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Current Concepts in Diagnosis and Treatment of Functional Neurological Disorders

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Espay, Alberto J., Aybek, Selma, Carson, Alan, Edwards, Mark J., Goldstein, Laura H., Hallett, Mark, LaFaver, Kathrin, LaFrance, W. Curt +7 more·2018·JAMA Neurology
DOI 10.1001/jamaneurol.2018.1264PMC PMC7293766
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Abstract

Importance: Functional neurological disorders (FND) are common sources of disability in medicine. Patients have often been misdiagnosed, correctly diagnosed after lengthy delays, and/or subjected to poorly delivered diagnoses that prevent diagnostic understanding and lead to inappropriate treatments, iatrogenic harm, unnecessary and costly evaluations, and poor outcomes. Observations: Functional Neurological Symptom Disorder/Conversion Disorder was adopted by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, replacing the term psychogenic with functional and removing the criterion of psychological stress as a prerequisite for FND. A diagnosis can now be made in an inclusionary manner by identifying neurological signs that are specific to FNDs without reliance on presence or absence of psychological stressors or suggestive historical clues. The new model highlights a wider range of past sensitizing events, such as physical trauma, medical illness, or physiological/psychophysiological events. In this model, strong ideas and expectations about these events correlate with abnormal predictions of sensory data and body-focused attention. Neurobiological abnormalities include hypoactivation of the supplementary motor area and relative disconnection with areas that select or inhibit movements and are associated with a sense of agency. Promising evidence has accumulated for the benefit of specific physical rehabilitation and psychological interventions alone or in combination, but clinical trial evidence remains limited. Conclusions and Relevance: Functional neurological disorders are a neglected but potentially reversible source of disability. Further research is needed to determine the dose and duration of various interventions, the value of combination treatments and multidisciplinary therapy, and the therapeutic modality best suited for each patient.

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Crossref · 10.1001/jamaneurol.2018.1264

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  • Both MS and FND are common conditions in neurological practice.

    “They also share a similar epidemiology, with a preponderance of female to male patients, and both are common conditions in neurological practice [1].”

    From Functional neurological disorder and multiple sclerosis: a systematic review of misdiagnosis and clinical overlap (2022) · cites this paper as [1]

    The Epidemiology of FND section reports that 5.4% of patients in a consecutive series of neurology outpatients had a primary FND diagnosis and concludes that FNDs are common. The supplied passages do not address whether MS is common in neurological practice, so the source supports only the FND part of the attributed claim. (LLM, conf=0.88)

    Experimental — accuracy not yet measured

  • Multiple sclerosis (MS) and functional neurological disorder (FND) are both diagnostically challenging conditions that can present with similar symptoms.

    “Multiple sclerosis (MS) and functional neurological disorder (FND) are both diagnostically challenging conditions which can present with similar symptoms.”

    From Functional neurological disorder and multiple sclerosis: a systematic review of misdiagnosis and clinical overlap (2022) · cites this paper as [1]

    The Importance passage reports that FND has often been misdiagnosed or diagnosed after lengthy delays, supporting the point about diagnostic difficulty for FND. The Phenomenology and Diagnosis section discusses distinguishing FND from other neurological disorders, but the paper does not address MS specifically or state that MS and FND present with similar symptoms; those parts of the claim are unsupported. (LLM, conf=0.85)

    Experimental — accuracy not yet measured

  • MS and FND share a similar epidemiology, with a preponderance of female to male patients.

    “They also share a similar epidemiology, with a preponderance of female to male patients, and both are common conditions in neurological practice [1].”

    From Functional neurological disorder and multiple sclerosis: a systematic review of misdiagnosis and clinical overlap (2022) · cites this paper as [1]

    The Epidemiology of FND section says women make up an estimated 60%–75% of FND patients and that FND is common in neurology clinics. It does not give comparable figures for MS or establish that the two conditions have similar epidemiology or are both common in neurological practice. Page numbers are unavailable in our copy. (LLM, conf=0.86)

    Experimental — accuracy not yet measured

  • The scientific landscape around FND has changed considerably in the last 10 years.

    “However, the scientific landscape around FND has changed considerably in the last 10 years [1].”

    From Functional neurological disorder and multiple sclerosis: a systematic review of misdiagnosis and clinical overlap (2022) · cites this paper as [1]

    The Treatment section describes emerging evidence for FND treatments, and the Physical Treatment of FND section says a greater role for physical therapy has recently been recognized. These passages support a changing scientific landscape, but the paper does not establish that the change occurred specifically over the last 10 years. (LLM, conf=0.82)

    Experimental — accuracy not yet measured

  • Diagnostic criteria for FND based on DSM-5 emphasize finding evidence of clinical incompatibility with recognized diseases, which in practice requires positive signs of internal inconsistency and incongruity.

    “Diagnostic criteria for FND based on DSM-5 emphasize finding evidence of clinical incompatibility with recognized diseases, which in practice requires the presence of positive signs of internal inconsistency and incongruity [1]”

    From Functional neurological disorder and multiple sclerosis: a systematic review of misdiagnosis and clinical overlap (2022) · cites this paper as [1]

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Authors
Espay, A. J., Aybek, S., Carson, A., Edwards, M. J., Goldstein, L. H., Hallett, M., LaFaver, K., LaFrance, W. C., Lang, A. E., Nicholson, T., Nielsen, G., Reuber, M., Voon, V., Stone, J., & Morgante, F.
Affiliations
  • University of Cincinnati (US)
  • University Hospital of Bern (CH)
  • University of Edinburgh (GB)
  • St George's, University of London (GB)
  • King's College London (GB)
  • National Institutes of Health (US)
  • University of Louisville (US)
  • Department of Psychiatry, Alpert Medical School of Brown University, Providence, Rhode Island
  • University of Toronto (CA)
  • Section of Cognitive Neuropsychiatry, Department of Psychosis Studies, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
  • Royal Hallamshire Hospital (GB)
  • University of Cambridge (GB)
  • Western General Hospital (GB)
  • University of Messina (IT)
ORCID
Venue
JAMA Neurology
Publisher
American Medical Association (AMA)
Published
2018-09-01
Volume
75
Issue
9
Pages
1132
ISSN
2168-6149 (ISSN-L)
DOI
10.1001/jamaneurol.2018.1264
PMC
PMC7293766
OpenAlex
W2805331168
Cited by
786
References
5
Citations by year
2026: 112 · 2025: 115 · 2024: 100 · 2023: 100 · 2022: 137 · 2021: 97 · 2020: 70 · 2019: 46 · 2018: 8
FWCI
8.40
Type
journal article
Language
en
Open access
Locations
  • JAMA Neurology (publishedVersion)
  • PubMed (publishedVersion)
  • St George's Online Research Archive (St George's University of London) (acceptedVersion)
  • PubMed Central (acceptedVersion)
  • Bern Open Repository and Information System (University of Bern) (submittedVersion)
  • White Rose Research Online (University of Leeds, The University of Sheffield, University of York) (submittedVersion)
  • Research Portal (King's College London) (submittedVersion)
Funders
  • National Institute for Health and Care Research (16/31/63, CS-2014-14-016)
  • National Institutes of Health
  • Medical Research Council (MR/M02363X/1, MR/P008747/1)
  • National Institute of Neurological Disorders and Stroke (ZIANS002667, K23NS045902)
Topics
  • Health Sciences › Medicine › Psychiatry and Mental health › Psychosomatic Disorders and Their Treatments
  • Health Sciences › Medicine › Psychiatry and Mental health › Fibromyalgia and Chronic Fatigue Syndrome Research
  • Health Sciences › Medicine › Surgery › Cardiovascular Syncope and Autonomic Disorders
Keywords
conversion disorder, DSM-5 diagnostic criteria, misdiagnosis, delayed diagnosis, supplementary motor area, sense of agency, physical rehabilitation, psychological intervention, multidisciplinary therapy, disability
MeSH terms
Brain, Conversion Disorder, Humans, Nervous System Diseases, Diagnostic and Statistical Manual of Mental Disorders

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