Could metacognitive therapy be a contender for first-line treatment for functional neurological disorder? The case for clinical trials

Metacognitive Therapy (MCT), grounded in a model first proposed more than three decades ago (Wells & Matthews, 1994), has been used to treat a range of mental health disorders and, more recently, extended to physical health conditions, including Long Covid (Johnson et al., 2024). This Opinion article argues for controlled trials to evaluate whether MCT should now be offered as a first-line treatment for functional neurological disorder (FND). Current Hallett et al, 2011Hallett et al, , 2016;;LaFrance et al, 2014.) In patients prone to somatosensory amplification, repeatedly focusing on illness beliefs may heighten threat-driven attention to bodily sensations, reinforcing the very hypervigilance that maintains their symptoms (Barsky & Silbersweig, 2023;Kube et al, 2020).Metacognitive therapy, by contrast, focuses on increasing the patient's awareness of their thinking styles and relationship with their thoughts. By discouraging extending thinking about thought content, MCT arrests the self-reinforcing feedback loops that maintain psychological distress and pathological coping. Regaining flexible attentional control frees individuals to reengage with their external world, rebuild agency, and modify detrimental higher order regulatory processes. Similarly, the FND literature proposes that excessive attention to the body disrupts normally automatic movement, and that reducing this hypervigilance may allow automatic motor function to resume (Edwards et al, 2012).Functional symptoms are common: anxiety, for example, may bring a dry throat, sweating palms, abnormal breathing, increased heart rate, and gastric disturbance. When their frequency, intensity and/or duration (over 6 months) interfere with daily functioning, treatment is indicated. Until DSM-5 (American Psychiatric Association, 2013; text revision 2022), these impairments were typically termed Medically Unexplained Symptoms, Hysteria or Conversion Disorders. The first term reflected a diagnosis of exclusion. The second and third signalled the legacy of Charcot and Janet at the Salpêtrière Hospital in nineteenth-century Paris and of Freud's emphasis on repressed conflict.Today, FND sits within the DSM-5 chapter on Somatic Symptom and Related Disorders, alongside other functional conditions in the cognitive, sensory, and motor domains. Individuals may experience symptoms across multiple organ systems, supporting the 'lumper' case for a polysyndromic phenotype. Functional presentations may overlay organic conditions (as with |Functional Seizures and Epilepsy) or co-exist with unrelated medical conditions. Symptoms may be positive (gastric disturbance, tremors, pain) or negative (weakness, fatigue, numbness). For the purposes of this piece, Functional Neurological Disorder (FND) denotes all functional disorders.The failure of the National Institute for Health and Care Excellence (NICE) to produce dedicated guidelines for the treatment of FND in England and Wales creates an opportunity to consider MCT as a candidate intervention. UK treatment delays (currently eight years) reflect the lack of a clear classification system, limited resources, and a historical knowledge deficit among clinicians, who often conveyed their view that symptoms were imagined or feigned. Patient factors include the condition's stigma and repeated requests for multiple medical tests and investigations, resulting in iatrogenic harm.Functional patients, 70% of whom are women, account for about a third of new outpatient presentations and up to half of GP appointments. The most recent figures for England put the annual NHS cost of treating functional conditions at £2.89 billion (then about 10% of its budget). A further £14 billion was attributable to illness benefits, sickness absence, reduced productivity, and impaired quality of life (QoL) (Bermingham et al., 2010). Bass and Pearce (2016) reported distress and disability in this group, comparable with that severe and enduring mental illnesses.In DSM-5 (2013), the criteria for somatic symptom disorder were recast to foreground positive clinical features: internal inconsistency/variability and symptoms incompatible with (neuro)anatomical pathology. The previous requirement of a psychological trigger (trauma or abuse) gave way to a focus on the patient's active-inference/illness beliefs and consequent behaviours , such as bodily hypervigilance illness-reinforcing coping. Clinicians have observed the same mechanisms (Phillips, 2025). This reorientation aligns closely with metacognitive theory, in which distress is maintained by the Cognitive Attentional Syndrome (CAS). The CAS consists of perseverative worry or rumination, threat monitoring (such as inward-focused attention) and unhelpful coping strategies, driven by maladaptive metacognitions. The CAS is MCT's primary target.MCT's efficacy already has a strong evidence base. What perhaps makes it particularly suitable for the treatment of functional and other somatic related disorders is that it shares the biological Bayesian model's understanding of how distress is induced and maintained. In the Bayesian framework, priors (expectations drawn from past experience) anticipate sensory input, with any discrepancy yielding a prediction error. This error updates the prior into a 'posterior,' which then becomes the new prior. The computational process continues until a Bayes-optimal decision is reached. Edwards et al. (2012) argued that a prior shaped by previous experience of illness, distorts the weighting of lower-level data, overriding the prediction error. The inference may be Bayes-optimal inference but, because the priors are aberrant (idiosyncratically biased), the outcome (a functional impairment) does not fit realworld data. As these processes happen outside conscious control, functional symptoms are experienced as involuntary. Although largely untested, the Bayesian model is increasingly used to explain the onset and maintenance of functional conditions.Metacognitive therapy maps comfortably on to the Bayesian model: both frameworks describe a multi-level architecture in which higher-order structures generate top-down expectations shaping lower-level processing. Their levels of explanation differ: MCT addresses psychological and experiential processes, while Bayesian inferences describe a cascading hierarchy of neural and computational ones. Even so, both converge on distress as the outcome of stochastic overweighting (high confidence that the prediction is correct) and fixated attention. Wells's (2009) metacognitive model, grounded in the Self-Regulatory Executive Function (S-REF) model (Wells & Matthews, 1994), posits that metacognitions (beliefs about one's own thinking) direct higher-order processing, governing the selection and appraisal of incoming data. Bottom-up sensory data from the body or the environment (for example, a percept or the absence of normal feeling) are briefly registered in working memory. There they give rise to thoughts processed in object mode, that is, taken as direct reflections of reality (for example, 'This sensation is not normal: I am unwell'). Prolonged inward-focused attention keeps these lower-level thoughts, images or perceptions of illness in constant iteration. This strengthens them and consolidates maladaptive metacognitions (for example, the belief that worry about symptoms is necessary for safety). The mind's natural tendency towards emotional homeostasis is thereby overruled. In turn, an internal view of the Self and the World that resists disconfirmation, frequently related to illness vulnerability, triggers a positive (self-reinforcing) feedback loop. Input incompatible with this mental model is appraised as 'noise' (not signal) and, like Bayesian prediction errors in functional disorders, suppressed. Wells's (2009) model traces a cyclic process in which the CAS is fuelled by both higher-and lower-order processes. The model identifies a Comparator, which assesses the discrepancy between the individual's current (distressed) state and their desired state (for example, achieving a sense of safety or certainty). The Cybernetic Code then selects a 'remedy', mobilizing the individual's familiar, self-defeating coping strategies, a key component of the CAS. Once these strategies are activated, the feedback loop intensifies and, paradoxically, strengthens the certainty of danger, leaving the individual with the belief that their worries are uncontrollable.Unlike the Bayesian model, MCTprovides both an explanation and a therapeutic framework.Staying in metacognitive mode fosters patient engagement and helps identify the metacognitions that drive distress.Although I argue for its suitability for DSM-5-TR's (2022) Somatic Symptom and Related Disorders, MCT does not require a psychiatric diagnosis. Freedom from a nosological framework distance it from the DSM-5-TR's continued labelling Functional Neurological Symptom Disorder as 'Conversion Disorder', albeit in brackets. Freud's legacy, the view that physical symptoms stem from unconscious conflict, may encourage patients with functional symptoms to self-stigmatise. MCT's diagnosis-free approach sidesteps that stigma.MCT restores choice and agency to patients overwhelmed by beliefs that their worries or rumination are uncontrollable. Anxiety, a contributory maintenance factor for some patients in FND, becomes less threatening as the individual learns that contrary to their previously beliefs, they can flexibly control their attention.Wells has developed two core techniques to target the CAS and undermine dysfunctional procedural/implicit knowledge. Detached Mindfulness trains patients to view their thoughts as products of consciousness (mental phenomena) separate from their sense of self.Individuals learn that their constant stream of thoughts is like water running freely in a sink; left alone, it drains away. It is only when they attribute importance to them (putting the plug in) do the thoughts build up and eventually overflow. This simple realisation often suffices to undermine the salience (in Bayesian terms, precision weighting) previously attributed to their beliefs and metacognitions.The second technique targets excessive attention, the engine of the feedback loop. The Attention Training Technique (ATT) disrupts the positive metacognition that certainty can only be achieved through chronic bodily hypervigilance (self-focused attention) together with constant worry, avoidance, and/or reassurance seeking. ATT normalises human experience, reminding the individual that negative thoughts or worries may intrude but need not derail them: they can simply notice them before returning to their goal. With increased cognitive capacity for goals and tasks, efficiency, productivity, and mood improve, whilst the fatigue accompanying many functional disorders may lessen.What next? The search for a unitary explanation for FND continues. Physicians' lack of diagnostic certainty and the historical neglect of research into female predominant disorders are cited as significant factors in the under-funding of this common condition (McLoughlin et al, 2023). Notwithstanding the fragmentation of care, there is growing evidence that individuals with functional movement disorders can be successfully treated with specialist physiotherapy, bypassing talking therapies altogether. LaFrance's CBT protocol for managing functional seizures is a validated treatment that returns agency to patients. (LaFrance et al, 2014). Other patients with functional disorders may opt for exploratory, cognitive-behavioural or values-based approaches, while still others will decline all therapeutic offers. Unknown numbers never reach tertiary services, attending only the Emergency Department or their own doctor. Many, usually men, are believed to be misdiagnosed with less stigmatizing conditions. (McLoughlin et al, 2023).Patients frequently come to therapy feeling stigmatized. Many report being repeatedly dismissed by consultants unfamiliar with functional symptoms (Kannan, 2009). For these groups, psychoeducation provides an important opportunity for them to air their grievances as well as restore their belief that treatment may be effective. Metacognitive Therapy does not typically offer psychoeducation about the aetiology of conditions and avoids being drawn into debates about the patient's view of their own condition. Instead, it actively discourages patients from ruminating about their experiences, viewing rumination as part of the CAS. This may be seen as a limitation. However, sharing the formulation-linking the presenting complaint to the patient's CAS processes that maintain it (in MCT terms, bridging) -may strengthen the therapeutic alliance and improve outcome. Moreover, the gold-standard practice of embedding therapy within a multidisciplinary framework allows psychoeducation to be provided elsewhere in the patient's care.Research into the biological underpinnings of FND (specific biomarkers, neurobiological mechanisms) and the evaluation of candidate therapies proceed along parallel, independent tracks. In the UK, however, CBT has become the default psychotherapy, reflecting its historical primacy. I argue that this has resulted in institutional inertia and -despite variable outcomes -a monopoly that disadvantages patients [CITATION?]. In a recent article, Marano and Mazza (2026) state that a core element of successful CBT protocols is 'addressing the metacognitive awareness of symptom awareness ' (p. 15). Yet, although some protocols incorporate decentring techniques, CBT's core targets -Negative Automatic Thoughts (NATs), Rules for Living and Core Beliefs -remain object-mode thoughts.The burden of FND on the sufferer, the Exchequer and society is huge and largely avoidable.MCT is acceptable to a majority of patients. It is parsimonious, transdiagnostic and evidencebased, showing large effect sizes and stable gains across mental health disorders (Andersson et al., 2025). Recent trials have highlighted its success in treating physical health conditions, including Long Covid, a condition that shares maintenance factors with FND. Furthermore, its understanding of distress reflects current research on the triggers and maintenance factors of FND. These considerations now warrant controlled trials of MCT in FND, so that it can take its place alongside other psychotherapies in relieving the physical and emotional suffering of this common yet undertreated disorder.