{
  "abstract": "Background FND is often conceptualised as a condition driven by a combination of biological, psychological and social factors. 1 Over the years, a multitude of frameworks have been developed to help describe the factors that contribute to the emergence and maintenance of FND symptoms, including psychodynamic,2 cognitive-behavioural3 and attentional models,4 5 as well as more recently, biological perspectives spurred on by results from brain imaging investigations.6 Despite major advances in the field, models tend to focus on the individual patient, with the role of psychosocial circumstances, interpersonal dynamics and relational maintaining factors of FND not fully considered. Two patients with FND symptoms that were strongly associated with psychosocial vulnerabilities will be described using the Pressure Cooker Model (PCM),7 8 a new biopsychosocial and patient-friendly model that emphasizes the important role of interpersonal triggers and social functions of symptoms in maintaining FND.Participants and Methods Patient #1 (positive diagnosis of FND and emotionally unstable personality disorder and patient #2 (FND and social anxiety disorder) were admitted for a period of high-intensity multidisciplinary inpatient neurorehabilitation for severe functional motor symptoms. The PCM was used as a formulation tool, with multidisciplinary treatment targeting the maintaining factors of FND, including emotional expression around the loss of important relationships and the presence of domestic violence (‘release of the unspeakable dilemma’ 9); developing meaningful relationships, daily activities and routines; reducing social isolation using behavioural activation, mobility practice and making community-based links. Multidisciplinary treatment also addressed important physical factors associated with FND, including deconditioning, equipment use and polypharmacy.Results Following treatment, both patients regained their ability to independently walk and participate in activities of daily life and were discharged to the community without a care package. Qualitative improvements were observed in mood, emotional expression, self-confidence and psychosocial functioning. Importantly, patients gained insight into the close association between interpersonal triggers and FND symptoms. Treatment outcomes were strongly influenced by the management of both patients‘ psychosocial vulnerabilities which resulted in a resolution of FND symptoms.Conclusions Both case studies highlight the importance of exploring psychosocial vulnerabilities and interpersonal triggers as prominent mechanisms driving FND symptoms and the necessity of managing the social environment to achieve optimal outcomes in FND. The PCM can serve as a valuable model that provides a coherent multidisciplinary narrative, using simple language that ties together biological, psychological and social factors contributing to the maintenance of FND, and emphasizes the important role of the social environment.References Fobian AD, Elliott L. A review of functional neurological symptom disorder etiology and the integrated etiological summary model. Journal of Psychiatry and Neuroscience 2019;44(1):8–18.Freud S. (1895). Studies on hysteria. SE, 2.Goldstein LH, Robinson EJ, Mellers JD, Stone J, Carson A, Reuber M, Medford N, McCrone P, Murray J, Richardson MP, Pilecka I, Eastwood C, Moore M, Mosweu I, Perdue I, Landau S, Chalder T. Cognitive behavioural therapy for adults with dissociative seizures (CODES): a pragmatic, multicentre, randomised controlled trial. The Lancet Psychiatry 2020;7(6):491–505.Edwards MJ, Adams RA, Brown H, Pareés I, Friston KJ. A Bayesian account of ‘hysteria’. Brain 2012;135(11):3495–3512.Brown RJ, Reuber M. Towards an integrative theory of psychogenic non-epileptic seizures (PNES). Clinical Psychology Review 2016;47:55–70.Perez DL, Nicholson TR, Asadi-Pooya AA, Bègue I, Butler M, Carson AJ, David AS, Deeley Q, Diez I, Edwards MJ, Espay AJ, Gelauff JM, Hallett M, Horovitz SG, Jungilligens J, Kanaan RAA, Tijssen MAJ, Kozlowska K, LaFaver K, LaFrance WC, Aybek S. Neuroimaging in functional neurological disorder: state of the field and research agenda. NeuroImage: Clinical 2021;30:102623.Van der Hulst EJ. (2023). A Clinician’s Guide to Functional Neurological Disorder: A Practical Neuropsychological Approach. Routledge.Van der Hulst EJ. (2024). A Patient’s Workbook for Functional Neurological Disorder: Helping To Release the Pressure. Taylor & Francis.Griffith JL, Polles A, Griffith ME. Pseudoseizures, families, and unspeakable dilemmas. Psychosomatics 1998;39(2):144–153.",
  "authors": [
    {
      "affiliations": [
        "Principal Clinical Neuropsychologist (Barts Health NHS Trust, Rapid Access Acute Rehabilitation and Outliers service, Major Trauma Centre, Royal London Hospital, Whitechapel, London)"
      ],
      "name": "Egberdina-Józefa van der Hulst"
    }
  ],
  "title": "#8215 The role of psychosocial vulnerabilities in FND: insights from the pressure cooker model",
  "uid": "efcf3910-e008-59aa-aad9-383391027e1b"
}