Managing Functional Neurological Disorder: Treatment Recommendations for Health Professionals in Australia
BMJ Neurology Open
Lehn, A., Petrie, D., et al. (2025).
BMJ Neurology Open, 7(1), e000970.
<div>This consensus-based, clinical practice guideline provides recommendations for the multidisciplinary approach to treatment functional neurological disorder (FND). Recommendations relevant to the scope of speech-language pathology are included in this article summary. </div>
Queensland Functional Neurological Disorder Special Interest Group (Australia)
FND Australia Support Services Inc.
<div>The following recommendations regarding SLP assessment of individuals with voice deficits secondary to FND were reported in the supplemental material of this guideline:</div>
<div>
<ul>
<li>First, the vocal folds should be examined to rule out any structural or neurological etiologies.</li>
<li>Routine perceptual voice assessment may be conducted alongside voice assessments across a range of speech tasks. More severe voice symptoms may arise when emotional topics are discussed. </li>
<li>Strategies to achieve reversal of symptoms and the elicitation of normal voice production should be considered as an assessment tool.</li>
<li>Clinicians should monitor for complaints of globus, as this often resolves alongside other voice complaints.</li>
<li>Clinicians should be aware that signs of functional voice disorder include:
<ul>
<li>incongruency between voice symptoms and the expected presentation based on visual inspection of the vocal cords;</li>
<li>inappropriate vocal quality for the client's age and gender;</li>
<li>inconsistency in vocal quality across tasks; and</li>
<li>exaggerated mouth, face, or neck movements during voicing attempts which may resolve with the return of the patient's usual voice. </li>
</ul>
</li>
</ul>
</div>
<div>The following recommendations regarding SLP assessment of individuals with dysfluency secondary to FND were reported in the supplemental material of this guideline:</div>
<div>
<ul>
<li>SLPs can use a variety of fluency assessment tasks such as automatic speech tasks, conversation, reading aloud, speaking with delayed auditory feedback, speaking in the presence of white noise, and singing.</li>
<li>Clinicians should be aware that signs of functional fluency disorders may include:
<ul>
<li>new onset stuttering in adults in the absence of aphasia, apraxia of speech, or dysarthria;</li>
<li>no periods of fluency on automatic speech tasks;</li>
<li>stuttering on all sounds in words;</li>
<li>continued stuttering during tasks that generally reduce dysfluency (e.g., singing, reading the same passage aloud multiple times, delayed auditory feedback);</li>
<li>an inconsistent pattern of dysfluency;</li>
<li>associated struggle behaviors such as facial grimacing, head jerking, hand slapping, eye squinting, and neck extension; and</li>
<li>rapid resolution of symptoms following brief intervention.</li>
</ul>
</li>
</ul>
</div>
<div>The following recommendations regarding SLP assessment of individuals with articulation deficits secondary to FND were reported in the supplemental material of this guideline:</div>
<div>
<ul>
<li>An oral mechanism exam should be conducted alongside recording speech samples.</li>
<li>Clinicians should know that signs of functional articulation disorder may include:
<ul>
<li>oromotor function that is inconsistent with speech presentation;</li>
<li>atypical speech sound errors with unusual and exaggerated mouth/tongue/lip movements or other unusual prosodic features;</li>
<li>consistent errors that are limited to particular sounds;</li>
<li>significantly variable speech sounds; and</li>
<li>speech sound errors that are similar to developmental errors (i.e., "wead" for "read").</li>
</ul>
</li>
</ul>
</div>
<div>The following recommendations regarding SLP assessment of individuals with language and cognitive-communication deficits secondary to FND were reported in the supplemental material of this guideline:</div>
<div>
<ul>
<li>Typical SLP assessments may be used to assess language and cognitive-communication function.</li>
<li>Clinicians should be aware that signs of functional language and cognitive-communication disorders include:
<ul>
<li>incongruency between language and cognitive-communication skills and the patients' expected clinical presentation based on neural imaging; and</li>
<li>significant variability in symptoms over time or across different situations.</li>
</ul>
</li>
</ul>
</div>
<div>The following recommendations regarding SLP assessment of individuals with swallowing deficits secondary to FND were reported in the supplemental material of this guideline: </div>
<div>
<ul>
<li>Clinicians may use bedside swallow assessment, instrumental swallow assessment including fiberoptic endoscopic evaluation of swallowing or videofluoroscopic swallowing studies, and validated self-report measures of dysphagia severity.</li>
<li>Other disease or structural/physiological abnormalities as the cause for dysphagia should be ruled out.</li>
<li>Clinicians should be aware that signs of functional dysphagia include:
<ul>
<li>being able to spit, but being unable to control anything else in the mouth;</li>
<li>being unable to swallow food and fluids despite normal saliva management; and</li>
<li>symptoms seen in other etiologies of dysphagia such as coughing, a sensation of choking, globus sensation, odynophagia, and feeling like swallowing is difficult. </li>
</ul>
</li>
</ul>
</div>
<div>The following recommendations regarding SLP treatment of individuals with voice deficits secondary to FND were reported in the supplemental material of this guideline:</div>
<div>
<ul>
<li>SLPs should explain to the patient that their voice can be brought under their control and that this is the goal of treatment. </li>
<li>Clinicians can use techniques to generate voice such as natural or reflexive vocal behaviors (e.g., cough, clear throat, yawn-sigh, easy onset with prolonged speech sounds), playful pre-linguistic vocal sounds (e.g., blowing raspberries with voicing), automatic utterances (e.g., counting, singing familiar songs), voicing with distraction techniques (e.g., altered auditory feedback, talking while walking or jumping), and physical maneuvers (e.g., circumlaryngeal massage with concurrent vocalization in cases of tension). </li>
<li>Traditional evidence-based dysphonia treatments (e.g., vocal function exercises, semi-occluded vocal tract exercises, resonant voice exercises) may be considered.</li>
<li>Direct therapy techniques (described above) can be effective alongside indirect approaches such as education and vocal hygiene. </li>
<li>If vocal symptoms are associated with any ongoing psychosocial issues, the patient should be made aware of this association and be given strategies to manage them in order to promote generalization beyond the therapy setting.</li>
</ul>
</div>
<div>The following recommendations regarding SLP treatment of individuals with dysfluency secondary to FND were reported in the supplemental material of this guideline:</div>
<div>
<ul>
<li>Patients should be educated about the importance of forward airflow and reduced muscle tension to achieve smooth speech.</li>
<li>SLPs can use visualization (e.g., imaging a surfer riding a wave) to facilitate smooth speech.</li>
<li>Developmental stuttering therapy techniques (e.g., slow rate, easy onset, connected speech) can be considered.</li>
<li>A typical treatment hierarchy (e.g., word repetition, short sentences, and then conversation) may be used.</li>
<li>Clinicians should aim to eliminate secondary movements through the use of distraction (e.g., finger tapping, squeezing a ball, or listening to music while talking), with a gradual fading out as symptoms resolve. </li>
<li>SLPs should collaborate with patients' mental health providers to manage any associated psychological distress or anxiety.</li>
</ul>
</div>
<div>The following recommendations regarding SLP treatment of individuals with articulation deficits secondary to FND were reported in the supplemental material of this guideline:</div>
<div>
<ul>
<li>Traditional articulation approaches used for developmental and neurological speech disorders may be effective to treat functional speech impairments. </li>
<li>Some specific treatment strategies that may be effective for functional articulation disorders include:
<ul>
<li>strategies to reduce musculoskeletal tension;</li>
<li>distraction techniques;</li>
<li>mindfulness activities during oromotor tasks as a way of maintaining focus on easy, smooth movements; and</li>
<li>the use of nonsense words, syllable repetitions, or singing as a way to demonstrate the potential for remediating speech deficits and to provide distraction from abnormal sounds.</li>
</ul>
</li>
</ul>
</div>
<div>The following recommendations regarding SLP treatment of individuals with language and cognitive-communication deficits secondary to FND were reported in the supplemental material of this guideline:</div>
<div>
<ul>
<li>Clinicians should be aware that these symptoms may resolve once other functional symptoms are treated.</li>
<li>Compensatory strategies may be taught if language and cognitive-communication difficulties persist (e.g., strategies for word retrieval). </li>
</ul>
</div>
<div>The following recommendations regarding SLP treatment of individuals with dysphagia secondary to FND were reported in the supplemental material of this guideline:</div>
<div>
<ul>
<li>Patients should be educated about normal swallow function including the fact that the pharyngeal stage of swallowing is an automatic process, that coughing is a protective function, that everyone penetrates/aspirates to a certain extent, and that choking usually only occurs with unchewed pieces of solid food. </li>
<li>Instrumental swallowing images should be used to provide a visual demonstration of the patient's swallowing.</li>
<li>Clinicians should acknowledge any anxiety or life stressors that are contributing to symptoms, collaborating with the patient’s mental health professional as appropriate to determine potentially useful cognitive behavioral therapy strategies. The patient may also receive direct treatment from a mental health professional for any comorbid mental health disorders.</li>
<li>SLPs should reinforce feeding strategies (e.g., sit upright for meals, don’t talk while eating, make sure food is chewed well and the mouth is not overfilled).</li>
<li>Any muscle tension related to swallowing should be addressed.</li>
<li>Clinicians should develop a hierarchy of difficulty with food/drink from the patient’s perspective and use desensitization/graded exposure to target anxiety around swallowing.</li>
<li>Clinicians should consider referrals for nutritionists/dieticians to help ensure the patient is able to achieve sufficient nutrition.</li>
</ul>
</div>
<div>Clinicians working with individuals with FND should understand the prevalence of stigma against people with this disorder.</div>
<div>
<ul>
<li>Clinicians should accept that FND is a disorder in which patients' symptoms are real. This provides consistency to patients who may have already experienced skepticism from medical providers.</li>
<li>In order for these patients to readily engage in treatment, clinicians should create a positive environment in which patients are supported, have the opportunity to ask questions, are able to understand their condition, and have the opportunity to improve.</li>
<li>Education about FND symptoms, diagnosis, and management should occur within a multidisciplinary context that enables these patients to receive the best possible care. </li>
</ul>
</div>
<div>Speech-language pathologists (SLPs) are uniquely qualified to assess and treat speech, fluency, voice, language, cognitive-communication, and swallowing deficits secondary to functional neurological disorders.</div>
<div>
<ul>
<li>SLP involvement allows for the effective diagnosis and treatment of these functional symptoms in patients with FND.</li>
<li>SLPs can sometimes manage functional symptoms independently. However, multidisciplinary team involvement is recommended in cases where additional symptoms are present or progress is limited. This ensures optimal patient access to comprehensive care and improved patient outcomes.</li>
<li>The first step in treatment is a correct diagnosis followed by detailed education about FND in terms that the patient can understand, with an emphasis on the major aspects of FND treatment (e.g., trigger identification/management, the role of attention and distraction in worsening and improving symptoms respectively).</li>
<li>SLPs should be aware that functional symptoms may:
<ul>
<li>vary across assessment tasks and contexts;</li>
<li>be worse when the patient is told a task may be difficult;</li>
<li>be worse when the patient is aware they are being assessed;</li>
<li>improve or completely resolve with distraction (e.g., casual conversation, when discussing a topic of interest); and</li>
<li>resolve after one to two therapy sessions.</li>
</ul>
</li>
</ul>
</div>
