Sensory Processing Difficulties in Patients

with Functional Neurological Disorder:

Occupational Therapy Management Strategies
and Two Cases
Julie MacLean,*,†,1 Sara A. Finkelstein,†,1 Sara Paredes-Echeverri,†,1 David L. Perez,†,z,2 and
Jessica Ranford*,†,2

Functional neurological disorder (FND) is a condition at the intersection of neurology and

psychiatry, with some patients experiencing sensory hypersensitivities and other sensory
processing difficulties. It has been postulated that poor integration and modulation of sen-
sory information with cognitive, affective and behavioral processes may play a role in the
pathophysiology of FND. In this article, we first succinctly review the role for occupational
therapy (OT) in the multidisciplinary therapeutic approach to managing patients with FND.
After highlighting previously published data identifying sensory processing difficulties in
patients with FND, we subsequently outline the components of the sensory-based outpa-
tient OT program for FND at the Massachusetts General Hospital. Here, we detail how
occupational therapists assess and treat sensory modulation difficulties with the aid of
resources like the Adolescent/Adult Sensory Profile (AASP), The Canadian Occupational
Performance Measure (COPM), and the Sensory-Motor Preference Checklist. We then
report on 2 clinical cases representative of the sensory modulation difficulties endorsed by
some patients with FND, illustrating how developing an individualized, sensory-based treat-
ment plan can help improve functional neurological symptoms and overall participation in
activities of daily living. Prospective, controlled research is needed to further operationalize
OT-based sensory modulation interventions, as well as define the tolerability and efficacy
of this intervention for pediatric and adult populations with FND.
Semin Pediatr Neurol 41:100951 © 2022 Elsevier Inc. All rights reserved.

Introduction

F unctional neurological disorder (FND) reflects a problem

of brain networks leading to neurological symptoms -
such as abnormal movements, seizure-like episodes and
From the *Department of Occupational Therapy, Massachusetts General
Hospital, Harvard Medical School, Boston, MA. speech difficulties - that are incongruent with other condi-
y
Division of Cognitive Behavioral Neurology, Department of Neurology, tions and have specific positive signs on examination.1-4
Functional Neurological Disorder Unit, Massachusetts General Hospital, While previously considered a purely psychological disorder,
Harvard Medical School Boston, MA. experts now formulate this condition as sitting at the inter-
z
Division of Neuropsychiatry, Department of Psychiatry, Massachusetts
General Hospital, Harvard Medical School, Boston, MA.
section of neurology and psychiatry, with biological, psycho-
Disclosures: D.L.P. has received honoraria for continuing medical education logical and sociocultural factors contributing to symptom
lectures on functional neurological disorder and is on the editorial board generation and maintenance.5,6 Although a preceding psy-
of Epilepsy & Behavior. chological stressor is not necessary for diagnosis, many
Address reprint requests to: Jessica Ranford, Massachusetts General Hospital, patients with FND have co-morbid mental health symptoms
55 Fruit Street, Boston, MA 02114. E-mail: jranford@partners.org
1
co-first authors.
such as anxiety or depression, as well as other bodily symp-
2
co-senior authors. toms such as pain and fatigue.7,8 FND symptoms are

https://doi.org/10.1016/j.spen.2022.100951 1
1071-9091/11/© 2022 Elsevier Inc. All rights reserved.
2 J. MacLean et al.
theorized to be at least partially driven by involuntarily
increased bodily attention, evidenced by symptoms decreas-
ing or resolving with distraction.9 Hypersensitivity to a range
of sensory inputs (e.g., bright lights, loud noises, etc.) may
also be present, with a subset of patients with FND endorsing
difficulties modulating their responses to sensory experiences
more broadly.10,11 It has been postulated that poor integra-
tion and modulation of sensory information with cognitive,
affective and behavioral processes may play a role in the
pathophysiology of FND.10 This is in line with other research
demonstrating a link between sensory processing difficulties
and psychiatric conditions such as anxiety and post-trau-
matic stress disorder (PTSD).12,13
Occupational Therapy and Sensory
Processing
A range of multidisciplinary (rehabilitative and psychological)
treatments are being identified for the treatment of FND,
including physical therapy (PT), occupational therapy (OT),
speech and language therapy (SLT), and
psychotherapy.3,9,14,15 Within this growing therapeutic tool-
kit, occupational therapists are well-positioned to effectively
combine physical and psychological interventions in the care
of patients with FND. The authors of studies in FND examin-
ing the utility of OT have shown that inpatient or outpatient
multidisciplinary therapy with an OT component is effective
in treating FND.16-25 A number of these authors documented
patients reporting sustained improvement at long-term fol-
low-up ranging from 2 to 36 months.16,17,20,22,24 Likewise,
the authors of studies conducted in pediatric populations with
a functional gait disorder have demonstrated similar effective-
ness of OT as part of a multidisciplinary approach.26,27
OT consensus recommendations have been published,
outlining interventions for the management of FND based on
expert opinion.9 Per these recommendations, occupational
therapists are encouraged to focus on patient education, goal
setting, teaching self-regulation, and promoting positive
health behaviors among other goals. These principles are
then applied to symptom-specific treatments. For example,
in a patient with functional motor symptoms, occupational
therapists help with movement retraining by practicing tasks
that promote normal movement and increasing task difficulty
over time; practical support for pain and fatigue management
through instruction on self-regulation strategies and pacing
can also be provided concurrently. Importantly, OT consen-
sus recommendations highlight emerging strategies for quan-
tifying and managing sensory processing difficulties, as these
factors can perpetuate symptoms and alter the pace of
treatments.9,10 Sensory processing profiles have previously
been used to inform clinical assessments in a variety of neu-
ropsychiatric settings and populations,12,28-30 including in
patients with FND.11 Given that a subset of patients with
FND have sensory processing difficulties, detailing an indi-
vidual’s sensory profile to characterize how an individual
processes and physically / affectively responds to sensory
stimuli can be relevant to OT goal setting and treatment
planning.11 Working on sensory modulation, the neurologi-
cal ability of the central nervous system to process, regulate,
and respond to sensory stimuli, can likely complement the
multidisciplinary treatment approach to FND.10
There are several tools that can be used to measure sensory
processing styles and their impact on behavior (see DuBois
et al. for a review on this topic31). The Adolescent/Adult Sen-
sory Profile (AASP) is a well-known measure used for ages 11
through 65 + to characterize the effect of sensory processing
on performance of activities, and has been used in a variety of
neuropsychiatric conditions including anxiety disorders,13
PTSD12 and FND.11 In this 60-item self-report questionnaire,
participants indicate the frequency of their behavioral
responses towards everyday sensory experiences. Scores are
translated into a patient-specific sensory profile based on the 4
Quadrant Model proposed by Winnie Dunn.32 According to
this model, sensory processing patterns can be categorized
based on 2 qualities: neurological threshold and behavioral
response. Neurological threshold refers to the amount of stimu-
lation required to generate a neuronal response: a person with
a low neurological threshold is easily activated or highly aware
of stimuli, while a person with a high threshold is less easily
activated and may be unaware of stimuli that others detect.
Behavioral response refers to the way in which a person reacts
to a stimulus, either passively or actively, in relation to their
neurological threshold: a passive response does not take action
to change a sensory experience, whereas an active response
would seek to control the experience (e.g., active avoidance).
Plotting these 2 qualities in a 2 by 2 table, the 4 quadrants
depict the following sensory tendencies: low registration, sen-
sation seeking, sensory sensitivity, and sensation avoiding (see
Fig. 1).32,33
The AASP identifies an individual’s sensory processing pat-
terns across each of the 4 quadrants and compares it to nor-
mative data stratified by age range. Scores in the 4 quadrants
are not mutually exclusive as people generally do not have
only one stereotyped sensory processing pattern, since these
can be influenced by a variety of factors (e.g., emotional state,
arousal, and type of stimuli, etc.). There is also a growing
body of evidence to suggest a relationship between affect and
sensory processing patterns.34 In comparing the sensory
processing patterns of 44 consecutive patients with FND to
normative data, 70%, 65% and 68% of individuals reported
elevated low registration, sensation seeking and sensation
avoiding scores, respectively (see Fig. 2). Furthermore, initial
univariate findings suggested that patients with functional
seizures showed higher low registration and sensation avoid-
ing scores compared to individuals with other functional
motor symptoms.11 Anecdotally, we have also encountered
that patients with FND in a heightened arousal state can
seemingly lower their neurological threshold for a behavioral
response to stimuli (e.g., being hypersensitive to loud or
unexpected sounds that subsequently trigger or amplify
functional neurological symptoms), leading to sensory avoid-
ance behaviors.
The sensory-based outpatient OT program for FND at the
Massachusetts General Hospital is rooted in the sensory
Sensory Processing Difficulties 3

Figure 1 Four quadrant sensory profile model. Based on the neurological threshold and behavioral response qualities,
the predominant sensory profile of a person can be mapped onto any of the four described categories.32 (Color version
of figure is available online.)

integration frame of reference, utilizing a combination of
practice guidelines published by the American Occupational
Therapy Association, the FND-specific OT consensus recom-
mendations, and sensory-based OT approaches in mental
health practice more broadly.9,35-39 An initial evaluation of a
patient with FND referred to our OT program includes
obtaining a sensory history, assessing motor performance,
identifying cognitive complaints, and determining changes in
performance of everyday activities. The semi-structured
interview aims to identify sensory sensitivities to specific
stimuli, sensory avoiding and/or sensory seeking behaviors,
positive and maladaptive coping strategies, warning signs
and triggers of FND symptoms, and symptom management
strategies. An over-arching principle is that awareness of
one’s unique sensory tendencies and preferences helps an
individual to more adaptively self-regulate and better engage
in meaningful activities. The AASP is used in the first session
to characterize a patient’s sensory processing patterns during

Figure 2 Characterization of sensory processing patterns in functional neurological disorder (FND). Compared to nor-
mative data, patients with FND generally follow a common pattern with high scores in low registration, sensory sensi-
tivity, sensation avoiding and low scores in sensation seeking. Replicated with permission from Ranford et al.11 (Color
version of figure is available online.)
4 J. MacLean et al.

everyday activities at home, work and the community. The
Canadian Occupational Performance Measure (COPM),40,41
an evidence-based outcome measure that captures a patient’s
self-perception of performance in everyday activities, is used
to identify and prioritize problems and track progress over-
time (e.g., dropping items related to functional tremors
impacting ability to cut food, button coat, etc.). A 10-point
Likert scale is then used by the patient to rate performance
and satisfaction: 1 = not able to do at all/not satisfied at all,
10 = able to do extremely well/extremely satisfied.40,41 From
our experience, use of the COPM with patients with FND
has helped identify improvement in daily activities for some
patients, even when improvement in FND symptoms is not
endorsed. When goal setting, problems identified during
administration of the COPM are utilized, as well as the 4
overarching goals of the Sensory Modulation Program (SMP)
as outlined below (see also Table 1).35
Information obtained from the sensory history and AASP
inform selection of specific, sensory-based treatment inter-
ventions to promote more adaptive behaviors. Goal setting is
individualized across sessions and is often an iterative pro-
cess, as patients may need to revisit previously achieved goals
periodically throughout treatment. The length of treatment
for patients in our short-term program is individualized,
depending on how well they move through the goals of the
SMP, ranging from 1-6 months and encouraging one treat-
ment session per week. Patient progress is routinely assessed
at 30-day intervals.
After the initial assessment, the first goal is to facilitate self-
awareness of sensory difficulties by reviewing AASP results
and explaining how behavioral responses are related to
sensory processing. The occupational therapist provides the
patient with a Sensory-Motor Preference Checklist42 that lists
numerous activities that engage each sensory system, such as
using a fidget ball, smelling essential oils, use of a weighted
blanket, or engaging in exercise or mindfulness activities.
The patient identifies activities that are calming, alerting, irri-
tating, or a combination to further enhance understanding of
their own preferences and tendencies. Coupled with this,
occupational therapists provide education on arousal states,
framed as existing on a continuum from low (e.g., lethargic)
to high (e.g., agitated), and how it can fluctuate throughout
the day and be influenced by sensory input.38
The second goal of the SMP is to explore self-regulation
strategies by trialing different sensory modalities and sensori-
motor experiences to achieve a “just right” level of arousal,
where one’s arousal state is appropriate for the task at hand.
The patient is asked to trial specific activities that were identi-
fied through the Sensory-Motor Preference Checklist and
reflect on how they influence their arousal. The aim is to
partner with the patient to develop a “sensory diet” of regu-
larly scheduled activities that provide the appropriate sensory
input required for them to manage FND symptoms and par-
ticipate in daily activities. A sensory diet includes use of regu-
larly scheduled sensory experiences and behaviors (“meals”),
as needed sensory experiences and activities (“snacks”), envi-
ronmental supports, quiet places and leisure activities to help
promote better functioning.35 The occupational therapist
provides training to assist patients in determining what sen-
sory tools are useful in managing extreme (unhelpful)
responses in different settings, such as when FND symptoms
are present or the patient is experiencing a warning sign or

Table 1 Core Principles and Treatment Strategies of the Sensory Modulation Program (SMP) in Patients with a Functional
Neurological Disorder
Core Principles Assessment/Treatment Strategies

Goal #1: Facilitate self-awareness of sensory  Adolescent/Adult Sensory Profile

processing difficulties
Goal #2: Explore self-regulation strategies by
trialing different sensory modalities and
sensorimotor experiences
Goal #3: Expand and refine self-regulation
skills by implementing their sensory diet
within home and community environments
Goal #4: Repertoire expansion/skill
enhancement
Based on each of the SMP treatment goals, specific occupational therapy strategies and tools can be leveraged to promote more adaptive sen-
sory modulation.
 Sensory-Motor Preference Checklist
 Education on individual sensory profile and self-regulation.
Sensory diet is a personalized, balanced and paced schedule of sensory-based
activities. The ‘diet’ aims to achieve a ‘just right’ level of arousal, where one’s
arousal state is appropriate for the task at hand.
 Sensory diet strategies include:
 Sensory meals: Regularly performed activities that promote self-regulation
(e.g., use of a weighted blanket nightly).
 Sensory snacks: As needed activities used to keep the body comfortable
and/or focused (e.g., chewing gum, use of a fidget ball).
 Environmental supports: Modest adaptations made to surroundings (e.g.,
reorganizing furniture, lighting a candle).
 Leisure: Activities/tasks done for fun, enjoyment (e.g., cooking, painting).
Independent and longitudinal use and modification of sensory diet.
Use and refine learned skills as applied to a variety of settings.
Sensory Processing Difficulties
trigger for FND symptoms. Once the patient has demon-
strated improved self-awareness and has learned the basics of
self-regulation, the third goal of the program is to expand
and refine self-regulation skills by implementing their sen-
sory diet within home and community environments longi-
tudinally.
The fourth and final goal of the SMP is skill enhancement.
As the patient continues to demonstrate improved symptom
management, they can use self-reflection to further indepen-
dently develop strategies that aid in eliciting change. Patients
begin to generalize use of strategies into novel environments
as they engage in more diverse activities and are encouraged
to build their own personal “toolkit” of strategies that they
can use as needed.
Below, 2 cases are presented to illustrate how a sensory-
based OT program can aid the treatment of patients with
FND. Cases were selected to show examples of progression
through program goals. Prior to OT referral, patients received
a rule-in diagnosis of FND during a FND clinic evaluation.43
Identifying case information has been modified to protect
patient privacy, and both individuals provided written
informed consent to have their medical records reviewed as
part of a larger FND characterization research study
approved by the Mass General Brigham Human Research
Committee.
Case Example 1
Ann is a 23-year-old female referred to OT for mixed FND,
with symptom onset 3 years prior. She described functional
seizures consisting of bilateral arm and leg jerking, facial pull-
ing to the left, slurred speech, and feeling disconnected. She
also had paroxysmal left-sided weakness with intermittent
loss of balance, and reported frequently dropping objects,
bumping into her surroundings, tripping and falling. Ann
Figure 3 Graphic depiction of the pre-treatment sensory profiles. Panel A) displays the pre-treatment sensory process-
ing profile of case 1, showing high scores in low registration, sensory sensitivity and sensation avoiding, whereas a low
score in sensation seeking. The initial profile of case 2 is displayed in Panel B) with high low registration and sensation
avoiding, and low sensation seeking. “++”: Much more; “+”: More; “=”: Similar; “-”: Less; “- -”: Much Less. (Color ver-
sion of figure is available online.)
5
endorsed stress as a trigger for her functional seizures,
including increased school demands. She was unable to iden-
tify any effective copings skills for these symptoms. Ann’s
medical history included current generalized anxiety disor-
der, dysthymia, irritable bowel syndrome and migraines; she
also had a history of PTSD secondary to childhood maltreat-
ment and a prior concussion with a resolved post-concussion
syndrome. Ann lived with her parents, worked part-time at a
pet store, and attended community college full-time studying
mathematics. She attended outpatient PT concurrently with
the majority of her OT care (see Maggio et al. for an overview
of our PT program44).
The OT evaluation consisted of a physical examination,
observation of motor skills and sensory processing assess-
ments. During motor testing, Ann displayed mild give-way
weakness in her upper extremities. Assessment of her sensory
processing patterns using the AASP demonstrated that Ann
experienced low registration, sensory sensitivity and sensa-
tion avoidance “much more than most people,” along with
sensation seeking tendencies “less than most people” (see
Fig. 3).45 The COPM helped Ann to identify her goals as fol-
lows: (1) complete activities without tripping and falling; (2)
sustain balance with a variety of activities; (3) complete activ-
ities without dropping items frequently; (4) maneuver
around her environment without bumping into objects; and
(5) manage stressors.
As identified in Ann’s AASP, her threshold for registering
sensory information was much higher than most, indicating
potential difficulties with processing information from her
environment to indicate where her body was in space. Such
findings can manifest as the symptoms she described of
bumping into things, dropping objects and tripping. Her
simultaneous hypersensitivity to certain sensory inputs
potentially led to her using avoidance-type behavioral
responses, such as no longer engaging in sports and social
6 J. MacLean et al.
activities within her community. Our formulation included
that reduced exposures to movement-based activities was
likely leading to Ann’s body receiving a level of sensory input
below the threshold required to maintain environmental
awareness and move her body effectively through space, thus
perpetuating some of her symptoms such as frequent trip-
ping. An additional factor identified during Ann’s evaluation
was a frequent state of heightened arousal, which we
explained to her as being in a state of “fight or flight.” This
hyperarousal can lower the neurological threshold for a
behavioral response to stimuli promoting sensory sensitivity
and self-regulation difficulties. Based on this assessment and
her availability, an individualized sensory-based treatment
plan was developed for Ann to attend OT every other week
for 2 months.
Initial sessions focused on educating Ann on her sensory
processing profile and how this related to self-regulation and
general functioning. She completed a Sensory-Motor Prefer-
ence Checklist and was asked to identify tasks that made her
feel alert, calm, irritated, or a combination of each, to aid in
better understanding her own sensory preferences and ten-
dencies. Activities identified within this list were then used
to help develop strategies for self-regulation. Different sen-
sory modalities to modulate arousal were explored, including
using a weighted blanket, manipulating therapy putty, chew-
ing gum, and using specific self-help and relaxation applica-
tions on her smartphone. Ann was then asked to reflect on
how these experiences influenced her arousal. Based on
responses from the Sensory-Motor Preference Checklist and
trials of different sensory activities, an individualized sensory
“diet” was created. Ann identified the following sensory
“meals” as helpful to aid coping and promote feeling bal-
anced: (1) using therapy putty and a weighted blanket
nightly and (2) following a balanced daily schedule, includ-
ing time for completing relaxation exercises and taking rest
breaks throughout the day. Sensory “snacks” identified as
beneficial included chewing gum when driving to help stay
focused. She also reported that spending time alone in a quiet
environment and performing progressive muscle relaxation
exercises assisted her in feeling regulated and less over-
whelmed by her environment. Because we had identified dif-
ficulty with body awareness, Ann received training in
Sensory-Enhanced Yoga46, an activity that can improve body
awareness by providing strong, intense movement input.
Across therapy sessions, ongoing education was provided
regarding the importance of following a balanced schedule
and including activities identified within her sensory diet to
achieve and maintain a “just right state” of arousal. Our aim
was for Ann to receive sufficient sensory input to maintain
body awareness (for which she required more input than she
was receiving), while simultaneously avoiding sensory over-
load and causing a “fight or flight” response (for example,
while driving).
Following 4 treatment sessions, Ann’s progress was
assessed. Ann demonstrated increased self-awareness of her
sensory preferences and tendencies, and independent use of
sensory strategies. These improvements were reflective of
improvements in COPM scores. She reported positive change
with regards to having fewer episodes of tripping, falling,
dropping items, and bumping into objects. Her ability to
manage stress was now endorsed as satisfactory and
improved. Her COPM scores of self-reported performance of
functional tasks improved by 3.6 and her satisfaction in task
performance improved by 5 (clinically meaningful change 
241). Building on these improvements, Ann was discharged
after completing 7 total OT sessions. At 4 and 8 months post
OT treatment, the patient reported in FND clinic being
“much improved” regarding her functional neurological
symptoms.
Case Example 2
Evan is a 42-year-old male referred to OT with 1-year history
of mixed FND, including functional seizures, functional
facial twitching of the lower two-thirds of the face, and stut-
tering (resolved). He described episodes lasting up to fifteen
minutes of full body shaking with some retained awareness
and brief episodes of blank staring, both triggered by stress
and anxiety. Medical history was notable for childhood onset
Attention Deficit Hyperactivity Disorder, dyslexia and
chronic left foot pain (resolved). At the time of his OT evalu-
ation, Evan was living with his wife and 11-year-old son. He
was unable to work as an excavator due to his seizures, and
his fatigue and motor symptoms also impaired his day-to-
day abilities. Prior to OT referral, Evan had successfully com-
pleted 9 sessions of SLT.3 He also attended community-
based cognitive behavioral therapy throughout the duration
of his SLT and OT treatments.
The initial OT evaluation included observation of motor
skills, obtaining a sensory history, identifying coping skills,
and assessing sensory processing. The history revealed sen-
sory avoidance behaviors related to crowds, where Evan
described feeling overwhelmed and, at times, leaving situa-
tions abruptly. He also endorsed periods of “boom and bust
behavior” by engaging in more activity on days with a low
symptom burden, which then necessitated an extended
recovery period with higher symptom burden for several
days. For example, Evan would spend the day cleaning the
house followed by attending his son’s football game, which
seemingly triggered increased fatigue and functional seizures.
He could not identify specific coping skills or strategies to
manage these symptoms. Physical examination demonstrated
intermittent left-sided facial twitching that was variable and
distractible. Assessment of his sensory processing tendencies
using the AASP demonstrated that Evan experienced low reg-
istration and sensory avoidance “more than most people,”
along with sensory seeking tendencies “less than most peo-
ple” (see Fig. 3). The COPM helped Evan to identify his goals
as follows: (1) manage facial twitching; (2) return to driving;
(3) return to work; (4) complete daily routines and reduce
napping; and (5) make decisions in a timely manner.
As identified in Evan’s AASP, his threshold for registering
sensory information was higher than most, indicating he
may have had a diminished ability to make efficient decisions
based on processing of environmental information or diffi-
culty recognizing internal cues that he was overexerting
Sensory Processing Difficulties
himself. His concurrent hypersensitivity to sensory input led
him to intermittently avoid crowds and reduce participation
in social activities within his community. By avoiding these
activities, Evan was likely not obtaining the level of sensory
input he needed to identify when he was “overdoing” an
activity, leading to the “boom and bust behavior” pattern he
was displaying and potentially facilitating an increase in FND
symptoms. Based on our case formulation, an individualized
treatment plan was developed for Evan to attend OT once
per week for 4-8 weeks.
Initial sessions focused on educating the patient on his
sensory profile and how this related to self-regulation and
functioning. Evan completed a Sensory-Motor Preference
Checklist that asked him to identify sensory tasks that made
him feel alert, calm, irritated, or a combination of each. Evan
explored different sensory modalities such as using a fidget
cube, diaphragmatic breathing, and self-help/relaxation
applications on his smartphone. He was asked to reflect on
how these affected his arousal levels (e.g., calm, alert, irritat-
ing, combination). Based on his responses and experiences
with other sensory activities, an individualized sensory “diet”
was created. Given Evan’s need for calming activities
throughout his day to aid his functional seizure management,
he was trained to perform quadruped rocking for his sensory
“diet”, as rocking has been shown to stimulate the parasym-
pathetic nervous system.46,47 Due to his higher threshold for
registering sensory information, he was also trained on the
practice of Sensory-Enhanced Yoga, which includes proprio-
ceptive input to aid bodily awareness. Evan identified deep
breathing, meditation and practice of Sensory-Enhanced
Yoga as beneficial sensory “meals” and was encouraged to
incorporate these into his daily routine. To address the
“boom and bust behavior” pattern of activity, education was
given regarding how sensory “diet” activities could be used
to promote pacing and create a balanced daily schedule that
avoided mental and physical overexertion. Evan successfully
adopted this pacing strategy, which resulted in an improved
ability to perform daily home tasks without eliciting FND
symptoms such as functional seizures.
At our standard 30-day assessment, Evan’s progress
towards his COPM and other treatment goals was assessed
after 5 sessions. Overall, he demonstrated an increased self-
awareness and independent use of sensory strategies. Evan
found that regular use of deep breathing, following a bal-
anced daily routine, meditation, and Sensory-Enhanced Yoga
helped reduce his functional seizure frequency, improved his
overall functioning, and lessened stress and anxiety. He spe-
cifically reported improved tolerance for attending and par-
ticipating in community-based activities, such as going on a
family vacation or attending a car show. He reported an
improved ability to make decisions in a timely manner and
felt ready to explore a return to work. He was unable to
achieve his goal of driving by the end of his OT treatment,
but 2.5 months later was cleared to resume local driving by
the FND clinic after being free of functional seizures for over
6 months48. Due to these improvements and demonstration
of ability to implement sensory strategies independently and
appropriately, Evan was discharged from OT following a
7
total of 7 sessions. At discharge, his COPM scores of self-
reported performance for functional tasks improved by 3.4
and his satisfaction in task performance improved by 2.2
(clinically meaningful improvement  2).
Discussion
These 2 cases with mixed functional neurological symptoms
illustrate the treatment principles of our OT-based SMP for
FND. In both instances, patients completed the AASP to help
themselves and clinicians understand their sensory process-
ing patterns, while the COPM aided the identification of indi-
vidualized treatment goals. To find potentially helpful
sensory-based activities that can prove calming or alerting
based on one’s moment-to-moment needs, patients also com-
pleted the Sensory-Motor Preference Checklist. All of this
information was used to develop collaboratively a sensory
"diet”  one that included regularly used sensory "meals”
and as needed sensory "snacks.” Over a series of outpatient
sessions, patients were then guided to refine their use of sen-
sory modulation strategies to the particulars of their circum-
stances, encouraging increasing independence in the process.
While sensory processing difficulties were identified across
patients with functional movement disorder and functional
seizures in our initial cohort study, both cases presented here
had functional seizures which is in keeping with the prelimi-
nary observation that patients with this FND subtype showed
tendencies toward more extreme sensory processing pat-
terns.11 We generally consider a role for the OT-based SMP
in patients with paroxysmal FND, particularly those endors-
ing that sensory experiences trigger and/or amplify their
functional neurological symptoms.
In terms of other patient selection considerations, both
cases depicted adults with FND  in keeping with the cur-
rent patient population of the Massachusetts General Hospi-
tal FND Clinic. However, there is a great need to expand
treatment programs for children and adolescents with FND
worldwide.49,50 Given that the OT-based SMP leverages prin-
ciples that are based in part on a literature found in children
and adolescents,39 we anticipate that the assessment and
treatment strategies detailed in this article would have the
potential to translate well to teenagers with paroxysmal FND.
However, prospective controlled clinical trials in patients
with FND across the lifespan must be conducted to rigor-
ously study the feasibility, tolerability and efficacy of this set
of therapeutic interventions. Furthermore, given the multi-
disciplinary treatments received by both cases, an important
confound is that the specific set of “ingredients” driving effi-
cacy at the individual level requires clarification. One poten-
tially fruitful, yet complex and ambitious, approach could be
to design a large-scale multisite clinical trial that investigates
the potential efficacy of treatment selection based on clinical
phenotype and the biopsychosocial formulation (assigning
select treatments to a given participant based on a set of avail-
able “modules”) vs. a pre-specified evidence-based treatment
algorithm (e.g., standardized physical rehabilitation plus cog-
nitive behavioral therapy).
8 J. MacLean et al.
Conclusion
These cases illustrate how OT-based treatment of sensory
processing difficulties can be a component of a multidisci-
plinary approach to FND treatment. While there is evidence
to support this approach within a wide range of pediatric
diagnoses, there is a paucity of research on its effectiveness
within pediatric and adult populations with FND. Given the
hypersensitivities endorsed by some patients with FND,
more research on sensory modulation disturbances (includ-
ing neurobiological characterization) is warranted. Research
should focus on a multidisciplinary approach to address sen-
sory modulation difficulties, as well as evaluate the specific
tolerability and efficacy of sensory-based OT interventions
for patients with FND.
Acknowledgements
None.
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