Table 2.

Diagnostic and Treatment Pitfalls in FND.

Diagnostic Pitfalls in FND
Pitfalls that can lead to a wrong FND Diagnosis	Pitfalls that can lead to failure to make a correct FND diagnosis
Jumping to conclusions based on psychological history/stress	Absence of psychological risk factors/stress
Failure to consider an additional medical/neurological cause	Failure to consider FND in presence of additional medical/neurological condition
Not basing diagnosis on presence of positive diagnosis signs	Lack of awareness of positive features of FND
Diagnosis based on ‘bizarre’ presentation alone	Male, older patient
Reliance on normal investigations	Placing too much weight on incidental imaging findings (e.g., white matter lesions)
Treatment Pitfalls in FND
Do’s	Don’ts
Explain the diagnosis on the basis of positive clinical features of FND	Only describe normal investigations or frame as a medical mystery
Where possible demonstrate positive clinical signs supporting the diagnosis. Explain to family and friends as well.	Jump straight to risk factors (‘stress’, ‘psychological’) when discussing possible causes of symptoms
Check and consolidate understanding of the diagnosis. Consider copying correspondence to patients. Provide written information. Signpost to online information and support organizations.	Only provide written/online information without also providing or referring on for treatment
Encourage early and active goal-directed rehabilitation. Engage family and friends with that process.	Encourage unrealistic expectations. Improvement is a gradual active process, and many patients do not improve.
Refer for appropriate therapies (physiotherapy, psychology, speech-language therapy, occupational therapy)	Discharge without any plan for follow-up or further treatment while patient remains significantly symptomatic and/or disabled by symptoms
Treat comorbidities - e.g., depression, anxiety disorders (including PTSD), sleep disorders. Refer to psychiatry if necessary.	Neglect to treat comorbid psychiatric disorders
Address unhelpful medication regimes; opiates, benzodiazepines, and other sedative medications can worsen symptoms of FND	Suddenly withdraw medications without warning
Connect with other professionals to prevent unnecessary and potentially harmful investigations or treatments. Support with training.	Assume that all new symptoms are FND; FND may be comorbid with or precede other neurological disorders. Assess new symptoms on their own merits.