Transcranial magnetic stimulation and sedation as treatment for functional neurologic disorders

Functional neurologic disorder (FND), also known as conversion disorder, is common and often associated with a poor prognosis. It has been relatively neglected by research and as such there is a conspicuous lack of evidence-based treatments. Physical and psychologic therapies are the main treatment modalities, over and above reassurance and sensitive explanation of the diagnosis. However there are two other historic treatments that have seen a recent resurgence of interest and use. The first is electric stimulation, which was initially pioneered with direct stimulation of nerves but now used indirectly (and therefore noninvasively) in the form of transcranial magnetic stimulation (TMS). The second is (therapeutic) sedation, previously known as "abreaction," where it was mostly used in the context of psychologic investigation and treatment, but now increasingly advocated during rehabilitation as a way to therapeutically demonstrate reversibility of symptoms. This chapter introduces the background of these treatment modalities, their evolution into their current applications before critically evaluating their current evidence base and exploring possible mechanisms of action. It also tentatively suggests when they should be considered in current practice and briefly considers their future potential. In summary there is encouraging preliminary evidence to suggest that both TMS and sedation may be effective treatments for FNDs.