Functional Neurological Disorder May Still Carry Stigma

Functional neurological disorder (FND) is often misunderstood and needs recognition and parity in medical education, research, and clinical service, according to a group of 46 neurologists, researchers, and other experts.

Because it predominantly affects women — and because women’s historical and societal factors continue to shape its narrative — FND is a feminist issue, wrote Laura McWhirter, MBChB, PhD, of the University of Edinburgh in Scotland, and co-authors in a recent review published in the Journal of Neurology, Neurosurgery, and Psychiatry.

In men, FND may be underrecognized due to potential diagnostic bias, the authors stated. Moreover, sexual abuse and violence are gender-weighted risk factors for FND, they observed.

“FND is the second most common reason for patients to attend neurology clinics, estimated to have an incidence of 4-5 per 100,000 and therefore to be present in the population at a similar frequency to multiple sclerosis and Parkinson’s disease,” McWhirter and colleagues wrote. “Women are disproportionately affected by FND across phenotypes, with rates of 70% in most large studies.”

FND refers to disorders caused by an abnormality in brain signaling with no significant structural brain damage. It can have a variety of clinical manifestations, including weakness, sensory changes, involuntary movements, gait disturbances, dissociative episodes, and speech problems. In the U.S., annual charges for emergency department and inpatient FND care are estimated at more than $1.2 billion per year.

Over time, FND has shifted from a “rule-out” diagnosis to one based on positive clinical signs. Despite this, stigma about FND is pervasive in both subtle and overt forms, the authors maintained, hindering patients’ ability to get diagnosed and treated.

“As clinicians working with people with FND every day, we see firsthand the damaging effects of discrimination and stigma in our patients and their ability to engage with treatment,” McWhirter told MedPage Today.

“Although FND affects both women and men, the history of FND — being wrapped up with history of ‘hysteria’ — has contributed to FND being stigmatized and neglected,” she continued. “Would this have happened to a disorder predominantly of men?”

The origins of FND stigma are complex, the authors said. The interplay of women’s health and societal factors has been studied in great depth historically, they noted, especially in Victorian depictions of neurasthenia and hysteria.

“The problematic history of hysteria needs to be clearly separated from current definitions of FND, which can be diagnosed on the basis of positive clinical signs with very low rates of misdiagnosis,” McWhirter said. Recent FND misdiagnosis rates have been reported at less than 4%, for example, and a 14-year follow-up study found a diagnostic revision rate of 1%.

“The stigma attached to FND also comes from an era when FND was confused with malingering — that is, the idea that patients were ‘faking’ their symptoms,” noted Alberto Espay, MD, MSc, of the University of Cincinnati, who wasn’t involved with the review.

“While this was entirely inaccurate, the effects have persisted,” Espay told MedPage Today. “As the authors point out, the evidence shows that FND is not compatible with feigning.”

“Clinicians need to be aware of the lingering prejudice against FND and the importance of making a diagnosis entirely dependent on the neurological exam and independent from the psychological stressors,” Espay added. “If it were not for the strong association of FND with sexual abuse, which disproportionally afflicts women, the prevalence of FND may be similar in men and women, quite different from what we have been led to believe.”

Despite FND being one of the most common reasons for presentation to the neurology clinic, there have been few randomized controlled multicenter trials looking at FND treatment, the authors observed. At the time the paper was written, 285 studies were recruiting for epilepsy, they noted; 185 were recruiting for motor neuron disease, 446 for multiple sclerosis, 556 for Parkinson’s disease, and 10 were recruiting for FND.

“FND, like other disorders historically seen as predominantly female, is massively neglected in terms of research and specialist clinical service provision,” McWhirter said.

“As clinicians, we have a responsibility to examine our own biases and preconceptions here and to recognize the discrimination many of our patients — male and female — have experienced prior to diagnosis,” she added. “We must work towards equity for FND in research and clinical services.”