How Can Psychotherapy Help With FNSD?
Understanding the role of cognitive behavioral therapy in treatment and recovery
Living with functional neurological symptom disorder (FNSD), commonly called functional neurological disorder (FND), can be frightening and disruptive. Symptoms may interfere with walking, speaking, working, or spending time with others. When psychotherapy is recommended, patients sometimes wonder whether their symptoms are being taken seriously.
Psychotherapy can be part of treatment for real, involuntary neurological symptoms. Its purpose is to help people understand symptom patterns, develop practical skills, reduce distress, and regain participation in daily life. Cognitive behavioral therapy (CBT) is among the most extensively studied psychological approaches, particularly for functional seizures. However, its benefits vary, and treatment should match the person’s symptoms and needs (Dworetzky & Baslet, 2025; Goldstein et al., 2020). PMC
Understanding why psychotherapy may help
FNSD involves disruptions in neurological functioning that can affect movement, sensation, or awareness. Contemporary explanations consider interactions among brain networks involved in attention, movement, emotional processing, and the experience of control over bodily actions. Biological, psychological, and social influences may contribute differently for each person (Dworetzky & Baslet, 2025).
Treatment therefore needs to be individualized. Someone with functional walking difficulties may need specialized physical therapy, while someone with functional speech symptoms may benefit from speech-language therapy. Psychotherapy may complement rehabilitation or serve as a central treatment for functional seizures. A referral for therapy should come with a clear explanation of how it addresses the person’s particular difficulties (Dworetzky & Baslet, 2025). PMC
What does the current evidence show?
The American Academy of Neurology’s 2026 guideline concludes that psychological interventions are possibly effectivefor improving functional seizure outcomes, including seizure freedom, seizure frequency, anxiety, quality of life, and psychosocial functioning. This wording reflects promising evidence alongside limitations in the available studies. The guideline recommends referral for interested, appropriate patients and emphasizes respectful communication, shared decisions, and continuity of care (Tolchin et al., 2026). pubmed.ncbi.nlm.nih.gov
The largest major trial of seizure-specific CBT, the CODES study, included 368 adults. Participants received either standardized medical care or CBT plus standardized medical care. At 12 months, CBT did not produce a statistically significant advantage on the primary outcome of monthly seizure frequency. Nevertheless, the CBT group improved on several secondary outcomes, including psychosocial functioning, psychological distress, how bothersome seizures felt, and the longest period without seizures (Goldstein et al., 2020).
These results support a balanced message: CBT may help people function and feel better even when seizures do not disappear. The secondary findings require appropriate caution because multiple outcomes were examined (Goldstein et al., 2020). PubMed
Evidence also extends to functional movement disorders. In a randomized trial involving 40 adults, combined specialized physiotherapy and CBT improved physical aspects of quality of life compared with psychological support. However, the study was small, and the combined treatment design cannot establish how much improvement resulted from CBT alone (Macías-García et al., 2024). PMC
What does CBT involve?
CBT is a collaborative treatment that examines relationships among thoughts, emotions, bodily experiences, and behavior. FNSD-focused CBT may include symptom education, identifying patterns, reconsidering threatening interpretations, reducing avoidance, developing coping skills, and setting practical goals. These components are selected according to an individualized understanding of the person’s difficulties (Myers et al., 2021). PMC
The following examples illustrate how these principles might be applied. They are examples of clinical reasoning, not a standardized treatment plan or promises of improvement.
1. Developing a shared understanding of symptoms
A useful starting point is discussing what the person understands about the diagnosis, what remains confusing, and what they want treatment to accomplish.
For example, a patient might say, “I understand the diagnosis, but I still don’t understand how therapy could help my legs.” The therapist can work with the rehabilitation team to connect psychological treatment to a concrete goal: reducing fear during movement practice, managing frustration, or rebuilding confidence in daily activities.
The conversation should leave room for uncertainty and questions. Agreement about a practical next step can be more useful than expecting immediate acceptance of every explanation.
2. Identifying patterns without assigning blame
CBT may use brief records to explore what happens before, during, and after symptoms. Relevant observations might include the setting, physical sensations, thoughts, emotional responses, and subsequent actions (Myers et al., 2021). PMC
For example, someone might notice that a difficult outing is followed by the thought, “I should never go out again.” Therapy can examine how that conclusion affects future choices while fully acknowledging how upsetting the episode was.
The aim is to identify useful intervention points. A pattern does not mean the person deliberately caused the symptoms.
3. Working with frightening predictions
A CBT conversation might explore a prediction such as, “If symptoms happen in public, I will be completely helpless.”
Rather than offering unrealistic reassurance, the therapist could ask:
- What happened during previous episodes?
- What assistance was useful?
- What does the medical team recommend?
- What would a manageable, supported outing look like?
A more balanced statement might be: “An episode would be difficult, but I can prepare, use my agreed plan, and ask for help.”
This approach recognizes uncertainty while making room for action.
4. Returning gradually to meaningful activities
CBT-based approaches may address feared or avoided activities through gradual, planned exposure. The goal is to increase participation while changing expectations and responses associated with symptoms (Dworetzky & Baslet, 2025). PMC
For example, someone hoping to return to social activities might begin with a brief visit from a trusted friend, then attempt a short outing with support. The steps would depend on the person’s abilities and clinical recommendations.
Progress could be measured by participation, confidence, or recovery after an episode—not solely by whether symptoms occurred.
5. Practicing skills between sessions
Depending on the formulation, therapy may incorporate grounding, relaxation, attention-shifting strategies, problem-solving, or emotional awareness. Other approaches, including mindfulness-based and psychodynamic therapies, have also been studied, although the strength of evidence differs across treatments and symptom presentations (Myers et al., 2021). PMC
A practical therapy assignment might be small: practicing one agreed strategy, completing one meaningful activity, or recording what helped during a difficult moment. Reviewing what did and did not work gives the therapist and patient information for adjusting treatment.
How does treatment differ for children and adolescents?
Adult findings should not automatically be applied to younger patients. A pilot randomized trial examined Retraining and Control Therapy (ReACT), a cognitive-behaviorally based intervention developed for pediatric functional seizures. It targeted catastrophic symptom expectations and a reduced sense of control and found promising short-term seizure outcomes. Because this was a pilot study, its findings should be interpreted within its sample size and follow-up limitations (Fobian et al., 2020). PMC
For a young person, meaningful goals might include attending classes, seeing friends, and participating in family activities. Treatment planning should consider developmental needs and the role of caregivers.
How can family members help?
With the adult patient’s permission, family members or other support people can participate in treatment. The AAN guideline recommends involving the support network in psychological treatment for functional seizures and evaluating for co-occurring psychiatric conditions and epilepsy (Tolchin et al., 2026). Neurology
A useful family discussion could clarify how to respond during familiar episodes, what assistance the person wants, and how to support independence. These decisions should be consistent with the treating team’s recommendations.
What should improvement look like?
A helpful treatment review asks more than, “Are the symptoms gone?” It can also ask:
- Are symptoms interfering less with daily activities?
- Is the person participating more in work, school, or relationships?
- Are episodes less distressing?
- Does the person feel better equipped to respond?
- Are the agreed treatment goals still relevant?
FNSD treatment requires realistic expectations and ongoing collaboration. Psychotherapy offers opportunities to build skills, address barriers, and support meaningful activity. CBT has an important place in that work, particularly for functional seizures, while research continues to clarify which approaches help which patients most.
References
Dworetzky, B. A., & Baslet, G. (2025). Functional neurological disorder: Practical management. Neurotherapeutics, 22(4), Article e00612. https://doi.org/10.1016/j.neurot.2025.e00612
Fobian, A. D., Long, D. M., & Szaflarski, J. P. (2020). Retraining and control therapy for pediatric psychogenic non-epileptic seizures. Annals of Clinical and Translational Neurology, 7(8), 1410–1419. https://doi.org/10.1002/acn3.51138
Goldstein, L. H., Robinson, E. J., Mellers, J. D. C., Stone, J., Carson, A., Reuber, M., Medford, N., McCrone, P., Murray, J., Richardson, M. P., Pilecka, I., Eastwood, C., Moore, M., Mosweu, I., Perdue, I., Landau, S., & Chalder, T. (2020). Cognitive behavioural therapy for adults with dissociative seizures (CODES): A pragmatic, multicentre, randomised controlled trial. The Lancet Psychiatry, 7(6), 491–505. https://doi.org/10.1016/S2215-0366(20)30128-0
Macías-García, D., Méndez-Del Barrio, M., Canal-Rivero, M., Muñoz-Delgado, L., Adarmes-Gómez, A., Jesús, S., Ojeda-Lepe, E., Carrillo-García, F., Palomar, F. J., Gómez-Campos, F. J., Martin-Rodriguez, J. F., Crespo-Facorro, B., Ruiz-Veguilla, M., & Mir, P. (2024). Combined physiotherapy and cognitive behavioral therapy for functional movement disorders: A randomized clinical trial. JAMA Neurology, 81(9), 966–976. https://doi.org/10.1001/jamaneurol.2024.2393
Myers, L., Sarudiansky, M., Korman, G., & Baslet, G. (2021). Using evidence-based psychotherapy to tailor treatment for patients with functional neurological disorders. Epilepsy & Behavior Reports, 16, Article 100478. https://doi.org/10.1016/j.ebr.2021.100478
Tolchin, B., Goldstein, L. H., Reuber, M., Stone, J., Perez, D. L., LaFrance, W. C., Jr., Fobian, A. D., Dorman, J., Hua, L. H., L’Erario, Z. P., Swanson, S. J., Gilli, P., Mildon, B., Takahashi, C., Botchway-Doe, K. A., Hamel, K. P., Silsbee, H. M., & Oskoui, M. (2026). Management of functional seizures practice guideline executive summary: Report of the AAN Guidelines Subcommittee. Neurology, 106(1), Article e214466. https://doi.org/10.1212/WNL.0000000000214466
