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Ten Myths of FND

This is a tweet thread I wrote in May 2020 to support a paper I wrote for the European Journal of Neurology about FND. I hope you find it useful as well

“Ten Myths about FND” just out in Eur Journal of Neurology  @SarahLidstone@rmmaraujo, myself and @basbloem@EANeurology. People with FND come up against a lot of these during diagnosis and treatment.

Functional Neurological Disorder is still emerging from a long period of scientific and clinical neglect. Many clinicians haven’t caught up with recent advances in practice, research or attitudes

We know its frustrating when papers are behind paywalls – so we thought we’d give you a rundown of our myths in an “FND myth tweetorial”. 

Myth 1: FND is a diagnosis of exclusion. No! It’s a “rule in” diagnosis based on typical signs such as Hoover’s sign or tremor entrainment. Figure from… 4/

From Current Concepts in the Diagnosis and Treatment of Functional Neurological Disorders

Myth 2: Patients have either FND or another neurological disorder. No! Having another condition like epilepsy or Parkinson’s disease is one of the strongest risk factors (about 10-20%). 

Myth 3: A bizarre presentation indicates FND. No! There are many examples of unusual presentations in patients with other neurological conditions. FND is not inherently more bizarre.  

Myth 4: Different phenotypes of FND indicate different disorders. No (sort of )! Although a seizure is a very different symptom to paralysis there are shared mechanisms and comorbidities such as pain, fatigue between all patients with FND. 

Myth 5: FND symptoms are voluntary. No! FND symptoms are involuntary; patients are not “putting them on” and feigning is rare. See neurophysiological studies, differential recovery in trials, consistent presentations comorbidities across cultures and across time. 

Myth 6: There is no role for investigations in the diagnosis of FND. No! Other neurological conditions are such a strong risk factor for FND – think – what else could this patient have? Some investigations such as Tremor analysis can help with positive diagnosis. 

Myth 7: There is less harm in missing a diagnosis of FND than missing another neurological disease. No! Any misdiagnosis is distressing but erroneously diagnosing FND, a potentially treatable condition, as another neurological condition can be as harmful as the reverse. 

Myth 8: FND is exclusively a psychological problem. No! Psychological factors are one of many possible risk factors for FND and should not be considered the sole etiological cause. For some they are the most important, for others they aren’t relevant. 

Myth 9: The prognosis of FND is usually good. No! Patients with FND have disability and impaired quality of life as patients with other neuro conditions. Some have complete recovery others long term problems. Dont just assume, ‘the patient will probably just get better’. 

Myth 10: The treatment of FND is SOLELY psychological. No (sort of !). FND needs individualised multidisciplinary treatment. Education, physical + psychological rehabilitation all can have a role. Psychological therapy can be the main treatment for some people with FND especially seizures. 

Attitudes and practices toward FND are changing but the many misconceptions that surround it continue to obstruct good medical care for these patients. 

Thanks @basbloem for having the idea for this paper, @SarahLidstone for leading the writing and @rmmaraujo for coauthoring. END! 

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