Treatment for FND: An Interview with Anton Scamvougeras

Part 1 of this interview can be found here.

Anton Scamvougeras, MBChB, FRCPC, is a neuropsychiatrist in the UBC Neuropsychiatry Unit at the University of British Columbia in Vancouver, British Columbia. He directs the Adult UBC Tourette's Clinic and since the mid-1990s has had a special interest in helping individuals with severe functional disorders.

MR: In your experience, what is the most effective treatment for FND?

AS: After very thorough assessment—where general medical causes for physical manifestations are thoroughly ruled out; where psychiatric and psychological factors are carefully reviewed—the understanding of the condition should be shared with the patient in a compassionate and supportive fashion. This is already the beginning of treatment.

An adequate assessment is often very time-consuming. This is a daunting challenge during times of universal resource restraint, but there is unfortunately no way of getting around this reality. We don't cut corners when it comes to a work-up for chest pain, why should it be any different for someone presenting with FND?

Almost needless to say, a good therapeutic alliance is exceptionally important. Individuals suffering FND have often gone through many frustrating steps before receiving a diagnosis. There is often anger voiced at past clinicians—and it can be useful to review that those prior steps, even the frustrating ones, may have been helpful in reaching the diagnosis. "The villain is the illness itself" is often a useful idea.

Management should be tailored for each patient. Therapy involves thoroughly understanding and treating their underlying dysphoria, and at the same time working towards the resolution of physical symptoms. The latter will often involve physical rehabilitation techniques, working with physiotherapists or occupational therapists.

Different therapies would be applied depending on the clinician's best assessment of the nature of the underlying psychological "engine." The dysphoria may be the result of a major psychiatric disorder, or an acute situational stressor, or associated with the more chronic emotional distress seen in some personality disorders. Older psychological understandings linked FND/conversion almost exclusively to childhood trauma. While that may still be the case for a subgroup of patients, many individuals with FND do not have histories of such trauma, but have symptoms driven by other forms of dysphoria.

The therapy for the dysphoria will also be shaped by the theoretical framework and skills of the treating clinician. I guide young clinicians to "treat as you would for similar dysphoria in any other setting." So exact therapy would also depend on the clinician-patient "fit"—some clinicians may favor different forms of psychotherapy, others would sooner recommend medications.

Treatment should be longitudinal and often needs to be tenacious. Goals are for complete resolution of the physical symptoms and optimal control of the underlying dysphoria. With this approach, prognosis will be similar to that for the same form of dysphoria in other settings.

MR: Thank you very much for your time, Dr. Scamvougeras. This has been an enlightening conversation. Do you think there is anything else readers should know about FND?

AS: Thank you, Mark. Your questions have been genuinely thought provoking.

I would like to add a comment about the understandable concern that some have voiced that using a psychological-engine model could result in some kind of regression to bad times. We have to acknowledge that the vast majority of people with FND/conversion were not well treated with prior approaches, in both the distant and recent past. But it seems clear to me that this was not the result of psychological models having been adopted: it was the result of the complexity of the disorders themselves, inadequate application of resources, and, most importantly, poor classification systems that blurred understanding and discouraged clinicians from engaging with this population. You cannot treat what you do not understand, and clinicians simply did not have a "handle" on these conditions.

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Agnostic approaches are not enough. For instance, a large study published just last week suggests that a "specialist physiotherapy" approach is no better than "treatment as usual," and even agnostic commentary on that study acknowledges that patients likely require the addition of psychotherapy for what the commentator prefers to call "limbic dysfunction"—a way of talking about "emotional distress" without using psychological terminology (Nielsen, 2024; Hallett, 2024).

By making use of a straightforward, flexible—"modern," if you like—psychological-engine understanding, far more clinicians will be in a position to help individuals with FND/conversion, and this will result in significantly better outcomes for far more patients. That is our central concern: getting effective treatment to as many people with FND as is feasible.

I'm particularly fond of the very old adage "truth is the daughter of time." The nature of these conditions will eventually come out, but the sooner the better.

Thanks for the conversation.

MR: Thank you.