The role of speech therapy in functional neurological disorder (fnd)
Functional Neurological Disorder (FND) is a condition where the nervous system has trouble sending and receiving signals correctly, despite scans and tests looking normal. Within speech-language pathology, this can affect speech, voice, and swallowing. Speech therapy helps by retraining the connection between the brain and the affected speech or swallowing system.
What does "functional" mean in FND?
Functional Neurological Disorder, or FND, can be referred to as a transmission or communication difficulty within the nervous system. Importantly, there is often no structural damage. This means that the structures involved, your brain, nerves, and associated muscles appear intact and normal.
The differences lie in your nervous system’s communication system. Think of the brain as air traffic control and your muscles as an incoming plane. The brain has the correct set of instructions and the muscles are ready to receive them, but the connection—your nervous system—is poor and the message keeps cutting out. As a result, your muscles might not know where to land or if they need to circle.
Essentially, the message gets scrambled.
To re-iterate, all the parts of the nervous system are present and intact, but they are miscommunicating with each other. This means that there are times where they do not function correctly. This is why you may find that imaging results come back normal, despite the fact that these symptoms are present and real.
FND is not a diagnosis of exclusion. It is a real and recognized condition with specific markers and neurological mechanisms and patterns. There are several sub-types of FND, including functional seizures, functional movement disorder, and functional cognitive disorder. Please refer to the bottom of this page for additional resources and education that extends beyond the scope of speech language pathology.
What are the symptoms of FND?
FND as it relates to speech and language may also be called Functional Speech Disorder. Sub-types may include:
Functional Swallowing or Functional Dysphagia
Functional Voice or Functional Dysphonia
Functional Fluency or Functional Stuttering
Functional Speech or Functional Dysarthria
Functional speech and swallowing symptoms can vary. You may experience one or more of these:
Stuttering or Dysfluency: This may appear suddenly in adulthood without prior speech difficulties or differences. Dysfluencies are often variable, with patterns that differ from those seen in developmental or neurogenic stuttering. Speech may be hesitant and dysfluencies can include extended pauses, whole word repetitions, single sound repetitions, stretchy sounds, amongst other characteristics.
Cognitive Communication: This can involve difficulties with word finding or verbal expression, memory, attention, and organization and may be described as ‘brain fog’. It may feel like the word is “on the tip of your tongue”. The right word can feel just out of reach, words may come out differently than intended, or the wrong word is used unintentionally. This may fall under the umbrella of Functional Cognitive Disorder.
Slurred Speech: This may sound similar to speech changes related to fatigue or weakness, but can happen variably and without any of the usual causes.
Voice Changes: It may feel like a lingering sore throat, despite not having been sick. This can include whispery or hoarse voice (dysphonia), loss of voice (aphonia), pitch changes, or what is called puberphonia, often seen in youths. The loss of voice control is involuntary, but may include excessive muscular tension, which can be addressed.
Swallowing Difficulties: Globus sensation refers to feeling like there is a lump in the throat, despite the throat being clear. This can make swallowing difficult, despite the throat being physically clear. A comprehensive assessment is recommended to rule out structural differences.
Chronic or Persistent Cough: This refers to ongoing coughing or laryngeal hypersensitivity without an underlying respiratory condition. This may arise from altered sensory processing.
Articulation: This can refer to difficulties with making specific speech sounds. The muscles may feel weaker or like it’s ‘talking through sand’.
This does not constitute the full scope of FND symptoms for speech and language. Other symptoms may include difficulties with functional mutism, intonation, or language expression. For example, some people also experience a rarer symptom called foreign accent syndrome, where the rhythm and melody of speech shifts enough that it sounds like a new accent has emerged.
Co-occurring symptoms can include feelings of ‘brain fog’, excess tension and tightness in the facial and neck regions, migraines, emotional stress and anxiety.
Do you need a diagnosis to start FND therapy?
Speech Language Pathologists do not diagnose FND in Ontario, although trained clinicians can identify and treat the presentation. For a formal diagnosis, you may contact your family doctor for a referral to a neurologist or ENT. If you’re unsure what you’re experiencing is FND, that’s okay. Get in touch with a professional to begin answering your questions.
At Cognicare Speech Therapy, you do not need a diagnosis to begin working with us. Speech and language therapy can start based on your symptoms and their impact on your day-to-day communication or swallowing, not on a specific label. For many people, therapy and the diagnostic process happen alongside each other, not one after the other.
What happens in FND speech therapy?
A Holistic Approach to FND
Speech and language therapy for FND is tailored to your specific symptoms and how they show up on the daily. We recognize that symptoms can wax and wane and that there is no one-size-fits-all approach to speech therapy. Sessions are structured to find and practice strategies that work for you as we retrain the connection between the brain and speech systems. Throughout the process, you will gain a clearer understanding of what's happening and why.
These symptoms do not exist in isolation and we believe in addressing the whole person. Intervention for FND involves empowering individuals through education, knowledge, and step-wise progressions. Education is essential to foster self-management, induce carryover, and reduce stress and fear. Healing is not linear and therapy meets you where you are. This includes creating a personalized therapy plan to integrate your goals, such as managing a stutter, eating at the family dinner table, or improving word finding.
Our founder, Mariya Kika, is a member of the FND Society, FND Hope, and the Canadian FND Network. She has received additional training in FND management and rehabilitation, and continues to advance her skills to be able to provide the best possible care.
Take the Next Step
Regardless of if you are navigating a new diagnosis, are in the diagnostic process, or have just begun to learn about your symptoms, please know that you do not have to have it all figured out before you walk through our door. Support is available. By addressing the physical, emotional, and cognitive aspects of the condition, we help you take meaningful steps toward improved communication, swallowing, and overall well-being.
We're here to help you understand what's happening. With the right support, you can experience meaningful improvements in your quality of life.
And if you still have questions, please reach out to our team. We are happy to help.
Additional Resources:
Neurosymptoms.org provides additional educational material regarding the full breadth of FND. Please note that it is not meant to replace formal diagnosis.
FND Hope provides additional educational material regarding FND. It also includes a global directory of FND providers across disciplines.