# Uncertainty as an operative construct and treatment target in functional neurological disorder

## TL;DR

This paper proposes a new framework for understanding and treating functional neurological disorder by focusing on uncertainty and hyperactivation in the brain and body.

## Contribution

The novel contribution is a unifying framework that integrates uncertainty intolerance and allostatic overload as key drivers of FND, suggesting a tiered behavioral treatment approach.

## Key findings

- FND is perpetuated by intolerance of uncertainty and multidimensional allostatic overload.
- Individuals with FND exhibit higher prediction error during uncertainty and lack adaptive resources to respond.
- A tiered behavioral approach combining symptom control and psychological therapies is proposed for treatment.

## Abstract

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.