Functional Movement Disorder (FMD) represents a significant subset of Functional Neurological Disorder (FND), characterized by abnormal movements including tremor, weakness, dystonia, gait disturbance, and jerking movements that are inconsistent with recognized neurological disease (Edwards & Bhatia, 2012). FMD constitutes approximately 20-25% of movement disorder clinic referrals and is associated with substantial disability, reduced quality of life, and high healthcare utilization (Hallett et al., 2022).

Over the centuries, various etiologies have been proposed to explain functional neurological disorders. These have included models relying on supernatural influences upon the body, emphasis on consequences of malfunctioning reproductive organs, the bodily expression of painful emotions involving traumatic memories, or cognitive distortions through attention and predictive biases. Many theorists, especially since the 19th century, have had overlapping themes that continue to be relevant in modern clinical use. Contemporary understanding of FMD emphasizes aberrant predictive processing, where the brain's internal models generate movement experiences that do not correspond to volitional motor commands (Edwards et al., 2012). Within this framework, emotional processing is theorised to play a modulatory role, potentially influencing the salience, attention, and predictive weighting assigned to motor signals (Pick et al., 2019). However, the specific relationships between discrete emotional states and motor symptom expression remain incompletely characterized.

Clinically, FMD demonstrates a distinctive motor phenomenology characterised by internal inconsistency and context-dependent modulation of movement. Symptoms frequently vary within a single assessment and may improve during distraction or automatic tasks, while intensifying when attention is directed toward performance. For example, functional tremor may change in frequency or amplitude with cognitive load; limb weakness may demonstrate preserved automatic activation despite impaired voluntary effort (e.g., positive Hoover’s sign);, and gait disturbance may appear disproportionate yet improve outside formal examination contexts (Edwards et al.,2023). These positive clinical features reflect preserved motor pathways alongside altered voluntary motor control (Hallett et al., 2022).

Such variability is highly relevant when considering the role of emotional states in motor symptom expression (Aybek et al., 2017). In clinical settings, patients commonly report exacerbation of symptoms during periods of heightened stress, fatigue, performance anxiety or sensory overload. Conversely, symptom reduction is often observed when attention is externally focused or when perceived threat is reduced. Understanding these patterns is therefore essential when examining how discrete emotional states may associate with, or modulate specific motor symptoms. Despite our knowledge growth in recent decades, our understanding of FMD is not as advanced as it is for other neuropsychiatric disorders.

Historical conceptualizations linked functional neurological symptoms to psychological conflict and conversion of emotional distress into physical symptoms (Freud, 1894/1962). While contemporary models have moved beyond simplistic conversion frameworks, evidence continues to support a relationship between emotional factors and FMD. A growing body of neuroimaging evidence suggests the notion that abnormal emotional processing is a key factor in the aetiology of FMD. Patients with FMD demonstrate elevated rates of anxiety disorders (35-60%), depression (20-50%), and prior psychological trauma (30-70%) compared to patients with organic movement disorders (Stone et al., 2010). Neuroimaging studies have identified altered connectivity between limbic regions and motor networks in FMD, with heightened amygdala activation during movement and altered insular-motor coupling (Voon et al., 2010). Task-based neuroimaging studies show limbic and paralimbic hyperactivation, abnormal limbic-motor circuit connectivity and altered activation of several prefrontal regions in emotion processing tasks in various groups of FND patients. These findings suggest that emotional processing systems may directly influence motor output in ways that differ from healthy controls. Also, unregulated emotional reactions may exert an abnormal influence on the motor system. Some brain areas in the neurocircuitry of FND may be at the intersection of negative affect, nociception, cognitive control, beliefs/expectations, self/emotional awareness, and developmental factors (Cretton et al., 2020; Deeley, 2016; Edwards et al., 2012; Shackman et al., 2011). Furthermore, a change of connectivity from the amygdala to the insula correlates with clinical improvement and the increased activation of the amygdala is functionally connected to symptom-specific neuronal networks.

Beyond these acute neurological responses, recent research suggests that more stable psychological structures also play a critical role in symptom development. Carle-Toulemonde et al. (2025) assessed the intensity of Early Maladaptive Schemas (EMS) in patients with FMD compared with those with Parkinson’s Disease (PD) and Organic Dystonia (OD). They found that the self-sacrifice schema is overrepresented in patients with functional motor disorders (FMD) and that this self-sacrifice schema may be specifically associated with FMD, independently of depressive and anxious symptoms. The characteristic phenomenon of 'la belle indifference' occurs in approximately 3% of patients with conversion disorder versus only 2% of controls. Transdiagnostic factors such as personality traits and maladaptive coping styles contribute to heightened emotional distress, change interoceptive processing, and increase the vulnerability to develop functional symptoms such as FMD. Since these factors directly impact emotional states, they modulate cognitive resources and neural connectivity (Lu et al., 2025). Therefore, we can link traits such as perfectionism and maladaptive schemas to emotional dysregulation and symptom severity as measured with the Symptom Amplification Model (SAM) of Neurolog (Painter, 2025b).

Individuals with FMD also have a reduced sense of agency i.e. disruption of binding between intentions and actions and are thus not able to control executing bodily movement(s) or thoughts. Further, a study suggests that patients with FMD had lower cognitive control over emotional stimuli and may activate different (“less cognitive”) emotion regulation strategies, reflected in sensorimotor network activation.

Despite these theoretical and empirical advances, the translation of these internal mechanisms into daily life presents a profound challenge for the individual. The impact of FMD on individuals is frequently profound, leading to significant disability, with challenges in daily function and significant lifestyle changes. Routine tasks we take for granted may become overwhelming, and the unpredictability of FND can disrupt autonomy and the sense of normalcy, as well as financial stability. Beyond the impact of the condition itself is the pervasive social stigma associated with FND and the accusation of malingering, leaving individuals feeling disbelieved (Rezaei & Stanley, 2025) and prevents them from seeking treatment.

This sense of being disbelieved often colors the clinical interaction and subsequent treatment engagement. An individual's emotional state can impact engagement in treatment and affect outcomes. Patients commonly deny psychosocial stressors or psychiatric symptoms due to fear of discrediting their neurological complaints (Adams et al., 2018), and a higher trait anxiety score can result in poorer outcomes (Saunders et al., 2024). Physicians struggle to believe in the truly subconscious nature of their patients’ psychosomatic symptoms and show a lack of confidence in treatment approach. As a result, they may deny active treatment, and show a tendency to refer patients back and forth between different medical and mental health professionals. On the other hand, the patients respond negatively to psychiatric explanations for physical symptoms. They do not have a good understanding of their diagnosis; report feeling confused, angry and “dumped” after physician consultation. If health professionals utilise approaches that infer the patient is "faking it," it presents a significant barrier to patients accessing treatment, and the importance of trust in a therapeutic relationship must not be undermined (Gilmour & Jenkins, 2021). A graded approach to anxiety-provoking tasks can aid with engagement (Nicholson et al., 2020).

When setting rehabilitation goals for individuals with FND, occupational therapists need to be mindful that FND presents unique challenges outside the usual range of neurological rehabilitation patients. The outcome is difficult to predict due to patterns of remission, patient hesitancy to accept their diagnosis, and the possibility of avoidance when making treatment recommendations. Therapists need to apply a flexible approach, with the individual leading and less focus on time Adams et al., 2018Nicholson et al., 2020. There is worldwide limited availability of specialist treatments for patients with FND, and published research into outcomes is limited. In addition, there is often a lack of a coordinated approach to FND patients in inpatient settings. Different health professionals approach patients' symptoms differently, leading to a sense of distrust. A coordinated, whole-team approach is essential; however, there is a scarcity of local resources and allied health professionals with specific knowledge of FND, with limited training alongside (O'Neal et al., 2021). Patient confidence remains the biggest predictor of outcomes, and it is essential that services treating FND are multi-disciplinary, personalised, intensive, and lengthy—this poses a challenge for under-resourced areas (Saunders et al., 2024). Therapists discharge patients with woefully little community support, with neurological outpatients and community services refusing to accept FND referrals.

Mobile health (mHealth) applications offer unprecedented opportunities to capture patient-reported symptoms and emotional states as they occur in daily life. Ecological momentary assessment approaches can reveal relationships that are obscured in retrospective or laboratory-based studies (Shiffman et al., 2008). To date, no large-scale analysis has examined the emotional correlates of motor symptoms using real-world tracking data from patients with FMD.

The present study aimed to:

The analysis included 1,194 patients who had completed at least one daily symptom log containing motor symptoms. Users self-registered on the platform and self-reported a diagnosis of FND or related conditions. No demographic restrictions were applied. Given the privacy-focused design of the platform, demographic data were limited; however, the population is presumed to reflect the known epidemiology of FMD (female predominance, mean age 30-50 years).

All data were collected through voluntary use of the NeuroLog platform. Users provided informed consent through the application's terms of service. Data were analyzed in aggregate and anonymized form. The study utilized existing de-identified data and did not involve direct participant contact.

Data were obtained from NeuroLog, a mobile health application designed for symptom tracking in patients with Functional Neurological Disorder (Painter, 2025). The platform allows users to log daily symptoms, emotional states, triggers, and overall severity on a 0-10 scale. All data was collected between July 2025 and January 2026.

Daily Symptom Logs.

Participants logged symptoms from a comprehensive list of FND-related symptoms including motor, sensory, cognitive, and autonomic categories. For the present analysis, motor symptoms were defined as: tremors/jerks, leg weakness, arm weakness, gait issues/walking difficulty, dystonia (neck, limbs, facial), muscle spasms, and related motor variants.

Emotional States. Participants selected from a list of 25+ emotional states including: Anxious, Frustrated, Sad, Calm, Overwhelmed, Neutral, Stressed, Content, Uncomfortable, Worried, Irritated, Empty, Indifferent, Happy, Grateful, Disappointed, Hopeless, Lonely, Uneasy, Nervous, and others. Multiple emotions could be selected per log.

Triggers. Participants identified triggers from a standardized list including: Stress, Physical Exertion, Anxiety, Lack of Sleep, Heat, Bright Light, Loud Noise, Anger or Frustration, Depression, Dehydration, Social Pressure, Conflict or Arguments, Hunger, Social Isolation, Crowded Spaces, Cold, Illness or Infection, and Excitement.

Severity. Overall symptom severity was rated on a 0-10 numeric scale where 0 = no symptoms and 10 = worst possible symptoms.

Descriptive statistics were calculated for emotion and trigger frequencies on motor symptom days. Mean severity was calculated for each emotional state and trigger. Comparisons between motor and non-motor symptom days were conducted using mean severity differences. Motor symptom subtypes (tremor, weakness, dystonia, gait) were analyzed separately to identify symptom-specific emotional correlates.

This study represents one of the largest real-world analyses of emotional correlates of functional motor symptoms to date. The findings provide empirical support for the role of emotional factors in motor symptom expression and severity, with several clinically relevant implications.

This real-world analysis of 3,486 motor symptom logs provides robust evidence that specific emotional states are not merely comorbid with Functional Movement Disorder (FMD) but are intrinsic correlates of symptom presence and severity. While the established link between anxiety and tremors is confirmed by its high frequency in patient reports , this study uncovers a more complex "emotional triad" for Dystonia and Gait which is dominated by frustration, anxiety, and sadness.

The findings suggest a critical shift in how we view the "non-motor" drivers of FMD:

Ultimately, the prominence of hopelessness (M=7.56) as a severity amplifier suggests that motor recovery in FMD cannot be achieved through physical rehabilitation alone. These findings support the integration of emotional assessment and regulation interventions into comprehensive FMD treatment approaches, such as ReAttach in combination with mirror training and movement (Van Dongen et al., 2025), to reduce arousal, address the underlying sadness, and restore the link between movement intent and muscle action.

Data were collected through the NeuroLog symptom tracking platform. The authors thank all participants who contented for the use of their data.

Steven Painter is the developer of NeuroLog.

The authors declare that the research was conducted in the absence of any commercial or financial relationship that could be construed as a potential conflict of interest.

The datasets generated for this study are available on request to the corresponding author.