Functional Neurologic Disorder Series - Part 4

In part four of this seven-part series on FND, Dr. Jon Stone and Dr. Gabriela Gilmour discuss the diagnostic explanation. 

Show citation: 

Stone J. Functional neurological disorders: the neurological assessment as treatment. Pract Neurol. 2016;16(1):7-17. doi:10.1136/practneurol-2015-001241 

Gilmour GS, Lidstone SC. Moving Beyond Movement: Diagnosing Functional Movement Disorder. Semin Neurol. 2023;43(1):106-122. doi:10.1055/s-0043-1763505 

Podcast transcript: 

Dr. Gabriela Gilmour: This is Gabriela Gilmour with the Neurology Minute. Jon Stone and I are back to continue with part four, of seven, of our series on functional neurological disorder. Today we will focus on the diagnostic explanation.

So many patients have never heard of FND before receiving this diagnosis. Can you share how you explain the diagnosis to your patients?

Dr. Jon Stone: So I'm aware that many neurologists do find this difficult. And I have to say, having thought about it for 20 years or so now, I think the answer is, don't be weird. Do what you normally do with any condition, when you explain it to patients.

I think what goes wrong is that people see FND as something weird and other, and they start to do weird things like telling people that their scans are normal, or telling them what they don't have before they've started to tell them what they do.

If you go with the normal rules of explanation, first of all, starting by giving it a name that you prefer, so you've got FND, or try and be specific if you can. You've got functional seizures, functional movement disorder. Give it a name to start with. Don't sort of spend a long time beating around the bush before you do that. Talk a bit about why you've made the diagnosis, because that's what you normally do.

So if someone's got a weak leg, show them their Hoover's sign. I think actually showing people their physical signs is probably one of the most powerful things you can do, brings the diagnosis away from the scanner and into the clinic room. And also, they can see in front of them the potential for improvement. So it feeds forward into treatment.

Yes, you might need to explain why they don't have some other conditions that they're worried about, but you can leave discussions about why it's happened for later. I think what tends to go wrong is people jump into that too early.

So the bottom line, just do what you normally do and things generally go a lot more smoothly.

Dr. Gabriela Gilmour: And when you're providing the diagnostic explanation, it can be really helpful to link the patient's experience and their symptoms to the diagnosis. And so, I wonder how you integrate that piece into your diagnostic explanation, or how you tailor your explanation to an individual patient.

Dr. Jon Stone: Yeah, I think tailoring is really important here. And this is where obviously if you've done your assessment, so helpful to ask the patient is, "Well, what do you think's wrong? What things were you worried about? " Some people say, "Look, I'm really worried I've got MS." Or some people say, "I haven't got FND. I've read about that. " Or sometimes people are wondering if they've got FND. So, you've got to try and tailor it to what the person is expecting and particularly previous experiences. If they're telling you how angry they were about doctors A, B, and C, then obviously you want to use that and try not to end up with the same outcome. Why would there be a problem with this diagnosis? It's because they haven't heard about it, because they've got misconceptions about it. Do they feel that this diagnosis would be saying it's all in their mind or something like that? You might need to be explicit about that.

But I think this links into how, it's not just about the diagnostic label, it's about a formulation, which is something we don't think about much in neurology. So there's a label for what's wrong, but in FND, a formulation, why have you got FND, in your particular case, is what we're sort of moving on to there based on the story that you've heard.

Dr. Gabriela Gilmour: Yeah. And I think in my experience and in working with trainees, really just practicing, saying it, is so important and saying it in a way that feels honest and correct to you as a clinician.

Dr. Jon Stone: Yeah, absolutely.

Dr. Gabriela Gilmour: So we will be back for more Neurology Minute episodes to continue our discussion on FND.

Next, we're going to be talking about treatment. Thanks for listening.