The French neurologist Charcot demonstrates his hypnotic therapy for conversion disorder in in this 1887 painting A Clinical Lesson at the Salpêtrière by André Brouillet. A young Dr. Freud attended these lectures, which inspired his psychoanalytic techniques.
Explaining psychogenic symptoms is the first step in treatment
STUDY: Buchholz A et al, CNS Spectrums 2026
STUDY TYPE: Expert clinical guidance
FUNDING: Independent
Background
Functional neurological (conversion) disorder is one of the most common reasons for a neurology visit, yet patients often leave feeling dismissed or accused of faking. Here, a team of psychologists and neurologists give practical tips from their experience at Johns Hopkins.
Results
The authors offer several facts to share with patients, including:
- Functional seizures make up about a third of epilepsy monitoring unit admissions.
- Misdiagnosis is rare, around 4%.
- Psychotherapy reduces functional seizures by 55% to 60% on average.
- About 5% to 20% of patients have both functional seizures and epilepsy.
Video EEG during typical events is the gold standard to evaluate functional seizures. For movement symptoms, the diagnosis rests on positive signs such as Hoover’s sign or a tremor that improves with distraction. Both rest on what the exam and recordings show, so you can make the diagnosis with confidence.
The authors give concrete advice for the conversation:
- Use current terms like “functional seizures” and “functional movement disorder.” Drop “pseudoseizures,” “psychogenic,” and “conversion.”
- Show patients the positive signs on exam so they see how you reached the diagnosis.
- Explain it as a software problem: the hardware (nerves, muscles, brain structure) is intact, but the brain’s signals have glitches that therapy can retrain.
- Say plainly that the symptoms are real and not faked.
- Don’t emphasize stress. Many patients have no clear trigger, and leading with a talk about stress can invalidate.
- Be honest that the science is still evolving, while emphasizing that the diagnosis is reliable and recovery is possible.
For treatment, cognitive behavioral therapy has the best evidence, with psychodynamic therapy rising in a new trial. Dialectical behavior therapy and hypnosis showing promise. Physical and occupational therapy are among the most effective options for functional movement disorder.
Send patients home with reading. Point them to NeuroSymptoms.org and FNDhope.org and use fndsociety.org/referral to find FND specialists. For functional seizures, the Taking Control of Your Seizures workbook is helpful (available as a therapist guide as well).
—Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report
