20. doi:10.3390/life15081322 
Benbadis S, et al. A broader perspective: Functional symptoms beyond Neurology. Epilepsy Behav Rep. 2021;18:100506. Published 2021 Nov 25. doi:10.1016/j.ebr.202

19    LONGITUDINAL GAIT CHANGES IN FUNCTIONAL NEUROLOGICAL DISORDER: A 12-MONTH PROSPECTIVE STUDY (Phenomenology/Epidemiology)
Sara Issak, PhD Candidate, University of Melbourne and Epworth Healthcare

Background: Functional gait disorder (FGD) is a subtype of functional neurological disorder (FND) characterised by abnormal walking patterns. Long-term symptom progression and factors influencing gait changes in FGD remain poorly understood. The aim of this study was to investigate longitudinal changes in gait and associated symptoms over 12 months in individuals with FGD and examine whether changes in specific symptoms are associated with changes in gait.

Methods: Individuals with FND and altered gait completed an online survey at baseline and 12-month follow-up. The survey collected data on symptom severity, gait changes, and standardised outcome measures. Analyses included descriptive statistics, linear mixed models, and spearman’s rank correlations.

Results: Of 156 baseline respondents, 65 completed the 12-month follow-up. Sixteen (28.5%) reported worsening gait, 17 (30.4%) no change, 13 (23.2%) improvement, and 10 (17.8%) fluctuating gait. Linear mixed-model analyses showed no significant within-subject changes in motor or non-motor symptom severity from baseline to 12 months. Greater baseline functional seizure severity was strongly associated with poorer gait outcomes at 12 months (Rₛ = –0.750, p < .001, n = 17). Higher muscle rigidity severity at 12 months was also strongly associated with worse gait (Rₛ = –0.604, p < .001, n = 30).

Conclusions: This study provides insights into the natural course of functional gait disorder over time, based on participant self-report, revealing heterogeneous trajectories. Exploratory analyses found that functional seizure and muscle rigidity severity were associated with gait decline. 

Reference: 10.1016/j.jpsychores.2025.112408

20    BUILDING A RESEARCH ROADMAP FOR THE MIGRAINE–FND INTERFACE: STAGED SCOPING REVIEW OF EMPIRICALLY TESTED CONSTRUCTS AND A UK CLINICIAN SURVEY (Etiology/Pathophysiology)
Marie Jasim, MBBS, Torbay and South Devon NHS Foundation Trust

Background: Migraine and FND frequently co-occur. How clinicians navigate overlap presentations and diagnostic boundaries is poorly characterised, limiting prioritisation of research questions. The empirical migraine–FND interface is hard to delineate. Papers addressing both conditions are sparse and heterogeneous, and proposed links are often mechanistic without direct testing. In migraine research, FND-relevant constructs may be operationalised under heterogeneous terminology and paradigms, so diagnostic co-mention searches may miss relevant evidence.

Methods: Mixed-methods exploratory design combining a clinician survey and staged scoping review. We surveyed UK consultant clinicians with a special interest in FND to contextualise challenges. We conducted a staged scoping review to map empirically operationalised constructs central to contemporary FND frameworks within migraine and migraine–FND interface literature. Searches (MEDLINE, Embase, PsycINFO) identified: (S1) papers where the migraine–FND interface was the primary focus, extracting proposed shared mechanisms and whether tested; (S2) a versioned construct lexicon anchored to five domains using an a priori framework [1] and the FNDS online resource library [2]; (S3) application of the lexicon to migraine literature with title/abstract screening, including adult empirical studies where constructs were operationalised.

Results: S1 identified 9 interface-focused publications; mechanistic overlap was commonly discussed but infrequently tested in comorbid samples. In S3, empirical coverage was uneven across domains and concentrated in emotion processing and attention [table1]. These studies most often used neuroimaging or electrophysiology; interoception studies more often included direct measures of interoceptive accuracy, sensibility, and prediction error style metrics. Survey responses (n=21; 29%) indicated high perceived comorbidity (median 50% of FND caseload) and diagnostic ambiguity at the hemiplegic migraine boundary (median estimate 90% of previously labelled hemiplegic migraine cases better conceptualised as migraine with functional symptoms).

Conclusions: Empirical migraine research operationalises several constructs central to contemporary FND frameworks, but coverage is uneven and comorbid mechanistic studies remain scarce despite high perceived clinical comorbidity and diagnostic uncertainty. Evidence is strongest for emotion processing/salience and attention, emerging for interoception, and minimal for explicitly tested agency and predictive processing under current terminology. Priorities include comorbid cohort designs using established paradigms and careful phenotyping at key diagnostic boundaries.

References:
1.Drane DL et al. A framework for understanding the pathophysiology of functional neurological disorder. CNS Spectr. 2020.
2.Functional Neurological Disorder Society. Pathophysiology and Etiology. https://www.fndsociety.org/members/fnds-resource-librar

21    THE STARDUST PROJECT: INVESTIGATING ALTERED MOTION PERCEPTION & ITS CONSEQUENCES IN PERSISTENT POSTURAL-PERCEPTUAL DIZZINESS (PPPD)BACKGROUND: PPPD IS A FUNCTIONAL NEUROLOGICAL DISORDER WITH CORE VESTIBULAR SYMPTOMS AND SPECIFIC PROVOKING FACTORS. THE STA (Etiology/Pathophysiology)
Andrew Jones, MBChB, University of Manchester

Background: PPPD is a functional neurological disorder with core vestibular symptoms and specific provoking factors¹. The STARDUST (STudy to Assess and Reduce Dizziness in PPPD Using Sensory Theory) project investigates altered sensory perception contributing to PPPD symptoms. Specifically, we test the mismatch hypothesis, suggesting that symptoms might arise from inappropriate compensation for reafferent visual signals. We also test the integration hypothesis suggesting that suboptimal visual-vestibular combination (compared to near-optimal integration in controls²) may contribute to PPPD pathophysiology. 

Methods: Individuals with PPPD (N=21) and age-matched controls completed experiments over two days. Dizziness symptom characteristics were assessed using questionnaires. Phase 1 consisted of stationary visual tasks simulating observer forward/backward motion, assessing compensation mechanisms for reafferent visual self-movement signals. Phase 2 consisted of motion platform tasks assessing visual-vestibular integration², motion-capture quiet stance posturography, and a VR walking task assessing gait and obstacle avoidance. Posturography was performed under different stance (Romberg, tandem) and visual input (eyes open/closed) conditions. Head kinematic time-series were used to derive sway metrics including path length, RMS acceleration, and sway area (95% prediction ellipse area). Here we present an interim analysis.

Results: Patients exhibited greater sway than controls, with sway increasing under more demanding balance conditions. However, during the most challenging tandem eyes-closed condition the PPPD group showed lower sway area than controls, potentially reflecting maladaptive postural stiffening [figure1]. A 2×(2×2) mixed ANOVA of log-transformed ellipse area showed a significant Group×Stance×Vision interaction (F(1,20) = 6.67, p = .018, ηp² = .25), indicating that sway responses to sensory conditions differed between groups. The overall group main effect was not significant (F(1,20) = 2.40, p = .137) in the interim analysis. Descriptively, in the tandem eyes-closed condition mean sway area was 0.066 ± 0.036 m² in controls compared with 0.020 ± 0.013 m² in PPPD [figure2]. Within the PPPD group, dizziness-related disability (DHI score) correlated positively with sway area in Romberg stance conditions (Romberg open: ρ = 0.71, p = .001, n = 18; Romberg closed: ρ = 0.68, p = .002, n = 17).

Conclusions: These interim findings provide evidence for altered postural control in PPPD consistent with maladaptive stiffening strategies, suggesting sensorimotor network dysfunction in the condition. Future work will integrate postural and visual-vestibular perceptual measures to investigate causal mechanisms underlying symptoms. Motion-capture posturography will also be evaluated as a potential outcome measure for VR-based rehabilitation interventions.

References
1. Staab et al., 2017. J Vestib Res.
2. Yakubovich et al., 2020. Brain Commun.

22    CHALLENGES & CARE RECOMMENDATIONS OF PERSONS WITH FUNCTIONAL NEUROLOGICAL DISORDER AND CARE PARTNERS (Phenomenology/Epidemiology, Treatment)
Daniyal Kashif, University of Toronto

Background: Functional Neurological Disorder (FND) is a common yet underrecognized neurological condition characterized by fluctuating motor, sensory, and cognitive symptoms arising from dysfunctional neural network communication. Despite its high prevalence, people living with FND frequently encounter stigma, diagnostic delays, and limited access to appropriate care. In Canada, patient informed research examining lived experiences with the healthcare system remains limited. This qualitative study explored challenges faced by people with FND and their care partners in navigating the Ontario healthcare system and identified patient driven recommendations to improve FND care.

Methods: A qualitative descriptive study informed by patient journey mapping was conducted. Purposive sampling recruited adult patients diagnosed with FND and care partners residing in Ontario, Canada. Two semi structured focus groups were held via Zoom in May 2025 following a provincial advocacy roundtable. Discussions explored diagnostic experiences, access to care, interactions with healthcare providers, and recommendations for improvement. Sessions were audio recorded, transcribed, anonymized, and analyzed using an inductive thematic approach with open, axial, and selective coding supported by NVivo software. Data collection continued until thematic saturation was reached. Ethics approval was obtained from the University of Toronto Research Ethics Board.

Results: Thirteen participants, including eleven patients and two care partners, participated [table1]. Participants reported substantial diagnostic delays, frequent misdiagnoses, repeated emergency visits, and high out of pocket healthcare costs. Three stages of the patient journey accounted for most challenges [figure1]: searching for a diagnosis that fits, accessing appropriate treatments, and seeking initial and recurrent medical care. Barriers included limited FND knowledge among healthcare providers, stigma and disbelief, long wait times for specialists, lack of publicly funded FND informed therapies, fragmented care models, and geographic and financial barriers. Participants often self educated and self advocated, leading to emotional distress and reduced trust in the healthcare system. Recommendations focused on four priorities: education and training, integrated service programs, patient led advocacy, and increased funding.

Conclusions: People living with FND in Ontario experience persistent challenges across the continuum of care driven by stigma, limited provider knowledge, and inadequate service infrastructure. Patient informed recommendations highlight the need for education, integrated care models, advocacy, and sustainable funding. Incorporating lived experience into policy and service design is essential to improving equity, access, and outcomes for this underserved population.

23    WHEN TIME MATTERS MOST: HEALTHCARE PATHWAY DELAYS PREDICT OUTCOME IN PEDIATRIC FUNCTIONAL MOTOR DISORDERS (Phenomenology/Epidemiology)
Dario Esposito, Sapienza University of Rome

Background: Prognostic indicators in pediatric Functional Motor Disorders (FMD) remain poorly defined. While overall outcomes are often favorable, the impact of healthcare pathway variables (such as diagnostic delay and referral fragmentation) has not been systematically examined in European multicenter pediatric cohorts. Previous pediatric data suggest heterogeneous outcomes and limited robust predictors of recovery [1], while adult studies highlight the negative impact of prolonged symptom duration [2].

Methods: We conducted a retrospective multicenter study across two tertiary pediatric hospitals (Italy and Czech Republic). Seventy-two patients aged 9–18 years with clinically established FMD were included. Motor severity was assessed using the Simplified Functional Movement Disorder Rating Scale (S-FMDRS) at baseline, 6 months, and 12 months. Clinical variables included disease duration at first evaluation, number of prior referrals, symptom phenotype, psychiatric comorbidity, and therapy timing. Longitudinal analyses and multivariable regression models were performed.

Results: Motor severity significantly improved over time (mean S-FMDRS: 10.25 at baseline vs. 3.55 at 12 months; p < .001), with remission in 43.1% of patients. Longer disease duration predicted higher severity at baseline (β = 1.18, p = .022), 6 months (β = 2.05, p < .001), and 12 months (β = 1.78, p < .001). A greater number of prior referrals independently predicted worse severity at 12 months (β = 1.05, p = .038). Delayed treatment initiation was associated with persistently higher motor severity across follow-up. No consistent prognostic role emerged for sex, symptom phenotype, or psychiatric comorbidity.

Conclusions: In pediatric FMD, healthcare pathway variables - particularly diagnostic delay, fragmented referrals, and late treatment initiation - are associated with poorer outcomes. These findings highlight modifiable system-level factors and support early, coordinated, multidisciplinary intervention to improve prognosis.

References:
[1] Yong K, Chin RFM, Shetty J, et al. Functional neurological disorder in children and young people: Incidence, clinical features, and prognosis. Dev Med Child Neurol. 2023;65:1238–1246.
[2] Gelauff JM, Stone J, Edwards MJ, Carson A. The prognosis of functional (psychogenic) motor symptoms: a systematic review. J Neurol Neurosurg Psychiatry. 2014;85:220–226.

24    PRIMARY BLEPHAROSPASM: A FUNCTIONAL NEUROLOGICAL DISORDER PHENOTYPE? A CASE REPORT (Treatment)
Saeid Saadi, Centro Integrato Neuroscienze

Background: Primary blepharospasm is classically considered an adult-onset focal dystonia; however, increasing evidence supports a disorder of distributed brain networks with prominent non-motor features. Several clinical characteristics, including sensory discomfort, cognitive symptoms, anxiety, and contextual modulation, overlap with functional neurological disorder (FND). We report a clinically typical blepharospasm showing marked improvement following an attention- and agency-focused intervention commonly used in motor FND.

Case Presentation: A 59-year-old woman presented with a 1-year history of recurrent involuntary eyelid closure associated with gritty ocular sensation, worsened by bright light, and moderate “brain fog,” leading her to stop driving and cycling. Previous antidepressant and anxiolytic therapies were ineffective. Neurological examination revealed very frequent blinking and recurrent, stereotyped, bilateral synchronous orbicularis oculi spasms consistent with primary blepharospasm (video available). She underwent a single 45-minute session combining slow diaphragmatic breathing, bilateral transcutaneous stimulation over the temporal regions (titrated to comfortable paresthesia), light-therapy glasses with sustained upward gaze and eyes open, and frontal EMG biofeedback with repeated cycles of targeted contraction-relaxation to enhance top-down motor control and downregulation of facial muscle activity. Improvement in blepharospasm and excessive blinking was observed immediately after the session and became more evident the following day. At 6-month follow-up, symptoms remained markedly improved with no significant recurrence. The patient was advised to continue home relaxation techniques, including diaphragmatic breathing and regular light-therapy use. A video documenting the clinical improvement is available.

Discussion: This single case suggests that a subset of blepharospasm presentations may overlap with the FND spectrum and reflect modifiable network-level dysfunction across attention, perceived agency, and sensorimotor systems rather than fixed structural pathology. Prospective studies should investigate whether clinically identifiable FND-like features, such as symptom variability, attentional modulation, and disproportionate non-motor symptoms, define a subgroup preferentially responsive to attention- and agency-targeted interventions.

References:
Marsden CD. J Neurol Neurosurg Psychiatry. 1976;39:1204-1209.
Perez DL, Edwards MJ, Nielsen G, Kozlowska K, Stone J. J Neurol Neurosurg Psychiatry. 2021;92:668-677.

25    MACHINE LEARNING AS A NEW APPROACH TO CLINICAL OUTCOMES IN FND (Treatment)
Amina Farah, St George's University Hospitals NHS Foundation Trust

Background: Predicting outcome measures is integral to rehabilitation, guiding clinicians in determining suitability for therapy, personalizing treatment plans, and allocating resources efficiently. Functional Neurological Disorder (FND) is characterised by disruption of motor, sensory, and/or cognitive functions in patterns not consistent with recognised structural disease of the nervous system[1]. This study builds on our pilot work applying machine learning to better categorise and predict rehabilitation outcomes and prognosis in individuals with FND[2].

Methods: This retrospective study evaluated clinical outcomes of patients admitted for FND rehabilitation at the Wolfson between October 2020 and October 2025. Data was extracted from electronic health records and the UK Rehabilitation Outcomes Collaborative database.
The primary outcome was change in the UK Functional Independence Measure and Functional Assessment Measure (UK FIM+FAM). Improvement was defined as a ≥25% increase from baseline or achievement of the maximum score. Logistic regression (Python v3.10.12, scikit-learn) predicted the likelihood of achieving ≥25% improvement. 

Results: 67 patients with FND were admitted, 60 had sufficient data to train the model. FND symptoms included motor (95%), cognitive (76.7%), and sensory (70%) features. Overall, 88.3% had documented co-morbidities, and 56.6% had a psychiatric diagnosis, of whom 54% had depression or anxiety.

Post-Traumatic Stress Disorder (PTSD) was significantly associated with achieving ≥25% improvement in UK FIM+FAM scores. Patients with PTSD demonstrated a greater likelihood of functional gains (coefficient = 1.09, p = 0.0001). Other psychiatric conditions (acute stress reaction, bipolar disorder) (coefficient = 0.58, p = 0.0736) and neurological conditions (coefficient = 0.41, p = 0.0623) also showed positive associations. Comorbid PTSD may represent an opportunity for targeted interventions.
The model was evaluated across 1,000 bootstrapped iterations, demonstrating robust predictive performance. Overall, the model achieved 90.8% accuracy with an AUROC of 0.97.

Conclusion: Machine learning (ML), an artificial intelligence tool, has been used in various research settings. Its application in rehabilitation medicine is relatively novel; with recent studies exploring its use in clinical settings. This study demonstrates the innovative application of a logistic regression based ML model in an FND population. The model’s high accuracy suggests that baseline clinical and demographic features can predict inpatient rehabilitation outcomes, supporting the feasibility of applying ML based approaches in this clinical context.

References:
Carson A, Lehn A. Chapter 5 - epidemiology, Handbook in Clinical Neurology. 139. Elsevier 2016
Farah A, Farah A, Hassan Sheikh S, Symeon C. Using Machine Learning to Predict Response to Inpatient Rehabilitation for FND Patients. BJPsych Open. 2025;11(S1):S171-S171. doi:10.1192/bjo.2025.10449

26    MOTOR IMAGERY AS AN ATTENTION-BASED STRATEGY FOR FUNCTIONAL TREMOR DURING GAIT REHABILITATION: A CASE REPORT (Treatment)
Ayla Fil, hacettepe university, faculty of health sciences, departmetnt of physiotherapy and rehabilitation

Introduction/Background: Functional tremor is a common manifestation of functional neurological disorder (FND) and is typically characterized by variability, distractibility, and attention-dependent modulation. Physiotherapy approaches focusing on motor retraining and attentional redirection are increasingly recommended in FND rehabilitation. However, the use of motor imagery as an attention-based strategy for FND symptome has received limited attention.

Case Presentation: A 70-year-old woman diagnosed with functional neurological disorder by a neurologist presented with severe tremor predominantly affecting the lower extremities and marked gait instability. Tremor intensity increased during observation but decreased with distraction. At the initial physiotherapy assessment the patient required assistance for ambulation. Balance assessment showed impairment (Berg Balance Scale [BBS]: 27; Timed Up and Go [TUG]: 16 s with a cane).

The patient participated in four outpatient physiotherapy sessions focusing on motor retraining and attention-based strategies. Exercises included reciprocal lower-extremity movements in sitting and supine positions, core stabilization exercises, sit-to-stand training, and marching-type gait patterns emphasizing coordinated reciprocal limb movements. Rhythmic upper- and lower-extremity movements were initially used as distraction strategies, resulting in temporary tremor reduction.

Motor imagery was introduced in later sessions. The patient was first asked to simulate reciprocal arm and leg movements associated with walking while seated and then to imagine walking with coordinated limb movements before performing the movement.

Motor imagery produced immediate tremor suppression during task performance. Tremor-free periods following motor imagery were longer than those observed with other distraction strategies. During the final session, tremor suppression lasted more than 10 minutes following motor imagery practice. Balance and gait improved markedly across sessions. Berg Balance Scale improved from 27 to 49, and TUG improved from 16 seconds with a cane to 11 seconds without an assistive device under supervision. The patient reported approximately 60% overall improvement and was able to ambulate independently.

Discussion: This case highlights the potential role of motor imagery as an attention-based strategy for tremor modulation during physiotherapy in FND. Incorporating motor imagery into motor retraining programs may facilitate tremor suppression and improve gait performance in patients with functional tremor.

References
1.Nielsen G, Stone J, Matthews A, et al. Physiotherapy for functional motor disorders: a consensus recommendation. J Neurol Neurosurg Psychiatry. 2015.
2.Srzich AJ, Byblow WD, Stinear JW, Cirillo J, Anson JG. Can motor imagery and hypnotic susceptibility explain conversion disorder with motor symptoms? Neuropsychologia. 2016.

27    FEASIBILITY AND RETENTION IN A WEEKDAY MENTAL HEALTH–BASED DAY PROGRAM FOR FUNCTIONAL NEUROLOGICAL DISORDER (Treatment)
Aryandokht Fotros, MD, Brown University

Background: Data regarding engagement of individuals with Functional Neurological Disorder (FND) in intensive outpatient mental health settings remain limited. Participation may be affected by symptom emergence during groups, variability in staff expertise managing functional episodes, limited cohort peer support, and insurance-related timeline constraints. We evaluated retention in a specialized FND track embedded within an established partial hospitalization (PHP) and residential mental health program.

Methods: We conducted a retrospective descriptive review of patients with FND enrolled in a specialized track within the La Selva PHP and residential programs between 2019 and 2021. The program curriculum was designed to span approximately 45 days, with treatment duration tailored to individual needs. Participants attended five days per week in a structured day-program model. The treatment model combined standard PHP/residential skills-based group programming with dedicated FND-specific closed groups. All patients received at least weekly neuropsychiatric evaluation and weekly individual psychotherapy. Duration of enrollment (in days) was the primary feasibility outcome.

Results: Thirty patients were included (age range 19–56 years; 80% women). FND subtypes included functional seizures, motor symptoms, speech disturbances, and cognitive symptoms. Twenty-five of 30 patients (83%) remained in treatment for at least 30 days. The mean length of stay was 59 days (median 57.5; range 12-119). Only 5 of 30 patients (17%) discontinued within the first 30 days. Reasons for early discharge included acute psychiatric comorbidity and external employment constraints.

Conclusion: In this naturalistic cohort, a specialized FND track embedded within an existing community mental health day program demonstrated sustained engagement, with most participants remaining engaged beyond the initial program curriculum and low early attrition. These findings support the feasibility of managing FND within psychiatric partial hospitalization and residential infrastructure rather than requiring neurology-exclusive settings. This model may offer a scalable framework for integrating FND-specific care into established mental health systems. Further analysis will evaluate clinical outcomes and predictors of retention.

References:
Martyna M, et al. Treatments for Functional Neurological Disorder: A Practical Guide for Program Development. J Neuropsychiatry Clin Neurosci. 2025.
Lopez MR, LaFrance WC Jr. Building a Functional Neurological Disorder Program: Finding Solutions to Common Obstacles. Semin Neurol. 2026.

28    FUNCTIONAL COGNITIVE DISORDER IN A VETERAN WITH FUNCTIONAL TREMOR: THE ROLE OF DISSOCIATION AND ALEXITHYMIA (Phenomenology/Epidemiology, Etiology/Pathophysiology)
Christina Galiano, Corporal Michael J. Crescenz VA Medical Center

Introduction: Functional Cognitive Disorder (FCD), a cognitive subtype of FND, involves persistent and distressing cognitive symptoms that interfere with functioning but are not explained by structural brain pathology or other recognized etiologies. FCD frequently co-occurs with other FND symptoms (e.g., motor), chronic pain, and psychiatric comorbidities. Literature suggests that dissociation and alexithymia may represent mechanisms contributing to FND. We present a complex case of a Veteran with suspected FCD who endorsed elevated dissociative symptoms and alexithymia. 

Case Presentation: Ms. XX is an approximately 50-year-old female Veteran who completed a neuropsychological evaluation in a VA Movement Disorders Clinic. Her history included fibromyalgia, functional tremor, hyperlipidemia, metabolic syndrome, depression with psychotic features, PTSD, anxiety, and remote alcohol and substance use disorders. She described longstanding progressive cognitive impairments in early adulthood, including “severely deficient autobiographical memory,” and declines in language, processing speed, attention, and executive dysfunction. She required assistance with IADLs. Neuropsychological testing showed variable learning and memory (mild to moderate encoding and retrieval inefficiencies but intact storage) and variable weaknesses in processing speed and working memory. Language, visuospatial skills, and executive functions were intact. Most performance validity measures were normal but one measure fell below cutoff. Behavioral observations included discrepancies between reported profound memory loss and detailed recall of events. Self-report measures indicated moderate depression, anxiety, and PTSD, as well as elevated dissociation and possible alexithymia. Psychological validity testing suggested symptom magnification. She did not meet criteria for a neurocognitive disorder. Her cognitive symptoms were conceptualized as multifactorial, with contributions from PTSD, anxiety, and depression as well episodes consistent with dissociation and frequent acute anxiety. Further, her distress about cognitive lapses likely reinforced her cognitive symptoms. Chronic pain, fatigue, sleep disturbance, and medication effects were contributory. In the context of functional tremor and somatic symptoms, her presentation was most consistent with FCD.  

Discussion: This case highlights the complexity of diagnosing FCD in individuals with FND and psychiatric comorbidities. Prior research links alexithymia to greater dissociation and impaired processing of emotionally salient sensory input, a potential mechanism in FND. Dissociation in FND is also associated with greater symptom severity and poorer quality of life. This case highlights careful diagnostic formulation and identifies dissociation and alexithymia as potential mechanisms and areas of intervention in FCD.  
References: Campbell et al., 2022; Jungilligens et al.,

29    FUNCTIONAL NEUROLOGIC DISORDER AMONG GENDER EXPANSIVE PEOPLE: CLINICAL PROFILES AND PARTICIPATION IN GROUP-BASED PSYCHOTHERAPY TREATMENT (Treatment)
EJ Gann, PT, DPT, University of Colorado

Background: Accumulating evidence suggests that gender expansive people (i.e., people who identify as transgender, nonbinary, etc.) are disproportionately affected by functional neurologic disorders (FND). Societal stressors, invalidation, and discrimination may contribute to mechanisms underlying gender differences in FND. Despite increasing recognition of risk factors for FND, few studies have examined FND treatment for gender expansive people. This is a critical gap, as gender expansive people may be hesitant to engage in treatment due to the same factors that elevate their risk for FND (e.g., discrimination). Understanding differences in treatment access and response for gender expansive people with FND is imperative for developing inclusive, targeted interventions. This study characterized gender expansive people treated in the University of Colorado FND Program and examined differences in treatment engagement compared with cisgender people.  

Methods: Medical record data were analyzed retrospectively from all patients seen in our program from 2020-2025. Clinical and psychosocial characteristics, including treatment-participation variables (i.e., group psychotherapy visits scheduled, visits completed) were extracted. Gender identity was categorized as cisgender if gender identity aligned with sex assigned at birth, or gender expansive if it differed. Comparisons between cisgender and gender expansive patients were conducted using Wilcoxon rank sum test, Fisher’s exact test, and T-test as appropriate. 

Results: Records from 1253 patients were reviewed. 57 patients (4.5%) identified as gender expansive (nonbinary n=36; transgender female n=6; transgender male n=4; other=11). Compared to cisgender patients, gender expansive patients were younger (mean age 28, SD=8; p<0.01), reported higher rates of suicidal ideation (p<0.01), and were more likely to have pre-existing psychological care (p<0.01). There were no differences between groups in time from onset of FND symptoms to diagnosis (p=0.31). Gender expansive patients scheduled and completed significantly fewer group-based psychotherapy treatment sessions than cisgender patients (p= 0.013 and p= 0.028).

Conclusion: This cohort study found that gender expansive individuals are overrepresented in an FND clinical population relative to the general population (approximately 0.5-4.5%). Our findings support previous literature showing that gender expansive people are disproportionately affected by FND and suggest their participation in FND treatment differs from cisgender peers. Future studies should examine differences in treatment response for gender expansive individuals using quantitative and qualitative methods to provide a deeper understanding of how to tailor FND interventions.

References:
1.Lerario MP et al. J Psychosom Res. 2023;174:111491
2.Bradlow RCJ et al. Int J Transgend Health. 2025. doi:10.1080/26895269.2025.2538742

30    ATTITUDES TOWARD TREATING FUNCTIONAL NEUROLOGICAL DISORDERS: PSYCHOLOGICAL SERVICE PROVIDER PERSPECTIVES (Treatment)
Robin Garrett, University of Arizona College of Medicine, Phoenix

Background: Functional neurological disorders (FND) are characterized by involuntary sensory and motor symptoms that cannot be explained by any medical condition. Once diagnosed, patients are sent to mental health providers for treatment. This study focuses on mental health providers’ knowledge of FND, attitudes toward FND patients, training experiences, services provided for FND (e.g., types of therapy, assessment), perceived barriers, and willingness to receive additional training in FND.

Methods: We conducted a U.S.-based online survey of practicing mental health providers (N = 286), including neuropsychologists, psychologists, psychiatrists, counselors, and social workers. The online survey was comprised of questions regarding participants’ demographics, professional background, and practice characteristics; knowledge of, attitudes toward, and methods of treatment for FND; and completed and desired education and training for, and barriers to training for, FND.

Results: Most providers reported limited exposure to FND in routine practice, with two-thirds reporting that fewer than 10% of their patients had FND (close to half reported that fewer than 5% of their patients had FND). While psychotherapy was commonly provided, confidence in treating FND was modest and perceived training adequacy for psychotherapy was low. Cognitive-behavioral therapy was the most frequently reported modality. Greater experience with FND and higher perceived adequacy of psychotherapy training were consistently associated with more positive attitudes, greater confidence in treating FND, greater enjoyment working with the population, and beliefs in symptom improvement. Neuropsychologists reported greater overall knowledge and confidence but were less likely to provide psychotherapy. Lack of interest was not a major barrier to training; rather, providers cited lack of access to FND patients and the cost-benefit ratio for training. 

Conclusions: Enhancing access to targeted training and consultation for mental health providers may improve confidence, reduce stigma, and expand the workforce capable of delivering effective treatment for FND. These findings have direct implications for training in psychology, interdisciplinary collaboration, and effective delivery of services for FND patients.

31    THE EXPERIENCE OF COGNITIVE OVERLOAD IN FUNCTIONAL COGNITIVE DISORDER: AN EXPERIMENTAL STUDY (Etiology/Pathophysiology)
Jule Beckers, University Hospital Knappschaft Kliniken Bochum

Background: Patients with functional cognitive disorder (FCD) commonly report feelings of reduced mental capacity and perceive everyday tasks to be excessively effortful. Cognitive overload has been proposed as a key mechanism underlying this experience, arising from hypervigilance and constant self-monitoring that may deplete attentional and working memory resources. Despite theoretical considerations, empirical evidence for cognitive overload in FCD remains limited. We aimed to investigate the relationship between experimentally induced cognitive load through a working memory task and patients’ subjective experience of it.

Methods: We present preliminary analyses from an ongoing study based on an initial sample of patients (FCD n = 4, mild cognitive impairment [MCI] n = 3, healthy controls [HC] n = 5). Cognitive load was experimentally induced by requiring participants to memorize a set of letters and subsequently decide whether a probe letter was part of the previously presented set. Cognitive load was manipulated by gradually increasing the set size. Subjective cognitive effort was measured throughout the task, using the NASA-TLX scale (items: mental demand and effort). We further present the feasibility and potential value of pupillometry as an objective marker for cognitive load. 

Results: No group differences were found for the maximum achieved set size (Kruskal–Wallis, p = .170) or the total number of mistakes (Kruskal–Wallis, p = .310), indicating comparable objective task performance. However, a trend-level group effect emerged for d′ as a measure of response sensitivity in discriminating target-present from target-absent trials (Kruskal–Wallis, p = .066), with FCD showing sensitivity comparable to HC (FCD M = 2.42; HC M = 2.29) and higher than MCI (M = 1.29).
Perceived cognitive effort (NASA-TLX ratings) differed between groups as a function of set size (Figure 1). At low working memory load, FCD and HC showed comparably low effort ratings, whereas MCI reported substantially higher effort. With increasing working memory demand, effort increased in all groups but most strongly in FCD, resulting in convergence with MCI at high cognitive load. Group differences in load-related change approached significance (Kruskal–Wallis, p = .057 and p = .066) and were associated with large effect sizes (ε² = .52 and .54). Pupillometry proved feasible as an objective marker for cognitive load and may further contextualize these findings. 
[figure 1]

Conclusion: Although the small sample size (ongoing study) precludes firm conclusions, we observed disproportionately higher subjective effort in FCD under increasing cognitive load despite preserved performance, suggesting heightened perception of task demands. These findings provide initial insight into potential FCD pathomechanisms and will further be enriched by assessing objective cognitive load through pupillometry.

32    LOW PREVALENCE OF FUNCTIONAL NEUROLOGICAL MOVEMENT DISORDERS IN CANCER PATIENTS COMPARED TO NEURO-ONCOLOGY PATIENTS (Phenomenology/Epidemiology)
Andrea Botturi, Fondazione IRCCS Istituto Neurologico Carlo Besta. Milano, Italy.

Background: Over the past 70 years, extensive research has consistently demonstrated that oncological disease is associated with significant psychiatric comorbidity, with an overall prevalence of mental disorders estimated at approximately 31.8%. Depression and anxiety are the most widely studied psychiatric condition in oncology. In neuro-oncology specifically, psychiatric disturbances are reported in 20% to 70% of patients. The literature is considerably sparser with regard to functional movement disorders (FMD) and psychogenic non-epileptic seizures in this population.

Material And Methods: A systematic literature search was conducted using the PubMed database, employing the following search terms: “conversion disorders AND oncology / neuro-oncology”, “Functional neurological disorders AND oncology / neuro-oncology”.  Only papers published in English between 2015 and 2026 were included.

Results: Only a small number of papers were identified reporting the presence of functional Neurological disorders in neuro-oncology patients. No studies specifically addressing functional neurological disorders in general oncology patients were retrieved.

Discussion: The epidemiological argument alone cannot justify the near-complete absence of reports from general oncology: the disproportion in the literature is far too large to be attributable solely to tumour type or anatomical location. First, an organ-specific diagnosis, particularly one involving the central nervous system, may act as a direct precipitant for the onset of functional symptoms. Second, organisational factors play a role: neurologists are systematically underrepresented in general oncology settings, which reduces the likelihood of these disorders being identified.  Furthermore, the limited training and clinical toolkit available to general oncologists for the recognition of FMD may cause their underrating and biased evaluations. Unlike neurologists, who are familiar with the positive clinical signs of FMD, oncologists are primarily oriented towards tumour staging, treatment toxicity, and performance status assessment, leaving little room for the systematic evaluation of motor or sensory symptoms that may be functional in origin. Consequently, such presentations are more likely to be attributed to treatment side effects, paraneoplastic phenomena, or disease progression, rather than being recognised and coded as functional neurological disorders.

Conclusion: The available evidence suggests that FMD are underdiagnosed and undertreated in general oncology, likely due to a lack of adequate training and appropriate clinical tools among oncologists. It is essential to equip clinicians working in oncological settings with the knowledge and instruments required to detect these disorders, as failure to do so carries direct implications for clinical decision-making and patient outcomes.

Refernces:
Innes sc et. al Brain Behav. 2025 Nov 30;15(12):e71107.

33    TALKING AND NOT TALKING; EXPLORING THE ELEMENTS OF EFFECTIVE INTERVENTION FOR FUNCTIONAL MUTISM IN TWO CASE STUDIES (Treatment)
Helen Clarke, St George's NHS Hospitals Trust

Introduction/Background: This poster will describe the journey and treatment for two patients with long term functional mutism, and the role of formulation and misdirected attention in the onset and maintenance of the symptoms. There is currently a very limited evidence base for the formulation and treatment of functional speech and voice symptoms. These two case studies will describe the approach taken and may provide guidance for similar cases. Many patients present with speech, language, voice, or communication symptoms as part of their FND; this can be their only functional symptom or be part of a wider constellation of symptoms. Patients with communication symptoms can experience significant distress and increased social isolation.

We make use of the updated mechanistic model of FND (Holt et al 2024) as a way to develop a shared narrative with the patients, and as a way to build a foundation for developing a rationale for intervention. 

Cases: Two cases of patients presenting to our specialist virtual FND service at St George’s Hospital with functional mutism in which they were unable to access voice or speech for communicative purposes. Local community services had not been successful with intervention, and the patients were experiencing high levels of distress. Both patients experienced their functional mutism in the context of other severely disabling symptoms including sensory sensitivity, full body shutdowns, functional seizures, intermittent loss of use of limbs, and severe fatigue. The mutism was not the initial onset symptom for either patient but had developed into a significantly distressing and disabling symptom above and beyond the other symptoms.

Speech and language therapy was delivered virtually via video conferencing. The elements of intervention provided included:
• assessment as part of developing a joint formulation, 
• psychoeducation and explanation of symptoms as part of developing a more resilient understanding of the body, 
• trialling strategies within the context of understanding the mind-body connection
• developing resilience with communication through communication identity work

Discussion: Both of these cases developed full speech and voice shutdown in the context of attentional misdirection and interoceptive overload resulting in over monitored motor outputs that over time developed into full mutism. By making use of the foundational elements of FND interventions such as psychoeducation, formulation, attentional redirection work, and communication identity development both patients were able to regain access to their speech and voice with a reduced need for alternative communication modes. Traditional SLT methods had not worked for either of these patients demonstrating that an FND specific approach is key with working with functional symptoms.

34    WHAT ARE THE EXPERIENCES OF SPEECH AND LANGUAGE THERAPIST IN NON-SPECIALIST COMMUNITY SERVICES WHEN WORKING WITH PATIENTS WITH FND, AND HOW DO THEY NAVIGATE THE CHALLENGES: A SERVICE EVALUATION. (Treatment)
Helen Clarke, St George's NHS Hospitals Trust    

Background: This is a mixed methods service evaluation exploring the confidence, skills, and knowledge of speech and language therapists working in adult community services in Sussex when they are faced with a referral for a patient with FND. Primary care services are being increasingly encouraged to accept referrals for treatment for people with FND. Speech and language disorders are a common presentation of FND: it is estimated that 20 – 25% of FND patients present with functional communication symptoms (McKenzie, 2024).

An MDT approach is believed to support improved treatment outcomes for FND patients (Dworetzky & Baslet, 2025). Barnett et al. (2022) suggest that SLT has a key role to play in the assessment, diagnosis and treatment of FND. However, there is limited research into how SLTs can effectively manage FND patients, and SLTs report feeling uncertain and anxious about their knowledge, skills and confidence in working with FND patients (McKenzie et al., 2024). SLTs have an awareness that working with people with FND requires a different framework from the one that they trained in, however they have no recourse to developing this. 

Our research through this service evaluation builds on the previous surveys carried out by Barnett et al (2022) and McKenzie et al (2024) through in depth thematic analysis of focus group conversations. Through the creation of a rich set of data we are able to demonstrate the nuances and challenges experienced by SLTs in the community with regards to understanding FND and providing treatment for their patients. This research is the first part of a wider service evaluation and development in using the qualitative data to inform suitable training and support for the SLTs in Sussex so that they are better able to manage their patients with FND and feel confident doing so.

Methods: Working with 10 SLTs we have explored their experiences quantitively and qualitatively through questionnaires and focus groups.The conversations were recorded and transcribed for deeper thematic analysis. All the SLT work in adult community services in the NHS across Sussex.  

Results: The data is currently being analysed, and we expect to be able to demonstrate the current interventions, and bases for clinical decision-making that are used by speech and language therapists in non-specialist community services when working with people with FND. We will present these in context with the service and pathway recommendations in the UK, the emerging evidence base regarding treatment approaches, and the current training for SLTs in the UK.

Conclusions: We provide a current and honest picture of lived experience, clinical decision making on the ground, and responses from SLT in non-specialist services who are now required to provide treatment to people with FND. The deeper nuance of understanding that this research provides will help inform effective training and support for SLTs to work with people with FND and get better outcomes.

35    EARLY-ONSET FUNCTIONAL NEUROLOGICAL DISORDER: A CASE-BASED PERSPECTIVE IN YOUNG CHILDREN (Phenomenology/Epidemiology)
Natalia Szejko, MD, PhD, Institute of Mother and Child, Warsaw

Introduction: Functional Neurological Disorder (FND) is increasingly recognized in pediatric populations; however, early-onset FND in school-age children remains underrepresented in the literature, which is largely derived from adolescent cohorts. Developmental stage has a substantial impact on symptom expression, comorbidity, diagnostic pathways, and treatment response. Functional seizures are a common pediatric FND presentation and are frequently misdiagnosed as epilepsy, particularly in younger children.

Objective: To illustrate the presentation and management of early-onset functional seizures through an illustrative case and to contextualize these findings within the current literature, emphasizing developmental differences between early-onset FND and FND in older children and adolescents.

Methods: We present two cases of the early onset FND: the case of a 9-year-old girl with functional seizures and 10-year-old with a combination of paralysis and functional seizures, alongside a focused narrative review of the literature on early-onset pediatric FND. Clinical features, diagnostic processes, comorbidity patterns, and treatment approaches were examined through a developmental lens.

Results: The 9-year old patient presented with recurrent paroxysmal episodes characterized by prolonged unresponsiveness, asynchronous movements, and closed eyes, occurring predominantly in the school setting. Repeated EEG recordings, including video-EEG during typical events, showed no epileptiform activity. Neurological examination and neuroimaging were normal. Developmental history revealed mild learning difficulties and anxiety traits. A diagnosis of functional seizures was established based on positive semiological features and normal electrophysiology. Management focused on developmentally adapted psychoeducation, family and school collaboration, and targeted psychological support, resulting in substantial symptom reduction and remission at follow-up. The second case is a 10-year-old girl who presented with a combination of paralysis and functional seizures with very dynamic changes in  clinical presentation. 
The literature indicates that early-onset FND differs from adolescent FND in several key domains: symptoms are more variable and context-dependent; neurodevelopmental vulnerabilities are more prominent than formal psychiatric comorbidity; identifiable psychosocial stressors may be absent; family and environmental factors play a central role; and outcomes are generally more favorable with early, developmentally informed intervention.

Conclusions: Early-onset functional seizures represent a distinct and clinically important presentation of pediatric FND. Recognition of developmental differences between early-onset and adolescent FND is essential to support timely diagnosis, reduce unnecessary investigations, and guide age-appropriate, family-centered management strategies.

36    SYSTEMATIC REVIEW OF PHYSIOTHERAPY INTERVENTIONS FOR PEDIATRIC FUNCTIONAL NEUROLOGICAL DISORDER (Treatment)
Natalia Szejko, MD, PhD, Institute of Mother and Child, Warsaw

Background: Functional Neurological Disorder (FND) is increasingly recognized in pediatric populations, frequently presenting with motor symptoms such as weakness, gait disturbance, tremor, and dystonia. Physiotherapy and multidisciplinary rehabilitation are considered core components of treatment; however, the evidence base guiding intervention approaches and outcomes in children and adolescents remains unclear.

Objective: To systematically review and synthesize the evidence on physiotherapy and rehabilitation interventions for pediatric FND, including motor FND, and to evaluate their effectiveness on functional, psychological, and participation-related outcomes.

Methods: A systematic search of electronic databases including MEDLINE, Embase, CINAHL, PsycINFO, and the Cochrane Library was conducted from inception to June 2025. Studies involving participants aged ≤18 years diagnosed with FND and receiving physiotherapy or rehabilitation-based interventions were included. Study designs encompassed randomized controlled trials, cohort studies, case series, and qualitative studies. Two reviewers independently screened 1,243 records, extracted data, and assessed methodological quality using appropriate appraisal tools. Due to heterogeneity in study designs and outcome measures, a narrative synthesis was performed.

Results: Twenty-three studies involving 1,012 pediatric participants were included. Interventions ranged from symptom-focused physiotherapy and graded motor retraining to intensive inpatient and multidisciplinary rehabilitation programs. Most studies reported improvements in motor function, mobility, symptom severity, and school attendance, particularly when physiotherapy was delivered within a biopsychosocial, goal-oriented, and developmentally informed framework. Evidence quality was generally low to moderate, with only three randomized controlled trials identified and substantial variability in outcome measures and follow-up duration.

Conclusions: Physiotherapy and rehabilitation interventions appear beneficial for children and adolescents with FND, particularly when embedded within multidisciplinary, psychologically informed care models. However, the current evidence base is limited by methodological weaknesses, small sample sizes, and heterogeneity of interventions and outcomes. High-quality prospective trials and standardized outcome measures are needed to establish evidence-based guidelines for pediatric FND rehabilitation.

37    SYSTEMATIC REVIEW OF OUTCOMES OF MULTIDISCIPLINARY PEDIATRIC FUNCTIONAL NEUROLOGICAL DISORDERS CARE PATHWAYS (Treatment)
Natalia Szejko, MD, PhD, Institute of Mother and Child, Warsaw

Background: Functional neurological disorder (FND) in children and adolescents is associated with significant functional impairment, school disruption, and high health-care utilization. Multidisciplinary care pathways integrating neurological, psychological, rehabilitative, and family-based interventions are increasingly recommended; however, outcomes of these approaches have not been systematically synthesized.

Methods: A systematic review was conducted in accordance with PRISMA guidelines. MEDLINE, Embase, PsycINFO, CINAHL, and Cochrane CENTRAL were searched from inception to March 2025. Eligible studies included children and adolescents (<18 years) diagnosed with FND who received treatment within a multidisciplinary care pathway, defined as coordinated care involving at least two professional disciplines (e.g., neurology, psychology/psychiatry, physiotherapy/occupational therapy, rehabilitation, or school liaison). Randomized, non-randomized, and observational cohort studies reporting clinical or functional outcomes were included. Primary outcomes were symptom remission or improvement and functional recovery (e.g., school attendance, return to activities). Risk of bias was assessed using ROBINS-I or RoB 2, as appropriate. Due to heterogeneity in interventions and outcome measures, a narrative synthesis was performed.

Results: A total of 17 studies comprising 765 children and adolescents met inclusion criteria. Study designs were predominantly observational cohorts evaluating inpatient rehabilitation programs, day-hospital models, or structured outpatient multidisciplinary clinics. Across studies, multidisciplinary care pathways were consistently associated with high rates of symptom improvement or remission, most commonly ranging from 65% to over 90% at short- to medium-term follow-up. Functional outcomes improved substantially, particularly in school attendance and return to age-appropriate activities. Where reported, health-care utilization decreased, including fewer emergency department visits and hospital admissions. Subgroup analyses in studies reporting FND phenotype suggested comparable functional improvement across motor FND and functional seizures, although outcome measures and follow-up periods varied. Overall risk of bias was moderate, reflecting non-randomized designs, variable follow-up durations, and lack of standardized outcome measures.

Conclusions: Multidisciplinary care pathways for pediatric FND are associated with meaningful improvements in symptoms and functional recovery, including return to school and reduced health-care utilization, across FND phenotypes. Despite methodological limitations, the consistency of findings supports integrated, biopsychosocial models of care as current best practice. Future research should prioritize standardized outcome sets, prospective comparative designs, and identification of pathway components most strongly associated with recovery.

38    SCHEMA THERAPY AS A PSYCHOLOGICAL ASSESSMENT AND TREATMENT APPROACH FOR FUNCTIONAL NEUROLOGICAL DISORDER: A SCOPING REVIEW (Treatment)
Tim Cousins, MPsych(Clin), The Prince Charles Hospital, University of the Sunshine Coast

Background: Evidence-based treatments for FND include psychological intervention. Some types of psychological therapy have support in treating FND, including Cognitive Behavioural Therapy (CBT) and Psychodynamic Therapy (PDT) which both have medium-effects (Gutkin et al., 2021). This scoping review sought to explore the evidence for Schema Therapy (ST), a type of psychotherapy which focuses on patients’ early maladaptive schemas (EMS), in the assessment and treatment of FND and other functional somatic symptoms (Young, 2003).

Methods: Preliminary searches of the literature demonstrated there was not enough articles to conduct a systematic review, hence a scoping review became an appropriate methodology. Searches were conducted in March 2025 and repeated in September 2025 on PUBMED, CINAHL, MEDLINE, PSYCINFO, Scopus and Google Scholar. Articles had to be in English, and search terms had to appear in Title, Abstract and relevant MESH terms on each database. Review papers were excluded.

Participants had to be 18+, and could have diagnoses of FND including motor, speech, dissociative seizure or other subtypes. Due to limited search results, conditions related to FND, such as functional gut disorders, chronic pain/ fatigue syndromes, fibromyalgia, and somatic symptom disorders were included.

Included studies had to provide either assessment of participants using validated schema therapy measures, or a schema therapy intervention to treat clinical symptoms. 

Results: A total of 2113 articles were identified, and 842 duplicates removed, leaving 1271 articles for title and abstract screening. Only 41 were eligible to progress to full-text review, and 18 articles had data-extracted.
The self-sacrifice (SS) schema was stronger for FND groups. Unrelenting standards (US) and SS were the strongest schemas amongst patients with chronic pain. US, SS and emotional deprivation (ED) are strong schemas in IBS populations. Intensity of pain in fibromyalgia patients was positively associated with strength of approval seeking (AS), unrelenting standards (US), insufficient self-control (IS), and mistrust/abuse (MA) schemas. 

Conclusions: Despite some trends, not enough data is available to describe any schema profiles of patients with FND or related disorders. No papers explored maladaptive coping modes. A true gap exists in using ST as a treatment approach for FND and related conditions. ST – often seen as an extension of CBT - focusses more on addressing patients’ EMS and their maladaptive coping modes, which are often present in FND patients. Given ST has evidence in treating other conditions that are comorbid with FND, such as Depression, PTSD and Borderline Personality Disorder, research exploring structured ST assessment, formulation and then thorough treatment in this patient cohort is warranted.

References:
Gutkin. et al (2021). https://doi.org/10.1136/jnnp-2019-321926
Young, J et al (2003). Schema Therapy: A Practitioner's Guide

39    BOTULINUM TOXIN TREATMENT FOR FUNCTIONAL DYSTONIA - A CASE REPORT (Treatment)
Jeannette Gelauff, Amsterdam UMC

Introduction: Functional dystonia can be highly disabling. First choice treatment options are physiotherapy and/or cognitive behavioral therapy, but these do not always resolve the symptoms. In non-functional dystonia, botulinum toxin A(BTA) therapy is considered a first-line symptomatic treatment. In Functional Neurological Disorders (FND), a trial into functional jerky movement has shown BTA to be as effective as placebo injections, with improvements in both.1 Literature on complex regional pain syndrome (CRPS) – a disorder that overlaps with functional dystonia – reports a possible effect of BTA on pain reduction in small studies.2

Case Presentation: Hereby we present a 29-year-old patient with functional dystonia since the age of 8, who was referred to our tertiary center for a second opinion concerning BTA treatment. The symptoms caused serious impairments, due to severe forward posturing from the hip, resulting in an inability to walk, posturing of the left foot and a clenched left fist. Several inpatient rehabilitation treatments did not result in improvements. At the age of 25, BTA treatment was started, in forearm, iliopsoas- and upper leg musculature. This resulted in marked improvement. Also, due to severe contractures, at the age of 26, a lower leg amputation was performed. 

BTA was evaluated at our center. At this point, posturing from the hip had improved dramatically and the patient had regained the ability to walk. BTA injections resulted in improved functioning: at maximal therapeutic effect, finger flexion was reduced, permitting the patient to grasp objects, gait also improved following each treatment. For this reason, BTA treatment was continued. 

Discussion: With this case we’d like to bring the possibility to treat patients with BTA in functional dystonia as a symptom-based treatment up for discussion. BTA can discontinue a pattern of ongoing muscle contraction, which might improve possibilities for physiotherapy. Another possible mechanism of action might be an altered perception of normalized posture by the brain or a psychological beneficial effect of the (temporarily) improved functioning, which might improve automatic movement control. However, if these results can be achieved by a short therapeutic trial, or long-term treatment, is unclear. A potential risk of long-term treatment would be that location and severity of the altered posturing in FND can increase overtime, which might result in an ever-increasing treatment dosage. Conversely, if this effect is not observed in clinical practice and patients, as in our case, demonstrate functional improvement following each treatment, one could argue that the situation is comparable to non-functional dystonia, where BTA is mainly used as symptomatic treatment. Generally, side-effect like muscle weakness and the possibility of a placebo-effect need to be taken into account. Randomised trials or N=1 studies could bring interesting outcomes.  

40    FEASIBILITY OF TELEVIDEO ADMINISTRATION OF THE SIMPLIFIED FUNCTIONAL MOVEMENT DISORDERS RATING SCALE (Phenomenology/Epidemiology)
Jordan Garris, MD, University of Virginia Health System

Background: The Simplified Functional Movement Disorders Rating Scale (S-FMDRS) is a recommended outcome measure for clinical trials in functional movement disorders1 and is shown to be valid, reliable, and sensitive to change with treatment.2 Televideo administration of the S-FMDRS would allow for expanded access to clinical trials in functional movement disorders. The purpose of this study is to determine feasibility of televideo administration of the S-FMDRS. 

Methods: Patients aged 10 and older with functional movement disorders completed the S-FMDRS rating scale both in-person and via televideo at home on the same day, with the order of these visits randomized at the time of consent. Family members or caregiver filmed patients with a mobile phone.  A neurologist scored the S-FMDRS and noted whether each element of the scale was scorable and whether any concerns about feasibility arose. Correlation between same day televideo and in-person administration scores was assessed via Spearman correlation.

Results: Nine patients of 15 planned completed the protocol: 7 with functional tremor, 1 with functional dystonia and myoclonus, and 1 with functional tics. All components of the S-FMDRS were able to be scored for all patients, though one patient’s feet were not visible for the majority of the video. In-person scores ranged from 2-19 (median 6) and televideo scores ranged from 0-23 (median 4). In-person and televideo scores were strongly correlated (rho=0.7259, p=0.0268).
Conclusions: Home-based televideo administration of the S-FMDRS is feasible for functional tremor in patients with a smartphone and caregiver support, and may extend to other functional movement disorder phenotypes. Specific instructions to parents have been developed accounting for observed video acquisition issues. 

References:
1.Pick S, Anderson DG, Asadi-Pooya AA, et al. Outcome measurement in functional neurological disorder: a systematic review and recommendations. J Neurol Neurosurg Psychiatry. 2020;91(6):638-649. doi:10.1136/jnnp-2019-322180
2.Nielsen G, Ricciardi L, Meppelink AM, Holt K, Teodoro T, Edwards M. A Simplified Version of the Psychogenic Movement Disorders Rating Scale: The Simplified Functional Movement Disorders Rating Scale (S‐FMDRS). Mov Disord Clin Pract. 2017;4(5):710-716. doi:10.1002/mdc3.12475

41    INTERDISCIPLINARY INTENSIVE REHABILITATION FOR ADOLESCENTS WITH MOTOR FUNCTIONAL NEUROLOGICAL DISORDER: A DUAL CASE PRESENTATION (Treatment)
Christina Dandar, PhD, Kennedy Krieger Institute

Background: FND presents with a wide range of symptoms in pediatric populations, often accompanied by emotional distress. These symptoms can disrupt school attendance as well. Although evidence supports interdisciplinary rehabilitation models, few programs incorporate the full spectrum of medical, psychological, educational, and family-based interventions. The Kennedy Krieger Institute Specialized Transition Program offers an outpatient intensive rehabilitation protocol for Chronic Health Impairment (CHI) that integrates physical and occupational therapy, behavioral psychology, education, and neuropsychology. Caregivers also complete a curriculum tailored to their child’s unique needs, emphasizing psychoeducation and skills training to support functional gains. Patients have the opportunity to participate in structured community outings to promote generalization of skills. 

Case Presentation: Two adolescent males (ages 12 and 15 years) with motor FND completed the CHI protocol. Both patients had a longstanding history of anxiety and mood symptoms. Neuropsychological assessment included the Wechsler Abbreviated Scale of Intelligence–Second Edition (WASI-II), Delis–Kaplan Executive Function System (DKEFS), and Behavior Rating Inventory of Executive Function–2nd Edition (BRIEF2; parent-report). Both patients displayed age-appropriate or higher core reasoning and performance-based executive functioning skills. In contrast, parent-report on the BRIEF2 showed meaningful difficulties in applying executive skills in everyday settings. Across the program, both exhibited improvements in functional mobility, independence in daily routines, and engagement in valued activities. Caregivers described enhanced confidence in managing functional symptoms and reduced reinforcement of somatic behaviors. Additional interdisciplinary measures including the Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Anxiety and Depression (short forms), assessing emotional distress symptoms, and the Canadian Occupational Performance Measure (COPM), evaluating perceived functional performance and satisfaction in everyday activities, will be presented in the final poster. 

Discussion: These cases illustrate how an intensive, interdisciplinary rehabilitation model can effectively address the complex interplay of motor, emotional, cognitive, and environmental factors in pediatric FND. Findings highlight the utility of comprehensive outpatient rehabilitation for adolescents with motor FND and underscore the importance of family involvement and individualized education in promoting durable functional recovery. 

References:
Mavroudis, I., et al. (2025). Comorbidities across functional neurological disorder subtypes: A comprehensive narrative synthesis. Life, 15(8), 1322.  
Borner, K., & Laptook, R. (2024). Supporting children and adolescents with functional neurological disorder in the school setting. Rhode Island Medical Journal, 107(11), 29–33.

42    INVESTIGATING THE STIMULUS-RESPONSE RELATIONSHIP WITH SOMATOSENSORY EVOKED POTENTIALS IN FUNCTIONAL NEUROLOGICAL DISORDER (Etiology/Pathophysiology)
Natasha Darcy, King's College London

Background: Investigating the pathophysiology of functional symptoms presents a number of challenges, notably the diversity and fluctuating presence of symptoms. FND is hypothesised as a network disorder within hierarchical systems in the brain, whereby (some) sensorimotor signals are processed differently at intermediary stages, resulting in an altered perceptual experience. Numerous small studies have found evidence of altered sensory attenuation, increased misses and false alarms in detection tasks as well as decreased interoceptive accuracy, often as a general phenomenon rather than specific to affected body parts. A few case reports have reported missing late potentials in functional numbness or anaesthesia.

Methods: Recording somatosensory evoked potentials (SEP) elicited by non-nociceptive median nerve stimulation, we investigated the behavioural and electrophysiological relationship between objective measure of stimulus intensity and subjective perceptual ratings in people with FND (N=21) versus age-matched non-clinical controls (NCC, N=21). After jittered visual cue they received stimulation at one of six levels of intensity to left or right hand (between 0-80% of observed motor twitch threshold, 480 trials total) and rated these on a continuous scale. Recordings were performed with a 64-channel EEG. Linear mixed effects models analysed behaviour and common SEP peak components. Concurrent pupillometry examined cue- and stimulus-locked effects of stimulation events.

Results: Sensory and motor thresholds did not differ between groups. Behavioural results trended towards greater variability in perceptual ratings per stimulus intensity. Several contralateral SEP peak amplitudes (P45, P3a and P3b) showed significant modulation by intensity and rating without group differences (see figure panel A). Topologically, the mid-latency potentials (P100, N140) showed slightly different distributions (B). An unexpected finding of topologically broad positivity in trials with 0% stimulation in FND, even those rated zero, contrasted with baseline activity in controls (A). 
NCC displayed cue-related (+0.59%) and earlier post-stimulus sustained pupil dilation with parametric increase by stimulus intensity, while FND showed a smaller effect of cue (0.39%), a longer latency for sustained response and reduced amplitudes (see C).

Conclusions: Though there were some indications of greater variability in behavioural stimulus-response relationships in FND, basic metrics of SEP amplitude modulation across components by objective and subjective measures was intact and comparable to the control group. Incorporating more complex source-level network analyses may elucidate further the observed differences in mid-latency components and delayed pupil responses.

Reference:
Voon et al. (2016) Functional Neuroanatomy and Neurophysiology of Functional Neurological Disorders (Conversion Disorder). doi: 10.1176/appi.neuropsych.1409021t

43    CLINICAL HYPNOSIS TO IMPROVE HOOVER’S SIGN: A CASE SERIES (Treatment)
Abhijit Das, Lancashire Teaching Foundations NHS Foundation Trust

Introduction/Background: Functional neurological disorder (FND) is a common and disabling condition characterised by symptoms arising from altered predictive processing, abnormal attention to the body, and an impaired sense of agency. Contemporary diagnostic practice emphasises positive signs that demonstrate preserved neurological capacity despite apparent impairment. Hoover’s sign, based on the automatic coupling between contralateral hip flexion and ipsilateral hip extension, is a well established positive sign of functional leg weakness. In functional weakness, voluntary hip extension is reduced while automatic extension during contralateral flexion is preserved, indicating intact corticospinal pathways but disrupted volitional motor output. Beyond its diagnostic value, Hoover’s sign offers a vivid, bedside demonstration that movement can return, supporting psychoeducation about reversibility in FND.

Case Presentation: We describe four patients with refractory functional lower limb weakness and unequivocally positive Hoover’s sign, despite prior multidisciplinary management. All underwent a single session of clinical hypnosis delivered in a neurology clinic setting. Hypnosis was used to focus attention, enhance responsiveness to suggestion, and create personalised imagery aimed at “reconnecting” with the affected limb. One patient imagined infusing her leg with a new, vibrant colour to make it feel “new,” while another, an HR director, visualised “emailing his leg” to improve communication. After hypnosis, all patients showed rapid reversal of Hoover’s sign, restoration of leg strength, and normalisation of gait. These gains were maintained at follow up beyond three months, with no relapse of disabling motor symptoms. 

Discussion: These cases illustrate how Hoover’s sign can function as an introduction to hypnosis. Hypnosis provided a flexible framework to re engage volitional control using imaginative suggestion that is congruent with contemporary models of FND emphasising altered agency, attention, and predictive processing. A recent systematic review by Connors and colleagues concluded that hypnosis and suggestion are promising interventions for FND, with clinically meaningful improvement reported in a substantial proportion of patients, although firm recommendations are limited by methodological heterogeneity. Against this background, our observations represent useful clinical experience showing how hypnosis can be pragmatically introduced into routine neurology practice, using Hoover’s sign as a concrete, bedside demonstration that change is possible and as an accessible entry point for suggestion based treatment as part of multi-disciplinary approach. 

References:
1. Connors MH, et al. Hypnosis and suggestion as interventions for functional neurological disorder: A systematic review. Gen Hosp Psychiatry. 2024;86:92-102.
2. Lukose A, Das A. Gen Hosp Psychiatry. 2025 Dec 31;99:1-3. doi:10.10

44    RAPID AND PERSISTENT IMPROVEMENT IN FUNCTIONAL NEUROLOGICAL DISORDER WITH HYPNOSIS: CASE SERIES OF A UNIQUE SUBSET (Treatment)
Abhijit Das, Lancashire Teaching Foundations NHS Foundation Trust

Introduction/Background: Functional neurological disorder (FND) is a common and disabling condition characterised by altered predictive processing, abnormal attention to bodily sensations, and an impaired sense of agency. Many patients remain symptomatic despite standard multidisciplinary care, highlighting the need for accessible, mechanism informed adjunctive treatments. Hypnosis, defined as a state of focused attention with increased responsiveness to suggestion, has shown promise in FND but remains under utilised in routine practice, particularly in patients with language barriers or longstanding, refractory symptoms. This case series describes rapid and sustained clinical improvement following a single hypnosis session in five patients with refractory FND, including motor and functional dizziness presentations, and one patient requiring live language translation.

Case Presentation: Case 1:  49 year old Pakistani woman with longstanding right sided weakness and sensory disturbance. A session delivered with live, rhythm preserving English–Urdu translation by a bilingual medical student allowed deep hypnotic engagement, leading to immediate improvements in mobility which was persistent at follow up.

Case 2:  66 year old man with chronic right sided radicular pain and right predominant leg “giving way” over 2–3 years, with positive Hoover’s sign. Brief hypnosis using relaxation and pain transformation imagery (“knife” pain placed safely in a “scabbard” and “melting away”) resulted in reversal of Hoover’s sign, restoration of leg power and return to hill walking without further sessions.

Cases 3: 66/F with long standing PPPD refractory to all modalities of treatment. Single session of hypnosis resulted in rapid resolution of symptoms and walked out alone. 

Cases 4–5 were women aged 37 & 62 years with refractory FND phenotypes (ongoing motor symptoms despite physiotherapy; and functional motor weakness). Each showed marked improvement in core functional symptoms after a single, tailored hypnosis session.

Discussion: Across heterogeneous FND presentations, a single, brief hypnosis session was associated with rapid and persistent improvement in patients who had not responded to usual care. These observations suggest that hypnosis can be flexibly adapted to individual phenomenology (motor, sensory, and dizziness symptoms) and, when necessary, across language barriers through careful adaptation. The striking and durable changes observed in this group challenge the pervasive assumption that FND is “untreatable” or only slowly modifiable, and instead highlight that, for at least some patients, symptoms can be highly responsive to targeted, mechanism informed intervention using personalised imagery and explanatory frameworks that reinforce reversibility and agency. While uncontrolled and limited by small sample size, this case series adds to emerging evidence that single session, suggestion based interventions may meaningfully augment standa

45    OPERATIONAL MODAL ANALYSIS OF FRONTAL FNIRS REVEALS LOW FREQUENCY HEMODYNAMIC STATE SHIFTS BEFORE AND AFTER HYPNOTIC INDUCTION IN FUNCTIONAL NEUROLOGICAL DISORDER (Treatment)
Anirban Dutta, University of Birmingham, UK

Introduction/Background: Low-frequency oscillations (0.01–0.1 Hz) in functional near-infrared spectroscopy (fNIRS) signals reflect cerebrovascular and neurovascular dynamics and have been proposed as physiological markers of brain state and autoregulatory control. Subspace-based operational modal analysis (OMA) can extract physiologically meaningful dynamical modes from fNIRS data. We examined whether covariance-driven stochastic subspace identification (SSI-Cov) could quantify changes in frontal hemodynamics associated with hypnotic induction in Functional Neurological Disorder (FND).

Case Presentation: Frontal 8-channel fNIRS (10 Hz sampling, Artinis Octamon+ device, The Netherlands) was acquired during baseline, hypnotic induction, and suggestion in five healthy controls and one patient with FND [1]. Frontal oxyhemoglobin (HbO) signals were segmented into pre-induction baseline and post-induction suggestion epochs. Preprocessing included linear detrending, 4th-order Butterworth bandpass filtering (0.008–0.12 Hz, zero phase), and resampling to 2 Hz.

OMA used covariance-driven SSI (blockRows = 150; model orders 5–50). Stabilization diagrams were computed over 0–0.1 Hz using stability criteria of df = 0.005 Hz, dz = 0.1, and MAC = 0.75 to distinguish physiological modes from numerical poles based on prior work [2]. Stable modes were clustered to estimate dominant modal frequency and damping ratio with cluster dispersion summarized by standard deviation.

Across epochs, SSI-Cov identified stable low-frequency modes within the target band. Post-induction epochs demonstrated increased stabilization density and tighter clustering of dominant modes compared with baseline. In the FND case, post-induction epochs showed tighter modal clustering within the 0.02–0.05 Hz band relative to baseline.

Discussion: Oscillations in the 0.02–0.05 Hz range are commonly associated with sympathetic vasomotor modulation. Reduced frequency dispersion and increased cluster stability after induction suggest a shift toward a more coherent low-frequency hemodynamic regime during hypnotic suggestion. These findings support modal parameters (frequency and damping) as candidate objective markers of hypnotic state transition.

Operational modal analysis complements conventional amplitude-based metrics by characterizing dynamical structure, potentially enabling more robust and generalizable biomarkers across sessions and individuals. Larger controlled studies in FND are needed to validate these preliminary findings and determine clinical utility.

References:
1.Walia P et al. Preprints. 2025; doi:10.20944/preprints202507.2405.v1.
2.Zhao F et al. Brain Sci. 2023;13:1099. doi:10.3390/brainsci13071099.

46    NEUROIMAGING-GUIDED EXTINCTION LEARNING FRAMEWORK FOR RECALIBRATING ACTION–AUTONOMIC CONTROL IN FUNCTIONAL MOVEMENT DISORDERS (Treatment)
Anirban Dutta, University of Birmingham, UK

Background: Functional Movement Disorders (FMD) are characterized by impaired voluntary movement despite preserved structural motor pathways. Contemporary models implicate aberrant predictive processing across salience, interoceptive, and agency networks. We hypothesize that FMD reflects maladaptive coupling between autonomic arousal regulation and action initiation in which threat perception action priors persist due to inefficient extinction learning. The cerebellum, central to prediction error signaling and forward model updating, may contribute to persistence of maladaptive priors when extinction mechanisms fail.

Methods: We integrated (i) resting-state functional connectivity signatures capable of classifying FMD [1], (ii) meta-analytic decoding of implicated hubs, and (iii) a mechanistically informed extended reality (XR) biofeedback platform incorporating wearable neuroimaging and physiological monitoring [2]. The XR paradigm includes a “brain-as-observer” phase targeting interoceptive stabilization followed by extinction-informed operant conditioning using graded salience exposure with reinforcement of agency. Neuromodulation targets were prioritized within cerebello-thalamo-cortical circuits.

Results: rsfMRI findings demonstrate that FMD can be classified from altered connectivity among the sensorimotor cortex, posterior insula, dorsolateral prefrontal cortex (DLPFC), and cerebellum [1]. This network supports predictive motor control where the cerebellum generates forward models, the sensorimotor cortex executes action, the posterior insula encodes interoceptive state, and the DLPFC modulates precision weighting. Disrupted coupling may impair cerebellar updating of motor predictions. Within a Kalman framework, reduced sensory precision leads to overweighted priors, increased prediction error, and unstable motor state estimation despite intact structural pathways. Simulation demonstrates that restoring sensory precision facilitated by external biofeedback improves state convergence (code available at https://github.com/Siagnos/ICRA2025). Disrupted predictive motor control in FMD likely involves cerebello–thalamo–cortical interactions that interface with basal ganglia circuits responsible for action selection and initiation, such that aberrant precision weighting propagates through these loops to bias motor output. Here, we predict that improvements in action–autonomic regulation will precede gains in self-initiated movement.

Conclusions: We propose a testable cerebellar neuromodulation within a neuroimaging-guided XR framework in which FMD reflects extinction-resistant action–autonomic priors. Neuroimaging-guided XR biofeedback combined with targeted neuromodulation offers a mechanistically grounded strategy to recalibrate cerebellar forward models and restore voluntary movement.

References:
1Waugh RE et al. Brain Connect. 2023;13:4–14. doi: 10.1089/brain.2022.0001.
2 Dutta A et al. JMIR XR Spatial Comput. 2025;2:e68580. doi: 10.2196/685

47    MODULATING PREDICTIVE PRECISION THROUGH HYPNOSIS (Treatment)
Barbara de Jong, Spaarne Gasthuis

Background: Functional Neurological Disorder (FND) is increasingly conceptualized as a disturbance in hierarchical predictive processing, in which overly precise top down predictions dominate sensory evidence. This imbalance can lead to altered bodily awareness, dissociation, and reduced sense of agency. Hypnosis is a state in which attention, expectation, and sensory precision can be systematically modulated. This makes hypnosis a promising tool for influencing the predictive mechanisms thought to underlie FND. A mechanistic account of how hypnosis may alter precision weighting could provide a foundation for both clinical innovation and experimental investigation.

Methods: This conceptual paper synthesizes current predictive processing models of FND with empirical literature on hypnosis, dissociation, and sensorimotor control. The proposed framework integrates findings from cognitive neuroscience, clinical hypnosis research, and multidisciplinary FND care. The model outlines how hypnosis may temporarily reduce the rigidity of maladaptive predictions, enhance the influence of interoceptive and sensorimotor signals, and facilitate recalibration within the predictive hierarchy. Potential clinical applications are described within a multidisciplinary care pathway involving neurology, physiotherapy, and psychiatry. The framework also identifies measurable targets—such as agency, interoceptive accuracy, and symptom variability—for pilot studies.

Results: The model predicts that hypnosis can modulate predictive precision in three key domains relevant to FND: 
- Interoceptive precision, potentially reducing dissociative experiences by restoring coherence between bodily signals and predictions. 
- Motor predictive flexibility, supporting recovery of agency by decreasing dominance of rigid top down motor expectations. 
- Sensorimotor integration, enhancing responsiveness to feedback during physiotherapy and facilitating new learning. 
These predicted effects generate testable hypotheses for future empirical work, including pre post assessments of agency, interoception, symptom expression, and responsiveness to sensorimotor retraining.

Conclusion: Hypnosis offers a theoretically grounded method for modulating predictive precision in FND. By influencing the balance between expectation and sensory evidence, hypnosis may help restore bodily coherence, reduce dissociation, and support recovery of agency. The proposed model provides a mechanistic rationale for integrating hypnosis into multidisciplinary FND care and outlines a research agenda for evaluating its effects on predictive processing and symptom change.

References:
1. Edwards MJ, Adams RA, Brown H, Pareés I, Friston KJ. A Bayesian account of ‘hysteria’. Brain. 2012;135(11):3495–3512. 
2. Terhune DB, Cleeremans A, Raz A, Lynn SJ. Hypnosis and top down regulation of consciousness. Neuroscience & Biobehavioral Reviews. 2017;81:59–74

48    UNMASKING FUNCTIONAL SEIZURES AFTER STROKE: A CASE OF FUNCTIONAL NEUROLOGICAL SYMPTOMS (Phenomenology/Epidemiology, Etiology/Pathophysiology)
Curtis Amankwah, WVU Rockefeller Neuroscience Institute

Background: Functional neurological symptoms commonly co-occur with structural brain disorders but are underrecognized in post-stroke populations. Functional seizures (also termed functional/dissociative seizures) may mimic or overlay epileptic phenomena, leading to diagnostic delay and management challenges. In patients with stroke-related anosognosia and neglect, epileptic semiology can be particularly masked, complicating differentiation. Reporting such nuanced clinical interactions contributes to improved recognition and multidisciplinary care in FND contexts.

Case Presentation: A 78-year-old man with a right frontoparietal intracerebral hemorrhage developed persistent left-sided neglect and anosognosia. Collateral history from family documented recurrent left arm clonic jerking. The patient, however, was unaware of these episodes. Video-EEG captured left-hemisphere ictal activity corresponding to these clonic events, confirming epileptic seizures. Antiseizure therapy was initiated with partial control. Following disclosure of the epilepsy diagnosis and increased symptom awareness, the patient began exhibiting intermittent right arm shaking spells. The new events were brief, inconsistent with epileptic patterns, distractible on examination, and lacked EEG correlates on prolonged monitoring. These features were consistent with functional seizures. Psychiatric evaluation supported the diagnosis of functional neurological symptoms triggering functional seizures contralateral to the structural stroke. Multimodal management included tailored education on functional symptoms, targeted psychological support, and continued optimized antiseizure therapy (for epileptic seizures).

Discussion: This case highlights a rare and instructive interplay between neurologic and functional phenomena in a post-stroke patient. First, anosognosia masked clinically overt epileptic seizures, underscoring the importance of collateral history and objective monitoring in detection. Second, the emergence of functional seizures following increased awareness of neurologic diagnosis illustrates how diagnostic disclosure may influence symptom expression in susceptible individuals. Third, the coexistence of epileptic and functional seizures presents both diagnostic and therapeutic challenges, emphasizing the need for integrated neurologic and psychiatric care. Recognizing functional seizure patterns in the context of structural neurologic insult can prevent misdiagnosis and facilitate appropriate, targeted intervention.

References:
1.Reuber M, Elger CE. Psychogenic nonepileptic seizures: review and update. Epilepsy Behav. 2003;4(3):205–216.
2.Edwards MJ, et al. Functional neurological disorders: assessment and diagnosis. Pract Neurol. 2019;19(3):187–201.

49    CLINICAL FEATURES AND DIAGNOSTIC CHALLENGES OF FUNCTIONAL COGNITIVE DISORDER (Etiology/Pathophysiology)
Paulina Soto-García, Clínica de trastornos funcionales Hospital Avicenne

Background: The concept of functional cognitive impairment (FCD) is relatively recent, has a heterogeneous etiology, and likely involves underlying mechanisms similar to those found in functional neurological disorders (FND). This study aims to establish a comprehensive clinical profile that allows for the differentiation of FCD from neurodegenerative diseases and secondary cognitive impairment.

Materials And Methods: This is a prospective observational study conducted at Avicenne Hospital (Île-de-France, France), which houses a specialized Memory Unit and a multidisciplinary Functional Neurological Disorders (FND) Unit.

Results: In the systematic symptom checklist, memory impairment was the most frequent cognitive complaint, reported by all patients.
Among patients classified as having FND, 95% presented at least one positive sign on examination, while 42.11% of those classified as having Functional Cognitive Disorder (FCD) showed at least one positive sign.

Conclusion: The key strength of this study lies in the detailed assessment across multiple domains. This reinforces the value of a comprehensive neurological examination in patients presenting with FCD and the detection of positive signs of FND.

Referenses:
1. Pennington C, Ball H, Swirski M. Functional cognitive disorder: diagnostic challenges and future directions. Diagnostics. 2019;9(4):131. doi: 10.3390/diagnostics9040131. 
2. McWhirter L, et al. Identifying functional cognitive disorder: a proposed diagnostic risk model. CNS Spectr. 2022;27(6):754–763. doi: 10.1017/S1092852921000845.

50    CLINICAL FEATURES AND DIAGNOSTIC CHALLENGES OF FUNCTIONAL COGNITIVE DISORDER (Phenomenology/Epidemiology)
Paulina Soto-García, Clínica de trastornos funcionales Hospital Avicenne

Background: The concept of functional cognitive impairment (FCD) is relatively recent, has a heterogeneous etiology, and likely involves underlying mechanisms similar to those found in functional neurological disorders (FND).
This study aims to establish a comprehensive clinical profile that allows for the differentiation of FCD from neurodegenerative diseases and secondary cognitive impairment.

Materials And Methods: This is a prospective observational study conducted at Avicenne Hospital (Île-de-France, France), which houses a specialized Memory Unit and a multidisciplinary Functional Neurological Disorders (FND) Unit.

Results: In the systematic symptom checklist, memory impairment was the most frequent cognitive complaint, reported by all patients.
Among patients classified as having FND, 95% presented at least one positive sign on examination, while 42.11% of those classified as having Functional Cognitive Disorder (FCD) showed at least one positive sign.

Conclusion: The key strength of this study lies in the detailed assessment across multiple domains. This reinforces the value of a comprehensive neurological examination in patients presenting with FCD and the detection of positive signs of FND.

References:
1. Pennington C, Ball H, Swirski M. Functional cognitive disorder: diagnostic challenges and future directions. Diagnostics. 2019;9(4):131. doi: 10.3390/diagnostics9040131. 
2. McWhirter L, et al. Identifying functional cognitive disorder: a proposed diagnostic risk model. CNS Spectr. 2022;27(6):754–763. doi: 10.1017/S1092852921000845.

51    PSYCHOTIC SYMPTOMS IN ADOLESCENT PATIENTS WITH FUNCTIONAL NEUROLOGIC DISORDER: A CASE SERIES (Phenomenology/Epidemiology)
Shannon Dean, Kennedy Krieger Institute/Johns Hopkins Hospital

Introduction: Functional neurologic symptom disorder is well known to co-occur with other psychiatric disorders, particularly anxiety and depressive disorders1.  Psychotic symptoms, in contrast, are far more rarely described.   We describe here three adolescent patients that presented to our functional neurologic symptom disorder multidisciplinary clinic who were later diagnosed with a disorder with psychotic features.  

Case Series: [Table 1] From January 2023 to January 2026, 338 patients were seen at the Kennedy Krieger Institute with functional neurologic symptom disorder.  During that time, 3 of our patients developed psychotic symptoms.  The first, a 16 year old male, first developed grandiose delusions and disorganized behavior 2 months before his functional symptoms.  The other two patients, a 12 and 19 year old female, presented first with functional symptoms and later developed psychotic symptoms 16 and 33 months later respectively.  These latter two patients were diagnosed respectively with schizophrenia and schizoaffective disorder.  All three patients had functional seizure like attacks, 2/3 had functional weakness, and 1/3 had functional tic like behaviors.  All three patients required psychiatric hospitalization for the safety of themselves and others.

Discussion: It is estimated that less than ten percent of adults and even fewer children with functional neurologic disorder have bipolar disorder[1], and the co-occurance of both functional neurologic symptoms and a primary psychotic disorders such as schizophrenia and schizoaffective disorder is described in only a handful of case series[2].  The cases presented above likewise represent less than 1 % of patients with functional neurologic symptom disorders seen in our clinic.  In 2 of the 3 patients, psychotic symptoms did not manifest until months after their initial presentation with functional neurologic symptoms.  While psychotic symptoms are rare in patients with functional neurologic symptom disorder, doctors who care for these patients should be aware of this possibility given the potential danger these symptoms present if they are unrecognized.

References:
1. Patron VG, Rustomji Y, Yip C, Jenkins LM. Psychiatric Comorbidities in Functional Neurologic Symptom Disorder. Pract Neurol (Fort Wash Pa). 2022 Mar-Apr;21(3):71-75. PMID: 36644502; PMCID: PMC9836030.
2. Wyllie E, Glazer JP, Benbadis S, Kotagal P, Wolgamuth B. Psychiatric features of children and adolescents with pseudoseizures. Arch Pediatr Adolesc Med. 1999 Mar;153(3):244-8. doi: 10.1001/archpedi.153.3.244. PMID: 10086400.

52    POST-COVID FUNCTIONAL MOVEMENT DISORDER: THE CONFLUENCE OF NEURODIVERGENT TRAITS AND INTEROCEPTIVE DYSREGULATION (Phenomenology/Epidemiology)
Kira Charles, Rush University Medical Center

Many biological and psychological factors contribute to the onset and progression of functional movement disorders (FMD), but the role of their interaction is unknown. Acute or subacute-on-chronic threats leading to autonomic arousal and hypervigilance often trigger FMD, while cognitive rigidity and perceptual and interoceptive dysregulation are predisposing and perpetuating factors. We present a case of FMD that began with a COVID-19 infection in a man with alexithymia and neurodivergent traits.

A 68-year-old right-handed man with coronary artery disease, diabetes and post-COVID syndrome (infected 2x in 2021) presented to the movement disorders clinic in 2025 with concerns for COVID-induced neurologic symptoms (internal vibrations, tremulousness, gait freezing, fatigue, jerking, and brain fog). Prior neurologic and autoimmune workup across 13 specialists was unrevealing.
Our neurological examination did not support prior diagnoses (essential tremor, myoclonus, or spastic gait). His had variable gait stance and stiffness but not unsteady and improved with touch. A delayed and exaggerated startle reflex required his awareness of a light or pressured touch to be provoked consistently.

Neuropsychiatric evaluation revealed autonomic cardiovascular instability provoked by ambulation and emotionally salient stimuli. Gait freezing was inducible by placing an obstacle in his path and reversible by manually lifting his own leg. Poor trigger identification was noted in a symptom log of 20+ symptoms, but without mention of psychosocial stressors. He denied impairments in daily function despite loss of employment.

He was diagnosed with a mild neurocognitive disorder despite a normal cognitive profile by an outside provider. Repeat neuropsychological testing demonstrated average to above average cognitive performances and normal self-report symptoms (somatic, depression, anxiety). He reported cognitive fluctuations that his wife linked to blood sugar changes. He was anxious, had poor social cognition, a history of restricted repetitive behaviors, and was fixated on perceived cognitive errors despite objective strengths. 

Gabapentin improved cognitive, motor and neuropsychiatric symptoms.

This case illustrates how the confluence of biological and psychological factors contribute to the development and perpetuation of FMD. In this man with alexithymia, symptom exacerbation from infection were likely overweighted in his conscious processing of functional symptoms and psychological elements of sensorimotor processing were discounted. Neurodivergent traits of cognitive rigidity and symptomatic fixation may have contributed to the prolonged disease course. Early identification of risk-traits may improve targeted FND interventions.

References:
D’Orsi, G., et al. (2023). A novel analysis of interoceptive underpinnings of anxious psychopathology in COVID-19 survivors. 
Ryan Van Patten, R., & Bellone, J. A. (2023). The neuropsychology of functional neurological disorders.

53    NUTRITONAL AND EATING-RELATED COMORBIDITIES AMONG YOUTH WITH FUNCTIONAL NEUROLOGICAL DISORDER (FND) IN AN INTERDISCIPINARY DAY PROGRAM (Phenomenology/Epidemiology)
DIane DerMarderosian, MD, Brown University/Brown University Health

Background: Functional neurological disorder (FND), previously termed Conversion Disorder (CD), has an estimated incidence of 2–4/100,000 for functional seizures and 4–5/100,000 for functional motor symptoms (Patron et al., 2022). Comorbidities are frequent and often lead to poorer outcomes. Emerging evidence shows elevated rates of FND in patients with eating disorders (ED), suggesting shared predisposing and maintaining factors. Youth with FND and EDs have increased risk of depression, anxiety, suicidality, and hospitalization compared to peers with only one condition (Tokatly Latzer et al., 2025). The Hasbro Children’s Partial Hospital Program (HCPHP) delivers interdisciplinary, family‑based care for youth with combined medical and psychiatric needs. A range of nutritional concerns in patients with FND have been observed beyond ED diagnoses. This study characterizes these concerns in youth with FND in HCPHP from 2015 to 2020.

Methods: Participants were 6–18 years with English speaking caregivers who enrolled in a research study during admission. Charts were reviewed for FND and associated clinical features, and formal diagnoses/clinically identified nutritional concerns were confirmed by an interdisciplinary team. Prevalence of FND and FND with nutritional concerns were assessed and categorized. Consent to be obtained for 2 brief vignettes.

Results: Of 243 participants, 24 (10%) had FND. Compared to others, they were older (15 vs 13; p=0.045) but did not differ by sex, race/ethnicity, LOS, or total diagnoses. Among the 24 with FND/CD, 12 (50%) had nutrition concerns requiring intervention. All 12 received treatment from a registered dietitian. Four had formal diagnoses (ARFID, anorexia nervosa, nutritional deficiency, abnormal weight loss); eight were identified clinically. Clinical concerns included picky eating, underweight, weight loss, restricted intake, limited food acceptance, low appetite, inability to self-feed, and poor growth.

Discussion: Nutritional concerns were common in FND, ranging from ED diagnoses to other clinically significant issues. All patients received nutrition screening (family history, eating patterns, growth trends, food related beliefs, sensory factors), and concerns were addressed in treatment. Because undernutrition impairs cognition, mood, and treatment engagement, engagement, addressing nutritional needs is essential in FND care and aligns with AACAP recommendation for universal ED screening. Clarifying if these issues stem from FND, a separate ED, and/or other comorbidities informs treatment planning. Future work should examine how nutritional concerns relate to FND symptom function and whether early identification improves outcomes. 

References:
Patron, V, Rustomji, Y, Yip, C, & Jenkins, L(2022). Psychiatric Comorbidities in FNDS. Practical Neurology, 21(3), 71–75.
Tokatly Latzer, I, Richmond, T, Zhang, B, & Pearl, P(2025). Eating disorders in adolescents with functional seizures. Epilepsy & Behavior, 172, 110402.

54    TAILORING FUNCTIONAL SEIZURE TREATMENT FOR PEOPLE WITH AUTISM SPECTRUM DISORDER (Treatment)
Daria Diakonova-Curtis, PhD, Cleveland Clinic

Functional neurological disorders (FND) are characterized by neurological symptoms, such as involuntary movements, sensory changes, and seizure-like episodes, that cannot be tied to an organic cause. Autism spectrum disorders (ASD) are neurodevelopmental syndromes that encompass difficulties with social communication along with restrictive and repetitive interests and behaviors. People with ASD also report challenges with motor control, sleep disturbance, somatic symptoms such as gastrointestinal issues, pain, and sensory sensitivities including heightened responses to light, sound, and touch. Recent research indicates that there may be more of a link between FND and ASD than previously thought (Gonzalez-Herrero, Happé et al. 2024), particularly due to shared mechanisms responsible for disruptions in interoception, emotion regulation, attention and cognition. 

Treatment for FND, particularly functional seizures (FS), has traditionally employed Cognitive- or Neuro-Behavioral Therapy that emphasizes improving one’s mind-body connection, understanding one’s physiological responses, increasing emotional awareness, and improving relaxation skills. However, little is known about whether this approach is effective for individuals with ASD and FS, given their specific struggles with understanding and interpreting sensory and emotional information, as well as difficulties with attention and social engagement. This abstract will focus on the treatment of FS for a patient with ASD, and discussion ways to tailor treatment. 
 
JC is a 24-year-old Caucasian woman who was diagnosed with ASD by her psychotherapist. She had recently developed seizure-like episodes with decreased awareness, drop attacks, and shaking of the limbs, and was referred by her primary physician to the hospital’s epilepsy monitoring unit. After confirming a diagnosis of FS with VEEG, JC was scheduled with the center’s psychologist to begin a 12-week treatment program for FS using the "Taking Control of Your Seizures" workbook (Reiter, Andrews et al. 2015). At the start, JC did not work or drive. She was living with her grandmother and spent most of her time in her room. She attempted online college courses but was unable to complete them due to issues with attention, memory, and functional seizures. She attended her church’s virtual Bible studies, and enjoyed engaging in arts and crafts. Table 1 demonstrates ways in which workbook chapters were adapted.

The "Taking Control of Your Seizures" workbook is an evidence-based treatment for FS with the goals of discovering and addressing triggers to seizures, improving interoception, alexithymia and emotion regulation, increasing assertive communication, addressing stressors, and gaining relaxation skills. Many of these are difficult for people with ASD and thus this treatment may need to be modified and adapted for those individuals. More research is needed to understand the overlap in FND and ASD , as well as ways to tailor treatments.

55    ALEXITHYMIA AND AFFECTIVE STYLE IN INDIVIDUALS WITH FUNCTIONAL APHONIA AND FUNCTIONAL/DISSOCIATIVE SEIZURES (Phenomenology/Epidemiology)
Maria Dietrich, Universitätsklinikum Bonn

Background: People with functional aphonia (FA) and functional/dissociative seizures (FDS) both involve disruptions in integrating emotional and cognitive processes.1,2 Investigating alexithymia and affective style is particularly interesting, as difficulties in identifying and expressing emotions as well as in emotion regulation may underlie functional disturbances therefore offering valuable insight into shared and distinct mechanisms. The study aimed to compare patient groups and healthy controls on alexithymia and affective style scores.

Methods: In a sample of n=17 individuals with FA (symptomatic; asymptomatic, FA in past), n=17 age and sex matched individuals with FDS, and n=8 healthy controls (HC), we investigated Suppression, Adjustment, and Acceptance scores from the Affective Style Questionnaire (ASQ) as well as the total score of the Toronto Alexithymia Scale (TAS-20) and its subscales Difficulty identifying feelings (DIF), Difficulty describing feelings (DDF), and Externally-oriented thinking (EOT). Multivariate analyses of covariance with post-hoc univariate analyses of covariance and contrasts correcting for age and sex were conducted. 

Results: Multivariate tests showed significant differences between groups. Follow-up univariate tests revealed significant group differences for the TAS-20 total score (p<.001, partial eta=.364), DIF (p<.0001, partial eta=.453), and EOT (p=.03, partial eta=.173). The FA and FDS groups showed elevated scores compared to the HC group. Only the FA group compared to the HC group presented with significantly increased EOT [figure1]. Significant group differences were also found for the ASQ scales Suppression (p=.009, partial eta=.237) and Adjustment (p=.004, partial eta=.274) [figure2]. The HC group compared to both patient groups presented with greater Adjustment. The FDS group alone compared to the HC group presented with significantly increased Suppression. Data collection continues.

Conclusions: Preliminary data show that both patient groups present with alexithymia, in particular difficulty identifying feelings. A disturbance in externally-oriented thinking emerged as specific to the FA group, pointing to a potentially distinct pattern of cognitive-emotional processing. People with FA and FDS share low adjustment, suggesting a reduced tendency to regulate emotions through cognitive or situational adaptation. The distinct affective style of people with FDS might be suppression, highlighting increased inhibition of emotions as potential maladaptive strategy.

References:
1.Baker J, Oates JM, Leeson E, Woodford H, Bond MJ. Patterns of emotional expression and responses to health and illness in women with functional voice disorders (MTVD) and a comparison group. J Voice. 2014;28(6):762-769. 
2.Novakova B, Howlett S, Baker R, Reuber M. Emotion processing and psychogenic non-epileptic seizures: A cross-sectional comparison of patients and healthy controls. Seizure. 2015;29:4-10.

56    EMERGENCY ASSESSMENT AND MANAGEMENT OF FUNCTIONAL NEUROLOGICAL DISORDER MIMICS OF ACUTE STROKE IN A COMPREHENSIVE STROKE CENTER (Treatment)
Alexander Doud, Physician, Providence Sacred Heart Medical Center

Introduction/Background: FND stroke mimics can present with abrupt loss of sensation, gait, motor or speech. This presents a diagnostic challenge for administration of thrombolytics, which risks lethal systemic and intracranial bleeding and requires ICU admission for 24 hours. Prior case series demonstrate that hypnosis can improve symptoms in FSM. The cases presented here demonstrate methods of synthesizing mindfulness, progressive relaxation, body scanning, and rapid hypnosis induction useful in confirming and resolving FND symptoms in the ED Stroke Code setting.

Case 1: A 51 y.o. male with a history of numerous presentations for recurrent symptoms of transient aphasia, right-sided hemiparesis, dysarthria, and stuttering speech, who had received TNK on at least three prior occasions. A stroke code was called one hour after onset of verbal mutism with retained writing. Iodine allergy prevented CTA and spinal stimulator prevented MRI. He was instructed to breathe deeply. He was asked to shake the examiner’s hand, which was interrupted with the examiner suddenly tapping him on the nasion.  A tuning fork was placed on the forehead, and he was told to visualize the vibration moving out through his body and face. He began to speak and was assured that speech would continue to normalize. TNK was not administered due to rapid resolution of deficits.

Case 2: 50 y.o. female with history of bipolar disorder, fetal alcohol syndrome, ICA stenosis, migraines, and numerous ED visits for recurrent episodes of hemiplegia and facial droop. She had been evaluated by 15 different Neurologists within the year. She received TNK on her first presentation and had received diagnoses of hemiplegic migraine FND or TIA. She arrived with hemiparesis of the left arm, leg, and face within the window for TNK.  The patient was asked to initiate deep breathing and was asked to make her best attempt to move her arm and leg. With a count to three, a snap of the fingers and a sudden tapping between the eyes, the patient was told that she may find that her arm could move again. Her arm and leg then demonstrated antigravity strength. A tuning fork was placed on the arm and leg. She was asked to visualize her strength returning as the vibration was subsiding. TNK was not offered due to complete resolution of deficits.

Discussion: FND stroke mimics are a challenge to medical resource stewardship and lead to significant disability, overtreatment, and confusion for patients [Table 1]. Patients with ingrained FND symptoms mimicking stroke can experience rapid symptom resolution with techniques integrating mindfulness, progressive relaxation and hypnosis. Success relies on rapport building, setting expectations for recovery, the brief introduction of an unexpected pattern altering stimulus, and confirmatory reassurance to patients as symptoms begin to resolve. Guided symptom resolution leads to curiosity and buy-in about how the patient can learn to control symptoms independent

57    POST-EVENT RELIEF IN FUNCTIONAL SEIZURES: A CROSS-SECTIONAL STUDY (Etiology/Pathophysiology)
Islam Elbanna, The George Washington University

Background: Functional seizures (FS), also known as psychogenic non-epileptic seizures (PNES), are paroxysmal events that resemble epileptic seizures but occur in the absence of ictal EEG activity, and are classified as a form of Functional Neurological Symptom Disorder (Conversion Disorder) [1]. Several hypotheses about the pathophysiology of FS implicate emotional dysregulation, suggesting that these episodes may alleviate psychological distress through mechanisms of primary gain [2,3]. We hypothesize that FS episodes represent dissociative phenomena that function as unconscious coping mechanisms, temporarily distancing individuals from overwhelming internal conflict, which may be entirely outside conscious awareness. The relief reported following an episode may therefore reflect a transient resolution or release of psychological distress, lending support to this conceptual framework.

Methods: Thirty-three patients with confirmed functional seizures on video-EEG (mean age 44 ± 16 years; 31 females) completed a two-item relief questionnaire and provided demographic and clinical data, including age, sex, and seizure frequency. Relief prevalence (95% CI), relief-type distribution, mean age differences (two-sample t-test), and associations with frequency (Fisher’s exact test) were calculated.

Results: Eleven of 33 patients (33.3%; 95% CI 19.8–50.4%) reported relief – 9 of whom (81.8%) mental, one (9.1%) physical, and one (9.1%) both. Twenty-two (66.7%) did not experience relief. Mean age was similar (relief vs. no-relief: 43.7 ± 15.5 vs. 44.0 ± 16.8 years; p = 0.96). Relief prevalence did not differ by sex (p = 1.00) or seizure frequency (p = 0.68).

Conclusions: In this pilot study, 33.3% of patients with FS reported an immediate sense of relief, providing preliminary support for the hypothesis that FS may serve as an unconscious coping strategy. In contrast, the majority of patients (66.7%) did not experience relief, highlighting heterogeneity in post-episode responses and suggesting the presence of distinct underlying mechanisms. This is an ongoing study, and we aim to achieve a more robust evaluation with increased sample size. If confirmed, post-event relief may represent a clinically useful marker for early differentiation between functional and epileptic seizures, potentially reducing diagnostic delay and unnecessary antiseizure medication use.

References:
1.LaFrance WC Jr, Baker GA. Nonepileptic Seizures: An Updated Review. Epilepsy Behav. 2012;24(3):297–305.
2.Krámská L, Hrešková L, Vojtěch Z, Krámský D, Myers L. Maladaptive emotional regulation in patients diagnosed with PNES compared with healthy volunteers. Seizure Eur J Epilepsy. 2020;78:7–11.
3.Feinstein A. Conversion disorder: Advances in our understanding. CMAJ. 2011;183(8):915–919.

58    FUNCTIONAL/DISSOCIATIVE SEIZURES IN LATIN AMERICA: A REVIEW OF REGIONAL RESEARCH DEVELOPMENTS (Phenomenology/Epidemiology)
María Agostina Gerbaudo, PhD Student, Consejo Nacional de Investigaciones Científicas y Técnicas (conicet) & Universidad de Buenos Aires

Introduction: Functional/Dissociative Seizures (FDS) represent a subtype of functional neurological disorders, characterized by the presence of symptoms that commonly include partial or complete loss of integration between memory, identity, and control of bodily movements, leading to alterations in consciousness. Although research on FDS has expanded internationally, the scope and characteristics of Latin American empirical studies were not systematically mapped. This review aims to synthesize Latin American empirical research on FDS, to describe its main features, and identify gaps and priorities for future research in the region.

Method: We conducted a narrative review, informed by a structured search of major databases for peer-reviewed empirical studies conducted in Latin America. Included studies were organized by study design, country, publication language, and sample characteristics. Findings were synthesized to identify patterns and research gaps.

Results: Thirty-four studies were included. Most studies used quantitative approaches (85%), non-experimental designs (88%), and a descriptive scope (52%).  Geographically, studies were concentrated in Argentina (n = 17) and Brazil (n = 14). Across studies, samples were predominantly women (79%), and 49% of participants were unemployed. Most articles (83%) were published in English, and “psychogenic non-epileptic seizures” was the predominant term. The studies were organized into four thematic categories: clinical characteristics, clinical interventions, diagnosis, and semiology. This mapping highlighted recurring patterns, gaps in the literature, and areas for future research.

Conclusions: Empirical research of FDS in Latin America is still incipient and concentrated in specialized centers, with gaps in controlled trials and in countries other than Argentina or Brazil. Multicenter studies, culturally appropriate adaptations, and greater dissemination in Spanish and Portuguese are needed to strengthen diagnosis, treatment, and professional training on FDS in Latin America.

59    THE TRANSFORMATIONAL ROLE OF NURSING IN FUNCTIONAL NEUROLOGICAL DISORDER CARE (Treatment)
Gabriela Gilmour, MD, FRCPC, University of Calgary

Background: Functional neurological disorder (FND) is a common and disabling condition with evidence supporting transdisciplinary care, particularly for patients with persistent and severe symptoms. Roles for various medical, psychology and allied health team members are frequently detailed in the literature, yet there remains opportunity to further define the role of nursing in FND care.

Case Presentation: A 38-year-old woman presented to our outpatient transdisciplinary FND service (including nursing, neurology, neuropsychiatry) for assessment of functional (dissociative) seizures and mixed hyperkinetic movements, most prominently with recurrent facial and jaw spasms resulting in broken teeth and jaw dislocation. Her past history was complex, with multiple abdominal surgeries for cesarian sections, appendicitis, hernia repair, hysterectomy, small bowel obstruction, horseshoe kidney and nephrolithiasis. She had chronic abdominal pain of unclear cause, for which she was taking high doses of hydromorphone. She frequently presented to the emergency department (ED) with pain crises and episodes of FND symptoms, with 30 ED presentations and 12 acute care admission (total 134 days) in the year prior. As part of our FND program, interventions included telephone nursing support, development of ED care plan, voluntary medical-psychiatry admission and subsequent transfer to general psychiatry to clarify pain diagnosis (gastroparesis) and taper opioids, FND education and strategies for symptom management, social work referral for financial support, and psychotherapy. In the year following admission to our program, her number of acute care admissions reduced to 8 (total 45 days) and ED visits reduced to 26. There was a significant improvement in frequency of FND events, while abdominal pain gradually improvement.

Nursing support was an integral part of this patient’s care. The patient had close contact with the FND nurse, with multiple telephone calls every month, many of which led the patient to not attend the ED. During these calls, the nurse listened with empathy and validated the patient’s experience, while providing education and guiding practice of strategies for reducing FND symptoms.  The nurse played a major role in developing the ED care plan and advocated for improvements based on patient experience. Given the large care team with frequent admissions and multiple non-functional medical illnesses, the nurse acted as care coordinator and advocate for the patient. 

Discussion: As evidence increases for transdisciplinary FND care, opportunity exists to further define the role for nursing. As this case illustrates, nurses on FND teams have the unique opportunity to provide an accessible point of contact for the patient, coordinate care teams, advocate for care, and provide education and rehabilitation strategies. Future economic analysis should aim to quantify the impact of nursing support to improve access to skilled FND nursing worldwide.

60    EFFECTIVENESS OF AN OUTPATIENT MODERATE INTENSITY INTERDISCIPLINARY REHABILITATION TREATMENT FOR YOUTH WITH COMORBID FND AND CHRONIC PAIN (Treatment)
Kyleigh Skedgell, PhD, Mary Free Bed Rehabilitation Hospital

Introduction: Functional Neurological Disorder (FND) is common in youth and multifactorial in its etiology and consequences1. Inpatient interdisciplinary treatment offering daily medical and therapeutic care has been shown to result in positive outcomes2. However, inpatient treatment may not be possible for many youth and their families who need to remain engaged in school and work. Additionally, the inpatient setting may inadvertently reinforce illness identity development and prolong functional recovery1. The following clinical vignette highlights the effectiveness of an outpatient moderate intensity interdisciplinary rehabilitation treatment on a youth’s physical, social, emotional, and school functioning. 

Case Presentation: “X”, a 15-year-old transgender child (he/him) with a medical history significant for FND and Amplified Musculoskeletal Pain Syndrome (AMPS), presented to an outpatient rehabilitation clinic for functional symptoms and chronic pain. X and his family participated in a joint medical and psychology evaluation to assess symptoms and functioning. X’s primary symptoms included psychogenic non-epileptic seizures, tremors, and vocal tics as well as back, hip, and leg pain and weakness. X was using bilateral crutches at the time of the evaluation. X was also missing school an average of twice weekly and spending most of his time at home. 

X was referred for a 10-week interdisciplinary rehabilitation treatment focused on improving functioning. X participated in twice weekly physical and occupational therapy, weekly psychology, and monthly medical visits. He was gradually exposed to movement with a focus on functional tasks and able to transition to a single crutch during the second week and then function without any assistive devices by the third week. X was also initiated on Zoloft and taught cognitive and behavioral strategies during treatment. He experienced improved anxiety and mood symptoms and returned to biking and going to the movies. X consistently attended school during treatment and applied for a job as well. X’s pre- and post-treatment outcome measures reflected his observable and reported progress [Figure 1]. X was discharged with the recommendation to continue primary care follow-up and community counseling for ongoing mental health support. 

Discussion: The above clinical vignette supports the effectiveness of outpatient moderate intensity interdisciplinary rehabilitation treatment for youth with comorbid FND and chronic pain. Youth participating in this model of care have opportunities to use learned skills in real-word scenarios as they remain engaged in daily routines and age-expected activities during treatment. Health care professionals encountering youth with FND, especially those in emergency settings, should consider outpatient moderate intensity care models whenever possible when triaging and establishing treatment plans. 

References: 
1. Fobian & Elliot, 2019
2. Vassilopoulos et al., 2022

61    EVENT-RELATED POTENTIALS IN PEOPLE WITH FUNCTIONAL MOVEMENT DISORDER BEFORE AND AFTER YOGA AND AEROBIC EXERCISE: A PILOT FEASIBILITY STUDY (Treatment)
Danielle Kipnis, MA, CYI-200, Teachers College, Columbia University

Background: Functional Movement Disorder (FMD) is a heterogeneous condition characterized by involuntary movement symptoms arising from alterations in brain network function. Yoga and aerobic exercise are promising adjunctive therapies for people with FMD (PwFMD)[1, 2]; yet, the neurophysiological mechanisms underlying their effects in PwFMD remain poorly understood. Electroencephalography (EEG) is a noninvasive neuroimaging technique that measures cortical electrical activity, and event-related potentials derived from EEG can index attentional processing (P3) and motor planning (contingent negative variation; CNV). Thus, EEG offers a promising way to examine differential neurophysiological effects of yoga and aerobic exercise for PwFMD.

Methods: This pilot feasibility study assessed neural responses to yoga and aerobic exercise among PwFMD versus controls. Participants completed questionnaires and two, 45-minute sessions of yoga or moderate-vigorous aerobic exercise one week apart. EEG testing before and after each session evaluated attentional resources via the P3 and motor planning via the CNV using a Posner-type cueing task. Yoga sessions used an individualized, trauma‑informed protocol and included meditation, pranayama, asana, and savasana. Aerobic exercise occurred on a Lode cycle ergometer at 60-80% of heart rate reserve. 

Results: Participants included PwFMD [n=4, mean age (SD) 57.3 (2.1)] and controls [n=4, mean age (SD) 41 (10.8)]. One FMD participant voluntarily withdrew before the aerobic exercise session due to symptom exacerbation concern. There were no reported adverse events. At baseline, PwFMD showed smaller CNV and P3 amplitudes than controls. P3 amplitude decreased for both groups following both movement conditions, with a larger reduction in PwFMD after yoga than aerobic exercise, possibly reflecting reduced hyper-attention for PwFMD after yoga. For all participants, CNV negativity increased after aerobic exercise and decreased after yoga, though controls consistently showed more negative CNV amplitude than PwFMD. This may indicate a blunted motor planning response for PwFMD, possibly impacted by aerobic exercise. 

Conclusions: Findings demonstrate feasibility of both yoga and aerobic exercise protocols, suggesting they may influence attention and motor planning. A next phase study is underway to further test hypotheses and evaluate how underlying mechanisms of these interventions may differentially influence PwFMD. 

References:
[1] Kozlowska et al. (2023). Evidence-Based Mind-Body Interventions for Children and Adolescents with Functional Neurological Disorder. Harvard Review of Psychiatry, 31(2), 60–82.
 [2] Nielsen et al. (2024). Specialist physiotherapy for functional motor disorder in England and Scotland (Physio4FMD): A pragmatic, multicentre, phase 3 randomised controlled trial. The Lancet Neurology, 23(7), 675–686.

62    LESSONS LEARNED FROM IMPLEMENTATION OF A PILOT GROUP EDUCATIONAL PROGRAM FOR PEOPLE WITH FUNCTIONAL MOVEMENT DISORDER (Treatment)
Sally Leung, MA, Teachers College, Columbia University

Background: An integrated treatment approach for people with Functional Movement Disorder (PwFMD) is becoming the standard of care; however such integrative care models are resource heavy and unfeasible for PwFMD due to inability to travel and unaffordability [1]. To address these gaps, our team established the FMD Clinic Education and Skills Program to provide high-quality group, interdisciplinary education for PwFMD unable to access specialist treatment. 

Methods: We conducted two, 12-week sessions, once a week over Zoom. Classes alternated between four topics: FMD resources and education, sensorimotor retraining, psychotherapy education, and yoga. Participants also participated in two, 30-minute consultations at the beginning and end of the program. The program had four main objectives: (1) to provide useful disease-specific knowledge, (2) to offer techniques for symptom management, (3) to create an accessible network of FMD resources, and (4) to create a lasting peer-support network.
Results: 17 participants expressed interest in the program, 11 enrolled over two sessions (n=5 and n=6 respectively, mean age = 45.2 ± 11.6, 8 female, 1 non-binary, 2 male), and one withdrew stating he did not like the group setting. Although all participants reported movement abnormalities, fatigue (40%) and chronic pain (50%) were reported as the most bothersome symptoms. Participants described useful skills learned including breathing, mindfulness, and attention, and successful implementation of self-monitoring, awareness, and breathing into their daily lives. Seven stated they learned something new about FMD and four reported increased confidence in social situations, symptom management, and behavior change. Barriers to implementing learned skills included severe and fluctuating symptoms, psychosocial factors (perceived stigma and invalidation), and intervention-related challenges (high cognitive burden). Participants reported generally positive interactions with others, lending support to the group format. Suggested improvements to the program included increasing accessibility to social services, improving lesson clarity, addressing fatigue and social pressures, and providing more individual coaching. 

Conclusions: This pilot FMD Clinic Education and Skills Program provided important lessons for creating and implementing group-based education for PwFMD. Overall interest in the program was high and many had positive feelings towards program content. However, the online format of the program made retention and engagement difficult, likely impacting effectiveness. To address these limitations, future research is underway to develop a modified version as a one-day, in-person, intensive program.

References:
[1]. Lidstone et al. (2020). Integrated Therapy for Functional Movement Disorders: Time for a Change. Movement Disorders Clinical Practice, 7(2), 169–174.

63    IMPLICIT MOTOR LEARNING DEFICITS IN FUNCTIONAL MOVEMENT DISORDER (Etiology/Pathophysiology)
Christian Amlang, MD, SUNY Downstate

Background: Functional movement disorder (FMD) is a brain network disorder that is characterized by a variety of different involuntary movements as well as other associated symptoms such as fatigue, cognitive impairment, dizziness, functional seizures and psychiatric features. The underlying pathophysiology of FMD is not fully understood. While there is a growing body of neuroimaging studies showing distinct brain network abnormalities including the salience, limbic and sensorimotor networks, it is unclear what the neurophysiologic mechanisms are that cause the symptoms seen in FMD (see ref 1). A novel approach to better understand the underlying neurophysiologic mechanism in FMD is to study the processes of learning and unlearning movements. Recently, motor learning and particularly de-adaptation of newly learned motor programs have been shown to be impaired in people with functional gait disorder (see ref 2). The aim of our study is to broaden this experimental approach and to investigate motor learning processes in different subtypes of FMD. 

Methods: This pilot study assessed implicit motor learning in people with functional movement disorder (PwFMD) and age- and sex-matched healthy controls (HC). Participants used a computer mouse to control the movement of a cursor and were asked to slice through targets appearing on their screen. The cursor movements first accurately reflected the real mouse location. Then, in the adaptation phase, the cursor movement was “broken” and did not follow the mouse movements. Participants were asked to ignore the erroneous cursor movements and to still attempt slicing through the target. In the final de-adaptation phase, the cursor followed the mouse movements again. 

Results: We recruited 16 PwFMD and 16 HC to participate in this online implicit motor learning task. PwFMD had various types of functional motor symptoms including functional tremor, functional dystonia, functional tics, functional parkinsonism, among others. In comparison to HC, PwFMD adaptation and de-adaptation were significantly delayed. Furthermore, de-adaptation was marked by an exaggerated, “overshooting” response. 

Conclusions: The findings of our study suggest that motor learning may not only be impaired in the functional gait subtype of FMD but also in other subtypes. It also suggests that implicit motor learning may be impaired in FMD – an intriguing finding given that FMD pathophysiology is thought to be associated with higher cortical motor control but implicit motor learning is mainly driven by the cerebellum. Further studies on motor learning in FMD are needed to better understand the underlying neurophysiologic mechanisms of the condition. 

References:
1 Perez 2020 A Decade of Progress in Motor Functional Neurological Disorder: Continuing the Momentum
2 Lin 2020 Dissociated motor learning and de-adaptation in patients with functional gait disorders

64    A PEDIATRIC INPATIENT FUNCTIONAL NEUROLOGICAL SYMPTOM DISORDER PATHWAY ENABLES EPIDEMIOLOGIC SURVEILLANCE WITHIN A HEALTHCARE SYSTEM (Phenomenology/Epidemiology)
Kelsey Gonring, Medical College of Wisconsin - Children's Wisconsin

Background: Functional Neurological Symptom Disorder (FNSD) accounts for a notable proportion of pediatric emergency and neurology admissions, yet health systems often face challenges identifying and characterizing these patients because of diagnostic variability, inconsistent terminology, and fragmented inpatient workflows. These barriers limit standardization of care coordination across providers and reliable epidemiologic tracking. Recent literature shows that structured diagnostic frameworks and multidisciplinary care models can improve diagnostic reliability and system-level outcomes. In response, Children’s Wisconsin implemented a standardized inpatient FNSD pathway within the electronic medical record (EMR) that includes a dedicated discharge order set to support diagnostic clarity, interdisciplinary consultation, and consistent documentation. Neurology and psychology consultations are designated core components, reflecting best practice biopsychosocial care while also creating structured data that can be used for health system analysis.

Methods: This retrospective descriptive study included all inpatient encounters in which the FNSD discharge order set was used. Extracted variables included demographics, admission source, hospital length of stay, time to first referred follow-up, insurance type, and inpatient consultation patterns. Consultation data were reviewed to assess adherence to pathway-designated stakeholders, with particular attention to neurology and psychology utilization as indicators of pathway uptake.

Results: A total of 184 inpatient encounters were identified. Mean age was 13.8 years (SD 2.7; range 7–22), and 71.7% of patients identified as female. Most admissions originated from the emergency department (69.0%), though 40 patients (22%) were transferred from outside hospitals. Mean hospital length of stay was 2.1 days (SD 3.2). Neurology consultation occurred in 79.9% of encounters and psychology in 74.5%, reflecting strong engagement with pathway-designated core services. Additional allied health consultations, including PM&R, psychiatry, and pain services, occurred less frequently and varied based on symptom presentation. The cohort reflected a diverse payer distribution, including a comparatively lower proportion of Medicaid-insured patients than commercial payers.

Conclusions: This inpatient FNSD pathway improves diagnostic consistency, supports interdisciplinary collaboration, and enables reliable case identification through structured documentation. The EMR-based discharge order set provides a practical mechanism for epidemiologic surveillance beyond traditional coding approaches and supports ongoing quality improvement. Regional transfer patterns demonstrate reliance on tertiary diagnostic expertise and highlight an opportunity for targeted outreach and education to referring institutions. The observed payer diversity further underscores the pathway’s relevance for equitable care delivery across patient po

65    THE VALUE OF MULTI-SPECIALITY/ DISCIPLINARY/ AGENCY ASSESSMENTS AND INTERVENTIONS IN THE SUCCESSFUL RECOVERY OF A YOUNG PERSON WITH FUNCTIONAL NEUROLOGICAL DISORDER (Treatment)
Simon Gosling, Birmingham Children's Hospital

Introduction: Functional neurological disorder (FND) is a neuropsychiatric condition caused by altered functioning of brain networks rather than structural abnormalities. Symptoms can be distressing and significantly impair daily functioning. Paediatric incidence is estimated at 1–18 per 100,000. The aetiology is often multifactorial, requiring multidisciplinary (MDT) assessment and management.

Case Presentation: Patient A, a 15-year-old girl presented with a one-year history of sequential knee locking, leading to inability to flex her knees. She subsequently developed bilateral ankle contractures with foot inversion and became wheelchair dependent. She was taking NSAIDs, paracetamol, and opiates.

Neurological examination showed no additional abnormalities. MRI, nerve conduction studies, whole genome sequencing, and neurometabolic investigations were normal. A dopamine trial produced no improvement. Orthopaedic assessment noted inability to weight bear despite normal knee X-ray findings.

Psychiatric assessment included developmental, family, and social history, mental state examination, and detailed exploration of symptom onset and potential triggers. A had a confirmed diagnosis of Autism Spectrum Disorder, specific learning needs, academic difficulties, low mood, anxiety, and self-harm behaviours. In private discussions, she disclosed alleged emotional, physical, and sexual abuse within a context of domestic violence. Her functional symptoms were observed to worsen with emotional triggers and improve when these were absent.
Management involved extensive multidisciplinary and multi-agency collaboration, including Neurology, Psychiatry, Orthopaedics, Psychology, Occupational Therapy, Physiotherapy, Speech and Language Therapy, Youth Workers, and the Children with Medical Complexities Team (CMIC). Community services, including education, social care, and mental health services, were also engaged.

Over a five-month inpatient stay, regular meetings facilitated shared understanding of A’s biopsychosocial formulation and empowered community teams to continue care. It was agreed that placement in a nurturing social care setting was in her best interests. Following discharge, A formed positive relationships with carers and gradually returned to her premorbid level of functioning.

Discussion: FND triggers are complex and multifactorial. Early, collaborative, biopsychosocial assessment and management across specialties and agencies are essential to optimise recovery. Although no dedicated FND service existed within the tertiary children’s hospital, coordinated input from relevant specialists supported a positive outcome.
However, the significant workforce and resource demands required to manage such complex cases highlight the need for formal commissioning and service development to improve care for children and young people with FND across tertiary and district hospitals in the United Kingdom.

66    MIXED-METHODS ANALYSIS OF FORMULATIONS IN FUNCTIONAL NEUROLOGICAL DISORDER (Etiology/Pathophysiology, Treatment)
Myles Gutkin, University of Melbourne

Background: Functional Neurological Disorder (FND) is a relatively common neuropsychiatric condition characterised by disabling or distressing, but potentially reversible, neurological symptoms. There are no well-validated treatments, despite emerging evidence for several psychotherapies. A formulation is a set of explanatory hypotheses answering the question ‘why does this patient suffer from this problem at this time?’ This study examined the formulations of adults with FND who were treated with Shared Individual Formulation Therapy (SIFT). SIFT uses clinical history-taking and hypothesis-refinement over several sessions to collaboratively formulate how symptoms have emerged in the context of the patient’s life experience, to identify relevant vulnerabilities and coping strategies. A shared individual formulation is co-written and verified with each participant to ensure it represents their experience accurately. Our objective was to explore the patterns and associations in these formulations.

Methods: We extracted the formulations from twenty-four letters generated during a prospective, open-label trial of SIFT for FND. Framework analysis was used to identify the key features (‘exposures’, ‘schemas’, ‘activations’ and ‘mechanisms’) within each formulation. Subgroups identified using hierarchical clustering were compared statistically across characteristics, therapy ratings and outcome scores.
Results: Three clusters were identified. Two were characterised by overvigilance and body focus (n=10), and one was characterised by dissociation and other directedness (n=14). There was some indication of possible differences in treatment response, but numbers were too small to draw firm conclusions.

Conclusion: Findings support the psychological heterogeneity of adults with FND. Analysis of formulations can be used to identify clinically distinct subgroups.

67    SEEING DIFFERENTLY: TRANSDISCIPLINARY REHABILITATION FOR FUNCTIONAL VISUAL LOSS (Treatment)
Lauren Keats, PsyD, re+active Therapy and Wellness

Introduction/Background: Functional visual loss is a presentation of Functional Neurological Disorder (FND) characterized by visual impairment despite normal neuro-ophthalmologic findings. Contemporary models conceptualize FND as altered predictive processing and maladaptive sensory weighting, in which attention, threat appraisal, and autonomic arousal disrupt integration of visual, vestibular, and somatosensory inputs. Although transdisciplinary care is recommended for FND, patients with functional visual symptoms are often referred for psychotherapy alone. Integrated neurorehabilitation may improve outcomes by targeting multisensory integration, graded exposure, and self-efficacy.

Case Presentation: A 59-year-old male presented with progressive functional vision impairment since 2015, describing difficulty interpreting visual stimuli (“I see it but I don’t understand it”), photophobia, visual motion sensitivity, impaired facial recognition, and depth perception difficulties. He wore dark sunglasses 80% of waking hours, frequently kept his eyes closed to reduce dizziness, and relied on a mobility cane for community ambulation. Driving was discontinued in 2018. Extensive evaluation revealed no structural etiology, and he was diagnosed with Functional Visual Loss.

Comorbidities included hemiplegic migraine and anxiety/depression. Transdisciplinary assessment identified impaired visual discrimination, reduced interoceptive awareness, cervical hypomobility, impaired motor control, and reduced sense of agency.
He completed a 6-week interdisciplinary outpatient program (PT, OT, psychology) targeting multisensory integration (optokinetic/vestibular habituation, proprioceptive retraining, visual discrimination), SUDS-guided graded exposure to visual motion and community environments, reduction of avoidance behaviors (including decreased sunglass use), and autonomic regulation.

Outcomes: On the Patient-Specific Functional Scale (0–10), improvements were observed:
Restroom navigation in a novel environment (without cane): 0 → 7.5
Detecting and anticipating waves while boating: 1.5 → 5
Identifying objects while riding in a car at 30–40 mph: 2 → 7
Keeping eyes open during a short car ride: 1 → 8
Patient Global Impression of Change score was 7 (“a great deal better”).

Discussion: The patient demonstrated meaningful improvements in visual tolerance, independence, and reduced reliance on safety behaviors. Gains generalized to complex environments and are consistent with sensory reweighting and reduced threat-driven attentional capture. This case supports transdisciplinary neurorehabilitation emphasizing graded exposure and multisensory integration in functional visual presentations within FND. 

References:
Aybek, S., & Perez, D. L. (2022). Diagnosis and management of functional neurological disorder. bmj, 376.
Ramsay, N., McKee, J., Al-Ani, G., & Stone, J. (2024). How do I manage functional visual loss. Eye, 38(12), 2257-2266.

68    CONTRIBUTORS TO MORTALITY IN FUNCTIONAL/DISSOCIATIVE SEIZURES COMPARED TO EPILEPSY (Phenomenology/Epidemiology)
Wesley Kerr, MD, PhD, University of Pittsburgh

Background: Functional/dissociative seizures (FDS), previously called psychogenic nonepileptic seizures (PNES), are episodic neurological symptoms commonly associated with biopsychosocial stressors. Some believe an FDS’ mortality rate is lower than epilepsy due to Sudden Unexpected Death in Epilepsy (SUDEP).

Methods: We evaluated the electronic health records of patients at least 12 years old seen at University of Pittsburgh Medical Center (UPMC) from 2014 through 2025 with epilepsy, FDS, or co-occurring FDS and epilepsy who were identified using multiple approaches. Mortality rate from the time from diagnosis until last encounter or death was evaluated using standardized mortality ratios (SMRs) and Cox Proportional Hazards (CPH). Primary contributors to death were categorized through manual review.

Results: We identified 1,968 patients with FDS alone (79% female; age median 33), 1,399 with co-occurring ES and FDS (75% female; age median 38), 41,942 patients with non-medication resistant epilepsy alone (53% female; age median 52), and 10,285 with medication resistant epilepsy alone (49% female; age median 36). SMRs were similar (FDS: 2.51 [95% CI: 1.94-3.20], epilepsy: 2.48 [95% Confidence Intervals (CI): 2.42-2.53], medication resistant epilepsy: 2.88 [95% CI: 2.72-3.04]). Contributors to mortality identified increased barriers to health management in FDS and more SUDEP in ES. Barriers to health management included profound impacts of social determinants of death (e.g., unable to afford food, house without running water) and sequelae of substance abuse (e.g., alcohol, nicotine, opiates). In some decedents with presumed FDS without observation of their seizures, the presumption of a diagnosis of FDS as compared to mimics may have contributed to mortality (e.g., sudden cardiac death in pregnancy after recurrent convulsive syncope initially thought to be FDS; probable SUDEP 2 months after discontinuation of lamotrigine due to 5 days of video-EEG monitoring without a seizure or epileptiform findings observed).

Conclusions: Mortality rates of FDS 2.5 higher than the general population indicated similar mortality implications of FDS compared to epilepsy. Addressing the main contributors to mortality may require holistic care, including addressing disability, social determinants of health, barriers to health management, nicotine, alcohol, substance abuse, and other biopsychosocial stressors. Addressing barriers to high-quality and high-certainty diagnostic evaluation of FDS and mimics is necessary to reduce harm from potential premature closure.

69    PREVALENCE OF APATHY IN PATIENTS WITH MOTOR FUNCTIONAL NEUROLOGICAL DISORDERS (Phenomenology/Epidemiology)
Zuzana Kosutzka, Second Department of Neurology

Background: Motor functional neurological disorders are frequently associated with non-motor symptoms that may contribute substantially to disability. Apathy, characterized by reduced motivation and goal-directed behavior, has been insufficiently studied in patients with functional movement disorders. Understanding its prevalence and relationship with motor severity and depressive symptoms may have important implications for clinical assessment and management. The aim of this study was to determine the prevalence of apathy in patients with motor functional movement disorders and to examine its association with clinical and affective variables.

Methods: A cross-sectional cohort study was conducted in a tertiary neurology setting. A total of n=20 patients with clinically established functional movement disorders were included (cervical dystonia=6, limb tremor=6, dystonic head tremor=2, mixed=6). Apathy was quantified using the Starkstein apathy scale, with clinically significant apathy defined as a score ≥14. Motor symptom severity was assessed using the S-FMDRS. Depressive symptoms were measured using the PHQ-9. Additional variables included age and disease duration in years. Prevalence of apathy was calculated. Associations between apathy scores and clinical variables were analyzed using Spearman rank correlation coefficients.

Results: Clinically significant apathy was present in 6/20 patients (30.0%). Median apathy score was 8.5, with a range from 5 to 24. Apathy severity showed a moderate to strong positive correlation with PHQ-9 score (Spearman r=0.78, p=0.008). No significant correlations were observed between apathy score and age (r=−0.35, p=0.33), disease duration (r=−0.09, p=0.79), or S-FMDRS score (r=−0.10, p=0.79). Patients with apathy scores ≥14 demonstrated higher depressive symptom burden compared with those below the cutoff, while motor symptom severity did not differ between groups.

Conclusions: Apathy is present in one third of patients with functional movement disorders and represents a common non-motor symptom in this population. Apathy severity is significantly associated with depressive symptom burden as measured by the PHQ-9, but not with motor symptom severity or disease duration. These findings suggest that apathy reflects an affective–motivational dimension rather than a direct consequence of motor impairment. Systematic assessment of apathy and depression may improve clinical characterization and inform multidisciplinary management strategies in functional movement disorders.

The study was supported by grants APVV-24-0369 and VEGA 1/0514/25.

70    RESOLVING FND THROUGH FUNCTION-BASED PSYCHOTHERAPEUTIC ANALYSIS AS A STAND-ALONE TREATMENT MODALITY: A RETROSPECTIVE CASE SERIES (Treatment)
Rebecca Scott, PsyD, Neuro Wellness Solutions Therapy Inc.

Background: Functional Symptom Disorder (FND), formerly called Conversion Disorder, was identified in the late 19th century as a defense-mechanism–based condition for which psychotherapy was successfully used as a standalone treatment. Neurological symptoms in these early patients resolved once the underlying psychological distress and protective purpose served by the defense mechanism were addressed. This approach differs from the current conceptualization of FND as a neural circuitry disorder (often described as a “hardware” rather than “software” problem) addressed through multidisciplinary care, with psychotherapy often limited to counseling support. This approach may take months to years to fully resolve. 

Methods: A retrospective observational case series from a single outpatient psychotherapy clinic examined outcome data from all patients who were treated with a neurologist-confirmed FND diagnosis between 2021–2025. FND symptoms were conceptualized as maladaptive defense mechanisms whose psychological underpinnings needed to be identified and addressed. To accomplish this, treatment consisted of a function-based psychotherapeutic analysis (FBPA) examining factors around symptom onset, identifying the protective psychological function served by the symptom, then identifying and addressing the underlying psychological need. Outcomes included frequency, treatment duration, psychotherapy-only group versus multimodality-treatment groups, and follow-up. 

Results: Thirty-one patients with FND were treated with FBPA between 2021 and 2025. Twenty-four completed treatment, while seven discontinued. Thirteen patients demonstrated ≥97% reduction in FND symptom frequency, with an average treatment duration of nine psychotherapy hours delivered over approximately two weeks. Of these, ten received psychotherapy alone and three received multimodality care. FBPA identified three cases in which symptoms had been misdiagnosed as FND but were attributable to underlying medical or neurodevelopmental conditions that had been minimized or overlooked. These patients were referred to outpatient specialty clinics for treatment of the underlying conditions. FBPA also identified eight additional cases in which symptoms had been misattributed to FND, resulting in revised diagnoses including autism, post-viral cognitive impairment, and post-concussive syndrome. Six-month follow-up suggested maintenance of treatment gains. 

Conclusions: Findings from this retrospective case series suggest that FND may resolve when symptoms are conceptualized as defense mechanisms and treated using FBPA to identify and address the underlying psychological processes. These findings suggest psychotherapy may function as an effective stand-alone treatment offering a faster and cost-effective alternative to multidisciplinary models. FBPA may also assist in identifying cases in which symptoms are misattributed to FND and facilitate referral for appropriate care.

71    WHO BUILDS THE TOOLS MATTERS: INTERDISCIPLINARY AND CAREGIVER COLLABORATION IN FUNCTIONAL NEUROLOGICAL DISORDER RESOURCES SHAPED BY THE CLINICIANS AND CAREGIVERS WHO USE THEM (Treatment)
Jason Kreuzman, OTR/L, Neurolog

Background: The prevalence rate of FND in the youth and young adult population is high, most recently noted to be at least 18.3/100,000.  Providers report a lack of access to information about FND diagnosis and treatment specific to the youth population.  Most resources and educational materials are geared toward the adult population requiring details be extrapolated for youth application. The FNDS Pediatric Special Interest Group was developed to aid in the collaboration of cross-disciplinary professionals and advocates who wanted to improve pediatric FND knowledge and care. A subset of this group, the Community Awareness Subgroup, identified the need for high quality education that is easily accessible for caregivers, schools, and other professionals.

Methods: The Community Awareness Subgroup was created through the development of the broader FNDS Peds SIG which virtually meets monthly. The Community Awareness Subgroup is led by an occupational therapist and has involvement from multiple disciplines, including psychology, neurology, psychiatry, physical therapy, medicine, nursing, and caregivers. The group discussed community education needs and identified specific areas- 1) an easily readable information sheet identifying key facts and highlighting high quality resources, and 2) resources to promote recommendations for success at school for youth with FND, including a tip sheet and sample letter for professionals. Once drafted, materials were reviewed and edited by the interdisciplinary team. If discrepancies arose, the team discussed and resolved these issues at virtual meetings. When the group agreed on the final product, the group moved from the development to dissemination phase.

Results: Through the processed outlined above, 12 resources/handouts have been created by the FNDS Peds Sig for free distribution. Feedback from initial resources have been positive from SIG members noting resources being helpful with education, transition back to school and symptom management. The groups newly developed resources, "What is FND" handout and school recommendations letter template, have been shared with providers awaiting response for efficacy of these resources. FNDS branding has also been applied for which will greatly increasing utilization and reach of these resources.  

Conclusions: Through collaboration of a diverse member set that includes caregivers from the start, resource creation and destigmatization can occur much more quickly and effectively than if worked on separately. 

References:
1) Yong K, Chin RFM, Shetty J, Het.al. 2023. ; Edinburgh Paediatric FND Study Group. Functional neurological disorder in children and young people: Incidence, clinical features, and prognosis. Dev Med Child Neurol. Sep;65(9):1238-1246

72    LOWER URINARY TRACT SYMPTOMS IN FUNCTIONAL NEUROLOGICAL DISORDER: A PROSPECTIVE COHORT STUDY (Phenomenology/Epidemiology, Etiology/Pathophysiology)
Evelaine Louis, MD, Frontlab team, Paris Brain Institute (ICM), Paris, France

Background: Lower urinary tract symptoms (LUTS) are common in neurological disorders, but data in functional neurological disorder (FND) are scarce. We aimed to determine the prevalence and phenotype of LUTS in FND and to identify associated factors.

Methods: In a two-year prospective cohort study at a tertiary center, consecutive patients assessed for FND were included after confirmation by positive clinical signs. Individuals with comorbid neurologic or urologic conditions likely to cause LUTS were excluded. LUTS, pelvic symptoms, psychiatric comorbidity, pain, and quality of life were assessed using validated questionnaires; anticholinergic burden was quantified using the Anticholinergic Drug Scale. LUTS were defined using cutoffs on the Urinary Symptom Profile and/or a visual analog scale VAS of pelvi-perineal discomfort. Multivariable logistic regression tested five pre-specified covariates: symptom count (functional and non-specific somatic symptoms), pain intensity (VAS), anticholinergic burden (ADS), childhood adversity (CTQ total), and anxiety–depressive symptoms (HADS total).

Results: Among 145 participants (mean [SD] age 43 [13.7] years; 81% women), 64 (44%) reported LUTS, predominantly storage-type (30/64, 47%). Coexisting bowel and sexual dysfunction was frequent (46/61, 72%). Participants with LUTS reported poorer quality of life (SF-36 global health 34.5 ± 17.7 vs 42.8 ± 18.7; p=0.007). In multivariable analysis, LUTS were independently associated (OR [95% CI] per 1-SD increase) with higher symptom count (1.79 [1.20–2.76]; p=0.006) and greater pain intensity (1.70 [1.13–2.66]; p=0.014).

Conclusions: LUTS are frequent in FND, predominantly storage-type, and often occur alongside other pelvic symptoms and impaired quality of life. Independent associations with greater symptom burden and pain suggest that LUTS may represent part of a broader high symptom-burden phenotype in FND. The high prevalence and clinical impact support routine screening and multidisciplinary management. Ongoing urodynamic testing and longitudinal follow-up may help clarify mechanisms and inform tailored care.

73    CONTINUOUS ASSESSMENT OF FUNCTIONAL MOVEMENT PATTERNS IN A HOME-LIKE ENVIRONMENT (Etiology/Pathophysiology)
Lydia Maderthaner, IoPPN, King's College London, UK, University Hospital Bern, Switzerland

Introduction: Functional Movement Disorder (FMD), the most common subtype of Functional Neurological Disorder, is characterized by disabling motor symptoms arising from altered brain network functioning rather than structural pathology. A core diagnostic feature is internal inconsistency and context-dependence, influenced by attention, stress, and affect (1). However, everyday life intra-individual movement variability has not been systematically quantified, and its impact on outcome remains largely unknown. As clinical assessments capture brief snapshots, and self-reports are prone to bias, we use continuous objective measures.

The primary aim is to determine feasibility and acceptability of continuous within-day multimodal monitoring in a home-like environment. Secondary aims are to quantify intra-individual movement variability and test the hypothesis that motor behaviour in FMD is context-sensitive rather than randomly fluctuating, such that task characteristics systematically modulate variability — with externally oriented, goal-directed tasks tending to stabilise motor output and interoceptive, body-focused contexts tending to increase variability. Exploratory analyses will examine associations between variability metrics and clinical (e.g., subtype, severity, duration) and psychological measures (e.g., interoception, illness processing, somatic/dissociative symptoms, affect, quality of life).

Methods: This single-center feasibility study will recruit 34 patients with clinically established FMD (planned start 04/2026). Participants complete an 8-hour stay in the NeuroTec Loft — an instrumented apartment with unobtrusive multimodal sensors and video (2). Data acquisition includes wearable and environmental sensors capturing movement, posture, physiological arousal, ambient context, and activity patterns.

Primary endpoints are feasibility and acceptability, defined as ≥80% usable movement data, dropout ≤20%, and subjective burden assessed post-exposure. Secondary analyses will quantify within-person variability and task-dependent modulation during standardized activities of daily living using statistical modelling complemented by exploratory data-driven analyses. Clinical and psychometric data will be related to variability measures.

Results:
Data collection is scheduled to begin in April 2026. Initial pilot data (n≤5) will evaluate feasibility metrics, data quality, and preliminary patterns of intra-individual movement variability and task-dependent modulation.

Conclusion:
This study introduces a novel approach to objectively characterize movement variability in FMD. By identifying intra-individual patterns of context-dependent variability — including task- and arousal-related and spontaneous fluctuations — it aims to clarify their clinical relevance and potential implications for prognosis, symptom trajectories, and targeted therapeutic strategies.

References:
1. Stone & Carson. Lancet Neurol. 2020.
2. Gerber et al. Sensors. 2022

74    DIFFERENCES AND OVERLAP AMONG FUNCTIONAL NEUROLOGICAL DISORDER SUBTYPES: A SYSTEMATIC REVIEW AND META-ANALYSIS (Phenomenology/Epidemiology)
Daniel Stiven Marín-Medina, FLENI

Background: Functional neurological disorders (FND) comprise distinct subtypes that share underlying mechanisms but differ in clinical presentation. This study aimed to compare demographic and clinical features across FND subtypes.

Methods: We conducted a systematic review of PubMed from inception to February 2, 2025. Studies comparing adult patients with different FND subtypes including functional movement disorder (FMD), functional or dissociative seizures (FDS), functional weakness (FW), functional dizziness (FD), and functional cognitive disorder (FCD) were included. Studies comparing FND with healthy controls or other psychiatric disorders, or not differentiating between FND subtypes, were excluded. Demographic, clinical, and psychometric data were extracted. Random effects meta-analyses were performed when sufficient data were available.

Results: Fourteen studies were included, comprising 1,409 patients (FMD = 657; FDS = 527; FW = 225). Comparisons included FDS vs FMD (nine studies), FMD vs FW (two), and FDS vs FW (two). No studies compared FD or FCD. 

Patients with FDS were significantly younger than those with FMD (mean difference −3.74 years, 95% CI −5.84; −1.63). There was a trend in age at onset to be lower in FDS (mean difference −4.06 years, 95% CI −9.43; 1.32) and a female predominance in FDS (OR 1.31, 95% CI 0.89; 1.94) [Figure 1].

In FDS vs. FMD comparisons, FDS patients reported higher frequencies of childhood abuse, stressors, acute onset, and longer illness duration. While subjective symptoms (pain, fatigue, cognitive issues) and psychiatric comorbidities (anxiety, depression) were similar across groups, FDS was associated with higher dissociation, neuroticism, and histrionic traits, whereas FMD showed more prominent somatic symptoms [Table 1].

In FDS vs FW comparisons, FDS patients tended to be younger and showed greater exposure to psychological stressors, family dysfunction, parental problems, more life events, and longer symptom duration. Subjective complaints and most comorbidities were similar, although borderline personality traits were more frequent in FDS. Patients with FDS rejected psychological explanations less strongly.

FW vs FMD comparisons showed largely similar demographics, although younger age was reported in FW when compared with functional tremor and gait disorders. Trauma history and symptom duration were comparable, while FW more frequently showed acute onset and sensory functional symptoms. Subjective complaints and psychological features were similar.

Conclusions: FND subtypes share overlapping features but differ in demographic profiles, life history factors, and psychological characteristics. FDS is associated with younger age, greater psychosocial adversity, and higher dissociative traits, whereas FMD is characterized by a more prominent somatic symptom burden. FW shows substantial overlap with FMD, with broadly similar demographic and psychological profiles.

75    ADAPTATION OF A MANUALIZED PHYSICAL THERAPY PROTOCOL WITH APPLICATION OF YOGA-INFORMED ACTIVITY TRAINING FOR THE TREATMENT OF MOTOR FND IN US VETERANS VIA TELEHEALTH (Treatment)
Charity Winters, Department of Veterans Affairs Key West Outpatient Clinic

Background: The Department of Veterans Affairs Miami Healthcare System provides comprehensive healthcare services to Veterans of South Florida and includes several satellite Community Based Outpatient Clinics (CBOCs). The Miami VA utilizes telehealth platforms to deliver diverse specialty care to Veterans in remote locations, including for the treatment of functional neurological disorder (FND). Starting in Aug 2024, a physical therapist (PT) from the Key West VA CBOC joined the multidisciplinary FND team from the Miami VA to offer physical therapy for Veterans with motor FND (gait, tremor, weakness, facial movements) (1). This abstract describes the process of adaptation of a manualized physical therapy program to address challenges related to the specific clinical context. 

Case Presentation: The PT adapted Nielsen and Holt’s Physiotherapy Intervention Manual for the Physio4 FMD Trial (2) to contextual limitations specific to location, reduced in person appointment availability and Veterans utilizing nonclinical spaces for therapeutic environments. Initial evaluations with the PT included a plan of care projection with a frequency of 1 weekly PT session for 8-12 weeks. Based on the Physio4FMD manual, clinical care focused on sitting postures, transfers, gait, arm and hand movement, pain management, fatigue awareness, and memory attention. Yoga-informed modalities were applied while following the manual’s recommendations for activity retraining, attention redirection, and sequential motor learning. PT sessions were scheduled for 1 hour and included therapeutic interventions with elements of chair and standing yoga, breath coordinated movement, timed read aloud, autogenic nervous system retraining, and patient education. Veterans were prescribed land-based home exercise programs and aquatic functional movement programs (where feasible) to reinforce clinical sessions. Veterans were discharged from PT with recommendations to continue with functional movement exercise programs. Discussion: Between Aug 2024 and Feb 2026, 19 referrals for FND-focused PT resulted in 17 initial PT assessments and 15 Veterans committing to a plan of care, all delivered via telehealth, except for 1 via blended in person and telehealth. A PT, utilizing synchronized telehealth, adapted the Physio4 FMD manual for the treatment of US Veterans with functional motor symptoms. The PT applied yoga-informed movement training for functional optimization. Research should be conducted to validate the incorporation of yoga-based modalities within a manualized PT treatment protocol (such as the Physio 4 FMD manual) delivered via telehealth in Veterans with motor FND.

References: 
1.Nielsen G, Stone J, Matthews A, et al. Physiotherapy for functional motor disorders: a consensus recommendation. J Neurol Neurosurg Psychiatry. 2015 Oct;86(10):1113-9. 
2.Nielsen G and Holt K.  Physiotherapy Intervention Manual for the Physio4 FMD Trial. St George’s, University of London.2023

76    RESTING STATE FUNCTIONAL CONNECTIVITY AND SENSORIMOTOR PREDICTION ERROR IN FUNCTIONAL MOVEMENT DISORDERS (Etiology/Pathophysiology)
Angela Marotta, University of Verona

Background: Sensory attenuation, the reduced perception of self-generated sensory stimuli, is a fundamental mechanism underlying sensorimotor prediction and the sense of agency [1]. Altered predictive processing has been proposed as a key pathophysiological mechanism in Functional Movement Disorders (FMD) [2], and previous studies have demonstrated a loss of sensory attenuation in this population. However, the neural patterns associated with these alterations remain poorly understood. The aim of this study is to investigate sensory attenuation in patients with FMD and to explore associated patterns of resting-state functional connectivity using functional magnetic resonance imaging (rs-fMRI).

Methods: Twenty-five patients with FMD and 23 healthy controls (HC) performed a force-matching task to assess sensory attenuation. Participants reproduced target forces applied to the left index finger either by pressing directly on the finger (direct condition) or by controlling an external device (indirect condition). Sensory attenuation is typically reflected by force overestimation in the direct condition. We calculated the SA Index as the ratio between the applied force and the target force. We then examined the effects of Group and Condition on the SA Index using a 3×2 mixed-design ANOVA. Rs-fMRI data were analyzed to assess group differences in functional connectivity and associations with SA within the FMD group. Relationships with clinical variables were also examined. The study was funded by the European Union (Next Generation EU, NRRP M6C2, Investment 2.1; PNRR-MAD-2022-12376826).

Results: Patients with FMD showed reduced SA index in the direct condition compared with HC, while no group differences emerged in the indirect condition. Rs-fMRI analyses revealed increased functional connectivity in FMD between the cerebellum and the basal ganglia, anterior cingulate cortex (ACC), and insula. Reduced connectivity was observed between the middle temporal gyrus and the precuneus and posterior cingulate cortex relative to HC. Within the FMD group, SA Index in the direct condition showed a positive association with cerebellar–ACC functional connectivity. No significant correlations were found with clinical variables.

Conclusions: In line with previous studies, we found impaired sensory attenuation in FMD. Patterns of resting-state functional connectivity were associated with sensory attenuation, suggesting network-level adaptations involving cerebellar–cingulate coupling that may partially support sensorimotor prediction without fully restoring normal sensory attenuation.

References:
[1] Blakemore SJ, Wolpert DM, Frith CD. Central Cancellation of Self-Produced Tickle Sensation. Nat. Neurosci. 1998: 1, 635–640. 
[2] Edwards MJ, Adams RA, Brown H, Parees I, Friston KJ. A Bayesian Account of “Hysteria”. Brain 2012: 135, 3495–3512. 

77    MAPPING FUNCTIONAL MOVEMENT DISORDER SUBTYPES: PHENOTYPE-SPECIFIC FUNCTIONAL AND STRUCTURAL BRAIN SIGNATURES (Etiology/Pathophysiology)
Sreeja Samineni, AIIMS, New Delhi

Background: Functional movement disorders (FMD) most commonly present as functional tremor (FT), followed by functional gait disorder (FGD) and mixed phenotypes. Although phenotype-specific resting-state connectivity changes have been reported, shared multimodal brain alterations remain unclear. We examined resting-state functional connectivity and cortical thickness across FMD subgroups and anxiety/depression profiles and compared them with healthy age matched controls.

Methods: Thirty-six FMD patients (17 FT, 6 FGD, 13 other phenotypes) and 13 age-matched healthy controls were enrolled in this prospective observational study. Demographic, clinical, and Hospital Anxiety and Depression Scale (HADS) data were collected. Resting-state fMRI was acquired using multiband single-shot EPI (EPI factor 43, FOV 230×230×144 mm, 3×3×3 mm isovoxel, TE 25 ms, TR 1000 ms, multiband factor 3). A 3D T1-weighted TFE sequence (TR/TE 8/4 ms, flip angle 8°, FOV 250×250×175 mm) was used for cortical thickness analysis. Group differences were tested with ANOVA/Kruskal–Wallis and Chi square/Fisher’s exact tests, and imaging analyses used general linear models computed at a statistical significance of PFDR <0.05 or P uncorrected <0.001. 

Results:
The mean age of study group was 31.3 ± 14.0 years. Demographic and clinical characteristics were comparable across groups, with no statistically significant intergroup differences except for HADS-D which showed a non-significant trend toward higher depressive symptom scores in FGD (Table 1). Significantly altered patterns of connectivity was observed in the phenotypic groups as compared to healthy as well as amongst groups (Figure1). Compared to healthy controls, inhibitory connectivity of sensorimotor network to frontoparietal regions and faciliatory cerebellar networks to frontoparietal areas were not observed in the FT group. (Figure 2) Altered Left Thalamus to Left Pallidum facilitatory connectivity was observed with loss of facilitatory connectivity from Right thalamus to right pallido-putaminal as compared to healthy controls. (Figure 3). Cortical Thickness was significantly reduced in the FGD group in the left supramarginal and left superior parietal cortex. (Figure 4)

Conclusions: Despite comparable demographic and clinical profiles, resting-state analyses revealed distinct phenotype-specific neuroimaging abnormalities. FT showed disrupted sensorimotor–frontoparietal and cerebello–frontoparietal coupling with asymmetric thalamopallidal connectivity, while FGD showed structural cortical thinning in left parietal regions. These findings support a distributed network model of FMD with subtype-specific functional and structural signatures, and phenotype specific connectivity patterns with  potential to  translate into biomarkers and development of therapy.

References: 
1.Gless CA et al. NeuroImage: Clinical. 2025 Jul 23:103850.

78    IMMEDIATE IMPACT OF A SAME-DAY INTERDISCIPLINARY FUNCTIONAL MOVEMENT DISORDER CLINIC ON DIAGNOSTIC UNDERSTANDING, ACCEPTANCE, AND TREATMENT ENGAGEMENT (Treatment)
Emmi Scott, PhD, Inova Health System

A clear diagnostic explanation can itself be therapeutic in functional neurological disorder, particularly when delivered consistently by clinicians who can link the diagnostic explanation directly to a treatment plan. Interdisciplinary care models are widely recommended for FND, yet the immediate impact of a single coordinated visit on diagnostic acceptance and early treatment engagement has not been studied systematically. We established a same-day “one-stop” interdisciplinary clinic for functional movement disorders (FMD) within Inova Health System serving the Northern Virginia/Washington, DC region. The clinic integrates a movement disorders neurologist, neuropsychologist, and physical therapist who aim to confirm the diagnosis, provide a unified diagnostic explanation, and develop an individualized treatment plan involving rehabilitation and/or psychotherapies. We present the feasibility of this model and its short-term (same day) impact on patient-reported diagnostic understanding, acceptance, and recovery expectations.

Consecutive patients evaluated in the interdisciplinary FMD clinic completed brief ratings immediately before and after the visit assessing understanding of the diagnosis (0-10), acceptance of the diagnosis (1-3), and expectations for recovery (0–10; adapted from Maggio et al. (2019). Feasibility outcomes included clinic no-show rate and treatment initiation within 30 days of the visit (i.e., attending at least one recommended session of outpatient psychotherapy, or rehabilitation therapy). Pre- to post-visit changes were examined using paired t-tests.
At the time of submission, 19 patients had completed the interdisciplinary clinic visit with 0 no-shows, suggesting strong demand and feasibility. Fourteen patients (74%) were offered treatment within our program, including psychotherapy (n=13), physical therapy (n=11), occupational therapy (n=3), and speech therapy (n=1). Overall, 82% of recommended therapies were initiated within 30 days of the visit. Interim pre/post patient-reported data (N=9; projected N=18) demonstrated large and significant improvements across all three constructs: diagnostic understanding (M=4.1→7.7, d=1.72, p=.001), recovery expectations (M=4.9→7.3, d=1.98, p<.001), and diagnostic acceptance, with all patients reaching the scale maximum post-visit (M=2.6→3.0, d=0.84, p=.035) [figure1].

A same-day interdisciplinary FMD clinic appears feasible within a large health system and produces immediate, large improvements in diagnostic understanding, diagnostic acceptance, and recovery expectations, factors that are central to treatment readiness in FND (Gilmour et al., 2024). Early uptake of recommended therapies was high, suggesting that integrating diagnostic explanation with rehabilitation planning may facilitate engagement with evidence-based treatments. These preliminary findings support interdisciplinary care models as a scalable approach to improving treatment readiness for patients with FND.

79    PREVALENCE OF FIBROMYALGIA IN FUNCTIONAL MOTOR DISORDER – A MULTICENTER STUDY (Phenomenology/Epidemiology)
Tereza Serranová, MD, PhD, Charles University

Background: Fibromyalgia is a chronic pain disorder affecting 2–3% of the population, characterised by widespread pain, fatigue, sleep disturbance, and cognitive symptoms.[1] Despite symptom overlap between functional motor disorder (FMD) and fibromyalgia, the prevalence of fibromyalgia in FMD established using the 2016 American College of Rheumatology (ACR) diagnostic criteria, as well as its impact on health-related quality of life (HRQoL), remains unclear.

Methods: In this multicentre, international study, 326 consecutive patients with clinically established FMD (265 females; mean age 43.5 ± 13.4 years) were recruited from four European tertiary FMD clinics: Prague, Czechia (n=89), Sevilla, Spain (n=70), Paris, France (n=81), and Verona, Italy (n=86). Participants completed the validated Fibromyalgia Survey Questionnaire assessing the Widespread Pain Index (WPI) and Symptom Severity Scale (SSS), together yielding the Fibromyalgia Severity Score (FSS). Fibromyalgia was defined according to the 2016 ACR criteria cut-offs for WPI and SSS, including the presence of generalised pain in ≥ 4 of 5 regions for ≥ 3 months. HRQoL was assessed using the 12-Item Short Form Health Survey (SF-12). Motor symptom severity was evaluated in 301 patients using the Simplified FMD Rating Scale (S-FMDRS). Fisher’s exact test, Pearson correlation, and linear regression were used for statistical analysis.

Results: Fibromyalgia was present in 130 patients with FMD (39.9%, 95% CI 34.5–45.4%) across all centres, with no significant between-centre differences in prevalence. FSS correlated moderately with S-FMDRS (r=0.40, p<0.001). In linear regression analysis, S-FMDRS scores were higher in patients with fibromyalgia compared to patients without fibromyalgia (p<0.001) and in Paris compared with other centres (p < 0.001), whereas age and sex were not significant predictors. Another linear regression showed that lower HRQoL was jointly predicted by higher FSS (both for physical and mental HRQoL p<0.001), fibromyalgia diagnosis (physical p=0.006; mental p=0.030), and S-FMDRS in physical HRQoL (physical p<0.001, mental p=0.24), whereas age and sex were not significant predictors, and HRQoL was higher in Paris and Verona than in Prague and Sevilla (p<0.003).

Conclusions: Fibromyalgia is highly prevalent in FMD and independently associated with poorer HRQoL. Although prevalence may be overestimated due to recruitment from tertiary centres managing more complex cases, these findings highlight the importance of recognising and addressing fibromyalgia in FMD, particularly in patients with greater motor severity. Variability in HRQoL across centres may partly reflect differences in symptom severity, but sociocultural and healthcare-related factors likely also contribute and warrant further investigation.
Supported by NW24-04–00456.

Reference:
1.    Sarzi-Puttini P, et al. Fibromyalgia: an update on clinical characteristics, aetiopathogenesis and treatment. Nat Rev Rheumatol. 2020;16, 645-660

80    ILLNESS THREAT AS A DISTINCT AND MODIFIABLE DIMENSION IN FUNCTIONAL MOVEMENT DISORDER (FMD): EVIDENCE FROM THE JOHNS HOPKINS FMD DIAGNOSTIC CLINIC (Phenomenology/Epidemiology)
Madeleine Smith, MS, Johns Hopkins University

Background: Functional movement disorder (FMD) is a motor-dominant subtype of functional neurological symptom disorder characterized by involuntary movements, weakness, and gait dysfunction incongruent with recognized neurological disease. Symptom burden in FMD is well-documented, including high rates of somatic symptoms, pain, anxiety, depression, and functional impairment (Perez et al., 2021). Beyond symptom burden, patients’ perceptions of their illness (i.e., perceived illness threat) may represent a distinct, clinically relevant dimension of the FMD experience (Joos et al., 2024). While symptom severity is not readily modifiable through diagnostic evaluation alone, illness threat may be directly influenced by how the diagnosis is communicated. The Johns Hopkins interdisciplinary FMD Diagnostic Clinic, established in 2024 as a collaborative diagnostic care model integrating neurology and neuropsychology, provides a setting uniquely positioned to examine illness threat as a potentially modifiable target of interdisciplinary diagnostic care. The present study examined whether (1) illness threat represents a distinct dimension of the FMD experience beyond symptom burden, affective distress, clinician-rated severity, pain interference, and alexithymia, and (2) illness threat changes following interdisciplinary diagnostic evaluation.
 
Methods: Patients evaluated at the Johns Hopkins FMD Diagnostic Clinic (N = 30) completed baseline self-report measures assessing physical, psychological, and behavioral symptoms. A subset (N = 12) completed the Brief Illness Perception Questionnaire (BIPQ) before and after interdisciplinary diagnostic evaluation. Analyses included descriptive statistics, paired t-tests to assess change in illness threat, and Spearman correlations examining baseline associations between illness threat and other clinical measures. 

Results: Illness threat decreased significantly following interdisciplinary diagnostic evaluation (t(11) = -7.00, p < 0.001), reflecting a large within-person effect (mean change = -11.08; 95% CI [-14.57, -7.60]; Hedges’ g = -1.89). At baseline (N = 30), illness threat demonstrated modest correlations across affective, somatic, pain, and clinician-rated severity measures (r = .22-.42), with no single domain accounting for the majority of variance. 

Conclusions: Illness threat represents a clinically relevant dimension of the FMD experience that is related to—but distinct from—symptom burden, affective distress, clinician-rated severity, pain interference, and alexithymia. Reductions in BIPQ scores following interdisciplinary diagnostic evaluation suggests that illness threat may be modifiable at the point of diagnosis through interdisciplinary care. These preliminary findings support further investigation of illness threat as a potential pathway influencing engagement, help-seeking behavior, and longer-term outcomes following interdisciplinary FMD care. 

References: Joos et al., 2024; Perez et al., 2021

81    BRIDGING GAPS IN OVERLAPPING SYMPTOMS IN FUNCTIONAL MOTOR DISORDERS AND MULTIPLE SCLEROSIS: PREVALENCE, PROGNOSIS, AND REHABILITATION EFFECTIVENESS (Phenomenology/Epidemiology, Treatment)
Melania Fasoli, University of Verona

Background: Functional Motor Disorders (FMDs) and Multiple Sclerosis (MS) are common, diagnostically challenging conditions characterized by fluctuating motor (weakness, tremor, gait disturbance) and non-motor symptoms (fatigue, pain) [1,2]. Their overlap becomes particularly problematic when FMD exacerbations mimic true MS relapses, leading to unnecessary treatments, delayed rehabilitation, increased healthcare utilization, and greater patient burden. Accurate differentiation is therefore essential for appropriate management and improving outcomes.

Methods: This multicenter prospective study will enroll 192 consecutive patients with definite MS presenting with acute symptoms worsening at two referral centers over 24 months. A standardized cross-sectional assessment will differentiate true MS relapses from FMD-related relapses using neurological examination based on the McDonald criteria and established FMD diagnostic criteria (Gupta and Lang; DSM-5-TR), clinician-administered scales, and patient-reported outcome measures (PROMs).
Participants will be followed at 1, 3, and 6 months to assess recovery trajectories and disability progression. Patients with MS–FMD overlap will enter a single-blind RCT comparing a multidisciplinary FMD-specific rehabilitation program with telemedicine follow-up versus standard MS rehabilitation.

Results: We will describe the prevalence of MS-FMD overlap symptoms in patients with definite diagnosis of MS and symptom’s worsening. We will identify potential clinical and imaging features that might discriminate FMD-related relapse from MS true relapse; preliminary evidence on the effects of a management for FMD symptoms will be explored.

Conclusions: Results will inform diagnostic and rehabilitation protocols to guide tailored multidisciplinary management in MS patients with FMD overlapping symptoms.

References:
[1] Walzl, D., Solomon, A. J., & Stone, J. (2022). Functional neurological disorder and multiple sclerosis: a systematic review of misdiagnosis and clinical overlap. Journal of neurology, 269(2), 654–663. https://doi.org/10.1007/s00415-021-10436-6
[2] Aybek, S., & Chan, A. (2023). The borderland of multiple sclerosis and functional neurological disorder: A call for clinical research and vigilance. European journal of neurology, 30(1), 3–8. https://doi.org/10.1111/ene.15568

82    CHANGES IN CLINICAL AND NEUROPHYSIOLOGICAL VALIDATED BIOMARKERS FOLLOWING MULTIDISCIPLINARY REHABILITATION IN FUNCTIONAL MOTOR DISORDERS (Treatment)
Melania Fasoli, University of Verona

Background: Functional motor disorders (FMDs) are common and disabling conditions, with diagnosis often hindered by clinical heterogeneity. Although multidisciplinary rehabilitation is an effective treatment [1], objective biomarkers capable of capturing rehabilitation-induced neurobiological changes and predicting clinical response remain lacking. Identifying such biomarkers may improve monitoring of treatment efficacy and provide prognostic insight [2].

The aim of this study is to evaluate changes in algorithm-selected biomarkers following multidisciplinary rehabilitation in FMDs patients and their association with motor and non-motor symptoms and quality of life, exploring their utility as indicators of treatment response and prognosis.  

These results are part of a project funded by the European Union (Next Generation EU, NRRP M6C2, Investment 2.1; PNRR-MAD-2022-12376826). Here, we report preliminary results concerning Aim 3 [2].

Methods: 34 patients with a clinically definite diagnosis of FMDs (Gupta & Lang Criteria) underwent a multidisciplinary rehabilitation program [1] and were evaluated before treatment (T0) and after 3 months (T1). Assessments include standardized clinical scales measuring motor and non-motor symptoms. Behavioral and neurophysiological biomarkers have been collected, alongside structural and a task-based functional MRI, as previously detailed [2], in order to develop a biomarker-based prognostic algorithm.

Results: All the participants returned after 3 months (30 females, Mean Age 42.77±11.02 SD). 59% of them reported an improvement in their condition according to the CGI Scale, confirmed also by a significant improvement in both motor (S-FMDRS, p<0.001) and non-motor symptoms scales (BDI, SF-12 Physical Score, MFI, all p<0.004). Among the algorithm-selected biomarkers, only the motor dual-task effect on gait speed showed a significant improvement at the 3-month follow-up (p = 0.039). Functional connectivity analyses are still ongoing.

Conclusions: Gait speed during a motor dual-task condition may represent a potential prognostic biomarker, reflecting the efficacy of multidisciplinary rehabilitation program.

References:
[1] Gandolfi M, Riello M, Bellamoli V, Bombieri F, Geroin C., Di Vico I.A., Tinazzi M. (2021). Motor and non-motor outcomes after a rehabilitation program for patients with functional motor disorders: A prospective, observational cohort study. NeuroRehabilitation, 48(3), 305–314. https://doi.org/10.3233/NRE-201617
[2] Gandolfi M, Sandri A, Mariotto S, Tamburin S, Paolicelli A, Fiorio M, et al. (2024). A window into the mind-brain-body interplay: Development of diagnostic, prognostic biomarkers, and rehabilitation strategies in functional motor disorders. PLoS ONE 19(9): e0309408. https://doi.org/10.1371/journal.pone.0309408

83    CHANGING THE CULTURE OF CARE FOR PEDIATRIC FUNCTIONAL NEUROLOGICAL DISORDER: IMPLEMENTATION OF A SIX-STEP INTERDISCIPLINARY INTEGRATED CARE PROTOCOL IN A TERTIARY CHILDREN’S HOSPITAL (Treatment)
Emma Prades Morera, Sant Joan de Déu Barcelona Children's Hospital

Background: Functional Neurological Disorder (FND) is a significant cause of neurological disability in pediatric populations, accounting for approximately 8–20% of referrals to pediatric neurology services. Recovery rates of 63–95% with timely diagnosis highlight the importance of early recognition and coordinated care. Despite growing international consensus, integrated inpatient protocols for children hospitalized with suspected FND remain scarce and are currently lacking in Spain, where no specialized pediatric units, clinical guidelines, or structured multidisciplinary pathways exist. To address this unmet need, Sant Joan de Déu Children’s Hospital, a tertiary referral center, developed a systems-level interdisciplinary integrated care protocol for pediatric patients hospitalized with suspected FND, aiming to promote diagnostic clarity, shared biopsychosocial formulation, therapeutic communication, and coordinated multimodal intervention.

Methods: A dedicated interdisciplinary team (Hospital Pediatrics, Neuropediatrics, Liaison Psychiatry/Psychology, Rehabilitation, Gastroenterology, Pain Unit, Social Work, Child Life, and Hospital School) co-designed and is implementing a structured six-step inpatient protocol, with the goal of future hospital-wide dissemination through targeted training.

The protocol consists of six sequential components designed to reduce diagnostic delay, prevent iatrogenia, and promote functional recovery:

Early detection and expectation alignment, establishing a unified and empathetic clinical message from admission.

Parallel interdisciplinary biopsychosocial assessment, combining neurological and mental health evaluations while minimizing unnecessary investigations.

Multidisciplinary diagnostic consensus, integrating clinical information into a shared formulation and coordinated care plan.

Structured therapeutic diagnostic communication with the patient and family, delivering a positive diagnosis, validating symptoms, and fostering engagement and hope.

Coordinated inpatient multimodal intervention, integrating rehabilitation, psychoeducation, family intervention, and functional activation according to symptom presentation.

Planned discharge with continuity of care, ensuring safe transition, relapse prevention, and coordination with outpatient services, school, and community resources.

Results: The protocol is currently being implemented in routine clinical practice, and prospective data collection is underway. Early clinical experience suggests improved interdisciplinary coordination, greater coherence in diagnostic communication, more appropriate referrals across therapeutic disciplines, enhanced family understanding, and increased patient engagement, with a shift toward function-oriented care during hospitalization.

Conclusions: By addressing a major gap in the Spanish healthcare system, this model may improve clinical trajectories and provide a scalable framework for pediatric FND care

84    INVESTIGATING THE EFFICACY OF A MINDFULNESS-BASED INTERVENTION FOR IMPROVING MINDFUL AWARENESS, PSYCHOLOGICAL WELLBEING, AND COGNITIVE PERFORMANCE IN FUNCTIONAL COGNITIVE DISORDER (Treatment)
Michael Ridley-Dash, Black Country Healthcare NHS Foundation Trust

Background: Functional cognitive disorder (FCD) is the experience of cognitive processing difficulties due to multisystem and higher order control dysfunction, not explained by central nervous system pathology. There is little evidence of effective treatments for FCD, meaning that there are no current treatment guidelines. Literature describing the effectiveness of mindfulness-based interventions for psychogenic seizures (Baslet et al, 2020) led to the adaptation of such  mindfulness training for rehabilitation of FCD, as a novel area of research.
 
Methods: Thirteen people with FCD attended a mindfulness-based training programme and completed outcome measures before and after the intervention to investigate the impact of improvements in trait-mindfulness abilities on psychological wellbeing and cognitive performance in FCD. 

Measures used included: 
• Five Facet Mindfulness Questionnaire
• Depression, Anxiety, Stress Scale 
• Addenbrooke’s Cognitive Exam-III
• Questionnaire for Assessing Blocking Beliefs

Results: Statistical analyses of reliable change found clinically meaningful improvements in observational awareness and statistically significant changes for non-reactivity, suggesting that mindfulness training does improve trait-mindfulness abilities in FCD. Correlational findings showed consistent negative associations between improved mindfulness abilities and fewer  symptoms of psychological distress, and positive correlations between improved mindfulness abilities and attentional task performance. Measurable benefits were found for more than half of the sample. 

Conclusion: This study supported predictions that mindfulness-based interventions assist with emotion regulation, behavioural activation towards wellbeing management, metacognitive adjustments, and act as cognitive remediation, meeting the neuro-psychosocial needs of those with FCD with the potential for effective symptom management. 

Reference:
Baslet, G., Ehlert, A., Oser, A. & Dworetzky, B. (2020). Mindfulness-based therapy for psychogenic nonepileptic seizures. Epilepsy and Behaviour, 103, 106534. DOI: 10.1016/j.yebeh.2019.106534

85    VIRTUAL ENVIRONMENT IMPROVES MOTOR DYSFUNCTION IN FUNCTIONAL NEUROLOGICAL DISORDER: EVIDENCE FROM VIRTUAL AND AUGMENTED REALITY (Etiology/Pathophysiology, Treatment)
Laure von der Weid, University of Fribourg

Background: Virtual and Augmented Reality (VR/AR) are increasingly used in medicine and may offer novel interventions for Functional Neurological Disorder (FND) by targeting mechanisms of impaired motor control. However, evidence for the effect of different modalities on movement in FND is limited. Moreover, it is hypothesized that visual feedback of one’s affected arm could reinforce FND symptoms through maladaptive self-monitoring. The present study aims to compare motor performance under visual feedback of a virtual avatar versus the real arm.

Methods: Fifteen FND patients and eighteen healthy controls completed a dual motor reaching task (touching a virtual fruit such as orange or apple appearing in front of them)  across three modalities: Augmented Reality (AR), where participants saw their real arm; Virtual Reality (VR), with a virtual arm; and Virtual Reality Improved (VRI), with artificially enhanced straightness and larger collision zone with the target.  Their movement speed, straightness and number of acceleration were calculated for each fruit catch. 

Results: FND participants were slower and produced less smooth movements in AR compared to VR (b = 1.09, z = 8.83, P < .001) and VRI (b = 0.85, z = 6.91, P < .001), a difference that was not found in healthy controls. Eye tracking showed that FND patients looked more at their body than controls across all modalities and especially in AR (b = 0.0056, z = 3.31, P < .001), and more at their affected hand than unaffected hand (b = 0.0129, t = -3.44, P > 0.001). 

Conclusions: Virtual feedback of their limb appears to support better motor performance, while visual feedback of their limb appears to exacerbate motor impairments in FND patients, likely reinforcing maladaptive self-monitoring. These findings highlight the therapeutic potential of VR interventions and provide the basis for future studies examining longer protocols, clinical outcome and potential implementation in standard motor rehabilitation.

References:
Distorted Visual Feedback as a Treatment for Functional Movement Disorders. Movement disorders clinical practice, 9(2), 275–277. https://doi.org/10.1002/mdc3.13386
Hadjipanayi, C., Banakou, D., & Michael-Grigoriou, D. (2024). Virtual reality exergames for enhancing engagement in stroke rehabilitation: A narrative review. Heliyon, 10(18).

86    WHEN BREATHING GUIDES ACTION: ALTERED COUPLING IN FUNCTIONAL NEUROLOGICAL DISORDER (Etiology/Pathophysiology)
Laure von der Weid, University of Fribourg

Introduction: In recent research, growing interest has emerged in the role of interoception in Functional Neurological Disorder (FND). New hypotheses suggest that abnormal processing of bodily signals by the brain may impact voluntary movement. Interoception is particularly relevant given its relationship with embodiment and motor control. Recent experiments in healthy individuals have shown that voluntary actions during the Libet clock task are coupled with the breathing cycle; specifically, button presses occur significantly more often during the expiration phase. This suggests a link between motor action and interoceptive timing. This study set out to examine whether this coupling is altered in patients with FND compared to healthy controls.

Methods: 27 FND patients and 28 age- and gender-matched healthy controls (HC) took part in the Libet Clock, while their respiration was recorded with a breathing belt. The timing of the voluntary action, i.e. the button press, was recorded while participants had to focus either on the position of their button press (Movement condition) or the position of their initial intention to press (Wanting condition) and subsequently indicate it (M-Judgement and W-Judgement, respectively). The actual button presses were then compared to the participant’s breathing cycle.

Results: In HC, a significant link between button pressing and the expiration phase was observed in the Movement condition (p = .0002) but not in the Wanting condition (p = .473). In contrast, FND patients exhibited this link in both conditions (p = .0004 in Movement, p = .0024 in Wanting) [Figure 1]. 

Conclusion: FND patients exhibit a stronger binding of their action to their breathing cycle compared to HC, even when the task’s instructions are different. This suggests a reduced flexibility in adapting their action-breathing coupling strategy. These results extend previous reports of deficits in agency in FND, and reveal a possible link to the respiratory system. Further research should look at the interplay between motor action and respiratory interoception. 

Reference:
Park, H. D., Barnoud, C., Trang, H., Kannape, O. A., Schaller, K., & Blanke, O. (2020). Breathing is coupled with voluntary action and the cortical readiness potential. Nature communications, 11(1), 289.

87    DEVELOPMENT OF CLINICAL HYPNOSIS/HYPNOTHERAPY GUIDELINES FOR THE TREATMENT OF FUNCTIONAL NEUROLOGICAL DISORDERS: A DELPHI STUDY (Treatment)
Mohit Mohan, South London and Maudsley NHS Trust

Background: Clinical hypnosis/hypnotherapy is effective and increasingly being integrated into functional neurological disorder (FND) management, yet practice remains heterogeneous and formal guidance is lacking. This study aims to develop evidence- and consensus-based recommendations for incorporating hypnosis/hypnotherapy within multidisciplinary FND care.
Methods: A three-round online Delphi process is underway involving clinicians experienced in treating FND with clinical hypnosis/hypnotherapy. Round 1 used an open-ended survey to explore current practice and generate preliminary recommendations across domains including treatment targets, indications and contraindications, techniques, session structure, outcomes, adverse effects, and implementation factors. Free-text responses were analysed using reflexive thematic analysis. Rounds 2 and 3 will transform derived themes into rateable statements to achieve expert consensus.

Results: Forty-three clinicians from thirteen countries completed Round 1. Reflexive thematic analysis of free-text responses identified eight overarching themes describing current clinical use of hypnosis/hypnotherapy in FND: (1) it is usually an adjunct embedded within broader care rather than a standalone cure; (2) key targets include arousal and anxiety regulation, coping, and self-efficacy, with symptom improvement often linked to these mechanisms; (3) core techniques include tailored direct and indirect suggestions using imagery and metaphor, as well as self-hypnosis and home practice; (4) delivery is clinic compatible, commonly involving 45-60 minute sessions with brief trance segments across several sessions, with flexible frequency and duration; (5) suitability is judged by readiness factors such as rapport, motivation, and willingness to practice, in addition to symptom profile; (6) safety boundaries emphasise consent and clinical stability, with caution or avoidance in impaired reality testing, mania or hypomania, high dissociation, or destabilising trauma; (7) adverse effects include transient symptom intensification or dissociation, managed through pacing, grounding, and structured session closure; and (8) implementation barriers include stigma and misconceptions about hypnosis, time and reimbursement constraints, and variable training standards.

Conclusions: Round 1 findings provide a structured synthesis of expert practice patterns, therapeutic principles, and safety boundaries for clinical hypnosis/hypnotherapy in FND. These results form the empirical foundation for developing consensus-based clinical recommendations in subsequent Delphi rounds.

References:
1. Connors MH, et al. Hypnosis and suggestion as interventions for functional neurological disorder: A systematic review. Gen Hosp Psychiatry. 2024;86:92-102.
2. Lukose A, Das A. Patient-reported outcomes and acceptability of suggestion and hypnosis-based therapy for functional neurological disorder within an NHS service. Gen Hosp Psyc

88    OBSTETRIC, MENTAL HEALTH, AND HEALTHCARE UTILISATION OUTCOMES IN FUNCTIONAL NEUROLOGICAL DISORDER DURING THE PERINATAL PERIOD: AN INTERNATIONAL RETROSPECTIVE STUDY (Phenomenology/Epidemiology)
Hamilton Morrin, King's College London

Background: Research on functional neurological disorder (FND) in pregnancy is limited, with the largest systematic review to date describing findings in 43 patients.

Methods: We used retrospective electronic health record data from the TriNetX network (135 health-care providers in 18 high and middle-income countries). For primary analyses, 2,626 women with pregnancy coding and previous FND diagnosis (ICD10 F44.4, F44.5, F44.6, F44.7, F44.80, F44.9) were compared with 2,626 controls with pregnancy coding and hallux valgus (M20.1). 

For secondary analyses, 1,225 women with a first diagnosis of FND made in the 21 months following first pregnancy coding were compared with 1,225 pregnant controls with a diagnosis of hallux valgus in the same time window.

Cases and controls were propensity-score matched on 47 covariates across: age, race, socioeconomic factors, pregnancy history, current physical health, and mental health and neurodevelopmental diagnoses.

Outcome incidences and cumulative risk ratios were calculated for the 21 months following earliest pregnancy coding.

Results: In primary analyses of women with FND pre-pregnancy, we found significantly increased risk (risk ratio [95% CI]) of: hyperemesis (1.18 [1.01 – 1.38]), depression (1.64 [1.34 – 2.01]), anxiety (1.45 [1.20 – 1.77]), PTSD (4.12 [2.66 – 6.43]), suicidal ideation (3.02 [1.69 – 5.41]), antidepressant (1.31 [1.08 – 1.60]), sedative (1.32 [1.12 – 1.56]), and antiepileptic prescription (1.92 [1.46 – 2.54]), and outpatient visits (1.67 [1.32 – 2.12]). We found reduced risk of: uncomplicated delivery (0.70 [0.61 – 0.80]), perineal tear (0.66 [0.58 – 0.75]), and analgesia prescription (0.87 [0.78 – 0.97]). No significant differences were found in Caesarean delivery, forceps delivery, epidural anaesthesia, labour induction, pelvic pain or miscarriage.

In secondary analyses, pre-matching, women who developed FND perinatally were significantly: younger, less white, with more socioeconomic deprivation, history of abuse, and mental illness. Significant risk ratios included: hyperemesis (1.73 [1.14 – 2.63]), labour induction (2.44 [1.40 – 4.27]), Caesarean delivery (3.14 [2.24 – 4.39]), supervision of high risk pregnancy (1.45 [1.10 – 1.90]), uncomplicated delivery (1.42 [1.04 – 1.94]), depression (1.72 [1.30 – 2.29]), anxiety (1.73 [1.34 – 2.23]), PTSD (3.75 [2.33 – 6.04]), substance use (1.48 [1.04 – 2.12]), suicidal ideation (3.26 [1.71 – 6.20]), hospital admission (3.56 [2.64 – 4.81]), outpatient visits (1.56 [ 1.11 – 2.19]), physio or occupational therapy (1.67 [1.27 – 2.20]), psychotherapy (3.39 [2.07 – 5.55]), and prescription of antiepileptics (2.48 [1.89 – 3.26]), antidepressants (2.15 [1.67 – 2.76]), sedatives (1.64 [1.33 – 2.01]), antipsychotics (2.12 [1.62 – 2.78]), and analgesia (1.28 [1.05 – 1.57]). 

Conclusions: These findings suggest the importance of proactive multi-disciplinary care for women with FND during the perinatal period. Future prospective studies are required.

89    THE CASE AGAINST THE S: IS FUNCTIONAL NEUROLOGICAL DISORDER(S) ONE CONDITION OR MANY? (Etiology/Pathophysiology)
David Palmer, The Queensland Brain Institute

Background: Functional neurological disorder (FND) is one of the most common, but least researched, conditions in neurology. Debate exists as to whether the clinical entity referred to as FND is truly a single disorder or is in fact multiple entities which have been erroneously amalgamated into the same condition. We sought to provide empirical evidence on this question by treating it as a problem of model comparison.

Methods: We formulated statistical models equivalent to: (1) FND being a single entity with variation in phenotype, represented by latent trait (binary factor/item response theory) models, and (2) FND being multiple discrete entities, represented by latent class analysis (LCA) models. We fitted these models to data on the symptoms experienced by 697 people with FND from the FND Research Connect database (fnd-research.org) and used Bayesian model comparison methods to compare them.

Results: All but one of the latent trait models, representing FND as a single entity with heterogeneous phenotype, fit the data better than all the LCA models. Secondary analysis of the LCA models showed results compatible with the models capturing discretisation of continuous variation rather than true discrete categories.

Discussion: Our results suggest that the symptom structure of FND is the result of a single pathophysiological process, either as a single entity, or a common pathway preceded by multiple causative processes where the common pathway is solely responsible for the phenotype of the condition.

90    FUNCTIONAL NEUROLOGICAL SYMPTOMS OCCUR COMMONLY IN HEALTHY ADULTS: IMPLICATIONS FOR THE PATHOPHYSIOLOGY OF FND (Phenomenology/Epidemiology)
David Palmer, The Queensland Brain Institute

Objectives: Functional neurological symptoms which do not meet clinical definitions of functional neurological disorder (FND) are common in clinical practice. Understanding the distinction between these ‘benign’ functional symptoms and FND is crucial in defining FND as an entity for study, and as a clinical syndrome. We aimed to measure the frequency of functional symptoms in people who do not have FND.

Methods: A survey was administered to 95 clinicians who attended an international conference on FND. Participants were asked to report the occurrence and characteristics of experiences with features of functional sensory or motor symptoms, or dissociation.

Results: Of the 95 people who responded to the survey, 57.4% reported having experienced any functional symptoms, and 47.9% reported having experienced functional motor or sensory symptoms [Fig 1]. The symptoms reported were generally short-lived and caused only mild distress and disruption. Most respondents who reported having experienced a functional symptom reported having had multiple events through their lives.

Interpretation: The results suggest that the lifetime occurrence of functional neurological symptoms is at least an order of magnitude higher than the prevalence of FND. The high prevalence of functional symptoms in people who have never had FND challenges the common assumption that the occurrence of functional neurological symptoms is synonymous with FND. We propose that FND is better conceived of as a failure of the mechanisms by which functional neurological symptoms resolve, rather than the occurrence of functional symptoms per se.

91    ESTABLISHING THE UK AHP FND NETWORK (Treatment)
Clare Nicholson, The National Hospital for Neurology and Neurosurgery

Background: Functional Neurological Disorder (FND) is a common and disabling condition requiring coordinated multidisciplinary care. Allied health professionals (AHPs), including occupational therapists, physiotherapists, speech and language therapists and psychological therapists, play a central role in FND care. Given this complexity, specialist training, peer support and mentorship are particularly important to support clinical reasoning, reflective practice and the delivery of consistent, evidence-informed care. However, within the UK National Health Service (NHS), access to such learning opportunities remains limited. To address this gap, and to complement existing international initiatives, the UK AHP FND Network was established in 2018 to provide a national forum supporting AHPs involved in NHS FND care.

Methods: The AHP FND Network is a free-to-access professional network hosting online meetings and educational webinars three to four times annually, featuring expert speakers and facilitated peer discussion. Membership is open to clinicians involved in FND care and is intended to support rather than replace existing professional and international networks. Running costs are supported through funding from FND patient charities and the National Brain Appeal. A descriptive evaluation of the network’s development, activities and engagement was undertaken, drawing on membership growth, meeting attendance and qualitative participant feedback.

Results: Since 2018, the network has grown to 1,850 members representing adult and paediatric services, acute care, inpatient and community rehabilitation. Between 2018-2025, 21 meetings were delivered, attracting 100–350 clinicians per event. Network activities focused on themes central to NHS FND rehabilitation practice, including outcome measurement, service development, symptom-specific education, interdisciplinary working and emerging research. Surveyed members reported benefits including increased confidence in working with people with FND, improved understanding of best practice and reduced professional isolation. The network has facilitated cross-disciplinary dialogue, highlighted gaps in service provision, supported new FND treatment pathways and research initiatives. The network website (https://www.ahpfndnetwork.org) and quarterly emails are used to share resources, training opportunities and key clinical updates.

Conclusions: The UK AHP FND Network represents a pragmatic and scalable model for supporting AHP education and strengthening FND care within the NHS. By providing structured opportunities for education, peer support, networking and multidisciplinary collaboration, the network complements existing international initiatives and contributes to more consistent, patient-centred rehabilitation practice. Ongoing work will evaluate the network’s impact on clinical service development and support future research priorities in FND rehabilitation.

92    CLINICAL SPECTRUM OF FUNCTIONAL NEUROLOGICAL DISORDERS: A CROSS-SECTIONAL STUDY FROM A TERTIARY CENTER IN INDIA (Phenomenology/Epidemiology)
Sanjay Pandey, Amrita Institute of Medical Sciences, Faridabad

Background & Aims: Functional neurological disorders (FNDs) are disabling disturbances of voluntary motor, sensory or perceptual systems that arise from abnormal brain network functioning rather than structural lesions [1,2]. The diagnosis is by inclusion, based on positive signs characteristic of FNDs [3]. Despite being a common cause of neurological disability [4], large scale data from India remain limited. This study aimed to describe the clinical spectrum of FNDs.

Methodology: A single centre cross-sectional study was conducted over three years, analysing consecutive patients diagnosed with FNDs. Relevant investigations including video EEG were performed when indicated.

Results: A total of 129 patients (mean age 36.19 ± 14.81 years; 74.4% females) were included. Chronic presentations (>6 months) were seen in 54.26% (70/129). Functional seizures (FS) were the commonest phenotype (57.4%), followed by functional movement disorders (FMD; 45%). Coexistence of both FMD and FS was observed in 12 patients (9.3%). Other less common phenotypes were cognitive impairment, pain, giddiness and blindness. As per Hubsch criteria, paucikinetic with preserved responsiveness (56.7%) was the most common FS followed by hyperkinetic prolonged attack with hyperventilation and aura (22.97%). Majority of FMD patients presented with tremor (36.2%), second common presentation was gait abnormality (17.24%), followed by jerks (10.3%) and craniofacial movement disorders (10.3%). Commonest trigger was interpersonal conflict followed by bereavement. Headache and anxiety were the leading medical and psychiatric comorbidities. 

Discussion: FNDs predominantly affect young women and frequently present as FS or FMD. The predominance of chronic presentations underscores the diagnostic delay that is frequently reported in FND, which may contribute to increased disability. Psychosocial stressors were commonly identified. Our study underscores the need for increased awareness and early recognition of FNDs to prevent chronicity and reduce unnecessary investigations. These findings contribute valuable regional data on the clinical characteristics of FNDs in the Indian population.

References:
1) Finkelstein SA, et al. Incidence and prevalence of functional neurological disorder: a systematic review. J Neurol Neurosurg Psychiatry. 2025;96(4):383-395. 
2) Hallett M, et al. Functional neurological disorder: new subtypes and shared mechanisms. Lancet Neurol. 2022;21(6):537-550. 
3) Espay AJ, et al. Current concepts in diagnosis and treat ment of functional neurological disorders. JAMA Neurol. 2018;75(9):1132–41
4) Bennett K, et al. A practical review of functional neurological disorder (FND) for the general physician. Clin Med (Lond). 2021 Jan;21(1):28-36.

93    FUNCTIONAL NEUROLOGICAL DISORDER IN CHILDREN (Phenomenology/Epidemiology)
Bhavna Pandey, MBBS, SVIMS - Sri Padmavathi Medical College For Women, Tirupati, India

Background: Functional neurological disorder (FND) as per DSM-5-TR is a diagnosis of inclusion with motor, sensory or cognitive symptoms resulting from impaired nervous system functioning in the absence of any structural pathology. The present literature on FND in children is limited.

Methods: A PubMed search was conducted on 3rd February 2026 using various keywords. 3013 articles on [functional Neurological disorders in children], 2301 articles on [functional movement disorder in children], 1319 articles on [pediatric functional movement disorders] and 147 articles on [psychogenic movement disorders in children] were found. About half of these articles were published only within the last 10 years. After removing the duplicates, relevant articles were analysed for the review.

Results: The earliest records of FND in children date back to 1748, when Ravlin reported hysteria in a young girl. Several studies reported the mean age of onset of FND to be around 12 years [1]. Female gender preponderance for FND is higher among children too [2]. The most common forms of FND observed in children include: myoclonus, tremor, dystonia, gait disturbances, and functional tics. A unique set of risk factors like child abuse, parental criticism, stressors at school, physical trauma, and rising rates of depression among youth along with underlying psychiatric illness triggers FND in children. Secondary gains in children include, receiving excessive parental care, staying home by avoiding school and getting attention from friends and family. Post COVID-19 pandemic, several studies reported increased incidence of FND amongst female adolescents and young adults. Dysfunction of neurometabolites like N-acetyl aspartate, myo-inositol, and GABA in glial cells and inhibitory neurons is seen in children with FND. Decreased cortisol awakening response also leads to deranged activation of the hypothalamus-pituitary axis in them. Hence, altered circadian rhythm and sleep disturbance serve as risk factors for FND in children. The overall prognosis is good with short duration of symptoms, acceptance of diagnosis, and management of stressors resulting in successful outcomes in such cases. A multidisciplinary treatment approach is needed to eliminate the stressors and improve the psychological environment of the child. 

Conclusions: FND in children is highly underreported. Children with FND have unique phenomenology at the time of presentation and have a separate set of stressors that trigger these attacks in them. The overall prognosis is good and it can be effectively managed with active parental participation in treatment and counselling of the child.

References: 
1. Cherian A, Kalikavil Puthanveedu D, R A, Sundaram S. A case series of functional movement disorders in paediatric population-phenomenology and clinical characteristics. Acta Neurol Belg. 2025 Oct;125(5)
2. Ferrara J, Jankovic J. Psychogenic movement disorders in children. Mov Disord. 2008 Oct;23(13)

94    REDUCED THALAMIC NUCLEI VOLUMES IN INDIVIDUALS WITH FUNCTIONAL NEUROLOGICAL AND SOMATOFORM DISORDERS (Etiology/Pathophysiology)
Anne Gro Parnemann, Oslo University Hospital

Background: The limited understanding of functional neurological disorder (FND) pathophysiology precludes the development of novel and personalized treatment options, makes explanation of the disorder and delivery of the diagnosis to patients challenging, and may contribute to the maintenance of stigma and negative patient experiences. Although the precise mechanisms underlying FND remain unknown, converging lines of evidence suggest that the thalamus may play central roles. The thalamus consists of distinct nuclei that support cognitive, sensory, and motor functions linked to FND pathophysiology. For instance, intralaminar nuclei may have important roles in awareness, attention and arousal, while ventral nuclei are involved in motor planning, voluntary movement, coordination and somatosensory signals. The goal of the present study is to provide novel insights into roles of the thalamus and its nuclei in FND and somatoform disorders. 

Methods: Magnetic resonance imaging (MRI)-based thalamic nuclei volumes were obtained from the UK Biobankfor seventy-three participants with ICD-10 F44 (dissociative/conversion disorders) or F45 (somatoform disorders) diagnoses (62% females, mean age=62 years) and 38 046 control participants without F or G diagnoses (52% females, mean age=61 years). T1-weighted MRI data was acquired with a Siemens Skyra 3T scanner and processed with Freesurfer 6.0, using Bayesian segmentation of thalamic nuclei based on ex-vivo MRI and histology (Iglesias et al., 2018).

Results: Total thalamic volume was reduced in participants with F44or F45 diagnoses, compared to controls. These had also reduced volumes in the intralaminar and ventral thalamic nuclei (both p=0.02). In the left thalamus, the participants diagnosed with F44 or F45 had significantly smaller (all p<0.05) centromedian (CM) and parafascicular (Pf) nuclei (both intralaminar nuclei), ventromedial (VM) and ventrolateral posterior (VLp) nuclei (both ventral nuclei), and anterior nucleus (PuA, posterior nuclei). In the right thalamus, these participants had significantly smaller (all p<0.05) CM and Pf, VM, VLp and ventrolateral anterior (VLa), as well as ventral posterolateral (VPL) and ventral anterior (VA) nuclei, relative to controls. These findings remained significant after excluding nine participants with comorbid neurological or psychiatric conditions.
 
Conclusions: Individuals with F44 or F45 diagnoses had smaller ventral and intralaminar thalamic nuclei volumes than controls. Further studies are needed to clarify whether the intralaminar and ventral nuclei contribute to cognitive and sensorimotor alterations in FND and somatoform disorders.

95    INTRUSIVE MEMORIES AND ANXIETY IN PATIENTS WITH FUNCTIONAL/DISSOCIATIVE SEIZURES (Phenomenology/Epidemiology)
Max Christian Pensel, Department of Psychiatry and Psychotherapy, University Hospital Bonn, Germany

Background: Functional / dissociative seizures (FDS) are often accompanied by significant distress and considerable impairment in daily life. Little is known about the subjective experience during, as well as immediately before and after FDS. 

Methods: A semi-structured interview  was used to assess the subjective experience regarding intrusive memories, psychoform dissociative phenomena, emotions, cognitions, and altered perceptions of their own body and the environment in 30 patients with FDS (m/f). Furthermore, the appearance of these phenomena regarding specific timepoints (preictual, ictual, postictual) was noted. Findings are presented descriptively.

Results: At group level, fewer phenomena are reported ictually (2.75 per patient) than for the preictual (3.38) and postictual (2.97) phase. Perceived bodily phenomena decrease during the seizure and then rise again to baseline level. While intrusive memories, psychoform dissociative phenomena and external perceptions decrease continuously over the time course, reported emotions and cognitions increase continuously. Significantly, over all three time points, 40% of patients report intrusive memories and/or flashbacks regarding stressful life events. As for emotions, anxiety takes center stage, periictualy indicated by 67% of patients. Intrusive memories / flashbacks (36%) as well as anxiety (50%) are hereby particularly reported preictually, and frequency decrase over time towards the postictual phase (intrusive memories / flashbacks 10%, anxiety 30%).

Conclusions: Despite the dissociative nature of FDS, patients are able to report many details regarding their internal, periictual state, when specifically queried. The relatively frequent mentioning of intrusive memories and/or flashbacks confirms psychopathological links to trauma associated disorders, like PTSD. The most frequently reported emotion is anxiety. The decrease of reported intrusive memories / flashbacks and anxiety over time is in line with the hypothesis from the literature that internal tension decreases over the course of FDA (1), while the specific roles of intrusive memories / flashbacks and anxiety in the presented results allow for a more nuanced description. Taken together, a differentiated look at phenomenology and the temporal sequence of inner states can contribute to a more comprehensive understanding of FDS, and may improve therapeutic approaches, e.g. targeting post-traumatic stress and anxiety.

References:
(1) Brown RJ, Reuber M. Towards an integrative theory of psychogenic non-epileptic seizures (PNES). Clin Psychol Rev. 2016 Jul;47:55-70. 
(2) Myers L, Vaidya-Mathur U, Lancman M. Prolonged exposure therapy for the treatment of patients diagnosed with psychogenic non-epileptic seizures (PNES) and post-traumatic stress disorder (PTSD). Epilepsy Behav. 2017 Jan;66:86-92.

96    IMPROVING CARE COORDINATION IN FUNCTIONAL NEUROLOGICAL DISORDER: A SERVICE EVALUATION OF A UK CARE ADVISOR ROLE (Treatment)
Alexander Phillips, St George’s Hospital

Background: Recent studies report the high level of healthcare usage in FND and suggest that this could be reduced by improving access and organisation of care. Coordination and case management roles are common in the UK for chronic neurological conditions but have only recently started appearing for FND. In 2023, the FND care advisor role was established as a pilot across Southwest London and Surrey UK, to aid adults with FND struggling to navigating a fragmented healthcare system. The role aims to create a link to better integrate regional, secondary and community care; provide education to patients, families and care teams; give coordination and self-management advice to those with established care-plans; and provide case management for those with frequent hospitalisation due to FND.

Methods: A mixed methods service evaluation was used measure the impact and sustainability of the role at 20 months. Quantitative data from 2019 onwards on A&E attendances, hospitalisations, total bed days, and outpatient attendances was collected for all patients under the care advisor role. For analysis, an Interrupted Time Series (ITS) with segmented regression was used to discern changes in healthcare usage since involvement of the care advisor role.  Retrospective patient and staff surveys were used to gather self-reported outcomes and evaluate peoples experience of the new role. 

Results: Across a caseload of 258 patients, there was sustained and significant reductions in hospitalisation, A&E admission, bed days and outpatient activity as seen. There were 31 respondents to the patient survey with the majority reporting improvement in experience of care and health outcomes. The staff survey had 38 respondents with the majority reporting improvements in care delivery, inter-service collaboration and patient outcomes, whilst also releasing capacity in their services.

Conclusion: Providing health care roles which provide integrative care coordination and selective case management for FND can deliver benefits to patients, staff and healthcare services. This was an single service evaluation on a new service and has multiple limitations. Despite this, these promising early results and it is worth considering that these roles can be valuable additions to FND care pathways.

References:
O’Mahony, B., Nielsen, G., Baxendale, S., Edwards, M. J., & Yogarajah, M. (2023). Economic cost of functional neurologic disorders: A systematic review. Neurology, 101(2). https://doi.org/10.1212/WNL.0000000000207388
Goodwin, N., Sonola, L., Thiel, V., Kodner, D. L., King’s Fund (London, England), Aetna Life & Casualty., & Aetna Foundation. (2013). Co-ordinated care for people with complex chronic conditions: Key lessons and markers for success. King’s Fund.

97    FND AMONG PATIENTS REFERRED TO EMG LABORATORY (Phenomenology/Epidemiology)
Masahiro Sonoo, MD, PhD, Teikyo University

Background: Frequency of FND among patients in different medical settings has been reported, such as in outpatient clinic of neurology, neurology ward, pain clinic, epilepsy center, stroke unit, or emergency room. EMG laboratory is another possible section where patients with FND might be referred since functional weakness (FW) is one of the most popular phenotypes of FND. However there has been no study so far that investigated the frequency of FND among EMG referrals. This study investigated the frequency of FND among patients referred to EMG laboratory. 

Methods: EMG database of the first author has been retrospectively reviewed and patients satisfying the following entry criteria have been identified: 1) referral to EMG clinics in hospitals for which the first author work part time; 2) new referral for two years, 2021 and 2022: 3) 15 or older age. Neurological examinations were conducted for all patients by the first author, and FND was diagnosed based on positive signs. At least three of reported positive signs were required for definitely making the diagnosis of FW. The breakdown of other disorders, including psychiatric disorders such as somatic symptom disorder and illness anxiety disorder, and structural disorders has been also investigated.

Results: Initially extracted were 270 records, among which 4 were excluded because it was not the initial examination for the patient, and 4 were excluded because of younger age than 15. Accordingly, 262 patients were finally identified. Breakdown was as follows: FW 29 (11.1%), suspect of FW (only two positive signs) 2 (0.8%), functional gait disorder 1 (0.4%). In all, 32 patients (12.2%) were diagnosed with FND or its suspicion. Their age was 43.3 ± 16.5 years (15 – 78) and 17 (53%) were females. Patients with FW presented with 5.3 ± 1.6 (mean ± SD) positive signs (range 3–8). Among patients with FND, diagnosis of the referring doctor included FND only in 5 patients (17%). Comorbidity of structural disorders (functional overlay) was observed in 14 patients (48%). Other than FND, 5 (1.9%) patients with illness anxiety disorder (ALS phobia) and 2 (0.8%) patients with somatic symptom disorder were identified, and therefore 39 patients (14.9%) were diagnosed with functional or psychiatric disorders. Other frequent structural disorders were cervical or lumbar spine disorders 67 (25.6%), ALS 42 (16.0%), and neuropathies 42 (16.0%). 

Conclusions: FND is a frequent disorder among patients referred to an EMG laboratory. Electromyographers should be familiar with FND and techniques of positive signs of FND, especially those for FW.

98    FEMALE-SPECIFIC BIOLOGICAL FACTORS AND FUNCTIONAL NEUROLOGICAL DISORDER: A SURVEY STUDY OF REPRODUCTIVE PHASE, HORMONAL STATUS, AND SYMPTOM CHARACTERISTICS (Phenomenology/Epidemiology)
Primavera Spagnolo, MD, PhD, Connors Center for Women's Health/Brigham and Women's Hospital

Background: Functional Neurological Disorder (FND) disproportionately affects women, yet female-specific biological factors—including reproductive phase, hormonal status, and comorbid female-predominant conditions—remain largely unexplored in relation to symptom onset, presentation, and course. Emerging models conceptualize FND as a network-based disorder involving stress, salience, and interoceptive systems, but reproductive transitions and hormonal dynamics have rarely been examined in this context. Despite the strong female predominance of FND, reproductive and hormonal variables are seldom systematically assessed in research or clinical evaluation.

Objective: To investigate whether female-specific factors—including reproductive phase, hormonal status, reproductive history, and comorbid women’s health conditions—are associated with FND symptom onset, presentation, and illness course.

Methods: We conducted a cross-sectional survey of women with clinician-confirmed FND (current N=20; ongoing enrollment). Participants completed structured questionnaires assessing reproductive phase (menstrual cycling, perimenopause, postmenopause), hormonal status (natural cycling, hormonal contraception, hormone therapy), reproductive history (including pregnancy and postpartum period), and comorbid female-exclusive or female-predominant conditions (e.g., endometriosis, polycystic ovarian syndrome, migraine, autoimmune disorders). FND-related outcomes included age and context of symptom onset, symptom phenotype (motor, sensory, dissociative/non-epileptic seizures), menstrual-cycle symptom fluctuation, and perceived illness course. Descriptive and exploratory analyses were performed.

Results: The average participant age was 42.6 years, with mean age at FND symptom onset of 31.6 years. Mean age at menarche was 12.4 years, and participants reported moderate overall health (mean=3.36 on a 1–5 scale). A substantial proportion reported FND symptom onset during hormonal transition periods, including postpartum and perimenopause. Many menstruating participants reported cyclical symptom variability, with most indicating symptom worsening following the onset of menstruation. Among postmenopausal participants (n=8), most reported improvement in FND symptoms after menopause. Female-predominant comorbidities, including migraine and chronic pain, were common (63%). Exploratory patterns suggested possible clustering of symptom phenotypes by reproductive phase and hormonal status, although analyses remain underpowered.

Conclusions: These preliminary findings suggest that reproductive stage, menstrual-cycle dynamics, and hormonal transitions may influence FND onset and symptom expression. Systematic assessment of reproductive and hormonal variables may represent an important step toward sex-informed mechanistic models and improved clinical characterization of FND.

99    FULL BODY AGENCY IN FUNCTIONAL NEUROLOGICAL DISORDER (Phenomenology/Epidemiology, Etiology/Pathophysiology)
Catheline Stancu, UNIFR Fribourg

Background: Alterations in the sense of agency (SoA) - the feeling that our actions are under one’s own control, have been reported in Functional Neurological disorders (FND) when assessed through focal motor action of one limb.  However, SoA for the entire body (full body agaency – FBA) has not been tested. We hypothesized that FBA is altered in patients with mixed FND compared to healthy controls. 

Aims: To compare FBA in patients with FND vs healthy controls using implicit and explicit measures in spatial and temporal sensorimotor conflict tasks during a validated embodied virtual reality paradigm.

Method: This ongoing cross-sectional study recruits patients with FND from the Fribourg Cantonal Hospital (Switzerland) (diagnosed by neurologists) and healthy controls (HC) from the community, with a target sample of 40 participants per group. Participants complete demographic, medical, psychiatric, and neurological assessment. Full-body agency is assessed in a motion-capture virtual reality setup in two tasks where participants are walking and observing their avatar on a screen. In the spatial deviation task (SDT), the avatar trajectory is veridical or deviated by 7.5, 15, or 30 degrees; The primary outcomes are implicit SoA, measured by total compensated angle, and explicit SoA, assessed via agency rating (binary judgment) and deviation detection accuracy (response accuracy). Confidence is recorded after each trial. In the temporal deviation task (TDT), the avatar gait is synchronous or delayed; the primary outcome is stride time across delays, with the same explicit ratings. 

Results: A total of n=25 FND participants and n=34 HC were included in the SDT analyses so far. Explicit agency was significantly higher in FND participants at the 15-degree deviation (p(corrected)=0.043), while implicit agency was comparable between groups as well as time to reach the target. FND participants showed lower deviation detection accuracy starting at 15 degrees (p(corrected)=0.011) and 30 degrees (p(corrected)=0.022), while confidence ratings did not differ between groups. In the TDT, four participants were unable to complete the experiment, and no conclusions could be drawn yet.

Conclusions: Full Body Agency testing in the spatial domain in FND showed preserved motor performance during perturbations but altered explicit agency, including higher agency ratings at moderate deviations alongside poorer deviation detection, despite preserved confidence. These findings suggest that agency alterations in FND selectively concern explicit jugdement and that SoA is a pathophysiological mechanism that goes beyond limb motor impairment, involving full body multisensory integration.

Reference:
Salomon R,et al.Agency deficits in a human genetic model of schizophrenia: insights from 22q11DS patients. Schizophrenia Bulletin. 2022;48(2):495-504.

100    FND IN ACUTE CARE: INTERDISCIPLINARY PROGRAM DEVELOPMENT (Treatment)
Lennie Swenson, PT, DPT, Movement is Medicine Neurologic and Vestibular Physical Therapy

Background: Functional neurological disorder (FND) is a neurological condition characterized by abnormalities in the functioning of brain networks rather than brain structures that can present with myriad sensory, motor, and cognitive symptoms. Although Physical Therapy (PT) is recognized as a first-line treatment for functional motor symptoms, there is limited literature on PT’s role in the Acute Care (AC) setting for this patient population.    

Our experience indicates that AC providers often have outdated and incomplete knowledge of FND, leading to potential secondary harm to patients. After diagnosis, there is frequently inconsistent communication with patients and discharges are rushed, leaving patients unprepared. Inpatient rehabilitation is often not covered by insurance, resulting in inadequate sub-acute rehabilitation options. Lastly, inconsistent referrals to outpatient providers and long waitlists further hinder patient outcomes. This abstract describes the program implemented at the University of Utah (UU) to improve care of patients with FND in the AC setting. 

Methods: In 2024, the UU Neurologic AC therapy team aimed to improve staff knowledge, consistency of care, and discharge preparation for patients with FND. The team conducted a thorough literature review, participated in continuing education, and consulted with outpatient experts to develop a comprehensive plan. 

Conclusions: The team identified barriers to diagnosis, communication, treatment, education, and discharge planning for patients with FND. Solutions were discussed with Neurology physicians, leading to consensus on the need for improved care and initiation of education for all providers, including PT, Nursing, Occupational Therapy, Speech Language Pathology, and Social Work. 

An AC Checklist was developed, including: confirming and communicating the FND diagnosis by the medical team, PT assessment, identifying positive clinical signs, evidence-based patient education, patient-centered goal setting, and discharge planning with team and family involvement. Discharge planning also includes a home program and referrals to appropriate post-acute services such as Movement Disorders clinics, PT, and psychotherapy.

Since patients with FND often admit to teams outside Neurologic AC, in-services were provided to all AC therapy teams with an emphasis on the checklist. Education topics included FND pathophysiology, clinical signs, and current treatments; resources provided included literature, an FND factsheet, and a list of outpatient providers. Therapy staff were surveyed about confidence in treating FND patients before the in-service and at a 6-month follow-up.

References
M. Hallett, S. Aybek,et al. (2022), Functional Neurological Disorder: New Phenotypes, Common Mechanisms, Lancet Neurology 
McKee, et al. The Inpatient Assessment and Management of Motor Functional Neurological Disorders: An Interdisciplinary Perspective, Psychosomatics 59/4, July/August 2018

101    GLYMPHATIC SYSTEM AND COGNITIVE FUNCTION IN FUNCTIONAL SEIZURES: A DIFFUSION TENSOR IMAGING ANALYSIS ALONG PERIVASCULAR SPACES (DTI-ALPS) STUDY (Etiology/Pathophysiology)
Jerzy P. Szaflarski, MD, PhD, University of Alabama at Birmingham

Background: The glymphatic system is a waste clearance pathway in the central nervous system that facilitates the movement of cerebrospinal fluid along perivascular spaces. It plays a critical role in removing metabolic waste products, including amyloid-beta and tau proteins, from the brain parenchyma. Traumatic brain injury (TBI) has been shown to disrupt glymphatic function, potentially contributing to long-term neurological sequelae. Recent evidence suggests that TBI may have negative effects on glymphatic drainage, resulting in accumulation of metabolic waste products. However, findings from human post-TBI studies have been inconsistent, with some showing increases and others showing decreases in glymphatic drainage. Dysfunction of the glymphatic system has been implicated in cognitive impairment. Our goal was to examine glymphatic system function using the Diffusion Tensor Imaging Analysis along Perivascular Spaces Index (DTI-ALPS-I) in a large sample of patients with functional seizures after TBI (FS), traumatic brain injury without functional seizures (TBI), and healthy controls (HC), and to investigate relationships between DTI-ALPS-I and cognitive measures.

Methods: 173 participants (40 HC, 74 FS, 59 TBI) underwent diffusion MRI scanning. DTI-ALPS-I was calculated bilaterally using methods previously described. Group differences were analyzed using linear mixed models with hemisphere as a within-subject factor. Age-adjusted analyses were performed using ANCOVA. Correlations between DTI-ALPS-I and cognitive measures (MoCA, QOLIE-31 subscales) were examined in patient groups.

Results: There were no group differences in age (p=0.186) but participants with FS had significantly lower number of years of education when compared to HCs and TBI participants (13.9 vs 16.4 (both groups); p<0.001). No significant main effect of group on DTI-ALPS index was observed (F(2,340) = 2.47, p = 0.086). A significant hemispheric asymmetry was found, with right hemisphere ALPS values lower than left (F(1,340) = 35.30, p < 0.001, η²p = 0.094). Post-hoc comparisons revealed participants with FS had significantly lower DTI-ALPS index when compared to TBI participants (p = 0.013). Age-adjusted analyses confirmed this pattern (FS vs. TBI: p = 0.046). Cognitive measures differed significantly between groups, with FS showing worse performance compared to TBI (MoCA 23.52 ± 5.08 vs. 26.9 ± 2.66, p<0.01; QOLIE-31 Cognitive Scale 40.79 ± 10.12 vs. 52.63 ± 11.42, p<0.001; QOLIE-31 Overall 35.88 ± 10.00 vs. 54.34 ± 11.67, p<0.001). There were no significant correlations between DTI-ALPS and cognitive measures within groups.

Conclusions: This large sample of patients with FS showed reduced DTI-ALPS-I compared to TBI participants without FS, suggesting potential differences in perivascular space function between groups. These differences did not correlate with cognitive performance.

102    QUALITY OF LIFE IN PATIENTS WITH FUNCTIONAL DISSOCIATIVE SEIZURES AND DRUG-RESISTANT EPILEPSY IN ARGENTINA (Phenomenology/Epidemiology)
Camila Wolfzun, CONICET-UBA

Background: Quality of life (QoL) is a key outcome in the assessment of neurological and functional disorders, extending beyond traditional clinical indicators such as seizure frequency or severity. Patients with drug-resistant epilepsy (DRE) and functional dissociative seizures (FDS) frequently experience significant impairments in physical, emotional, and social well-being. Although QoL has become a central outcome in research involving these populations, evidence from Latin America remains scarce. The aim of this study was to compare QoL between patients with DRE and FDS in Argentina.

Methods: A total of 83 participants were included: 63 patients with DRE and 20 patients with FDS, evaluated at video-electroencephalography monitoring units of two public hospitals in Buenos Aires between June 2020 and December 2023. QoL was assessed using the Argentine version of the Quality of Life in Epilepsy Inventory (QOLIE-31P), which has been culturally adapted and validated for the local population. Statistical analyses were conducted using RStudio. Parametric or non-parametric tests were applied according to data distribution.

Results: No significant differences were found between the DRE and FDS groups in the total QOLIE-31P score or in any of its subscales. In contrast, participants with a comorbid mental disorder showed significantly lower QoL scores, regardless of their primary diagnosis.

Conclusions: This study provides local evidence on QoL in patients with DRE and FDS in Argentina. The findings highlight the importance of considering mental health–related and contextual factors, beyond neurological or functional diagnosis alone, when assessing QoL in these populations.

References:
Jones, B., Reuber, M., & Norman, P. (2016). Correlates of health-related quality of life in adults with psychogenic nonepileptic  seizures: A systematic review. Epilepsia, 57(2), 171–181. https://doi.org/10.1111/epi.13268
Sarudiansky, M., Lanzillotti, A. I., Gerbaudo, M. A., Wolfzun, C., Kochen, S., Stivala, E., D’Alessio, L., & Korman, G. P. (2023). Cultural adaptation and psychometric properties of the Patient-weighted Quality of Life in Epilepsy 31 Inventory (QOLIE-31P) in Argentina. Epilepsy and Behavior, 141, 109132. https://doi.org/10.1016/j.yebeh.2023.109132

103    REDUCING HIGH-COST HEALTHCARE UTILIZATION IN FUNCTIONAL NEUROLOGICAL DISORDER: A SCALABLE MIND–BODY IMPLEMENTATION MODEL IN A PUBLIC HEALTHCARE SYSTEM IN A LOW-RESOURCE SETTING (Treatment)
Lucia Tesolin, MD, Ospedale di Bolzano, Italia

Background: Access to specialized multidisciplinary care for Functional Neurological Disorder (FND) remains extremely limited in low- and middle-income countries (LMICs), where workforce shortages, resource constraints, and limited clinician training restrict access to evidence-based treatment. While multidisciplinary rehabilitation is effective in high-resource settings, scalable models integrated into existing healthcare systems are urgently needed [1]. Mind–body interventions may improve FND symptoms through enhanced interoception, autonomic regulation, and reduced symptom-related fear and avoidance [2]. 

Methods: This implementation study was conducted within the Rebagliati network of EsSalud (Peruvian Social Security healthcare system) in Lima, Peru. A pilot program used a task-sharing model involving a physiotherapist, psychologist, and nurse from the existing Complementary Medicine Unit, already experienced in breathing regulation, functional goal-oriented rehabilitation, and emotional awareness. They received condensed FND-specific training and ongoing case-based supervision from an FND-specialized neurologist, who also provided diagnostic confirmation and structured illness education. The intervention consisted of up to 12 small-group sessions over three months integrating mind–body techniques (tai chi, yoga, biodanza, mindfulness, reflexotherapy, acupuncture, aromatherapy, and sound-based relaxation), with intensity adapted to symptom profile. Patients with chronic, refractory FND attended one or two fixed weekly sessions to reduce travel burden and work disruption. 

Results: Twenty consecutive patients with chronic, refractory FND and high prior healthcare utilization were included. At baseline, patients had a median of three emergency visits, frequent hospitalizations, extensive diagnostic investigations, polypharmacy, and marked disability; several were unable to work or wheelchair-dependent. At 6-month follow-up, emergency visits decreased from a median of three to zero, FND-related hospitalizations were eliminated, and unnecessary diagnostic testing ceased. Most patients discontinued unnecessary medications, showed meaningful functional improvement, returned to work or usual activities, and several regained independent ambulation. The program expanded treatment capacity while substantially reducing high-cost healthcare utilization.

Conclusions: Brief FND training for complementary medicine providers combined with specialist neurological supervision enables effective multidisciplinary care where dedicated services are unavailable. Group-based mind–body interventions delivered through existing staff represent a low-cost, scalable model that improves outcomes while optimizing healthcare resources. This framework can be expanded within Peru and adapted for other LMICs to reduce the global FND treatment gap.

References:
1.Thomas ST et al. BMJ Neurol Open. 2024.
2.Kipnis D et al. Int J Yoga Ther. 2024;34.

104    LOST TO FOLLOW-UP: EXPLORING PREMATURE TERMINATION IN PSYCHOTHERAPY AMONG PATIENTS WITH FUNCTIONAL NEUROLOGICAL DISORDER (Treatment)
Becky Tilahun, PhD, Cleveland Clinic

Background: Poor adherence to psychotherapy is a major challenge in the management of functional neurological disorder (FND) in general, and in functional seizures (FS) in particular. Dropout rates are as high as 85% and nearly half of patients fail to complete recommended treatment (Tolchin et al., 2019). Early termination limits therapeutic benefit, prolongs disability, and increases healthcare utilization. Nonadherence is often misattributed solely to low patient motivation. This case highlights multi-level factors contributing to dropout and strategies to improve engagement.

Case Presentation: A 20-year-old patient with FS, PTSD, substance use disorder, and well-controlled epilepsy (levetiracetam 2000 mg/day) presented for FS management. Additional risk factors included childhood sexual trauma, family dysfunction, and substance use. Despite initial motivation, she discontinued psychotherapy after three sessions due to frustration with inconsistent communication from the medical team and persistent seizures.

When she returned to treatment, interventions focused on education to address misconceptions about FS and comorbid conditions in multidisciplinary meetings. Therapy was adapted to the patient’s cognitive level to improve comprehension and adherence. Family therapy targeted substance use and family dysfunction. Following this comprehensive intervention, the patient completed neurobehavioral therapy for FS and additional psychotherapy for PTSD. At one-year follow-up, she remained seizure-free with improved mood and functioning.

Discussion: Dropout in FS reflects cumulative, modifiable barriers rather than low patient motivation alone. A multidisciplinary approach can address contributing factors including: patient-level (diagnostic acceptance, psychiatric comorbidities, trauma, cognitive limitations, substance use, limited support), provider/system-level (inconsistent communication, diagnostic ambiguity, fragmented referrals, limited access, trust issues), and treatment-level (misalignment with readiness, insufficient psychoeducation, lack of family involvement, unaddressed comorbidities). By addressing the various barriers that prevented the patient's compliance with psychotherapy, the patient was enabled to complete the full treatment course.  

Conclusion: Targeted, patient-centered, multimodal interventions can improve treatment engagement by identifying and addressing multi-level barriers that can increase treatment acceptability.

References:
Tolchin, B., Dworetzky, B. A., & Baslet, G. (2019). Adherence with psychotherapy and treatment outcomes for psychogenic nonepileptic seizures. Neurology, 92(7), 311–312.

105    ATTENTIONAL BIAS IN FUNCTIONAL VOICE DISORDERS (Etiology/Pathophysiology)
Miriam van Mersbergen, PhD, CCC-SLP, University of Memphis

Background: Functional Voice Disorders (FVD), such as muscle tension dysphonia, are increasingly recognized as a subtype of functional neurological movement disorder (mFND). 1 Previous FVD research has identified traits (e.g., personality and temperamental characteristics, emotional processing tendencies, etc.) and states (e.g., traumatic histories, life difficulties, etc.) which are common among those with FVD. It is believed that some combination of trait vulnerabilities and state stressors leads to disrupted vocal function. Similar trait and state interactions are seen in mFND, and in mFND research, there exists more clarity and empirical evidence supporting a few facilitating factors which link these interactions to physical dysfunction. One such area investigates attention, specifically attentional biases towards threatening stimuli and attentional control abilities.2 To date, little is known about the role of attention in FVD. Therefore, this investigation aims to characterize attentional bias to threat and attentional control in individuals with FVD. 

Methods: Adults with FVD, social anxiety (SA; disordered control), and healthy controls (HC) completed self-reports, behavioral voice assessments, baseline measures, and a visual Dot Probe (DP) task. Self-reports included measurements of voice symptoms, anxiety, and attention. Behavioral voice assessments included self-reports of symptoms and clinical measures of breathing, respiratory-laryngeal coordination, and vocal quality. Baseline measures included resting electroencephalography (EEG) Theta-Beta Ratio (TBR; indicative of attentional control) and heart rate variability (HRV; indicative of autonomic function). The DP task consisted of threat-related and neutral word stimuli presented in lateralized visual fields. Four blocks of 80 trials were completed, with each block representing an experimental condition: neutral, general threat, voice, and communication. Event-related potentials (ERP) of visual attention were measured following target (N2pc) and probe (P3) presentations, and response times to probes were collected. 

Results: Data are ongoing and due to be completed by March 31; however, initial results indicate that individuals with FVD differ from those with SA and HC in measures of attentional bias to disorder-congruent threats (voice- and communication-related words), attentional control, and autonomic function. 

Conclusions: The present results support FVD as a disorder of attentional control and threat processing, which can be seen to fit within mFND models. Examining the disorder from the context of behavioral, neural, and autonomic measures could potentially offer a more sensitive approach to illuminating the cognitive-affective basis of the symptoms of FVD, thus potentially providing the groundwork for developing interventions that target the key processes of attention. 

References: 
1.Baker J. Functional voice disorders. In: Hallett M, St

106    IN-HOME EXPERIENTIAL EDUCATION (EE) DELIVERED TO ONE FAMILY AFFECTED BY FND (Treatment)
Yadira Velazquez-Rodriguez, MD, Science & Shamanism, LLC

Introduction/Background: In-Home assessment, management and therapies were traditionally used in medicine, since the late 1800s. These modalities have not been studied in Functional Neurological Disorders (FNDs). We report highlights from 1 month In-Home multi-network functional (1) education approach. 

Case Presentation: RM, a family man born in 1981, living with his female partner and children aged 2 and 7 years old, was serviced at home with Experiential Education Methodology (Figure 1) for 1 month during 2025, by a neurologist and educator. Multiple risk factors for FND were discovered, several dating back to his adolescent years, some still present. Dozens of specific processes affecting limbic, emotional, cognitive, sensory motor, automatic processes were detected, many corrected through various techniques derived from Cognitive Behavioral Therapy, Emotionally Focused Therapy, Somatic Experiencing, Hypnosis, Ancestral Shamanic Modalities, Neurosciences, Social Sciences, among others. Whenever possible, the theory behind the techniques used was disclosed in an educational manner, to aid with inter-personal and intrafamilial training. The speed, frequency, and duration of training sessions was determined based on multi-network feedback cues. Partner assessment and education were provided. Children were assessed. A few training techniques were provided to partners to prevent multinetwork dysfunction. Brief training sessions were provided for children, age specific, throughout the day, as opportunities arose. Multigeneration and poly-branch family assessment was performed during a birthday gathering. Investigation of social, epidemiological perpetuating factors and activist actions were undertaken at a local hospital, university, rehab center and governmental agencies, with patient and family involvement. Local news was contacted. A detailed video recorded report was given. The material has not been released.

Feedback has been continuously and directly obtained from RM and partner through WhatsApp. Wife provided telephone feedback 3 weeks after program completion. Feedback questionnaire is shown in Table 1.   

Discussion: Novel ways of providing FNDs and FDs epidemiological investigation, teaching, education and social activism are possible and doable. Collaborative actions are necessary. 
Further investigation into the social and cognitive patterns affecting the progression of such and similar health care, educational and preventive initiatives, shall be investigated. Patients and healthcare professionals should design similar modalities worldwide. Such program could be particularly helpful to foster education and training in students and residents from various related specialties. 

References:
Functional Neurological Disorder: Historical Trends and Urgent Directions Yadira Velazquez-Rodriquez, Brooke Fehily. Journal of Neurology Research, North America, 13, oct. 2023. doi: https://doi.org/10.14740/jnr754

107    TIME, TRUST AND TRANSPARENCY: THE FOUNDATIONS OF DEVELOPING AN FMD SERVICE LINE (Treatment)
Meagan Watson, MPH, MBA, University of Colorado

Introduction: Developing treatment pathways for functional movement disorders (FMD) remains challenging, partly because there is no blueprint guiding program design. While others have published their treatment models and outlined practical aspects of care, descriptions rarely address operational realities required to develop and integrate a service line within a health system.1, 2 Critical components like intentional, prospective planning, deliberate relationship building among interdisciplinary partners, and systematic communication are underrepresented. This study describes the University of Colorado (CU) FND Program’s 10-month journey to develop a system-wide FMD service line and provides initial descriptive results.

Methods: Figure 1 describes the CU FND Program model. We conducted a chronological analysis of activities undertaken to develop our FMD service line (Figure 2). Each activity was categorized using a priori coding framework reflecting major domains of program development. Uncategorized but intentional scaffolding to build trust and ensure transparency included regular email updates, access to the core team (neurology and behavioral health), and weekly care conferences available to rehabilitation clinicians. Process and engagement outcomes were systematically documented and analyzed. 

Results: Figure 3 describes the proportion of development activities by category. Roughly 68% focused on human effort - hiring clinicians, building workforce, and engaging stakeholders. Given fragmentation risk in multidisciplinary care, a nurse navigator and case manager were hired to strengthen coordination. 12% of activities developed patient and clinical materials to set expectations (e.g. referral criteria) and align communication across the pathway (e.g. diagnostic language). While funding and resource acquisition only represented 12%, it was essential. Eight satellite rehabilitation sites were onboarded. 32 rehabilitation specialists were trained (10 OTs, 15 PTs, 7 SLPs). Of 75 total referrals, 55 (73%) were immediately eligible for the FMD service line suggesting feasible referral criteria. 10 referrals were later accepted after clarification (e.g., ongoing workup). Of 65 referrals eligible, 46 (70%) attended behavioral health evaluation to date, 34 (74%) were scheduled for both group therapy and rehabilitation, 7 (15%) for rehabilitation only, 2 (4%) for group therapy only, and 3 (7%) for 1v1 therapy (Figure 4). 
Conclusion: This work outlines the often unspoken, operational effort necessary to build a sustainable FMD service line. Future analyses are necessary to understand generalizability and efficacy. 

References:
Finkelstein SA, et al. Setting up Functional Neurological Disorder Treatment Services: Questions and Answers. Neurol Clin. 2023;41(4):729-43
Gilmour GS, et al. Developing an Outpatient Transdisciplinary Functional Movement Disorder Program: 1-Year Experience. Mov Disord Clin Pract. 2025;12(11):1756-60

108    CONTEXTUALIZATION OF HEALTHCARE ENGAGEMENT IN AN OUTPATIENT FUNCTIONAL NEUROLOGICAL DISORDER (FND) SAMPLE (Phenomenology/Epidemiology)
Amy Werry, PsyD, UT Health San Antonio

Background: Research has demonstrated high healthcare utilization and cost for inpatient and emergency department services related to FND symptoms. Comparatively less is understood about factors associated with outpatient healthcare engagement for individuals with an established FND diagnosis. The current study sought to characterize outpatient healthcare utilization through the lens of insurance status and social determinants of health related to access to care. We hypothesized that patients without access to private health insurance, those living in more impoverished areas, and those living in more rural areas would have lower healthcare utilization due to lower accessibility of care

Methods: Data were collected via Epic Slicer Dicer  (version 2025, Epic Systems, Verona, WI), an electronic medical record, self-service data exploration tool. Inclusion was based on three ICD-10 codes for FND/conversion disorder (F44.5, F44.6, F44.7). Patients over 65 were excluded to minimize over sampling for use of government sponsored Medicare. Deidentified data were included for patients who received services through the UT Health San Antonio (UTHSA) system in at least one outpatient visit over the course of three years (May 2022-May 2025). 673 patients were divided into dichotomized groups based on utilization of commercial or private medical insurance  for any UTHSA visit during the three-year period versus only using government sponsored insurance, charitable coverage, or self pay. Two-tailed independent samples t-tests were performed to compare the means for variables of healthcare engagement including number of visits, number of procedures, and number of medical diagnoses on record  and variables. Chi-square tests of independence were used for categorical variables. 

Results : Patients who utilized commercial medical insurance for any visit during the period carried a greater number of diagnoses in medical records, had more procedures ordered and completed, had more missed appointments, and were from areas of greater deprivation (Table 2). Chi-square tests were also significant for legal sex, ethnicity, and race  (Table 1). No differences were found for age, preferred language, and rural-urban commuting area .  

Conclusions: People with an FND diagnosis are more likely to have higher healthcare utilization for outpatient medical services when they have access to commercial medical insurance and greater area financial resources, suggesting greater potential for overutilization of services. Notably, more patients utilized non-commercial than commercial insurance during this period  and may have less access to medical services including diagnostic clarity. Continued medical work-up may contribute to confusion surrounding the diagnosis and delay engaging in FND specific treatment. The current study does not address medical comorbidities nor delivery of FND diagnosis and education and their role in driving these variables of healthcare utilization.

109    OBJECTIVE MEASUREMENT OF HOOVER’S SIGN IN HEALTHY CONTROLS AND PATIENTS WITH FUNCTIONAL NEUROLOGICAL DISORDER (Phenomenology/Epidemiology)
Andrew Whitfield, King's College Hospital, London

Background: Hoover’s sign, first described in 1908 [1], is characterised by transient improvement of weakness in hip extension by flexion of the contralateral hip against resistance. Here, ‘voluntary’ extension improves through ‘involuntary’ activation. Such ‘positive signs’ are central to diagnostic specificity and can be used therapeutically aiding patient understanding in functional neurological disorder (FND). Despite its clinical relevance, few attempts have been made at quantitative measurement of the sign.
 
Methods: We have developed a novel apparatus utilising digital force gauges for objective measurement of Hoover’s sign and have begun testing in healthy controls (n=20) and in patients with unilateral functional leg weakness (n=20). Our novel protocol investigates the accuracy and reliability of a blinded neurologist using MRC rated power compared to our apparatus and a handheld force gauge.
 
Results: Previous work has demonstrated an increased ratio of ‘involuntary’ to ‘voluntary’ hip extension in patients with FND compared to healthy controls [2]. We aim to replicate these findings and determine the relationship of quantitative measures to physician examination. Results will be presented.

Conclusion: Validated objective measurements of functional signs could aid in earlier diagnosis, serve as novel outcome measures in clinical trials and separate out functional components to a mixed presentation. Future work will compare to neurological control groups and use EEG to measure voluntary movement potentials during the task.

References: 
[1] Hoover CF. A new sign for the detection of malingering and functional paresis of the lower extremities. JAMA. 1908;LI(9):746. doi:10.1001/jama.1908.25410090028001h
[1] Ziv I, Djaldetti R, Zoldan Y, Avraham M, Melamed E. Diagnosis of “non-organic” limb paresis by a novel objective motor assessment: the quantitative Hoover’s test. Journal of Neurology. 1998;245(12):797-802. doi:10.1007/s004150050289

110    FUNCTIONAL/DISSOCIATIVE SEIZURES (FDS) IN WALES, A RETROSPECTIVE STUDY USING ROUTINELY COLLECTED DATA (Phenomenology/Epidemiology)
Teja Zeribi, FND Hope

Method: We performed a retrospective study using linked, anonymised health and census data from the Secure Anonymised Information Linkage databank. We identified incident FDS and/or epilepsy cases in Wales (2003–2023), using routinely-collected diagnosis codes, and age, deprivation, and sex-matched comparators. We validated case ascertainment using 877 definite/probable FDS cases, and 4611 individuals without FDS. 

Results: We identified 2808 FDS cases (algorithm sensitivity=47.7%, specificity=99.8%). 74.5% were female, 30% had epilepsy. FDS incidence increased from 2.9/100,000 (99%CI=2.2–3.9) in 2012 to 9.4/100,000 in 2023 (99%CI=8.0–11.0). FDS prevalence is >0.1%.  

Individuals with FDS had: increased mortality risk compared to comparators (HR=1.7 (95%CI=1.48–2.00); increased emergency department attendance  (1.43 visits/person/year in 2023 [99%CI=1.37–1.48], versus 0.77 [99%CI=0.75–0.78] for epilepsy cases, 2.03 [99%CI=1.93–2.14] for epilepsy and FDS, and 0.34 [99%CI=0.33–0.35] for comparators); higher rates of common mental health disorders (80% versus 49% [epilepsy cases] and 45% [comparators]);  lower rates of currently working (28% versus 26% [epilepsy cases] and 57% [comparators]) and higher rates of long-term sickness (35% versus 23% [epilepsy cases] and 7% [comparators]). 

Significance: FDS incidence in Wales is increasing. People with FDS have significantly higher rates of healthcare utilisation, psychiatric comorbidity and mortality when compared to matched comparators. 

111    A SERVICE EVALUATION OF THE RECOGNITION, CARE AND MANAGEMENT OF FUNCTIONAL SEIZURES WITHIN A UK AMBULANCE SERVICE (Treatment)
David Williams, UWE Bristol

Introduction: Functional seizures, a subtype of functional neurological disorder, are frequent presentations within the emergency department and wider hospital setting. There is a lack of research exploring pre-hospital care for this patient group. The aim of this service evaluation was to explore ambulance staff recognition, care and management of functional seizure presentations within a UK ambulance service trust. 

Methods: An online survey was conducted using a convenience sample of clinical staff from South Western Ambulance Services NHS Foundation Trust. Respondents were asked a mixture of distinct and free-text answers exploring questions around identification, care and management of functional seizure presentations. Results were analysed using a mix of descriptive statistics and qualitative content analysis. 

Results: There were 96 responses to the survey. 82% (n=81) of respondents reported they attend functional seizures at least once monthly, with 18% (n=17) of those attending functional seizures weekly. Ambulance staff confidence in the recognition and management of functional seizures is high, but notably 66% (n=63) have received no previous training or education for functional seizure care. Definitions and causes of functional seizures reportedly relied predominantly on a psychological component. Identification was based on history, seizure features and clinical guidelines. Management of functional seizures focused on reassurance. Challenges identified by ambulance staff included stigma, perceived diagnostic complexity, fear and limited education. 

Conclusion: Ambulance staff frequently attend functional seizures but receive limited training, leading to misconceptions, stigma, and diagnostic challenges. Identification relies on unreliable signs and complex histories. Management aligns with clinical guidance, yet uncertainty remains for prolonged events. Fear of misdiagnosis, harmful attitudes, and poor education highlight urgent need for targeted education and future research.

112    “YOU PRESSED CTRL/ALT/DELETE AND REBOOTED MY BRAIN!”: VIRTUAL REALITY IN THE MANAGEMENT OF FUNCTIONAL NEUROLOGICAL COMMUNICATION DISORDERS (Treatment)
Cath Gregory, University of Technology Sydney

Background: Interest in using virtual reality (VR) for neurological and psychiatric disorders is growing. VR shows promise in rehabilitation by modifying beliefs and diverting attention, making it a valuable tool for conditions with abnormal sensory feedback and bodily awareness, including functional neurological disorders (FND) [1]. Functional Neurological Communication Disorders (FNCD) refer to symptoms affecting speech, voice, and language [2]. Current FNCD treatment involves use of distraction techniques during therapy [2]. However, unlike functional movement disorders, VR has not yet been specifically applied to treat FNCD. Addressing this gap is crucial, as VR’s immersive and reproducible environments provide significant therapeutic potential.

Methods: Adults (18+) with FNCD who had not responded to traditional therapy were recruited to experience three different VR applications, each offering varying levels of distraction, during a 30-minute session at the University of Technology Sydney. Speech was assessed for intelligibility and naturalness at baseline, during, and after VR use. After each application, participants completed a survey and, at session end, a semi-structured interview. Interview data underwent inductive descriptive content analysis.

Results: Preliminary findings (n=5) show immersive VR experiences were well received and positively impacted FNCD symptoms (see Figure 1). One participant experienced complete symptom resolution lasting over 8 months. However, three participants saw temporary symptom worsening with certain VR applications, suggesting that distraction is not the sole factor, and individual triggers must be considered when selecting VR interventions.

Conclusions: Changes in speech naturalness and intelligibility during and after VR suggest VR is a feasible FNCD treatment tool. However, careful, individualised selection of VR applications is essential. VR’s potential to rapidly influence FND symptoms when exposed to specific triggers also indicates a possible assessment and awareness training role. Participants’ feedback highlighted that immersion and bodily awareness were key to positive outcomes, suggesting clear mechanistic targets for future research and clinical implementation.

References:
1)Brouwer et al., 2024, BMJ Neurology Open, 6(2), e000622
2)Baker et al., 2021, Journal of Neurology, Neurosurgery and Psychiatry, 92(10), 112-1125

113    SUSTAINED RECOVERY FOLLOWING VIRTUAL REALITY EXPOSURE IN FUNCTIONAL NEUROLOGICAL COMMUNICATION DISORDER: A CASE REPORT (Treatment)
Cath Gregory, University of Technology Sydney

Introduction: Functional neurological communication disorder (FNCD) affects speech, voice, and language (Baker et al., 2021). Although distraction techniques are commonly used in treatment, virtual reality (VR) may offer a more immersive and reproducible way to redirect attention and alter symptom expression (Brouwer et al., 2024). 

Case Presentation: The participant was a 57-year-old woman with FNCD affecting speech and voice, with symptoms for more than two years. She initially presented with dysfluency and had completed approximately 12 months of the Camperdown program, followed by a further 12 months with an FND-experienced speech pathologist using distraction-based approaches. Dysfluency had improved, but significant speech and voice symptoms remained.

In a mixed methods case series, she completed three VR applications in a 30-minute session. Baseline speech assessment showed equal and excess stress, monotone quality, reduced intensity (50.5 dB), short maximum phonation time (2.4 seconds), and reduced CPP (9.9 dB). Speech naturalness was rated 5/9 and voice quality was moderately strained and breathy, with pitch and phonation breaks.

Responses differed clearly across applications. During a guided meditation app (VR1), speech normalised perceptually and objective measures improved, including intensity (72 dB), maximum phonation time (12 seconds), and CPP (14.4 dB). Speech naturalness improved to 1/9. The participant was immediately aware of changes and described being “blown away” that her “speech has gone back to normal”. In contrast, a puzzle solving based app, Hand Physics Lab (VR2) triggered severe dysfluency and early cessation; she described it as “frustrating and confusing”, with a cognitive load that “felt so big”. Post VR2, baseline speech and voice features returned. Re-exposure to VR1 at the end of the session again resulted in natural sounding speech.

Follow-up emails indicated sustained benefit. Her teaching registration was re-approved, allowing return to work, and improvement remained evident at 9 months.

Discussion: This case is notable because symptoms persisted despite prolonged speech pathology treatment by an experienced speech pathologist yet improved rapidly and sustainably during one VR condition only. The contrasting responses across applications suggest that benefit was not due to distraction alone, but to the type and cognitive demands of the immersive experience. In the larger pilot study, she was the only participant (1/6) to maintain long term improvement after short VR immersion, and the reasons for this require further investigation. VR may have value not only as treatment, but also as a way of identifying helpful versus triggering conditions in FNCD.

References:
Baker, J., et al. (2021). Journal of Neurology, Neurosurgery & Psychiatry, 92(10), 1112-1125.
Brouwer, D., et al., (2024). BMJ Neurology Open, 6(2), e000622

114    CONTROL OF FUNCTIONAL NEUROLOGICAL STUTTERING WITH TRANSCUTANEOUS ELECTRICAL NERVE STIMULATION (TENS) (Treatment)
Cath Gregory, University of Technology Sydney

Introduction: Functional Neurological Disorder (FND) symptoms can include acquired dysfluency/stuttering. Functional neurological stuttering typically has sudden onset, variable severity, and differs from developmental stuttering, often worsening with attention and improving with distraction. Symptoms are genuine and disabling, but evidence for treatment is limited with early access to treatment usually required for effective rehabilitation (Baker et al., 2021).

Case: A 62-year-old man was referred in 2025 for treatment of functional neurological stuttering that began suddenly in September 2020. He had experienced workplace trauma in 2019 and was diagnosed in mid 2020 with major depressive disorder, anxiety, and panic attacks.
Initially described as “amusing”, he reported the dysfluency worsened by December 2020 until he could barely speak, causing social withdrawal and reduced quality of life. He also reported two previous episodes of dysfluency in his life, during severe stress and pain, both of which had resolved spontaneously.

Speech was characterised mainly by whole-word and syllable repetitions, rated severe (SR-7) in conversation. Traditional treatment with prolonged speech techniques improved his dysfluency, but felt “robotic”, so he used it sparingly. Transcutaneous electrical nerve stimulation (TENS) machine use has previously shown promise in treatment of persistent developmental stuttering (Merlo, 2020). A trial of low-intensity wireless TENS device use on the abdomen produced immediate cessation of dysfluency (SR-0). After six months of regular use, stuttering with friends has remained at SR-0 without the device, although he still uses TENS to control his dysfluency with unfamiliar communication partners. TENS use was associated with marked quality-of-life improvement and resolution of social avoidance.

Discussion: This case demonstrates immediate modulation of functional neurological stuttering associated with low intensity TENS. The precise underlying mechanism remains unknown, however the rapid effect of the device and effectiveness of TENS with placement of electrodes on the abdomen is consistent with sensitivity to sensory input and diverted attention. TENS may be a useful adjunct within symptom-focused rehabilitation of functional neurological dysfluency and warrants further investigation.

References:
Baker, J., et al. (2021). Management of functional communication, swallowing, cough and related disorders: consensus recommendations for speech and language therapy. Journal of Neurology, Neurosurgery and Psychiatry, 92(10), 1112-1125. https://doi.org/10.1136/jnnp-2021-326767 
Merlo, S. (2020). Surface Electrical Stimulation for Persistent Stuttering and Concomitant Orofacial Disorders: A Multiple Case Study. Perceptual and Motor Skills, 127(4), 698–721. https://doi.org/10.1177/0031512520915027

Video: https://youtube.com/shorts/MMWnl5gEODc

115    PSYCHOEDUCATION IN THE CONTEXT OF PSYCHOTHERAPY TREATMENT GROUP FOR FUNCTIONAL COGNITIVE DISORDER: PRELIMINARY FINDINGS IN BRAIN MEDICINE CLINIC COHORT STUDY (Phenomenology/Epidemiology, Treatment)
Khian Boon Ng, University of Toronto

Background: Functional Cognitive Disorder (FCD) is a common cause of cognitive complaints in specialty clinics and is frequently associated with functional impairment, maladaptive illness beliefs, psychological distress, and preserved objective cognitive functioning. Psychoeducation is considered a core component of FCD management, aiming to reframe symptom understanding within a functional neurobiopsychosocial model. However, its immediate impact on diagnostic understanding and treatment engagement remains underexplored. This study aimed to characterize the first cohort of an FCD psychotherapy treatment group within a tertiary Brain Medicine Clinic and evaluate early changes following a structured psychoeducation session.

Methods: We conducted a retrospective pre–post observational cohort study of patients enrolled in the first FCD psychotherapy treatment group (pilot cohort n = 10; total planned n = 80) at a tertiary Brain Medicine outpatient clinic.

Participants completed questionnaires before and after a structured psychoeducation session introducing a neurobiopsychosocial model of functional cognitive symptoms and treatment approaches such as cognitive behavioral therapy.

Primary outcomes included diagnostic agreement with FCD, belief in treatment effectiveness, and readiness for change, assessed using Likert scales and the University of Rhode Island Change Assessment (URICA).

Results and Discussion: Ten participants were included (mean age 51.7 years, SD 12.2; 40% White, 10% White and Indigenous, 50% Asian). Mean illness duration was 12.2 years, and 50% had psychiatric comorbidities.

Following psychoeducation, diagnostic agreement increased (5.1 to 5.5), belief in treatment effectiveness improved (5.0 to 5.3), and readiness for change increased (URICA 9.47 to 10.37). Precontemplation scores decreased (14.10 to 10.80), suggesting reduced resistance toward a psychological framework of symptoms.

Qualitative interviews revealed high satisfaction with the group environment and peer support. Participants requested longer and additional sessions and described challenges completing weekly homework due to overwhelm, procrastination, and time management difficulties. 

Conclusions: Patients with FCD demonstrated prolonged illness duration and significant psychological burden. A structured psychoeducation session was associated with improvements in diagnostic acceptance, treatment beliefs, and readiness for change. These findings suggest psychoeducation may function as an early therapeutic intervention and represent an important component of group-based treatment approaches for FCD.

References:
Cabreira V, et al. Functional cognitive disorder in memory clinics. 2023.
Stone J, et al. Functional neurological disorders and cognitive symptoms.
 

Poster Session
Monday, June 15, 2026
12:30 pm – 2:00 pm

 
125    STRUCTURAL INEQUITIES IN FUNCTIONAL NEUROLOGICAL DISORDER CARE: A QUALITATIVE STUDY IN THE REPUBLIC OF IRELAND (Phenomenology/Epidemiology)
Emma-Jane Bane, Royal College of Surgeons in Ireland

Introduction/Background: Functional Neurological Disorder (FND) is a condition arising primarily from dysfunction of the nervous system rather than identifiable pathophysiological disease (Stone et al., 2020). Historical marginalisation and stigma have contributed to limited research investment and underdevelopment of clinical services. Despite an estimated 9,000 people living with FND in Ireland (FND Ireland, 2024), dedicated services remain scarce. Qualitative research exploring patient experiences of navigating the Irish healthcare system with FND is limited.

Objective: To explore the experiences of individuals with FND in accessing healthcare services in Ireland.

Methods: A qualitative study using semi-structured interviews was conducted with adults diagnosed with FND. Ethical approval was granted by RCSI REC. Patient and Public Involvement (PPI) contributors were involved throughout study design, data interpretation, and validation to ensure alignment with lived experience priorities. Sixteen participants aged 18–58 years were recruited through purposive sampling across Ireland, including 3 males, 1 non-binary trans man, and 12 females. Interviews were conducted via Microsoft Teams and lasted 28–91 minutes. Data was analysed inductively using reflexive thematic analysis (Braun & Clarke, 2022). Ten percent of transcripts were independently peer-reviewed, and identified themes were presented to the PPI group for validation.

Results: Five themes were identified, highlighting structural inequities in FND care. Participants described an absence of post-diagnostic pathways, frequent reliance on websites as primary post-diagnostic support, and prolonged delays in accessing psychology, counselling, physiotherapy, and occupational therapy. Many sought private, overseas, or alternative care, often incurring financial burden, or relied on emergency departments as a route to services.

Dismissive and inconsistent healthcare interactions were commonly reported, including limited professional knowledge of FND and misattribution of symptoms, some of which were gendered. Participants frequently assumed the role of educator to healthcare professionals, increasing treatment burden and emotional distress. Fragmented and poorly coordinated care shifted responsibility for care planning and coordination onto patients and families, requiring sustained self-advocacy. Positive experiences were largely dependent on individual clinicians who independently advocated, upskilled or coordinated care, highlighting reliance on personal rather than systemic solutions. Participants articulated a clear vision of equitable FND care emphasising accessible multidisciplinary clinics, ongoing contact with services, flexible delivery and improved clinician education. 

Conclusion: Disparities in FND care are rooted in systemic rather than individual factors. Addressing these inequities requires integrated, accessible, multidisciplinary FND pathways alongside improved education and training for clinicians.

126    INTEGRATING PSYCHIATRIC MEDICATION MANAGEMENT INTO INTERDISCIPLINARY CLINICAL TREATMENT FOR FUNCTIONAL NEUROLOGICAL DISORDER: A TWO PATIENT CASE SERIES (Treatment)
Ahmed Alhassan, University of Alabama at Birmingham

Introduction/Background: Functional Neurological Disorder (FND) is a common and disabling condition characterized by genuinely experienced neurological symptoms arising from dysfunction in brain networks rather than structural disease. Contemporary guidelines emphasize that FND is a rule-in diagnosis based on positive clinical signs and should be managed using a multidisciplinary, individualized approach [1] [2].  While psychotherapy and rehabilitation are central to treatment, the role of integrated psychiatric medication management within FND programs remains under described.

Case Presentation: Case 1 involved an 18-year-old woman with functional seizures and comorbid bipolar disorder, anxiety, dissociative features, trauma-related symptoms, and chronic suicidal ideation predating her FND diagnosis. Within an interdisciplinary program incorporating ReACT (Retraining and Control Therapy), her functional seizures improved significantly. However, mood instability and trauma-related nightmares persisted. Targeted psychiatric medication management supported emotional regulation and sleep, enabling sustained engagement in behavioral therapy. Although psychiatric symptoms did not fully remit, being connected to THRIVE (Toward Hope, Recovery, Interpersonal Connection, and Value Based Living), she developed diagnostic insight, improved coping, and sustained reduction in suicidal ideation.

Case 2 involved a 60-year-old man with mixed FND symptoms and significant medical comorbidities, including Parkinson disease, who reported chronic suicidal ideation with repeated interrupted firearm-related attempts. Functional gains were limited due to neurodegenerative illness. Coordinated psychiatric medication management, aligned with THRIVE was associated with marked reduction in suicidal ideation, improved affective stability, and increased treatment engagement despite persistent neurological limitations.

Discussion: Both cases illustrate that psychiatric medication management functioned as a clinical enabler rather than a primary treatment for FND symptoms. Aligning pharmacologic strategies with behavioral goals enhanced emotional and cognitive capacity for participation in evidence-based therapies, consistent with multidisciplinary care models recommended in recent guidance [1] [2]. Importantly, reductions in suicidality and improvements in coping occurred independently of full neurological recovery, underscoring the need to distinguish psychiatric risk reduction from functional symptom resolution when evaluating outcomes.

Embedding psychiatric medication management within interdisciplinary FND care may reduce suicide risk, strengthen engagement in rehabilitation and psychotherapy, and support meaningful recovery even when functional symptoms persist or are constrained by comorbid neurological disease.

References:
1. Dworetzky BA, et al. Neurotherapeutics. 2025. PMID: 40399224.
2.Aybek S, et al. BMJ. 2022;376:e068628

127    BRIDGING THE GAP: PEDIATRIC FUNCTIONAL NEUROLOGICAL DISORDER AND CHRONIC PAIN- UNIFIED APPROACHES TO REHABILITATION (Treatment)
Katherine Bentley, MD, AAPMR

Background: Functional Neurologic Disorder (FND) in pediatric patients is often underdiagnosed due to overlap with many other conditions like chronic pain syndrome (CPS). Both FND and CPS share biopsychosocial origins and respond to similar multidisciplinary treatments that integrate physical rehabilitation, cognitive behavioral therapy, and pain management. Despite these similarities, FND treatment is frequently underrecognized in pediatric care. This study explores the outcomes of a comprehensive rehabilitation approach for FND and CPS in children and adolescents.

Methods: Data from a random sample of 150 pediatric patients were extracted from the REDCap chronic pain database of two tertiary children’s hospitals. We analyzed demographic information, psychiatric history, and functional outcomes (PedsQL, LEFS, UEFI, COPM, BOT-2, FDIC, FDIP) across three groups: FND (n=40, 26.6%), FND+CPS (n=35, 23.3%), and CPS (n=75, 50%). Nonparametric tests (Kruskal-Wallis, Wilcoxon signed-rank) and ANOVA were used as appropriate.

Results: Mean age was 15.2±2.8 yrs. There were 124 (82.7%) female and 105 (73.4%) identified as white with no significant difference in demographic data between groups. Mean length of stay was 27.5±10.7 days.  45 (31.7%) had a history of injury and 108 (72.5%) had a history of psychiatric disorder. Admission pain scores did not differ between groups (median 7,p=0.989), but all groups demonstrated significant reduction in pain at discharge (median difference of 2,p<0.001). PedsQL, LEFS, UEFI, COPM, BOT-2, FDIC, and FDIP scores showed significant improvement from admission to discharge across all groups (all p<0.001), with no significant between-group differences in magnitude of improvement for most measures. LEFS admission scores were lower in FND compared to CPS (p=0.0027). Baseline COPM performance differed across groups (p=0.0289), but change scores were similar. BOT-2 and FDIP discharge scores showed some group-specific differences, yet the degree of improvements was consistent across the three groups.

Conclusions: Pediatric patients with FND, CPS, and comorbid FND+CPS exhibit significant functional gains during inpatient rehabilitation. Despite baseline differences in some measures, the magnitude of improvement across motor, functional, pain, and quality-of-life domains was largely similar. These findings demonstrate that pediatric patients with FND and CPS achieve similar benefits in functional recovery from a comprehensive, multidisciplinary rehabilitation approach.

References:
Espay AJ, Aybek S, Carson A, et al. Current Concepts in Diagnosis and Treatment of Functional Neurological Disorders. JAMA Neurol. 2018;75(9):1132-1141. doi:10.1001/jamaneurol.2018.1264
Martes J, Holden J, Bosques G. Functional Syndromes in the Pediatric Population and Their Rehabilitation Management: Chronic Pain Syndrome and Functional Neurologic Disorder. Phys Med Rehabil Clin N Am. 2025;36(3):625-645. doi:10.1016/j.pmr.2025.03.006

128    EFFECTIVE CONNECTIVITY BETWEEN PRIMARY MOTOR CORTEX AND TEMPOROPARIETAL JUNCTION IN FUNCTIONAL MOVEMENT DISORDER (Etiology/Pathophysiology)
Christina Bolte, Institute of Systems Motor Science

Background: The temporoparietal junction (TPJ) has been an area of interest in pathophysiological research of functional movement disorders (FMD), as both altered responses and connectivity to other brain regions have been observed in patients. Transcranial magnetic stimulation (TMS) is a non-invasive brain stimulation tool to investigate brain circuits, with dual-pulse/dual-coil paradigms offering the possibility to investigate connectivity between two brain areas. Thus, this could be particularly suitable for investigating TPJ connectivity in FMD.

Methods: To assess connectivity between the right TPJ and the ipsilateral and contralateral primary motor cortex (M1), a neuronavigated dual-coil paradigm has been adapted from a study investigating interhemispheric connectivity of the angular gyrus[1]. rTPJ-M1 connectivity was calculated as the change in motor evoked potential (MEP) between stimulating the M1 alone and stimulating both M1 and rTPJ. 34 FMD patients (22 female, mean age 46 years) and matched healthy controls were measured. In addition, the magnetically induced electric fields (EF) were individually simulated to assess any correlation of EF magnitude and rTPJ-M1 interaction. Furthermore, each simulation result was mapped onto the subdivisions of the inferior parietal cortex and the temporo-parieto-occipital junction as parcellated in the HCP-MMP1 atlas[2] in order to delineate the simulation effect topographically.

Results: No difference between stimulating the M1 alone and stimulating both M1 and rTPJ was found, with both stimulation states yielding the same muscle reaction. Furthermore, a linear mixed model of group (patient or healthy control) and condition (ipsilateral or contralateral), controlling for stimulation intensity, medication and time of the experiment revealed no influence on rTPJ-M1 interaction. In patients, there was no correlation between symptom severity and TMS data. The EF simulation revealed no correlations between dosage in the defined regions and the rTPJ-M1 interaction. The strongest EF magnitude was found in two regions in the inferior parietal cortex (PF and PFm), and a region in the temporo-parieto-occipital junction (PSL).

Conclusions: It is possible that the stimulation protocol used in our study, which was limited to one ISI per condition and one stimulus intensity due to time constraints in the study design, was not sufficient to comprehensively assess rTPJ-M1 connectivity. The dual coil TMS was well tolerated and EF simulation revealed that targeting of the TPJ was successful, rendering this a viable method for further, more systematic exploration of TPJ connectivity in the future.

References: 
1. Baarbé, J. et al. Interhemispheric interactions between the right angular gyrus and the left motor cortex: a transcranial magnetic stimulation study. J. Neurophysiol. 125, 1236–1250 (2021).
2. Glasser, M. F. et al. A multi-modal parcellation of human cerebral cortex. Nature 536, 171–178 (2016).

129    ACUTE FUNCTIONAL MOTOR DISORDER MIMICKING POST-OPERATIVE COMPLICATION: A CASE REPORT (Phenomenology/Epidemiology)
Fouad Jameel Rashid Al-Zaidi, MD, Al-Farabi Kazakh National University

Introduction: Functional neurological disorder (FND) is a complicated mix of neurology and psychiatry. Physical trauma, encompassing both minor and major surgical interventions, is a well-documented catalyst for the abrupt emergence of functional motor symptoms. It is very important to recognize FND in post-surgical settings to avoid unnecessary invasive tests, reduce patient distress, and make it easier for early, appropriate multidisciplinary intervention to happen.

Case Presentation: A 28-year-old woman developed sudden weakness in both legs right after a simple laparoscopic appendectomy. The patient said she couldn't move her legs when she woke up from general anesthesia, which made doctors think she might have a spinal cord lesion or a problem that happened during surgery. The vital signs were stable. The neurological exam showed that both legs were very weak, but the deep tendon reflexes were normal, the sensation was intact, and there was no problem with the bowel or bladder. A positive Hoover's sign was crucially elicited, indicating normal hip extension in the apparently paralyzed leg during contralateral hip flexion against resistance testing. A full neuroaxis magnetic resonance imaging (MRI) scan with and without contrast showed no structural problems, ischemic events, or compressive lesions [table1]. The diagnosis of functional motor disorder was made based on the positive clinical signs and negative structural imaging [figure1]. The diagnosis was conveyed to the patient by elucidating the notion of a software malfunction within the nervous system, notwithstanding the preservation of anatomical hardware. Physical therapy began right away, and over the course of three days before discharge, motor function slowly returned.

Discussion: This case underscores the necessity of sustaining a heightened index of suspicion for Functional Neurological Disorder (FND) in surgical wards when patients exhibit acute neurological deficits that are inconsistent with established anatomical or physiological norms. The existence of affirmative clinical indicators, such as Hoover's sign, facilitates a conclusive rule-in diagnosis rather than depending exclusively on a diagnosis of exclusion. Early detection in the surgical environment mitigates iatrogenic injury resulting from repetitive testing and decreases extended hospitalizations. In addition, giving the diagnosis in an open and non-judgmental way is an important first step in treatment that leads to targeted physical rehabilitation.

References:
Stone J, Carson A, Hallett M. Explanation as treatment for functional neurologic disorders. Handb Clin Neurol. 2016;139:603-617.
Aybek S, Perez DL. Diagnosis and management of functional neurological disorder. BMJ. 2022;376:o64.

130    OUTCOMES OF A 5-DAY INTENSIVE MULTIDISCIPLINARY REHABILITATION PROTOCOL FOR FUNCTIONAL MOTOR DISORDERS: A PROSPECTIVE STUDY (Treatment)
Fouad Jameel Rashid Al-Zaidi, MD, Al-Farabi Kazakh National University

Background: Functional Neurological Disorder (FND) leads to considerable disability, but conventional outpatient treatment frequently experiences high dropout rates and prolonged recovery. Intensive, focused rehabilitation is thought to help the nervous system "retrain" itself more effectively. This study assessed the clinical effectiveness of a "Fast-Track" 5-day intensive multidisciplinary rehabilitation program (IMRP) for functional motor symptoms [1].

Methods: This prospective study comprised 35 patients (mean age 34.2) diagnosed with "rule-in" functional neurological disorders (FND). The IMRP intervention consisted of five consecutive days of intensive therapy (6 hours daily), including: (1) specialized physical therapy for movement automaticity; (2) occupational therapy for ADL reintegration; and (3) cognitive-behavioral educational sessions. The Berg Balance Scale (BBS) was used to measure stability and the EQ-5D-5L was used to measure quality of life (QoL) at the start and three months later. A standardized communication protocol was employed to establish therapeutic alliance [table1].

Results: At three months, 82.8% of the participants showed clinically significant improvement in their motor skills. The mean BBS scores went up from 34.2 ± 5.1 to 48.5 ± 4.2 (p < 0.001), which shows a change from a high risk of falling to being able to live on your own. Scores on the EQ-5D-5L went up by 45%, and patients said they felt more in control and less anxious. The program had a 95% completion rate, which is higher than the average for outpatient programs. Qualitative feedback indicated that the daily format inhibited maladaptive habit interference, promoting enduring neuroplastic transformation. The workflow stresses a short, focused time frame to get the most functional benefits [figure1].

Conclusions: A 5-day intensive protocol is very good at helping people with FND recover quickly [2]. This high-dose model should be prioritized in clinical guidelines as a primary intervention to optimize patient outcomes and reduce long-term socioeconomic burdens by circumventing the limitations of sporadic care.

References:
[1] Maggio, M. G., Latella, D., Maresca, G., Giliberto, S., & Calabro, R. S. (2024). Intensive rehabilitation in functional neurological disorders: A systematic review of the literature. Journal of Clinical Neuroscience, 121, 45-53.
[2] Nielsen, G., Stone, J., Matthews, A., Brown, M., Sparkes, C., Farmer, R., ... & Edwards, M. J. (2015). Physiotherapy for functional motor disorders: a consensus recommendation. Journal of Neurology, Neurosurgery & Psychiatry, 86(10), 1113-1119.

131    MOVING LESS, FEELING MORE: PHYSICAL ACTIVITY AND AUTONOMIC SYMPTOM BURDEN IN FUNCTIONAL SEIZURES VERSUS EPILEPTIC SEIZURES (Etiology/Pathophysiology)
Kelly Boylan, MD, Mass General Brigham

Background: Functional seizure disorder is a common, often treatment-resistant functional neurological disorder (FND) diagnosed and cared for by epileptologists, thus representing a key patient group in the broader spectrum of seizure disorders. Little is known about physical activity patterns and autonomic symptom burden in seizure populations.  

Methods: Fifty patients with functional seizures and 50 patients with epilepsy completed the European Prospective Investigation into Cancer Study-Norfolk cohort Physical Activity Questionnaire (EPICPAQ2) and Composite Autonomic Symptom Score (COMPASS-31) to characterize subjective physical activity patterns and autonomic symptom burden. 

Results: Patients with functional seizures report significantly more autonomic symptoms (two-sample t-test, p=<0.001, CI [−22.30-−8.76])) and are less physically active (two-sample t-test, p=0.004, CI [22.78-114.37]) when compared to patients with epileptic seizures. Multivariate logistic regression modeling was used to show that these differences are present even when accounting for anxiety symptom severity, depressive symptom severity, sleep quality, dissociative symptoms, age, sex, gender, and level of education. COMPASS-31 score was moderately negatively correlated with total physical activity (Pearson r = −0.37), indicating that higher autonomic symptom burden was associated with lower activity levels.

Conclusions: Functional seizure patients have distinct patterns of autonomic symptoms and self-reported physical activity compared to epileptic seizure patients. This project creates a foundational framework for future work on the objective measurement of networks of autonomic control in functional seizures—and how these networks may be influenced by exercise

132    FUNCTIONAL NEUROLOGICAL DISORDER AMONG TRANSGENDER PEOPLE: A RETROSPECTIVE COHORT STUDY USING ELECTRONIC HEALTH RECORDS (Etiology/Pathophysiology)
Richard Bradlow, The Victoria Clinic

Background: Functional neurological disorder (FND) significantly impacts quality of life and appears disproportionately common among transgender and gender-diverse (TGD) populations. However, there is limited large-scale evidence examining prevalence and associated risk factors within these populations.

Methods: A retrospective cohort study was conducted using electronic health record data from 165 million individuals in the TriNetX database in April 2025. Participants included those diagnosed with FND (n=217,900) or with transgender-related diagnoses (n=148,100), identified through specific ICD-10 codes. TGD status and prescription of feminising or masculinising gender-affirming hormone therapy (GAHT) prior to FND diagnosis were assessed. Primary outcome was FND prevalence, with secondary outcomes including psychiatric comorbidities (autism, PTSD, ADHD, depression, borderline personality disorder, eating disorders, cannabis and alcohol use disorders) and relative risk (RR) of FND associated with feminising versus masculinising GAHT.

Results: FND prevalence was significantly higher in TGD individuals (1.77%) compared to cisgender individuals (0.13%; RR=13.6, 95% CI: 13.1–14.1, p<0.0001). Psychiatric comorbidities including PTSD (RR=4.87), borderline personality disorder (RR=6.47), autism (RR=3.13), and depression (RR=1.94) were markedly elevated in TGD individuals with FND compared to those without. Feminising GAHT was associated with an increased risk of developing FND compared to masculinising GAHT (RR=1.17; p=0.0067).

Conclusions: People with TGD related medical codes exhibit significantly higher FND prevalence, strongly associated with psychiatric comorbidities and feminising hormone therapy. These findings highlight the necessity of adopting trauma-informed, gender and neurodiversity-affirming clinical approaches for TGD patients.

133    PARENTAL AND FAMILY TRAUMA HISTORY IN PEDIATRIC FUNCTIONAL NEUROLOGICAL DISORDER (Etiology/Pathophysiology)
Davon Breedlove, M.S., UT Southwestern Medical Center

Background: Trauma has been proposed as a contributing factor in the development and maintenance of Functional Neurological Disorder (FND), yet evidence linking trauma to symptom severity and functional outcomes in pediatric populations remains mixed. While intergenerational trauma may influence illness perception and family dynamics, its relationship to clinical severity at presentation is unclear. This study examined whether parent history of adverse childhood experiences (ACEs) is associated with child trauma exposure, quality of life, and clinician-rated symptom severity at intake in youth with FND. 

Methods: Participants were 156 children and adolescents diagnosed with FND and evaluated in a multidisciplinary outpatient FND clinic at Children’s Medical Center, Dallas. Parents completed the Adverse Childhood Experience Questionnaire for Adults assessing their own history of childhood trauma. Child trauma exposure was assessed using the Pediatric ACEs and Related Life Events Screener (PEARLS; caregiver and child report). Child quality of life was assessed using the Pediatric Quality of Life Inventory (PedsQL; caregiver and child report). Clinicians rated baseline symptom severity using the Clinical Global Impression-Severity (CGI-S). Independent samples t-tests compared outcomes between high and low parental ACE groups. Statistical analyses controlled for child age and sex assigned at birth.

Results: Higher parental ACE scores were significantly associated with greater caregiver and child reported patient trauma exposure (p < .001). Higher parental ACEs were also associated with lower parent-reported child quality of life (p = .03 after controlling for age and sex). No significant associations were observed between parental ACEs and clinician-rated baseline severity (p = .18) or child self-reported quality of life (p = .12).
 
Conclusions: Findings suggest that parental trauma history is associated with increased child trauma exposure and caregiver perceptions of reduced functioning, but not with clinician-rated symptom severity or with child perception of functioning. These results highlight the intergenerational influence of trauma in pediatric FND and suggest that caregiver trauma history may shape family context and illness perception.. Incorporating caregiver trauma screening into pediatric FND evaluations may enhance trauma-informed, family-centered assessment and care. 

References:
Felitti, V. J., Anda, R. F., Nordenberg, D., Williamson, D. F., Spitz, A. M., Edwards, V., Koss, M. P., & Marks, J. S. (1998). Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. American journal of preventive medicine, 14(4), 245–258. https://doi.org/10.1016/s0749-3797(98)00017-8
Stone, J., & Carson, A. (2011). Functional neurologic symptoms: assessment and management. Neurologic clinics, 29(1), 1–vii. https://doi.org/10.1016/j.ncl.2010.10.011

134    FROM “IF YOU'RE REALLY CONCERNED, GO TO THE EMERGENCY ROOM” TO STRUCTURED NURSE TRIAGE IN PEDIATRIC FUNCTIONAL NEUROLOGICAL DISORDER CARE (Treatment)
Katie Carey, BSN, RN, Texas Woman's University

Background: Pediatric patients with Functional Neurological Disorder (FND) frequently experience symptom fluctuations that prompt unscheduled contact with outpatient neurology services. Telephone triage calls and electronic portal messages are often the first point of clinical response between visits. In the absence of standardized workflows and condition-specific training, triage responses may unintentionally contribute to unnecessary escalation of care, inconsistent messaging, or erosion of therapeutic alliance. Despite the central role of outpatient nurse triage in managing symptom-related outreach, this aspect of FND care delivery remains underrepresented in discussions of pediatric treatment implementation.

Case Presentation: This case study describes a composite scenario derived from recurrent outpatient neurology triage encounters involving pediatric patients diagnosed with FND, including patients with comorbid epilepsy. Within the clinic, patients with FND or FND plus epilepsy were clearly identified in the electronic medical record to support consistent triage decision-making. Nurses received periodic training focused on FND-informed assessment, communication, and alignment with established treatment plans. A standardized electronic smartphrase guided triage calls, prompting targeted questions to differentiate functional events from epileptic seizures when relevant, assess potential triggers, review self-care strategies, and evaluate use of previously taught coping skills. These encounters commonly involved caregiver concern regarding safety and diagnostic uncertainty, requiring careful balance between reassurance and clinical vigilance.

Discussion: Reflection on these encounters informed a structured nurse triage framework designed to support safe, consistent, and treatment-aligned responses for pediatric patients with FND. Key elements included: (1) safety-first assessment without alarm, using structured screening to identify red-flag features and distinguish functional symptoms from epileptic events when applicable; (2) validation without reinforcement, acknowledging distress while avoiding language that implied structural pathology or minimized symptoms; and (3) redirection to active management, reinforcing individualized coping strategies and maintaining continuity with interdisciplinary care plans. A defined goal of triage encounters was for caregivers to conclude calls with increased confidence in symptom management and clearer guidance regarding when escalation was or was not indicated.

References: 
Duggan, D., Karmarkar, S., Bala, T., & Carey, K. (2025, October 8). Experiences from a nurse-led functional neurological disorder pilot clinic [Podium presentation]. Association of Child Neurology Nurses Annual Conference, Charlotte, NC.
Kozlowska, K., Perrin, L., & Voon, V. (2021). The role of clinician communication in the treatment of functional neurological disorder. Journal of Paediatrics and Child Health, 57(9), 1392–1398.

135    MEDICAL COMPLEXITY IN TREATMENT OF FND (Treatment)
Emily Garai, PhD, Children's Healthcare of Atlanta

Cognitive behavioral therapy (CBT) is one of the leading treatments for functional neurological disorder (FND). However, it is often insufficient at relieving symptoms and is geared towards increased functioning. Even when integrated with physiotherapy & medical treatment, there remain many people who do not improve. Little is known about additional treatments in these cases 1,2. 

Aurora is a 14-year-old Mexican American female who was diagnosed with FND in February 2025 in the ER. While admitted, she was seen by neurology and completed a routine EEG and MRI. Multiple events of concern with no EEG correlate were captured; MRI was normal. She was diagnosed with FND, completed a psychiatry consultation, and was referred to outpatient services. 

Predisposing factors include difficulties sleeping, being part of an immigrant family, and social anxiety. Precipitating factors include change in the presidential administration and associated immigration policies. She also believed that keeping her sexual identity secret from her family contributed. While the ongoing immigration situation continues to be a stressor, she came out to her family and feels relief. Protective factors include intelligence, family support, self-advocacy, and engagement in treatment. 

She began outpatient psychotherapy in April 2025 and outpatient psychiatry in June 2025. She continued neurological follow-up with an outpatient neurologist. Psychiatric treatment includes fluoxetine 30 mg for anxiety. Psychotherapy followed Reset & Rewire: The FND Workbook for Kids & Teens by Katie Carey, BSN, RN & Meagan Watson, MPH in addition to other topics from CBT. While she reported a reduction in distress caused by her symptoms, she continued to experience FND episodes daily.  

During treatment, she mentioned additional medical symptoms, including blood in her stool, unexpected weight loss, loss of vision that is not commonly associated with FND, and new weakness. Further blood work revealed chronic inflammation. As such, she was referred to gastroenterology and rheumatology. At the time of this abstract, she is awaiting more testing from GI. Rheumatology has ruled out major medical conditions. 

Aurora successfully implemented all strategies covered in treatment and has reported reduction in anxiety symptoms, yet she continues to experience FND. The extent to which her other physical health concerns contribute is unknown. As such, it is important that treatments consider not just psychological risk factors but also medical ones. This necessitates frequent care coordination. Further work is needed to advocate for consultation and integration of medical and mental health providers for patients with FND. 

136    THE PATIENT AS THE ARCHITECT: A COLLABORATIVE, TRANSDISCIPLINARY APPROACH TO COMPLEX FND AND CRPS RECOVERY (Treatment)
Ava Cicio, PT, DPT, re+active Physical Therapy and Wellness

Introduction / Background: Traditional medical models often relegate patients with Functional Neurological Disorder (FND) and Complex Regional Pain Syndrome (CRPS) to passive roles, and protocols that may overlook individual nuances. However, centering the patient as the primary expert in their own lived experience is essential for meaningful recovery. This case study demonstrates how a collaborative, patient-led approach, utilizing trans disciplinary co-treatment and community-based interventions, facilitated a successful transition from wheelchair reliance to functional mobility and sensory habituation.

Case Presentation: The patient is a female Speech-Language Pathologist (SLP) diagnosed with comorbid FND and CRPS. At the outset of treatment, she was primarily wheelchair-dependent, experiencing high levels of sensory overstimulation and significant loss of autonomy.
Treatment began with a collaborative conceptualization of her "pie chart" model to prioritize key underlying factors contributing to her symptoms. IInterventions included:

Integrated Co-Treatments: Physical Therapy (PT) and Psychology worked simultaneously to address movement and autonomic regulation in real-time.

Physical Therapy: Focused on enhancing automatic movement, implementing sensory tools as a way to promote motor control, graded exercises for autonomic regulation and community ambulation 

Occupational Therapy: Focused on creating a pacing framework, implementing calming/energizing sensory tools, as well as graded exposure to sounds 

Autonomy: Clinicians modeled regulation strategies and adjusted sensory environments based on the patient's daily status, pivoting treatment plans dynamically.

Community Re-entry: Patient-directed outings (e.g., walking in Redondo Beach, navigating public spaces)

Family Integration: The patient’s partner participated in sessions to learn shared communication strategies, ensuring the patient’s needs remained the priority over external familial expectations.

Discussion & Outcomes: Centering the patient transformed the clinical dynamic from "fixing impairments" to "restoring autonomy." The use of experiential learning, providing concrete explanations of symptoms, co-treats with PT and Psychology, and real-world exposure, allowed the patient to gain tools to promote autonomy. The outcome was a significant reduction in symptom severity: the patient transitioned from a wheelchair to independent walking, developed a framework for pacing, and the resilience to tolerate complex sensory environments.
Patient Specific Functional Scale (PSFS): 0 is unable to perform and 10 is able to perform without difficulty.
Go back to work: 0/10 →  7/10
Return to Walking: 2/10 → 8/10 
Activity Beyond 2 Hours: 5/10 → 9/10

Patient Global Impression of Change Scale (PGIC). PGIC: 1 = No change, and 7 = A great deal better and a considerable improvement
PGIC Rating: 7

References
LaFaver, K., et al. (2021). Functional Neurological Disorder: A

137    "WHY IS THIS HAPPENING?” YOUTH AND CAREGIVER BELIEFS IN PEDIATRIC FUNCTIONAL NEUROLOGICAL DISORDER (FND) (Phenomenology/Epidemiology)
Alexandria Crawford, MA, Yale University

Background: Functional Neurological Disorder (FND) is a neurological condition that involves altered nervous system functioning without structural disease and is commonly treated using a biopsychosocial approach (Vassilopoulos et al., 2022). Though provider perspectives have been evaluated (Iskander et al., 2025), little is known about youth and caregivers' perspectives at initial evaluation and treatment, including how they understand what is happening in the body and why symptoms are occurring. This study will examine youth and caregivers’ narratives regarding symptom understanding and perceived causes at intake in a pediatric FND clinic.

Methods: Participants include youth with FND and their caregivers presenting for initial evaluation in a specialty pediatric FND clinic. Youth and caregivers independently responded to open-ended questions asking what they believed was happening as well as why symptoms were occurring. Responses will be analyzed using qualitative content analysis; a codebook will be developed using inductive and deductive approaches to identify themes related to illness understanding and perceived causes of symptoms. Three coders will independently code responses to ensure interrater reliability. Themes identified, as well as concordance between youth and caregivers, will be examined descriptively.

Results: All data are collected, but not yet analyzed; approximately 50 youth and their caregivers have provided responses. We hypothesize that multiple themes will be identified, including structural or medical, functional, and/or emotional explanations, as well as uncertainty or unknown causes. We hypothesize that concordance between youth and caregiver explanations will vary, with some dyads demonstrating mismatched beliefs regarding symptoms and their causes.

Conclusions: This study aims to evaluate youth and caregivers’ beliefs regarding pediatric FND. Findings have the potential to inform psychoeducation, clinical communication, and intervention by identifying how families conceptualize symptoms at initial presentation and the factors that shape these beliefs. Understanding these perspectives early on may help clinicians and other providers identify barriers to diagnostic understanding (e.g., misconceptions and/or perceived stigma related to FND), and by addressing them, promote stronger patient and caregiver buy-in, ultimately improving the effectiveness of intervention in pediatric FND.

References:
Iskander, J. M., Kreuzman, J., Watson, M., Chesley, G., Zeribi, K., Hopper, A., Powell, T., Simon, L., Fobian, A. D. (2025). Provider perspectives of barriers to delivering care for pediatric Functional Neurological Disorder: A thematic analysis. Pediatric Neurology, 165, 68-73. 
Vassilopoulos, A., Mohammad, S., Dure, L., Kozlowska, K., & Fobian, A. D. (2022). Treatment approaches for Functional Neurological Disorders in children. Pediatric Neurology, 24(2), 77-97.

138    DISTINCT EMOTIONAL PROFILES IN FUNCTIONAL SEIZURES VERSUS FUNCTIONAL MOVEMENT DISORDER: EVIDENCE FROM DIGITAL PHENOTYPING (Phenomenology/Epidemiology, Etiology/Pathophysiology)
Abhijit Das, Lancashire Teaching Foundations NHS Foundation Trust

Background: Functional neurological disorder (FND) is clinically heterogeneous, with emotion and interoception increasingly recognized as key mechanisms. Within the theory of constructed emotion, affect (valence/arousal) arises from interoceptive predictions in the context of allostasis, and discrete emotions are constructed when the brain categorizes affect and sensory data using learned emotion concepts. When such concepts are unavailable or not applied, sensations may instead be labelled as non-emotional bodily or illness states (e.g., “shaking,” “unwell”). Disruptions at multiple points in this “emotion category construction stream” may generate functional neurological and other functional somatic symptoms. It is unknown whether seizure-predominant and movement-predominant FND have distinct daily emotional signatures that might mark different disruption points and guide subtype-tailored interventions.

Methods: We analysed 6,031 longitudinal daily logs from 1,459 users of NeuroLog, a free, anonymous mobile application developed by individuals with lived experience of FND to be used as a research platform (https://neurologtech.com/). We compared self-reported emotional states between participants with predominantly functional seizures (FS; n=164) versus functional movement disorder (FMD; n=290). We examined anxiety-related emotions, emotional shutdown patterns, and emotional versus physical intensity ratios across 3,690 logs with emotion data.

Results: During acute flare events, FS presentations demonstrated a fear-dominant profile, with higher endorsement of Scared (18.4%) and Panic (13.3%) compared with non-seizure flares. FS participants also reported more frequent emotional shutdown in daily reporting (10.8% vs 7.5%) and showed a steeper mood decline surrounding flares (mean pre-flare mood 5.98 to post-flare 3.18 on a 10-point scale). In contrast, FMD presentations showed frustration as the modal emotion during flares (29.5%) and higher rates of Indifferent (13.3%). 

Conclusions: FS and FMD presentations in FND show distinct, real-world emotional signatures. Interpreted via constructed emotion theory, FS may more often involve high-arousal affect categorized as fear, plus shutdown episodes reflecting transient failures of emotion construction or dissociative uncoupling. FMD may instead feature frustration-linked action readiness and/or reduced affective differentiation, suggesting distinct precision-weighting and learning dynamics in predictive processing. Clinically, these findings support subtype-specific interventions: for FS, enhancing interoceptive tolerance, emotional granularity, and reducing catastrophic fear labelling during arousal surges; for FMD, targeting frustration, agency, and flexible recategorization of bodily sensations and movement predictions. Future studies should test whether these profiles predict exacerbations and potential treatment response.

References:
1.https://doi.org/10.1093/brain/awac204

139    EMOTIONAL PHASES PRECEDING FUNCTIONAL SEIZURES: A LONGITUDINAL DIGITAL PHENOTYPING STUDY (Phenomenology/Epidemiology, Etiology/Pathophysiology)
Abhijit Das, Lancashire Teaching Foundations NHS Foundation Trust

Background: Predictive processing and allostatic models propose that functional seizures (FS) emerge when regulating internal state becomes increasingly effortful and bodily/contextual cues are categorised in ways that constrain behavioural options. Within constructed emotion theory, this reflects disruption of the “emotion category construction stream,” where affect is interpreted via learned emotion concepts. Flexible, granular categorisation can channel arousal into adaptive action, whereas rigid, threat weighted patterns may escalate activation of a “seizure scaffold.” Identifying reproducible pre ictal emotional phases could reveal time sensitive intervention points for self management and clinical care.

Methods: Using nine months of longitudinal data from NeuroLog, a free, anonymous mobile application developed by individuals with lived experience of FND to be used as a research platform (https://neurologtech.com/), we examined 309 seizure flare events from 123 participants, analysing self reported emotions in daily logs from the three days preceding each event. We compared pre ictal emotional profiles against baseline periods and within event seizure reports, treating emotion labels as a window onto how participants were constructing affect at each timepoint.

Results: A distinct three phase emotional progression emerged across the 72 hours before seizures. -3 days, calm (8.6%) and anxious (7.4%) states predominated, consistent with relatively regulated affect plus low grade threat monitoring. -2 days, frustration rose to the dominant emotion (8.2%), accompanied by increased physical and emotional intensity, suggesting mobilised but blocked action tendencies. -1 day, frustration peaked (9.8%) with rising discomfort (6.1%), indicating a shift toward more somatically anchored, burdensome states. Despite this worsening emotional pattern, both intensity ratings showed a paradoxical dip one day pre ictally, potentially reflecting partial shutdown or reduced conscious access to interoceptive signals. During seizures, the profile shifted sharply to acute threat: overwhelmed (26.2%), scared (18.4%) and panic (13.3%) emerged prominently, while calm dropped below 5%.

Conclusions: FS appear to be preceded by identifiable emotional phases, evolving from mixed calm–anxious states through escalating frustration and discomfort to acute fear and overwhelm at the event. This trajectory suggests FS are not purely sudden but emerge from evolving predictive and allostatic dynamics that shape affect construction over time. Clinically, the findings imply a 48–72 hour warning window potentially amenable to targeted self management and therapeutic intervention, including early enhancement of emotional granularity and context, mid phase strategies for frustration and goal obstruction, and late phase techniques to prevent threat dominated categorisation.

References:
1. https://doi.org/10.1093/brain/awac204
2. https://doi.org/10.1016/j.seizure.2016.10.029

140    SUCCESSFUL REHABILITATION OF A PATIENT WITH SEVERE FUNCTIONAL NEUROLOGICAL DISORDER (MOTOR) USING CROSS-SPECIALITY WORKING IN A NON-SPECIALIST CENTRE (Treatment)
Tmadher Bawazir, County Durham and Darlington NHS foundation Trust

Introduction: FND is characterised by a variety of neurological symptoms without an identifiable organic cause. Physiotherapy and psychotherapy are primary treatment modalities but access to inpatient rehabilitation services for severely disabling cases are rare in the UK and innovative cross-speciality working is required.

Case presentation: A 31-year-old female with a history of spinal surgery was referred to the stroke clinic with left sided weakness. Previously, she was mobile with a walking frame and independent with self-care. At that point or referral she was using a wheelchair for mobility, and required hoist-assisted transfers and 24 hour care. Clinical assessment showed left upper and lower limb weakness with coachable improvement, resistance to passive movement in the absence of true spasticity and significant overlay of pain and anxiety. A diagnosis of FND (motor) was made. Due to the profound disability of a patient who had previously lived independently, the decision was made to admit to a general inpatient rehabilitation ward, aiming to restore mobility and support independent living. This was based on a single case agreement between hospital based physicians and physiotherapists supported by the regional team who lead on FND care but who have no access to inpatient rehabilitation. The FND team includes psychiatrists, clinical psychologists, specialist physiotherapists and occupational therapists. It sits within mental health services and receives no funding from acute medical services. Inpatient rehabilitation followed a functional approach, using graded activity, distraction techniques, and task-based strategies. Stand aid practice was also included in the routine. The general rehabilitation team was supported a medical physician with a interest in FND and by regular visits from the FND team, including psychology services. As a result of this cross-service collaboration, the patient achieved independent mobility with a controlled gait within 2 months. She demonstrated strong motivation and active engagement throughout rehabilitation. As an outcome, the patient achieved independence in transfers, most activities of daily living, and mobility. She remains independent 1 year later.

Discussion: Patients with FND face significant rehabilitation challenges due to service structures and funding. Multidisciplinary team involvement is essential for restoring functional independence. Historically, FND has fallen between the gaps of acute medical services and outpatient services often led by psychiatry or psychology and therefore patients have had limited access to the appropriate rehabilitation if this requires inpatient support and intensity. In this case, crossservice working agreement, along with the patient’s strong motivation and positive response to strategies facilitated rapid and sustained recovery. It could be replicated in future cases across different organisations.

141    A PILOT STUDY OF PSYCHOLOGICAL AND DAILY FUNCTIONING IN INDIVIDUALS WITH FUNCTIONAL SEIZURES AND CHRONIC PAIN (Phenomenology/Epidemiology)
Alyssa Day-Gorman, West Virginia University

Background: Chronic pain (CP) is reported by 47-70% of individuals with functional seizures (FS). FS and CP are separately linked with difficulties in psychological, social, and physical functioning. However, pain is understudied within FS. Study aims were to 1) characterize pain and psychological functioning within a sample of individuals with FS and CP and 2) explore these factors in relation to daily functional outcomes.

Methods: This pilot study recruited adults with FS (confirmed via vEEG) and CP (>3 months) via emails and flyers at epilepsy-and FND–focused outpatient clinics. Psychological characteristics were measured via self-report and included depression, anxiety, trauma exposure, alexithymia, pain catastrophizing, and resilience. Pain and daily functioning were measured with PROMIS measures (Pain Intensity, Pain Interference, Physical Functioning, and Participation in Social Roles and Activities); scores were converted to T-scores based on US community norms. As available, established cutoffs of self-report measures were used to describe the sample. Correlations and ANOVAs were used to assess the associations between pain and psychological factors with functional outcomes.

Results: The study sample included 19 participants. Mean physical functioning (T=36.6, SD=8.2) was moderately reduced. Average societal participation (T=40.0, SD=5.5) was mildly-to-moderately reduced. On average, participants reported moderate pain intensity (T=65.9, SD=6.4) and pain interference (T=63.8, SD=6.3). Psychological distress was common; 73.7% and 47.4% of participants reported elevated depression and anxiety symptoms, respectively. Pain catastrophizing and alexithymia were both elevated in 32% of participants. Average resilience in this sample was below the 25th normative percentile. All participants reported at least one traumatic event in their lifetime and 78% of participants reported direct exposure to five or more traumatic experiences. Physical functioning was moderately and inversely correlated with greater trauma exposure (r= -0.47; p=0.042), pain intensity (r= -0.48; p=0.040), and pain interference (r= -0.47; p=0.040). Physical functioning was not associated with any other psychological characteristics. Societal participation had moderate inverse relationships with greater trauma exposure (r= -0.57; p=0.011) and depression symptoms (r= -0.55; p=0.014) but was not associated with anxiety, pain catastrophizing, alexithymia, resilience, or pain variables.

Conclusion: People with comorbid FS and CP are at risk for reduced daily functioning. Trauma exposure was common and associated with reduced daily functioning. Pain was related to physical functioning but not societal participation. A larger sample is needed to explore smaller relationships with psychological factors and assess complex relationships among those with comorbid FS and CP. This work may guide clinical conceptualization and targeted interventions to improve functional outcomes.

142    NETWORK-LEVEL FUNCTIONAL CONNECTIVITY CHANGES FOLLOWING TREATMENT IN MOTOR FUNCTIONAL NEUROLOGICAL DISORDER (Etiology/Pathophysiology, Treatment)
Mert Demirel, MD, Department of Neurology, Hacettepe University Faculty of Medicine

Background: Recent studies have focused on imaging characteristics in functional neurological disorder (FND); however, alterations in functional connectivity (FC) following treatment remain insufficiently investigated. This study aimed to evaluate FC changes and neuropsychiatric assessments following standard treatment in patients with motor FND.

Methods: Fourteen participants with functional movement disorder (FMD) (64% women; mean age: 44.6 years) and ten healthy controls were included. Baseline and 30-day magnetic resonance (MR) imaging, including T1-weighted and resting-state functional sequences, were performed, along with two neuropsychiatric assessments (Libet’s clock task and the bead task). Over a one-month period, patients received standard treatment consisting of cognitive behavioral therapy and physiotherapy modalities. Clinical response to treatment was evaluated using the Clinical Global Impression (CGI) scale and the Visual Analog Scale (VAS). Structural and functional analyses were conducted using VolBrain software and the CONN toolbox. Statistical significance was set at p ≤ .05.

Results: Structural analysis demonstrated reduced gray matter volume in the right thalamus (p = .024) and left insular cortex (p = .002), as well as increased volumes in the right supplementary motor cortex (p = .005) and right amygdala (p = .048) in patients with FMD compared with controls. In the patient group, post-treatment resting-state fMRI (n = 9) revealed decreased connectivity between the frontal eye field (FEF) of the dorsal attention network and the anterior cingulate cortex (ACC), a region associated with both the default mode network (DMN) and the salience network (p = .010). Connectivity between the right prefrontal cortex (salience network) and the left occipital cortex increased (p < .001). Connectivity between the right inferior frontal gyrus and the left precentral gyrus also increased (p = .02). Changes in the Libet’s clock paradigm and the bead task were inconclusive following treatment.

Conclusions: The intervention-related changes in functional connectivity demonstrated in this study contribute evidence to the current literature. The flexibility of attentional allocation to visual information appears to represent a key network mechanism underlying disease pathophysiology.

References: 
Hallett, M., et al., Functional neurological disorder: new subtypes and shared
mechanisms. The Lancet Neurology, 2022. 21(6): p. 537-550.
Sasikumar S, Strafella AP. The neuroimaging evidence of brain abnormalities in functional movement disorders. Brain. 2021 Sep 4;144(8):2278-2283. 

143    DISRUPTED SENSE OF AGENCY IN FUNCTIONAL NEUROLOGICAL DISORDER: EVIDENCE FROM THE LIBET CLOCK TASK AND EEG READINESS POTENTIAL (Etiology/Pathophysiology)
Laure von der Weid, University of Fribourg

Introduction: One proposed underlying mechanism of Functional Neurological Disorder (FND) involves disruptions in the sense of agency i.e the ability to feel in control of one's own actions. One popular way to access this construct is the Libet clock task, which requires participants to perform a voluntary action. However, the use of this task showed some conflicting results in FND, with two studies showing abnormalities in patients, when a third  one did not. Furthermore, no study so far has  explored this task with EEG in FND. We set out to test the Libet task in a mixed cohort of FND and explore its neural electrophysiological correlates with EEG.

Methods: 27 patients with FND  and 28 age- and gender-matched healthy controls (HC) took part in the Libet Clock, while their brain activity was recorded with electroencephalogram (EEG) to assess readiness potential (RP). The timing of the voluntary action, i.e. the button press, was recorded while participants had to focus either on the position of their button press (Movement condition) or the position of their initial intention to press (Wanting condition) and subsequently indicate it (M-Judgement and W-Judgement, respectively). 

Results: The FND group showed a higher variability in the reported position of the intention to press (F1,51  = 14.769, p = < .001) [figure 1] during the W_Judgment and were quicker to evaluate their W_Judgment than their M_Judgment  (t = 5.284, P = <0.001), an effect that was not found in healthy controls (t = 1.774, p= .247). The readiness potential (RP) showed an interaction in the amplitude between group and condition (F(1, 53) = 4.982, p = .03, η² = 0.016) with healthy controls showing a bigger amplitude in the Wanting than in the Movement condition and the opposite pattern was present in FND. Additionally, the RP amplitude correlated positively with symptom severity and with participant’s estimation of their button press’ position. 

Conclusion: These findings extend prior evidence of disrupted agency in FND, particularly in the temporal and neural representation of intention. The increased variability and accelerated self-reporting of intention, coupled with a reversed RP pattern, suggest a dissociation between internal volitional cues and motor execution. The EEG interaction provides neurophysiological support for this disruption, further validated by its correlation with clinical severity.

References:
Baek, K., Doñamayor, N., Morris, L. S., Strelchuk, D., Mitchell, S., Mikheenko, Y., ... & Voon, V. (2017). Impaired awareness of motor intention in functional neurological disorder: implications for voluntary and functional movement. Psychological medicine, 47(9), 1624-1636.
Jungilligens, J., Wellmer, J., Schlegel, U., Kessler, H., Axmacher, N., & Popkirov, S. (2020). Impaired emotional and behavioural awareness and control in patients with dissociative seizures. Psychological Medicine, 50(16), 2731-2739.

144    THE IMPACT OF HORMONAL CHANGES ON FUNCTIONAL NEUROLOGICAL DISORDERS: AN INTERNATIONAL ONLINE STUDY (Etiology/Pathophysiology)
Laure von der Weid, University of Fribourg

Introduction: Functional Neurological Disorder (FND) shows an important gender gap with a proportion of women that is three times higher than men. The explanation is traditionally imputed to the highest prevalence of trauma and diagnostic biases but the impact of hormones has been overlooked. It is  unknown if sex hormonal changes have an impact on symptoms. We aimed at exploring potential links between hormonal changes and symptom severity changes in a large sample of women.

Methods: An online questionnaire, available in 6 languages (french, german, english, italian, spanish, portuguese) was used to measure self-observed change of symptoms in relation to hormonal events, in female and gender diverse participants with FND. The hormonal events under study were: The start of intake of hormonal contraception, getting pregnant, the menstrual cycle, menopause and hormonal replacement therapy. Participants were able to indicate on a 5-points scale whether they observed a worsening, improvement or no change in symptoms (motor, functional/dissociative seizures, sensory, cognitive, vertigo). 275 respondents from 13 countries have filled the questionnaire.

Results: 95.17% of participants were women, with 2.1% of men, 1.3% of transgender women, 1% of transgender men and 0.5% of non-binary individuals. The mean age was 39.22 +/-12.9 years. The intake of hormonal contraception and pregnancy both show a worsening of motor, cognitive and vertigo symptoms with no effect on seizures and sensory symptoms. The analysis of the menstrual cycle shows a general worsening of symptoms during the luteal phase and the periods but an improvement during the follicular phase. Menopause is associated with more drastic worsening of symptoms in all categories. The limited number of FND-affected participants undergoing a gender transition does not allow us to draw conclusions on its effects on symptoms. 

Conclusion: It is very likely that hormonal changes are linked to the pathophysiology of FND, which results in symptom fluctuations. More specifically, the menstrual cycle results suggest that oestrogens (which are mostly present in the follicular phase) could participate in an improvement of symptoms. On the opposite side, progesterone which is high in the luteal phase and during pregnancy could play a role in worsening  symptoms. Further prospective research exploring a causal link and more fine grain analysis of symptom changes is needed to better understand how sex hormones could play a role in  the pathophysiology of FND. 

References:
Baizabal‐Carvallo, J. F., & Jankovic, J. (2020). Gender differences in functional movement disorders. Movement disorders clinical practice, 7(2), 182-187.
McLoughlin, C., Hoeritzauer, I., Cabreira, V., Aybek, S., Adams, C., Alty, J., ... & McWhirter, L. (2023). Functional neurological disorder is a feminist issue. Journal of Neurology, Neurosurgery & Psychiatry, 94(10), 855-862.

145    CLASSIFYING FUNCTIONAL SEIZURE SEMIOLOGY WITH A NOVEL THREE-AXIS MODEL (Phenomenology/Epidemiology)
Christoph Dietze, SEIN

Background: Functional seizures’ (FS) semiology shows considerable variability, making reliable description in clinical practice challenging and resulting in the development of various classification schemes. Most existing schemes focus primarily on motor features and levels of responsiveness in a static way. However, FS are dynamic and evolving events, and this dynamic nature should be reflected in their semiologic description and classification. 

Methods: Different seizure categories from previously proposed classification schemes mapped onto a two-dimensional framework with movement/motor activity and responsiveness as the two dimensions provide four consistent semiologic categories. However, this approach also revealed limitations in describing FS with evolving or mixed semiologic features. To address this, we integrated time as an additional dimension, which allows the dynamic nature of FS semiology to be captured in this three-axis model.
 
Results: The proposed novel three-axis model characterizes individual FS semiology along three orthogonal dimensions: (1) motor features, (2) responsiveness, and (3) time. Within the motor–responsiveness plane, four consistent semiologic building blocks emerge: nonmotor with preserved responsiveness, nonmotor with impaired responsiveness, minor motor with variable responsiveness, and hypermotor with impaired responsiveness. The added time axis captures the sequential appearance, evolution, and duration of these features within a single seizure, allowing complex or mixed semiologies to be described as dynamic combinations rather than static categories.

Conclusion: The three-axis model provides a clinically intuitive and flexible framework that integrates both static and dynamic aspects of FS semiology. By incorporating temporal evolution, the model overcomes key limitations of prior classification schemes and offers a standardized approach for describing individual FS events. This framework may enhance diagnostic clarity, and support future validation and refinement of FS classification systems.

References:
Dietze CS, van Gorp TC, Meppelink AM, Jansen FE, LaFrance WC Jr, van der Salm SMA, Zijlmans M. Functional seizures: Scoping review of classifications and proposal of novel three-axis model. Epilepsy Behav. 2025 Oct;171:110484. doi: 10.1016/j.yebeh.2025.110484. Epub 2025 May 26. PMID: 40424815.
Szabó L, Siegler Z, Zubek L, Liptai Z, Körhegyi I, Bánsági B, Fogarasi A. A detailed semiologic analysis of childhood psychogenic nonepileptic seizures. Epilepsia. 2012 Mar;53(3):565-70. doi: 10.1111/j.1528-1167.2012.03404.x. Epub 2012 Feb 14. PMID: 22332748.

146    INTEGRATING NEUROIMAGING, ELECTROENCEPHALOGRAPHY, AND SURGICAL INTERVENTION: HOW MULTIMODAL EVIDENCE ILLUMINATES ABNORMAL MOTOR CONTROL IN FUNCTIONAL NEUROLOGICAL DISORDER (Phenomenology/Epidemiology, Treatment)
Ellinor Eckhouse, Johns Hopkins All Children's Hospital

Background: Functional Neurological Disorder (FND), particularly Functiognal Motor Disorder (FMD), is increasingly characterized as a disorder of abnormal network communication rather than structural pathology. Prior work highlights disrupted integration between limbic and motor systems, reduced cortical inhibition, and altered connectivity within the supplementary motor area (SMA) and primary motor cortex (M1). This study synthesizes multimodal evidence to clarify how network dysfunction contributes to impaired motor control in FND.

Methods: Thirty peer-reviewed studies using functional MRI (fMRI), resting-state fMRI, electroencephalography (EEG), intraoperative stimulation, and computational modeling were systematically reviewed. Imaging metrics included BOLD activation patterns and resting-state connectivity. EEG measures included beta-band desynchronization, Bereitschaftspotential timing, and cortical excitability indices. Intraoperative findings and graph-theoretical models of network efficiency were incorporated. Reported statistical approaches included two-sample t-tests, z-score normalization, permutation-based correction, and machine-learning classification of functional connectivity patterns.

Results: Across modalities, three consistent abnormalities emerged in FND: (1) network dysfunction, including reduced salience–sensorimotor coupling and increased limbic hyperconnectivity; (2) altered cortical excitability, reflected by diminished beta-band ERD, delayed Bereitschaftspotential, and reduced intracortical inhibition; and (3) SMA–M1 hypoactivation with excessive amygdala and insula influence during voluntary movement. Computational studies showed decreased network efficiency and disrupted hub centrality within SMA, insula, and the temporoparietal junction. Machine-learning models achieved >80% accuracy distinguishing FND patients from controls. Intraoperative recordings revealed intact structural pathways but abnormal excitability, supporting the concept of a reversible “functional lesion.”

Conclusions: Multimodal evidence supports FND as a dynamic disorder of network connectivity involving impaired communication between motor and limbic circuits. The convergence of fMRI, EEG, and intraoperative data provides objective biomarkers of motor dysfunction and reinforces a rule-in diagnostic framework. These findings highlight SMA–amygdala circuitry as a key mechanistic pathway and suggest promising targets for neuromodulation and personalized rehabilitation in FND.

References:
Espay, A. J., et al. (2024). Clinical Neurophysiology of Functional Motor Disorders.
Voon, V., et al. (2023). Network Abnormalities in Functional Movement Disorders.

147    CO-OCCURRING FUNCTIONAL NEUROLOGICAL DISORDER AND POSTURAL ORTHOSTATIC TACHYCARDIA SYNDROME IN A PEDIATRIC CLINICAL SAMPLE (Phenomenology/Epidemiology)
Lindsey Elliott, PhD, University of Texas at Austin

Background: Youth with functional neurological disorder (FND) and postural orthostatic tachycardia syndrome (POTS) experience similar challenges including functional impairment, stigma, and limited access to evidence-based treatment (Boris, 2018). Further, these mind-body conditions have several shared co-morbidities and underlying mechanisms which may explain the overlap in conditions (Ducroizet et al., 2023). Errors in predictive coding, impairments in agency, and central sensitization are thought to be relevant to both disorders. However, there has been little research related to prevalence of comorbidity. The current study explores the prevalence of these disorders and semiology within a pediatric sample.

Methods: Twenty-five pediatric patients with co-occurring FND and POTS were identified from the FND Clinic at Dell Children’s Medical Center. A chart review was conducted to examine which is the preceding diagnosis and characterize FND semiology within this population. 

Results: Out of 395 patients being followed by the FND Clinic at Dell Children’s Medical Center, 25 of them (6.3%) had co-occurring diagnoses of FND and POTS. Most (68%) had a POTS diagnosis that preceded FND; 20% were diagnosed with FND first and 12% received both diagnoses during the same hospital admission. The most prevalent FND symptoms were functional seizures (56%), weakness or paralysis (52%), and functional syncope (44%). Additionally, abnormal movement (24%), sensory symptoms (20%), and speech symptoms (8%) were reported. When characterizing the ‘primary’ presentation, 40% demonstrated primary presentation of functional seizures, 36% with weakness or paralysis, and 24% with functional syncope. However, most patients (68%) reported multiple types of symptoms, with 36% endorsing two types and 32% endorsing three or more.

Conclusions: Patients with POTS and FND most commonly presented with functional seizures, weakness, and syncope, with most endorsing more than one type. This may present challenges in teasing apart FND and POTS symptoms and identifying treatment targets. However, psychological treatment for both diagnoses overlap in many ways, including clear explanations of pathophysiology, increasing function, stress management, and improvement in health habits. Therefore, shared conceptualization and treatment goals for patients with co-occurring conditions is critical for reducing functional impairment. In this sample, POTS diagnoses more commonly preceded FND diagnoses; therefore, it is important to better understand the role of POTS symptoms as a risk factor for FND or how symptom and mechanistic overlap may complicate diagnostic processes. 

References:
Boris, J. R. (2018). Postural orthostatic tachycardia syndrome in children and adolescents. Autonomic Neuroscience, 215, 97-101. 
Ducroizet et al., (2023). Functional neurological disorder: clinical manifestations and comorbidities; an online survey. Journal of Clinical Neuroscience, 110, 116-125.

148    ADOLESCENT-ONSET FUNCTIONAL MOTOR DISORDERS: CLINICAL FEATURES AND DIAGNOSTIC PATHWAYS IN A LARGE MULTICENTER COHORT (Phenomenology/Epidemiology)
Tommaso Ercoli, MD, PhD, AOU Sassari

Background: Functional Motor Disorders (FMDs) represent a frequent yet challenging condition in pediatric neurology, particularly during adolescence, when symptoms often overlap with neurological and psychiatric disorders [1]. However, clinical data specifically focusing on adolescent-onset FMD remain limited. This study aimed to characterize adolescent-onset FMD and to explore the distribution of motor phenotypes and their associations with clinical variables.

Methods: We conducted an observational study using data from the Italian Registry of Functional Motor Disorders, including patients with a clinically definite diagnosis of FMD consecutively evaluated at 25 tertiary movement disorders centers across Italy [2]. Patients were stratified according to age at symptom onset, and adolescents (10–19 years) were compared with adult-onset cases.

Results: Among 847 patients with FMD, 93 (10.9%) had adolescent-onset symptoms. The distribution of motor phenotypes was similar between adolescent- and adult-onset groups, with the exception of parkinsonism, which was observed only in adults. Adolescents showed a longer disease duration and reported a higher number of medical consultations before receiving a diagnosis. Functional seizures were more frequent in adolescents, whereas insomnia, fatigue, and antipsychotic use were less common compared with adults. In multivariable analysis, adolescent-onset FMD was independently associated with a higher number of medical consultations and with the presence of functional seizures. Within the adolescent group, pain was significantly associated with combined motor phenotypes.

Conclusions: Adolescent-onset FMD accounts for approximately one-tenth of patients evaluated in tertiary movement disorders centers and shares many clinical features with adult-onset cases. However, adolescents appear to follow a more complex diagnostic pathway and more frequently present with functional seizures. These findings support the importance of early recognition of FMD in adolescents to facilitate timely diagnosis and management.

References:
[1] Harris SR. Psychogenic movement disorders in children and adolescents: an update. Eur J Pediatr. 2019
[2] Tinazzi M, Morgante F, Marcuzzo E, et al. Clinical Correlates of Functional Motor Disorders: An Italian Multicenter Study. Mov Disord Clin Pract. 2020

149    OCCUPATIONAL BACKGROUND AND FUNCTIONAL MOTOR DISORDERS IN WORKING-AGE INDIVIDUALS (Phenomenology/Epidemiology)
Tommaso Ercoli, MD, PhD, AOU Sassari

Background: The role of occupational background in functional motor disorders (FMDs) remains poorly defined [1]. In particular, controlled data using standardized occupational classifications and information on education level are limited. The aim of this study is to assess the association between occupational background and FMDs in working-age individuals and to examine the role of education level in this relationship.

Methods: We conducted a case–control study using data from the Italian Registry of Functional Motor Disorders [2]. Patients aged 30–65 years with available occupational information were included and compared with healthy controls frequency-matched for age and sex. Occupations were classified according to the 2021 Italian National Institute of Statistics classification. Education level was expressed as years of schooling. Multivariable logistic regression models were used to assess the association between occupational categories and FMD status after adjustment for age, sex, and years of schooling.

Results: A total of 479 patients with FMDs and 252 healthy controls were included. Patients had fewer years of schooling than controls. Occupational distribution differed between groups. Qualified professions in commercial activities and services, artisans and skilled workers, and machine operators were more frequent among FMD patients. In multivariable analysis, these occupational categories and years of schooling were independently associated with FMD status. Healthcare professions were not associated with FMDs.

Conclusions: Occupational background and education level were independently associated with FMDs in working-age individuals. These findings support the view that occupational factors may be relevant to symptom expression within the biopsychosocial model of FMDs, without implying a causal relationship.

References:
[1] Stone J, Warlow C, Deary I, Sharpe M. Predisposing Risk Factors for Functional Limb Weakness: A Case-Control Study. J Neuropsychiatry Clin Neurosci. 2020
[2] Tinazzi M, Morgante F, Marcuzzo E, et al. Clinical Correlates of Functional Motor Disorders: An Italian Multicenter Study. Mov Disord Clin Pract. 2020

150    ASSESSMENT OF EXPECTATIONS OF PATIENTS WITH FUNCTIONAL NEUROLOGICAL DISORDER REGARDING A THERAPEUTIC EDUCATION GROUP (Treatment)
Hadi Faiz, Hôpital Avicenne (AP-HP)

Background: Therapeutic patient education (TPE) aims to help patients acquire knowledge and skills enabling them to become active participants in their care. In Functional Neurological Disorder (FND), understanding the underlying mechanisms and restoring meaning to symptoms is a key step in recovery. Previous studies have highlighted the benefits of educational interventions for FND patients, including improved understanding and acceptance of the diagnosis, as well as increased hope and belief in recovery, even in patients with long-standing and severe symptoms. The present study aimed to assess patients’ expectations regarding a therapeutic education programme in order to inform the development of a tailored intervention within a specialised FND unit in Bobigny, France.

Methods:
A questionnaire was distributed to patients evaluated in our specialised FND unit, as well as to a broader population via the national patient association Cap TNF and healthcare professionals and specialised FND centres across France. The survey was conducted between September 2024 and January 2026. It assessed participants’ age and gender, disorder-related characteristics (symptoms and duration of illness), their experience of the diagnostic process, their perception of the cause of the disorder, their views on current management, their informational needs regarding the condition, the topics they would like to see addressed in the programme, and their opinions on practical aspects (number of sessions, frequency, group size, in-person versus remote format, travel time, and involvement of relatives).

Results: Ninety-three patients responded to the questionnaire; 78.4% were women, and 28.2% reported symptom duration longer than two years. The topics patients most wished to be addressed in the programme were symptom management (46.7%), links between FND and other physical symptoms (43.5%), disease course and prognosis (42.4%), scientific explanations of FND (39.1%), and acceptance of the disorder (38%).

Conclusion: Patients expressed a strong need for better understanding and acceptance of FND, as well as access to practical tools to help manage symptoms in daily life. These findings highlight the importance of developing patient-centred therapeutic education programmes tailored to patients’ expectations.

Reference:
Cope SR, Smith JG, Edwards MJ, Holt K, Agrawal N. Enhancing the communication of functional neurological disorder diagnosis: a multidisciplinary education session. Eur JNeurol. janv 2021;28(1):40‑7.

151    PERSONALISING MULTIDISCIPLINARY INPATIENT REHABILITATION FOR FUNCTIONAL NEUROLOGICAL DISORDER IN AN INDIVIDUAL WITH CO-OCCURRING LEARNING DISABILITY: A CASE STUDY (Treatment)
Marta Ferri, University College London NHS Trust

Background: Individuals with learning disability (LD) are increasingly presenting to specialist Functional Neurological Disorder (FND) services yet remain underrepresented in research and face barriers to effective rehabilitation. Challenges include adapting education, promoting engagement, and supporting self-management. This case study describes a personalised multidisciplinary inpatient rehabilitation approach for an individual with LD and FND at the National Hospital for Neurology and Neurosurgery (UCLH), London.

Case presentation: D. is a 54-year-old man with mild LD who developed FND in 2016 following traumatic bereavement. His symptoms included unilateral functional leg weakness and functional seizures, leading him to stop work as a shop assistant. He was admitted to the inpatient FND rehabilitation programme in January 2026. D.’s LD affected literacy, numeracy, and information processing. Rehabilitation goals focused on understanding seizure triggers and developing preventative strategies. A comprehensive assessment addressed both FND formulation and learning needs, enabling therapy and education to be individually tailored. Existing easy-read resources were insufficient, so clinicians used a generative artificial intelligence (AI) tool to co-create a personalised, easy-read workbook, which was clinically reviewed for accuracy and accessibility. This supported education on FND, fatigue, and functional seizures. Interventions across disciplines emphasised visual, practical, and experiential learning. Grounding and distraction techniques (e.g. box breathing, category naming), supported by videos and a laminated key-ring prompt, improved understanding of symptom mechanisms and links with anxiety. Supervised graded exposure to fatigue and seizure-triggering activities facilitated application of strategies. Family involvement was integral, with step-by-step guidance and face-to-face education to support seizure management and goal progression. By discharge, D. demonstrated improved recognition of early seizure warning signs, increased independent use of grounding strategies and increase confidence around his physical and cognitive abilities.

Discussion: This case demonstrates that individuals with FND and co-occurring LD can engage effectively in inpatient rehabilitation when learning needs are identified early and interventions are adapted. Personalised education, paced delivery, experiential learning, and family involvement supported understanding, emotional regulation, and self-management. The use of AI to develop accessible, individualised resources offers a practical and scalable solution where standard materials are insufficient, highlighting the importance of inclusive and flexible FND service design.

References:
NHS England. Inclusive digital healthcare: a framework for NHS action on digital inclusion. 
M. Edwards et al., FND clinical frameworks (Lancet Neurology / Practical Neurology)

152    DISCRIMINATING FUNCTIONAL SPEECH DISORDER FROM NONFLUENT PRIMARY PROGRESSIVE APHASIA USING A MACHINE LEARNING APPROACH ON CONNECTED SPEECH (Phenomenology/Epidemiology)
Jennifer Freeburn, MS, CCC-SLP, Massachusetts General Hospital

Background: The speech variant of Functional Neurological Disorder (FND-speech) and nonfluent variant primary progressive aphasia (nfvPPA) share overlapping clinical characteristics complicating differential diagnosis. We aim to use computational speech analysis to develop a machine learning classifier to distinguish FND-speech from nfvPPA based on brief connected speech samples, and to identify disease-specific linguistic signatures as a potential adjunctive digital biomarker.

Methods: We analyzed speech samples from 189 participants: 54 nfvPPA patients (69.2±9.0 years), 30 FND-speech patients (45.8±14.2 years), and their respective age-matched controls (29 for nfvPPA; 76 for FND-speech). Speech was elicited and recorded via two commonly used picture description tasks during clinical assessment. A validated automated pipeline extracted linguistic and acoustic features. To control for age and task confounds, we screened features for significant diagnosis-by-group interactions, ensuring differences between patient groups exceeded those between controls. Features passing this filter were z-scored within each cohort relative to its controls. An XGBoost classifier was developed using forward feature selection within nested cross-validation. SHapley Additive exPlanations (SHAP) analysis interpreted feature contributions.

Results: Interaction screening identified a set of linguistically and acoustically informative features. Forward selection yielded a final model with five features: Light Verb to all Verb Ratio, Mean Pause Duration, Gerund to all Verb Ratio, total speech duration, and Noun to Verb Ratio. The model achieved a mean cross-validated AUC of 0.892 for discriminating nfvPPA from FND-speech. SHAP analysis indicated that nfvPPA exhibited longer inter-word pause durations, employed fewer light verbs, produced a higher proportion of nouns, and used more verbs in gerund form compared to FND-speech.

Conclusions: Our findings demonstrate that a nuanced computational analysis of brief connected speech samples can accurately differentiate between FND and nfvPPA. The model's robust performance highlights computational speech analysis as a viable digital biomarker for this critical differential diagnosis. Given the relative ease of collecting connected speech samples clinically, computational analysis of such samples holds high potential to become a scalable adjunctive tool to reduce diagnostic uncertainty and guide targeted interventions.

References: 
Freeburn JL, Finkelstein SA, Westlin C, Perez DL, Rezaii N. Using Digital Speech Markers to Classify Functional Speech Disorder: A Proof‐of‐Concept Pilot Study. Movement Disorders. 2025;40(8):1704-1708. doi:10.1002/mds.30256
Rezaii N, Ren B, Quimby M, Hochberg D, Dickerson BC. Less is more in language production: an information-theoretic analysis of agrammatism in primary progressive aphasia. Brain Commun. 2023;5(3):fcad136. doi:10.1093/braincomms/fcad136

153    MENTAL HEALTH COMORBIDITIES IN CHILDREN WITH EPILEPSY AT ALDER HEY CHILDREN’S HOSPITAL: ASSESSMENT AND FOLLOW-UP (Phenomenology/Epidemiology)
Manorama Gadde, Alder Hey children's Hospital

Background: Children with epilepsy are at increased risk of mental health (MH) comorbidities, including anxiety, depression and neurodevelopmental disorders like ADHD and autism. These could potentially negatively impact their epilepsy treatment and follow up, leading to poorer outcomes. Early identification and structured follow-up are essential to optimize outcomes, yet MH assessment in paediatric epilepsy services is often inconsistent.

Aim: To evaluate the proportion of children with epilepsy who receive MH assessment, the types of MH concerns identified, and subsequent follow-up or referral pathways within the Alder Hey paediatric epilepsy service. 

Methods:
• Retrospective audit of randomly selected children with epilepsy.
• Data collected: demographics, epilepsy type, treatment, neurodevelopmental status, NES diagnosis, MH assessment completion, identified concerns, CAMHS referrals, and follow-up outcomes.

Key Findings:
• Young cohort (mean 10.9 years), 55% female, predominantly British origin.
• Focal epilepsy most common (55%), largely EEG-confirmed.
• Over one-third (35%) on lamotrigine-containing regimens.
• High neurodevelopmental burden:
   o 26% confirmed autism (+16% under assessment)
   o ADHD present or under assessment in 10%
• Mental health assessment completed in only 39%.
   o Majority of those assessed required referral.
   o Anxiety was the most frequently identified concern.
   o Referrals primarily clinician-led.
• 23% diagnosed with Non-Epileptic Seizures, typically mid-adolescence.
   o Ongoing neurodevelopmental and anxiety comorbidity within this subgroup

Conclusion: While the epilepsy service demonstrates strong continuity of care, MH assessment and timely referral remain inconsistent. Implementation of routine MH screening and structured follow-up could enhance early identification and management of comorbidities.

Recommendations:
1.Introduce standard MH screening protocol for all children with epilepsy.
2.Empower epilepsy nurses to perform MH assessments and initiate referrals where appropriate.
3.Track MH assessment completion and outcomes as part of regular service audit.

154    UNDERSTANDING SCHOOL REFUSAL AND FUNCTIONAL IMPAIRMENT IN PEDIATRIC FND: PILOT OUTCOMES FROM A MULTIDISCIPLINARY OUTPATIENT PROGRAM (Treatment)
Julie Gardner, Med, Kennedy Krieger Institute

Background: Current research in FND interventions highlights persistent gaps in guidance and resources for supporting students, as well as inconsistent communication among healthcare providers, parents, and school personnel. This complicates return-to-school planning following medical or rehabilitative interventions. The academic and social burden of FND is evident in multiple studies (Janssens et al, 2011). Chronic impairments and FND can negatively impact ADL performance, social interaction, school attendance, sleep, and family life.  
There is a call for multidisciplinary programs to address reduced daily participation for those with FND. Most published multidisciplinary protocols are in adult populations (Petrochilos, et al., 2020). To date, there has been a lack of outcome tools addressing the reasons for school refusal in this population. This poster will describe the factors that impact school attendance for children experiencing FND. The outcomes of an intensive interdisciplinary outpatient treatment program in a cohort of consecutively enrolled patients will be reported. 

Methods: Patients were evaluated at intake and discharge, via standardized questionnaire (e.g., medical history, family history, current level of functioning) and standardized measures including the School Refusal Assessment (SRA), Functional Disability Inventory (FDI) and Canadian Occupational Performance Measure. Patients attended interdisciplinary therapy OT, PT, Behavior Psychology, Neuropsychology, Educational services with medical oversight 5 days a week for 4 weeks.  

Conclusions: This pilot evidence highlights the importance of implementing coordinated, biopsychosocially informed strategies, particularly during critical transitions such as returning to school following intensive rehabilitation programs. Lack of trialed protocols in pediatrics leaves therapists adapting adult protocols. Given the impact on school attendance, this poster is a first step to outline a strategy to address the unique needs of youth with FND. 

References:  
Janssens, K. A., Oldehinkel, A. J., Dijkstra, J. K., Veenstra, R., & Rosmalen, J. G. (2011). School absenteeism as a perpetuating factor of functional somatic symptoms in adolescents: the TRAILS study. The Journal of Pediatrics, 159(6), 988–93. e1. https://doi.org/10.1016/j.jpeds.2011.06.008  
Petrochilos, P., Elmalem, M. S., Patel, D., Louissaint, H., Hayward, K., Ranu, J., & Selai, C. (2020). Outcomes of a 5-week individualised MDT outpatient (day-patient) treatment programme for functional neurological symptom disorder (FNSD). Journal of Neurology, 267(9), 2655–2666. https://doi.org/10.1007/s00415-020-09874-5

155    OUTCOMES OF PATIENTS WITH PSYCHOGENIC NONEPILEPTIC SEIZURES AFTER NEUROBEHAVIORAL THERAPY (Treatment)
Robin Garrett, University of Arizona College of Medicine, Phoenix

Background: Compared to patients with epilepsy, patients with psychogenic nonepileptic seizures (PNES) experience a higher burden of comorbid psychiatric disorders and are not effectively treated with the same medical therapies used for epileptic seizures (Yerdelen and Altintas, 2016). This study aims to describe the treatment efficacy and patient-centered outcomes of manualized neurobehavioral therapy (NBT) for patients with F/DS.

Methods: We conducted a retrospective chart review of 50 patients who received NBT for PNES to determine self-reported non-epileptic seizure (NES) frequency before and after treatment. Of these patients, 31 received manualized NBT following a standardized regimen that included administration of the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Quality of Life (QOL), and Quality of Life in Epilepsy (QOLIE) questionnaires before and after treatment. Changes in symptom comorbidities (social functioning, depression, anxiety, and sleep quality) were assessed through a self-reported treatment outcome response grid completed during the patient’s last visit.

Results: The frequency of NES events decreased significantly from baseline to post-treatment in both the  full sample (p < 0.01) and those who received manualized CBT (p < 0.01). Additionally, among 15 patients for whom complete BDI, BAI, and QOLIE data were available, there was significant improvement in measures of BDI (p < 0.01), BAI (p = 0.01), QOL (p < 0.01), and the QOLIE seizure worry subscale (p < 0.01). Psychiatric comorbidities affected a high percentage of patients in the study sample, with the most common diagnoses being anxiety (94.0%), depression (62.0%), and post-traumatic stress disorder (32.0%). Among patients who completed the treatment outcome response grid and had depression, 90.0% reported improvement in depression, while 73.3% of those with anxiety reported improvement in anxiety. Among those who experienced impaired social functioning as a comorbid symptom, 89.5% reported improved functioning upon completion of NBT.

Conclusions: The results of this study suggest that manualized NBT effectively reduces seizure frequency and improves quality of life and symptom comorbidities for patients with PNES. Psychiatric comorbidities, especially anxiety and depression, were highly prevalent in the study sample, demonstrating the importance of therapies that specifically target psychiatric symptoms. This study supports the value of psychotherapy as a primary or adjunct treatment modality for patients with PNES and indicates the need for additional studies comparing psychotherapy models in this population.

References:
1.Yerdelen D, Altintas E. Health related quality of life in patients admitted for video-electroencephalography monitoring diagnosed with epilepsy or psychogenic non-epileptic seizures. Neurosciences Journal. 2016 Jan 1;21(1):47-51.

156    FUNCTIONAL TIC-LIKE BEHAVIORS: A SYSTEMATIC NARRATIVE REVIEW (Phenomenology/Epidemiology)
Joseph Gary, MD, Johns Hopkins Hospital / Johns Hopkins SOM

Background: Functional tic-like behavior (FTLB) has emerged as a prominent clinical presentation within functional neurological disorder (FND), particularly during the Covid-19 pandemic. Although FTLB shares phenomenological overlap with primary tic disorders (PTD), evidence suggests meaningful differences in demographics, semiology, psychiatric comorbidity, disease course, and treatment response. The rapid rise of FTLB, coupled with diagnostic confusion and stigma, highlights the need for an integrated synthesis of the expanding literature.

Methods: We conducted a systematic narrative review following PRISMA guidelines. PubMed and PsycINFO were searched on November 11, 2024, using terms related to functional tics, tic disorders, and COVID-19. Inclusion criteria were English-language studies reporting clinical data on FTLB with sample sizes of 10 or greater. Case reports, non-human studies, and commentaries were excluded. Thirty-four studies were included. Data were extracted on demographics, sociocontextual factors, semiology, phenomenology, psychiatric and neurodevelopmental comorbidity, disease course, and treatment outcomes, and synthesized qualitatively by theme and study site.

Results: FTLB predominantly affects adolescents and young adults and shows a strong female predominance, with disproportionately high representation of gender-diverse individuals. Compared with PTD, onset is typically abrupt, and FTLB are characterized by complex motor and vocal behaviors, frequent coprophenomena, self-injury, context dependence, and greater impairment. A large percentage have comorbid PTD and FTLB. Psychiatric comorbidity is highly prevalent, particularly anxiety, depression, and other FND, while rates of OCD, ADHD, and family history of tics are generally lower than in PTD. Exposure to tic-related social media content and other forms of social modeling is common and associated with greater symptom severity and persistence. Prognosis is heterogeneous, and worse outcomes are associated with presence of comorbid FND. Pharmacologic treatments show limited benefit, whereas multimodal, non-pharmacologic interventions emphasizing psychoeducation and therapy are associated with improvement in most cohorts.

Conclusions: FTLB represents a distinct FND phenotype rather than an atypical form of primary tic disorder. The literature supports conceptualizing FTLB within contemporary frameworks that emphasize psychosocial stress, affective dysregulation, identity formation, and social modeling, particularly in digitally mediated environments. Younger age, early diagnostic clarity, and FND-informed, multimodal treatment appear to improve outcomes. Future research should focus on longitudinal trajectories, mechanisms of social influence, and evaluation of targeted interventions.

157    DEVELOPMENT OF EDUCATIONAL RESOURCES FOR DIFFERENT AUDIENCES: WORK BY THE FNDS PSYCHOLOGICAL TREATMENT SIG EDUCATION SUBCOMMITTEE (Treatment)
Gaston Baslet, MD, Bruce W. Carter Department of Veterans Affairs Miami

Background: Despite recent advances in the field of Functional Neurological Disorder (FND), the disorder remains widely misunderstood and often stigmatized, even by medical professionals (1). This misunderstanding is perpetuated by clinicians' lack of knowledge and training, biased views and assumptions about the diagnosis, and limited time to seek out additional resources. These barriers contribute to uncertainty about how to discuss the diagnosis, introduce therapeutic options, and facilitate prompt treatment referrals, ultimately impacting patient care (2). Improving education for healthcare professionals, patients, and their families about the role of psychological therapies in FND through easily accessible materials can help expedite referrals and promote engagement in the recommended treatment. 

Methods: The first initiative of the Education and Dissemination subcommittee under the Psychological Treatment SIG at FNDS was to develop educational materials aimed at enhancing understanding of FND and its treatment with psychotherapy, where indicated. After a series of consensus meetings, the subcommittee decided to create short, accessible pamphlets tailored to educate different audiences involved in the process of care in FND: patients and their families, mental health professionals, and non-mental healthcare professionals. To achieve this, the subcommittee members divided into three audience-focused subgroups. We collaborated with a representative with lived experience for the patient and family-focused pamphlet and sought feedback from non-mental healthcare professionals for the pamphlet directed at their peers.

Results: We produced three pamphlets aimed at reaching three distinct audiences. Each subgroup adhered to the subcommittee's guidelines, which included a maximum length of two pages, language tailored to the target audience's background, links to additional resources, and the use of bullet points to synthesize information. The initial drafts were harmonized to ensure consistency in format and content. Additional feedback is being solicited and incorporated from other leadership groups within FNDS, with the goal of obtaining final approval for these pamphlets as organization-endorsed documents.

Conclusion: Organization-endorsed, accessible materials tailored for specific target audiences can be created to enhance education on the role of psychological treatment in FND. To further broaden access, translation into different languages and the development of animated versions are being considered. These materials may help legitimize and destigmatize the FND diagnosis, thereby expediting access to and acceptance of psychological interventions. 

References:
1.MacDuffie, K. E., et al. (2020). CNS Spectr: 1-6.
2.Asadi-Pooya, A. A., et al. (2023). Epilepsy & Behavior 145: 109292.

158    A NATIONAL ASSESSMENT OF PNES AND MEDICAL HYPNOSIS INSTRUCTION IN EPILEPSY FELLOWSHIPS (Treatment)
Luciana Giambarberi, MD, Stanford University School of Medicine

Background: Psychogenic nonepileptic seizures (PNES) are commonly encountered in epilepsy centers, yet the degree of formal education in their diagnosis and management within epilepsy fellowship programs remains unclear. Medical hypnosis is a useful tool to support diagnostic clarification in PNES. However, its presence in epilepsy training has not been evaluated previously. Identifying existing training practices and unmet educational needs may help guide the development of targeted instructional materials for future clinicians.

Objectives: To assess the extent to which ACGME-accredited epilepsy fellowship programs in the United States provide training in PNES and in medical hypnosis, and to evaluate program directors’ interest in receiving supplemental training videos in these areas.
Methods: We developed a brief, anonymous web-based survey distributed to program directors of all ACGME-accredited epilepsy fellowship programs in the United States. Survey items assess whether programs currently offer training in PNES and in brief medical hypnosis.  Those who do not currently offer training are asked whether they would be interested in receiving structured on-demand video-based educational materials. Quantitative data will be summarized with descriptive statistics.

Results: Data collection is planned/ongoing.

Conclusion: This national survey will characterize PNES and medical hypnosis training across U.S. epilepsy fellowship programs and may inform the creation of standardized educational resources to address identified gaps.

159    RHYTHMIC AUDITORY STIMULATION (RAS) FOR FUNCTIONAL GAIT DISORDER (FGD): A CASE SERIES (Treatment)
Caitlin Hebb, MT-BC, NMT Fellow, MedRhythms Therapy

Background: Rhythmic auditory stimulation (RAS) is a technique of Neurologic Music Therapy that uses external rhythm along with the mechanism of auditory-motor entrainment to facilitate intrinsically rhythmic movements such as walking. RAS may also be a potential therapy for functional gait disorders (FGD), as it embodies many strategies used to rehabilitate functional neurological disorder (FND) at large, including shifting of attention, alteration of motor tasks, strengthening of self-agency, and emotion regulation. 
 
Case Description: Ten community-dwelling adult participants with chronic FGD.  

Intervention: An outpatient course of RAS was adapted to FGD and co-delivered by physical therapists and neurologic music therapists (NMTs). Standardized neurological outcome assessment of functional mobility, walking speed and capacity, and dynamic balance were collected pre- and post-intervention and at three-month follow-up. Baseline demographic and patient-reported measures were also collected. Following the intervention, participants qualitatively described their experience with RAS. 

Outcomes: Adapting and applying RAS to the FGD population proved feasible and acceptable. Improvements were observed in all participants across a majority of measures.
Discussion: The incorporation of RAS into rehabilitation therapies in FGD has the potential to broaden and further facilitate treatment goals. A variety of proposed mechanisms may account for the potential benefit of RAS for FGD. 

References: 
Hebb, C., Raynor, G., Perez, D. L., Nappi-Kaehler, J., & Polich, G. (2022). The use of rhythmic auditory stimulation for functional gait disorder: A case report. NeuroRehabilitation, 50(2). https://doi.org/10.3233/NRE-228005
Thaut, C., & Rice, R. (2014). Rhythmic Auditory Stimulation (RAS). In M. Thaut & V. Hoemberg (Eds.), Handbook of Neurologic Music Therapy (pp. 94–105). Oxford.

160    PHENOTYPIC CHANGE IN FUNCTIONAL NEUROLOGICAL DISORDER FOLLOWING DISSOCIATIVE AMNESIA: A CASE REPORT (Phenomenology/Epidemiology)
Tanja Goltnik, University Medical Centre Ljubljana

Background: Dissociative amnesia is a heterogeneous condition characterized by profound retrograde memory impairment in otherwise alert individuals, occurring in the absence of structural brain pathology. It may represent a distinct diagnostic entity or a negative dissociative symptom within another disorder, primarily affecting episodic-autobiographical memory. Onset is often acute and temporally associated with severe psychological trauma, but may also follow minor stressors, typically in the context of prior adversities or chronic psychological stress. A multifactorial etiology involving dissociative processes and altered cortico-limbic connectivity is proposed. Irrespective of psychiatric comorbidity, dissociative amnesia is associated with substantial functional impairment (Staniloiu & Markowitsch, 2014). Persistent dissociative amnesia in functional neurological disorder (FND) is rarely reported, and its interaction with co-occurring functional symptoms remains poorly characterized.

Case presentation: We report a case of persistent dissociative amnesia in a 20-year-old female student with FND, comorbid autism spectrum disorder and mood disorder. The patient developed initially paroxysmal and later persistent functional lower limb weakness. Following physiotherapy, she regained independent ambulation but subsequently developed short episodes of whole-body paralysis and a functional speech disorder, during which she communicated via electronic devices or whispering. One year after the initial presentation, following an episode of functional paralysis triggered by her first night in a student dormitory, the patient developed profound dissociative amnesia, resulting in a complete loss of episodic-autobiographical memory preceding the event. She no longer recognized herself in the mirror and lacked memory of key personal autobiographical information, including the identities of close family members and her partner. Anterograde memory and procedural skills were preserved, but inconsistent impairments were noted in semantic memory (e.g., failing to recognize some common objects like coffee or phone). The previously impaired speech function normalised abruptly. Despite no recollection of her diagnosis or previous symptoms, episodes of paralysis recurred, requiring the diagnosis to be explained anew. Three months later, amnesia persists. The patient is receiving ongoing psychological treatment. 

Discussion: 
This case illustrates the clinical complexity of FND, with selective improvement and persistence of functional symptoms occurring independently of conscious recollection. From a predictive processing perspective, dissociative amnesia may reflect a reorganization of self-representation, accompanied by a change in the pattern of functional symptoms. This case highlights that functional symptoms can appear and evolve independently of explicit memory.

Reference:
Staniloiu, A., & Markowitsch, H. J. (2014). Dissociative amnesia. The Lancet Psychiatry, 1(3), 2

161    EXPANDING ACCESS TO CARE FOR FUNCTIONAL NEUROLOGICAL DISORDERS THROUGH A MANUALIZED MINDFULNESS-BASED SKILSS TRAINING PROGRAM IN GROUP FORMAT (Treatment)
Irene Gonsalvez, MD, BWH/Harvard Medical School

Background: Functional neurological disorder (FND) is highly prevalent and disabling, yet access to clinicians with expertise in evidence-based FND treatment remains limited. Group-based care offers a potential strategy to expand access while delivering evidence-based care and maintaining clinical oversight.

Objective: To describe the delivery, retention, and dropout patterns of a manualized outpatient skills-based group therapy program for patients with FND.

Methods: We delivered a structured 12-week mindfulness-based skills program in group format for patients with confirmed FND. Groups met weekly for 90 minutes facilitated by 2 psychiatric Licensed Independent Clinical Social Workers with expertise in trauma-informed and FND-specific care along with experience with the mindfulness-based therapy protocol that was followed. The clinicians had ongoing consultation support from a neuropsychiatrist. Each treatment cohort was defined by the start of each cycle and encompassed all patients who began the program, including those who discontinued prior to completion. We summarized the number of patients treated across cohorts, cohort size, wait time to cohort start, clinical phenotype, psychotherapy engagement, and reasons for discontinuation among patients who dropped out after initiating treatment.

Results: Across eight cohorts delivered between 07/2023 and 11/2025, 87 treatment episodes were initiated, representing 81 unique patients. Six patients returned to repeat the program to reinforce skills learned during their initial course. Cohort size ranged from 6 to 14 participants. Median wait time from waitlist entry to cohort start varied across cohorts, ranging from 13.5 to 100 days. Most patients completed the program, with post-initiation discontinuation occurring in 15 patients (82.8% treatment completion rate). Among those who discontinued, documented reasons reflected post-initiation barriers rather than access failure. These included scheduling or work changes, personal or family stressors, difficulty tolerating the virtual format, preference for individual treatment, and perception that the group setting was not a good fit. Across the treatment episodes, presenting phenotypes included functional seizures (55.6%), mixed FND symptoms (18.1%), motor FND (15.3%), functional dizziness/PPPD (6.9%), sensory FND (2.8%), and cognitive FND (1.4%).

Conclusions: A manualized mindfulness-based group program enabled treatment initiation for 87 FND episodes for 81 unique patients across eight cohorts, with median wait times ranging up to 100 days. Retention was high, with most patients completing the program, and discontinuation primarily reflected circumstances after treatment began rather than barriers to accessing care. Evaluating treatment initiation and retention in real-world implementation clarifies how group-based FND care functions and identifies opportunities to support sustained participation in treatment.

References: PMID: 34922325; 3996535

162    THE LADDER TO RECOVERY: A TIERED, TEAM-BASED MODEL FOR YOUTH WITH FND (Treatment)
Jessica Gore, DPT, Brown University Health/Hasbro Children's Hospital

Background: Functional Neurological Disorder (FND) is a psychiatric and neurological condition commonly encountered across physical therapy (PT) settings. PT is a central part of multidisciplinary treatment (MDT), and psychologically informed PT (PIPT) strategies have shown promising outcomes (1). This case series examines a PIPT treatment tool ("ladder") applied in youth with complex FND which targets task-specific functional mobility and recreational goals, shifting attention away from symptoms and impairment while providing positive reinforcement and expectations of improvement in incremental steps. Within our service line, a three-tiered ladder-based approach (TTLBA) is developed with MDT team and family input. A stepwise paced progression initiates novel skills in PT sessions first, the program day second, and the home environment third. Key components include consistent messaging, unified reinforcement of mobility goals, strengthening skill acquisition, confidence building, and treatment adherence in all three settings. Though mobility goals are utilized as ladder steps in these cases, a variety of goals, including activities of daily living and return to recreational activities, can be used.

Case Description: Three patients (A-12-year-old female, B-16-year-old male, C-17-year-old female) treated in a pediatric hospital system are presented. Each had a complex biopsychosocial formulation and significant functional impairments requiring physical assistance or mobility devices. None were able to attend school, engage in recreational activities, or participate in meaningful social interaction due to limitations. The Lower Extremity Functional Scale (LEFS) was administered pre- and post-treatment (2). Treatment duration varied: A for 13 weeks, 4x/week in the outpatient setting, B for 17.5 weeks, 5x/week inpatient and outpatient, and C for 7 weeks, first 5x/week inpatient, then 3x/week outpatient. All cases utilized the TTLBA to PIPT. Each patient returned to fully independent functional mobility without an assistive device and resumed preferred recreational activities. LEFS scores improved by 69 (86%), 70 (88%), and 74 (92%) points respectively, well above the 9-point threshold for clinically meaningful change.

Discussion: This case series supports the ladder approach as an effective PIPT intervention for youth with FND. The ladder complements the broader evidence-based framework for PIPT by integrating graded exposure, functional relevance, and consistent reinforcement. The TTLBA enhances treatment by improving communication across MDT members, supporting mobility progression in multiple environments, and promoting consistent, unified expectations, ultimately supporting skill acquisition and improved functioning.

References:
1. Gray, N et al (2020).  The Journal of neuropsychiatry and clinical neurosciences, 32(4), 389–395. https://doi.org/10.1176/appi.neuropsych.19120355
2. Binkley, J et al (1999). Physical therapy, 79(4), 371–383.

163    HETEROGENEITY AND PSYCHOLOGICAL DIVERSITY IN FND (Etiology/Pathophysiology, Treatment)
Myles Gutkin, University of Melbourne

Background: The pathophysiology of FND is widely believed to involve predictive processing errors at the level of information processing in the brain. What causes predisposition and persistence of these errors can be usefully understood as giving rise to the heterogeneity of FND. These relate, predominantly, to psychological processes, which may be generalised or compartmentalised.

Methods: Published research on heterogeneity, clustering and formulation in FND were used to inform the development of a dimensional approach to understanding the psychological drivers of heterogeneity in FND.  
 
Results: The dimensional model is under development and will present an approach to understanding heterogeneity through psychological diversity. Dimensions include arousal-suppression; defensiveness-pessimism; denial-integration and exploitation-allostasis. Further results will be available at the time of presentation.

Conclusions: The heterogeneity of FND can be understood as relating predominantly to psychological diversity with potential to inform management.  

164    A SHORT METHOD TO DIAGNOSE AND TREAT FNDS (Treatment)
Saeid Saadi, Centro Integrato Neuroscienze (CIN)

Introduction/Background: FND is a common and disabling condition for which effective, rapidly acting therapeutic strategies remain limited. We present a clinical case series of patients with FND evaluated at the CIN outpatient clinic (Rimini, Italy), where a combined Neurophysiological Modulation approach was developed as a complementary therapeutic option to standard care. All patients underwent a structured multimodal intervention: 1) active patient engagement; 2) targeted modulation of autonomic nervous system activity through reduction of sympathetic tone and enhancement of parasympathetic regulation; 3) integrated use of relaxation techniques, therapeutic verbal guidance, low-intensity peripheral electrical stimulation with motor retraining and additional neuromodulatory and psychophysiological strategies within a multidisciplinary framework. Symptom severity was self-rated before and after treatment using a 0–10 Visual Analogue Scale (VAS).

Case Series/Results: Between July 2025 and January 2026, 99 patients with FND were treated (33 men, mean age 53, range 22–80; 66 women, mean age 50, range 18–88). Diagnosis was based on clinical presentation, positive neurological signs and targeted investigations to exclude structural disease. Twelve patients (12.1%) presented with a single FND symptom, while the remainder had multiple symptom domains. Among patients with autonomic and bodily symptoms (n=95), mean VAS reduction was 5.3 (SD 3.1); 53 (55.7%) reported complete same-day recovery. In movement disorders (n=54), mean reduction was 5.1 (SD 3.4); 28 (51.8%) achieved complete same-day recovery. In sensory symptoms (n=31), mean reduction was 3.7 (SD 2.7); 15 (48.4%) reported complete recovery. In cognitive symptoms (n=19), mean reduction was 2.4 (SD 2.1); 7 (36.8%) achieved complete recovery. In seizure-like episodes and speech (n=8) and swallowing disorders (n=3), mean reduction was 2.3 (SD 2.6). Only 6.1% showed no immediate improvement. A subset returned for follow-up; most requested additional treatment and longitudinal data are currently under analysis.

Discussion: Preliminary findings suggest that targeted neurophysiological modulation within a structured biopsychophysiological framework may produce rapid and clinically meaningful symptom improvement across multiple FND domains. The high proportion of same-day recovery and strong patient-reported benefit support further controlled investigation of this approach.

References:
Bennett K, Diamond C, Hoeritzauer I, Gardiner P, McWhirter L, Carson A, Stone J. A practical review of functional neurological disorder (FND) for the general physician. Clin Med. 2021 Jan;21(1):28-36 
McLoughlin C, McWhirter L, Pisegna K, Tijssen MAJ, Tak LM, Carson A, Stone J. Stigma in functional neurological disorder (FND) - A systematic review. Clin Psychol Rev. 2024 Aug;112:102460
Aybek S, Perez DL. Diagnosis and management of functional neurological disorder. BMJ. 2022 Jan 24;376

165    INTEGRATING PEER SUPPORT INTO MULTIDISCIPLINARY FND CARE: DEVELOPMENT AND IMPLEMENTATION OF A PATIENT AMBASSADOR PROGRAM (Treatment)
Mackenzi Moore, MPH, University of Colorado

Background: Following diagnosis of Functional Neurological Disorder (FND), patients often experience uncertainty and emotional distress related to prognosis, symptom legitimacy and treatment expectations, which may impact engagement in recommended care. Peer support from individuals with lived experience may provide validation and reduce feelings of isolation as patients begin their treatment.1 However, despite their role in other neurologic disorders, structured peer support programs remain uncommon in FND care. This study evaluates the integration of a novel patient ambassador program into the early stages of care within a multidisciplinary FND program. 

Methods: The University of Colorado (CU) FND Program developed a patient ambassador program in partnership with UCHealth Hospital. Patient ambassadors are selected by CU FND Program clinicians from a pool of interested volunteers. Ambassadors are former patients who have completed a full course of treatment in the program. To ensure safety and quality, ambassadors must demonstrate psychiatric and medical stability, with a low likelihood of symptom exacerbation when engaging in peer-support activities. Ambassadors are not required to be symptom free but exhibit strong self-management strategies, which are further evaluated in an initial interview with UC Health Volunteer Services. A structured training manual was developed to define ambassador roles, boundaries and escalation protocols. Ambassadors engage with CU FND Program patients following their neurological assessment. They do not provide clinical care but answer questions about the program and help set expectations across the care continuum. Descriptive analysis was used to assess the ambassador program’s impact on patient adherence to subsequent behavioral health (BH) evaluations. 

Results: Between 9/2025 and 12/2025, 32 patient ambassador encounters were documented across 20 unique patients. Phone-based peer support was provided to 65% (n=13), with educational resources and support provided to 3 patients. Among patients successfully contacted, 76.9% (n=10) completed their BH evaluation in the CU FND Program and 53.8% (n=7) enrolled in a group therapy session (Table 1).

Conclusion: This study demonstrates that incorporating trained patient ambassadors is safe and feasible within a FND clinical workflow and offers a scalable approach to enhancing patient-centered care. Preliminary findings suggest ambassadors may reduce ambivalence toward engaging in treatment. Peer support leverages lived experience as an adjunct to clinical expertise, creating a more comprehensive support model for individuals navigating FND treatment. 

References:
Bailey C,  et al. Illness perceptions, experiences of stigma and engagement in functional neurological disorder (FND): exploring the role of multidisciplinary group education sessions. BMJ Neurol Open. 2024;6(1):e000633. Published 2024 Jun 5. doi:10.1136/bmjno-2024-000633

165    THE MIMICRY CHALLENGE: FUNCTIONAL NEUROLOGICAL DISORDER OVERLAPPING WITH STIFF-PERSON SYNDROME (Treatment)
Saeid Saadi, Centro Integrato Neuroscienze (CIN)

Introduction/Background: Functional neurological disorder (FND) represents a significant challenge in clinical practice due to its ability to simulate or coexist with organic neurological conditions. Stiff-person syndrome (SPS) is a paradigmatic example of this complexity: it frequently lacks clear radiological or instrumental evidence and its clinical onset can be preceded or accompanied by psychiatric symptoms. This neuropsychiatric interface often creates a diagnostic gray area where organic pathology and functional overlays coexist. Recognizing this duality is crucial, as failure to identify a functional component can lead to therapeutic failure and iatrogenic harm.

Case Presentation: We present the case of a 48-year-old female with a clinical diagnosis of SPS and low-titer anti-glutamic acid decarboxylase (anti-GAD) antibodies. The patient suffered from refractory spasms and a severely impaired quality of life. Notably, conventional electromyography (EMG) proved difficult to perform and interpret; despite attempts at distraction, the frequency and intensity of spasms made the recording inconclusive. Previous pharmacological trials with clonazepam and baclofen yielded no benefit, only increasing adverse effects. Given the clinical impasse, a brief multimodal neuromodulation intervention (~30 minutes) was performed, integrating therapeutic alliance, psychoeducation, diaphragmatic breathing, immersive virtual reality (VR) for attentional distraction, and percutaneous stimulation with an explicit time-locking frame.

Discussion: Post-intervention, the patient performed immediate motor tasks with a complete subjective resolution of symptoms, with consolidation over the following hour. This case highlights that in SPS, the absence of robust instrumental evidence—compounded by the technical difficulty of performing an EMG during severe episodes—can lead to diagnostic overshadowing. The anti-GAD positivity initially anchored the focus to a purely organic framework, yet the rapid response to neuromodulation confirms a dominant functional overlay. This scenario underscores that organic markers do not exclude FND. High clinical vigilance is required to identify when FND coexists with syndromes like SPS, shifting the focus from a binary diagnostic model toward an integrated biopsychosocial approach to avoid ineffective pharmacological escalation.

References:
1. Espay AJ, et al. Functional neurological disorder: frontiers and challenges. Lancet Neurol. 2018;17(11):969–983.
2. Newsome SD, Johnson T. Stiff person syndrome spectrum disorders: more than just stiffness and spasms. Curr Opin Neurol. 2022;35(3):339–345.

166    OPTIMIZING MANAGEMENT OF CO-OCCURRING EPILEPSY AND FUNCTIONAL NEUROLOGICAL DISORDER: DEVELOPMENT AND IMPLEMENTATION OF A STANDARDIZED PROTOCOL (Treatment)
Deena Haque, Johns Hopkins

Background: Functional neurological disorder (FND), which includes functional seizures, frequently co-occurs with epilepsy. Studies estimate that at least 20% of patients with functional seizures also have co-morbid epileptic seizures. A diagnosis of both conditions can be very difficult to manage because FND symptoms, specifically functional seizures, can clinically mimic epilepsy and often lead to misdiagnosis and dangerous over-treatment. Epileptic seizures require anti-seizure medications and sometimes emergent stabilization to prevent further morbidity. In contrast, functional seizures require more behavioral interventions. Misdiagnosis can delay appropriate treatment for epileptic seizures, while excessive medicalization or unnecessary interventions may inadvertently reinforce functional seizures. Current clinical practice lacks standardized guidance for managing patients with both conditions. Our goal was to develop, implement, and evaluate a standardized protocol for managing patients with co-morbid epilepsy and FND. 

Methods: We developed guidelines on how to document individualized seizure semiology for patients with both diagnoses, tools outlining characteristic features of epileptic versus functional seizures, a response protocol for how to acutely stabilize patients depending on seizure type, and guidance on how to minimize reinforcement of functional episodes. We also plan to deliver educational training sessions to nursing and other staff focused on seizure semiology, de-escalation techniques, and stabilization strategies. Pre- and post-training surveys will assess nursing confidence and knowledge of how to manage functional versus epileptic seizures.  
  
Results: We hypothesize that implementing this protocol will help standardize care practices, increase confidence in differentiating seizure types, reduce inappropriate pharmacologic interventions of functional seizures, and decrease the risk of misclassifying functional seizures as epileptic. We also anticipate improved communication amongst care teams and enhanced patient-centered care.   
 
Conclusion: Patients with co-morbid FND and epilepsy represent a uniquely vulnerable population given the lack of standardized guidance when it comes to recognizing and treating functional versus epileptic seizures. Thus, a structured, standardized protocol combined with targeted education for other healthcare professionals on care teams can reduce diagnostic ambiguity, promote appropriate stabilization, and improve quality of care. This project aims to address a critical gap in current clinical practice of FND and epilepsy and provide a model for managing this complex population of patients.  
  
Reference:
Kutlubaev MA, Xu Y, Hackett ML, Stone J. Dual diagnosis of epilepsy and psychogenic nonepileptic seizures: systematic review and meta-analysis of frequency, correlates, and outcomes. Epilepsy Behav. 2018;89:70–78.

167    RE-PROGRAM: AN INTERNET INTERVENTION FOR FUNCTIONAL SEIZURES: A RANDOMISED CONTROLLED TRIAL (Treatment)
Lana Higson, Monash University/Alfred Hospital

Background: Functional seizures are poorly understood, and treatment is limited by a lack of effective evidence-based interventions. We prospectively evaluated Re-PROGRAM, the first internet-based e-intervention for functional seizures. 

Methods: In this 3-arm parallel randomized controlled trial, adult participants with a diagnosis of functional seizures and ≥four seizures in the preceding four weeks were recruited and randomly assigned to Re-PROGRAM telehealth therapist-guided, Re-PROGRAM self-guided, or standard care (SC). Assessments blinded to treatment allocation occurred before (T0) and 6 weeks (T1), 3-months (T2), 6-months (T3) and 12-months post-randomisation. Primary outcome was change in monthly seizure frequency from T0 to follow up collected in the intention-to-treat population via self-report across four weeks prior to each timepoint and calculated as the ratio of seizure frequency at follow-up relative to T0. Secondary outcomes were anxiety, depression, quality of life, psychosocial functioning, and somatic symptoms. The trial was prospectively registered (ACTRN 12622000262707). 

Results: Between Feb 2022 and March 2024, 220 potential participants were screened for eligibility; 113 (51%) were excluded or declined involvement; and 107 were recruited and randomly assigned to a treatment arm (37 self-guided, 36 therapist-guided, 34 SC). Self-guided Re-PROGRAM demonstrated a significantly favourable change in seizure frequency compared with SC at T1 (RRR=0.37, 95% CI: 0.19–0.73, HBp=0.012) and T3 (RRR=0.41, 95% CI: 0.21–0.83, HB-p=0.039); and significantly greater improvement in depression at T3 (MDC=–2.52, 95% CI: –4.32 to –0.73, HBcorrected p=0.018) and T4 (MDC=–2.28, 95% CI: –4.13 to –0.43, HB-corrected p=0.018) and anxiety at T3 (MDC=–3.98, 95% CI: –6.62 to –1.34, HB-corrected p=0.009) and T4 (MDC=–3.81, 95% CI: –6.12 to –1.49, HB-corrected p=0.004) relative to SC. There were no adverse events in any group. 

Conclusions: Self-guided Re-PROGRAM offers an accessible, scalable, and promising adjunct to standard care for more favourable seizure reduction, and improvement in anxiety and depression.

169    PREDICTORS OF ILLNESS PERCEPTIONS AND TREATMENT ADHERENCE IN PATIENTS WITH FUNCTIONAL/DISSOCIATIVE SEIZURES (Phenomenology/Epidemiology)
Ainsley Lotito, MPHc, Colorado School of Public Health

Background: Engagement in evidence-based psychological treatment promotes better outcomes among Functional/Dissociative Seizure (FDS) patients (Carlson & Nicholson Perry, 2017), yet adherence is still low. Illness perceptions (an individual’s cognitive and emotional appraisal of their condition) may influence treatment engagement. This study examined demographic and clinical factors associated with higher illness threat perceptions as measured by the Brief Illness Perception Questionnaire (BIPQ) (Broadbent et al., 2006) and assessed whether higher BIPQ scores predict treatment adherence in FDS patients. 

Methods: We conducted a retrospective cohort study of adults with FDS enrolled in the University of Colorado Functional Neurological Disorder Program between April 2020 and April 2025. Demographic and clinical data were extracted from electronic medical records. Illness perceptions were measured using the BIPQ and scores were dichotomized as High (>50) versus Low or Moderate (0-49). Logistic regression with stepwise model selection identified factors associated with High BIPQ scores. Treatment adherence was defined as the proportion of scheduled visits attended. Inverse probability weighting using propensity scores from the logistic model was used to balance confounders, followed by weighted linear regression to estimate the association between BIPQ score and adherence. Cluster robust standard errors were applied. 

Results: Among 441 patients who completed the BIPQ, the mean age was 41.6 years (SD 13.9) and participants had a mean of 7.28 (SD 3.22) comorbid conditions. In multivariable analysis, each additional comorbid condition increased the odds of a High BIPQ score by 25 percent (OR 1.25; 95% CI 1.14 to 1.38), while substance use doubled the odds (OR 2.00; 95% CI 1.21 to 3.39). Driving status was protective (OR 0.57; 95% CI 0.35 to 0.93) [table1]. After propensity score weighting, High BIPQ scores were not significantly associated with treatment adherence (β 0.03, 95% CI -0.04 to 0.10), with negligible effect size (Cohen’s d 0.05) [table2]. 

Conclusions: Higher illness threat perceptions in FDS are associated with indicators of clinical complexity and psychosocial vulnerability but do not independently predict treatment adherence after balancing confounding factors. Findings suggest that illness perceptions reflect broader functional and psychological burden rather than acting as a primary driver of engagement. Identifying clinical vulnerabilities at intake may better inform targeted strategies to support adherence than illness perception measures alone. 

References:
Broadbent E, Petrie KJ, Main J, Weinman J. The Brief Illness Perception Questionnaire. J Psychosom Res. 2006. 
Carlson P, Nicholson Perry K. Psychological interventions for psychogenic nonepileptic seizures. Epilepsy Behav. 2017. 

170    DIFFERENTIAL LEARNING AS A REHABILITATION TOOL FOR FOCAL FUNCTIONAL GAIT DISTURBANCE (Treatment)
Kate Holt, City St George’s, University of London

Background: Differential Learning (DL) is a motor-learning framework with evidence from sports science and task-specific movement disorders that deliberately introduces variability into practice to promote exploration and flexible motor solutions. DL may have applications in FND, particularly for patients with persistent motor symptoms that do not respond to multidisciplinary rehabilitation and standard approaches. 
We hypothesised that DL may be well suited to patients with entrenched movement patterns seen in some forms of FND and related gait disturbances.

Aims:
1. To apply DL theory to gait disorders arising from FND 
2. To develop a structured set of DL-based gait exercises
3. To pilot this approach in a small cohort with persistent symptoms

Methods: We adapted DL exercises to the needs of patients with persistent functional gait disorder (FGD). We created a programme with four levels of increasing complexity, and approximately 20 variations per level.  

Patients with treatment resistant FGD were invited to take part in the DL programme. The exercises were taught in a face-to-face session, and the participants were encouraged to continue practice at home using an online platform that randomised the exercises and allowed participants to select difficulty levels. The home programme was supported by monthly scheduled online review appointments. The participants were followed up in-person at six months.

Results: Three people completed the programme, including six month follow up. The mean age at symptom onset was 56.3 (SD 11.5 years) and the mean duration of symptoms was 4.3 years (range 3). Differential learning produced small gains across the cohort and a meaningful improvement in one participant, despite prior non-response to FND-specific physiotherapy. Acceptability was high, participants described the training as challenging and novel, with strong engagement in the exercise programme and online follow-up.

Conclusions: Differential learning may be a useful addition to the neurophysiotherapist’s toolkit for gait disturbance in FND, particularly where patients present with persistent, stereotyped movement patterns.  In contrast to sequential motor learning approaches that emphasise stabilisation and repetition of symptom-free movement components, differential learning prioritises variability and exploration of movement, allowing learning to emerge implicitly. From a motor-control perspective, this may help disrupt highly automatised motor patterns and expand the available motor repertoire. We discuss limitations, candidate mechanisms and integration of remote delivery into routine care.

References:
1.Sadnicka A & Rosset-Llobet J (2019) A motor control model of task-specific dystonia and its rehabilitation.  10.1007/s00415-019-09242-9
2.Schöllhorn, et al. (2012): The Nonlinear Nature of Learning: A Differential Learning Approach. DOI: 10.2174/1875399X01205010100 

171    THERAPEUTIC CHALLENGES AND INTERDISCIPLINARY MANAGEMENT OF A FND CASE WITH COMORBID ASTHMA AND VON WILLEBRAND DISEASE (Treatment)
Afnan Hussain, Ministry of Health - Madinah Health Cluster, KSA

Introduction: Functional Neurological Disorder (FND) is challenging to manage, especially when comorbid with chronic conditions such as asthma and von Willebrand Disease (VWD). Psychological stress can exacerbate symptoms, and no single treatment addresses both functional and medical conditions simultaneously.

Objective: To present a complex FND case with comorbid asthma and von Willebrand Disease, focusing on management and prevention of deterioration.

Case Presentation: A 36-year-old single female with severe childhood asthma developed VWD in 2017 in the UK, coinciding with FND onset likely triggered by academic stress. She experienced recurrent asthma exacerbations, prolonged bleeding, poor appetite, weight loss, bowel changes, anxiety, cognitive dysfunction, and insomnia.

FND manifestations included functional seizures, abnormal limb and facial movements, balance disturbances (“floating” sensation), transient visual and sensory changes, dissociation, and occasional dysarthria.

Interventions:  
Pharmacological treatment: Limited benefit; side effects included nausea, abdominal pain, and limb swelling, occasionally requiring emergency visits.
CBT (Cognitive Behavioral Therapy): Partial improvement in psychological symptoms and concentration; no side effects.
EMDR (Eye Movement Desensitization and Reprocessing): Poorly tolerated, worsened symptoms by confronting trauma; discontinued.
Psychoanalysis: Poorly tolerated, worsened symptoms by confronting trauma, preventing continuation.
Drawing and writing therapy: Improved emotional processing; delayed side effects occurred several hours post-session.
Self-Treatment 
Cinematherapy & Support Groups: Enhanced emotional insight and coping; side effects occurred during or after participation.
Bibliotherapy: Improved understanding and emotional articulation; no side effects reported.
Sessions were often private; hospital-based recommended to prevent events.

Discussion: CBT and bibliotherapy were associated with partial benefits without side effects, supporting their suitability for ongoing use.
In contrast, EMDR and psychoanalysis exacerbated symptoms during trauma confrontation, preventing continuation.
Cinematherapy, support groups, and drawing/writing therapy offered partial benefits, likely via peer modeling and vicarious emotional processing, but side effects limited use. Low-Arousal Therapy may provide a safer option for high-stress interventions. Overall, therapeutic decisions should balance benefit with patient tolerance and safety.

Potential Future Directions: Neuro-monitoring using EEG (Electroencephalography) and BCI (Brain–Computer Interface) during therapeutic sessions may identify stress-related neural patterns and allow safer intervention adjustments. Both techniques are non-invasive and safe.

References:
Haeyen, S., van Hooren, S., & Wanten, F. (2024). Effectiveness of Trauma-Focused Art Therapy (TFAT) for psychological trauma: A mixed method single case study.

172    PEDIATRIC FND: UNDERSTANDING FACTORS THAT INFLUENCE WHO COMPLETES INTENSIVE TREATMENT (Treatment)
Jeannette Iskander, PhD, Akron Children's Hospital and Northeast Ohio Medical University

Background: Functional neurological disorder (FND) is best understood as a multi-network brain disorder which exists at the intersection of neurology and behavioral health. The prevalence in pediatrics is estimated to be as high as 18.3 in 100,000,1 making it one of the most common presentations in neurology clinics. Despite its prevalence, accessing treatment can be challenging. Although prognosis is generally favorable when FND is treated in an appropriate and timely manner, little is known regarding how patients are triaged and who completes treatment for FND2. Therefore, the goal of the current study is to identify youth, family, and socioeconomic characteristics that distinguish, 1) individuals who are accepted into and complete an intensive Day Rehabilitation Program for FND versus those who do not. 

Methods: A retrospective chart review was completed on youth (ages 8 -21 years) who were evaluated in a monthly multidisciplinary clinic for youth with FND from October 2021 – September 2025. Questionnaires, including the Functional Disability Inventory (FDI) and Pediatric Quality of Life Inventory (PedsQL), were administered to youth beginning in December 2023. Neighborhood opportunity was measured using the Child Opportunity Index (COI) 3.0, a validated, nationally normed index ranging from 1 to 100, with higher scores indicating more favorable neighborhood conditions for child health and development. Bivariate analyses and logistic regressions were conducted to examine demographic, clinical, and social characteristics associated with (1) acceptance into the FND day rehabilitation program, (2) completion of the FND program, and (3) completion of the FND program among all accepted patients, regardless of acceptance status.

Results: Seventy-eight youth (M = 14.6 years) with FND were evaluated in the clinic; 59 were accepted and 48 completed the program. Age significantly predicted who was invited and completed the program, with younger individuals being more likely to complete the program (p = 0.003). Further, individuals with a lower COI score were less likely to complete the program (p = .034). Finally, youth who reported greater functional disability (p = .0004) and lower overall quality of life (p = .018) were more likely to complete the program. 

Conclusions: Several factors were shown to influence acceptance and completion of an intensive day rehabilitation program for youth with FND, suggesting there are opportunities in terms of triaging these individuals to the appropriate level of care. Future research is needed to better understand why youth with a lower COI were less likely to complete the program and how to best support this subset of the population to ensure that their FND treatment needs are being met. Additional research is also needed to determine whether incorporating standard measures of functional disability and quality of life may help make decisions regarding how to best triage pediatric patients with FND.

173    EVALUATING AN INTERDISCIPLINARY OUTPATIENT REHABILITATION PROGRAM FOR FUNCTIONAL NEUROLOGICAL DISORDERS: AN AUSTRALIAN COHORT (Treatment)
Sara Issak, PhD Candidate, University of Melbourne and Epworth Healthcare

Background: Functional Neurological Disorders (FNDs) are common and disabling, accounting for 15% of new patients seen in general neurology clinics.  Interdisciplinary treatment is recommended, incorporating neuropsychiatric and rehabilitation perspectives to improve function. There are few interdisciplinary rehabilitation programs offering treatment for FNDs in Australia, with limited examination of treatment efficacy. The aim of this study was to examine the treatment efficacy of patients attending the Epworth FND outpatient rehabilitation program.

Methods: A retrospective observational study was conducted, extracting routine clinical care data for patients attending between 1st July 2021 to 31st December 2022 inclusive, from electronic medical records. Data included demographic information and participant work, study, volunteering and driving outcomes. Routine outcome measure data collected included the patient reported clinical impression scale (CGI), 36-item short form survey (SF36) , work and social function (WSAS), physical symptoms questionnaire (PHQ15) and the hospital anxiety and depression scale (HADS). Descriptive statistics, paired samples t-tests and Wilcoxon sign rank tests were conducted for available pre- and post-treatment data points. Ethics approval was granted by the Epworth Research Ethics Committee (Reference: EH2023-1013).
  
Results: Fifty-nine patients were referred to the program, with 47(79.7%) patients completing treatment, and 12 (20.3%) exited the program early due to various reasons. The majority of the cohort was female (39/59, 66.1%), with a mean age of 38.3 (SD 13.6) years. Twenty-nine (29/47, 62%) patients had complete sets of at least one pair of pre- and post-treatment outcome measure. Within-subject CGI ratings following treatment resulted in 14/20 (70%) patients reporting improvements (minimally, much and very much combined), 5/20 (25%) reporting no change, and 1/20 (5%) reporting a worse outcome. Post-treatment scores indicated significant improvement in SF36 physical limitations (p<0.011), wellbeing (p<0.001), and social function (p<0.003) sub-domains, as well as WSAS scores (p=0.006) , and HADS-anxiety scores (p=0.009). There were no statistically significant improvements in remaining SF36 domains, PHQ15 scores, the HADS-depression scores or driving outcomes. Work, study and volunteering outcomes indicated improvements from 39 patients with available data, with 43.6% of participants engaged in paid work at completion of treatment (baseline of 25.6%),  20.51% of patients engaged in study (compared to 5.1%), and 7.69% engaged in volunteering (compared to 2.6%). 

Conclusions: Treatment outcomes following interdisciplinary rehabilitation in the Epworth FND outpatient service indicated positive improvements for people with FND. Given the limited Australian data, further rigorous evaluation of treatment efficacy is required to justify and support the expansion of FND services nationally.

174    TREATMENT CARRYOVER IN FUNCTIONAL NEUROLOGICAL DISORDER: A LEARNING SCIENCE–INFORMED FRAMEWORK (Treatment)
Leela Johnstone, MS, Independent Consultant

Background: Psychological and rehabilitative interventions for Functional Neurological Disorder (FND) require sustained use of therapeutic skills over time (Dworetzky & Baslet, 2025). Across modalities, clinical improvement depends on patients’ ability to practice and apply motor, cognitive, and behavioral strategies beyond the clinic. When carryover breaks down, outcomes suffer; if FND treatment depends on skill acquisition and transfer, the instructional and contextual conditions supporting that transfer warrant examination.
Evidence from learning science and Human Performance Technology (HPT) indicates that carryover is shaped not only by treatment content, but by the alignment of instruction, practice, feedback, supports, and environmental conditions. Applying these principles to FND care identifies modifiable determinants of therapeutic carryover within existing modalities.
 
Methods: To apply this perspective within FND care, a structured, theory-informed analysis was conducted using principles from learning science, cognitive load theory, and HPT (Sweller et al., 2019). Representative psychotherapy manuals, rehabilitation protocols, diagnostic frameworks, and psychoeducational materials were analyzed.

Predefined performance analysis constructs were translated into a healthcare context and applied to identify instructional and contextual conditions supporting skill acquisition and transfer (i.e., therapeutic carryover).

Results: Recurrent modifiable instructional and contextual conditions relevant to therapeutic carryover were synthesized into four domains (CARE):
Clarity: Explicit, sequenced explanations and therapeutic strategies, with clear role expectations for clinicians, patients, and families.
Aids: Structured rehearsal supports (e.g., homework, guided practice, modeling, feedback, chunking, checklists).
Resources: Adequate time, clinician support, practical tools, and symptom stabilization.
Environment: Clinical, home, and work contexts that reinforce predictability, agency, and safety.
Gaps in these modifiable conditions were evident across modalities. For example, homework exercises frequently lacked explicit clarity, structured rehearsal supports, or contextual reinforcement mechanisms.

Conclusions: Therapeutic carryover beyond the clinic is a core determinant of treatment response in FND. This analysis identifies modifiable instructional and contextual conditions within existing evidence-based modalities that shape patients’ ability to sustain and apply therapeutic skills. The CARE domains provide a framework for examining and strengthening these conditions in clinical practice. Prospective study is warranted to evaluate whether systematically applying this framework improves treatment response and functional outcomes.

References:
Dworetzky BA, Baslet G. FND: Practical management. Neurotherapeutics. 2025;22(4):e00612.
Sweller J, et al. Cognitive load theory. Educ Psychol Rev. 2019;31:261–292.

175    GIVE-WAY WEAKNESS IN GUILLAIN–BARRÉ SYNDROME: A DIAGNOSTIC PITFALL IN EARLY ASSESSMENT (Phenomenology/Epidemiology)
Takamichi Kanbayashi, Teikyo University

Background:  Give-way weakness (GW) is commonly regarded as a positive clinical sign suggestive of functional weakness.1) However, previous study has shown that GW can also be observed in structural neurological disorders, mainly stroke.2) We had a preliminary impression that GW is frequently observed in patients with Guillain–Barré syndrome (GBS). When GW is observed in patients with GBS, it may raise suspicion of functional weakness and potentially delay an accurate early diagnosis. This study aimed to clarify the frequency and characteristics of GW in GBS, as well as its impact on early diagnosis.

Methods: We retrospectively identified patients admitted to our hospital between April 2011 and December 2025 with a final diagnosis of GBS. Inclusion criteria were: symmetric limb weakness, reduced or absent deep tendon reflexes in weak muscles, a monophasic disease course with nadir reached between 12 hours and 28 days, nerve conduction studies performed during the disease course, and manual muscle testing (MMT) of both proximal and distal limb muscles conducted by board-certified neurologists. Patients aged younger than 15 years, those with insufficient MMT documentation, or those with considerable pain that may potentially influence MMT were excluded. Patients were classified into subtypes based on Ho’s electrodiagnostic criteria. The frequency of GW and its characteristics, as well as its presence in patients initially suspected of functional weakness, were analyzed.

Results: Ninety-two patients with GBS were identified. Among them, 74 met the entry criteria, and GW was observed in 22 patients (30%). According to the electrophysiological subtype, GW was present in 4 of 30 patients (13%) with axonal, 11 of 24 (46%) with demyelinating, and 7 of 20 (35%) with equivocal subtypes. GW was significantly more frequent in the demyelinating subtype than the axonal type. Functional weakness was initially suspected by neurologists at the first assessment in 3 patients, all of whom exhibited GW.

Conclusions: GW is not uncommon in GBS, particularly in demyelinating subtype and may lead clinicians to suspect functional weakness during early assessment. Overreliance on GW as a diagnostic marker of functional weakness may increase the risk of misdiagnosis. These findings underscore the importance of interpreting GW within the overall clinical context and of diagnosing functional weakness based on multiple positive signs.

References:
1) Dolbow J, El-Azzouni S, Zhang Y, et al. A practical guide to assessing functional motor weakness: a review of validated techniques. J Neurol 2025;272:427.
2) Gould R, Miller BL, Goldberg MA, et al. The validity of hysterical signs and symptoms. J Nev Ment Dis 1986;174:593-597.

176    STANDARDIZING PHYSICAL AND OCCUPATIONAL THERAPY FND CARE: DEVELOPMENT OF A SCOPING REVIEW AND TREATMENT GUIDELINES (Treatment)
Lori Kile, PTA, Children's Hospital of PHiladelphia

Background: Functional Neurological Disorder (FND) in the pediatric population remains a challenging condition to treat, particularly within Physical Therapy (PT) and Occupational Therapy (OT), where standardized, evidence-based treatment approaches are limited. Variability in clinician knowledge and persistent misconceptions regarding patient presentations have contributed to reduced confidence and inconsistent care delivery for this population. 

Methods: To address these barriers and improve clinical outcomes and staff proficiency, the Children’s Hospital of Philadelphia’s rehabilitation department assembled a group of PT and OT staff to develop FND treatment guidelines and resources. The group first surveyed staff to determine their initial understanding of FND and their comfort in providing care to patients with FND.  A scoping review was then completed and synthesized to identify best practice recommendations for the rehabilitation management of pediatric FND.  A total of 140 articles were reviewed and appraised using the Johns Hopkins Evidence-Based Practice Model for Nursing and Healthcare Professionals, resulting in 61 articles with applicable evidence to clinical practice. The compiled evidence was translated into institution-specific clinical resources, including education on the neurobiological and psychological mechanisms of FND and practical guidelines for PT and OT evaluation and intervention across FND subtypes and clinical settings. All resources were organized and saved in a central electronic location that is accessible to all staff. [Table1] Implementation of these resources aimed to standardize care, improve clinician confidence and competency, and promote function and patient-centered rehabilitation strategies. To achieve this, the FND group introduced resources during department meetings, developed mentorship opportunities, and presented a 4-part CEU series. The CEU series served to provide a more in-depth look at FND as well as begin implementation of current best practice.

Outcomes:  A post-education survey to re-evaluate staff knowledge and comfort with FND treatment is scheduled for April 2026.

Discussion: Our goal is to share the process and structure of the work that was conducted from December 2023 to June 2025 [Table2] and to support the creation of similar resources at other pediatric institutions. This work supports a structured, evidence-informed approach to pediatric FND rehabilitation with the potential to improve therapeutic engagement, consistency of care, and functional outcomes. 

References:
Nicholson C, Edwards MJ, Carson AJ, et al. Occupational therapy consensus recommendations for functional neurological disorder. Journal of Neurology, Neurosurgery & Psychiatry. 2020;91(10):1037-1045. doi:10.1136/jnnp-2019-322281
Nielsen G, Stone J, Matthews A, et al. Physiotherapy for functional motor disorders: a consensus recommendation. J Neurol Neurosurg Psychiatry. 2015;86(10):1113-111

177    FIVE YEAR MISDIAGNOSIS OF FUNCTIONAL NEUROLOGICAL DISORDER WITH OVERLAPPING COVID VACCINE, CERVICAL SURGERY, ANESTHETIC STRESS, AND A 52 HOUR HANDCUFF RESTRAINT (Treatment)
Joseph Korzen

Background: Functional neurological disorder (FND) is now defined as a rule‑in diagnosis based on abnormal brain‑network activity rather than structural lesions[7]. Early identification is essential because premature antipsychotic medication and coercive restraint aggravate symptoms and generate legal consequences[5]. FND diagnosis was verified by NIH‑funded research protocol Diagnosis and Natural History Study of Patients With Neurological Conditions.

Case Presentation:
2021 – After a COVID‑19 booster: progressive upper‑body tightening with fatigue CICP claim.
2022 Sept – C5‑C6 ACDF persistent foraminal stenosis. Intra‑operative "fighter‑flight" stress triggered functional symptoms.
2023 Oct – VCU EMG: chronic left C6 radiculopathy, mild right median mononeuropathy; no brachial plexus injury. Pinched nerve at C6 post-op.
2023 Dec – NIH EEG/EMG: Bereitschaftspotential and no epileptiform activity  functional chorea confirmed.
2025 Feb – 2.5‑hour non‑epileptic seizure: ED diagnosed "psychotic break," gave haloperidol 5 mg IM + risperidone 1 mg q12 h before neurophysiology, issued TDO. Called 911 after staff refused release; handcuffed to bed 52 hrs, accused of "eloping."
Patient‑directed communication: Text‑to‑speech request for GP ignored returned without GP involvement. This is a local hospital that has all my data. I've been going there for years.

Data compilation: Former school system USDA IT specialist applied audit‑style validation to create 5‑year de‑identified case file.

Discussion: Systemic failures: (1) Premature antipsychotics without neurophysiologic confirmation; (2) Fragmented care and 52‑hr restraint amplified symptoms; (3) Legal actions based on unsubstantiated psychiatric label (firearms ban, "eloping" accusation). Onabotulinumtoxin A trial showed no benefit beyond CBT, confirming need for diagnostic confirmation before intervention[6]. BMJ review stresses early rule‑in diagnosis and rehab improves outcomes[5]. Multiple triggers (vaccine, incomplete surgery, anesthetic stress) converged to produce FND; misdiagnosis snowballed into medical‑legal crisis. Recommendations: (a) Mandatory functional neuroimaging before psychiatric labeling; (b) Early multidisciplinary pathways; (c) Respect patient‑directed communication (e.g., text‑to‑speech GP requests) to prevent unnecessary restraint.

References:
Vizcarra JA et al. Onabotulinumtoxin A and CBT in functional dystonia. Parkinsonism Relat Disord. 2019;46:1‑8. https://pubmed.ncbi.nlm.nih.gov/30777651/
Aybek S, Perez DL. Diagnosis and management of FND. BMJ. 2022;376:o64. https://www.bmj.com/content/376/bmj.o64

178    PAINLESS LEGS MOVING TOES SYNDROME, A CASE SERIES OF 3 PATIENTS: IS IT FUNCTIONAL OR NOT? (Phenomenology/Epidemiology)
Ejaz Shamim, MD, MS, MBA, FAAN, Kaiser Permanente Mid-Atlantic States, Mid-Atlantic Permanente Medical Group

Introduction: Painful legs moving toes syndrome is different from Painless legs moving toes syndrome (PLMTS), which is a relatively new condition and appears to have functional characteristics of distractibility and entrainment.  Here we describe three patients who have PLMTS without these characteristics.

Case Presentation: Our 1st patient is 29-year-old white female with symptoms starting in the right 2nd and 3rd toes 5 years before presentation.  She had trauma to the leg prior to developing the painless side to side movements of these toes.  The toe movements are not completely distractible and do not entrain. She has Chiari 1 and lumbar radiculopathy without weakness.  These movements do not stop her from doing anything.

Our 2nd patient is a 35-year-old white male with abnormal involuntary movements of the right big toe.  This started 15 years ago after his friend passed away from a stroke at a very young age.  The big toe continuously moves and is not completely distractible and does not entrain.  There is no history of trauma, and it does not stop him from doing anything.

Our 3rd patient is a 75-year-old Indian female with Parkinson’s disease (PD) with involuntary painless movements of the right medial three toes that is not completely distractible and do not entrain. There is no history of trauma.  It is not stopping her from doing anything.

Discussion: While Painful legs moving toes syndrome is considered an organic condition, PLMTS is thought be a functional condition.  While functional characteristics are present, it is possible that subcortical movement generators may be partially modulated by intentional movements1 leading to incomplete distractibility in these three patients. This may suggest an organic etiology with functional overlay. In our 1st patient, known organic causes for PLMTS exist and the phenomenology is without pain.  In the 3rd patient with PD, early dyskinesia can cause these movements and typically PD related dyskinesias are not modulated by distracting maneuvers.  Based on these cases, one would wonder if PLMTS may have an organic basis with a functional overlay.   

Reference:
1 N Vanegas-Arroyave, P Panyakaew, D Lamichhane, L Shulman and M Hallett “Possible Functional Moving Toes Syndrome.” Tremor and other Hyperkinetic Movements. 2016 Mar 22;6:352. doi: 10.7916/D8CZ36XT (PMID 27144090)

179    FUNCTIONAL CONNECTIVITY PREDICTORS AND MECHANISMS OF SYMPTOM CHANGE IN FUNCTIONAL NEUROLOGICAL DISORDER (Etiology/Pathophysiology)
Christiana Westlin, PhD, Massachusetts General Hospital

Background: Clinical trajectories in functional neurological disorder (FND) are variable, and the mechanisms underlying this heterogeneity remain poorly understood. This longitudinal study examined resting-state functional connectivity predictors and mechanisms of symptom change in FND.
 
Methods: Thirty-two adults with FND (motor and/or seizure phenotypes) completed baseline questionnaires and a functional MRI (fMRI) session, followed by naturalistic treatment for 6.8±0.8 months. All participants completed follow-up questionnaires; 28 individuals completed a follow-up fMRI. At each timepoint, three graph-theory network metrics of functional connectivity were computed: weighted-degree (global centrality), integration (between-network connectivity), and segregation (within-network connectivity). Analyses adjusted for age, sex, anti-depressants, head motion, time between sessions, and baseline score of interest – with cluster-wise correction applied. Results were contextualized against 59 healthy controls (HCs). 

Results: Based on patient-reported Clinical Global Impression of Improvement, 59.4% improved, 31.3% were unchanged, and 9.3% worsened. Psychometric scores of core FND symptoms and non-core physical symptoms showed variable trajectories, with no group-level changes. Greater improvement in core FND symptoms was associated with higher baseline between-network integrated connectivity and reduced integration longitudinally within salience, frontoparietal, and default mode network regions. Right anterior insula integration emerged as a prognostic marker and mechanistic site of reorganization, with the most improved participants showing elevated baseline integration compared to HCs. Increased baseline within-network segregated connectivity in dorsal attention network regions correlated with non-core physical symptom improvement. Findings remained significant adjusting for FND phenotype.

Conclusions: This study identified large-scale network interactions as potential prognostic and mechanistically-relevant sites of reorganization related to symptom change in FND. 

180    A TECHNIQUE FOR INDUCING HOOVERS SIGN IN HEALTHY CONTROLS: INSIGHTS INTO MECHANISMS IN FUNCTIONAL NEUROLOGICAL SYMPTOMS (Phenomenology/Epidemiology)
Andrew Whitfield, King's College Hospital, London

Background: Hoover’s sign describes an improvement in weakness of hip extension during flexion of the contralateral hip against resistance. Here, ‘voluntary’ extension improves through ‘involuntary’ activation. This dissociation between ‘voluntary’ and ‘involuntary’ motor output is a key diagnostic feature of functional neurological disorder (FND), but can also be found in apraxia, chronic fatigue and pain. We have identified a technique that induces a transiently positive Hoover's sign in healthy people. Observations suggest that application of a vibrating 128Hz tuning fork to the patella for 10 seconds induces a transient reduction in ‘voluntary’ hip extension which normalises with ‘involuntary’ activation through flexion of the contralateral hip. The induced Hoover’s sign seems to resolve spontaneously after 30-45 seconds in healthy controls and longer in those with FND. The weakness seems to be less pronounced if the subject moves (or even imagines moving) the contralateral side during induction.
 
Methods: We have designed an experiment to quantify the effects of this technique in healthy controls (n=20) and FND patients (n=20) using a novel force gauge apparatus. 128Hz vibration will be applied to the patella for 10 seconds with repeat measures of ‘voluntary’ and ‘involuntary’ hip flexion at 15 second intervals for a minute using a novel force measurement apparatus (fig.1). A neurologist, blinded to time of induction, will also rate power using MRC grading and give a binary judgement of whether Hoover’s is positive. A handheld pressure gauge will also be used and order of these tests randomised. [Fig.1]

Results: Objective measurement of this observed effect will be presented.

Conclusion: FND has been proposed to reflect abnormalities of predictive processing, sensory attenuation [1], and proprioceptive integration, leading to an altered sense of agency. Vibratory stimuli distort proprioception disproportionately in FND [2]. By coupling proprioceptive perturbation with altered voluntary motor output, this paradigm offers mechanistic insights into the development of FND. 

References:
1. Pareés I, Brown H, Nuruki A, Adams RA, Davare M, Bhatia KP, Friston K, Edwards MJ. Loss of sensory attenuation in patients with functional (psychogenic) movement disorders. Brain. 2014 Nov;137(Pt 11):2916-21. doi: 10.1093/brain/awu237. Epub 2014 Aug 26. PMID: 25161293. 
2. Tinazzi M, Marotta A, Zenorini M, Riello M, Antonini A, Fiorio M. Movement perception of the tonic vibration reflex is abnormal in functional limb weakness. Parkinsonism Relat Disord. 2021 Jun;87:1-6. doi: 10.1016/j.parkreldis.2021.04.011. Epub 2021 Apr 20. PMID: 33895678.

181    FUNCTIONAL NEUROLOGICAL DISORDER, IMPACT ON WOMEN AND GENDER MINORITES (Phenomenology/Epidemiology, Treatment)
Kimberly Williams, MD, MSc, FRCPC, University of Calgary

Background: Functional neurological disorder (FND) is a common and disabling condition existing at the interface of brain, mind and body. FND disproportionately affects women1 and emerging evidence shows it also impacts those who identify as gender divesre2 who historically are often left out of research.  Like other health conditions with a predominance in women or minorities, it is under-diagnosed, under-treated and under-researched, despite the impacts on quality of life being like other neurological conditions3. The Calgary Functional Neurological Disorder Program was established in 2023. This women-led clinic recognizes that women and gender minority individuals may present with different clinical factors than cis-gendered men. This study aimed to examine these clinical factors to ensure FND programs broadly support all patients in a data-driven way. 

Methods: All patients who consented and attended an initial assessment completed an intake questionnaire as part of a registry. Assessing physicians completed post-assessment data on factors that may affect patient treatment. This data was analyzed using descriptive statistics to better understand this group of women and gender diverse individuals. 

Results: One-hundred and twelve patients were included in this study. Most patients identified as women (66%), and reported a history of abuse (71%). Those who identified as gender diverse (p= 0.01) were significantly more likely to report a history of abuse (80%) than cis-gender men (41%). Women reported longer time to diagnosis than men (30 versus 27 months), while those who identified as gender diverse the wait was considerably less (15 months). The most common FND-relevant factors for women were somatic preoccupation (54%), autonomic hyperarousal (56%) and propensity to disassociation (47%). For gender diverse individuals it was similar with a somatic preoccupation (83%) and propensity to dissociation (83%). Although men also had a somatic preoccupation (59%), they were more likely to struggle with emotional avoidance (35%). Women (61%) and gender diverse people (67%) were likely to be ready for change, which is a positive prognostic factor for rehabilitation. 

Conclusions: Little research exists on this topic specifically focused on women and those who identify as gender diverse, despite the gender burden of this disorder. This study starts to better understand factors affecting both women and gender diverse patients. FND remains a gender issue as sexual abuse and violence are more often experienced by women and gender diverse individuals than men, and are risk factors for FND1. Women have a longer delay to diagnosis, but are often ready for change which is a positive prognostic factor. Historically gender diverse people are often not included in research, with further research needed to ensure FND programs are supporting all individuals living with this disorder.

182    IT'S NOT ALL IN THEIR HEAD: NURSE PERCEPTIONS AND KNOWLEDGE  GAPS ABOUT FUNCTIONAL NEUROLOGICAL DISORDER (Treatment)
Lynzie Wylie, BSN, RN, CPN, CNRN, Arkansas Children's Hospital

Background: Functional Neurological Disorders in pediatric patients are frequently misdiagnosed or misunderstood in clinical settings, leading to inconsistent management and potential harm. Nurses play a crucial role in recognizing and managing FND, yet there is a lack of standardized education and training specific to pediatric FND, contributing to delays in diagnosis, inadequate communication with families and fragmented care.

Methods: Qualitative design using survey methods and semi-structured interviews.
The study was approved by the AC Research Council and the Institutional Review Board (IRB) of the University of Arkansas for Medical Sciences (UAMS). Participants were nurses who provide direct care at: Arkansas Children's (AC), hospital system in Little Rock and Springdale, Arkansas, and Public schools across the state of Arkansas. An 8-item survey measured nurses’  perceptions and understanding of FND. Optional semi-focused interviews were conducted with 11 main questions focusing on their knowledge and experience with FND. 

Results: AC Nurses: The mean number of FND patients reported in the last six months was 6 (SD 8.8). 82.4% reported they are moderately or very prepared to care for FND patients.58.8% agree or strongly agree that their coworkers understand FND. School Nurses: The mean number of FND patients reported in the last six months was 2 (SD 1.4). 77.7% reported they are moderately or very prepared to care for FND patients. Only 11.6% agree or strongly agree that their coworkers understand FND, which is much lower than the AC nurses. 

To date, 11 interviews have been conducted. Preliminary findings indicate that school nurses often have minimal baseline knowledge of FND, and lack formal protocols. Participants commented:"These patients and their families often express they feel like their concerns/complaints are overseen and not taken seriously.""This [FND] needs to be taught all over the state as people do not understand this diagnosis. Patients are dismissed, accused of "faking" their illness, and many times this can lead the patient to other maladaptive coping, which can be harmful or life threatening."

"I feel morally and ethically in limbo for treating them...more education, pathways and protocols need to be developed."

Conclusions: Hospital nurses demonstrated slightly greater familiarity but reported diagnostic challenges, inconsistent interdisciplinary understanding, limited mental health resources, and frequent repeat presentations. Braun, V., & Clarke, V. (2006). Using thematic analanalysis in psychology. Qualitative Research in Psychology, 3(2), 77--101. https://doi.org/10.1191/1478088706qp063oa

References:
Tanner, A., von Gaudecker, J., Buelow, J. M., & Miller, W. R. (2025). Adolescents' Perceptions oof School Nurses' Role in Functional Seizures at School. The Journal of school nursing : the official publication of the National Association of School Nurses, 41(5), 625–631

183    PERSISTENT PALATAL MYOCLONUS: TWO CHALLENGING CASES (Treatment)
Irem Yıldız, Hacettepe University

Introduction: Palatal myoclonus (pm) is a rare movement disorder characterized by rhythmic, involuntary contractions of the soft palate. Functional pm may present diagnostic and therapeutic challenges, particularly when symptoms persist despite conventional treatment. Distinguishing functional from structural causes requires careful clinical assessment and often a multidisciplinary approach. We present two cases of persistent functional pm illustrating the complexity of diagnosis and management.

Case Presentation: The first case involved a 31-year-old woman with a 1.5-year history of palatal myoclonus. Symptoms began after the death of her father and initially presented as a burning sensation in the throat followed by rhythmic palatal contractions and facial muscle tension. Continuous movements caused chronic nausea and distress due to persistent clicking sounds described as “gluck-gluck.” She denied tinnitus or objectively audible ear clicks. Her history included surgical intervention on the left thyroid cornu performed at another center, after which symptoms worsened. Imaging later showed calcification of laryngeal cartilages. Palatal movements were absent during sleep and speech but prominent during rest. Botulinum toxin injections reduced the clicking sound but did not alter movement frequency. Nasoendoscopy demonstrated variability with distraction, supporting a functional etiology. A speech and language therapy program including diaphragmatic breathing temporarily reduced symptoms.

The second case was a 36-year-old female teacher with a history of avascular necrosis who had completed 54 sessions of hyperbaric oxygen therapy. During the final session, she developed ear fullness and clicking sounds. Following ventilation tube placement for suspected eustachian tube dysfunction, palatal tremor emerged. Neuroimaging, eeg, and laboratory tests were normal. Palatal movements decreased during speaking and chewing but intensified at rest, interfering with sleep. After eight sessions of speech and language therapy, only mild symptomatic improvement was observed, although daily functioning improved.

Discussion: These cases suggest that emotional stressors and medical interventions may contribute to the development of refractory functional palatal tremor. The absence of structural abnormalities and the modulation of symptoms with distraction represent important diagnostic clues. Variable responses to multidisciplinary rehabilitation highlight the need for long-term, integrated therapeutic approaches in complex functional movement disorders.

References:
Bhatia kp, edwards mj, espay aj, et al. Functional movement disorders: consensus criteria for diagnosis. Movement disorders. 2018.

184    SYSTEMATIC DEVELOPMENT OF A QUESTIONNAIRE TO QUANTITATIVELY ASSESS STIGMA IN FUNCTIONAL MOTOR DISORDER: A CROSS-SECTIONAL STUDY AMONG SWISS PHYSIOTHERAPISTS (Phenomenology/Epidemiology)
Corina Zweifel, Bern University of Applied Sciences, School of Health Professions, Bern, Switzerland

Background: Stigma among healthcare professionals towards people with functional motor disorder (FMD) is well documented and associated with decreased patient quality of life and iatrogenic harm. However, there is a lack of research assessing stigma among physiotherapists, who are increasingly seen as a central part in FMD rehabilitation. To date, no validated instrument exists to quantify stigma in this population. This study aims to close this gap by systematically developing such an instrument and to examine the current state of FMD stigma in Swiss physiotherapists.

Methods: Building on research on FMD stigma of McLoughlin et al. (2024, https://doi.org/10.1016/j.cpr.2024.102460), a systematic synthesis of questionnaire items was conducted. Items underwent expert content validation by four individual experts in FMD, who rated each item regarding relevance and clarity. Items with an Item-Content Validity Index >0.9 were maintained for feedback from people living with FMD and pilot tested with physiotherapists. The final questionnaire includes 33 stigma items on a 5-point Likert-scale. The total score ranges from 33 to 165, with higher scores indicating higher stigma. [figure1] From October 2025 to January 2026 a cross-sectional online survey with a multi-stage purposive sampling approach was conducted.

Results: Out of 576 people who initially engaged with the survey, 452/576 (78.5%) reported that they knew the term FMD. Within this group 64/452 (14.2%) reversed their response after reading the definition. Excluding missing data, this left 159/576 (27.6%) participants unfamiliar with the definition of FMD. 407/576 (70.7%) participants met eligibility, 301 (74.0%) of which completed all 33 stigma items. Internal consistency was high (Cronbach’s α=.91, 95% CI [.81, .91]). The mean score was 68.5 (SD 13.2) and the median 70 (IQR 58-77). [figure2]
A multiple linear regression was applied to examine the relationship between stigma score and the participants’ age, specialisation and prior FMD education. Only prior education was significantly associated with stigma, with respondents who received FMD education scoring significantly lower (t = 4.689, p<.001).

Conclusions:The systematic development of an instrument to quantify physiotherapists’ stigma towards FMD yielded a 33 item questionnaire with high internal consistency.

Overall stigma scores in Swiss physiotherapists were in the lower third of the scale. Further threshold testing is required to determine if this translates to low stigma.

While stigma did not depend on age or specialization, prior FMD education was associated with lower scores. The high number of respondents unfamiliar with FMD’s definition suggests gaps in knowledge and potential challenges related to inaccurate self-assessment of competence.
Educators and policy makers should ensure that physiotherapists receive adequate FMD training to enhance their understanding and potentially reduce stigma.

185    THE NEURAL UNDERPINNINGS OF ALEXITHYMIA DURING NEGATIVE FACIAL PROCESSING IN INDIVIDUALS WITH CURRENT AND PAST FUNCTIONAL APHONIA (Etiology/Pathophysiology)
Maria Dietrich, Universitätsklinikum Bonn

Background: Functional aphonia (FA) is a functional voice disorder characterized by a loss of audible voice. The neural underpinnings of alexithymia in individuals with current and past FA remain elusive. People with alexithymia have difficulty identifying, processing, or describing feelings in self or others implicating brain areas involved in emotion processing, empathy, and self-awareness.1,2 In this study, we investigated the association between alexithymia scores and brain regions during complex emotion processing of faces.

Methods: In a sample of n=10 individuals with current FA, n=7 with past FA, and n =8 healthy controls (HC), we investigated the total score of the Toronto Alexithymia Scale (TAS-20). A univariate analysis of covariance with post-hoc contrasts correcting for age and sex were conducted. Of those individuals, n=15 also underwent an fMRI study presenting faces in the emotional state conditions (fear, happy, neutral). A General Linear Model was fitted to each individual's functional data to map task-related brain activity during the stimulus contrast “fear greater neutral.” Across the sample, a multiple regression and whole brain approach (p<.001 unc., extent threshold=10) was used for an exploratory test of the association with TAS-20 scores (age and sex as covariates). 

Results: Group differences in the TAS-20 scores were significant (p<.0001, partial eta²=.607). Follow-up contrast revealed significant differences between healthy controls compared to people with current (p<.001) and past FA (p=.004). Across the sample, we found a positive association between TAS-20 scores and peak voxels located in the bilateral cerebellum (xyz=-9 -40 -19, k=23, p<.0001, xyz=6 -67 -16, k=18, p<.0001 unc., xyz=9 -37 -16 k=10, p<.0001 unc.) and the right thalamus (xyz=24 -25 11, k=15, p<.0001 unc.) [figure1]. Data collection is ongoing.

Conclusions: Exploratory data analysis in this difficult-to-recruit population showed that people with current FA compared to controls presented with elevated alexithymia. During the processing of fearful compared to neutral faces, the higher alexithymia score was associated with increased BOLD signal in subcortical regions implicated in early-stage salience detection (thalamus) and cerebellar regions spanning sensorimotor (lobules III-V) and affective-regulatory territories (vermis VI). These preliminary data may suggest heightened bottom-up emotion reactivity in individuals with greater alexithymia scores. 

References: 
1.Huber M, Herholz K, Habedank B, et al. Different patterns of regional brain activation during emotional stimulation in alexithymics in comparison with normal controls. Psychother Psychosom Med Psychol. 2002;52(11):469-478.
2.Rosenberg N, Ihme K, Lichev V, et al. Alexithymia and automatic processing of facial emotions: behavioral and neural findings. BMC Neurosci. 2020;21(1):23.

186    ECONOMIC DISPARITY IN FUNCTIONAL NEUROLOGICAL DISORDER: RISING HEALTHCARE COSTS, CONTINUED LOW RESEARCH INVESTMENT (Phenomenology/Epidemiology)
Christopher Stephen, MB ChB, FRCP,  MSc, SM, Massachusetts General Hospital, Harvard Medical School

Background: Functional neurological disorders (FND) have high costs and healthcare utilization, comparable with other investigation and pharmacologically-intensive neurological disorders [1]. Previous data showed that the costs of FND have continued to rise despite a small relative share of research funding, when compared to rare and common neurological disorders [2]. We sought to assess the US inpatient and emergency department (ED) costs across its major subtypes, and comparison to national research funding updated to 2025.

Methods: We used 2008-2019 Healthcare Cost and Utilization Project data to assess adult (age >18) and pediatric (5-17 years) inpatient hospitalizations and adult/pediatric ED visits and associated charges. ICD-10-CM codes for functional neurological symptom disorder (F.44.4-F44.7) defined FND and its subtypes vs. neurological comparators neuro-inflammatory diseases, refractory epilepsy, and anterior horn cell diseases. NIH research funding (2017-2025) was assessed using NIHRePORTER, and compared across other neurologic and psychiatric diseases.

Results: In 2019, adult inpatient charges (95% CI) for FND were $1,614.1 million ($1,492.8–$1,735.4 million), representing a 47% increase since 2017 and exceeding all neurological comparators. Pediatric FND inpatient charges were $105.7 million ($83.5–$127.8 million), a 37% increase since 2012 but lower than comparator conditions. Adult ED charges for FND in 2019 were $257.9 million ($230.1-285.8 million), a 67% increase since 2017, exceeding all neurological comparators except refractory epilepsy. 2019 Pediatric FND ED charges were $27.7 million ($16.0–39.4 million), a 108% increase since 2017, greater than all comparators. Functional seizures accounted for most FND costs, while motor/mixed FND had the highest per-patient costs. 2019 inpatient/ED charges for adult/pediatric FND were over $2.0 billion, a 49% increase since 2017. The relative proportion of NIH funding to total inpatient/ED charges was lowest in FND vs. neurological comparators, and other neurological and psychiatric conditions, although there are encouraging signs of new early-stage investigator funding.

Conclusions: Inpatient and ED charges associated with FND have risen substantially over time, yet research investment has not kept pace. Relative to its clinical and economic burden, FND receives disproportionately low NIH funding compared with other neurological and psychiatric disorders, highlighting a persistent mismatch between healthcare utilization and research support.

References:
1. Stephen CD, Fung V, Lungu CI, Espay AJ. Assessment of Emergency Department and Inpatient Use and Costs in Adult and Pediatric Functional Neurological Disorders. JAMA Neurol. 2021;78(1):88-101. 
2. Stephen CD, Fung V, Perez DL, Espay AJ. Comparison of Inpatient and Emergency Department Costs to Research Funding for Functional Neurologic Disorder: An Economic Analysis. Neurology. 2025;104(6):e213445.

187    FUNCTIONAL FACIAL PALSY IN A HILLY POPULATION OF EASTERN INDIA: A RETROSPECTIVE OBSERVATIONAL STUDY (Phenomenology/Epidemiology)
Mahammad Samim Mondal, Mitra's Clinic and Nursing Home

Background: Facial nerve palsy is a common neurological presentation with diverse organic etiologies. Functional Facial Palsy (FFP), a subtype of Functional Neurological Disorder, remains underrecognized, particularly in geographically isolated hilly populations where psychosocial stressors are prevalent. This study aimed to determine the prevalence, demographic characteristics, and psychosocial risk factors associated with FFP among patients presenting with facial paralysis in the hilly regions of West Bengal, India.

Methods: This retrospective observational study included 807 consecutive patients presenting with facial paralysis between January 2020 and December 2025 at a tertiary care center serving predominantly hilly regions. Among them, 478 patients had upper motor neuron facial palsy due to central nervous system causes including stroke, demyelination, and other central etiologies. Lower motor neuron facial palsy was identified in 201 patients due to idiopathic causes, sarcoidosis, Sjogren syndrome, IgG4 related disease, vasculitis, and Lyme disease. Functional Facial Palsy was diagnosed in 128 patients based on positive clinical signs, internal inconsistency, symptom reversibility, and exclusion of organic pathology. Demographic variables, living status, family structure, interpersonal stressors, belief systems, and substance use were analyzed. Odds ratios with 95 percent confidence intervals were calculated using chi square analysis.

Results: Functional Facial Palsy accounted for 15.9 percent (128 of 807) of all facial paralysis cases. Female predominance was significantly higher in the functional group (72.6 percent) compared to organic facial palsy (OR 2.48, 95 percent CI 1.68–3.67, p<0.001). The most affected age group was 25–30 years, comprising 34.4 percent of cases (OR 2.11, 95 percent CI 1.42–3.12, p=0.002). Living alone showed a strong association with Functional Facial Palsy (OR 2.86, 95 percent CI 1.91–4.29, p<0.001). Psychosocial stressors including family conflict (OR 3.02, 95 percent CI 2.01–4.54, p<0.001), interpersonal relationship issues (OR 2.67, 95 percent CI 1.74–4.09, p=0.001), broken family structure or orphan status (OR 3.54, 95 percent CI 2.18–5.75, p<0.001), and lack of spiritual affiliation or atheism (OR 1.89, 95 percent CI 1.11–3.22, p=0.018) were significantly associated. Academic and professional stress was an independent risk factor (OR 2.41, 95 percent CI 1.58–3.68, p=0.001). Substance use and behavioral addictions were also significantly more common in the functional group (OR 2.23, 95 percent CI 1.41–3.51, p=0.004).

Conclusion: Functional Facial Palsy constitutes a substantial proportion of facial paralysis in the hilly population of West Bengal, predominantly affecting young adult females. Social isolation, family dysfunction, academic and occupational stress, and substance use are key associated factors, highlighting the need for early recognition and a biopsychosocial management approach.

188    WHEN ‘EPILEPSY’ IS NOT EPILEPSY: A STUDY ON THE SPECTRUM OF FUNCTIONAL/DISSOCIATIVE SEIZURES (Phenomenology/Epidemiology)
Mahammad Samim Mondal, Mitra's Clinic and Nursing Home

Background: Functional/dissociative seizures(FDS) are a frequent cause of diagnostic uncertainty in neurology practice and are often misdiagnosed as epilepsy. Misdiagnosis may lead to delayed treatment, unnecessary antiseizure medications, financial burden, and persistent stigma. This study evaluated the clinical spectrum, determinants, distinguishing features, and overlap between FDS and epilepsy in a real-world setting.

Methods: From July 2024–January 2026, consecutive patients with suspected seizures across outpatient, inpatient, and emergency services were prospectively evaluated. All underwent EEG, video-EEG capturing≥2 habitual events, epilepsy-protocol MRI, and psychiatric assessment in FDS cases. Suggestive induction was used during video-EEG (glabellar tap with reflex hammer and rubbing chin with spirit and cotton swab). Final FDS diagnosis followed ILAE staged criteria with video-EEG confirmation.

Results: Among 1,547 patients, 148 had FDS and 14 epilepsy patients later developed overlapping FDS. FDS predominantly affected females(93.9%vs57.3%), most aged 20–30 years(66.2%), and was more associated with low socioeconomic status(38%vs24%), education <10 years (34%vs29%), living alone(2.7%vs0.7%), atheism(5.4%vs0.7%), and mood disorders (68.9%vs12.7%) (p<0.05 for all).
Semiology strongly favored FDS: slow falling(81.8%vs30.0%;OR10.5), tightly closed eyes (84.5%vs5.6%;OR91.5), eyelid quivering(50.7%vs0.4%;OR286.6), out-of-phase limb movements (UL 68.9%vs3.4%;OR63.8; LL 33.1%vs6.4%;OR7.3), pelvic thrusting(32.4%vs3.0%;OR15.4), hand tremor(69.6%vs11.3%;OR17.9), gasping(66.2%vs1.7%;OR112.3), crying(9.5%vs0.3%;OR36.4), awareness without response(97.3%vs14.4%;OR63.5), presence of others(83.8%vs39.1%;OR7.9), emotional triggers(94.6%vs18.3%;OR81.2), prolonged post-event sleep (72.3%vs9.2%;OR176.9), and rapid recovery after stimulation(water 28.4%vs5.4%;OR6.9; bitter liquid 50.0%vs1.2%;OR80.3; nail pressure 68.2%vs6.2%;OR32.4). Eyelid blinking and upward eye rolling favored epilepsy; frothing was more frequent in FDS(73.6%vs62.9%;OR1.6). (p<0.05 for all).

Psychosocial stressors were common in FDS, including marital/interpersonal conflict(31.8%/29.7%), sexual dissatisfaction(31.8%), body image concerns(26.4%), sleep deprivation(23.6%), medical stress(18.9%), workplace stress(11.5%), relationship issues(12.8%), and divorce(8.1%); ≥1 stressor occurred in 52.7%. In epilepsy–FDS overlap(n=14), all had additional events with multiple triggers, most frequently poor seizure-control confidence and ASM anxiety(35.7%), fear of seizures and financial concerns(28.6%), new stressors and pregnancy concerns(21.4%), and intrusive memories/suggestion triggers(14.3%).

Conclusions: FDS demonstrates distinct demographic, psychosocial, and semiological signatures with strong odds ratios across multiple features, enabling reliable differentiation from epilepsy when systematic video-EEG and psychosocial assessment are integrated into routine clinical care.

189    TREATMENT OF FUNCTIONAL/DISSOCIATIVE SEIZURES IN AN ADOLESCENT WITH ISTDP (Treatment)
William Watson, PhD, University of Rochester Medical Center

Introduction: Patient is a 15 year-old female referred by her neurologist for psychological consultation regarding worsening functional/dissociative seizures (FDS) since discharge from LTM admission 8 months ago, lately occurring daily, up to 10 per day, with worsening correlated with sudden passing of grandfather and brother's suicide attempt. Episodes began 3 years prior when then-boyfriend became physically, sexually, and emotionally abusive

2 main types: 
- Ones out of anxiety happens most - she can hear during them.  Begins with tics, then buzzing feeling, feels off, overwhelming, unsettling feeling. Progresses to shaking/jerking, arching back, eyes flutter. 
- Ones she is not aware of - may look "dissociated" beforehand. She then falls over, doesn't seem to try to protect herself. She then goes into non-rhythmic jerking movements. Lasts 1-2 minutes and she is scared afterwards. She may seem to go into a panic attack after where she is breathing really fast. She can be more exhausted for even a full day after. These episodes were initially lasting 30-60 minutes. Returns to baseline quickly. Mom has seen 5 of these in the last few weeks. 

On LTM admission she had multiple spell types captured and all were non-epileptic. Her EEG background was abnormal though and was consistent with IgE trait. She was noted to have generalized discharges that may have correlated with eye blinks, which can be seen in Jeavons syndrome. Mom says that patient has had periods of eye blinking with eyes rolling backwards and staring, especially if looking in the sun, as well as hand jerks when she is tired or sleep deprived. Mom also notes that these episode often happen before she goes into one of her PNEA events.

Case Presentation: Patient is engaging, people-pleasing, conflict avoidant, problems with boundary setting, and avoidant of anger, both hers and others’. Successful emotion-focused treatment was initiated employing Intensive Short Term Dynamic Therapy. During treatment, patient was able to access and then discharge buried rage towards her abuser and others who had taken advantage, with gradual improvement in seizure frequency and then nearly complete cessation within several months of weekly treatment. 

Discussion: Case illustrates importance of assisting Functional/Dissociative Seizures with processing avoided anger, and the utility of ISTDP as a treatment modality in this case. In addition, extensive empirical evidence in the literature supports the validity and effectiveness of this approach in treating Functional/Dissociative Seizures. 

References: 
1. Russell, L., Abbass, A., Allder, S., A review of the treatment of functional neurological disorder with intensive short-term dynamic psychotherapy, Epilepsy & Behavior (2022), 130, 108657,
2. Abbass, A., & Haghiri, B., Intensive short-term dynamic psychotherapy for functional somatic disorders: a Scoping review,  Clinical Neuropsychiatry (2025) 22, 2, 111-120.

190    RECURRENT TARDIVE DYSKINESIA - A NEW TYPE OF FUNCTIONAL MOVEMENT DISORDER (Phenomenology/Epidemiology)
Steven Trau, MD, University of North Carolina at Chapel Hill School of Medicine

Introduction: Delayed-onset, involuntary orofacial movements during or after antipsychotic treatment are the classical features of tardive dyskinesia (TD). There are few reports of TD in pediatric patients. Functional movement disorders (FMD) are disruptions in motor function that are not attributable to structural pathology. Here, we present the first case of recurrent tardive dyskinesia as a manifestation of FND.

Case Presentation: An autistic 7-year-old boy presented to clinic with worsening tics. The tics began at age three and worsened over several years. At age 8, following onset of self-harm, he started aripiprazole. Aripiprazole led to significant improvement in mood and social interactions, but his tics continued to worsen. Five months later, new tics emerged, including head jerking and asynchronous eye darting. Aripiprazole was increased. One week later, the patient became more irritable and fatigued. He developed phonophobia and a tic-compulsion for staring at the sun. His behavior worsened to the point of suicidal ideation. His psychiatrist transitioned him from aripiprazole to quetiapine. He was admitted twice with negative workup for autoimmune encephalitis. Six months after onset of behavior change, complex movements developed including orofacial dyskinesia, myoclonus, dystonia, choreoathetosis, and akathisia. He described severe akathisia as the cause of his worsening behaviors and suicidal ideation. A diagnosis of tardive dyskinesia was made. His dose of quetiapine was increased, and a course of clonazepam was started. His TD improved and eventually resolved 5 months after diagnosis. 

Almost exactly one year after diagnosis, his typical tics and irritability began worsening. Several weeks later, nearly one year to the day after his hospitalization, he developed akathisia and identical movements as those leading to his TD diagnosis. The reemergence of tics resulted from the stress of a change in routine at the end of the school year. Recurrence of his tardive symptoms was felt to be a functional movement disorder in the setting of the anniversary of the hospitalization. One day after the diagnosis of functional tardive dyskinesia, the patient’s movements completely resolved (figure1).

Discussion: Our patient is the first case ever reported of recurrent TD as a manifestation of FND. There are likely many contributing factors to his FND, including autism, delayed diagnosis of FND, the loss of social structure at the end of the school year with subsequent increase in tics, and the one-year anniversary of admission and diagnosis of TD. Our patient’s functional tardive dyskinesia resolved immediately after the diagnosis, and he has not had recurrence. This case emphasizes a FMD phenomenology as well as the importance of early diagnosis of FND. 

191    ASSESSMENT OF 14 LIMBIC AND INTERRELATED NETWORKS’ FUNCTIONAL PROCESSES IN 133 INDIVIDUALS (Phenomenology/Epidemiology)
Yadira Velazquez-Rodriguez, MD, Science & Shamanism, LLC

Background: Limbic functional processes are important for overall nervous system and organism’s health. Previous research(1) mentions the need to incorporate integrative healing modalities that consider mental, emotional, sensori-motor, autonomic and spiritual concepts, in the treatment of all illnesses, especially functional. Multiple pathophysiological targets have been summarized (1, 2).  

Methods: Between June 2021 and February 2026, anonymous self-assessment questionnaires evaluating emotional parameters and related networks, were collected from individuals looking to receive integrative functional training. 

Results: Born between 1945 and 1998, 126 participants with a myriad of medical conditions and symptoms (table 1 provided online at https://www.scienceandshamanism.com/research-FNDS), and 7 reportedly healthy, completed the assessment. 14 questions evaluated limbic/emotional and interconnected neural systems functional processes (table 2). 97.76% of respondents demonstrated at least one abnormal limbic functional process  The most frequent dysfunctional process was emotional bottling/overwhelm affecting 60.9% of individuals. Only 3 participants answered correctly to all emotional functional statements.

Conclusions: Functional limbic specific assessments appear useful and necessary across medical and psychological integrative functional care. Questionnaire validation and further research on how the correction of such emotional processes influence overall wellbeing shall be undertaken.  Useful could be to create additional functional questionnaires evaluating other networks. 

References:
1) Velazquez-Rodriguez Y, Brooke F. Functional Neurological Disorder: Historical Trends and Urgent Directions. J Neur Res 13(1):12-32, 2) Experiential Education Methodology Targets FND Pathophysiology: An Interventional Study. Velazquez-Rodriguez Y, 5th International Conference on Functional neurological Disorders; 2024 June 8-11th, Verona, Italy

192    DISCREPANCIES BETWEEN PATIENT- AND PHYSICIAN-REPORTED SEVERITY AND DISABILITY IN FUNCTIONAL AND NON-FUNCTIONAL MOVEMENT DISORDERS (Phenomenology/Epidemiology)
Olof Vermeulen, University Medical Center Groningen

Background: Functional movement disorder (FMD) is a common cause of debilitating symptoms in neurology patients. Due to the stigma that is associated with FMD, it is possible that discrepancies between patient and physician judgements of severity and disability are more pronounced in FMD compared to non-FMD. A patient-physician discrepancy in judgement may be explained by associated comorbid non-motor symptoms.

Methods: In the prospective TASMAN study 171 FMD and 294 non-FMD patients were recruited from the Netherlands and Australia. Patient characteristics included non-motor symptoms: depression, anxiety, dissociation, pain, and fatigue. Patient- and physician-reported
severity and disability were collected using 7-point Likert scales. A quantitative measure of discrepancies was calculated by subtracting the physician’s score from the patient’s score. Associations between non-motor symptoms and disability were analysed using linear
regression.

Results: Patients reported significantly higher severity and disability compared to physicians in both groups. Patient-physician discrepancies in both severity and disability outcomes were not statistically different between FMD and non-FMD. FMD patients scored significantly higher on all non-motor symptoms compared to non-FMD. Patient-reported, but not physician-reported, disability was associated with increased pain and fatigue in both the FMD and non-FMD group. In FMD dissociation was associated with disability in both patient and physician-reported outcomes. In non-FMD depression was associated with disability in patient- and physician-reported outcomes.

Conclusions: Our results do not support notions of ongoing FMD-specific stigmatisation in physicians. Similar patient-physician discrepancies regarding severity and disability exist in FMD and non-FMD patients. Patient-physician discrepancies in disability in all movement disorder patients might be in part explained by different appreciation of the importance of non-motor symptoms.

193    THE GATEKEEPER’S DILEMMA: WHY SUSTAINABLE FUNCTIONAL SEIZURE CARE BEGINS WITH YOUR REFERRAL (Treatment)
Meagan Watson, MPH, MBA, University of Colorado

Background: Functional Neurological Disorders (FND) are poorly understood and frequently mishandled in healthcare systems.1 Despite established diagnostic criteria and evidence-based treatments, patients often experience misdiagnosis, stigma, and ineffective care. Central to these challenges is variability in the referral process. While referrals are intended to support timely, coordinated care, in practice, they are highly setting-dependent and fragmented, particularly for conditions that challenge medical categorization, like FND. This study examined referrals to an established ambulatory, multidisciplinary FND program and analyzed reasons for referral ineligibility.

Methods: The University of Colorado (CU) FND Program’s treatment paradigm has been published previously.2 Between 7/2024 and 12/2024, 318 referrals were reviewed by the CU team. At time of data collection, only functional/dissociative seizure (FDS) was accepted. Eligibility criteria are found in Figure 1. Data originated from electronic medical records and included referral setting, referring provider specialty, diagnosis, relevant diagnostic testing, and demographics. Chart review determined eligibility. Ineligibility was further categorized based on whether additional records might establish eligibility. Descriptive statistics characterized referred patients. Unadjusted associations were evaluated using chi-square tests for categorical variables and t tests for continuous variables. Outcomes included ineligibility, meeting ILAE criteria, and acquisition of requested documentation. Missing values were excluded. Multivariable logistic regression examined factors associated with outcomes, with variables selected a priori for clinical relevance. Adjusted odds ratios and 95% confidence intervals were reported. Subgroup analyses focused on Medicaid recipients.

Results: Of 318 individuals referred (Table 1), 47% were enrolled. 48% were ineligible, primarily due to incomplete diagnostic documentation (30%) (Figure 2). While 56% of referrals originated from neurology (Table 2), only 42% met ILAE criteria (Table 3). Insurance status strongly predicted referral ineligibility, with uninsured patients (OR 12.40, p<0.01) and Medicaid recipients (OR 2.39, p=0.01). Inpatient status (OR 0.15, 0<0.01) and Hispanic ethnicity (0.40, p=0.04) protected against ineligibility. Inpatient settings referrals were more likely to meet ILAE criteria (OR 10.08, p<0.01).  

Conclusions: Although the CU FND Program has been established since 2016, with standardized referral pathways, ongoing referral variability highlights that FND program sustainability and resultant quality begins with referral. 

References: 
Stone J, et al. Who is referred to neurology clinics? the diagnoses made in 3781 new patients. Clin Neurol Neurosurg. 2010;112(9):747-51. 
Libbon R, et al. The feasibility of a multidisciplinary group therapy clinic for the treatment of nonepileptic seizures. Epilepsy Behav. 2019;98(Pt A):117-23.

194    PSYCHIATRIC SYMPTOMS AND DIAGNOSIS IN PSYCHOGENIC NONEPILEPTIC SEIZURES: PRELIMINARY FINDINGS OF A SYSTEMATIC REVIEW (Phenomenology/Epidemiology)
Antonella Maino, HUG

Background: Patients with psychogenic nonepileptic seizures (PNES) often experience a significant burden of psychiatric comorbidities, affecting prognosis, access to appropriate treatment, and overall quality of life. Reported prevalence rates vary widely due to methodological heterogeneity, such as differences between formal psychiatric diagnoses and symptom assessments. This systematic review aims to examine how psychiatric comorbidities are assessed in PNES and to summarize reported prevalence rates. The final findings will support the development of a clinical project to implement systematic psychiatric screening in first-episode PNES patients at our institution.

Methods: A systematic literature review was conducted using PubMed and reference list screening. Search terms included (“psychogenic nonepileptic seizures” OR PNES OR “functional seizures”) AND (psychiatric OR “mental disorders” OR comorbidity OR depression OR anxiety OR PTSD). No overlapping reviews were found in the PROSPERO database. Eligible studies included PNES cohorts reporting either (1) psychiatric diagnoses based on standardized criteria (e.g., DSM, SCID, MINI, K-SADS) or (2) psychiatric symptoms assessed using validated instruments (e.g., BDI, HADS). Studies focused on personality traits, neuroimaging, treatment outcomes, screening validation, or registry data without PNES cohorts were excluded.

Results: Out of 838 studies, 28 reporting standardized psychiatric diagnoses were included. These used structured psychiatric interviews (SCID, MINI, DSM-IV/DSM-5) or documented diagnoses in clinical histories. Reported prevalence varied widely: major depressive disorder (21.5–72.5%), anxiety disorders (6–54%), PTSD (5–58%), dissociative disorders (4.5–71%), and personality disorders (6–50%). This heterogeneity reflects differences in sample characteristics, clinical settings, diagnostic instruments, and classification methods, limiting comparability across studies.

Quantitative synthesis has not yet been performed for psychiatric symptoms studies, and are described qualitatively. Depression, anxiety, trauma-related, and dissociation symptoms were consistently elevated in PNES populations. Screening tools, thresholds, and analytic aims varied substantially, and positive screenings were rarely followed by standardized diagnostic confirmation.

Conclusions: The preliminary results of this systematic review demonstrate a high psychiatric burden in individuals with PNES, but relatively few studies provide standardized diagnoses with extractable prevalence data. Studies varied widely in cohort composition, stratification, and use of psychiatric variables. These findings highlight a gap between symptom screening and formal diagnostic evaluation in PNES research. Future studies should prioritize standardized diagnostic criteria and longitudinal designs to better evaluate the impact of psychiatric comorbidities on PNES outcomes.

195    LIMB VASOMOTOR CHANGES IN FND (Etiology/Pathophysiology)
Victor Mark, MD, University of Alabama at Birmingham

Background: Patients in our Functional Neurological Disorder (FND) clinic often complain that their distal extremities can become either cool or cyanotic. Thus far there has been no prospective study as to the extent of such "acrocyanosis" (Demircioğlu and Öztürk Durmaz 2025), nor their specificity, with FND. Such changes have been reported in other neurological disorders, particularly Multiple System Atrophy (Klein et al 1997). Understanding these apparent vasomotor changes in FND may pertain to its disease mechanism. 

Methods: The feet of adults diagnosed with FND and age-similar control participants without brain disorder were video recorded. The following were measured from the video recordings by using NIH ImageJ: (1) the greyscale intensity changes following gentle manual compression, sufficient to blanch the skin, in the altered region of interest, and (2) the amount of time for capillary refilling following compression. Evaluations were performed by observers who were blinded to subject group membership. 

Results: This study explored the responses in 15 FND patients (mean age 46) and 15 non-neurologic illness controls (mean age 52, no difference).  The greyscale intensity changes after compression were greater in FND patients (mean 22.2, SD 23.3), vs healthy controls (mean 18.2, SD 13.8), though not significantly different. Similarly, the capillary refill times did not differ between groups, but surprising was that the FND patients' refill time was faster (2.4 sec, SD 2.0) than in controls (mean 3.4 sec, SD 2.3). 

Conclusions: In this preliminary study, FND patients non-significantly had skin tone changes after manual compression and faster capillary refilling. It is possible that variations in capillary refilling and skin tone changes following gentle compression are little understood in the general population. Further investigations are ongoing to measure the skin temperatures in the feet, because many FND patients indicate that they feel colder compared to before the onset of the illness. 

References: 
Klein C, Brown R, Wenning G, Quinn N. The "cold hands sign" in multiple system atrophy. Mov Disord 1997;12:514–518.
Demircioğlu D, Öztürk Durmaz E. Acrocyanosis: the least known acrosyndrome revisited with a dermatologic perspective [review]. Dermatol Res Pract 2025;2025:2904301.

196    DRIVING ASSESSMENT IN PEOPLE WITH FUNCTIONAL/DISSOCIATIVE SEIZURES – AN INTERNATIONAL SURVEY AMONG MEDICAL PROFESSIONALS (Phenomenology/Epidemiology)
Urs Fisch, University Hospital Basel, Basel, Switzerland

Background: Data on driving safety in people with functional/dissociative seizures (PwFS) are limited. We used a “wisdom of the crowd” approach to assess medical professionals’ opinions regarding driving recommendations for PwFS.

Methods: We conducted a global, web‑based survey of medical professionals addressing driving in PwFS. The survey was available from February to September 2025 and disseminated through major professional societies (AAN, ACNS, AES, EAN, FNDS, ILAE). Only complete responses were analyzed.

Results: 320 respondents from 48 countries completed the survey. Most were neurologists (79%); the remainder were neuropsychologists, therapists, and advanced practice nurses. Respondents were predominantly based in English‑speaking countries (69%).

Features most frequently considered incompatible with driving (multiple responses permitted) included loss of responsiveness (81.9%), motor or sensory semiology (73.4%), and prior seizure‑related injuries (42.2%); in contrast, 9.1% reported no incompatible features. Features considered compatible with driving despite ongoing functional/dissociative seizures (multiple responses permitted) included seizures occurring exclusively in non‑driving contexts (e.g., in bed) (65.9%), a sufficiently long prodrome (54.7%), and reliably avoidable triggers (51.9%); however, 11.9% endorsed that PwFS should not drive at all.

Regarding decision making factors, respondents ranked items on a 5 point scale from 1 (most important) to 5 (least important). Expert clinical opinion, local regulations, and published research were consistently ranked higher than institutional practice and personal experience (all pairwise adjusted p < 0.001; Kendall's W = 0.07).

Recommended seizure‑free intervals varied substantially, most commonly 6 months (33.4%), 3 months (25.3%), and 12 months (17.8%). Shorter or longer intervals were each endorsed by fewer than 9%, while 14.5% reported that no seizure‑free interval was required.

Conclusions: Most medical professionals support individualized driving decisions for PwFS based on specific clinical features; however, there is substantial variability in recommended seizure‑free intervals. These findings underscore the need for evidence‑based guidance while reflecting current reliance on expert judgment and local regulatory frameworks.

197    NEUROLOG: A SYSTEMATIC DIGITAL SYMPTOM MONITORING PLATFORM PRODUCING REAL-WORLD LONGITUDINAL DATA IN FUNCTIONAL NEUROLOGICAL DISORDER (Phenomenology/Epidemiology)
Jason Kreuzman, OTR/L, Neurolog

Background: NeuroLog is a free app that is made for individuals with FND. Users fill out three different kinds of structured logs. Daily records record the overall severity, physical and emotional intensity, mood, symptoms, triggers, and free-form thoughts. Flare logs keep track of short-term events in excellent detail, including the symptoms, triggers, emotional states, therapies utilized, perceived effectiveness, and mood before and after the event. Adaptive response questionnaires gather contextual data regarding symptom patterns, activity levels, and coping mechanisms, with questions that adapt according to individual data over time. The platform keeps track of 49 different emotional states, 14 different sorts of interventions, and many different symptom categories that include motor, cognitive, sensory, and autonomic symptoms. Users also fill out a comorbidity questionnaire that asks about the type of ailment and when it started in relation to the onset of FND. Phenotype scores are calculated for cognitive, somatic, seizure, and movement presentations. All data is kept safe and anonymous.

Results: More than 1,700 people had signed up for the platform by the beginning of 2026. There are more than 6,000 daily logs, 800 flare logs, and 7,400 adaptive reactions in the dataset. During flare episodes, users report an average of 11 concurrent symptoms across motor, cognitive, and sensory domains. The average daily physical intensity is 6.1 out of 10, while the average daily emotional intensity is 5.5 out of 10. There is a strong positive association between the two (r = 0.20). Flare episodes correlate with an average mood decline of 2.4 points. Stress (38%), worry (29%), and anger or annoyance (20%) are the most common things that cause flares. Social support (6.8/10) and environmental change (6.6/10) are viewed as better ways to deal with stress than breathing exercises alone (4.1/10). Comorbidity data from 3,385 entries reveals that 72% of users reported having at least one physical health issue prior to their FND diagnosis.

Conclusions: NeuroLog offers a scalable, organised method for gathering real-world FND data that goes beyond current self-management solutions. Preliminary descriptive results indicate that the platform can capture the multisystem, context-dependent characteristics of FND at an unprecedented scale. The dataset provides a basis for exploring how triggers relate to symptoms, how emotions affect symptom severity, how well treatments work, grouping similar symptoms, and how existing health issues make someone more likely to have FND.

References:
Shiffman, S., Stone, A. A., & Hufford, M. R. (2008). Assessment of ecological moments. Annual Review of Clinical Psychology, 4, 1–32.

198    FUNCTIONAL MOTOR DISORDERS REHABILITATION THROUGH GAMIFIED EXTERNAL-FOCUS TRAINING: A CASE SERIES (Treatment)
Marcela León, PT, INMOV

Background: Functional neurological disorders (FND) of gait generate substantial disability and often require specialized physiotherapy focusing on external attention. Gamified digital tools may increase motivation, promote automaticity of movement, and support motor relearning, but evidence in FND gait rehabilitation remains limited.

Methods: We report a series of five women (aged 40–71) diagnosed with functional gait disorders by a movement-disorders neurologist. All patients presented severe, continuous gait dysfunction with symptom duration ranging from two months to three years. Each participant completed three to five physiotherapy sessions emphasizing external focus and action-oriented tasks using the interactive application Active Arcade. Sessions were delivered twice weekly by specialized physiotherapists, with additional home use. Baseline severity was recorded using the Simplified Functional Movement Disorder Rating Scale (S-FMDRS). Perceived improvement (%) and final gait outcome were documented at the end of treatment. Total sessions varied according to feasibility and achievement of independent gait, as shown in Table 1 [table1].

Results: All patients demonstrated observable improvement from the first session, with perceived improvement ranging from 70% to 90%. Four participants achieved independent gait indoors and outdoors, while one returned to her baseline level (gait with cane). Despite varying chronicity and different assistive devices at baseline (walker, bilateral canes, wheelchair), rapid functional gains were consistently observed.

Conclusions: Therapeutic gamification with external focus using Active Arcade appears to be an accessible, engaging, and effective strategy for functional gait disorders. This approach may facilitate rapid functional reorganization and improve automatic gait control, even in severe or long-standing cases. These preliminary findings support integrating motivational digital tools into FND rehabilitation and highlight the need for controlled studies assessing durability and generalization of effects.

References:
Kelmanson AN, Kalichman L, Treger I. Physical rehabilitation of motor functional neurological disorders: a narrative review. Int J Environ Res Public Health. 2023;20(10):5793.
Wulf G, Lewthwaite R. Optimizing performance through intrinsic motivation and attention for learning: The OPTIMAL theory of motor learning. Psychon Bull Rev. 2016;23:1382–1414.

199    MATERNAL ENMESHMENT: A POTENTIAL COMPONENT OF FORMULATION FOR MEN WITH FND (Phenomenology/Epidemiology, Treatment)
Daniel Millstein, PhD, Mgb

Background: Population-based studies show men diagnosed with Functional Neurological Disorder (FND) at a rate of approximately 20-40%.1 This discrepancy may make detecting FND in male patients more challenging. In an effort to improve recognition of clinical presentations, it is important to delineate subtypes of males presenting with FND. One under-explored formulation for symptoms of FND in men involves enmeshment. This is a family therapy term to refer to an over-involved family relationship with porous boundaries.2 Specifically, with a stressful family dynamic (e.g. substance abuse, intimate partner violence), a mother may involve a son in her life in a way that can be overly close and arrest aspects of the son’s development. Enmeshment patterns in men can be associated with guilt, relationship difficulties, and tendencies towards self-criticism. Less work has been done exploring the role that maternal enmeshment might play in FND.

Case Presentation: A 48 year-old male with a history of FND with abnormal movements (hyperkinetic movements) as well as photophobia, chronic pain, and some sleep difficulty. Psychiatric history included early alcohol abuse, history of anxiety, depression (ECT a decade earlier), and possible mania/hypomania.  He had previously benefitted from CBT for insomnia and occupational therapist. He was currently on disability living at home with his mother. Family history was positive for early adverse childhood experiences (e.g. abusive father with alcoholism), and patient taking family role of protecting mother and siblings from father’s abuse. He had previously been in a long-term romantic relationship marked by partner’s infidelity and financial deception. Patient shared history of experiencing emotionally “fused” relationships with siblings. Presently, he noted observing that his mother’s non-specific health issues seemed to worsen when he was recovering from FND and moving towards more independent functioning. Over the course of treatment, he was able to clarify his own emotions, identify patterns of enmeshment, and practice communicating with his family and responding to them on his terms. Upon termination, he shared that knowledge of enmeshment patterns, along with appropriate medical treatments and psychopharmacology, played an important role in improving FND symptoms and increasing adaptive functioning (e.g. working, dating.)

Discussion: Exploring enmeshment and maternal enmeshment can help more clearly identify and recognize men with FND symptoms. Ideally, this focus of attention will help improve formulation and treatment. 

References:
1 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.
2 Adams, K. M. (2007). When he's married to mom: How to help mother-enmeshed men open their hearts to true love and commitment. Simon and Schuster.

200    ALTERED INTEROCEPTIVE APPRAISAL AND FUNCTIONAL AUTONOMIC SYMPTOMS IN FUNCTIONAL NEUROLOGICAL DISORDER: A CASE REPORT (Etiology/Pathophysiology, Treatment)
Xin Lyu, George Washington University

Introduction/background:  Interoceptive disturbance has been identified as a key factor in the development and maintenance of functional neurological disorder (FND) symptoms (Drane et al., 2020). However, how interoceptive difficulties manifest clinically and how psychotherapy can help address the issues at the individual level remain under studied. 

Case presentation: The case involved an adult individual diagnosed with FND with mixed symptoms, including functional autonomic symptoms alongside motor and cognitive features. Neurological and neuropsychological did not reveal identifiable structural or neurological abnormalities. The individual reported difficulty appraising and responding to bodily signals, particularly during periods of increased emotional or physiological arousal. 

Functional formulation suggested altered appraisal and integration of interoceptive signals, led to disengagement from bodily cues, rather than impaired signal generation and transmission. Intervention focused on psychoeducation regarding FND, increasing interoceptive awareness, and fostering acceptance of emotional states. Over the course of treatment, improvements were noted across autonomic, motor, and cognitive domains, including reduced frequency of incontinence and falls, improvement in gait stability, and improved cognitive clarity. These changes were accompanied by improved perceived control and shorter recovery time following symptom exacerbations. While multiple symptom domains showed clinical improvement; the present discussion focuses on autonomic symptoms given their relevance to interoceptive appraisal. 

Discussion: This case highlights impaired use of interoceptive information in the absence of identifiable neurological abnormalities. The clinical course supports conceptualizations of FND emphasizing altered appraisal and integration of bodily signals, rather than primary sensory deficits. These findings suggest the potential utility of psychotherapy interventions targeting interoceptive awareness, appraisal processes, and acceptance of emotional states, underscoring the importance of a mechanism-based approach to case conceptualization and treatment planning. 

References:
Drane, D. L., Fani, N., Hallett, M., Khalsa, S. S., Perez, D. L., & Roberts, N. A. (2020). A framework for understanding the pathophysiology of functional neurological disorder. CNS spectrums, 1–7. Advance online publication. https://doi.org/10.1017/S1092852920001789

201    ALTERED INTEROCEPTION AND FUNCTIONAL NEUROLOGICAL DISORDER: MAPPING MECHANISMS TO PSYCHOTHERAPY TARGETS (Etiology/Pathophysiology, Treatment)
Xin Lyu, George Washington University

Background:  Accumulating evidence suggests that altered interoceptive processing plays an important role in the development and maintenance of symptoms in Functional Neurological Disorder (FND) (Drane et al., 2020). However, findings remain heterogeneous, and the relevance of specific interoceptive alterations to psychotherapy targets is not well synthesized. This systematic review aimed to integrate current evidence on interoception in FND and link proposed mechanisms to psychotherapeutic implications.

Methods: A systematic literature review was conducted across databases to identify peer-reviewed studies examining interoception and related constructs in FND and closely related functional neurological presentations. Empirical, non-review studies meeting inclusion criteria were retained for qualitative synthesis.

Results: Fifty unique articles were identified, of which 30 empirical studies underwent full-text review. Studies assessed multiple dimensions of interoception, including interoceptive accuracy, sensibility, and metacognitive appraisal. Findings were heterogeneous, with no single interoceptive domain consistently implicated across studies.

Conclusions: The reviewed literature suggests that altered interoception is a relevant but multidimensional construct in FND, with inconsistent findings across interoceptive domains. Rather than reflecting a global deficit in interoceptive accuracy, emerging evidence points toward a multifaceted explanation, including reduced confidence in evaluating bodily sensations and altered subjective ratings of arousal states and symptom severity. Aligned with this mechanistic understanding, psychotherapy approaches that target reduction in avoidance of feared bodily sensations, and enhancement of interoceptive awareness through increased trust in bodily signals and greater tolerance of the feared sensations have demonstrated symptom improvement in many patients (Panchmatia et al., 2025). However, these conclusions remain preliminary due to the small sample sizes across studies included in this systematic review. A key recommendation moving forward is to design psychotherapeutic interventions that explicitly target the mechanisms underlying FND symptoms and to evaluate their efficacy in larger, more diverse patient populations.

References:
Drane, D. L., Fani, N., Hallett, M., Khalsa, S. S., Perez, D. L., & Roberts, N. A. (2020). A framework for understanding the pathophysiology of functional neurological disorder. CNS spectrums, 1–7. Advance online publication. https://doi.org/10.1017/S1092852920001789
Panchmatia, K., Poliakoff, E., & Brown, R. J. (2025). Feasibility and acceptability of Body Signal Integration training for Functional Neurological Disorder (FND): A case series. Counselling & Psychotherapy Research, 25(1), 1. https://doi.org/10.1002/capr.12876
Note: This abstract has also been submitted for presentation at the American Psychological Association (APA) 2026 Annual Convention

202    STRUCTURAL BRAIN DIFFERENCES ASSOCIATED WITH SUBJECTIVE VISUAL DISTURBANCES IN FUNCTIONAL NEUROLOGICAL PRESENTATIONS: A PRELIMINARY MRI STUDY (Phenomenology/Epidemiology)
Yoshifumi Mori, Spinoza Centre for Neuroimaging

Background: Dissociative tendencies have been associated with subjective visual distortions occurring without identifiable structural abnormalities, a presentation often seen in functional neurological contexts. These distortions may include reduced color vividness, blurred clarity, and altered perceptual experience, and have been linked to higher dissociative traits [1]. The neurobiological basis connecting dissociation to visual symptoms, however, remains unclear, and it is unknown whether individuals with visual disturbances show distinct structural brain patterns compared with those without. Systematic neuroimaging studies addressing this question are limited.

Methods: We present preliminary structural MRI analyses using FreeSurfer cortical surface–based morphometry in three groups: healthy controls (HC, n=33), individuals with dissociative symptoms without visual complaints (NV, n=11), and individuals with dissociative symptoms including subjective visual disturbances (VD, n=8). Vertex-wise comparisons of cortical volume and thickness were performed using general linear models with cluster-wise correction (cache=2.0, th20). Group contrasts (HC vs VD, HC vs NV, NV vs VD) were conducted while controlling for age and gender, with multiple-comparison correction applied.

Results: Relative to healthy controls, individuals reporting visual dissociative symptoms (VD) showed cortical volume differences involving medial temporal (entorhinal) and parietal (precuneus, supramarginal) regions, as well as frontal areas implicated in higher-order integration. Individuals with dissociative symptoms without visual complaints (NV) demonstrated a more limited pattern of structural variation compared to HC, primarily involving frontal regions. Direct NV vs VD comparisons highlighted cortical distinctions in medial temporal and superior frontal cortices, suggesting that subjective visual distortions may be associated with a partially distinct structural profile. Thickness analyses similarly revealed differences in temporal and parietal cortices across phenotypes.

Conclusions: These preliminary structural MRI findings suggest that subjective visual distortions may relate to distinct cortical morphometric patterns. The regions identified overlap networks involved in perceptual integration and self-referential processing, consistent with clinical observations that visual distortions can accompany dissociative experiences. While larger samples and refined characterization of visual symptoms are needed, structural variation may reflect differential vulnerability within neural systems supporting perceptual stability and dissociative modulation. Ongoing task-based functional MRI analyses are underway to further interpret the observed morphometric differences.

Reference:
1. Lipsanen, T., et al. (1999). Visual distortions and dissociation. The Journal of nervous and mental disease, 187(2), 109–112.

203    A CASE BASED EDUCATIONAL MODULE TO TEACH FUNCTIONAL NEUROLOGICAL DISORDER TO MEDICAL STUDENTS: A PROOF OF PRINCIPLE STUDY (Phenomenology/Epidemiology, Etiology/Pathophysiology)
Michael Nemeh, MD, UCSF

Background: Functional neurological disorder (FND) is a condition associated with significant morbidity. Lately, awareness around this condition has increased. However, patients with FND still face stigma, including from clinicians, which perpetuates suboptimal outcomes for this population. This stigma persists, in part, because many trainees receive little structured education on FND [1]. To address this, we developed a case‑based module to teach contemporary FND diagnosis, pathophysiology, and management to medical students in psychiatry clerkships.

Methods: We designed a multi‑part module featuring a patient who has both functional seizures and functional tremor. To meet the needs of diverse learning styles, this module incorporates a variety of educational modalities, including chart review, video‑based observation, and guided differential diagnosis. Brief didactic components emphasize rule‑in signs, relevant neurobiological constructs, how to effectively communicate the diagnosis, and management strategies for FND. An embedded quiz assesses knowledge acquisition.

Results: Learners will demonstrate an ability to identify positive diagnostic signs to differentiate functional seizures and tremors from non-functional etiologies of these conditions [2]. Participants will increase their confidence in compassionately and clearly communicating the diagnosis of FND using validating, brain-based language. Learners will come to understand the role of psychotherapy and multidisciplinary care for patients with FND.

Conclusions: This proof‑of‑principle project demonstrates that a structured, case‑based module can effectively teach rule‑in diagnosis, neurobiological mechanisms, and management of FND. Future work will evaluate learning outcomes across institutions and explore integration into national psychiatry and neurology curricula, ideally tying those outcomes to enhanced patient care.

References:
[1] Stone J, Burton C, Carson A. Recognizing and explaining functional neurological disorder. BMJ. 2020
[2] Aybek S, Perez DL. Diagnosis and management of functional neurological disorder. BMJ. 2022

204    POSITIVE SIGNS OF FUNCTIONAL WEAKNESS IN PARKINSON’S DISEASE AND PARKINSON’S SYNDROME: A RETROSPECTIVE INPATIENT STUDY (Phenomenology/Epidemiology)
Masayuki Ohira, National Center of Neurology and Psychiatry National Center Hospital

Background: Parkinson’s disease (PD) frequently overlaps with functional neurological disorder. When functional symptoms coexist with PD, they may obscure clinical assessments and influence treatment responses because symptoms driven by functional mechanisms may respond poorly to dopaminergic therapy. In recent years, several easily identifiable positive signs related to functional weakness have been described; however, few studies have compared the frequency and clinical relevance of these positive signs between patients with PD and those with Parkinson’s syndrome other than Parkinson’s disease (PS) using a unified assessment framework. This retrospective study investigated the frequency and clinical correlations of positive signs suggestive of functional weakness in patients with PD and PS.

Methods: Of 418 patients admitted between 1 January 2023 and the present, 235 were diagnosed with PD or PS using established clinical criteria. Of these, 104 patients with sufficient neurological examination records and reliable bedside strength testing results were included. Patients were excluded if cognitive impairment or reduced consciousness prevented assessment. Positive signs were assessed uniformly regardless of subjective complaints of weakness because functional features may coexist with PD and modify the clinical presentation of PD. Positive signs were defined as findings suggestive of functional weakness, including signs such as give-way weakness as well as upper-limb–focused signs such as paradoxical wrist flexion and a positive shoulder rotation test. At least two signs were required to classify a patient as positive. The primary outcome was the frequency of patients with positive signs, which we compared between the PD and PS groups.

Results: The median age of the 104 analyzed patients was 68.7 years (interquartile range 63–75.3 years), with no significant age difference between groups (p = 0.43). Similarly, sex distribution did not differ significantly between the groups (p = 1.00). Seventeen patients (16%) were classified as positive for functional signs (15 women, 2 men). Of the patients with PD, 12 of 49 (24%) were classified as positive. By contrast, just 5 of 55 (9.1%) patients with PS were classified as positive; however, this apparent difference did not reach significance (p = 0.061; odds ratio 0.31, 95% confidence interval 0.08–1.05).

Conclusions: Although patients with PD appeared to exhibit positive signs suggestive of functional weakness more frequently than those with PS, this difference was not significant. The focus on easily identifiable upper-limb positive signs and the relatively small sample size may have influenced our results. Further studies with larger cohorts and standardized assessment procedures are warranted to clarify the clinical importance of these positive signs in PD and related disorders.

205    JOURNEY THROUGH THE HEALTHCARE SYSTEM: BASELINE FINDINGS FROM THE CALGARY FUNCTIONAL MOVEMENT DISORDER REGISTRY (Phenomenology/Epidemiology)
Andrea Soumbasis, Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary

Background: Functional movement disorder (FMD), a subtype of functional neurological disorder, is a complex neuropsychiatric syndrome characterized by inconsistent and incongruent motor symptoms. Despite its relatively high prevalence, FMD remains associated with delayed diagnosis, significant disability, and limited evidence to guide individualized treatment. The Calgary FMD Clinic employs an integrated neurological–psychiatric assessment model, and its registry offers an opportunity to describe characteristics of FMD. 

Objectives: To describe baseline demographic and clinical features of patients enrolled in the Calgary FMD Registry with particular attention to prior healthcare utilization and neuropsychiatric risk factors.

Methods: This prospective registry-based cohort study includes patients with clinically established FMD evaluated by a neurologist and neuropsychiatrist at a tertiary center in Calgary, Canada. Standardized data collection encompasses demographics, motor and non-motor symptoms, psychiatric comorbidities, healthcare utilization, and validated outcome measures assessing symptom severity and impact. Descriptive and comparative statistics were performed between FMD phenotypes.

Results: Seventy-seven participants were enrolled between April 2024 and April 2025. The cohort was predominantly female (62%), with a median age of 43 years and median diagnostic delay of 12 months. Episodic presentations were more common (57%), while constant phenotypes demonstrated greater symptom burden and disability, revealed by higher Clinical Global Impression–Severity (CGI-S) scores(1) [Figure 1]. Fatigue and anxiety were highly endorsed among both groups.

Conclusion: The Calgary FMD Registry employs a unique neurological–psychiatric assessment model to characterize FMD phenotypes and neuropsychiatric correlates. This dataset provides a relative representation of the Canadian FMD population who are considered for intensive rehabilitation, with the intention to inform future stratified rehabilitation and treatment pathways.

References:
1.Guy, W. (1976). ECDEU assessment manual for psychopharmacology (US Department of Health, Education, and Welfare, Public Health Service …).

206    WHO CAN GET FUNCTIONAL NEUROLOGICAL DISORDER AND HOW DO THEY GET IT? PATHOPHYSIOLOGICAL INSIGHTS FROM EPIDEMIOLOGICAL DATA (Etiology/Pathophysiology)
David Palmer, The Queensland Brain Institute

Background and Objectives: Functional neurological disorder (FND) is one of the most common neurological conditions, however much remains unknown about its pathophysiology. In both casual conversation and research publications, FND specialists and researchers imply a variety of models for onset of the condition with respect to both the process culminating in its onset, and the distribution of susceptibility to the condition across the population. We aimed to use population-level data as evidence to arbitrate between these generative models of the condition.

Methods: We identified six hazard distributions corresponding to different pathophysiological processes [Fig 1] and four distributions of population susceptibility as the assumptions underlying the range of plausible generative models resulting in the observed distribution of age of onset of FND. We combined these model families into 24 parametric proportional hazards models and fitted each to the observed distribution of reported age at onset in two large FND datasets, one for functional movement disorders (FMD) and one for functional seizures (FS). Out of sample predictive accuracy for these models was compared using Bayesian model comparison.

Results: Strong trends were seen across model families with different distributions of population susceptibility to FND. For both datasets, the best-fitting model family overall was the mixture-cure family, which represents susceptibility as binary, with a susceptible and an unsusceptible proportion of the population. For the FMD dataset, some models in the log-normal frailty family had comparable fits to the mixture-cure models, and for the FS dataset, a number of the gamma frailty family had comparable fits. The variance parameters for each of these frailty distributions were so large as to imply binary risk, approximating mixture-cure models.
Models with exponential hazard distributions—which correspond to a generative process where a single trigger in a susceptible person brings about the condition—were universally poor fits for the observed data. Other hazard distributions were insufficiently distinguished by their out of sample predictive accuracy to make further inference as to the underlying process resulting in onset of FND in susceptible individuals.

Interpretation: Our results suggest that susceptibility to FND is approximately binary, with the susceptible proportion of the population extremely likely to develop FND in their lifetime. The results also argue strongly against the generative model where a single trigger is sufficient to cause the onset of FND in a susceptible person.

207    IMPROVING EDUCATION ABOUT FUNCTIONAL-DISSOCIATIVE SEIZURES IN NEUROLOGY TRAINING USING VIDEO AND DIDACTIC BASED CURRICULUM (Phenomenology/Epidemiology)
Palak Patel, MD, Hackensack Meridian School of Medicine

Background: Diagnosis and management of functional dissociative seizures (FDS) is an essential competency for neurologists and should be developed early during residency training. Gaps have been identified in FDS education in neurology residency due to lack of structured curriculum in the US(1). Previous studies have only focused on video and didactic intervention to improve semiological recognition of FDS in trainees(2). We aimed to improve knowledge and recognition of FDS using a Quality Improvement (QI)-based approach. We first established baseline knowledge, attitudes and accuracy of FDS diagnosis based on video assessment in our neurology trainees. We then measured improvement in the knowledge, change in attitude and diagnostic accuracy after a  comprehensive didactic intervention.

Methods: We conducted a prospective, mixed-method survey among neurology residents at the JFK University Medical Center. The study consisted of a baseline 7-item pre-test survey(5-point Likert scale), 10-item questionnaire with multiple choice, and video evaluation consisting of 13 patient video events followed by a 43 minute didactic. A 12-item post-test survey, 10-item questionnaire and video evaluation (with same video events) was completed at a median of 32 days (IQE 35.5 days)  after pretest to assess improvement.  The didactic was delivered in a hybrid manner either in-person or by a recorded video lecture on a rolling basis. The surveys were anonymous. All the pre- and post-test evaluation were completed under supervision during a regular in-person didactic session. A descriptive analysis was performed using MS Excel.

Results: A total of 28 residents that included PGY II-IV completed both pre and postsurvey. Residents reported increase in comfort and confidence in diagnosis and management of FDS after the didactic intervention (Figure 1). They also reported that didactic intervention was “valuable” and “improved their knowledge: of FDS. Video based learning (71%) was the most effective aspect of the project. AI search and textbooks were most common references used to attain knowledge on FDS prior to the post-survey. Resident also scored higher on the post-test questionnaire (Figure 2). Video evaluations showed overall improvement in identification of FDS (Figure 3).

Conclusion: A combination of teaching methods using pre-test/post-test design and video evaluation may be effective in improving education about FDS and  should be included in neurology residency curriculum.  

References:
1. Milligan TA, Yun A, LaFrance Jr WC, et al. Neurology residents’ education in functional seizures. Epilepsy & Behavior Reports. 2022;18:100517. doi:10.1016/j.ebr.2021.100517
2. Seneviratne U, Ding C, Bower S, Craig S, Leech M, Phan TG. Video-based training improves the accuracy of seizure diagnosis. Journal of Neurology, Neurosurgery & Psychiatry. 2014;85(4):466-470. doi:10.1136/jnnp-2013-306618

208    IMPLEMENTING A MULTIDISCIPLINARY FND UNIT IN FRANCE: A STEPWISE PATHWAY AND KEY CHALLENGES (Treatment)
Juliette Palisson, Hopital Avicenne

Background: Functional neurological disorders (FND) affect approximately 70 000 people in France and are often associated with delayed diagnosis and fragmented care.  In that perspective, the first multidisciplinary FND unit was created at Avicenne Hospital in March 2024. We aim at describing the pathway of the implementation of this unit. 

Methods: We first examine  how the unit was established, focusing on the funding process, recruitment of trained specialists, and partnerships with local healthcare facilities to ensure tailored care. We then describe patients’ clinical pathways through the unit, including the subsequent care options and programs offered (therapeutic patient education (TPE), ConnecTNF, coordinated referrals…).

Results: We secured funding from complementary sources: the Organizational Innovation Fund in Psychiatry (FIOP) for clinical implementation, the Hospital–University Federation (FHU) for research, and the Regional Health Agency (ARS) to address the care and social challenges associated with FND.

More than 250 patients were evaluated in our FND day care unit between march 2024 and January 2026 with a mean of 80-100 referral requests per month. Admission criteria were: patients residing in Ile de France area and referred by a neurologist for specialized assessment. Three TPE groups were implemented, including two adult groups and one youth group delivered over six sessions. Due to limited group capacity, about 6 to 8 patients participated in each group. A TPE workshop targeting functional cognitive disorders is in development. The unit also contributed to establishing ConnecTNF, a patient oriented association launching in February 2026 offering complementary interventions such as art therapy, hypnosis, and dance/movement therapies. 4 research protocols are undergoing and 2 more are on the way. 

Conclusions: Implementation of a multidisciplinary FND unit within a day hospital setting is feasible and supports coordinated diagnostic assessment and individualized care orientation. Integrating psychoeducation, research, structured group interventions, and community initiatives may enhance engagement and continuity of care. Future research will evaluate clinical outcomes.

References:
Stone, J., Carson, A., & Hallett, M. (2016). Explanation as treatment for functional neurological disorder. In M. Hallett, J. Stone, & A. Carson (Eds.), Handbook of clinical neurology (Vol. 139, pp. 543–553). Elsevier.
Garcin, B., Roze, E., Mesrati, F., Apartis, E., Vidailhet, M., & Degos, B. (2020). Diagnosis and management of functional neurological disorder in adults: Recommendations from the French expert group. Revue Neurologique, 176(5), 361–370.

209    POSITIVE SIGNS FOR FUNCTIONAL NEUROLOGIC DISORDERS : HOW ACCURATE ARE THEY ? (Phenomenology/Epidemiology)
Enzo Panfili, Nancy University Hospital, France

Introduction: The diagnosis of Functional neurological disorders (FNDs) is now based on the identification of 'positive' clinical signs, as defined by current classifications, notably the DSM-5, rather than on a diagnosis of exclusion. Despite the existence of numerous clinical signs suggestive of FND, their diagnostic performance remains inadequately evaluated, particularly in patients with other neurological disorders. Consequently, it is imperative to assess their discriminatory capacity in order to enhance the reliability of clinical diagnosis.

Materials and Methods: A prospective, two-centre study was conducted in order to make a comparison between the presence and diagnostic performance of 23 positive clinical signs in two populations. The initial population comprised patients with confirmed isolated FND (n = 147), who were recruited at Avicenne Hospital. The second population consisted of patients with other neurological conditions without suspicion of functional overlap (n = 105), who were included at Nancy University Hospital, including vascular, inflammatory, tumour, degenerative and peripheral conditions. A systematic approach was adopted in the evaluation of clinical signs, with the objective of assessing the diagnostic performance of each in terms of sensitivity, specificity, predictive values and likelihood ratios.

Results:
The mean number of positive clinical signs was found to be considerably higher in FND patients than in patients with other neurological conditions (5.72 versus 1.07; p < 10⁻⁵⁸). Some signs, notably those pertaining to the walk, trunk posture and movements disorders, exhibited remarkably high specificity levels, with values exceeding 90%. However, these signs demonstrated a comparatively low level of sensitivity, with values falling short of 40%. For instance, the sign of non-economical posture' exhibited a positive predictive value (PPV) of 96% and a negative predictive value (NPV) of 50%, while the sign of 'splitting the midline' demonstrated a PPV of 90% and an NPV of 52%. The ensuing results enabled the classification of the clinical signs according to four levels of diagnostic performance, primarily based on specificity, PPV and positive likelihood ratio. This process revealed a lower diagnostic value of Hoover's sign compared to previous studies.

Discussion and Conclusion: Whilst positive clinical signs of FNDs are highly specific, their low sensitivity limits their diagnostic value when considered in isolation. Eight signs are identified as having high discriminatory power: non-economical postures, knee buckling, spinal injury test, entrainment effect, whack-a-mole, fixed dystonia, convergence spasm and oculomotor disturbance. These results underscore the necessity for expert clinical assessment, predicated on the combined interpretation of multiple signs, as a solitary sign might not be enough for a diagnosis of FND. 

210    THE CAREGIVER BURDEN IN FUNCTIONAL NEUROLOGICAL DISORDERS: INSIGHTS FROM A SURVEY STUDY (Treatment)
Giulia Pedrotti

Background: Functional Neurological Disorders (FNDs) are common and highly disabling conditions with a clinical impact comparable to neurodegenerative disorders. While caregivers play a crucial role in patient support, their perspective on disease burden and treatment outcomes in FND has not been adequately investigated [1,2]. We aim to assess caregiver burden in FNDs and its association with patient rehabilitation over 3 months.

Methods: Caregivers of FNDs patients participate in an online survey from September 2025 collecting sociodemographic, physical and mental health. Caregiver burden is assessed using the Zarit Burden Interview (ZBI), and anxiety and depression with the Hospital Anxiety and Depression Scale (HADS).

Results: Of 29 caregivers invited, 22 complete the survey (80,8%; mean age 50 ± 15.0 years; 50% female). Most are married (72,7%), live with the patient (86.4%), and have provided care for >24 months (59.0%). Care demand are high: 59.1% assist 5-7 day/week and 45.4% >3 hours/day. Caregiving affects daily life in 54.6% of caregivers, and completely disrupts routines in 9.1%. 36.4% of caregivers had to reduce working hours. 

Physical and emotional consequences are common, with fatigue (16.7%), and sleep disturbances (12.5%); other symptoms (back pain, weight changes, anger, social isolation, crying) occur in <7%. The most requested supports are a direct point of reference (18.1%), financial reimbursement (12.5%), psychological (12.5%) and multidisciplinary care (6.94%). 

Mean ZBI scores indicate moderate burden (24.18 ± 16.43). Specifically, 12 caregivers (54.5%) reported low burden, 6 caregivers (27.3%) moderate burden, and 4 caregivers (18.2%) high burden. Across the sample, mean HADS scores indicated mild levels of both anxiety (5.64 ± 4.28) and depression (6.32 ± 3.41), with a total mean score of 11.95 ± 7.11, suggesting generally low to borderline emotional distress.

Conclusion:  The findings show substantial caregiver burden in FNDs, supporting the need for targeted psychological support and multidisciplinary care and for longitudinal evaluation of burden changes with patient rehabilitation.

References
1.Tinazzi, M., Morgante, F., Marcuzzo, E., Erro, R., Barone, P., Ceravolo, R., Mazzucchi, S., Pilotto, A., Padovani, A., Romito, L. M., Eleopra, R., Zappia, M., Nicoletti, A., Dallocchio, C., Arbasino, C., Bono, F., Pascarella, A., Demartini, B., Gambini, O., Modugno, N., … Geroin, C. (2020). Clinical Correlates of Functional Motor Disorders: An Italian Multicenter Study. Movement disorders clinical practice, 7(8), 920–929. https://doi.org/10.1002/mdc3.13077
2.Rutten S, Bradley-Westguard A, Nicholson TR, Pick S. Outcome measurement in functional neurological disorder: A qualitative study on the views of patients, caregivers and healthcare professionals. J Neurol. 2025 Feb 11;272(3):189. doi: 10.1007/s00415-025-12912-9. PMID: 39932584; PMCID: PMC11814038.

211    A CASE OF FUNCTIONAL DYSTONIA DURING A MAJOR LIFE TRANSITION (Phenomenology/Epidemiology)
Syeda Munir, Tulane University School of Medicine

Introduction/Background: Functional Neurological Disorder (FND) describes the presence of neurological symptoms, such as seizures and dystonia, that arise from alterations in nervous system functioning and sensorimotor integration rather than structural pathology. FND often co-occurs alongside and can be precipitated by major life stressors and emotional difficulties. Diagnosis of FND is performed clinically and subsequently should be supported by positive clinical signs. In this case, we describe a patient presenting with functional dystonia in the setting of a major life transition.

Case Presentation: An 18-year-old female Navy recruit with a prior diagnosis of FND presented to the emergency department with acute worsening right-sided weakness. Her symptoms were exacerbated during a high-stakes occupational transition involving completion of boot camp and anticipated progression to technical training for her new role in IT. This transition was marked with concerns of potential limitations in the patient’s functioning and subsequent possible military separation. Although the patient reported minimal subjective distress, she demonstrated difficulty identifying and appropriately verbalizing affective states. During a therapeutic exercise involving the use of an emotion wheel, the patient associated emotional states with distinct somatic sensations, including lower-extremity heaviness and forehead coldness. Neurological examination demonstrated a fixed inverted position of the right ankle, a known positive clinical sign consistent with functional dystonia. The patient’s history was notable for prior hospitalization for focal neurological deficits, as well as a witnessed episode of loss of consciousness with limb movements that raised concern for psychogenic nonepileptic seizures (PNES). 

Discussion: This case underscores the importance of recognizing positive clinical features of FND and highlights how differences in emotional awareness and contextual stressors may contribute to the development of neurological symptoms during major life transitions. Early identification with the use of tools such as the emotion wheel may support timely diagnosis and effective multidisciplinary care.

References:
1. van Dijl TL, Aben HP, Synhaeve NE, de Waardt DA, Videler AC, Kop WJ. Alexithymia and facial emotion recognition in patients with functional neurological disorder. Clinical Neurology and Neurosurgery. 2024;237:108128. doi:10.1016/j.clineuro.2024.108128
2. Frucht L, Perez DL, Callahan J, et al. Functional Dystonia: Differentiation From Primary Dystonia and Multidisciplinary Treatments. Front Neurol. 2021;11. doi:10.3389/fneur.2020.605262

 

212    DIFFERENTIATING FUNCTIONAL AND AUTONOMIC DISORDERS USING ANXIETY BASED MODELS IN PERSONS WITH PERSISTENT DIZZINESS: ENHANCING DIAGNOSTIC CLARITY FOR PPPD AND POTS (Etiology/Pathophysiology)
Michelle Petrak, Interacoustics

Background: Persistent dizziness is a common presenting complaint in clinical settings and may arise from a range of vestibular and autonomic disorders with overlapping symptom profiles. Persistent postural-perceptual dizziness (PPPD) is a chronic functional vestibular disorder that frequently shares clinical features with autonomic conditions such as postural orthostatic tachycardia syndrome (POTS) and post-acute sequelae of COVID-19 (Long COVID). Psychological distress, particularly anxiety, is also highly comorbid with dizziness and imbalance. Despite this overlap, there is currently no definitive diagnostic test to reliably differentiate PPPD from other autonomic or complex vestibular disorders. This study aimed to examine the relationship between psychological symptom profiles and vestibular diagnoses, and to evaluate whether anxiety-based machine learning models applied within Videonystagmography (VNG) software could aid in distinguishing PPPD from POTS and other vestibular conditions.

Method: Questionnaire data assessing psychological symptoms were collected from patients presenting with persistent dizziness. These data were integrated into machine learning models within the VNG software and analyzed in conjunction with vestibular test findings.

Results: Patients with lower anxiety model scores were more likely to show findings consistent with typical vestibular abnormalities. In contrast, patients with higher anxiety scores were more strongly associated with patterns of PPD, POTs or complex vestibular diagnoses even when standard vestibular testing appeared normal.

Conclusions: As research increasingly links psychological symptoms with vestibular function, this study adds evidence by integrating patients’ vestibular test results with anxiety model responses, helping to distinguish overlapping symptoms of PPPD and POTS.
The findings suggest that psychological symptom profiles differ across vestibular conditions and may provide clinically useful insight when standard vestibular testing does not identify a clear cause. Complex vestibular disorders, including PPPD, appear to be associated with higher levels of psychological distress. Incorporating psychological symptom modeling into vestibular assessments may improve diagnostic differentiation between PPPD and autonomic disorders such as POTS in patients presenting with persistent dizziness.
These models may assist clinicians in  their differential diagnoses, enabling more timely and appropriate referrals for effective treatment.

References:
Gurvich, C., Maller, J. J., Lithgow, B., Haghgooie, S., & Kulkarni, J. (2013). Vestibular insights into cognition and psychiatry. Brain Research, 1537, 244–259. https://doi.org/10.1016/j.brainres.2013.08.058
Steensnaes, M.H., Knapstad, M.K., Goplen, F.K. et al. Persistent Postural-Perceptual Dizziness (PPPD) and quality of life: a cross-sectional study. Eur Arch Otorhinolaryngol 280, 5285–5292 (2023). https://doi.org/10.1007/s00405

 

213    TRAPPED IN ONE'S OWN PERCEPTION - MODELLING METACOGNITIVE PROCESSES IN FUNCTIONAL MOVEMENT DISORDERS AND PSYCHOSIS (Etiology/Pathophysiology)
Justine Polle, University of Lübeck, Institute for Systems Motor Science (ISMS)

Background: Metacognition encompasses the capacity to monitor and regulate cognitive processes, serving as critical interface between internal self-representation and external perception. Its dysfunction has been implicated as core feature in neuropsychiatric disorders. Several studies showed global metacognitive deficits of schizophrenia spectrum disorders (1). Likewise, functional neurological disorders (FND) are characterized by dysregulated metacognitive processes. Both functional movement disorders (FMD) and psychotic disorders (PDs) exhibit disruptions in predictive coding and sense of agency (SoA), albeit in opposing directions: In FMD, SoA is attenuated, whereas PDs are characterized by hyper-attribution of agency. Our own research showed reduced motor metacognitive efficiency in people with FMD (2). The comparison with PDs using a neurophysiological paradigm investigating other domains of metacognition could lead to a better understanding of clinically reported abnormal environmental and self-perception. 

Methods: To test visual and auditory metacognition, we compared patients with FMD and age-, sex-, and education-matched patients with PDs and healthy controls (HC) (nFMD=13, npsych=28, nHC=36, age 18-49). A perception-based target detection task was used to assess metacognition. Participants categorized presented stimuli as either a human voice/face or not and rated their confidence in their perception using a 4-point confidence rating. Before each section, a cue indicating the expected proportion of target stimuli was given [figure1]. Metacognitive efficiency was modelled using a hierarchical Bayesian framework.   

Results: Significant group differences emerged in visual perceptual sensitivity between HC and FMD patients (p=0.012). Hallucination-like percepts were more frequent in FMD, with significant effects in auditory (p=0.022) and visual (p<0.001) modalities. No significant differences were observed between the clinical groups. Descriptively, FMD patients showed higher sensitivity in the auditory and more frequent hallucination-like percepts in the visual task [figure3A,C]. Decision bias appeared stronger in PDs [figure3B], whereas confidence ratings were comparable across groups [figure3D]. Metacognitive efficiency (µ M-ratio) followed a graded pattern, highest in HC (0.73), intermediate in FMD (0.64), and lowest in PDs (0.56) [figure2A].

Conclusion: Preliminary findings indicate that reduced metacognitive abilities in FMD extend beyond altered body perception to the processing of external stimuli, paralleling patterns observed in PDs. Ongoing work will expand the FMD sample and examine associations with clinical and neurophysiological measures. Future studies will further investigate the role of metacognitive insight in the pathophysiology of FMD, particularly stimulus processing and decision bias.

References:
1.Franzen et al. (2023). Eur Psychiatry 66(S1): S129–S130.
2.Verrel et al. (2023). Mov Disord 38: 435–443.

 

214    DEVELOPING A MULTIDISCIPLINARY CARE PATHWAY FOR FUNCTIONAL NEUROLOGICAL DISORDER IN A HYPERACUTE STROKE SETTING (Treatment)
Vidya Rajbhoj, North West London University Hospital NHS

Background: Functional Neurological Disorder (FND) commonly presents to acute stroke services, often mimicking stroke. Despite increasing recognition, structured FND services remain limited. At Northwick Park Hospital (NPH), patients with confirmed or suspected FND are regularly admitted to the Hyperacute Stroke Unit (HASU) and Acute Stroke Unit (ASU). No formalised inpatient pathway exists, resulting in variability in assessment, diagnostic communication, management, referral, and follow-up. To address this gap, we initiated development of a multidisciplinary FND pathway across stroke and neurology services. We began with a two-month pilot review of current practice and a Delphi-based survey to identify priorities for pathway development.

Methods: A multidisciplinary working group was established. A two-month prospective pilot audit is collecting data on patients presenting with functional neurological symptoms on HASU/ASU wards, including referral patterns, investigations, length of stay, management, and discharge planning.

To explore clinician perspectives, we developed a structured questionnaire using adapted Delphi methodology to build consensus on key elements of FND care. Ten to twenty stroke multidisciplinary team members were recruited. The survey will examine confidence in diagnosing and explaining FND, current management strategies, perceived barriers, referral pathways, and essential components of a standardised pathway. Participants include neuropsychologists, occupational therapists, physiotherapists, speech and language therapists, and medical staff. Responses will be analysed descriptively using predefined consensus thresholds.

Results: Preliminary discussions indicate variability in diagnostic communication, limited access to psychology, prolonged length of stay in some cases, and inconsistent onward referral where diagnostic uncertainty persists. We anticipate consensus on the need for structured diagnostic explanation, early psychology and therapy involvement, standardised patient information, and clear referral pathways to community or specialist FND services. Expected barriers include limited training, time constraints in acute settings, and lack of commissioned specialist services.

Conclusions: FND presentations to hyperacute stroke services are frequent yet managed without a structured pathway, leading to inconsistent care. Our pilot review and Delphi survey aim to demonstrate multidisciplinary consensus for an integrated FND pathway within acute stroke services at NPH. Findings will inform development of a practical framework incorporating clear diagnostic communication, early multidisciplinary input, and defined referral routes to improve patient experience and clinician confidence.

Reference:
Neurology National Advisory Group (NNAG). (2023). Optimum clinical pathway for adults: Functional Neurological Disorder

 

215    INTEGRATION OF A SENSORY MODULATION INTERVENTION WITHIN A MULTIDISCIPLINARY OUTPATIENT TREATMENT PROGRAMME FOR FUNCTIONAL NEUROLOGICAL DISORDER(FND) (Treatment)
Heather Sheldon, OT, UCLH

Introduction: Sensory symptoms are frequently reported in Functional Neurological Disorder (FND) and can significantly contribute to distress and reduced functional ability¹. Emerging research, including work by Ranford et al.², highlights the relevance of sensory-based interventions within FND treatment. This case study describes the integration of sensory screening and individualised sensory modulation strategies within occupational therapy as part of a multidisciplinary outpatient rehabilitation programme for an individual with FND at the National Hospital for Neurology and Neurosurgery, London.

Case Presentation: Y was a 57 year old woman with a four year history of vocal and motor tics, including facial grimacing and vocalisations, alongside fatigue, reduced concentration and memory, and significant sensory hypersensitivity to light, noise, and smells. Her tics were exacerbated by social anxiety, particularly in public environments. Her psychiatric history included an eating disorder, depression, anxiety, and self-harm, and she was awaiting assessment for adult ADHD.

Her rehabilitation goals included improving work-related stress and organisation, reducing tic frequency and impact, managing fatigue, and pursuing further education.

Y completed a five week multidisciplinary outpatient programme comprising occupational therapy, cognitive behavioural psychotherapy, and physiotherapy, delivered in two one hour sessions per week. Occupational therapy included education about FND, routine, fatigue management, relaxation strategies, and workplace adaptations.

Sensory assessment using the Adolescent/Adult Sensory Profile (AASP) demonstrated heightened sensory sensitivity and high low registration scores, indicating challenges in sensory regulation. Tailored sensory modulation strategies were introduced, for use at work and during leisure activities.

Outcomes measured using the Canadian Occupational Performance Measure showed clinically significant improvements in performance (4.3 to 6.2) and satisfaction (2.2 to 5.8), alongside reported reductions in fatigue, stress, and tic frequency.
At six month follow-up, Y reported temporary tic cessation, with increased levels of daily activity  but tics later recurred on return to work.

Discussion: This case study highlights the value of integrating sensory modulation interventions into occupational therapy for individuals with FND and sensory processing difficulties. Sensory education within multidisciplinary rehabilitation may enhance self-management of symptoms, daily functioning, stress, and fatigue.

References:
1.Ranford J et al 2020. Sensory Processing difficulties in functional Neurological Disorder: A possible Predisposing Vulnerability? Psychosomatics 2020 Jul-Aug;61(4):343–352
2.Ranford J, Maclean J, 2023. Outpatient Approach to Occupational Therapy for Paroxysmal Functional Neurologic Symptoms: Sensory Modulation Training as an Emerging Treatment. Neurologic Clinics 2023 Nov;41(4):695–709

 

216    BRAIN DYNAMICS OF PERSISTENT PERCEPTUAL POSTURAL DIZZINESS AT REST REVEAL ALTERATIONS IN MULTISENSORY AND MOTOR HUBS (Phenomenology/Epidemiology, Etiology/Pathophysiology)
Catheline Stancu, UNIFR Fribourg

Background: Persistent Perceptual Postural Dizziness (PPPD), a subtype of Functional Neurological Disorder, is characterized by chronic dizziness and vertigo, impacting everyday life. It is thought to stem from a disruption in the integration of sensory signals, such as visual and vestibular signals, alongside disturbances in higher-order regions involved in postural control. There is however little evidence on the relationship between brain networks and postural alterations. 

Aims: to characterize dynamic brain activity in PPPD patients and its relationships to objective postural measures, stress markers, and clinical self-reports. 

Methods: A multi-modal, case-control study of 20 PPPD patients and 20 age- and gender-matched healthy controls (HC) was conducted. Participants underwent a resting state fMRI recording, postural assessments, and saliva sampling to assess cortisol and amylase as stress markers. The fMRI dataset was pre-processed using a standard pipeline and analysed using a co-activation patterns (CAPs) approach, a novel method to investigate dynamic functional connectivity of the brain at rest. Three different seed regions were chosen based on previous neuroimaging and behavioural studies reporting alterations in PPPD: the right temporo-parietal junction, the caudate nucleus and the hippocampus. 

Results: 17 PPPD patients and 20 HC were included in analyses. PPPD patients show distinct brain-wide CAPs temporal characteristics compared to controls, seeded from the right temporo-parietal junction, similarly to other FNDs. Additionally, PPPD patients show altered CAPs dynamics seeded from the caudate nucleus and the hippocampus, highlighting alterations in brain hubs of motor control and spatial navigation. Instead, no differences are found in CAPs seeded from the vestibular cortex OP2. Additionally, no groups differences were found in the stress markers cortisol and amylase. 

Conclusion: This study reveals a dynamic brain signature of altered high-level motor control and multisensory processing, and supports the hypothesized absence of alterations in primary vestibular unimodal regions. Additionally, neither chronic nor acute stress was found altered in this cohort. Next, the relationship between brain CAPs and features of posture, levels of stress markers, and scores of clinical self-reports will be assessed (ongoing).

 

217    THE OXYTOCINERGIC SYSTEM IN FUNCTIONAL NEUROLOGICAL DISORDER: TESTING ASSOCIATIONS WITH INTEROCEPTION AND CHILDHOOD TRAUMA (Phenomenology/Epidemiology, Etiology/Pathophysiology)
Catheline Stancu, UNIFR Fribourg

Background: The oxytocinergic system has been proposed as a vulnerability factor in the pathophysiology of Functional Neurological Disorder (FND), a condition associated with stressful life-events and disturbed bodily awareness. Recent work from our group demonstrated reduced interoceptive function alongside elevated salivary oxytocin (OXT) levels in patients with mixed-FND.

Method: Here, we tested the same N = 41 patients with FND and N = 48 matched healthy controls of that study, addressing two additional aims: (I) testing the genetic associations of the oxytocin receptor gene (OXTR) (i.e. investigating both genetic and epigenetic variables between groups and in interaction with interoceptive measures), and (II) evaluating whether integrating (epi)genetic and OXT measures improves overall model fit to explain interoceptive dysfunction and self-reported childhood trauma scores.

Results: No group difference was observed regarding the allelic distribution of the rs535767 SNP or in OXTR methylation levels. For salivary OXT, an interaction effect between OXTR genotype and intron methylation (p = 0.036), as well as an interaction between group and genotype (p = 0.026) was identified. With respect to aim II, including oxytocinergic variables in the model did not explain additional interoceptive variance. However, including OXTR promoter methylation rates and salivary OXT levels alongside the group variable improves model fit and explains more variance in self-reported childhood trauma.

Conclusion: While our genetic findings need to be interpreted with caution due to limited sample size, we suggest future research to profit from the inclusion of oxytocinergic markers when investigating risk-factors associated with FND.

 

218    DEVELOPMENT OF A COMMUNITY KNOWLEDGE PLATFORM FOR PRACTICAL SELF-MANAGEMENT STRATEGIES IN FUNCTIONAL NEUROLOGICAL DISORDER (Treatment)
Irene Roura Garcia

Background: FND is characterized by heterogeneous neurological symptoms and recovery trajectories. Many individuals report a gap between receiving a diagnosis and accessing practical strategies to regulate symptoms and support recovery. Through lived experience and engagement with treatment, therapeutic approaches, educational resources, and peer support, people living with FND gain insight into strategies that support wellbeing. However, these lived-experience insights are rarely systematically collected or shared. This project aimed to develop a community-informed knowledge platform to gather and share practical self-management techniques reported by individuals living with FND as helpful for regulating symptoms and supporting recovery.

Methods: The project used an exploratory participatory approach combining practice-informed observations, patient feedback collected through wellbeing and educational sessions, a structured community survey, and lived-experience reflections. Initial thematic categories were informed by insights from prior clinical practice delivering wellbeing support and educational sessions for people with FND. Predefined categories included breath, senses, pacing, thoughts, movement, art, social connection, nutrition, nature, and compassion. In the structured community survey, participants were invited to share techniques they found helpful across these categories and to provide reflections describing their experiences and perceived impact on symptoms and wellbeing.

The project is implemented through the FND Care Guide, a freely accessible online platform (www.fndcareguide.com) developed by Irene Roura García, Mental Health Nurse, in collaboration with people living with FND. To date, circa 200 individuals have submitted feedback forms describing techniques helpful for managing symptoms, and 30 survey responses reviewed and incorporated into the platform.

Results: Contributions described multiple strategies perceived as helpful for symptom regulation and daily functioning. These included breathing exercises, sensory grounding practices, pacing strategies, cognitive reframing approaches, movement-based activities, creative expression, social engagement, nutrition habits, nature-based practices, and self-compassion techniques. Contributors frequently reported improved symptom regulation, increased body awareness/agency, and support for gradual recovery.

Conclusions: This initiative demonstrates the feasibility of developing a community knowledge platform centered on lived experience to identify and share practical self-management strategies for FND. By systematically collecting and organizing techniques reported as helpful by people living with FND, the platform bridges the gap between diagnosis and access to practical tools that support symptom regulation and recovery. Community-informed resources of this kind may complement clinical care and contribute to a more patient-centered understanding of recovery in FND.

 

219    BEHAVIORAL AND NEUROPHYSIOLOGICAL BIOMARKERS INFORMING FUNCTIONAL MOTOR DISORDERS DIAGNOSIS: A PRELIMINARY ANALYSIS IN ORGANIC MOTOR DISORDERS (Etiology/Pathophysiology)
Angela Sandri, PhD, University of Verona

Background: Functional motor disorders (FMDs) are common and disabling, with diagnosis hindered by heterogeneity and lack of reliable biomarkers. We developed a multimodal diagnostic algorithm integrating motor and neurophysiological measures to distinguish FMDs from healthy controls (HCs). Our aim here is to report the preliminary behavioral and neurophysiological biomarkers underlying the algorithm by comparing FMDs with organic motor disorders (OMDs)[1].

Methods: This multicenter, cross-sectional study included FMDs, HCs, and OMDs (dystonia, essential tremor). Previously identified biomarkers across motor, exteroceptive, and interoceptive domains were analyzed. MRI data will be incorporated in future validation. Analyses were corrected for multiple tests, p-value<0.05 was set as significance threshold. The study was funded by the European Union (Next Generation EU, NRRP M6C2, Investment 2.1; PNRR-MAD-2022-12376826).

Results: Participants included 153 HCs (75.5% female; 43.5±13.4 years), 149 FMDs (63.4% female; 44.8±13.9 years), and 99 OMDs (53.5% female; 65.0±9.2 years). FMDs were age-matched to HCs but younger than OMDs. Anxiety, depression, and fatigue were highest in FMDs (all p≤0.001). SF-12 physical and mental scores were lowest in FMDs, intermediate in OMDs, and highest in HCs (p=0.001). Proprioceptive errors were higher in FMDs than HCs (p=0.001) but lower than OMDs (p=0.011), while interoception did not differ. Across gait conditions, FMDs showed altered spatiotemporal parameters versus HCs and intermediate abnormalities relative to OMDs, including longer stride and stance times, shorter stride length, reduced speed, and increased variability (p<0.05). In postural control, the motor dual-task effect on sway area (eyes closed) was lower in FMDs than HCs (p=0.036) and OMDs (p=0.028). OMDs showed lower N2P2 amplitudes than HCs and FMDs (all p<0.001). Blink reflex R2 areas were reduced in FMDs versus HCs (p<0.001) and OMDs for baseline contralateral R2 (p=0.020).

Conclusions: These findings support the specificity of key behavioral and neurophysiological biomarkers for FMDs and represent a step toward implementation of a multimodal diagnostic algorithm.

References:
[1] Gandolfi M, et al. (2024) A window into the mind-brain-body interplay: Development of diagnostic, prognostic biomarkers, and rehabilitation strategies in functional motor disorders. PLoS ONE 19(9): e0309408.

 

220    DIAGNOSTIC AND THERAPEUTIC UTILITY OF TRANSPARENT VERBAL SUGGESTION IN EPISODIC FUNCTIONAL UNRESPONSIVENESS MIMICKING BASILAR MIGRAINE (Phenomenology/Epidemiology, Treatment)
Soaham Desai, Shree Krishna Hospital, Pramukhswami Medical College, Bhaikaka University, Anand, Gujarat, India

Background:  Paroxysmal functional unresponsiveness is frequently misdiagnosed as migraine with brainstem aura or epilepsy, leading to extensive diagnostic odysseys. Current Functional Neurological Disorder (FND) criteria rely on capturing spontaneous events, which is resource-intensive. This case report evaluates the diagnostic and therapeutic utility of transparent verbal suggestion to induce episodes in episodic FND, facilitating immediate formulation and targeted therapy.

Case Presentation: A 45-year-old female with a 5-year history of migraine with aura (5–8 episodes/month) presented with a 1-year history of new paroxysmal episodes. Symptoms included headache followed by phonophobia, somnolence, and prolonged unresponsiveness ("unconscious, does not wake up") lasting 1–8 hours. She was refractory to multiple preventative and acute treatments including flunarizine, verapamil, escitalopram, sertraline, magnesium, botulinum toxin, and CGRP monoclonal antibodies. Extensive workup (MRI, angiogram, venogram, 5-day video-EEG, sleep study, cardiac monitoring, metabolic panels) was normal. Initially diagnosed as Episodic Migraine with Brainstem Aura, the prolonged isolated unresponsiveness without brainstem signs prompted reconsideration for FND. Since spontaneous events did not occur in clinic, transparent verbal suggestion was employed to induce an episode. The induced event demonstrated clear incongruency and inconsistency with organic coma. Recovery was achieved immediately following therapeutic suggestion. Subsequent management included psychoeducation and Cognitive Behavioral Therapy (CBT).

Discussion: This case highlights the dual utility of verbal suggestion in episodic FND. Diagnostically, it allows for direct observation of positive signs (incongruency, inconsistency) when spontaneous capture fails, saving time and resources. Therapeutically, successful reversal via suggestion serves as a powerful intervention to demonstrate reversibility to the patient, reinforcing the functional diagnosis and enhancing engagement with CBT. The overlap of migraine and FND suggests shared central sensitization mechanisms, requiring integrated management. Ethical practice requires framing suggestion as collaborative empiricism rather than deception ("trick vs. treat"). Following diagnostic formulation and CBT, the patient experienced complete resolution of symptoms over a 1-year follow-up.

Transparent verbal suggestion is a valuable tool for diagnosing and treating episodic functional unresponsiveness, preventing diagnostic odysseys and facilitating recovery. Clinicians should consider standardized provocation protocols for refractory episodic symptoms mimicking organic disease. Early integration of CBT following diagnostic confirmation yields excellent long-term outcomes.

 

221    STIGMA, DIAGNOSTIC DELAY, AND THE EPILEPSY OVERLAP IN PSYCHOGENIC NON-EPILEPTIC SEIZURES: A RURAL INDIAN PERSPECTIVE (Phenomenology/Epidemiology)
Soaham Desai, Shree Krishna Hospital, Pramukhswami Medical College, Bhaikaka University, Anand, Gujarat, India

Background: Psychogenic Non-Epileptic Seizures (PNES) represent a significant proportion of Functional Neurological Disorders (FND), yet data from low-resource, rural settings remains scarce. We hypothesized that PNES patients in rural India face disproportionately higher stigma and diagnostic delays compared to other FND subtypes, compounded by complex comorbidities.

Methods: In this cross-sectional study at a rural tertiary care hospital in a state in Western part of India (Nov 2022–Jan 2024), 250 consecutive FND patients were evaluated. Subgroup analysis focused on 120 PNES patients (48% of study population). Assessments included the Mini-International Neuropsychiatric Interview (MINI), Stigma Scale for Chronic Illness (SSCI-24), and healthcare utilization metrics. Diagnostic delay was defined as time from symptom onset to final diagnosis and measured in months.

Results: Patients with PNES exhibited the highest mean stigma scores among FND subtypes (Mean SSCI: 52.7±18.1 vs. PPPD: 46.7±21.2). Diagnostic delay was profound in PNES (mean 50.0±58.0 months) compared to functional weakness (8.0±9.8 months). Psychiatric comorbidity was present in 90% of PNES patients, primarily anxiety (73.3%) and dysthymia (45.0%). Major depression and adjustment disorders were also significant, affecting 30.0% and 23.3%, respectively. Notably, 49 patients (40.8% of the PNES subgroup) had comorbid epilepsy, presenting a significant double-diagnosis challenge. Overall, 44.8% of patients incurred substantial out-of-pocket expenses (>10,000 INR) prior to diagnosis.

Conclusions: In rural India, PNES is associated with exceptional stigma, prolonged diagnostic odyssey, and high rates of comorbid epilepsy. These findings underscore the need for culturally tailored communication strategies and integrated neurology-psychiatry pathways to reduce delay and stigma in resource-limited settings.

References:
1. Karakis I, Janocko NJ, Morton ML, Groover O, Teagarden DL, Villarreal HK, Loring DW, Drane DL. Stigma in psychogenic nonepileptic seizures. Epilepsy Behav. 2020 Oct;111:107269. doi: 10.1016/j.yebeh.2020.107269. Epub 2020 Jul 8. PMID: 32650291.
2. Labudda K, Frauenheim M, Illies D, Miller I, Schrecke M, Vietmeier N, Brandt C, Bien CG. Psychiatric disorders and trauma history in patients with pure PNES and patients with PNES and coexisting epilepsy. Epilepsy Behav. 2018 Nov;88:41-48. doi: 10.1016/j.yebeh.2018.08.027. Epub 2018 Sep 18. PMID: 30241052.

 

222    PATIENT EXPERIENCES, OUTCOMES AND HEALTHCARE UTILISATION IN FUNCTIONAL NEUROLOGICAL DISORDER IN AOTEAROA NEW ZEALAND: AN INTERIM ANALYSIS (Phenomenology/Epidemiology)
Benjamin Scrivener, Waipapa Taumata Rau, University of Auckland

Background: Globally, Functional Neurological Disorder (FND) often results in substantial disability and healthcare use (1), yet little is known about patient experiences within Aotearoa New Zealand (NZ). This study aims to characterize healthcare utilization, patient-reported experiences, and quality of life (QOL) among people with FND, and to explore differences by age, gender and ethnicity.

Methods: A cross-sectional, web-based survey is being conducted, combining validated instruments and bespoke healthcare utilization items. Measures include the EQ-5D-5L (health-related QOL), the P3C-EQ (person-centred coordinated care experience), NZ Health Survey items for service use, and free-text experience questions. Inclusion criteria: age ≥16 years, self-reported or clinician-diagnosed FND, resident in Aotearoa NZ. Exclusion: inability to complete the survey in English. Recruitment is via online FND communities. The target final sample size is ≥75 to allow for subgroup comparisons. 

Results: This interim analysis includes responses from 57 participants, with ages ranging from 16 to 84 years. The most common age bands are 55-64 years (22%), 25-34 years (19%), and 45-54 years (17%). Women comprise 90% of the cohort, and 27% identify as Māori. Mean EQ-5D-5L index score = 0.44 (SD = 0.28) and median P3C-EQ score = 11.00 (IQR = 7.84). Healthcare utilization: 100% of participants report attending their usual medical centre in the past 12 months, with a median of 6 visits. In the past 12 months, 50% report an emergency department attendance related to FND, 67% have been admitted to a hospital at least once related to FND, and 51% attended outpatient or community appointments. Free text responses frequently describe delayed diagnosis, fragmented care pathways, and stigmatization by clinicians that together exacerbate patient distress. Planned analyses will compare subgroup variation in EQ‑5D‑5L, P3C‑EQ, and healthcare utilisation by age, gender, and ethnicity.

Conclusions: This is the first national survey of FND experiences, QOL and health service use in Aotearoa New Zealand. Interim findings indicate high healthcare utilization and variable experiences of person‑centred and coordinated care among people with FND. This preliminary sample also shows markedly lower QOL than other comparable NZ neurological populations (2). Subsequent analyses will inform clinicians and service planners.

References: 
1.Carson A, et al. Disability, distress and unemployment in neurology outpatients with symptoms 'unexplained by organic disease'. J Neurol Neurosurg Psychiatry. 2011 Jul;82(7):810-3. Epub 2011 Jan 21. PMID: 21257981.
2.Claflin S, et al. Using the EQ-5D-5L to investigate quality-of-life impacts of disease-modifying therapy policies for people with multiple sclerosis (MS) in New Zealand. Eur J Health Econ. 2023 Aug;24(6):939-950.  Epub 2022 Sep 23. PMID: 36149605

 

223    IATROGENIC HARM IN ACUTE FND: RETHINKING THE HYPERACUTE PATHWAY (Treatment)
Dhiren Shivji, The National Hospital for Neurology and Neurosurgery, UCLH, London

Background: Functional Neurological Disorder (FND) is a common stroke mimic within hyperacute neurology services. While exclusion of time-critical pathology is essential, delayed explanation, repeated investigations, inconsistent messaging and fragmented follow-up can themselves generate iatrogenic harm. These processes contribute to patient distress, recurrent emergency presentations and prolonged disability. Stigma and unhelpful clinical interactions further influence outcomes. We reframed our hyperacute FND pathway as a patient-safety intervention aimed at reducing avoidable harm rather than solely improving efficiency.

Case Presentation: A physiotherapy-led hyperacute FND clinic was embedded within emergency, TIA and hyperacute stroke pathways in a UK tertiary neuroscience centre. Adults newly diagnosed with FND were offered early specialist review incorporating joint neurophysiotherapy–neuropsychiatry assessment with neurology input as required. The pathway emphasised positive diagnostic explanation, consistent multidisciplinary language, early symptom-management strategies and structured self-management education, alongside coordinated onward referral.

Seventeen consecutive patients seen between December 2021 and January 2023 were included. Emergency healthcare use and hospital admissions were examined before and after first clinic review using routine clinical records and regional data systems.

Results: FND-related emergency attendances reduced from 56 pre-clinic to 11 post-clinic. Seventy-six percent of patients did not re-present to acute services, and no patients required admission following clinic review compared with multiple admissions prior to intervention. Median pre-intervention length of stay was three days. Using conservative NHS unit cost estimates, the pathway was associated with estimated cost avoidance of £27,000–£56,000 across the cohort, excluding potential savings from reduced investigations and outpatient activity.

Discussion: This pilot service evaluation conceptualises delayed diagnosis, repeated acute presentations and poorly framed explanations as modifiable sources of iatrogenic harm in FND. Early specialist physiotherapy within hyperacute pathways appeared to reduce diagnostic uncertainty and interrupt cyclical emergency care use. Economic estimates represent indicative cost avoidance rather than formal health-economic evaluation. Because the model is embedded within standard hyperacute stroke workflows and relies primarily on role clarity rather than additional infrastructure, it is potentially transferable across diverse stroke services internationally.

References:
Finkelstein S, Cortel-LeBlanc MA, Cortel-LeBlanc A, Stone J. Functional neurological disorder in the emergency department. Academic Emergency Medicine. 2021;28(6):686–696.
Stone J, Carson A, Edwards MJ, et al. Stigma and functional neurological disorder: a research agenda. BMJ Neurology Open. 2024;6:e000633.

 

224    INTO THE LIGHT: A CASE SERIES ON VIRTUAL INTERDISCIPLINARY REHABILITATION FOR SEVERE FUNCTIONAL NEUROLOGICAL DISORDER (Treatment)
Christopher Symeon, St George's University Hospitals NHS Foundation Trust

Background: A subgroup of patients with functional neurological disorder (FND) experience profound disability associated with severe fatigue and sensory sensitivities. Some become confined to bed in darkened, low stimulus environments due to extreme intolerance to light and sensory input, making attendance at conventional outpatient, community or inpatient rehabilitation programmes impossible. Consequently, these individuals often fall outside the reach of specialist multidisciplinary FND services.

This case series describes patients with severe FND treated through a virtual interdisciplinary FND (vFND) rehabilitation programme delivering specialist care directly in the patient’s home environment.

Methods: We describe four cases treated within the virtual interdisciplinary FND service of the Wolfson Neurorehabilitation Pathway at St George’s Hospital, London. All patients were unable to access existing specialist rehabilitation programmes because of profound fatigue, sensory hypersensitivity and prolonged bed confinement.

The vFND programme was delivered by video-conferencing in three phases. Assessment involved interdisciplinary evaluation followed by a shared formulation and education meeting with the patient and family. The active treatment phase consisted of blocks of interdisciplinary therapy delivered virtually across physiotherapy, occupational therapy, psychology and other disciplines. Interventions were individually tailored using graded sensory exposure, movement retraining and pacing, alongside psychological strategies addressing threat processing and excessive attention to symptoms. The self management phase provided ongoing support while patients consolidated gains.

Results: Across the four cases, clinically meaningful improvements were observed in sensory tolerance, mobility and participation.

Patients previously confined to darkened rooms developed increased tolerance to light through graded exposure. One patient who had spent nearly two years in complete darkness was able to tolerate daylight and interact with others during the day.

Patients with prolonged immobility also achieved substantial gains. One patient who had spent most of the day in an adapted chair progressed to walking and returned to recreational activities including tennis. Another patient who had not stood for several years regained the ability to stand and perform transfers.

Improved sensory tolerance and mobility enabled greater participation in family life and daily activities.

Discussion: This case series demonstrates the feasibility of a virtual interdisciplinary rehabilitation model for patients with severe FND who cannot access conventional services. Delivering specialist care directly into patients’ homes enabled engagement with treatment that would otherwise have been inaccessible and helped guide patients out of prolonged sensory confinement and back into the light of everyday life.

 

225    THE FUNCTIONAL NEUROLOGICAL DISORDER OF IDA SAXTON MCKINLEY (Phenomenology/Epidemiology)
Nelson Tarr

Ida McKinley (First Lady, 1897–1901 and wife of William McKinley) received diagnoses of epilepsy, phlebitis, depression, muscle weakness, and partial paralysis. Her fluctuating neurological symptoms, trauma, and sensory sensitivities raise the possibility that her condition may be more consistent with FND including NES, rather than primary epilepsy alone.

Before age 26, Ida was described as physically active, cognitively intact, highly intelligent, and without neurological symptoms. At this time, she experienced multiple acute psychosocial stressors: the death of her mother shortly before the birth of her second child, the infant’s death four months later, and the subsequent death of her surviving daughter at age three.
After this cluster of traumatic events, she developed symptoms including episodic seizures, limb weakness, impaired ambulation, chronic pain, migraines, and fluctuating partial paralysis affecting one leg. Sensory hypersensitivities to noise, light, tactile stimuli, and specific colors were documented. Her husband modified state dinner protocol to conceal events during public functions. Immediately following seizures, Ida continued conversations as if nothing had transpired.1

Her symptoms fluctuated over time and appeared temporally associated with stressors, including being First Lady and persistent fear of presidential assassination. Notably, historical accounts describe improvement in her health following Pres. McKinley’s assassination.
Ida employed structured repetitive handcraft - most notably crocheting thousands of slippers for charities - as a consistent coping strategy. She frequently remained seated at public events and held bouquets to stabilize her hands, suggesting compensatory mechanisms for tremors or psychomotor instability.

Ida’s symptom profile demonstrates several features consistent with modern concepts of FND: onset following psychological trauma, fluctuating neurological deficits, unilateral weakness without progressive neurological decline, sensory hypersensitivity, chronic pain, and seizures characterized by preserved awareness and immediate return to baseline.2 Historical attribution of her condition to epilepsy and phlebitis occurred during an era when diagnostic frameworks for functional neurological symptoms were limited.
Retrospective diagnostic reinterpretation cannot be definitive; however, this case illustrates how historical figures diagnosed with epilepsy may warrant reconsideration. Re-examining such cases contributes to historical accuracy and broader discussions regarding neuropsychiatric misdiagnosis. 

References:
1.Anthony CS. Ida McKinley: The Turn-of-the-Century First Lady Through War, Assassination, and Secret Disability. Kent State University Press; 2013.
2.LaFrance WC Jr, Baker GA, Duncan R, Goldstein LH, Reuber M. Minimum requirements for the diagnosis of psychogenic nonepileptic seizures: a staged approach. Epilepsia. 2013;54(11):2005-2018. doi:10.1111/epi.12356

226    EMOTION, BRAIN NETWORKS, AND PSYCHOEDUCATION IN FUNCTIONAL NEUROLOGICAL DISORDER (FND): INTEGRATING PSYCHOLOGICAL HETEROGENEITY WITH CONTEMPORARY NEUROBIOLOGICAL MODELS (Treatment)
Cristina Tenreyro, University of Buenos Aires

Background: Functional Neurological Disorder (FND) is a common neuropsychiatric condition characterized by motor, sensory, or cognitive symptoms arising from functional alterations in brain networks rather than structural pathology. Contemporary diagnosis emphasizes positive clinical signs and network level dysfunction. Research highlights psychological heterogeneity in FND, including variability in emotional regulation, dissociation, and psychosocial vulnerability. Psychoeducation is a key component of multidisciplinary treatment; however, its theoretical framing remains inconsistent, particularly regarding the integration of emotional mechanisms within neurobiological models.

Methods: We conducted a narrative synthesis of contemporary neuroimaging, neurophysiological, and theoretical models of FND, with emphasis on predictive processing, emotional regulation, and large-scale brain networks. We analyzed how these findings may inform the structure and content of psychoeducation delivered in clinical practice.

Results: Neuroimaging and neurophysiological studies demonstrate altered connectivity among limbic, salience, attentional, and sensorimotor networks in FND. Emotional arousal and stress physiology influence interoceptive processing, motor control, and perception. Predictive processing frameworks propose that prior expectations, often shaped by emotional context, may outweigh sensory input and contribute to symptom generation, altered sense of agency, and symptom fluctuation. Integrating emotional mechanisms within a network based model provides a coherent explanatory framework. Clinically, emotion informed explanations may improve diagnostic acceptance, reduce stigma, and enhance engagement with physiotherapy and psychotherapy.

Conclusions: Framing emotional influences within a neurobiological model supports a unified and non-dualistic explanation of FND symptoms. This approach strengthens psychoeducation, promotes treatment engagement, and aligns with contemporary models of network dysfunction and neuroplasticity. This poster proposes that effective psychoeducation should place neurological information and emotional awareness at its core to support understanding, symptom integration, and clinical outcomes.

References:
1. Mechanisms and Vulnerabilities in Functional Neurological Disorder
Prudente, E., Savioz, V., Concetti, C., & Aybek, S. (2026).
Mechanisms and vulnerabilities in functional neurological disorder. Seminars in Neurology. Advance online publication.
https://doi.org/10.1055/s-0045-1801823 
2. Psychological heterogeneity in functional neurological disorders: systematic review
Mammì, A., Harper, K., Gray, C., Reuber, M., & Brown, R. J. (2026).
Psychological heterogeneity in functional neurological disorders: A systematic review of studies exploring psychopathological sub-types. Journal of Psychosomatic Research, 200, Article 112473.
https://doi.org/10.1016/j.jpsychores.2025.112

 

227    FUNCTIONAL TIC-LIKE BEHAVIORS VERSUS NEURODEVELOPMENTAL TICS: ESTABLISHING A DIAGNOSTIC TOOL TO ACCURATELY DIFFERENTIATE TICS (Phenomenology/Epidemiology, Treatment)
Laurie Thompson, PhD, Ann & Robert H. Lurie Children's Hospital

Background: Since the global pandemic in 2020, clinicians around the world have observed an increase in patients experiencing tic-like symptoms distinct from traditional neurodevelopmental tics. The new tic-like symptoms are characterized by explosive onset of complex abnormal movements that change rapidly and are inconsistent across settings. Youth with this condition often first appear in emergency departments and are significantly debilitated. The expert consensus has been that these tic-like symptoms are a subtype of Functional Neurological Symptom Disorder and are referred to as functional tic-like behaviors (FTLB). A recent Delphi survey identified specific phenomenological features of FTLB and suggested criteria for diagnosis (Pringsheim et al., 2023). However, diagnostic reliability, validity and sensitivity have not been empirically evaluated. The aim of this study is to develop a diagnostic tool for FTLB, assess the validity of these criteria in a retrospective sample, and examine inter-rater reliability in interpreting criteria and using the tool.

Methods: The proposed clinical consensus criteria were converted into a clinician rating tool using the expertise of two pediatric psychologists and two child neurologists. Then the tool was implemented on 113 retrospective charts from pediatric patients presenting to an initial neurology visit for a concern of abnormal movements. Two pediatric psychologists independently reviewed the charts and completed the clinician rating tool with the information available in the clinical documentation. Analyses consisted of a kappa statistic for interrater reliability and reliability with the neurologist. Chi squares were conducted to evaluate differences in demographics across diagnostic groups.

Results:  Thirty patients were diagnosed with FTLB in the sample. Slightly over half of patients (53%) were female. Patients of color were 57% of the sample. Mean age was 11.5 years, with the range from an infant to age 18. Females were significantly more likely to be in the FTLB group than males (p<.0001), as were patients of color (p<.0001). Age was not a significant predictor of diagnostic group, despite this being included as a major diagnostic criteria for FTLB. The diagnostic tool was generally consistently applied between raters (kappa = 0.74), and showed good consistency with the neurologist’s diagnosis (kappa = 0.84). 

Conclusions: These pilot data suggest that the diagnostic tool was reliability utilized between two raters and demonstrated validity as compared to the neurologist’s diagnosis. Early analyses suggest that patient sex and gender may be more valid to include in diagnostic criteria than patient age.

References:
Pringsheim, T., et al. (2023). European Society for the Study of Tourette Syndrome 2022 criteria for clinical diagnosis of functional tic-like behaviours: International consensus from experts in tic disorders. European Academy of Neurology, 30(4), 902-910.

 

228    WHITE MATTER MICROSTRUCTURE IN FUNCTIONAL NEUROLOGICAL DISORDER: EVIDENCE FROM A DIFFUSION MRI MEGA-ANALYSIS (Etiology/Pathophysiology)
Petr Sojka, General University Hospital in Prague

Background: Functional neurological disorder (FND) is associated with altered brain network functioning, yet diffusion-weighted imaging (DWI) evidence for white matter microstructural abnormalities has been inconsistent, largely due to small sample sizes and site-specific effects. Mega-analytic approaches that combine multi-site data with harmonization techniques may improve sensitivity and reproducibility. We investigated white matter microstructure in a large multi-centre sample of patients with FND and healthy controls using an atlas-based region-of-interest (ROI) approach.

Methods: DWI data were pooled from five international sites, including 218 patients with clinically diagnosed FND (121 functional motor disorder, 97 functional seizures) and 231 demographically matched healthy controls. Preprocessing was performed using the PreQual pipeline, including denoising, correction for susceptibility-induced distortions, eddy currents, motion, and bias field inhomogeneity, followed by automated quality control. Fractional anisotropy (FA) maps were derived using diffusion tensor modelling, and median FA values were extracted from 48 bilateral white matter tracts defined by the JHU ICBM-DTI-81 atlas. To address inter-site and inter-scanner variability, FA values were harmonized using ComBat while preserving biological effects of group, age, and sex. Group differences were assessed using a hierarchical Bayesian regression model with subject-level random intercepts and tract-level random slopes, allowing tract-specific patient–control effects with partial pooling.

Results: Compared with healthy controls, patients with FND showed lower FA in a subset of white matter tracts. The largest patient–control differences were observed in limbic and fronto-temporal association pathways, including the bilateral hippocampal and cingulate components of the cingulum bundle, the uncinate fasciculus, and the anterior corona radiata. Additional reductions were observed in the pontine crossing tract and external capsule. Posterior probabilities indicated strong evidence for reduced FA in these tracts (posterior probability of FA reduction ≥0.99), with no tracts showing increased FA in patients compared with controls.

Conclusions: This large-scale mega-analysis provides evidence for selective reductions in white matter microstructural integrity in FND, particularly within limbic and fronto-temporal association pathways. By combining standardized preprocessing, ComBat harmonization, and hierarchical tract-level modelling, this study demonstrates a robust and sensitive framework for detecting subtle white matter alterations in heterogeneous, multi-site clinical datasets. These findings support the utility of harmonized mega-analytic DWI approaches for improving reproducibility and anatomical specificity in neuroimaging studies of FND.

References:
Cai, Leon Y., Qi Yang, Colin B. Hansen, et al. 2021. “PreQual: An Automated Pipeline for Integrated Preprocessing and

 

229    SENSORY MOTOR FUNCTIONAL NEUROLOGICAL DISORDER TREATMENT IN INTENSIVE INTERDISCIPLINARY PAIN TREATMENT: A PEDIATRIC CASE REPORT (Treatment)
Catherine Stewart, PhD, Boston Children’s Hospital

Background: Functional neurological symptom disorders (FNSD) and chronic pain syndromes are increasing in prevalence in children and adolescents, and approximately 6-17% of youth with chronic pain syndromes also experience FNSD. Intensive interdisciplinary pain treatment programs (IIPT) use a biopsychosocial approach relevant for youth with chronic pain and overlapping FNSD; however, the evidence for the effectiveness of these treatment programs for youth with motor and sensory functional neurological symptom disorders is limited.  

Case Presentation: This case describes biopsychosocial outcomes for a 17-year-old female (“Nina” ) with FNSD with mixed symptoms, including upper and lower extremity motor and sensory changes and chronic widespread pain. Upon admission, Nina presented in a manual wheelchair, dependently pushed by caregivers. She could not stand, complete self-care tasks, or ambulate without assistance. Nina completed 8 weeks of IIPT (40 hours/week outpatient rehabilitation). Outcomes are reported for program admission, discharge, and 15 week follow up visit. Nina reported severe pain across all timepoints; 7/10 on a numeric rating scale. She was unable to complete a 6-minute walk test at admission, and progressed to 200ft with a walker at discharge, and 864ft without an assistive device at follow-up. Full descriptions of her scores are provided in [Table 1]. Subjective reports of disability, mood, and pain-related distress all improved at discharge. She reported some worsening of mood, and pain-related distress at follow-up compared to discharge, but remained improved from admission [Table 1]. Biopsychosocial formulation of symptoms and details of IIPT intervention for this patient will be discussed.  

Discussion: Nina demonstrated significant improvements in her independence with self-care and mobility after participation in IIPT. In line with evidence for youth with functional seizures, IIPT programs may be well suited to support youth with motor sensory FNSD in recovering independence with function and participation in valued activities. To better understand treatment prognosis of youth with FNSD treated in IIPT settings, larger studies tracking patient outcomes and diagnostic characteristics are needed. Functional and resting state imaging techniques may also help explore FNSD mechanisms and pathways of recovery as prior studies implicate aberrant connections, structure, and neurobiology of sensorimotor and emotional brain regions. 

References: 
Mason I, Renée J, Marples I, McWhirter L, Carson A, Stone J, Hoeritzauer I. Functional neurological disorder is common in patients attending chronic pain clinics. Eur J Neurol. 2023 Sep;30(9):2669-2674. 
Scheurich, J. A., Klaas, K. M., Sim, L. A., Weiss, K. E., Case, H. F., & Harbeck-Weber, C. (2024). Characteristics and outcomes of youth with functional seizures attending intensive interdisciplinary pain treatment. Epilepsy & Behavior, 153.

 

230    CLINICAL AND EPIDEMIOLOGICAL PROFILE OF FUNCTIONAL NEUROLOGICAL DISORDERS: AN OBSERVATIONAL STUDY IN A BRAZILIAN NEUROLOGICAL REHABILITATION HOSPITAL (Phenomenology/Epidemiology)
Letícia Swerts, Rede Sarah

Background: Functional neurological disorder (FND) is a prevalent and disabling condition at the interface between neurology and psychiatry, characterized by motor, sensory, and cognitive dysfunctions that cannot be explained by structural neurological diseases. Despite its clinical relevance, epidemiological and therapeutic data are scarce, particularly in Latin America. This study aimed to characterize the clinical and epidemiological profile of patients diagnosed with FND at a neurological rehabilitation hospital in Brazil.

Methods: We conducted a retrospective observational study including patients diagnosed with FND according to DSM-5 criteria who were followed between 2018 and 2025. Data were obtained from the hospital’s electronic medical records, including demographics, marital status, education, occupation, prior diagnoses, and diagnostic delay.

Results: Eighty-six patients were analyzed, of whom 72 (83.7%) were women and 14 (16.3%) were men. The mean age was 51.8 years, with 57% of patients between 40 and 59 years old. The youngest patient was 24 years old, and the oldest was 81. Regarding marital status, 56.98% were married or in a stable partnership, 27.91% were single, 11.63% were divorced, and 3.49% were widowed. The mean level of education was 12 years.

The five most frequent occupations were homemaker, elderly caregiver, driver, teacher, and construction worker. Thirteen patients worked in healthcare, including elderly caregivers (6), nursing technicians (3), physician (1), nurse (1), physiotherapist (1), speech-language pathologist (1), community health worker (1), and massage therapist (1).

FND was the primary diagnosis in 74% of cases. However, 80 patients had received another diagnosis prior to FND, most commonly neuromuscular disorders, movement disorders, and cerebrovascular diseases. Six patients had no prior diagnosis. The mean diagnostic delay was 43 months.

Conclusions: The majority of patients were adult women, married or in a stable partnership, and had a secondary level of education. Only a minority worked in healthcare. Diagnostic challenges were frequent, often leading to years of delay from symptom onset and, consequently, a poorer prognosis in the rehabilitation program. These findings underscore the need for greater awareness and earlier recognition of FND in clinical practice.

References:
1. Aybek S, Perez DL. Diagnosis and management of functional neurological disorder. BMJ 2022;376:o64.
2. Perez DL, Edwards MJ, Nielsen G, Kozlowska K, Hallett M, LaFrance WC, Jr. Decade of progress in motor functional neurological disorder: continuing the momentum. J Neurol Neurosurg Psychiatry 2021.

 

231    A RETROSPECTIVE STUDY OF THE CLINICAL PRESENTATION, COMORBIDITIES AND OUTCOME  OF FUNCTIONAL NEUROLOGICAL DISORDERS (FND) IN CHILDREN AND YOUNG PEOPLE (CYP) AT OUR TERTIARY PAEDIATRIC CENTRE (Treatment)
Sivakami Chelladurai

Background: Our aim was to study the clinical presentation of FND in CYP, including presenting symptoms, associated co-morbidities, management and outcome. 

Methods: We analysed data of 30 patients from computerised case notes and clinic letters for a cohort of CYP who were diagnosed with FND in the last 7 years. 

Results: The ages of onset of symptoms range from 5 to 15 years with a mean of 11.6 years and a median of 12 years. There was a female predominance of up to 74.3% (22). 26.6% (8) were males. The common presentations were pain, weakness, difficulty in mobility, numbness, 
abnormal movements, memory issues, cognitive regression, visual symptoms and bladder/bowel symptoms. The duration between onset of symptoms to diagnosis ranged from less than a month to 12 years, with a mean duration of 16.6 months. Associated factors were parental separation in 6, death of immediate family members in 3, road traffic accidents in 4, bullying at school in 3, chronic medical illnesses in family members in 7 and mental health problems in family members in 3. Multiple other comorbidities such as autism, attention deficit and hyperactivity disorder, anxiety, chronic fatigue syndrome, complex regional pain syndrome, gender dysphoria, eating disorder and Tourette 
syndrome were observed. Multiple subspecialty consultations were involved in patient care. 22 CYP (73.3%) received targeted therapy at least for a brief period during the illness, in the form of input from occupational therapy, psychology, chronic fatigue service, pain team and child and adolescent mental health services (CAMHS). 23 CYP (76.7%) had significant disruptions to school attendance. The latest outcome showed that 10 CYP (33.3%) reported improvement of symptoms, 16 (53.3%) reported ongoing symptoms or a waxing and waning course and 4 (13.3%) CYP reported worsening of symptoms with significant limitation of function. 

Conclusions: FND presents a challenging landscape for CYP, their families, and the healthcare professionals involved. Research on FND in children is limited, and the lack of structured services further complicates the situation. The clinical presentation is highly variable and 
complex. Management often requires a multidisciplinary approach, which can lead to over investigation. However, early targeted interventions have been shown to lead to better outcomes.