What causes Functional Neurological Disorders (FNDs)?

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We see many Functional Neurological Disorders as being linked to changes in emotion processing. This particular view is based on our experience of seeing and treating thousands of people with functional neurological disorders of different kinds. This is a model that has been developed in Sheffield, which seems to explain the problems our patients have. We know that there are other models of FND around, but we have found them less understandable and less helpful.

It was once thought that our minds and our bodies were different systems, separate from each other. We now know that this is not the case and that the brain links together all the different aspects of our experiences – our physical sensations and functioning, our emotions, and the thoughts and memories going through our minds moment-to-moment. These components are all connected and can affect each other. So what we are seeing, hearing, smelling, tasting, touching can trigger memories and affect our emotions. Our emotions can affect our body reactions and functioning.

Normally all these components work together so that our experiences make sense. However, when different aspects of our experiences interfere with each other and don’t work together smoothly we develop functional symptoms. We call them that because it means that something is not functioning as it should.

We have found that if people are not able to recognise, accept, express and share their feelings they are more likely to develop functional symptoms.

What are emotions?

A major part of the human brain is concerned with emotions. It is sometimes thought that emotions are ‘primitive’ or in some way unimportant to human beings, but in fact humans have the most highly developed emotions of any living creature. There are very good reasons for this. Emotions are extremely important for living in complex societies, and enable us to make rapid judgments to keep ourselves safe without having to rely on the conscious reasoning, which is slower. The parts of the brain that produce emotions and allow us to recognise them are therefore highly ‘evolved’ and important.

The emotional parts of the brain monitor the messages that reach the brain from your sensory organs. They also respond to all thoughts or memories generated in the brain itself. Part of their job is to keep you safe by looking out or anything that might be risky. They communicate ‘fear to alert you to danger. When this happens you may realise that you are feeling frightened, and notice that your heart is beating harder, your breathing is more rapid and your muscles are tensed ready to run or fight. This process is largely outside your control. However, we can get disconnected from our emotions and do not realise that we are afraid we may just notice the physical responses with no accompanying emotion.

A similar thing can happen with other emotional reactions such as anger, grief or stress. You can also become disconnected from these emotions, either deliberately or automatically suppressing them in order to cope with difficult circumstances. If this state of disconnection persists it becomes part of your personality. This has some advantages – it can make you very resilient to difficulties and demands made on you. It may make you feel and appear strong and resistant to ‘stress’. This is a state of ‘emotional disconnection’.

You may then only be dimly aware of the bodily reactions to these emotions.

If you are the sort of person who is good at managing or suppressing painful feelings or stresses in your life, that does not mean you are immune to stress. If you overstretch your ability to control the symptoms of stress, you may find you get physical symptom instead of emotional ones, and you may not recognise that these have an emotional cause at all.

What is emotional processing?

The parts of the brain that deal with emotions, do not work in a straightforward way. This means that someone may have an emotional response to an experience, but if this emotion is not talked about or expressed (for example through tears or shouting), we might not be aware it is happening but have physical symptoms. If we are able to feel our emotions, we might find them very confusing, overwhelming and out of control. Learning to express our emotions and put words to our emotional experiences allows effective ‘emotional processing’.

When people have difficulties with the communication between the parts of the brain controlling emotions and the parts of the brain that makes sense of the emotions (put it into words, sharing it or expressing it), we think of it as a disorder of ‘emotion processing’. This can make someone more likely to develop Functional Neurological Disorders.

We can explain more about emotion processing (and how to change it) in psychotherapy.

Do childhood experiences affect FND?

There are many reasons why people may suppress emotions, particularly painful or negative emotions. Our patterns of dealing with emotions are laid down in childhood, as a way of responding to people and things around us as we grow up. There are lots of ways people try to cope with difficult experiences in childhood. If they are lucky, they might be able to go to their mother or father, or find a friendly aunt, uncle, grandma, neighbour, teacher who can reassure them and allow them to feel safe as they learn how to cope with the difficulties life throws at us. The patterns of managing our emotions changes and matures throughout lives.

Some people are not so lucky. They may have grown up in situations where they would be ridiculed or even punished if they showed that they were upset. It might have been that as they grew up other people around them were depending on them so that they felt they always had to be strong, and that it was weak or selfish to show their own feelings. Sometimes people learn to suppress their feelings because they would otherwise be too painful. We see some people who never cry no matter how upset they feel and others who try never to get angry or who hide sadness behind a smile.

A way to cope is to try not to think about or remember bad experiences and to find ways to cut off from them as they are actually happening. For example some children describe how they imagined that they were out in the garden playing while they were being badly treated, or that they were on the ceiling looking down on that is happening rather than actually experiencing it. That way, they don’t have to have the feelings. This is called “dissociation” and something we talk more about in a separate section. Once children have learned to dissociate, the process can become an automatic response to all sorts of challenging situations in later life. Those who dissociate a lot when they are children are much more likely to do it as adults.

Do relationships affect FND?

The way in which we relate to others around us is based on our previous experiences, especially what happened to us in childhood. These learnt relationship patterns can affect our stress levels and happiness when we are adults. For example, someone who was abandoned by one of their parents in childhood may grow up expecting that people should not be trusted, or feeling that they are not loveable. This may make it hard for them to develop a trusting relationship in later life, and they may feel the need to test the boundaries of their relationships to convince themselves they are safe. A partner or friend may see this as provocative or difficult.

Alternatively, a child with an ill or disabled parent, carer or sibling may learn that, to gain approval, they always had to put their own needs and feelings on hold. As adults they may feel unable to say “no” to the demands of their family, friends or colleagues and take time for themselves. This sort of relationship pattern can have an impact on people’s lives and make them more likely to develop FND’s.

Does trauma affect FND?

We have found that many (but not all) of the people who have been referred to us have developed problems with emotion processing after experiencing psychological trauma earlier in their lives, or deficits in nurturing which can be experienced as traumatic. Trauma is a term we use to describe events and experiences that are so frightening or shocking that it feels as if our life, bodily safety or even our sanity is threatened.

Traumas are characteristically:

  • Outside our control
  • Intolerable or unacceptable

‘Trauma’ is different to ‘stress’, in that it causes a much greater emotional reaction.

The emotional response to trauma is complicated. Often there is an initial panic or emergency stress response, where we may feel out of control, freeze or collapse. Sometimes, however, the effects of the trauma may be numbing so we do not feel the importance of the events immediately, and it is only later that we start to feel disturbed or shocked. If the trauma is long lasting we may feel that our emotional responses get distorted. Sometimes we never feel the emotional impact properly.

Whether or not we feel upset by a trauma, there are effects of trauma on our emotion processing. The conscious mind will usually try to block or ignore the emotions caused by trauma, as they are so disturbing and disruptive. If traumatic experiences happen repeatedly or at a particularly sensitive part of personal development, such as childhood, this tendency to block out emotions can become part of the victim’s personality. This helps the victim cope with the trauma at the time, and may make them appear emotionally strong and resilient to an outsider. At its most severe, traumatised people can seem emotionless and ‘hard’. The emotional suppression tends to produce a predisposition to develop physical symptoms in response to stress rather than emotional ones.

There are many experiences that can make us respond in this way, e.g. accidents, natural disasters, war, operations, being attacked, childhood abuse of various kinds. Things that happen to us in childhood are more likely to be traumatic because children are more vulnerable and dependent on their caregivers for their survival. If they experience neglect, abandonment, threatening behaviour or the death of a close family member this can also have an impact on how they have learned to deal with difficult situations later on and make them liable to develop functional symptoms in later life.

The effect of traumatic events can build up in a person. If someone has had problems when they were young which makes them feel insecure, such as conflict in the family or loss of someone very close, then they are more susceptible to the effects of trauma in their later life.

After the immediate response there are longer-term effects of trauma on our emotions. If the trauma is repeated, emotions may be down-regulated so that we feel numb and emotionless. This is a protective response to the trauma, and the effect may last for a long time, sometimes years. Gradually, however, the emotions may return. Sometimes it is as the emotions return that people start to develop FND. This may be the reason why people often find it strange that the symptoms begin sometime after the difficult life circumstances have resolved or improved.

What are trauma memories?

Memories are laid down in the brain according to their importance. Trivial things are easy to forget, but important things are very firmly written in the brain.

Memories of traumatic events are important and strongly written in the brain, but they are also different from ordinary memories in another way. Traumatic memories can be very persistent and vivid – someone may describe the memories as being as if the event happened just a few days ago even after many years have elapsed. Traumatic memories seem to be stored together with the memory of the emotions that occurred at the time of the trauma, and have a tendency to come back into the mind at the least provocation. When they do come back they are very vivid and disturbing, ‘as if they are happening now’, and accompanied by the emotional memory. They are often known as ‘flashbacks’. Flashbacks are usually very unpleasant, frightening and upsetting and can feel overwhelming. They can be so intense that people feel that the flashbacks threaten their mental health.

Some people develop the tendency to dissociate instead of experiencing flashbacks. This can be seen as an automatic, or reflex, response that protects the person against experiencing the trauma again and the bad effects that would have on their emotional wellbeing.

Many functional seizures are forms of dissociation (which is why they are sometimes referred to as dissociative attacks).

What is dissociation?

Dissociation is form of disconnection that can be a normal part of human experience. You may have thought about being somewhere else or imagined yourself reliving a previous experience when you were uncomfortable. If people are with you they may say ‘you look as if you are miles away’. This occurs when you direct your attention strongly towards something and ignore what is going on around you. This separation of your conscious thoughts from the environment is a mild form of ‘dissociation”.

This can be useful when you need to distance yourself from something stressful, like a visit to the dentist. So you might deal with all the fear that you feel when you are having a filling by imagining that you are somewhere else, more pleasant.

Another form of dissociation happens when you distract yourself with another sensation. People may, for example, play themselves music when they go for a run or scratch or cut themselves to blot out an unpleasant feeling (self-harm).

Dissociation can also be the way toavoid very intense feelings, unpleasant memories or overwhelming emotions. In such circumstance it can occur automatically, as a ‘reflex’ without you realising what is happening. This is a way the brain protects itself from things it finds unacceptable and intolerable.

The most severe dissociative attacks can come on apparently without warning. These episodes sometimes occur in response to intolerable memories or emotions, for example flashbacks of traumatic events in their lives. Instead of experiencing the flashback, which can be overwhelming, the brain automatically switches attention strongly away from the memory. Often the person can be seen to shake, and there may be other features suggesting the underlying emotional cause, such as fighting movements if the person has a memory of a physical assault. The person is often completely unaware of what is going on around them, including the memory, and consciousness is blank. Sometimes, however, they may be vaguely conscious of things going on around them. As someone recovers from a dissociative attack, they may feel exhausted and emotional, and may cry. Then things can feel strange and people can be disconcerted by their experiences.

Other forms of dissociation

  • Derealisation is when your surroundings feel strange or unreal, sounds may seem loud or distant. People often describe feeling as if they are under water or in a tunnel.
  • Depersonalisation is a feeling of unreality in your body. People may describe feeling as if they were stepping out of their body, or watching themselves from above, or feeling as if they are dissolving.
  • A dissociative fugue is when someone travels away from home, and may even be away for some hours or days, behaving apparently normally, but then subsequently have no memory of how they got there or what they have been doing.
  • Dissociative identity disorder is a severe form of dissociation in which the person seems to have a number of different identities, each with a different personality or age who ’come out’ and take control of the body at different times.

Psychotherapy can be a way of making sense of what is going on and starting to remake some of the connections that have been lost.

Why do we have panic attacks?

Many people with FNS also have panic attacks, where they suddenly feel so overwhelmed with fear that they cannot think or act normally, and may even feel that they can’t breathe. These may be a response to past trauma, but usually the panic seems to come on out of the blue and the triggers are not immediately obvious.

This can happen when the nervous system reacts to ‘reminders’ of past traumatic events. Reminders can take many forms – they can be a thought or memory, a smell, sound, song, place, body sensation or even something seen on TV. For example, some people who have been in wars start to panic when they hear a loud bang, because the bang might remind them of a time when they were being shot at.

Often, however, it is difficult to know where the feelings of panic are coming from. People may not be able to recall what the earlier event was or be thinking about it at the time. Once they have had a panic attack many people start to get anxious about the panic response because it is so unpleasant and makes them feel out-of-control. They begin to avoid doing anything that might set it off, so that they stop doing many of the normal things of everyday life, seeing friends, going to busy places even going out of the house, which makes life very difficult.


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