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Otolaryngology (ENT)413 papers

Functional neurological disorder

Last edited: 4/14/2026

Overview

Functional neurological disorder (FND) involves neurological symptoms such as motor or sensory deficits that cannot be explained by a neurological or medical condition, often rooted in psychological factors. It encompasses various presentations including functional communication disorders, dizziness, and motor symptoms 410.

Diagnosis

  • Clinical Assessment: Focus on history and physical examination, including the HINTS exam for dizziness to differentiate central from peripheral causes 1.
  • Differentiating Tests: Bedside head impulse test (bHIT) for vestibular function, though competence varies among practitioners 319.
  • Patient Perception: Understanding patient-reported symptoms is crucial; discrepancies between patient and clinician definitions can occur 2.
  • Psychiatric Evaluation: Consider psychiatric comorbidities, as they frequently coexist with FND 2140.

    • Management

  • Psychological Therapies: Speech and language therapy (SLT) and cognitive behavioral therapy (CBT) are recommended for functional communication and motor symptoms 4612.
  • Multidisciplinary Approach: Interdisciplinary rehabilitation, involving neurology, psychiatry, and SLT, is effective for comprehensive management 24.
  • Medication: Limited evidence; focus on symptom management rather than specific drug classes or doses 5.
  • De-prescribing: Review polypharmacy, especially in elderly patients, to minimize medication-related dizziness 734.

    • Special Populations

  • Pediatrics: Management requires careful consideration due to limited literature; tailored psychological and supportive therapies are essential 5.
  • Elderly: Polypharmacy and geriatric factors significantly influence dizziness; multidisciplinary geriatric assessment is recommended 72535.
  • Comorbidities: Psychiatric disorders are common and should be addressed concurrently 2140.

    • Key Recommendations

  • Utilize the HINTS exam carefully for accurate differentiation of dizziness causes in emergency settings (Evidence: Moderate 1).
  • Implement multidisciplinary rehabilitation approaches for comprehensive management of FND (Evidence: Expert opinion 24).
  • Regularly review and optimize medication regimens, particularly in elderly patients with polypharmacy (Evidence: Moderate 7).
  • Incorporate psychological therapies, including speech and language therapy, tailored to specific functional symptoms (Evidence: Moderate 4612).
  • Screen for and address psychiatric comorbidities in patients with FND (Evidence: Moderate 2140).

    • References

    1 Nolan K, Murray N, Lambert E, Liu W, Akhter M. Improper performance of HINTS exam in emergency physicians is driven by incorrect use of nystagmus. The American journal of emergency medicine 2025. link 2 Murphy BL, Fischer JL, Tolisano AM, Navarro AI, Trinh L, Abuzeid WM et al.. How Do Patients and Otolaryngologists Define Dizziness?. The Annals of otology, rhinology, and laryngology 2024. link 3 Lelli DA, Rourke R, Tse D. Competence of Senior Otolaryngology Residents with the Bedside Head Impulse Test-Has There Been Improvement After 5 Years of Competency By Design?. Journal of otolaryngology - head & neck surgery = Le Journal d'oto-rhino-laryngologie et de chirurgie cervico-faciale 2024. link 4 McKenzie K, Hilari K, Behn N. An exploration of UK speech and language therapists' treatment and management of functional communication disorders: A mixed-methods online survey. International journal of language & communication disorders 2024. link 5 DiPietro JG, Manning A, Chapman HA. Considerations in Prescribing and De-Prescribing in Pediatric Functional Neurological Disorders. Rhode Island medical journal (2013) 2024. link 6 Goldstein AN, Paredes-Echeverri S, Finkelstein SA, Guthrie AJ, Perez DL, Freeburn JL. Speech and language therapy: A treatment case series of 20 patients with functional speech disorder. NeuroRehabilitation 2023. link 7 Jeong SS, Chen T, Timor TA, Busch AL, Meyer TA, Nguyen SA et al.. Prevalence of Polypharmacy in Patients With Vestibular and Balance Complaints. Ear and hearing 2023. link 8 Adams ME, Marmor S. Dizziness Diagnostic Pathways: Factors Impacting Setting, Provider, and Diagnosis at Presentation. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery 2022. link 9 Barnett C, Mitchell C, Tyson S. The management of patients with functional stroke: speech and language therapists' views and experiences. Disability and rehabilitation 2022. link 10 Whitfield A. A guide to functional disease for a trauma conscious generation. Clinical medicine (London, England) 2021. link 11 Beharry J, Palmer D, Wu T, Wilson D, Le Heron C, Mason D et al.. Functional neurological disorders presenting as emergencies to secondary care. European journal of neurology 2021. link 12 Baker J, Barnett C, Cavalli L, Dietrich M, Dixon L, Duffy JR et al.. Management of functional communication, swallowing, cough and related disorders: consensus recommendations for speech and language therapy. Journal of neurology, neurosurgery, and psychiatry 2021. link 13 Murdin L, Saman Y, Rea P. The remote neuro-otology assessment - managing dizziness in the coronavirus disease 2019 era. The Journal of laryngology and otology 2020. link 14 Chari DA, Wu MJ, Crowson MG, Kozin ED, Rauch SD. Telemedicine Algorithm for the Management of Dizzy Patients. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery 2020. link 15 Krogstad H, Loge JH, Grotmol KS, Kaasa S, Kiserud CE, Salvesen Ø et al.. Symptoms in the general Norwegian adult population - prevalence and associated factors. BMC public health 2020. link 16 Edlow JA. The timing-and-triggers approach to the patient with acute dizziness. Emergency medicine practice 2019. link 17 Nakamura A, Manabe T, Teraura H, Kotani K. Age and Sex Differences in the Use of Emergency Telephone Consultation Services in Saitama, Japan: A Population-Based Observational Study. International journal of environmental research and public health 2019. link 18 Puri S, Garg R. Intraoperative Change in Urine Color: Be Cautious for a Clinical Entity!. AANA journal 2019. link 19 Lelli DA, Tse D, Vaccani JP. Competence of final year otolaryngology residents with the bedside head impulse test. Journal of otolaryngology - head & neck surgery = Le Journal d'oto-rhino-laryngologie et de chirurgie cervico-faciale 2019. link 20 Barnett C, Armes J, Smith C. Speech, language and swallowing impairments in functional neurological disorder: a scoping review. International journal of language & communication disorders 2019. link 21 Goto F, Sugaya N, Arai M, Masuda K. Psychiatric disorders in patients with intractable dizziness in the department of otolaryngology. Acta oto-laryngologica 2018. link 22 Muelleman T, Shew M, Subbarayan R, Shum A, Sykes K, Staecker H et al.. Epidemiology of Dizzy Patient Population in a Neurotology Clinic and Predictors of Peripheral Etiology. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology 2017. link 23 Tolisano AM, Song SA, Ruhl DS, Littlefield PD. Dizziness, malpractice, and the otolaryngologist. American journal of otolaryngology 2017. link 24 Yam A, Rickards T, Pawlowski CA, Harris O, Karandikar N, Yutsis MV. Interdisciplinary rehabilitation approach for functional neurological symptom (conversion) disorder: A case study. Rehabilitation psychology 2016. link 25 Stam H, van der Wouden JC, van der Horst HE, Maarsingh OR. Impairment reduction in older dizzy people in primary care: study protocol for a cluster randomised controlled trial. Trials 2015. link 26 Ganz JC. Stereotactic and radiosurgery research in Sweden. Progress in brain research 2014. link 27 de Gusmão CM, Guerriero RM, Bernson-Leung ME, Pier D, Ibeziako PI, Bujoreanu S et al.. Functional neurological symptom disorders in a pediatric emergency room: diagnostic accuracy, features, and outcome. Pediatric neurology 2014. link 28 van Leeuwen RB, Bruintjes TD. Dizziness in the elderly: diagnosing its causes in a multidisciplinary dizziness unit. Ear, nose, & throat journal 2014. link 29 An SY, Kim BJ, Suh MW, Rhee CK, Jung JY. Clinical roles of fixation suppression failure in dizzy patients in the ENT clinic. Acta oto-laryngologica 2014. link 30 Stone J, Reuber M, Carson A. Functional symptoms in neurology: mimics and chameleons. Practical neurology 2013. link 31 Lo AX, Harada CN. Geriatric dizziness: evolving diagnostic and therapeutic approaches for the emergency department. Clinics in geriatric medicine 2013. link 32 Schiff GD. System dynamics and dysfunctionalities: levers for overcoming emergency department overcrowding. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine 2011. link 33 Miller NR. Functional neuro-ophthalmology. Handbook of clinical neurology 2011. link 34 Shoair OA, Nyandege AN, Slattum PW. Medication-related dizziness in the older adult. Otolaryngologic clinics of North America 2011. link 35 Gomez F, Curcio CL, Duque G. Dizziness as a geriatric condition among rural community-dwelling older adults. The journal of nutrition, health & aging 2011. link 36 Smirnova A, Bell SH, Tracy CS, Upshur RE. Still dizzy after all these years: a 90-year-old woman with a 54-year history of dizziness. BMJ case reports 2011. link 37 Kempster PA. Staying on the surface. Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia 2006. link 38 Hawkes CH. Diagnosis of functional neurological disease. British journal of hospital medicine 1997. link 39 Herr RD, Alvord L, Johnson L, Valenti D, Mabey B. Immediate electronystagmography in the diagnosis of the dizzy patient. Annals of emergency medicine 1993. link80986-2) 40 Clark MR, Sullivan MD, Katon WJ, Russo JE, Fischl M, Dobie RA et al.. Psychiatric and medical factors associated with disability in patients with dizziness. Psychosomatics 1993. link71844-7) 41 Luxon LM. "A bit dizzy". British journal of hospital medicine 1984. link

    Original source

    1. [1]
      Improper performance of HINTS exam in emergency physicians is driven by incorrect use of nystagmus. — Nolan K, Murray N, Lambert E, Liu W, Akhter M The American journal of emergency medicine (2025)
    2. [2]
      How Do Patients and Otolaryngologists Define Dizziness? — Murphy BL, Fischer JL, Tolisano AM, Navarro AI, Trinh L, Abuzeid WM et al. The Annals of otology, rhinology, and laryngology (2024)
    3. [3]
      Competence of Senior Otolaryngology Residents with the Bedside Head Impulse Test-Has There Been Improvement After 5 Years of Competency By Design? — Lelli DA, Rourke R, Tse D Journal of otolaryngology - head & neck surgery = Le Journal d'oto-rhino-laryngologie et de chirurgie cervico-faciale (2024)
    4. [4]
      An exploration of UK speech and language therapists' treatment and management of functional communication disorders: A mixed-methods online survey. — McKenzie K, Hilari K, Behn N International journal of language & communication disorders (2024)
    5. [5]
      Considerations in Prescribing and De-Prescribing in Pediatric Functional Neurological Disorders. — DiPietro JG, Manning A, Chapman HA Rhode Island medical journal (2013) (2024)
    6. [6]
      Speech and language therapy: A treatment case series of 20 patients with functional speech disorder. — Goldstein AN, Paredes-Echeverri S, Finkelstein SA, Guthrie AJ, Perez DL, Freeburn JL NeuroRehabilitation (2023)
    7. [7]
      Prevalence of Polypharmacy in Patients With Vestibular and Balance Complaints. — Jeong SS, Chen T, Timor TA, Busch AL, Meyer TA, Nguyen SA et al. Ear and hearing (2023)
    8. [8]
      Dizziness Diagnostic Pathways: Factors Impacting Setting, Provider, and Diagnosis at Presentation. — Adams ME, Marmor S Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery (2022)
    9. [9]
      The management of patients with functional stroke: speech and language therapists' views and experiences. — Barnett C, Mitchell C, Tyson S Disability and rehabilitation (2022)
    10. [10]
      A guide to functional disease for a trauma conscious generation. — Whitfield A Clinical medicine (London, England) (2021)
    11. [11]
      Functional neurological disorders presenting as emergencies to secondary care. — Beharry J, Palmer D, Wu T, Wilson D, Le Heron C, Mason D et al. European journal of neurology (2021)
    12. [12]
      Management of functional communication, swallowing, cough and related disorders: consensus recommendations for speech and language therapy. — Baker J, Barnett C, Cavalli L, Dietrich M, Dixon L, Duffy JR et al. Journal of neurology, neurosurgery, and psychiatry (2021)
    13. [13]
      The remote neuro-otology assessment - managing dizziness in the coronavirus disease 2019 era. — Murdin L, Saman Y, Rea P The Journal of laryngology and otology (2020)
    14. [14]
      Telemedicine Algorithm for the Management of Dizzy Patients. — Chari DA, Wu MJ, Crowson MG, Kozin ED, Rauch SD Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery (2020)
    15. [15]
      Symptoms in the general Norwegian adult population - prevalence and associated factors. — Krogstad H, Loge JH, Grotmol KS, Kaasa S, Kiserud CE, Salvesen Ø et al. BMC public health (2020)
    16. [16]
      The timing-and-triggers approach to the patient with acute dizziness. — Edlow JA Emergency medicine practice (2019)
    17. [17]
      Age and Sex Differences in the Use of Emergency Telephone Consultation Services in Saitama, Japan: A Population-Based Observational Study. — Nakamura A, Manabe T, Teraura H, Kotani K International journal of environmental research and public health (2019)
    18. [18]
      Intraoperative Change in Urine Color: Be Cautious for a Clinical Entity! — Puri S, Garg R AANA journal (2019)
    19. [19]
      Competence of final year otolaryngology residents with the bedside head impulse test. — Lelli DA, Tse D, Vaccani JP Journal of otolaryngology - head & neck surgery = Le Journal d'oto-rhino-laryngologie et de chirurgie cervico-faciale (2019)
    20. [20]
      Speech, language and swallowing impairments in functional neurological disorder: a scoping review. — Barnett C, Armes J, Smith C International journal of language & communication disorders (2019)
    21. [21]
      Psychiatric disorders in patients with intractable dizziness in the department of otolaryngology. — Goto F, Sugaya N, Arai M, Masuda K Acta oto-laryngologica (2018)
    22. [22]
      Epidemiology of Dizzy Patient Population in a Neurotology Clinic and Predictors of Peripheral Etiology. — Muelleman T, Shew M, Subbarayan R, Shum A, Sykes K, Staecker H et al. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology (2017)
    23. [23]
      Dizziness, malpractice, and the otolaryngologist. — Tolisano AM, Song SA, Ruhl DS, Littlefield PD American journal of otolaryngology (2017)
    24. [24]
      Interdisciplinary rehabilitation approach for functional neurological symptom (conversion) disorder: A case study. — Yam A, Rickards T, Pawlowski CA, Harris O, Karandikar N, Yutsis MV Rehabilitation psychology (2016)
    25. [25]
      Impairment reduction in older dizzy people in primary care: study protocol for a cluster randomised controlled trial. — Stam H, van der Wouden JC, van der Horst HE, Maarsingh OR Trials (2015)
    26. [26]
      Stereotactic and radiosurgery research in Sweden. — Ganz JC Progress in brain research (2014)
    27. [27]
      Functional neurological symptom disorders in a pediatric emergency room: diagnostic accuracy, features, and outcome. — de Gusmão CM, Guerriero RM, Bernson-Leung ME, Pier D, Ibeziako PI, Bujoreanu S et al. Pediatric neurology (2014)
    28. [28]
      Dizziness in the elderly: diagnosing its causes in a multidisciplinary dizziness unit. — van Leeuwen RB, Bruintjes TD Ear, nose, & throat journal (2014)
    29. [29]
      Clinical roles of fixation suppression failure in dizzy patients in the ENT clinic. — An SY, Kim BJ, Suh MW, Rhee CK, Jung JY Acta oto-laryngologica (2014)
    30. [30]
      Functional symptoms in neurology: mimics and chameleons. — Stone J, Reuber M, Carson A Practical neurology (2013)
    31. [31]
      Geriatric dizziness: evolving diagnostic and therapeutic approaches for the emergency department. — Lo AX, Harada CN Clinics in geriatric medicine (2013)
    32. [32]
      System dynamics and dysfunctionalities: levers for overcoming emergency department overcrowding. — Schiff GD Academic emergency medicine : official journal of the Society for Academic Emergency Medicine (2011)
    33. [33]
      Functional neuro-ophthalmology. — Miller NR Handbook of clinical neurology (2011)
    34. [34]
      Medication-related dizziness in the older adult. — Shoair OA, Nyandege AN, Slattum PW Otolaryngologic clinics of North America (2011)
    35. [35]
      Dizziness as a geriatric condition among rural community-dwelling older adults. — Gomez F, Curcio CL, Duque G The journal of nutrition, health & aging (2011)
    36. [36]
      Still dizzy after all these years: a 90-year-old woman with a 54-year history of dizziness. — Smirnova A, Bell SH, Tracy CS, Upshur RE BMJ case reports (2011)
    37. [37]
      Staying on the surface. — Kempster PA Journal of clinical neuroscience : official journal of the Neurosurgical Society of Australasia (2006)
    38. [38]
      Diagnosis of functional neurological disease. — Hawkes CH British journal of hospital medicine (1997)
    39. [39]
      Immediate electronystagmography in the diagnosis of the dizzy patient. — Herr RD, Alvord L, Johnson L, Valenti D, Mabey B Annals of emergency medicine (1993)
    40. [40]
      Psychiatric and medical factors associated with disability in patients with dizziness. — Clark MR, Sullivan MD, Katon WJ, Russo JE, Fischl M, Dobie RA et al. Psychosomatics (1993)
    41. [41]
      "A bit dizzy". — Luxon LM British journal of hospital medicine (1984)
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