Functional neurological disorder diagnosis divides patients and clinicians

Clinical takeaway: When considering functional neurological disorder (FND) in patients with systemic autoimmune rheumatic diseases (SARDs), explain clearly why symptoms are being attributed to FND rather than autoimmune disease, acknowledge diagnostic uncertainty, and avoid language that implies symptoms are voluntary or “all in the patient’s head.”

Neurologic symptoms such as weakness, tremor, sensory changes, cognitive dysfunction, and nonepileptic seizures can occur in both FND and autoimmune rheumatic diseases, making attribution difficult. Misattribution in either direction may affect treatment decisions, while stigma surrounding functional diagnoses can undermine trust and engagement in care.

An international mixed-methods study explored views of FND co-diagnoses among 1,853 patients with SARDs, 400 clinicians, and 463 members of the public, supplemented by interviews with 19 patients and 27 clinicians. Researchers found striking disagreement about the validity and usefulness of FND diagnoses in autoimmune disease.

Patients were far more likely to agree that a diagnosis of depression was correct (86%) than fibromyalgia (53%) or FND (30%). Just 7% agreed with diagnoses explicitly labeled “psychosomatic.” Meanwhile, about 30% of clinicians believed FND diagnoses in lupus were incorrect at least half the time, highlighting uncertainty even among specialists.

Interviews revealed concerns about both overdiagnosis and underdiagnosis of FND. Some clinicians worried that autoimmune symptoms were being mislabeled as functional, while others felt functional symptoms were driving unnecessary immunosuppressive treatment. Many rheumatologists reported limited training in FND, and clinicians described widely differing thresholds for making the diagnosis.

How clinicians communicated the diagnosis appeared to be critical. Patients reported greater acceptance when physicians listened carefully, explained their reasoning, and distinguished FND symptoms from those attributed to autoimmune disease. In contrast, poorly explained diagnoses were associated with shame, loss of trust, and, in some cases, suicidal thoughts. The authors concluded that multidisciplinary care, diagnostic humility, and patient-centered communication are essential when managing complex neuropsychiatric symptoms in autoimmune disease.

“People need to know that their symptoms are being taken seriously, understand why doctors think a particular diagnosis fits, and feel able to come back if things change,” patient co-author Michael Bosley said in a news release.

Source: Sloan M, et al. (2026 Oct 26) Rheumatol Int. “False dichotomies” and “FND fundamentalists”: an international mixed methods exploration of clinician and rheumatology patients’ views and experiences of functional neurological disorder (FND) co-diagnoses