Functional neurological disorders (FND) represent a substantial and heterogeneous group of conditions characterized by neurological symptoms that are inconsistent with recognized diseases yet are genuine, disabling, and associated with altered brain functioning. Epidemiological research over the past two decades has consistently shown that FND are common in neurology and emergency settings, with prevalence and incidence estimates that rival, or in some subgroups exceed, many traditional neurological conditions. However, wide variability in reported rates reflects differing diagnostic criteria, study designs, and case ascertainment methods, highlighting a critical need for standardized approaches as a core research priority.
In general neurology outpatient clinics, FND are now among the most frequent single diagnoses, with functional seizures and functional movement disorders being particularly prominent. Population-based estimates remain scarce, largely because health systems and administrative databases often lack specific and reliable coding for these conditions. Many patients are misclassified under epilepsy, stroke, multiple sclerosis, or nonspecific somatoform categories. This under-recognition leads to systematic underestimation of true disease burden, obscuring the scale of the problem for planners, funders, and policymakers. Well-designed epidemiological studies using harmonized definitions and modern case-finding methods, including linkage across primary care, emergency, neurology, and psychiatry records, are therefore among the most urgent priorities for the field.
Epidemiological data that do exist indicate that FND affect individuals across the lifespan, with peaks in young to middle adulthood but with meaningful numbers of children and older adults also affected. While earlier literature suggested a predominantly female distribution, more recent studies have nuanced this view, showing sex ratios that vary by symptom subtype and care setting. Socioeconomic gradients are also evident, with increased risk associated with social adversity, unemployment, and barriers to accessing appropriate care. Yet most evidence originates from tertiary or quaternary centers in high-income countries, introducing substantial referral and selection bias. Large-scale, community-based, and cross-cultural studies are needed to clarify global prevalence, incidence, risk, and protective factors, including the role of gender, ethnicity, and social determinants of health.
Longitudinal epidemiological work remains particularly underdeveloped. FND have historically been considered to have a relatively poor prognosis, but this picture is based on small, highly selected cohorts and older diagnostic frameworks. Contemporary studies suggest a more complex and variable course, with some patients experiencing substantial improvement and others showing persistent or fluctuating disability. Robust prospective cohorts with long-term follow-up are necessary to identify early prognostic markers, service-related influences on outcome, and modifiable factors such as comorbid psychiatric conditions, physical health problems, and ongoing social stressors. This type of research will help refine prognosis, guide timing and intensity of interventions, and inform health economic modeling.
Diagnostic challenges begin with the fundamental conceptualization of FND. Historically framed as diagnoses of exclusion or as purely psychological conditions, they were often made only after exhaustive testing had failed to identify structural pathology. This approach is inefficient, stigmatizing, and prone to both over- and under-diagnosis. Contemporary consensus instead emphasizes positive diagnostic criteria based on characteristic clinical signs, internal inconsistency of symptoms, and incongruence with known neurological disease, while recognizing that FND commonly co-occur with structural or degenerative conditions. Translating this modern understanding into consistent clinical practice worldwide remains a major challenge and a key area for education and implementation research.
One central diagnostic issue is the wide variability in how criteria are operationalized by clinicians across disciplines and regions. Neurologists, psychiatrists, emergency physicians, and primary care providers may use different terminology, frameworks, and thresholds for diagnosis. Some rely heavily on imaging and laboratory exclusion, while others focus primarily on clinical examination findings. This fragmentation creates inconsistencies in patient labeling, referral pathways, and access to treatment. Development, validation, and dissemination of pragmatic, field-tested diagnostic algorithms that emphasize positive signs and can be implemented in busy clinical environments should be a top priority, accompanied by training and systematic evaluation of diagnostic reliability.
Misdiagnosis can occur in both directions. On the one hand, patients with early or atypical presentations of degenerative, autoimmune, or metabolic neurological conditions may be incorrectly diagnosed with FND, delaying disease-modifying therapy. On the other hand, patients with FND are frequently mislabeled with epilepsy, stroke, or other neurological diseases, leading to unnecessary medications, procedures, and hospitalizations, with significant harm and cost. Current evidence suggests that when modern criteria and expert assessments are used, long-term diagnostic revision from FND to another neurological disease is relatively rare, but this finding has mostly emerged from specialty centers. Systematic studies across diverse care levels are required to quantify misdiagnosis rates, clarify risk factors for diagnostic error, and identify safety nets for high-risk scenarios.
Communication of the diagnosis presents another major challenge. Even when clinicians recognize FND, they may struggle to convey the diagnosis in a way that is accurate, non-stigmatizing, and acceptable to patients and families. Poorly delivered explanations, framed in terms of symptoms being “all in the mind” or “not real,” can erode trust, reduce engagement with treatment, and contribute to health care avoidance or doctor-shopping. Research priorities include developing and testing structured communication strategies, scripts, and educational materials to support diagnostic disclosure, as well as examining how language, metaphors, and cultural factors influence patient understanding, acceptance, and subsequent outcomes.
Access to appropriate diagnostic expertise is highly uneven. In many regions, there are few clinicians trained in the recognition of FND, and referral pathways are unclear or nonexistent. Patients may repeatedly cycle through emergency departments, neurology clinics, and mental health services without receiving a coherent, positive diagnosis. This not only inflates costs but perpetuates uncertainty and distress. Health services research is needed to map current diagnostic pathways, identify bottlenecks and geographical inequities, and test models such as rapid-access FND clinics, telemedicine consultations, and integrated neuropsychiatric assessment services. Such work will require close collaboration across specialties and health systems.
Another diagnostic challenge lies at the interface of FND with comorbid medical and psychiatric conditions. Many patients have co-occurring anxiety, depression, post-traumatic stress, personality traits, or chronic pain syndromes, which can complicate both recognition and attribution of symptoms. Some clinicians may mistakenly attribute all complaints to psychological causes, while others may ignore psychological factors entirely in favor of an overly narrow neurological frame. Epidemiological studies that systematically characterize the full spectrum of comorbidities, including substance use and sleep disorders, and that examine how these interact with symptom onset, maintenance, and health care utilization are essential for refining diagnostic frameworks and tailoring interventions.
Heterogeneity within FND subtypes further complicates epidemiology and diagnosis. Functional seizures, functional movement disorders, functional weakness, and functional sensory symptoms show distinct demographic patterns, comorbidity profiles, and triggering contexts. Yet research often aggregates these groups, obscuring subtype-specific risk factors and course trajectories. Future epidemiological work should be powered to examine both shared and unique features across subtypes and explore whether there are meaningful clusters based on symptom combinations, onset precipitants, and psychosocial context. Clarifying this structure will help refine diagnostic taxonomies and inform targeted intervention strategies.
The lack of widely accepted biomarkers remains a major limitation. While promise has emerged from neuroimaging, electrophysiological techniques, and digital phenotyping, no objective test has yet reached sufficient sensitivity, specificity, and practicality for routine clinical use. Nonetheless, combining carefully phenotyped epidemiological cohorts with biomarker discovery efforts could yield more robust diagnostic models and help distinguish FND from mimicking conditions, especially in equivocal cases. Research that integrates clinical signs with quantitative measures such as accelerometry, EEG features, or autonomic markers in real-world settings may offer incremental gains in diagnostic confidence and reproducibility.
Cross-cultural considerations are also underexplored in both epidemiology and diagnosis. Cultural beliefs about illness, stigma related to mental health, explanatory models of bodily distress, and health system structures all influence how FND symptoms are expressed, interpreted, and labeled. Much of the existing evidence stems from Western, specialized centers, limiting its generalizability. Collaborative international research networks should prioritize recruitment from low- and middle-income countries and from diverse cultural groups within high-income nations, using standardized but adaptable diagnostic tools to allow meaningful comparison. Such collaboration will be crucial for developing globally relevant diagnostic guidelines and for understanding variations in clinical presentation.
Data quality and coding practices present another barrier. Health records frequently use outdated, overly broad, or nonspecific diagnostic labels such as “conversion disorder,” “psychogenic,” “somatization,” or “medically unexplained.” Such labels obscure differences between FND and other functional or somatic symptom conditions, making it difficult to compare studies or track trends over time. Advocacy for updated and precise diagnostic codes in classification systems, along with guidance for clinicians and coders on their use, should be coupled with research evaluating how coding changes affect apparent incidence, service utilization, and patient outcomes.
The patient voice in defining epidemiological priorities and diagnostic challenges has historically been limited. Patients often report long diagnostic delays, invalidating encounters, and fragmented care. Incorporating patient-reported experiences into epidemiological designs, such as through mixed-methods studies and patient-led registries, can highlight overlooked barriers and inform more nuanced diagnostic criteria that better reflect lived realities. Sustained collaboration among clinicians, researchers, and patient organizations is essential to designing research that captures the true burden of FND, clarifies where in the diagnostic journey failures occur, and tests remedies that are both scientifically robust and acceptable to those directly affected.
Neurobiological mechanisms and brain network dysfunction
Understanding the neurobiological basis of functional neurological disorders has become a central focus of contemporary research, shifting the field away from purely psychological or exclusion-based models toward mechanistic explanations grounded in brain network science. Evidence from functional MRI, structural imaging, electrophysiology, and neurophysiological paradigms consistently supports the view that symptoms arise from abnormal patterns of brain function and connectivity, rather than from structural damage. Priorities now include moving from descriptive imaging findings to testable, mechanistic models that can be linked to specific symptoms, prognostic groups, and treatment response.
One of the most influential frameworks conceptualizes symptoms as arising from disturbances in brain networks governing agency, prediction, and attention. Patients with functional weakness, movement symptoms, or seizures frequently show altered activity and connectivity within networks integrating motor intention, sensory feedback, and self-monitoring. For example, several studies have demonstrated increased activity in prefrontal and limbic regions, such as the anterior cingulate cortex and amygdala, in response to symptom provocation or emotionally salient stimuli, accompanied by reduced effective connectivity to primary motor and sensory cortices. This pattern supports the hypothesis that top-down influences—such as expectations, beliefs, and heightened emotional salience—can override or distort normal sensorimotor processing, resulting in involuntary, yet subjectively compelling, symptoms.
The concept of impaired sense of agency has been particularly fruitful in understanding functional motor symptoms. Experimental paradigms that manipulate voluntary movement, imitation, or motor imagery show that patients may exhibit abnormal brain responses in regions associated with self-other distinction and action monitoring, including the temporoparietal junction and supplementary motor area. These alterations are often interpreted within a predictive coding framework, in which the brain constantly generates predictions about bodily states and updates them based on incoming sensory information. In FND, aberrant priors or prediction errors may lead to persistent misattribution of internally generated signals, creating movements or sensations experienced as involuntary. Future research priorities include quantifying these predictive processes more precisely, using computational modeling and neurophysiological measures to relate them to specific symptom dimensions.
Beyond motor systems, abnormalities in attentional and salience networks appear central. Functional imaging and neuropsychological studies consistently point to biased allocation of attention toward symptom-relevant bodily sensations, alongside difficulties disengaging from internally focused monitoring. Altered connectivity between the salience network (including insula and anterior cingulate), the default mode network, and sensorimotor systems has been reported in multiple FND subtypes. These findings suggest that symptoms may be sustained by a maladaptive loop in which heightened interoceptive sensitivity and self-focused attention amplify bodily signals, which are then interpreted in the context of prior expectations or fears. Refining these models, and testing whether they generalize across functional seizures, functional movement disorders, and functional sensory symptoms, remains a key target for mechanistic research.
Limbic and autonomic system involvement is another recurring finding, linking emotional processing to symptom generation. Many patients show exaggerated autonomic responses, altered heart rate variability, or abnormal electrodermal activity during symptom episodes or stress-provoking tasks. Neuroimaging demonstrates heightened amygdala reactivity and altered amygdala–prefrontal connectivity, suggesting impaired regulation of emotional responses. However, not all individuals with FND have overt trauma histories or psychiatric comorbidities, underscoring that limbic dysregulation may be necessary but not sufficient for symptom development. Research is needed to dissect which aspects of emotional processing—such as threat appraisal, fear conditioning, or extinction learning—are specifically disrupted, and how these mechanisms interact with genetic, developmental, and environmental factors to confer vulnerability.
Electrophysiological and neurophysiological studies have yielded some of the most promising candidate biomarkers, particularly in functional seizures and movement disorders. In functional seizures, video-EEG monitoring typically shows absence of epileptiform activity during events, but more sophisticated analyses reveal subtle differences in EEG spectral power, functional connectivity, and network dynamics before, during, and after episodes. Similar work in functional movement disorders, using techniques such as transcranial magnetic stimulation (TMS), has identified abnormalities in cortical excitability, inhibition, and plasticity, as well as alterations in readiness potentials preceding movements. These findings point to potentially reversible changes in motor system physiology and raise the possibility of targeted neuromodulation interventions. A key priority is to validate these measures in large, well-characterized cohorts and determine their sensitivity and specificity relative to organic mimics.
Sensory processing and interoception also appear disturbed in FND. Experimental paradigms assessing pain, touch, proprioception, and internal bodily signals (such as heartbeat detection) often demonstrate either heightened sensitivity or paradoxical hypo-responsiveness, depending on context. Neuroimaging studies implicate insular cortex, somatosensory regions, and brainstem nuclei in these abnormalities, suggesting that both bottom-up sensory processing and top-down modulation are altered. Further work is required to clarify whether these changes reflect trait vulnerabilities, state-dependent effects of symptoms, or consequences of chronic illness and attentional bias. Longitudinal and cross-sectional designs that include relatives or high-risk groups could help disentangle these possibilities.
Structural imaging in FND has yielded more subtle and variable results than functional studies, but converging data indicate that microstructural and volumetric differences can be detected in regions involved in emotion regulation, sensorimotor integration, and self-referential processing. For instance, differences in gray matter volume or cortical thickness have been reported in the anterior insula, prefrontal cortex, cingulate regions, and cerebellum. Diffusion imaging has highlighted alterations in white matter tracts connecting limbic and motor regions. While these findings are not specific and may overlap with other disorders, they challenge older assumptions that FND are “structurally normal” and emphasize the need for multi-modal imaging approaches that integrate structural, functional, and connectivity metrics. Large, harmonized datasets and international collaboration will be necessary to overcome heterogeneity and clarify which structural features, if any, have diagnostic or prognostic value.
Genetic and epigenetic contributions to FND remain underexplored. Existing work is limited and often underpowered, but there is growing recognition that individual differences in stress reactivity, emotional regulation, and pain sensitivity may have heritable components that interact with environmental exposures across development. Epigenetic changes in genes linked to hypothalamic–pituitary–adrenal axis function, inflammatory processes, or synaptic plasticity have been hypothesized as potential mediators between early adversity and later vulnerability to functional symptoms. Advancing this line of research will require carefully phenotyped cohorts, attention to comorbidities, and integration with neuroimaging and psychophysiological data to construct multi-level models of risk.
A critical challenge is to bridge group-level findings with clinically meaningful individual-level biomarkers. Many neuroimaging and neurophysiological studies report significant differences between groups of patients and controls, yet effect sizes often overlap, limiting immediate diagnostic utility. Priorities include developing analytic approaches that capture individual network signatures—such as machine learning classifiers or network-based statistics—and testing their robustness across sites, scanners, and symptom subtypes. Importantly, biomarker research should not focus solely on diagnosis; markers of treatment response, relapse risk, and long-term outcome may be equally, if not more, valuable for guiding clinical decision-making and personalizing care.
Mechanistic insights must ultimately be linked to modifiable targets for interventions. For instance, if altered attention to bodily sensations and aberrant predictive coding processes are central to symptom maintenance, therapies could be designed to recalibrate these systems through cognitive training, attention retraining, or exposure-based methods that update maladaptive priors. Similarly, evidence of disrupted motor planning and agency could inform rehabilitation protocols that emphasize graded re-establishment of voluntary control, explicit relearning of movements, and feedback-based techniques that restore a sense of agency. Neuroimaging and neurophysiological tools can then be used to monitor how these interventions reshape brain networks, providing a mechanistic bridge between treatment and symptom change.
Noninvasive brain stimulation and neuromodulation approaches are emerging as promising adjuncts to psychological and physical therapies, but their use remains in early phases. Pilot studies using repetitive TMS or transcranial direct current stimulation over motor or prefrontal regions have suggested potential benefits for some patients, consistent with the notion of network-level dysfunction that may be amenable to modulation. However, optimal targets, stimulation parameters, patient selection criteria, and combinations with behavioral interventions are largely unknown. Rigorous, mechanistically informed trials that integrate stimulation with imaging and electrophysiological endpoints are needed to determine whether neuromodulation can reliably shift dysfunctional networks and produce durable clinical gains.
Another priority area involves clarifying the temporal dynamics of symptom generation. Many current studies capture brain activity at rest or during simple tasks, but FND symptoms are often context-dependent, fluctuating with stress, fatigue, interpersonal interactions, or environmental cues. Ambulatory and ecological momentary assessment methods, combined with wearable sensors, mobile EEG, or portable neuroimaging surrogates, could help track how brain network states evolve across real-world contexts and how they relate to symptom flare-ups or remission. This type of research may identify transient states of heightened vulnerability that represent windows of opportunity for targeted interventions, whether behavioral or neuromodulatory.
Importantly, neurobiological models must accommodate the heterogeneity within and across symptom subtypes. Functional seizures, for example, may involve particularly pronounced alterations in limbic–motor coupling and arousal regulation, whereas functional movement disorders may show more prominent abnormalities in motor planning networks and sense of agency. Functional sensory symptoms might be driven by distinct patterns of sensory gating and interoceptive misinterpretation. Comparative studies that directly contrast subtypes using standardized paradigms and analytic pipelines are necessary to identify both shared mechanisms and subtype-specific signatures. This knowledge could ultimately support more precise stratification strategies and tailored therapies.
Interdisciplinary collaboration will be essential to advance these mechanistic agendas. Integrating expertise from neurology, psychiatry, psychology, neuroscience, engineering, data science, and rehabilitation medicine can help refine experimental designs, analytic approaches, and theoretical models. Collaborative consortia can pool data across sites to achieve the sample sizes needed to address heterogeneity and reproducibility challenges, while shared protocols and open science practices can facilitate cross-study comparisons and meta-analyses. Equally important is the involvement of patients and advocacy groups in shaping research questions, ensuring that mechanistic work remains anchored in clinically and personally meaningful outcomes rather than purely academic endpoints.
Neurobiological research in FND must navigate ethical and communication challenges. Findings that highlight alterations in brain networks risk being oversimplified as evidence that symptoms are “all in the brain,” potentially reinforcing dualistic thinking and new forms of stigma. Conversely, a strong focus on psychological or social contributors may be misinterpreted as negating biological reality. Thoughtful integration of mechanistic data into clinical explanations, co-developed with patients, can help counter these risks by emphasizing that FND reflects real, functional changes in brain–body systems that are dynamically shaped by life experiences, context, and learning, and that are amenable to targeted, evidence-based interventions.
Clinical assessment tools and outcome measurement priorities
Advancing clinical care and research in functional neurological disorders depends heavily on the development of robust, reliable, and feasible assessment tools that capture the complexity of symptoms and their impact over time. Current practice often relies on clinician impression, unstandardized examination, and generic outcome measures borrowed from other neurological or psychiatric conditions. This approach hampers comparability across studies, obscures true treatment effects, and limits the ability to stratify patients or personalize interventions. Establishing shared priorities for assessment and outcome measurement is therefore essential for building a coherent and cumulative evidence base.
A central task is to define core clinical domains that should be assessed consistently across FND studies and services. These domains extend beyond observable neurological symptoms to include symptom severity and frequency, functional disability, health-related quality of life, psychological distress, cognitive and attentional functioning, social and occupational participation, and health care utilization. Because FND frequently involve fluctuations, episodic phenomena (such as functional seizures), and context-dependent symptom expression, temporal patterns and triggers also need to be captured. Consensus-building exercises, such as Delphi processes that bring together clinicians, methodologists, and people with lived experience, are needed to identify a minimum core outcome set that can be recommended for clinical trials and longitudinal cohort studies.
Symptom-specific assessment tools for major FND subtypes remain patchy and unevenly validated. For functional seizures, event frequency is often the primary metric, yet counting seizures alone provides an incomplete picture of disability, safety risks, and psychological burden. Detailed seizure diaries, standardized semiology descriptions, and patient-reported measures of postictal state, anticipatory anxiety, and loss of role functioning are needed to complement frequency data. In functional movement disorders, clinical rating scales developed for Parkinson’s disease or dystonia are frequently repurposed, despite not being designed to capture variability, distractibility, and inconsistency that are hallmark features of functional symptoms. Developing and validating FND-specific motor rating scales that rate both observable phenomenology and internal experience of control represents a high-yield research priority.
Similarly, functional weakness and sensory symptoms pose assessment challenges because conventional neurological scoring systems, such as standard motor strength grading, tend to overlook positive signs of internal inconsistency and the impact of symptoms on real-world functioning. Novel tools should incorporate structured examination maneuvers that elicit functional signs (for example, Hoover’s sign or entrainment of tremor) alongside standardized ratings of functional mobility, self-care, and participation in daily activities. Clinician-rated instruments must be paired with patient-reported outcome measures to ensure that aspects of fatigue, fluctuating effort, and subjective distress are not missed. For functional cognitive symptoms, there is a need for tools that distinguish between performance on traditional neuropsychological tests and real-life complaints of “brain fog,” attentional lapses, or executive dysfunction, acknowledging that standard testing may either under- or over-estimate true impairments.
Developing and validating patient-reported outcome measures tailored to FND is a particularly pressing need. Generic instruments such as the SF-36 or PROMIS measures offer comparability across diseases but may be insensitive to symptom-specific issues such as fear of attacks, perceived loss of control over the body, or stigma related to contested illness. FND-specific questionnaires should be co-designed with patients to capture domains they identify as most meaningful: ability to work or study, maintain relationships, care for dependents, enjoy leisure activities, and feel safe in public spaces. Psychometric development requires rigorous, stepwise work, including item generation, cognitive interviewing, factor analysis, and assessment of reliability, validity, and responsiveness to change. International collaboration can ensure that instruments are culturally adaptable and available in multiple languages.
Outcome measurement must also grapple with the multidimensional nature of treatment response. Improvement in one domain, such as symptom frequency, may not translate into better functioning or quality of life if, for example, avoidance behaviors, health anxiety, or comorbid conditions remain unaddressed. Composite outcome indices that integrate symptom change, functional gains, and patient satisfaction may provide a more realistic picture of treatment benefit. However, composite measures must be carefully constructed and transparently reported to avoid obscuring heterogeneity of response. Research comparing different composite indices, and testing their ability to predict long-term trajectories such as return to work or sustained remission, is a key methodological priority.
Timing and frequency of assessment are additional considerations. FND symptoms often show diurnal variation, stress-related exacerbations, and spontaneous remissions, which can lead to misleading impressions if only single time points are sampled. Repeated measures designs, including brief, regular assessments between clinic visits, are needed to characterize trajectories accurately and to detect early signs of relapse or treatment failure. Digital tools, such as smartphone-based symptom diaries, ecological momentary assessment platforms, and wearables that monitor movement, heart rate, or sleep patterns, offer powerful opportunities to capture real-time data with minimal burden. Research is required to validate these digital measures, determine optimal sampling frequencies, and identify thresholds for clinically meaningful change.
Objective and semi-objective markers, including neurophysiological tests and digital phenotyping, hold promise as adjuncts to clinical scales but are not yet ready to serve as definitive biomarkers. In functional seizures, for example, video-EEG remains the gold standard for diagnostic confirmation in many settings, yet it is not feasible as a routine outcome measure. Exploratory work using quantitative EEG features, heart rate variability, and accelerometry-based seizure detection could pave the way for more objective monitoring of treatment response, but these methods must be tested for reliability in real-world conditions, including at-home environments. For functional movement disorders, wearable sensors can quantify tremor amplitude, frequency, and variability; combined with machine learning algorithms, these data might differentiate functional from organic tremor and track changes over time. Establishing standardized protocols for sensor placement, recording durations, and data analysis is a foundational research task.
Neuroimaging and neurophysiological measures have great appeal as potential surrogate outcomes that reflect underlying mechanisms targeted by interventions. For instance, changes in functional connectivity between limbic and motor networks following psychotherapy, physiotherapy, or neuromodulation could serve as intermediate markers of treatment engagement and brain network reorganization. However, reliance on complex imaging as primary outcomes risks limiting generalizability, increasing costs, and excluding sites without advanced imaging infrastructure. A realistic priority is to integrate mechanistic measures into early-phase and proof-of-concept trials, while ensuring that later-phase trials focus primarily on clinically meaningful outcomes that are accessible across diverse health systems. Harmonized imaging protocols and pre-specified analytic pipelines will be important for ensuring comparability across studies and preventing overinterpretation of small or inconsistent effects.
Another key issue is the operationalization of “recovery” and “remission” in FND. Current studies use heterogeneous definitions, ranging from complete absence of symptoms to specified percentage reductions in event frequency, or subjective ratings of being “much improved.” These discrepancies undermine cross-trial comparisons and meta-analyses. Collaborative efforts are needed to develop consensus definitions that incorporate both symptom burden and functional status, acknowledging that some individuals may continue to experience occasional symptoms while nonetheless achieving satisfactory quality of life and social participation. Differentiating between symptomatic remission, functional recovery, and personal recovery (as defined by the individual’s own goals and values) will allow more nuanced and patient-centered outcome evaluation.
Clinician-rated global impression scales, such as the Clinical Global Impression–Improvement scale, are widely used across medical disciplines but have specific limitations in FND, where clinician attitudes, level of expertise, and expectations can strongly shape ratings. Training materials and calibration exercises could improve consistency, but reliance on such global scales as primary endpoints should be reconsidered. Instead, they might be better suited as secondary outcomes, complementing more granular measures. Studies comparing clinician global impressions with patient-reported changes, objective functional indices (such as return to work), and digital symptom tracking could shed light on discrepancies and help refine how global impressions are interpreted.
Assessment tools must be sensitive to the influence of comorbidities, including anxiety, depression, post-traumatic stress, chronic pain, and sleep disorders. Standardized measures of these conditions—such as validated anxiety and depression inventories or pain intensity and interference scales—should be routinely incorporated into FND assessment batteries. Doing so not only aids in comprehensive case formulation but also enables examination of how changes in comorbid symptoms relate to FND outcomes. For example, research can clarify whether improvements in mood or trauma-related symptoms precede, follow, or occur independently from changes in neurological symptoms, informing treatment sequencing and combined interventions.
The development of pediatric-specific assessment tools is an area of particular neglect. Children and adolescents with FND often present differently from adults, and standard adult scales may not adequately reflect their developmental context or priorities, such as school attendance, peer relationships, and family functioning. Age-appropriate symptom rating scales, child- and parent-reported outcome measures, and school-based functional indicators (for example, days of school missed, participation in physical activities) should be developed and validated using child-centered methodologies. Attention to literacy level, developmental stage, and family dynamics is critical to ensure that pediatric measures are both accurate and acceptable.
Cross-cultural validity of assessment tools deserves stronger emphasis. Many existing instruments were developed and validated in Western, high-income settings, using English-language items and culturally specific concepts. As FND research and services expand globally, it is crucial to adapt and revalidate tools in diverse linguistic and cultural contexts. This involves not only translating items but also ensuring conceptual equivalence, sensitivity to local explanatory models of illness, and appropriateness of response options. Collaborative, international research networks can coordinate translation, back-translation, and cultural adaptation processes, and can pool data to compare measurement properties across regions.
Implementation science approaches are required to understand how assessment tools are used in real-world practice and how they can be integrated into busy clinical workflows without adding unsustainable burden. Electronic health record integration, automated scoring, and brief screening versions of longer instruments can facilitate routine outcome monitoring. Studies that examine barriers and facilitators to uptake—including clinician attitudes, time constraints, and perceived usefulness—can inform strategies to promote sustained use. Embedding pragmatic trials of outcome measurement strategies within routine care settings will allow researchers to evaluate not only psychometric properties but also the impact of systematic outcome monitoring on clinical decision-making and patient engagement.
Another emerging area is the use of individualized or goal-based outcome measures, where patients identify a small number of personal goals (such as returning to driving, resuming specific work tasks, or participating in family activities) and rate progress toward these over time. Such approaches align with patient-centered care principles and may capture meaningful change that is not reflected in generic scales. Nevertheless, standardized methods for eliciting, recording, and scoring individualized goals are needed, as well as research on their reliability, responsiveness, and relationship to standardized measures. Combining individualized goal attainment scaling with core standardized outcomes could offer a balanced framework that respects individual priorities while preserving comparability across studies.
Coordinated collaboration among stakeholders is essential to accelerate progress in assessment and outcome measurement. Multidisciplinary working groups that include neurologists, psychiatrists, psychologists, physiotherapists, occupational therapists, methodologists, and patient advocates can drive the development of consensus-based core outcome sets, oversee validation of new instruments, and produce practical toolkits for clinicians and researchers. Open-access repositories of validated measures, with guidance on scoring, interpretation, and recommended use cases, would support harmonization across studies and reduce duplication of effort. Aligning assessment priorities with those of regulatory bodies, funding agencies, and health services planners will ensure that new tools are not only scientifically sound but also influential in shaping policy, resource allocation, and standards of care for people living with functional neurological disorders.
Treatment development and optimization for functional neurological symptoms
Developing and refining treatments for functional neurological symptoms requires a coordinated strategy that spans mechanistic research, clinical trials, service delivery, and long-term follow-up. Historically, interventions were fragmented, often based on untested assumptions about psychological causation or on extrapolation from other conditions. Contemporary approaches recognize that effective care must target interacting mechanisms across motor, cognitive, emotional, and social domains, and must be embedded in systems that support continuity and patient engagement. Priorities include building a robust evidence base for existing therapies, optimizing multimodal treatment packages, clarifying which patients benefit from which approaches, and ensuring that interventions are scalable and accessible.
One central task is to strengthen and expand the randomized controlled trial literature for psychological and behavioral treatments. Cognitive-behavioral therapy and related approaches have shown promising effects for functional seizures and other FND subtypes, but trials are relatively few, often single-center, and vary in content and intensity. Future research should focus on manualized, clearly described interventions that target hypothesized maintenance factors, such as maladaptive beliefs about symptoms, avoidance behaviors, hypervigilance to bodily sensations, and difficulties with emotion regulation. Trials need sufficient sample sizes, multisite recruitment, and adequate follow-up durations to assess durability of benefit and relapse patterns. Adaptive trial designs could be used to refine intervention components in real time, eliminating ineffective elements and enriching those that drive change.
Rehabilitation-based approaches, particularly specialized physiotherapy and occupational therapy, are emerging as key pillars of treatment for functional motor and sensory symptoms. These interventions differ from standard neurological rehabilitation by emphasizing retraining of movement with explicit attention to agency, distraction from symptoms, and graded exposure to feared or avoided activities. Therapists use positive signs of internal inconsistency to demonstrate the potential for normal movement, thereby altering expectations and reinforcing new motor patterns. However, protocols vary widely across services, and controlled trials remain limited. A priority is to develop consensus treatment manuals, test them against usual care or nonspecific therapy, and examine dose–response relationships to determine optimal intensity, duration, and formats (inpatient, outpatient, or day programs).
Multidisciplinary inpatient or day hospital programs have long been used for complex FND, particularly when symptoms are severe or long-standing. These programs typically combine physiotherapy, occupational therapy, psychological therapy, nursing input, and medical oversight, sometimes including family work and social support. Observational studies suggest that many patients experience meaningful gains in function and quality of life, but there is substantial heterogeneity in program structure and content, and rigorous comparison with less intensive or community-based options is lacking. Future evaluations should address which patient profiles justify intensive programs, what core components are essential, and how to maintain gains after discharge. Research comparing stepped-care models, in which less intensive outpatient interventions are attempted before progressing to high-intensity programs, would inform efficient, equitable use of resources.
The development of treatments for functional seizures illustrates many of these broader issues. Tailored psychological therapies that address seizure triggers, dissociative processes, and avoidance have shown benefits in seizure frequency and distress, but not all patients respond, and long-term seizure remission rates remain modest. Integrating seizure-focused therapy with interventions for comorbid post-traumatic stress disorder, depression, or substance use may improve outcomes but requires coordination across specialties. Trials should systematically measure seizure characteristics, mood, trauma symptoms, and functional status, allowing analysis of which domains need to change to achieve sustained seizure control. Pragmatic trials embedded in epilepsy and neurology services would help determine how best to deliver these interventions at scale, including via telehealth or group formats.
For functional movement disorders, treatment development is still at an earlier stage. Specialized physiotherapy protocols emphasizing implicit motor learning, distraction from abnormal movements, and positive reinforcement of normal movement patterns have demonstrated promising results in uncontrolled series and small trials. Combining physiotherapy with psychological interventions that address beliefs about control, illness identity, and fear of movement may further enhance outcomes. Key priorities include head-to-head comparisons of physiotherapy alone versus combined physiotherapy–psychological packages, identification of predictors of response to each modality, and detailed characterization of mechanisms of change, such as shifts in attentional focus, sense of agency, or movement-related anxiety. Incorporating motion capture, wearable sensors, and neurophysiological measures into trials could provide objective indices of motor retraining and help identify early response markers.
Functional cognitive and sensory symptoms pose particular challenges for treatment optimization. Standard cognitive rehabilitation approaches, designed for structural brain injury, may be of limited value if they focus narrowly on compensatory strategies without addressing underlying attentional biases, worry about cognitive decline, or unhelpful patterns of self-monitoring. Interventions that integrate psychoeducation about attention and memory, metacognitive strategies, and graded behavioral experiments to test catastrophic beliefs may be more effective, but require systematic evaluation. Similarly, for functional sensory loss or visual symptoms, rehabilitation needs to balance sensory retraining with careful communication to avoid reinforcing maladaptive explanatory models. Trials in these domains should prioritize patient-centered outcomes, such as confidence in daily functioning, social participation, and reduction in health care seeking driven by fear of undiagnosed disease.
Pharmacological strategies for FND remain underdeveloped and should be viewed with caution. There is no evidence for medications that directly and specifically reduce functional neurological symptoms. Instead, pharmacotherapy is typically used to treat comorbid conditions such as depression, anxiety, post-traumatic stress, insomnia, or chronic pain, which can indirectly influence symptom severity and overall functioning. Nevertheless, systematic research on medication use, benefits, and harms in FND populations is sparse. Prospective studies are needed to examine whether targeted treatment of comorbidities enhances the effectiveness of psychological and rehabilitation-based interventions, or whether certain medications exacerbate dissociative tendencies, fatigue, or cognitive difficulties. Any pharmacological trials should be grounded in clear mechanistic hypotheses, such as modulation of arousal or emotion regulation circuits, and should incorporate careful monitoring of functional outcomes, not just psychiatric symptoms.
Noninvasive neuromodulation methods, including repetitive transcranial magnetic stimulation and transcranial direct current stimulation, have attracted interest as potential adjuncts to behavioral therapies, inspired by evidence of altered cortical excitability and connectivity in FND. Early-phase studies suggest that stimulation over motor or prefrontal regions might facilitate motor retraining or modulate emotional processing, but effect sizes and durability are uncertain. Future work should prioritize mechanistically informed protocols, in which stimulation targets are selected based on neuroimaging or electrophysiological markers of network dysfunction in each symptom subtype. Trials should compare neuromodulation plus standard therapy with therapy alone, assess dose and scheduling effects, and investigate whether baseline brain network characteristics predict response. If successful, such approaches might enable more personalized, mechanism-based combinations of neuromodulation and rehabilitation.
Digital and remote interventions offer promising avenues for expanding access to care, particularly in regions with limited specialist services. Telemedicine delivery of diagnostic feedback and follow-up has already demonstrated feasibility and acceptability in many settings. Building on this, structured video-based physiotherapy, remote group psychoeducation, and online cognitive-behavioral programs tailored to FND could substantially increase reach. However, digital formats raise questions about treatment fidelity, therapeutic alliance, patient safety (especially in those with functional seizures), and equity of access for individuals with limited digital literacy or unstable internet connections. Controlled trials comparing remote, hybrid, and in-person formats, coupled with qualitative studies of patient and clinician experiences, are needed to determine where digital interventions are most appropriate and how to mitigate potential harms.
Stepped-care and stratified-care models represent important targets for service-level treatment optimization. In stepped-care frameworks, all patients might receive high-quality diagnostic explanation and basic self-management guidance, with progression to more intensive, specialized interventions reserved for those with persistent symptoms or high disability. Stratified-care models, in contrast, aim to match initial treatment intensity and modality to individual risk profiles or prognostic indicators, such as symptom duration, comorbidities, and social support. Developing and validating predictive tools that can guide such decisions is a key research priority. These tools may integrate clinical variables, patient-reported measures, and, in the future, mechanistic biomarkers to classify patients into subgroups with differing likely treatment trajectories and best-response pathways.
Communication of the diagnosis and early psychoeducation are themselves therapeutic interventions that require refinement and systematic study. Evidence suggests that clear, confident, and empathetic explanations, emphasizing the legitimacy and reversibility of symptoms and providing a coherent model linking brain and body, can improve engagement with subsequent treatments and reduce health care utilization. Yet the content and style of explanations vary widely across clinicians and settings. Trials comparing structured communication strategies, including the use of metaphors, diagrams, videos, and written materials, could help identify best practices. Important outcomes include not only symptom change but also trust in clinicians, adherence to treatment recommendations, and reduction in unhelpful health care seeking or avoidance.
Family and social context play a major role in the development and maintenance of functional symptoms, especially in children and adolescents but also in adults. Family-based interventions that address patterns of response to symptoms, communication about illness, expectations regarding functioning, and stressors within the home may be particularly valuable. For pediatric FND, structured programs that involve parents, schools, and pediatric services in coordinated plans for attendance, activity pacing, and response to symptom episodes are emerging, but robust evaluation is still limited. Research should address how family involvement can be integrated into adult services, how to navigate situations of family conflict or skepticism about the diagnosis, and how social support can be harnessed as a facilitator of recovery.
Cultural factors influence treatment engagement, explanatory models, and preferences for care, making cross-cultural adaptation of interventions essential. Many psychological and rehabilitation protocols were designed in Western contexts, with assumptions about individual autonomy, disclosure of emotional experiences, and illness narratives that may not translate readily elsewhere. Collaborative work with clinicians, patients, and community representatives from diverse cultural backgrounds is needed to adapt language, metaphors, and treatment structures while retaining core therapeutic principles. Pragmatic trials across varied settings can help determine which components are universally effective and which require tailoring. Such efforts will be most successful when grounded in sustained, bidirectional collaboration rather than one-way export of existing models.
An overarching challenge is to determine how to measure and promote meaningful, patient-defined recovery during and after treatment. Interventions should not aim solely to reduce symptom frequency or intensity but also to support return to valued roles, autonomy, and sense of self. Goal-based approaches, in which individuals identify key life domains they wish to reclaim, can be integrated into treatment planning and progress monitoring. Research is needed to evaluate how goal setting can be structured to maximize motivation while remaining realistic, how to handle shifts in goals over time, and how progress toward goals relates to standard symptom and function measures. Longitudinal cohort studies following patients after completion of treatment programs can shed light on which treatment features and post-treatment supports are associated with sustained gains.
Implementation science provides a crucial lens for understanding how to move from efficacy studies to real-world effectiveness and scalability. Interventions that show benefit in specialized centers may be difficult to reproduce in community settings with fewer resources and less FND-specific expertise. Studies should examine barriers and facilitators to adoption, including clinician training needs, institutional support, reimbursement structures, and competing clinical priorities. Hybrid effectiveness–implementation trials can test new treatments while simultaneously evaluating strategies to embed them in routine practice, such as integrated care pathways, decision support tools, or supervision networks. Such work requires close collaboration among clinicians, researchers, administrators, and patient organizations to ensure that interventions are not only effective but also feasible and acceptable.
Interdisciplinary collaboration is central to successful treatment development and optimization. FND care often spans neurology, psychiatry, psychology, physiotherapy, occupational therapy, speech and language therapy, social work, and primary care. Establishing shared conceptual frameworks, common terminology, and coordinated treatment plans can reduce fragmentation and conflicting messages to patients. Joint clinics, cross-specialty training, and multidisciplinary case conferences are practical mechanisms for fostering collaboration, but systematic evaluation of these models is still limited. Research should compare integrated versus siloed care structures, assess effects on outcomes and satisfaction, and identify cost-effective ways to build and sustain collaborative teams, including in resource-limited settings.
Treatment development must be guided by meaningful involvement of people with lived experience. Patients and families can contribute unique insights into treatment acceptability, burdens, and perceived benefits, as well as highlight gaps in existing services. Co-design methods, such as participatory workshops, advisory panels, and patient-led research initiatives, can help shape intervention content, delivery formats, and research questions. Evaluations should routinely include qualitative components that explore experiences of care, reasons for dropout or nonresponse, and suggestions for improvement. By embedding patient perspectives throughout the treatment development cycle, the field can ensure that new interventions not only target relevant mechanisms but also resonate with those they are intended to help, thereby increasing uptake, adherence, and real-world impact.
Health services, education, and patient-centered care priorities
Health service delivery for functional neurological disorders is marked by fragmentation, inconsistent access, and variability in expertise across regions and specialties. Many individuals encounter multiple clinicians and services before receiving a coherent diagnosis and treatment plan, resulting in high costs, avoidable investigations, and cumulative distress. Addressing these systemic gaps demands explicit research priorities that examine how care is organized, how pathways function in practice, and which service models deliver the best outcomes for patients and families. Rather than focusing solely on individual-level interventions, there is a pressing need to study the structures, processes, and cultures of care that shape the experience and trajectory of people living with these conditions.
Integrated, multidisciplinary care pathways are widely regarded as an ideal model for FND, but their implementation remains uneven. Some centers have developed coordinated services that bring together neurology, psychiatry, psychology, physiotherapy, occupational therapy, and social work under a unified framework, while many regions still rely on ad hoc referrals and siloed treatment. Systematic evaluation of different service configurations is needed, including comparisons between centralized specialist hubs, networked regional services, and hybrid hub-and-spoke arrangements that support local teams through remote consultation. Key outcomes include time to diagnosis, patient satisfaction, symptom burden, functional status, and health care utilization. Health economic analyses should quantify costs and cost-effectiveness, recognizing that investment in coordinated services may reduce repeated emergency visits, unnecessary procedures, and long-term disability.
Primary care, emergency departments, and general hospital services are often the first points of contact for people with FND, yet these settings frequently lack clear guidance and training. Clinicians may feel uncertain about diagnosing FND, worry about missing alternative pathology, or perceive these patients as particularly challenging. This can result in defensive practice, including excessive investigations and hospital admissions, as well as strained clinical relationships. Research should map typical patient journeys across these entry points, identifying where delays, miscommunication, and iatrogenic harms occur. Pragmatic trials of service-level interventions—such as standardized assessment templates, decision support tools, rapid-access FND consultation clinics, and liaison teams—could inform scalable strategies to improve early identification and management, while maintaining patient safety.
Training and education for health professionals represent a foundational area for improvement. Medical, nursing, psychology, and allied health curricula have historically given limited attention to FND, often relying on outdated or stigmatizing concepts. Many clinicians report a lack of confidence in explaining the diagnosis, formulating treatment plans, or managing complex presentations. Research on educational interventions is needed across the continuum of professional development, from undergraduate training to specialist fellowships and continuing professional education. Studies might compare different formats—such as interactive workshops, simulation-based training, case-based e-learning modules, and supervised clinical placements—and examine outcomes including knowledge, attitudes, diagnostic accuracy, communication skills, and behavior change in clinical practice. Importantly, educational content should integrate contemporary models of brain–body mechanisms, highlight positive diagnostic signs, and provide practical scripts for patient-centered communication.
Interprofessional collaboration is crucial for effective FND care, yet organizational structures and professional cultures can impede it. Different specialties may hold divergent explanatory models and priorities, leading patients to receive conflicting messages about the nature of their symptoms and appropriate interventions. For example, some clinicians may emphasize psychological trauma, others motor retraining, and others symptom monitoring for possible organic disease, without a shared framework that integrates these perspectives. Implementation research should explore models that foster collaboration, such as joint neuropsychiatry or neurorehabilitation clinics, shared care plans embedded in electronic records, multidisciplinary case conferences, and cross-specialty training initiatives. Outcomes of interest include coherence of explanations provided to patients, adherence to agreed treatment plans, and perceived alignment among team members, as well as clinical and functional measures.
From a policy perspective, the lack of clear recognition of FND within many health systems contributes to inequitable access and inconsistent commissioning of services. Classification and coding practices may relegate FND to ill-defined categories, hindering accurate tracking of prevalence, outcomes, and resource use. Advocacy efforts informed by robust data can support the development of commissioning guidance, clinical standards, and quality indicators specific to FND. Research priorities include analyzing how different coding systems and reimbursement structures influence clinical behavior, service development, and patient outcomes; determining which performance metrics best reflect high-quality FND care; and examining the impact of policy changes on real-world practice. Engagement with policymakers, insurers, and regulatory bodies is essential to ensure that evidence-based models are translated into sustainable funding and governance arrangements.
Patient-centered care demands that individuals with FND have meaningful involvement in decisions about their care, yet many report feeling dismissed, disbelieved, or excluded from planning. Experiences of stigma—both external and internalized—are common and can be compounded by previous invalidating encounters in health care. Empirical work is needed to characterize the specific forms of stigma and epistemic injustice experienced by people with FND, including differences across settings, cultures, and diagnostic subtypes. Intervention studies might evaluate clinician communication training, peer support programs, and co-produced educational materials designed to reduce stigma and foster mutual trust. Measures of success should include patients’ sense of validation, empowerment, and shared decision-making, alongside more traditional clinical outcomes.
The process of diagnostic communication is a particularly powerful point of leverage within health services. How the diagnosis is explained can shape patients’ beliefs, engagement with interventions, and overall trajectory. While there is growing consensus on key elements of an effective explanation—such as emphasizing that symptoms are real, common, and potentially reversible—there is limited evidence on optimal wording, sequencing, and use of visual or digital aids. Randomized and observational studies can test structured communication approaches against usual practice, exploring effects on understanding, acceptance of the diagnosis, readiness for change, and subsequent uptake of recommended therapies. Such research should also consider the needs of family members and caregivers, who often play a central role in day-to-day management and may hold their own explanatory models and concerns.
Children and adolescents with FND require developmentally informed, family-centered services that differ in important ways from adult models. Pediatric pathways must coordinate among child neurology, child and adolescent mental health services, school systems, and social care, recognizing the central role of caregivers and educational environments in shaping activity levels, expectations, and reinforcement of symptoms. Research is needed to compare different pediatric service designs, such as hospital-based multidisciplinary teams versus community-oriented liaison models, and to identify key elements that promote school attendance, peer engagement, and family resilience. Investigations should also examine how transition from pediatric to adult services is managed, as poorly organized transitions can lead to disengagement, relapse, or loss of previously gained skills.
Culturally sensitive care is another core dimension of patient-centered services. Cultural beliefs about illness, mind–body relationships, and help-seeking strongly influence how FND is experienced, expressed, and interpreted. Yet many existing services rely on explanatory frameworks and therapeutic approaches developed in Western, urban settings that may not resonate with diverse populations. Research should employ qualitative and mixed-methods designs to explore how different communities understand functional symptoms, what barriers they face in accessing care, and which metaphors or models are most acceptable. These insights can inform adaptation of educational materials, clinician training, and service structures to enhance cultural safety and relevance. Community engagement and partnership with local leaders and organizations will be vital to ensure authenticity and sustainability.
Health inequalities in FND care are shaped by socioeconomic status, geography, race and ethnicity, gender, disability, and other axes of marginalization. Individuals from disadvantaged backgrounds may have less access to specialist services, face greater diagnostic delays, and experience more severe social and occupational consequences. Yet equity-related data are rarely collected or analyzed systematically in FND research or service evaluation. Future studies should incorporate equity-focused indicators, disaggregating outcomes by demographic and socioeconomic variables, and explicitly testing whether new models of care benefit all groups equally. Co-designed interventions may be needed to address specific barriers—for example, providing transport support for intensive programs, using interpreters and culturally adapted materials, or integrating FND care within community health centers serving underserved populations.
Digital health technologies can help bridge gaps in access, but they also risk reinforcing existing disparities if not implemented thoughtfully. Telemedicine for diagnosis, psychoeducation, and follow-up can extend specialist input to remote or under-resourced areas, support collaboration between local and expert teams, and reduce travel burdens for individuals with mobility limitations. Online support groups, apps for symptom tracking, and remote physiotherapy programs offer additional avenues to engage patients between clinic visits. Research is required to evaluate not only the effectiveness and safety of these digital interventions, but also their acceptability, usability, and impact on the therapeutic alliance. Special attention should be paid to digital inclusion, ensuring that services are usable for people with limited health literacy, sensory or cognitive impairments, or restricted access to technology.
Embedding routine outcome monitoring within health services can provide real-time feedback on how individuals are doing and support more responsive, personalized care. Standardized measures of symptom severity, functioning, mood, and quality of life, supplemented by individualized goals, can be collected at regular intervals and integrated into clinical decision-making. Implementation studies should explore which outcome measures are feasible to use in everyday practice, how to integrate them into electronic health records, and how to present feedback to clinicians and patients in ways that inform collaboration rather than generate pressure or blame. Over time, aggregated outcome data across services and regions can create powerful learning health systems, enabling benchmarking, identification of best practices, and continuous quality improvement.
Patient and public involvement is essential not only in treatment design but also in shaping health services and research agendas. People with lived experience can provide critical insights into which aspects of care are most helpful or harmful, which outcomes matter most to them, and how services might be reorganized to better meet their needs. Structured mechanisms for involvement—such as advisory councils, co-production workshops, and patient researchers embedded within teams—should be evaluated for their impact on service design, clinician–patient relationships, and research relevance. Funding bodies and institutions can encourage meaningful involvement by mandating and supporting co-production, while research should document both the benefits and challenges of such approaches in FND contexts.
Care coordination across time and settings is a recurrent problem for many individuals with FND, especially those with chronic and fluctuating symptoms. Without clear responsibility for ongoing management, patients may oscillate between services, with each episode of crisis prompting new investigations and sometimes conflicting recommendations. Research should test models of longitudinal care coordination, such as designated FND care coordinators, shared care protocols between specialists and primary care, and structured follow-up pathways after intensive programs or hospitalizations. These models can be assessed for their ability to reduce duplication, improve satisfaction and continuity, and support sustained recovery, while also being evaluated for feasibility and cost in different health system contexts.
Work, education, and social participation are central concerns for individuals with FND, yet occupational issues are often peripheral in clinical encounters. Vocational rehabilitation services, liaison with employers or schools, and graded return-to-work or return-to-study plans can make the difference between long-term disability and productive engagement. Empirical work is needed to understand common barriers to participation—including stigma, lack of accommodations, and fear of relapse—and to evaluate structured interventions that support re-entry into work or education. Collaboration with occupational health professionals, educators, and employers is vital to develop practical guidance and to study the impact of workplace and school-based policies on outcomes for people with FND.
The development of robust, patient-centered health services for FND will depend on coordinated, interdisciplinary collaboration across clinical specialties, research disciplines, health systems, and patient communities. Networks that bring together clinicians, researchers, service planners, and people with lived experience can harmonize definitions, share tools and protocols, and undertake large-scale studies that go beyond the capacity of single centers. Priority-setting partnerships, in which all stakeholders jointly identify the most pressing questions about service organization, education, and care delivery, can ensure that research resources are directed to areas of greatest need and potential impact. By building such collaborative infrastructures, the field can move toward health services that are not only clinically effective and efficient, but also humane, inclusive, and aligned with what matters most to those living with functional neurological disorders.
