Abstract Background/Aims In DSM-5-TR, functional neurological disorder (FND) is listed under the diagnosis of “conversion disorder (functional neurological symptom disorder)” and in ICD-11 as “dissociative neurological symptom disorder”. Presentations include limb weakness, tremors, non-epileptic seizures, cognitive and sensory symptoms. FND represents a diagnostic challenge due to shared symptoms with systemic autoimmune rheumatic diseases (SARDs). FND is an increasingly common co-diagnosis with many autoimmune diseases, yet there is limited knowledge of its potential co-morbidity with SARDs. Increased understanding of FND as a potential SARD co-diagnosis, and improved FND diagnostic processes, would reduce misattributions in both directions. Methods Mixed methods were used to explore the justifiability, acceptability, accuracy, and helpfulness of FND as a co-diagnosis in SARDs. Online surveys were completed as part of the international INSPIRE project, with interviewees purposively selected from survey respondents to ensure sociodemographic diversity. Quantitative data were presented descriptively, with t-tests and ANOVA used for comparisons of groups. Qualitative data were analysed thematically. Results Survey responses (N = 1853 patients, N = 301 clinicians, and N = 463 general population) and in-depth interviews (N = 18 patients, N = 26 clinicians), revealed strong and conflicting viewpoints. Patients’ agreement with co-diagnoses was higher for depression (86%) than FND (30%), and lowest for diagnoses explicitly using the term “psychosomatic” (7%). The proportion of clinicians estimating that FND was incorrectly given in “around half of all cases or more” for lupus patients was 30%. Misdiagnoses were reported in both directions. Communication of an FND co-diagnosis was often felt to be poor, and particularly distressing when thought to imply that symptoms were within the patient’s control. Analysis of successful diagnostic appointments found that a key component was an empathetic and accessible description of a functional disorder. This included explanations of how it fits with the patient’s symptoms, and how it differs from symptoms directly attributable to the SARD. Interviews suggested that the chance of receiving an FND co-diagnoses was heavily influenced by the clinician’s position on FND, which were strongly divided. Dualistic categorisations of symptoms (e.g., functional versus “organic”) were used by some clinicians. Other clinicians considered this dualism particularly unhelpful in SARDs due to the multiplicity, complexity and inter-relatedness of symptoms and aetiologies. Clinicians working in the FND field and/or psychiatry discussed the key importance of a biopsychosocial explanation, but felt that many clinicians could be dismissive of functional symptoms and that currently: “with FND there’s probably more bad experiences and bad clinician behaviour than good” (Clinician 12, Neurologist). Conclusion FND as a SARD co-diagnosis is highly contentious among clinicians and currently not often communicated and/or received well. Although attribution is essential for management with the appropriate combination of pharmacotherapy and psychosocial treatments, our data supports the biopsychosocial model as opposed to dualistic and (currently) stigmatising co-diagnoses. Disclosure M. Sloan: Consultancies; MS reports consultancy fees paid to the department of Public Health from Otoimmune. Grants/research support; MS reports grants to her Long-Term Conditions Group from The Lupus Trust, Lupus UK, Vasculitis UK, SRUK and The NIHR. G. Leschziner: None. A. Arunasalam: None. D. D’Cruz: None. L. Calderwood: None. R. Harwood: None. A. Kaul: None. M. Bosley: None. M. Pitkanen: None. S. Gnanapavan: None. M. Yates: None. S. Taylor: None. A. Bortoluzzi: None. J.A. Bourgeois: None.
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