Functional movement disorders: diagnosis, pathophysiology, and treatment

PURPOSE OF REVIEW: Functional movement disorders (FMD) are common and potentially reversible causes of movement disorders, yet they remain under-recognized and frequently misdiagnosed. RECENT FINDINGS: Diagnosis has shifted from an exclusion-based model to a positive rule-in approach grounded in positive clinical signs such as inconsistency (distractibility and variability), with electrophysiology providing useful support in selected cases. Current pathophysiological models suggest that FMD arise from interacting abnormalities in predictive coding, sensorimotor integration, altered sense of agency, maladaptive attentional focus, and disrupted limbic-motor network connectivity. These mechanisms may contribute both to symptom generation and maintenance. Prognosis is variable and often guarded, highlighting the importance of early diagnosis and timely intervention. Management should rely on a clear and validating explanation of the diagnosis, individualized rehabilitation focused on movement retraining, and tailored psychotherapy addressing perpetuating cognitive, behavioral, and emotional factors. Pharmacological treatment has a mainly an adjunctive role, particularly for comorbid psychiatric symptoms, pain, and sleep disturbances. SUMMARY: FMD require an integrated, multidisciplinary, and patient-centered approach to optimize functional recovery and long-term outcomes.