Functional Neurological Disorder in a Patient With Schizoaffective Disorder: Challenges in Diagnosis, Management, and Disposition

Functional neurological disorder (FND) is a disease with no known cause and variable presentation, which may delay its diagnosis and management. Patients often present with an underlying psychiatric disorder,¹ further complicating management of both the psychiatric disorder and FND. This case on the diagnosis and management of FND in a patient with schizoaffective disorder illustrates how stigma around psychiatric conditions can impact patient disposition, particularly in patient populations with complex neurological disorders requiring constant attention by caretakers. This patient with FND and schizoaffective disorder presented with psychogenic seizures, tremors, and urinary retention, often triggered after the patient was notified of a pending discharge. This report seeks to elaborate on the difficulties faced by patients with FND and psychiatric illness, particularly in relation to the disposition of this segment of patients.

Case Report

The patient was a 54-year-old woman with longstanding schizoaffective disorder (bipolar type), mild intellectual disability, and multiple medical comorbidities (hypertension, urinary incontinence, and osteoarthritis). She was admitted to the hospital for aggressive, disorganized, psychotic behavior and agitation. Her home medications were unknown, and she was initially refusing oral medications.

At admission, she required sedatives as needed and was placed in a quiet room for safety. Over several days, she gradually improved and started accepting some antipsychotic and mood-stabilizing medications, became less agitated, and began to ambulate under observation. Concurrently, she developed paranoid delusions related to poisoning. She refused solid food and accepted only liquid caloric supplemental products (Ensure, juices).

On hospital day 5, staff witnessed a brief episode (∼1–2 minutes) of unresponsiveness with generalized shaking. No tongue biting or incontinence occurred. The episode resembled a seizure, but immediate workup including glucose and vital signs was within normal limits. The neurology team noted atypical features (eyes closed, asynchronous jerking) consistent with a functional seizure (pseudoseizure). A noncontrast head computed tomography scan and video-electroencephalogram (EEG) were ordered; while the EEG was pending, the event spontaneously resolved without neurological deficit. Throughout the following days, whenever it was communicated to the patient that she would be discharged, these events repeated.

The patient remained in the psychiatry unit and gradually stabilized on oral risperidone and lithium. She became less agitated and more cooperative, including with a physical therapy referral for persistent tremors and intermittent arm weakness. Nutritional intake was limited to supplements due to persistent paranoid delusions. Disposition planning proved difficult, as her long-term care facility lacked the capacity to manage both functional neurological symptoms and chronic psychiatric illness.

Discussion

Nine percent of all acute neurological admissions are due to FND.² Despite this high prevalence, FND is important to distinguish from feigning and malingering.³ While the literature has described interventions in this population,^4,5 little research has been conducted to evaluate the disposition of patients with both FND and psychiatric illness. This combination is quite common, with symptoms of FND found to be strongly correlated with underlying psychiatric disorders.¹ Patients with psychiatric illnesses are not strangers to stigma. However, a lack of awareness on the manifestations of FND in this subset of the patient population can lead to delays in diagnosis and management and potential adverse effects in care.

Patients with FND often present with a wide variety of symptoms, making it a challenge for clinicians to include the disease as part of a focused differential. Historically, FND was a diagnosis of exclusion. More recent classification systems include a “rule-in” approach to diagnostics, where pertinent clinical signs are evaluated for positive clinical features.⁶ The literature has also described various modalities for management of FND, reporting success with patient education,⁵ psychotherapy,⁷ neurobehavioral therapy,⁸ and paradoxical therapy.⁹ Despite these many avenues for symptom resolution, special care should be taken for patients such as ours who reside within inpatient psychiatric wards.

Patients with both psychiatric illness and FND present a complex challenge for the clinician and the patient’s caretakers. Treatment modalities that involve patient communication can be limited, as the patient is often an unreliable conversant. The patient’s caregivers, especially in long-term care settings with limited medical staff, often lack the training to effectively manage FND alongside psychiatric illness. As a result, they may mistake these episodes for seizures and more rapidly elect to transfer the patient to the nearest hospital, leading to unnecessary admission.

Such frequent hospital admissions disrupt continuity of care, increase health care costs, and may exacerbate patient distress and confusion. Once admitted, health care staff may hesitate to provide certain care out of fear of triggering more episodes, which can limit the support the patient receives. This also complicates discharge planning, as facilities may be reluctant to accept patients with ongoing symptoms, resulting in longer inpatient stays. Furthermore, the stigma associated with FND can influence decisions about patient placement and resource allocation, potentially limiting access to appropriate rehabilitative services and multidisciplinary care.

Article Information

Published Online: April 7, 2026. https://doi.org/10.4088/PCC.25cr04035
© 2026 Physicians Postgraduate Press, Inc.
Prim Care Companion CNS Disord 2026;28(2):25cr04035
Submitted: July 2, 2025; accepted August 26, 2025.
To Cite: Umer W, Imtiaz M, Arain F, et al. Functional neurological disorder in a patient with schizoaffective disorder: challenges in diagnosis, management, and disposition. Prim Care Companion CNS Disord 2026;28(2):25cr04035.
Author Affiliations: Rutgers New Jersey Medical School, Newark, New Jersey (Umer, Arain, Hussain); Fatima Jinnah Medical University, Lahore, Pakistan (Imtiaz).
Corresponding Author: Waez Umer, BS, Rutgers New Jersey Medical School, Newark, New Jersey ([email protected]).
Relevant Financial Relationships: None.
Funding/Support: None.