Functional neurological disorder in veteran and active-duty military cohorts appears more prevalent than in many civilian populations, although exact rates vary widely because of differing diagnostic criteria, under-recognition, and variations in study design. Large tertiary referral centers serving veterans consistently report a substantial proportion of neurology clinic visits attributable to functional symptoms, including functional seizures, motor and gait disturbances, and sensory complaints. In some military-focused samples, functional neurological presentations account for a notable share of medically unexplained neurological symptoms, particularly in individuals with complex medical and psychiatric comorbidities. Patterns suggest that service members exposed to combat, multiple deployments, or high operational tempo may be at elevated risk, reflecting the cumulative burden of physical and psychological stressors unique to this population.
Exposure to trauma is a central risk factor, though not all individuals with functional neurological disorder have a history of a single, clearly identifiable traumatic event. In veterans, trauma can include direct combat exposure, blast injuries, moral injury, military sexual trauma, severe accidents, and near-death experiences. These events interact with pre-existing vulnerabilities—such as prior adverse childhood experiences, family dysfunction, or pre-service psychiatric conditions—to shape how the nervous system and stress-response systems adapt over time. The mismatch between high threat exposure and limited opportunities for processing or recovery during active service can leave individuals physiologically sensitized and more likely to develop functional symptoms when faced with subsequent stress, illness, or injury.
Post-traumatic stress disorder is consistently overrepresented in military cohorts with functional neurological disorder. PTSD, with its hallmark features of hyperarousal, re-experiencing, avoidance, and negative alterations in mood and cognition, may alter attentional processes, threat detection systems, and bodily awareness. These changes can promote heightened vigilance to bodily sensations, misinterpretation of benign symptoms as dangerous, and reinforcement of maladaptive illness beliefs. This interaction can set the stage for the emergence and maintenance of functional neurological symptoms such as non-epileptic attacks, limb weakness, or tremor. Comorbid PTSD also complicates clinical trajectories, often correlating with more severe functional impairment, greater healthcare utilization, and poorer prognosis if not explicitly addressed in treatment.
Operational and occupational stressors beyond direct combat also play a significant role. Long deployments, compressed training schedules, sleep deprivation, chronic pain from musculoskeletal strain, and ongoing performance pressure may gradually erode resilience. Individuals might suppress distress because of strong cultural norms around toughness and mission-focus, leading to somatic expressions of psychological strain. Frequent relocations and separations from family or social support networks further compound vulnerability. When combined with limited time for recovery between missions or assignments, these demands can heighten allostatic load, contributing to dysregulated stress physiology that is increasingly recognized as a contributor to functional syndromes.
Physical injuries, particularly mild traumatic brain injury, are notable risk factors in veteran and military groups. Blast exposures, concussions from training accidents, and head injuries sustained in vehicle incidents are all common in modern conflicts and training environments. While many individuals recover fully, a subset develops persistent symptoms—headache, dizziness, cognitive fog, sleep disruption, and mood changes—that intersect with functional neurological phenomena. Diagnostic uncertainty around mild TBI, especially when neuroimaging is normal, creates conditions in which functional symptoms and neurologic injury can coexist or be misattributed to one another. This overlap can delay appropriate recognition of functional mechanisms and perpetuate disability.
Chronic pain and other functional somatic disorders, such as irritable bowel syndrome or fibromyalgia, also cluster with functional neurological disorder in veterans. Shared mechanisms may include central sensitization, alterations in pain modulation, and learned patterns of symptom-focused attention. The frequent use of opioids or sedative medications for chronic pain can compound fatigue, cognitive issues, and mood disturbances, further blurring the clinical picture. Multisystem symptom complexity is especially common among those with long service histories, multiple injuries, and cumulative physical wear-and-tear from physically demanding roles.
Psychiatric comorbidities extend beyond PTSD. Depression, generalized anxiety, panic disorder, and substance use disorders are frequently reported in veterans with functional neurological symptoms. These conditions can precede the development of functional symptoms, arise as a consequence of chronic disability, or interact bidirectionally in a reinforcing cycle. Elevated rates of suicidal ideation and attempts in some cohorts underscore the severity of distress and the need to consider functional neurological disorder within a broader mental health and psychosocial context. Social determinants—including unemployment, housing instability, and relationship breakdown after discharge—can intensify psychological stress and worsen functional symptom expression.
Military culture itself is an important contextual factor. Strong values of stoicism, self-reliance, and loyalty to the unit may discourage help-seeking for emotional distress, especially early in the course of illness. Some service members fear stigma, loss of career opportunities, or negative evaluations of fitness for duty if they acknowledge mental health concerns. In such settings, neurological symptoms may be perceived as more acceptable or legitimate than psychological complaints, increasing the likelihood that distress is channeled into bodily symptoms. This dynamic can partially explain why some individuals present with dramatic motor or seizure-like events rather than overt expressions of anxiety or sadness.
Pre-service factors can also shape susceptibility to functional neurological disorder in the military. Individuals enlisting with unresolved childhood adversity, prior mental health diagnoses, or patterns of somatic symptom expression may be more vulnerable when exposed to the rigors of training and operational environments. Similarly, personality traits such as high conscientiousness and perfectionism, although often valued in military roles, can contribute to internal pressure and self-criticism, heightening stress reactivity. For some individuals, the discrepancy between their perceived duty to perform at a high level and actual limits imposed by injury or illness can create intense internal conflict, potentially manifesting as functional symptoms.
Gender-related factors merit particular attention. Women in the military and among veterans often face distinct stressors, including higher rates of military sexual trauma and, in some settings, greater scrutiny or pressure to prove competence in traditionally male-dominated roles. These experiences may intersect with prior trauma histories and socialized patterns of coping, shaping pathways to functional neurological presentations. Epidemiologic data suggest that women are overrepresented among patients with functional neurological disorder generally, and similar trends appear in military health system samples, although male service members and veterans remain substantially affected as well.
Organizational characteristics of military and veterans’ healthcare systems influence both observed epidemiology and risk profiles. Thresholds for referral to neurology, availability of mental health services, and diagnostic practices around conditions like epilepsy or TBI all affect which cases are identified as functional. In some settings, limited access to care or long wait times for specialty services may lead to prolonged periods of undiagnosed symptoms, during which maladaptive illness narratives and disability beliefs can solidify. Conversely, systems that prioritize early multidisciplinary assessment may identify functional mechanisms sooner, potentially altering the apparent prevalence and severity distribution.
Post-deployment periods are particularly high-risk windows for the emergence or escalation of functional neurological symptoms. Transitioning from high-threat environments to comparatively routine life can unmask or intensify previously suppressed distress. Service members might first notice symptoms when operational demands decrease, or when they are exposed to reminders of events that occurred during deployment. Changes in social roles, loss of unit cohesion, and attempts to reintegrate into family and civilian structures can bring latent difficulties to the surface, sometimes expressed through sudden onset of functional seizures, gait disturbances, or sensory loss that prompt urgent medical evaluation.
Discharge from active duty and entry into veteran status can modify risk dynamics again. Some individuals lose the structured environment, identity, and social network that previously helped contain or organize distress. Economic stress, difficulties securing employment, or challenges navigating benefits systems can add to the burden. In this phase, functional neurological symptoms may be one part of a broader cluster of post-service health issues, including chronic pain, PTSD, depression, and substance misuse. Patterns of repeated emergency department visits, frequent imaging, and multiple specialist consultations are common in veterans prior to recognition of a functional diagnosis, reflecting both high symptom burden and fragmented care.
Health literacy and prior medical experiences play additional roles. Veterans who have previously received inconsistent explanations for their symptoms, or who felt dismissed when no structural lesion was identified, may become increasingly skeptical of psychological or functional formulations. This can influence how they interpret new symptoms and which providers they trust. In environments where functional neurological disorder is poorly understood, miscommunication and adversarial interactions can occur, unintentionally reinforcing disability and healthcare-seeking behaviors. Conversely, veterans with early exposure to clear, respectful explanations of mind–body interactions may be more open to understanding their symptoms through a functional framework, altering risk of chronicity.
Risk for functional neurological disorder in military and veteran populations cannot be separated from broader patterns of comorbidity, service exposures, and system-level factors that shape access to care. The convergence of combat and non-combat trauma, PTSD, chronic pain, mild TBI, and psychosocial stressors creates a complex risk environment in which functional neurological symptoms are one possible endpoint of dysregulated adaptation. Recognizing these patterns at the epidemiologic level is critical for planning targeted prevention, early identification, and integrated treatment efforts tailored to the distinctive experiences and vulnerabilities of veterans and service members.
Clinical presentation and diagnostic challenges in service members
Functional neurological symptoms in service members often emerge in high-intensity, high-visibility contexts, such as training exercises, field operations, or during and after deployment. Common presentations include sudden onset of seizures without EEG correlates (functional seizures or dissociative attacks), limb weakness or paralysis, abnormal movements such as tremor or jerks, gait disturbances, and episodes of unresponsiveness. These symptoms can be dramatic, prompting urgent medical evacuation or emergency evaluations, especially when they occur in austere environments where rapid differentiation from stroke, traumatic brain injury, or epileptic seizures is required. The acute onset and apparent severity frequently lead clinicians and commanders to assume a structural brain or spinal pathology until more detailed evaluation is possible.
Functional seizures are among the most frequently described manifestations in active-duty personnel and veterans. These episodes may involve convulsive movements, staring, collapse, or apparent loss of consciousness, but often with features that differ from typical epileptic seizures, such as prolonged duration, asynchronous limb movements, closed eyes, side-to-side head shaking, or occurrence mainly in the presence of others. In the military context, such events may follow intense stress, exposure to reminders of trauma, sleep deprivation, or conflicts about duty assignments. However, the overlap with genuine post-traumatic epilepsy after head injury or blast exposure makes real-time discrimination difficult, leading to substantial use of antiseizure medications and restrictions on duties until a clearer diagnosis is made.
Motor and gait symptoms commonly present as sudden limb weakness, inability to stand or walk, or unusual postures that do not conform to known patterns of neurological disease. Service members might describe legs “giving out,” knees buckling, or profound fatigue that appears disproportionate to objective findings. On examination, clinicians may detect inconsistency, such as normal strength when the patient is distracted but marked weakness when formally tested, or a gait that appears unsafe yet rarely results in falls. These features are characteristic of functional motor disorder, but in the setting of recent injury, orthopedic problems, or mild TBI, they can be difficult to separate from structural or pain-related limitations, especially for providers less familiar with functional examination signs.
Sensory symptoms, including numbness, tingling, altered vision, or hearing disturbances, also occur. Patterns may be non-dermatomal, sharply demarcated at joints, or inconsistent over time, raising suspicion for functional mechanisms. Visual loss with normal ophthalmologic and neuroimaging evaluations, or fluctuating double vision in the absence of cranial nerve pathology, can be particularly challenging in operational environments where visual function is critical for weapon handling and navigation. Because sensory complaints sometimes coexist with blast exposure, noise injury, or eye trauma, clinicians may initially attribute them to those events, which can delay consideration of functional explanations.
Cognitive and speech-related functional symptoms are frequently embedded within broader post-concussive or post-traumatic presentations. Service members may report feeling “brain fog,” difficulty concentrating, word-finding problems, or episodes of stuttering or speech arrest that began after a concussion, psychological trauma, or prolonged stress. Neuropsychological testing may reveal variable performance, internal inconsistency, or disproportionate subjective complaints relative to objective findings. However, distinguishing functional cognitive disorder from residual effects of mild TBI, PTSD, depression, or sleep disruption is complex and often requires specialized assessment that may not be immediately available in forward or small-base medical facilities.
Co-occurring PTSD, anxiety, and depressive symptoms shape how functional neurological presentations unfold and are interpreted. Hyperarousal, intrusive memories, and avoidance behaviors can influence the timing and context of attacks, such as functional seizures triggered by loud noises reminiscent of combat or by interpersonal conflict. Some individuals experience functional symptoms as part of dissociative episodes, with partial or complete amnesia for the event. Others may notice that symptoms intensify when discussing traumatic experiences or facing evaluations related to fitness for duty or medical discharge. These connections are not always obvious to the patient or the clinician, and the strong cultural emphasis on mission focus may lead individuals to minimize or deny associations with trauma.
Diagnostic challenges begin early in the pathway of care. In acute settings, the priority is to rule out immediately life-threatening causes such as stroke, status epilepticus, cord compression, or acute brain injury. As a result, clinicians rightly order imaging, EEG, and other investigations. When tests return normal or inconclusive, however, there may be reluctance to ascribe symptoms to a functional etiology, particularly in individuals with documented combat exposure, blast injuries, or high-risk military occupations. Providers might fear missing an organic diagnosis, worry about medicolegal consequences, or feel uncomfortable explaining functional mechanisms to service members who expect a clear structural cause.
Complicating the picture further, some individuals genuinely have both structural and functional components. A service member with a prior mild TBI or a small structural lesion on MRI may later develop functional seizures or gait disturbance, resulting in a “mixed” presentation. In such cases, clinicians may attribute all ongoing symptoms to the original injury, reinforcing expectations of permanent neurological damage. This can inadvertently maintain disability and limit engagement in active rehabilitation strategies that are effective for functional symptoms. Determining the relative contribution of structural and functional factors requires careful, often multidisciplinary evaluation that is not uniformly accessible across all military treatment facilities.
Stigma and beliefs about illness strongly influence clinical presentation and the diagnostic process. Many service members view physical symptoms as more legitimate and less stigmatized than psychological distress, particularly fears related to PTSD or other mental health diagnoses that might affect their career trajectory. As a result, individuals may unconsciously channel emotional distress into neurological symptoms that feel more acceptable to report. When providers emphasize the absence of organic disease without offering a positive functional diagnosis and explanatory model, patients can feel dismissed or accused of exaggeration. This dynamic may fuel anger, mistrust, or further symptom escalation, complicating ongoing care and access to care.
Within military systems, another diagnostic challenge arises from the intersection of health status with administrative and occupational decisions. A diagnosis of functional neurological disorder can influence determinations about deployment eligibility, duty restrictions, and medical separation from service. Some clinicians may hesitate to label symptoms as functional for fear of appearing to minimize a service-connected condition or jeopardize disability claims, while others may overemphasize psychological factors without acknowledging real distress and impairment. Service members, in turn, may worry that accepting a functional diagnosis will undermine future claims or suggest that they are “faking,” leading to partial disclosure of symptoms or resistance to recommended treatments.
Communication barriers often arise around terminology. Many veterans and active-duty personnel have never heard of functional neurological disorder and may interpret it as synonymous with malingering or “all in your head.” Explaining that FND reflects genuine changes in brain functioning rather than structural damage, and that it is common after trauma and stress, requires time and skill. In brief encounters, clinicians may rely on phrases such as “nothing is wrong” or “all tests are normal,” which can inadvertently convey the message that symptoms are imagined or unimportant. This miscommunication can become entrenched over repeated clinical contacts, especially if multiple providers offer inconsistent or contradictory explanations.
Another layer of complexity stems from the high prevalence of overlapping somatic conditions in this population, including chronic pain, headaches, gastrointestinal symptoms, and fatigue. When functional neurological features arise in the context of long-standing, unexplained somatic complaints, clinicians may experience “diagnostic fatigue,” defaulting to broad labels such as somatoform disorder or medically unexplained symptoms without conducting the targeted neurological examination needed to make a positive FND diagnosis. Consequently, patients may undergo extensive workups, including repeated imaging and invasive procedures, without receiving a coherent account of their symptoms or a specific treatment plan.
Operational constraints can limit the depth and continuity of evaluation. In deployment environments, clinicians often work under time pressure with limited diagnostic tools, rotating medical staff, and competing priorities such as battlefield injuries. Subtle examination signs that distinguish functional from structural weakness or gait disturbance may be missed. After redeployment, service members might be seen by different providers at multiple facilities, each lacking full access to prior records. This fragmentation can lead to repeated investigations, incomplete transfer of diagnostic impressions, and delays in offering a unified explanation and management strategy.
Gender and cultural factors introduce additional diagnostic challenges. Women in uniform who present with functional symptoms may encounter gendered assumptions about emotionality or “stress,” leading to premature psychological attributions without adequate neurological assessment. Conversely, men may be perceived as less likely to have functional disorders, prompting prolonged searches for structural pathology and delayed recognition of FND. Cultural and ethnic diversity within the forces means that expressions of distress and illness beliefs vary widely; some service members may describe symptoms in somatic rather than emotional terms based on cultural norms, while others may fear discrimination or career harm if mental health issues are documented, contributing to complex, sometimes ambiguous clinical pictures.
Legal, compensation, and benefit systems intersect with diagnostic processes in ways that can influence both clinician and patient behavior. When a functional diagnosis may affect disability ratings, fitness-for-duty determinations, or compensation for service-connected injuries, concerns about secondary gain or perceived bias can surface. Clinicians must navigate these systems carefully, avoiding assumptions about motivation while still providing accurate, evidence-based assessments. Clear documentation that FND is a recognized, treatable neurological condition—rather than evidence of deception—is essential to prevent misinterpretation in administrative or legal settings.
Because of these overlapping factors, many veterans report long diagnostic journeys characterized by repeated emergency visits, unclear or conflicting labels, and trial-and-error pharmacologic treatments that provide little relief. Recurrent use of antiseizure medications for functional seizures, opioids for pain, or sedating agents for sleep can worsen fatigue, cognition, and mood, thereby amplifying functional symptom severity. Without targeted education and structured rehabilitation focused on retraining movement, attention, and bodily responses, the disorder can become entrenched, with increasing disability and social withdrawal. Early recognition, accurate communication, and coordinated care pathways are therefore essential to reduce diagnostic delay and improve outcomes for service members and veterans living with functional neurological disorder.
Assessment strategies and screening tools in military settings
Assessment of functional neurological disorder in military and veteran settings requires a structured, stepwise approach that can operate effectively across a wide range of clinical environments, from forward-deployed aid stations to tertiary veterans’ hospitals. The core aim is to identify positive features of FND—rather than diagnosing it only by exclusion—while simultaneously screening for common comorbidities such as PTSD, depression, anxiety, chronic pain, and substance use. Because service members often move between facilities and providers over the course of a single episode of illness, assessment strategies must be standardized enough to support continuity of care, yet flexible enough to adapt to time constraints, limited diagnostic resources, and operational demands.
The clinical interview remains the foundational assessment tool, but in military contexts it often needs to be tightly focused and prioritized. Providers typically begin by clarifying the onset and temporal pattern of symptoms, with attention to precipitating events such as physical injury, blast exposure, acute medical illness, or psychological trauma. Particular emphasis is placed on the relationship between symptoms and duty-related factors: recent deployment or redeployment, changes in unit or role, disciplinary or occupational stress, and concerns about fitness for duty. Detailed exploration of prior medical evaluations, imaging studies, and treatments helps distinguish longstanding, stable conditions from more recent functional changes that may have layered onto an existing medical history.
Standardized screening for mental health comorbidities is integral to assessment in this population. Brief instruments such as the PTSD Checklist for DSM-5 (PCL-5), the Patient Health Questionnaire (PHQ-9) for depression, and the Generalized Anxiety Disorder scale (GAD-7) can be administered quickly in primary care, neurology, or rehabilitation clinics. These tools provide quantitative indices of symptom burden that inform diagnostic formulation and treatment planning. Because many service members underreport psychological symptoms out of fear of stigma or career impact, repeated screening over time, coupled with clear assurances about confidentiality and the purpose of assessment, can help uncover clinically significant PTSD or depression that may be driving or maintaining functional presentations.
Neurological examination tailored to the detection of positive FND signs is a critical component of assessment. Providers are encouraged to use well-validated bedside maneuvers that demonstrate internal inconsistency or incongruity with known patterns of structural disease. For motor symptoms, this might include Hoover’s sign for leg weakness, the drift without pronation sign for arm weakness, or observation of movement during distraction and dual-task activities. For functional tremor or jerks, tests such as entrainment (asking the patient to copy a rhythmic movement with another limb) can reveal variability that is highly suggestive of FND. Training military clinicians—particularly general neurologists, physiatrists, and primary care providers—to recognize and document these signs is essential for early, accurate diagnosis.
In deployed or resource-limited settings, formal neurophysiological testing may be unavailable, so greater reliance is placed on clinical features and structured observation. For suspected functional seizures, standardized event documentation forms can be used to record key semiologic characteristics: duration, motor pattern, eye position, responsiveness, triggers, and post-event recovery. Consistent use of these forms by medics, nurses, and physicians across facilities allows later comparison and expert review, even when video-EEG is not immediately feasible. Education of front-line medical personnel on common distinguishing features between epileptic and functional events improves early identification and can reduce unnecessary emergency medication use and prolonged duty restrictions.
When available, video-EEG monitoring remains the gold standard for characterizing seizure-like episodes. Military and veterans’ hospitals increasingly maintain epilepsy monitoring units where suspected functional seizures can be evaluated. Capturing a typical event with normal EEG background during the attack, alongside clinical features consistent with FND, allows a confident diagnosis and provides a powerful educational tool for the patient. Given limited access to such units in some regions or during active deployment, tele-neurology consultation and remote review of video recordings captured on secure devices have become important adjuncts, helping bridge gaps in access to care and specialized expertise.
Neuropsychological assessment plays a complementary role, particularly for veterans with complex cognitive complaints after mild traumatic brain injury, blast exposure, or prolonged stress. Comprehensive testing can identify patterns of variable effort, internal inconsistency, and disproportionate cognitive difficulties relative to neurological findings, supporting a functional cognitive disorder diagnosis. At the same time, testing can reveal specific strengths and weaknesses that guide rehabilitation planning and workplace accommodations. In military systems, shorter, targeted cognitive screening batteries may be used initially, with referral to full neuropsychological evaluation when results are incongruent with the clinical picture or when high-stakes decisions about fitness for duty or medical retirement depend on accurate characterization of function.
Standardized questionnaires focused specifically on functional symptoms can augment clinical assessment. Instruments such as the Screening for Somatoform Symptoms (SOMS), the Somatic Symptom Scale (SSS-8), or broader health questionnaires that quantify physical symptom burden help capture the multisystem nature of presentations in many service members. Including items that address symptom variability, triggers, and contextual factors (such as proximity to trauma reminders or work-related conflict) can highlight patterns characteristic of FND. Integration of these tools into electronic health records within military and veterans’ health systems facilitates longitudinal tracking and enables population-level analyses to identify high-risk groups or gaps in service provision.
Interdisciplinary assessment models are particularly well suited to the complexity of FND in this population. Many military treatment facilities and Veterans Affairs (VA) centers have developed combined clinics that bring together neurology, psychiatry or psychology, physical therapy, occupational therapy, and social work. In these settings, service members can undergo coordinated evaluations that consider motor function, cognition, mood, sleep, pain, and social determinants such as housing, employment, and family support. Case conferences allow clinicians to synthesize findings into a unified formulation and deliver consistent messages to the patient, reducing the confusion that often arises when different providers offer conflicting explanations.
Physical and occupational therapists contribute specialized functional assessments that are central to both diagnosis and treatment planning. For patients with gait disturbance or limb weakness, therapists can systematically evaluate movement patterns, postural control, balance strategies, and response to distraction or dual tasks. Sudden improvements when attention is shifted away from the affected limb, or marked discrepancies between observed functional abilities in the gym and reported disability in daily life, can support a diagnosis of FND. These observations are most effective when clearly documented and communicated back to the broader team, reinforcing the positive, rule-in nature of the diagnosis rather than implying that nothing is wrong.
In addition to clinician-administered assessments, self-report measures targeting illness beliefs, perceived control over symptoms, and health-related quality of life can inform the selection and focus of interventions. Questionnaires exploring beliefs about injury, brain damage, and prognosis reveal misconceptions that are common following deployment-related injuries or exposure to blast. Identifying strongly held beliefs that symptoms indicate permanent structural damage provides a starting point for psychoeducation and cognitive restructuring within both medical and psychological treatment frameworks. Such assessments also help clinicians anticipate adherence challenges, such as reluctance to engage in graded exercise or movement retraining due to fears of harm.
Screening for risk and protective factors related to suicidality, self-harm, and substance misuse is a crucial part of assessment, given elevated rates of these problems among veterans with chronic functional symptoms. Brief, validated tools for suicide risk assessment, combined with careful clinical inquiry into prior attempts, access to lethal means, and current coping strategies, guide safety planning and intensity of follow-up. Substance use assessments—using measures such as the Alcohol Use Disorders Identification Test (AUDIT) or Drug Abuse Screening Test (DAST)—help identify individuals whose reliance on alcohol or sedative medications may be exacerbating symptoms or undermining participation in rehabilitation. Close coordination with mental health and addiction services ensures that these risks are addressed alongside functional neurological symptoms.
Occupational and administrative considerations are also integral to assessment in military environments. Providers often need to evaluate how FND symptoms affect key job tasks: weapon handling, driving, operating machinery, flight duties, or leadership responsibilities. Functional capacity evaluations, performed in collaboration with occupational therapy and command leadership, can document specific limitations and residual strengths in a structured way. This approach allows nuanced duty modifications or temporary restrictions that preserve as much role identity and unit connection as possible while ensuring safety. Transparent communication about how assessment findings inform administrative decisions helps maintain trust and reduces fears that a functional diagnosis will automatically end a career.
Because many service members access care in short, dispersed encounters—urgent care visits, brief neurology consults, or telehealth appointments—there is growing emphasis on brief, scalable assessment tools and pathways. Algorithm-based clinical decision support embedded in electronic records can prompt clinicians to consider FND when certain patterns are detected, such as recurrent seizure-like events with normal EEG and imaging, or multiple emergency visits for neurological complaints without clear structural explanation. These prompts may suggest targeted questions, recommended bedside tests, and appropriate referrals, thereby enhancing detection in busy clinics and improving equity in access to care for those at risk of being overlooked.
Training and education for clinicians form a critical backdrop to all assessment strategies. Many providers receive limited formal instruction in recognizing or managing FND during their core training, leading to uncertainty and sometimes adversarial interactions with patients. Military and VA systems can address this gap through continuing education programs, simulation-based training that uses standardized patients to demonstrate functional signs, and online modules tailored to the realities of operational medicine. Emphasizing that FND is common, neurologically based, and treatable helps shift assessment from a skeptical, exclusionary process to a confident, positive diagnostic approach that supports timely intervention.
Systematic documentation and data collection during assessments create opportunities for ongoing quality improvement and research. Recording standardized symptom measures, examination findings, comorbidity screens, and treatment recommendations in a structured format allows health systems to monitor outcomes, identify bottlenecks in referral pathways, and evaluate the impact of new screening tools or educational initiatives. For veterans and active-duty personnel alike, such system-level assessment efforts can ultimately translate into earlier recognition, more coherent explanations, and better-tailored rehabilitation programs, reducing long-term disability associated with functional neurological disorder.
Treatment approaches and rehabilitation programs for veterans with fnd
Treatment for functional neurological disorder in veterans and active-duty personnel works best when it is multidisciplinary, recovery-focused, and explicitly framed as neurological retraining rather than as a search for hidden structural damage. Early, clear explanation of the diagnosis is the foundation of any effective approach. Clinicians emphasize that symptoms are real, arise from altered brain functioning rather than tissue injury, and are potentially reversible with targeted interventions. In military and veterans’ systems, this explanation is often delivered jointly by neurology and mental health providers, using language that resonates with service culture: analogies to software–hardware problems, misfiring circuits, or “glitches” in automatic movement and threat-response systems help normalize the condition and reduce shame.
Psychoeducation is typically the first structured step in treatment. Many programs offer individual or group sessions in which clinicians review how stress, trauma, mild traumatic brain injury, and chronic pain can change patterns of attention, bodily awareness, and movement control. For veterans with long diagnostic histories, these sessions also address prior negative experiences with healthcare, clarifying that functional neurological disorder is distinct from malingering or factitious disorder. Written materials, videos, and web-based modules are tailored to common military experiences such as blast exposure, deployment cycles, and reintegration challenges. By providing a coherent model that links symptoms to understandable brain processes, psychoeducation aims to increase perceived control and readiness to engage in active rehabilitation.
Specialized physical therapy is a core component for those with functional motor symptoms, gait disturbance, or balance problems. Unlike conventional neurological rehabilitation focused on strengthening weak muscles or compensating for fixed deficits, therapy for FND prioritizes restoring automatic, effortless movement. Therapists use techniques such as distraction, dual-task exercises, and rapid transitions between tasks to bypass maladaptive conscious control of movement. For example, a veteran who cannot voluntarily move a leg in bed may be able to step and pivot when attention is shifted to catching a ball or following a rhythm. These “movement breakthroughs” are reinforced and explained in real time, helping the patient experience firsthand that the nervous system remains capable of normal function.
Intensive, time-limited rehabilitation programs have shown particular promise for veterans with severe disability. Some Veterans Affairs and military hospitals run inpatient or day-hospital FND tracks where patients receive several hours per day of coordinated physical therapy, occupational therapy, psychology, and nursing support. Treatment goals are framed in functional terms: walking independently, managing stairs, performing self-care, or resuming childcare duties. The structured environment allows rapid titration of activities, real-time feedback on maladaptive movement patterns, and consistent messaging from all staff. Programs often include education groups that address pacing, sleep hygiene, pain management, and relapse prevention, recognizing that functional neurological symptoms frequently fluctuate over time.
Occupational therapy focuses on translating motor and cognitive gains into meaningful daily activities and roles. Therapists work with service members to re-engage in tasks linked to identity and purpose, such as household responsibilities, hobbies, school work, or, when feasible, specific military tasks. They use graded exposure and activity scheduling to counteract avoidance patterns that maintain disability. For example, a veteran who developed functional seizures in crowded settings might gradually reintroduce community outings with structured safety plans and coping strategies. Adaptive equipment is used sparingly and strategically, as overreliance on mobility aids or protective gear can reinforce perceptions of fragility and entrenched disability.
Psychological therapies are tailored to the individual’s symptom profile, comorbidities, and preferences. Cognitive-behavioral therapy adapted for FND commonly targets catastrophic interpretations of symptoms, rigid beliefs about permanent damage, and safety behaviors such as constant self-monitoring or avoidance of movement. Therapists help patients experiment with behavioral changes—gradual increases in activity, deliberate shifts in attention, or controlled exposure to symptom triggers—while tracking their impact on functioning. In veterans with prominent PTSD, evidence-based trauma-focused treatments such as Cognitive Processing Therapy or Prolonged Exposure are integrated carefully, either in parallel with FND-focused work or sequentially once basic symptom management skills are established.
For some individuals, particularly those whose symptoms are closely linked to dissociation or unresolved trauma, integrative approaches that address both PTSD and FND mechanisms are beneficial. Therapists may draw on models that conceptualize functional symptoms as learned responses within the nervous system’s defense hierarchy, with freeze or shutdown states manifesting as paralysis, non-epileptic attacks, or mutism. Treatment then combines grounding techniques, emotion regulation skills, and trauma processing with explicit retraining of bodily responses. Coordination with psychiatry ensures that medications prescribed for depression, anxiety, or PTSD support rather than undermine rehabilitation by minimizing sedation and cognitive blunting.
Group-based interventions offer advantages in military and veteran populations, where shared experience and unit cohesion are powerful motivators. FND groups typically combine psychoeducation, movement exercises, and skills training in stress management and communication. Participants learn to normalize fluctuations in symptoms, challenge stigma, and share strategies for returning to valued roles. In some programs, peer specialists—veterans who have experienced and recovered from functional neurological symptoms—co-facilitate groups, providing credible models of recovery and helping others navigate practical issues such as workplace accommodations, benefits, and family communication.
A critical element of treatment planning is careful review and rationalization of medications. Many veterans with FND are prescribed complex regimens that include antiseizure drugs, opioids, benzodiazepines, and sedating sleep agents, often initiated before a functional diagnosis was made. These medications can worsen fatigue, reduce concentration, and blunt emotional processing, thereby impeding engagement in active therapies. Neurologists and psychiatrists collaborate to taper unnecessary or ineffective agents while introducing evidence-based pharmacologic treatments for comorbid depression, anxiety, or PTSD when indicated. The process is explained as part of a shift from passive, medication-centered care to active rehabilitation, emphasizing safety and close monitoring.
Telehealth has become an increasingly important modality for delivering FND treatment to veterans who live far from tertiary centers or have mobility limitations. Video-based sessions allow neurologists, psychologists, and therapists to provide education, monitor progress, and guide home-based exercises. For motor symptoms, therapists may coach patients through movement tasks in their domestic environment, helping them generalize skills learned in clinic to real-world settings. Telehealth also improves access to care for those reluctant to attend mental health clinics in person because of stigma, offering a more discreet path to engage in psychological treatment.
Family and partner involvement is often pivotal to successful outcomes. Many veterans rely on spouses or relatives for transportation, daily assistance, and emotional support, but well-intentioned caregiving can inadvertently reinforce disability when it consistently substitutes for tasks the patient could gradually resume. Treatment programs therefore include family education sessions that explain FND mechanisms, outline realistic expectations for recovery, and teach supportive responses that encourage independence. Families are coached to recognize when they may be inadvertently enabling avoidance and to collaborate in graded exposure to feared activities, while also learning strategies to manage their own stress and burnout.
Vocational rehabilitation plays a key role in longer-term recovery, particularly for veterans transitioning from active duty to civilian life. Counselors and occupational therapists assess work history, skills, and interests, then help design stepwise plans for re-entry into employment or education. For some, this may involve temporary light-duty or modified roles within the military; for others, it means retraining for civilian occupations that align with current capacities and limitations. FND-focused vocational interventions emphasize building confidence through small, achievable successes, supporting disclosure decisions in the workplace, and coordinating with employers or educational institutions to implement reasonable accommodations without reinforcing excessive medicalization of transient symptom flares.
Care coordination and case management are essential in systems where individuals may see multiple specialists across different facilities. Designated care coordinators—often nurses, social workers, or rehabilitation psychologists—help align treatment goals, reduce redundant appointments, and ensure consistent messaging about the diagnosis. They assist veterans in navigating benefits, transportation, housing, and other social determinants that can profoundly affect engagement in treatment. For those with co-occurring substance use disorders, chronic pain syndromes, or severe PTSD, integrated case management helps balance competing priorities and prevents functional neurological symptoms from being addressed in isolation from the broader clinical picture.
Many programs incorporate structured self-management components to foster long-term resilience. Patients learn to identify early warning signs of symptom escalation—such as rising stress, sleep disruption, or increased avoidance—and apply preplanned strategies, including relaxation techniques, grounding exercises, pacing, and brief movement routines. Written relapse-prevention plans outline steps to take when symptoms flare, including when to adjust activity, seek peer or family support, or contact clinicians. This approach aims to reduce emergency department use and promote a sense of agency, reinforcing the message that while symptoms may recur, individuals have tools to influence their course.
Physical health optimization is addressed alongside neurological and psychological treatment. Sleep interventions, often delivered by behavioral sleep medicine specialists, focus on regularizing schedules, reducing stimulants, and introducing cognitive-behavioral strategies for insomnia. Pain management emphasizes non-pharmacologic approaches such as graded activity, relaxation training, and cognitive-behavioral techniques for pain, integrating them with FND-specific movement retraining. Nutritional counseling may be offered when appetite, weight, or gastrointestinal symptoms are contributing to fatigue and reduced activity. When cardiovascular deconditioning is present after prolonged inactivity, exercise physiologists or physical therapists design gradual aerobic conditioning programs that are closely monitored to avoid symptom exacerbation.
For individuals whose symptoms substantially impair safety-sensitive duties—such as pilots, drivers, or weapons handlers—treatment plans integrate occupational risk assessment and staged return-to-duty protocols. Clinicians collaborate with command leadership and occupational medicine to define clear, functional benchmarks for resuming specific tasks, such as a defined period free of functional seizures or demonstration of reliable balance and coordination under stress. Rehabilitation exercises may be designed to mimic job demands in controlled environments, for example simulating rapid position changes, multi-tasking, or exposure to auditory and visual stimuli reminiscent of deployment settings. Transparent communication about progress and limitations helps reduce anxiety about career prospects and fosters realistic planning.
In some cases, especially when FND has persisted for years with marked social withdrawal and loss of roles, more intensive psychosocial interventions are needed. Social workers and peer specialists assist with reconnecting to community resources, veteran organizations, recreational programs, and educational opportunities. Participation in adaptive sports, creative arts therapies, or service-oriented volunteer roles can help rebuild identity beyond illness and reconnect veterans with values of teamwork, mastery, and contribution that were central during military service. These activities are framed as part of rehabilitation rather than as optional extras, reinforcing their importance for brain health and functional recovery.
Implementation of these treatment strategies across military and veterans’ systems requires ongoing clinician training and organizational support. Facilities that have developed dedicated FND clinics or pathways typically invest in staff education, protocol development, and outcome monitoring. Clinicians learn to present a unified, non-stigmatizing framework, avoid unnecessary investigations once a positive diagnosis is established, and shift resources toward evidence-informed rehabilitation. Data on functional outcomes, return-to-work rates, hospital utilization, and patient-reported quality of life guide iterative improvements, helping systems refine which combinations of interventions are most effective for specific subgroups, such as those with prominent PTSD, chronic pain, or long-standing disability.
Across all levels of care, the overarching goal is to align treatment with the realities of military and veteran life: high exposure to trauma, complex comorbidities, and frequent transitions between care environments. When functional neurological disorder is addressed through coordinated, multidisciplinary rehabilitation that honors service culture and emphasizes recovery, many veterans experience meaningful improvements in mobility, symptom control, and participation in valued roles. Ensuring timely access to care, minimizing conflicting messages from providers, and embedding FND-informed practices within existing trauma, TBI, and pain services are key to translating individual treatment gains into sustained, system-wide improvements for this population.
Policy implications and recommendations for military and veterans’ healthcare systems
Policy development for functional neurological disorder in military and veterans’ healthcare systems requires explicit recognition of FND as a common, disabling, and treatable condition that frequently co-occurs with PTSD, chronic pain, mild traumatic brain injury, and other deployment-related exposures. Formal inclusion of FND in strategic planning documents, clinical practice guidelines, and performance metrics signals its legitimacy and ensures it is not overlooked in favor of more familiar diagnoses. At the system level, this means specifying FND in neurology, mental health, pain, and rehabilitation policies, rather than allowing it to remain under generic categories such as “medically unexplained symptoms.” Clear definitional language also helps distinguish FND from malingering and factitious disorder, reducing stigma and supporting fair access to care and benefits for affected veterans and service members.
One of the most pressing policy implications involves standardizing diagnostic pathways and care models across military treatment facilities and Veterans Affairs centers. Policies can mandate the use of positive diagnostic criteria—based on recognizable examination signs and validated investigations—rather than requiring exhaustive exclusion of every possible structural disease. Standardized clinical pathways should outline when primary care can manage FND, when neurology or mental health consultation is indicated, how quickly referrals should occur, and what minimal investigations are recommended before a functional diagnosis is confirmed. Embedding these pathways in electronic health record order sets and decision-support tools helps ensure consistency and reduces unnecessary, costly, and potentially iatrogenic testing.
Workforce training and competency standards represent another critical policy domain. Many clinicians receive little formal education on FND, resulting in inconsistent explanations, fragmented care, and inadvertent reinforcement of disability. Military and veterans’ health systems can address this by setting minimum training requirements for neurology, psychiatry, psychology, primary care, and rehabilitation staff, including continuing education credits specifically focused on FND. Policies might encourage or require participation in simulation-based training, case conferences, and online modules that highlight practical skills such as delivering the diagnosis, documenting positive signs, and coordinating multidisciplinary treatment. Including FND content in residency and fellowship curricula for neurology, psychiatry, physical medicine and rehabilitation, and emergency medicine helps build a pipeline of clinicians equipped to manage these cases.
To operationalize multidisciplinary care, policy frameworks can support the creation and maintenance of dedicated FND or “functional symptoms” clinics within larger facilities, as well as virtual hubs that serve smaller or remote sites. These clinics typically bring together neurologists, psychologists or psychiatrists, physical and occupational therapists, and social workers under a shared protocol. Policies can define eligibility criteria, referral mechanisms, recommended intensity and duration of treatment, and outcome measures such as functional mobility, symptom frequency, quality of life, and return-to-work or return-to-duty rates. Funding models should recognize that the upfront cost of integrated rehabilitation is often offset by reductions in emergency visits, unnecessary imaging, polypharmacy, and long-term disability.
Telehealth policies are particularly important in ensuring equitable access to care for veterans living in rural areas, Guard and Reserve members, and active-duty personnel stationed far from tertiary centers. System-level guidance should facilitate the use of secure video platforms for diagnostic consultations, psychological therapies, and physiotherapy-based movement retraining, with clear rules for cross-state or cross-jurisdiction practice when care is delivered across facility boundaries. Reimbursement and workload-credit policies need to treat telehealth FND services on par with in-person care, removing disincentives for clinicians to offer these modalities. Standardized telehealth protocols can specify which assessments and interventions are appropriate for remote delivery, how to handle emergencies such as seizure-like events on camera, and how to coordinate with local providers for safety-sensitive issues.
Integration of FND care with existing PTSD, TBI, and chronic pain programs is a major policy priority, given the strong overlap in risk factors and clinical presentations. Policies can require routine screening for functional neurological symptoms in post-deployment health assessments, TBI clinics, and PTSD treatment programs, ensuring that FND is actively considered rather than incidentally discovered. Conversely, FND clinics should be required to screen for trauma histories and PTSD symptoms, with streamlined referral pathways to evidence-based trauma-focused therapies. Joint clinical practice guidelines that address the management of co-occurring FND and PTSD can provide practical algorithms for whether to prioritize trauma processing, FND-specific rehabilitation, or a phased combination of both, reducing unwarranted practice variation.
Occupational health, fitness-for-duty, and disability-determination policies must be updated to reflect current understanding of FND as a genuine but potentially reversible disorder. Traditional approaches that implicitly equate functional symptoms with lack of motivation or voluntary control can lead to punitive responses, prolonged administrative uncertainty, or unnecessary separation from service. Revised policies should emphasize individualized functional assessment, time-limited duty restrictions linked to active treatment participation, and staged return-to-duty protocols when safe and feasible. For those transitioning out of service, disability evaluation systems should incorporate guidance on rating impairment related to FND, acknowledging fluctuating symptoms and the role of effective rehabilitation, while avoiding assumptions that improvement with treatment invalidates prior disability.
Documentation standards and coding practices carry significant policy implications. Accurate recording of FND diagnoses using appropriate ICD or DSM codes is necessary for tracking prevalence, allocating resources, and evaluating outcomes. Policies can specify preferred coding hierarchies that distinguish functional seizures, motor FND, and other subtypes from generic somatoform or conversion disorder labels, which may not reflect contemporary diagnostic frameworks. Encouraging or requiring clinicians to document positive neurological signs, explanation of the diagnosis to the patient, and agreed treatment plans in a structured format promotes clarity for subsequent providers and supports research and quality-improvement initiatives using administrative data.
Stigma reduction and patient-centered communication should be explicit policy goals, not merely educational aspirations. Institutional statements, patient-rights documents, and clinical communication guidelines can affirm that functional neurological symptoms are recognized as legitimate, distressing, and deserving of compassionate, evidence-informed care. Policies might discourage language in records that implies exaggeration or feigning without clear evidence, and instead encourage neutral, descriptive terminology that separates observation from speculation about motivation. Incorporating FND into broader anti-stigma campaigns around mental health and invisible injuries reinforces the message that seeking help for these symptoms is consistent with military values of readiness, responsibility, and strength.
Addressing social determinants of health within policy frameworks is essential, given the high rates of unemployment, housing instability, and relationship strain among veterans with chronic FND. Health systems can promote integrated case management models that link clinical care with benefits counseling, vocational rehabilitation, housing assistance, and peer support services. Policies should ensure that veterans with FND are eligible for, and actively referred to, existing programs for homelessness prevention, supported employment, educational assistance, and family services. Recognizing FND as a qualifying condition for certain support programs—where functional impairment, rather than only structural diagnosis, determines eligibility—helps mitigate the downstream impact of persistent symptoms on social and economic stability.
From a prevention standpoint, policies can encourage early identification and intervention in high-risk groups, such as service members with repeated emergency visits for seizure-like episodes, unresolved post-concussive complaints, or complex trauma histories. Implementation of brief FND-informed screening tools in primary care, behavioral health, and post-deployment clinics can be mandated or strongly recommended, with clear criteria for when to initiate early psychoeducation and referral to rehabilitation. System-level monitoring of key indicators—such as repeated normal neuroimaging, prolonged antiseizure medication use without confirmed epilepsy, or frequent non-specific neurology referrals—can trigger targeted reviews and quality-improvement initiatives aimed at reducing diagnostic delay.
Research and data infrastructure policies have a major impact on the evolution of care. Military and veterans’ health systems are uniquely positioned to conduct large-scale, longitudinal studies on FND, given their integrated records and well-defined cohorts. Policies that prioritize FND in research agendas, allocate dedicated funding streams, and encourage collaboration between neurology, psychiatry, rehabilitation, and health services researchers can accelerate the development of tailored interventions. Encouraging the creation of registries that track symptoms, comorbidities, treatments, and outcomes across facilities provides the evidence base needed to refine guidelines, identify best practices, and understand which subgroups of veterans benefit most from specific rehabilitation models.
Quality-assurance and performance-measure frameworks should explicitly incorporate FND-related metrics. Targets might include reductions in redundant diagnostic testing after a positive FND diagnosis, increased rates of documented delivery of a clear explanatory conversation, timely referral to multidisciplinary rehabilitation programs, and improvements in functional outcomes or patient-reported satisfaction. Performance dashboards can highlight facility-level variation, prompting peer learning and targeted support for underperforming sites. Importantly, metrics should avoid incentivizing premature closure of diagnostic workups or discouraging appropriate evaluation for coexisting structural disease; instead, they should reward adherence to balanced, evidence-based pathways that combine safety with efficiency.
Inter-agency and cross-system coordination is another important policy area, particularly for service members transitioning from active-duty care to veterans’ healthcare systems, or moving between Department of Defense, VA, and civilian providers. Policies can mandate standardized transfer summaries that include FND diagnoses, positive examination findings, key investigations, and current rehabilitation plans, preventing loss of critical information during handoffs. Joint DoD–VA clinical practice guidelines and shared educational materials help ensure that explanations and treatment recommendations remain consistent across systems, reducing confusion and mistrust for individuals who must navigate multiple healthcare environments over time.
Compensation, legal, and benefits policies intersect with clinical care in ways that can either support or inadvertently complicate FND management. Clear guidance to disability evaluators, legal officers, and benefits adjudicators about the nature of FND—that symptoms are involuntary, can be severe, and may coexist with structural injuries—helps prevent misinterpretation of improvement with treatment as evidence of prior deception. At the same time, policies can encourage collaborative communication between clinical teams and evaluators, ensuring that reports emphasize functional capacities, response to rehabilitation, and realistic prognosis. Transparent criteria for service connection and disability ratings related to FND reduce uncertainty for veterans and clinicians alike, and minimize the risk that financial or legal considerations will distort clinical decision-making.
Policies should address the sustainability and scalability of FND services within constrained resource environments. This may involve tiered care models that match intervention intensity to clinical need, with brief psychoeducation and self-management resources for milder cases and comprehensive multidisciplinary rehabilitation for those with severe impairment. Task-sharing approaches, in which trained nurses, social workers, or peer specialists deliver certain components of education and self-management support under specialist supervision, can extend the reach of limited specialist workforce. Strategic planning that incorporates projected demand, workforce capacity, and technology-enabled solutions helps ensure that improvements in FND care are not confined to a few centers of excellence but are accessible to veterans and service members across the entire system, regardless of location or service era.
