Real-World CBT Improves Distress but Not Pain in Functional Neurological Disorder

Navigating the Treatment Landscape for Functional Neurological Disorder

Functional neurological disorder remains a highly disabling condition that frequently challenges clinicians due to its complex presentation and the historical scarcity of targeted treatments. In recent years, psychological interventions, particularly cognitive behavioral therapy, have emerged as a cornerstone of multidisciplinary management for these patients, with systematic reviews of 19 prospective studies demonstrating medium-sized benefits for physical symptoms, mental health, and daily functioning [1]. While controlled trials suggest that psychotherapy improves outcomes in specific subtypes like dissociative seizures [2] or functional cognitive disorder (a condition driven by abnormal focused attention, high memory expectations, and poor metacognition rather than neurodegeneration), translating these findings into routine outpatient care often proves difficult. For instance, a recent 30-patient feasibility trial of a digital intervention for functional cognitive disorder showed significant post-treatment improvements in depressive symptoms (mean change -2.96, P=0.008) and quality of life (mean change 10.06, P=0.03) [3]. Physicians frequently struggle to determine whether these specialized psychological interventions actually deliver measurable benefits in everyday clinical practice outside the rigorous constraints of a clinical trial. A new retrospective analysis now offers specific data on how patients with functional neurological disorder respond to specialist cognitive behavioral therapy in a real-world healthcare setting, directly informing outpatient referral and treatment planning.

Evaluating Real-World Outcomes in Outpatient Care

Functional neurological disorder is a common and disabling condition associated with high levels of functional impairment and psychological distress. To address these complex clinical presentations, psychological therapies such as cognitive behavioral therapy are increasingly recommended as part of multidisciplinary care. However, evidence from real-world clinical settings remains limited. To bridge this gap, researchers conducted a retrospective observational cohort study (an analysis looking back at existing patient records to identify trends and outcomes) that evaluated a specialist cognitive behavioral therapy program for adults with functional neurological disorder. By utilizing routinely collected clinical data, the investigators captured a pragmatic picture of how these psychological interventions perform during standard outpatient care, outside the strict inclusion criteria of randomized trials.

Data from 234 patients were analyzed to determine the effectiveness of this routine clinical intervention. Reflecting the typical demographic distribution seen in clinical practice for this condition, the patient cohort was 70.5 percent female with a mean age of 40.9 years. By examining this specific group of adults, the study provides clinicians with highly relevant demographic insights into the population actively receiving targeted psychological support for functional neurological symptoms, helping physicians anticipate which patients might be referred to such programs.

Tracking Psychological and Physical Metrics

To capture a comprehensive clinical picture, the researchers tracked a wide array of patient-reported outcomes. Specifically, they collected self-report measures of depression, anxiety, psychological distress, functional impairment, physical functioning, pain, and six cognitive-behavioral responses. By administering these assessments at three distinct time points (before, during, and at the end of treatment), the clinical team aimed to monitor symptom trajectories and functional changes throughout the course of the cognitive behavioral therapy program.

To rigorously evaluate how these symptoms evolved, the investigators analyzed the data using linear mixed-effects models (a statistical approach well-suited for tracking repeated measurements in the same patients over time while accounting for missing data). This analysis included a correction for multiple testing, which adjusts statistical thresholds to reduce the risk of false-positive results when evaluating numerous symptom domains simultaneously. The researchers noted a common challenge inherent to real-world retrospective studies: there was low completion of measures at follow up. Despite this limitation in post-treatment data collection, the statistical models allowed the team to maximize the utility of the available data points captured during the active treatment phase, providing a reliable estimate of patient progress.

Divergent Effects on Distress and Physical Symptoms

The analysis revealed a clear divergence in how different symptom clusters responded to the intervention. Significant improvements were observed in psychological distress across treatment, alongside significant improvements in functional impairment. Furthermore, the therapy successfully targeted the underlying mechanisms of the disorder, as significant improvements were observed in five of the six cognitive-behavioral response domains. However, the psychological benefits did not translate into direct somatic relief. The researchers noted that no significant change was seen in physical functioning measures, and similarly, no significant change was seen in pain measures. For clinicians, this indicates that while cognitive behavioral therapy effectively reduces the emotional burden and daily disability associated with functional neurological disorder, it does not directly alleviate physical pain or motor limitations.

To ensure the robustness of these outcomes, the investigators conducted sensitivity analyses excluding patients who received three or fewer sessions (a method to verify that the main findings hold true even when early dropouts are removed from the dataset). These sensitivity analyses produced a consistent pattern of results, confirming that the lack of physical symptom improvement was not simply due to inadequate treatment exposure. Ultimately, these findings suggest that specialist cognitive behavioral therapy for functional neurological disorder delivered in routine clinical practice is associated with meaningful improvements in distress, functioning, and key cognitive-behavioral maintenance processes. Because the therapy effectively mitigates the psychological and functional toll of the condition, the findings support the role of specialist cognitive behavioral therapy within multidisciplinary care, where it can be paired with physical therapy and other targeted interventions to address the full spectrum of patient symptoms.

References

1. Gutkin M, McLean L, Brown R, Kanaan RA. Systematic review of psychotherapy for adults with functional neurological disorder.. Journal of neurology, neurosurgery, and psychiatry. 2020. doi:10.1136/jnnp-2019-321926

2. Goldstein LH, Stone J, Reuber M, et al. Reflections on the CODES trial for adults with dissociative seizures: what we found and considerations for future studies.. BMJ neurology open. 2024. doi:10.1136/bmjno-2024-000659

3. Cabreira V, Frostholm L, Stone J, Carson A. Feasibility trial of a self-help digital intervention for functional cognitive disorder. Brain Communications. 2025. doi:10.1093/braincomms/fcaf248