The 5th international conference on FND “Mechanisms to Therapy” organised by the Functional Neurological Disorder Society (FNDS) took place in the iconic city of Verona, between the 8th and 11th of June, 2024. The conference welcomed over eight-hundred in-person and virtual attendees from forty-two different countries at the beautiful Palazzo della Gran Guardia. This was a great opportunity to expand your knowledge, learn new skills and build long-lasting connections.
This year’s conference introduced a new format, by offering an optional in-person education and training day. The day consisted of sessions covering common skills in FND assessment, treatment planning and barriers, as well as creating sustainability in FND practice. The day also offered a selection of workshops on FND specific treatment skills for neurological care, rehabilitation, psychological treatment and paediatric care. Each workshop was run by a panel of experts in their field and covered such interesting topics that it was difficult to choose one workshop.
I attended the psychological treatment workshop, which included a range of psychological skills, from initial assessment to adaptations of various psychological therapies: cognitive behavioural therapy (CBT), psychodynamic interpersonal therapy, eye movement desensitisation and reprocessing, mindfulness psychotherapy and hypnosis and catalepsy induction. The workshop generated interesting discussions and reflections.
The official 1st day of the conference was opened by Mark Hallet, Michele Tinazzi and Alan Carson. The focus of the day was on updates for functional seizures and functional motor disorder, covering diagnosis and treatment. One of the talks discussed the terms of use, emphasising that neither “psychogenic” nor “non-epileptic” terms should be used to refer to functional dissociative seizures (FDS, preferred terminology). The term “functional” implies reversibility, highlighting the role of brain networking difficulties and the role of biological stress response.
Stoyan Popkirov discussed the experience and semiology of FDS, bringing it all together in a model conceptualising different parts of the illness, and suggesting potential targets for treatment (e.g. arousal, dissociation). Dara Albert highlighted clinical features that differentiate FDS from epileptic seizures and the use of a checklist as a decision support tool, that can help identify FDS, alongside video recordings of seizure activities. While these tools are available, the emphasis was placed on getting a detailed history and description of the event, as EEG is not always possible or needed. Her talk highlighted the importance of accurate diagnosis to help the patient move forward with the appropriate treatment. Kasia Kozlowska presented the stress system intervention developed in Australia for FDS for children and adolescents, which recently has been adapted into a programme for adults.
The sessions that focused on mechanisms to pathophysiology in Functional Motor Disorder (FMD) included discussions of evidence regarding brain network dysfunction in FMD, particularly those involved in agency. Predictive coding has been highlighted as the key mechanism. Further talks reviewed evidence for the role of changes in the amygdala/limbic-motor interaction that require further explorations. Glen Nielsen presented the findings from a randomised controlled trial of physiotherapy for FMD (Physio4FMD). The results deemed physiotherapy to be a valuable intervention, despite high level of complexity present within the sample. Patients reported high satisfaction with treatment and specialist physiotherapy intervention was associated with better self-efficacy. The trial resources can be adapted and are freely available.
The final session of the day covered shared issues in therapeutic interventions – ranging from pain and fibromyalgia, common comorbidities in FND, treating FND in resource limited settings, what to do when FND treatment response is sub-optimal and challenges of managing FND in primary care. Prof Chris Burton encouraged information sharing with GPs, especially in relation to FND diagnosis explanation. Mike Dilley, a neuropsychiatrist at King’s, discussed the value of formulation of informed treatment in “difficult to treat” cases, where factors related to the person, illness and treatment need to be addressed. He highlighted the importance of addressing comorbidities and treating one condition at a time. The day ended with a case discussion and a welcome reception.
The second day began with exploring the range of functional disorders that are commonly present in people with FND. The talks focused on chronic fatigue, psychosomatic medicine and the VA national program for FND. Michael Sharpe’s talk focused on the brief history of chronic fatigue, illness maintaining factors and treatment targets. He spoke about the role of CBT in targeting fear of activity, illness beliefs and other maintaining factors, as well as the role of graded exercise and a combination of the latter two approaches. Curt LaFrance presented the “Mind Brain Program” for FND, a transtheoretical model, that has been successfully implemented at the national VA centre in the USA.
The second session focused on FND and other conditions, such as Multiple sclerosis (MS), Parkinson’s disease (PD), headaches and migraines, as well as autism and ADHD. Andrew Solomon highlighted that misdiagnosis of MS is a common and frequent phenomenon, where people actually have FND and other disorders such as migraines and fibromyalgia. Nonetheless, this can happen the other way around, where MS is being missed. Often, the presence of psychiatric diagnoses can delay the diagnosis of MS. Isabel Parees discussed that in some cases, FMD may precede the diagnosis of PD or co-occur in 60% of cases, and highlighted the need for further research. Similarly, Jon Stone highlighted that between 6 to 53% people with FND also have a comorbid migraine. Frequently, an overdiagnosis of migraine occurs in FND cases.
The final, presidential session chaired by Barbara Dworetzky, explored long covid and other topics in the news, such as Havana Syndrome and Tik-Tok Tics. Research from long covid revealed that people experienced a broad range of cognitive difficulties and there was no one consistent profile of such difficulties. However, the findings demonstrated that anxiety and depression predicted cognitive difficulties post covid. When discussing the Tik-Tok Tics, Davide Martino postulated the role of social media acting as a catalyst. Functional tics have been described for over 15 years, highlighting that it is not a new phenomenon. However, the prevalence of functional tics appeared to have risen during the COVID-19 pandemic and diminished since, but not to pre-pandemic levels. Mark Hallett presented on Havanah syndrome and highlighted common co-occurring presentations. While participants showed no brain abnormalities, 50% of the cohort had a diagnosis of FND, some had rare presentations of cognitive difficulties, and others had migraines or rare forms of headaches.
Throughout the day, attendees had the opportunity to explore a wide range of posters. The second day ended with a case discussion that brought all the topics of the day together, including neurology, psychiatry, allied health and mental health, followed by the gala dinner.
The third and final day of the conference started with a session on functional dizziness pathophysiology and treatment, and functional cognitive disorder (FCD) following mild Traumatic Brain Injury (mTBI). Prof Nadine Lehnen discussed the role of prediction errors in pathophysiology of functional dizziness, while Prof Jeffrey Stabb discussed treatment targets. Noah Silverberg discussed recent evidence on common factors observed in individuals with functional cognitive difficulties following mTBI. The findings suggested that cognitive symptoms correlate with levels of psychological distress. Those with FCD following mTBI approached cognitive tests more effortfully, were hard on themselves, were rated as anxious by the tester and differed dramatically on self-reported measures compared to those who recovered well after mTBI. The groups did not differ on metacognition tasks or accuracy of their performance.
The second session was a patient session, with speakers from different charities and a person with lived experience, by far the most powerful session of the conference. FND Action charity presented their #informthedoctor campaign, downloadable information for GPs and other health professionals. They have also questioned the use and meaning of phrases such as “illness beliefs” and “maladaptive behaviours”. Once again emphasising the importance of using plain English and user friendly language.
The CEO from FND Hope highlighted recent findings that 61% of people with FND felt traumatised as a result of the diagnosis stigma, questioning how do we break free from FND and medical trauma. She spoke about creating PEACE in clinical encounters – valuing differing perspectives, fostering equality in shared decision making, promoting shared accountability by providing clear information and consistent interaction, navigating complexity with respect and empowering individuals with FND.
Dr Katherine Gill from FND support services in Australia spoke about codesign and co-production, the phrase that resonated “Nothing about us without us”. Callum Alexander, FND Hope UK Co Deputy Chair shared his journey of FND diagnosis and recovery journey, addressing the postcode lottery in the UK, where he was able to work with a specialist physiotherapist because of where he lived. Callum also spoke about the value of making use of available support services.
The third session of the day focused on research highlights “best of FND posters”, where 12 posters were selected and the candidates completed a 5 minute talk on their poster. Before the final session, there was an opportunity to join different discussion groups, which allowed further networking and development opportunities. As a result of this, various special interest groups were formed, connecting people across the globe.
The final session covered shared concepts of aetiology and mechanisms: interoception, emotions and “why more women than men”, addressing the stigma and gender bias in FND. Followed by a closing keynote by Seamus O’Mahony and closing farewell by Michele Tinazzi and Barbara Dworetzky.
Once again, the FNDS conference brought the most up to date evidence in the field of FND, excellent networking opportunities and motivation to do better. The conference demonstrated how much growing interest and research is happening across the globe, how much knowledge we have accrued in the recent years. However, it still highlighted the remaining stigma attached to FND and other functional disorders, medical trauma and inequity in service provision. I cannot wait to see what the next few years bring in FND research and practice.
Until we meet again in Baltimore, in 2026.
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