Uncertainty as an Operative Construct and Treatment Target in Functional Neurological Disorder

Beth Keys Rush^1*Meagan M. Watson²Traci A. Marfilius³Anushka Irani¹Brigid Waldron Perrine⁴Robin A. Hanks⁵

• ¹Mayo Clinic Florida, Jacksonville, United States
• ²University of Colorado Anschutz Medical Campus Department of Neurology, Aurora, United States
• ³Mayo Clinic in Florida, Jacksonville, United States
• ⁴Waldron Neurorehabilitation Psychology, Plymouth, Michigan, United States
• ⁵Wayne State University School of Medicine, Detroit, United States

Functional neurological disorder (FND) is a prevalent neurologic condition, yet existing treatment approaches yield inconsistent outcomes. We propose a unifying framework that conceptualizes FND as a disorder triggered and perpetuated by individuals lacking targeted tools to reconcile the cumulative impact of intolerance of uncertainty (IU) and multidimensional allostatic overload. Expanding upon predictive coding and IU theories from neuroscience and psychology research, we argue that during times of uncertainty, individuals with FND exhibit a higher rate of prediction error but lack the energy, resources, and adaptive capacity to respond. This sustained hyperactivation of the brain and body trigger and perpetuate FND. We propose that FND treatment requires a strategic and progressively tiered behavioral approach. First, the individual with FND must be taught behavioral skills to gain immediate symptom control and shift automatic, hyperactive processes into conscious awareness. Only then, can practices from Acceptance and Commitment Therapy, Dialectical Behavioral Therapy, and Mindfulness Therapy be leveraged. These practices help explicitly identify sources of uncertainty and teach how to effectively respond to hyperactive processes with skills that optimize function, commitment to values, and well-being. This framework offers testable hypotheses and a pathway to more effective, individualized care for FND.