Cognitive Behavioral Therapy (CBT) is an effective way to help manage Functional Neurological Disorders (FND). FND is a condition in which there is a malfunction in the way the brain receives and processes information to the rest of the body. It was previously referred to as conversion disorder and it is a complex condition that is hallmarked by a variety of neurological symptoms including but not limited to limb weakness, non-epileptic seizures, tremors, gait disorder, dystonia, and visual symptoms. Some patients only have one or two symptoms, while others have many.
Another way to think of FND is that your brain is the hardware of a computer and your symptoms are caused by a malfunction in the software of the computer (how your brain processes information received), not because of a malfunction in the hardware (meaning there is no injury, illness, or structural abnormality in the brain). FND symptoms play a significant role in a person's mood, and a person’s mood plays a significant role in the severity of FND symptoms.
Many people with FND report difficulties with emotional functioning, including anxiety and depression. Common emotions that individuals with FND experience include shame, anxiety, despair, hopelessness, helplessness, and fear. It is important to know that your feelings are valid and your symptoms are real. Many people with FND report that they have experienced instances where they feel invalidated in their experiences and have been told they are either making up their symptoms or “it is all in your head.” Understanding your symptoms is one thing, but it is important to acknowledge the validity of them and how they make you feel emotionally.
There are brain studies that show that emotions may influence the ability to initiate or control the motor system resulting in symptoms like weakness or an essential tremor. For many people the more they worry about their symptoms the more apparent they are, or excessive awareness of their symptoms increases the amount or severity of symptoms, like when you are having a conversation about fleas, and you suddenly feel itchy.
Treating a FND often requires a multidisciplinary approach working with neurologists, physical therapists, and mental health professionals. There are many studies showing promising effects of using CBT to help treat FND. Using CBT to treat FND is aimed at improving day-to-day wellbeing, understanding what your symptoms are, understanding what causes your symptoms, and understanding how to change your responses to them.
CBT is an evidence-based therapeutic process developed by Aaron Beck in the 1960s. It combines techniques from both cognitive therapy and behavioral therapy into one package. CBT emphasizes the relationship between your beliefs and your emotions and behaviors. Within CBT your distorted thoughts will be identified and challenged and the maladaptive behaviors that are supported by these thoughts will be challenged and modified. It is a highly structured, time-limited, problem-focused, and goal-oriented form of therapy. Many times booster sessions are offered after the initial course of therapy and family members (or caretakers) may be included in therapy sessions, in order to develop a more comprehensive treatment plan. CBT is often viewed as an educational adventure. More can be read about Cognitive Behavioral Therapy here.
CBT for FND is focused on identifying the precipitating events leading to physical symptoms and finding ways to limit the occurrence of these symptoms. There are five bases to CBT for FND, they are psychoeducation and rapport building, identification of stressors, symptom control and behavior management, reestablishing life routines, and the importance of using the skills learned.
Psychoeducation and Rapport Building: The first several sessions of CBT therapy for FND revolve around psychoeducation and building trust. The process of building trust between the therapist and the client is something that is done in any therapy session regardless of theoretical orientation. When building trust with the client it is important to validate their experience and provide reassurance. Within the first session the client will identify areas of most distress and work with the therapist to identify goals for therapy. Many clients seeking treatment for FND have goals that include, acquiring tools and strategies to manage their symptoms, to return to the activities they enjoy, to reduce their number of symptoms or the frequency of them, to process with school and/or work, to increase their confidence, and to increase their understanding of their condition. During the first session the therapist will impress upon the importance of self-monitoring and at-home practice (which are tenets of CBT).
Identification of Stressors: The following sessions will focus on identifying stressors and creating a stressor hierarchy. Relaxation training will often be used during these sessions with the hope that the client will use the relaxation techniques at home. Another technique that may be used during these sessions is activity scheduling.
Symptom Control and Behavior Management: The sessions during this section of treatment will focus on symptom control and behavior management. During these sessions the client will review their homework with the therapist. Common homework tasks include thought tracking, mood tracking, relaxation techniques, and exposure tasks. The client will learn problem solving strategies during these sessions and exposure and response prevention techniques. The client will identify common thoughts they have, and the therapist will challenge the unhelpful thoughts.
Reestablishing Life Routines: The sessions during this section of treatment will focus on the reestablishment of regular life routines, for example it will include increasing the amount of time spent doing pleasurable activities. The client will continue exposure tasks and thought challenging. During this section they will learn assertiveness skills and communication skills. Clients will be taught mindfulness activities to help them accept things outside of their control.
Importance of using the Skills Learned: The final sessions of therapy include learning the importance of using the skills they have learned in their sessions. The client will discuss the progress they have made and identify areas of continued effort and ongoing challenges. Areas of continued challenges can provide insight into what the client should be focusing on inside and outside of therapy.
CBT targets thoughts, particularly our unhelpful thoughts. Unhelpful thoughts can make you feel physically and emotionally worse. Unhelpful thinking causes unhelpful changes in your mood, and unhelpful changes in your behavior. Mood changes can include feeling more down, guilty, anxious, ashamed, stressed, or depressed. Behavior changes can include stopping or reducing what you normally do, avoiding things that worry you or cause you stress, or you could engage in activities that make you feel better in the short term but backfire in the long term. Some other techniques that may be used in CBT work for FND include cataloging feelings, identifying helpful versus unhelpful behaviors, activity planning, and teaching relaxation techniques, like Box Breathing.
Cataloging your feelings: Cataloging the feelings you have about your FND symptoms is a useful intervention, because no two FNDs look alike neither do the emotions associated with them. Some people view their symptoms as overwhelming, frustrating, or demoralizing, whereas others view them as a nuisance. It is important to recognize that your emotional response to your symptoms can change daily, or even hourly.
Identifying your behaviors: When symptoms arise you often do things to try to improve them, those behaviors can be helpful or unhelpful. The goal is to identify behaviors that improve symptoms and help you to feel better and safer, even if it is just short term improvement. Some helpful behaviors include maintaining an appropriate level of physical activity, pacing yourself, socializing at a level you can cope with, and doing planned activities. Some unhelpful behaviors include going nonstop so you do not have time to think and reflect, excessively monitoring symptoms, excessively seeking reassurance from others, and pushing away those who care about me.
Activity planning: Activity planning is a key behavioral activation component to CBT therapy. It involves creating a schedule of activity for the days ahead, being mindful not to overwhelm yourself by creating a hectic schedule. Within the plan you build in time for leisure activities that you enjoy. Activity planning helps promote engagement in activities you enjoy that you might not have been able to because of time constraints or perceived lack of energy. Studies have shown that planning activities greatly increases the chance that they will be completed. As with any intervention, reflecting on how you feel afterwards is important and it is important to remember the plan is not carved in stone, it can be altered to fit your needs.
Box Breathing: Box Breathing is a relaxation technique that helps you slow down your breathing. It works by refocusing your mind by counting to four and focusing on your breath, thus calming your nervous system. When doing box breathing you inhale, while counting to four slowly, then hold your breath for four seconds, slowly exhale through your mouth for four seconds, and finally hold your empty breath for an additional four seconds. The exercise can be repeated as many times as necessary.
CBT offers training for clients, in the form of homework, in areas including balancing and pacing your day, exercise, pain management techniques, mindfulness training, sleep hygiene training, relaxation techniques, and grounding techniques.
If you’d like to give CBT for FND a try, please reach out to 215-922-5683 x 100 or schedule directly online. For your convenience, we have five in-person offices and can also provide counseling and therapy virtually.
