In their 2026 article “Approach to the Patient with FND: Evaluation, Diagnosis, and Developing a Treatment Plan,” published in Seminars in Neurology, Michael Daniel DeDominicis and Sarah Lidstone propose reframing functional neurological disorder (FND) as a brain network disorder involving altered predictive processing, attention, and sense of agency. They argue that moving away from older “psychogenic” or “conversion” labels is essential because some patients and clinicians find these terms stigmatizing or dismissive (i.e., “it’s all in your head”).
The authors explicitly propose downplaying or omitting psychiatric etiologies, comorbidities, or mechanisms in the diagnosis and explanation, presenting FND as a legitimate brain disorder on par with other (“more respectable” my words) neurological conditions.
I see several problems with this publication, one of which is that the authors are mixing apples and oranges through a forced inclusion PNES into the FND category. Although the article attempts to address differences between the two in a section on episodic symptoms and another on continuous symptoms, this distinction remains inadequate. PNES differs markedly from other FND presentations not just in its episodic nature, but also due to its significant psychiatric comorbidities, and especially, its evidence-based psychotherapeutic treatments.
Why PNES is problematic for the FND movement
Empirically-based trials show that the most effective treatments for PNES are tailored psychotherapies. Meta-analyses indicate that tailored psychological interventions lead to seizure freedom in approximately 47% of completers and at least a 50% reduction in seizures for around 82% (Carlson & Perry, 2017). Randomized controlled trials have provided evidence that specific approaches such as cognitive behavioral therapy (LaFrance et al, 2014) and, more recently, prolonged exposure therapy for patients with trauma histories are effective in treating PNES (Myers, et al, 2026). Mindfulness-based therapies have also shown promise (Baslet et al, 2020).
Yet the article confidently states “It has become clear that a solely psychiatric lens for approaching FND is insufficient” and urges “Care must be taken to avoid the problematic and stigmatizing tendency to ascribe any psychological symptoms or previous diagnoses as being etiological,” warning that this can be “problematic and stigmatizing.”
Clearly, these statements create a logical tension: if psychiatric concepts are minimized or completely excluded in the explanation to the patient when presenting the diagnosis, how does one coherently justify referring patients for psychotherapy?
Other illogical arguments
The authors further attempt to justify their questionable logic by noting similarly high psychiatric comorbidity rates in FND (51–95%), and in epilepsy or Parkinson’s disease (44–77%). While the numbers may be similar, treatment implications do not necessarily follow. We do not treat epilepsy or Parkinson’s primarily with psychotherapy; conversely, no robust evidence supports treating PNES with resective brain surgery or deep brain stimulation. Furthermore, no research shows that physiotherapy or occupational therapy should be considered as first-line interventions even though they appear helpful for functional motor disorders. Again, apples and oranges.
The authors appear to endorse the view that minimizing the “psych” component of FND represents a progressive, destigmatizing approach. However, this position risk becoming self-righteous posturing and with a dangerous potential if the true ramifications of this viewpoint are not carefully considered. I fear that instead of genuinely helping the patients they aim to serve, they are creating a convoluted and confusing pathway for those very patients who are very much at risk of not reaching the actual treatments that would allow them to recover.
Key Problems with this Approach
- Conceptual Incoherence: You cannot fully “neurologize” a condition whose best-supported interventions rely on psychological mechanisms without acknowledging the mind-brain interface. Downplaying the “psych” element may provide a more pleasant initial conversation with patients, but it risks leaving them with an incomplete or evasive model of their condition and murky treatment recommendations.
- Practical Risks to Patient Care: Neurologists delivering the diagnosis in non-psychiatric terms may unintentionally steer patients away from psychiatry or psychology referrals. Patients told “this is a brain network problem” may later resist or delay psychotherapy when they discover that effective treatment involves weekly sessions addressing thoughts, emotions, and trauma.
- Stigma Trade-Off: Replacing “psychogenic” with “functional” aims to reduce stigma by emphasizing brain-based legitimacy. However, overly sanitizing the explanation can backfire. Patients who recognize psychological contributors in their own lives may feel gaslit, and those who need psychotherapy may struggle to accept it if the framing avoids any indication of psychogenesis.
- Selective Framing: The article draws on neuroscience to legitimize FND while recommending psychotherapy specifically for PNES. The selective framing of the entire FND category in largely non-psychiatric terms while de-emphasizing psychological factors is inconsistent. In the end, the authors use brain network models for credibility, but then fall back on psychological treatments for actual management when it comes to nonepileptic seizures. In colloquial parlance: Make it make sense!
In Conclusion
While destigmatization of all psychiatric conditions is worthwhile, simply changing names of diagnostic terms and sweeping etiological factors under the rug to avoid offending a patient, is necessarily going to fall short. We need honesty about differences within FND and to be ready to recognize that the similarities between PNES and FND are less profound than originally thought. Lastly, the professional field needs to stop to thoughtfully analyze whether this push to “De-Psychiatrize” FND is actually beneficial to patients or if it risks steering the field down a disadvantageous pathway.
DeDominicis & Lidstone (2026) Approach to the Patient with FND: Evaluation, Diagnosis, and Developing a Treatment Plan, Semin Neurol, DOI: 10.1055/a-2835-0301
Carlson & Perry, Psychological interventions for psychogenic non-epileptic seizures: A meta-analysis, Seizure, Volume 45, 2017, Pages 142-150, ISSN 1059-1311, https://doi.org/10.1016/j.seizure.2016.12.007
LaFrance WC Jr, Baird GL, Barry JJ, Blum AS, Frank Webb A, Keitner GI, Machan JT, Miller I, Szaflarski JP; NES Treatment Trial (NEST-T) Consortium. Multicenter pilot treatment trial for psychogenic nonepileptic seizures: a randomized clinical trial. JAMA Psychiatry. 2014 Sep;71(9):997-1005. doi: 10.1001/jamapsychiatry.2014.817. PMID: 24989152.
Myers, Vaidya-Mathur, Zeng, Hammer, Lancman, A pilot randomized controlled trial of prolonged exposure therapy vs. psychoeducation for psychogenic nonepileptic seizures and comorbid post-traumatic stress disorder, Epilepsy & Behavior, Volume 180, 2026, 111019, ISSN 1525-5050, https://doi.org/10.1016/j.yebeh.2026.111019. (https://www.sciencedirect.com/science/articl
Baslet G, Ehlert A, Oser M, Dworetzky BA. Mindfulness-based therapy for psychogenic nonepileptic seizures. Epilepsy Behav. 2020 Feb;103(Pt A):106534. doi: 10.1016/j.yebeh.2019.106534. Epub 2019 Oct 31. PMID: 31680023.