“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
11 affiliations
- 1Faculty of Medicine and Health, University of East Anglia, Norwich, UK
- 2Department of Public Health and Primary Care Unit, University of Cambridge, Cambridge, UK
- 3Department of Neurology, Guy’s and St Thomas’ Hospitals NHS Foundation Trust, London, UK
- 4Institute of Psychiatry, Psychology and Neuroscience, King’s College London, and South London and Maudsley NHS foundation trust, London, UK
- 5Department of Rheumatology, Guy’s and St Thomas’ Hospitals NHS Foundation Trust, London, UK
- 6Patient and Public Co-investigators, Cambridge, UK
- 7Swansea University Medical School, Swansea, Wales
- 8Department of Rheumatology, St George’s Hospital Trust, London, UK
- 9Department of Neurology, Bart’s Hospital Trust, London, UK
- 10Rheumatology Unit, Department of Medical Sciences, University of Ferrara and Azienda, Ospedaliero-Universitaria S. Anna, Ferrara, Italy
- 11Department of Psychiatry and Behavioral Sciences, Davis Medical Center, University of California, Sacramento, CA USA
Abstract
Functional neurological disorder (FND) presentations include limb weakness, tremors, non-epileptic seizures, and sensory symptoms. FND can present diagnostic challenges in systemic autoimmune rheumatic diseases (SARDs) due to overlapping neuropsychiatric symptoms. Evidence regarding its role and impact as a potential co-diagnosis in SARDs remains limited. Mixed methods data from international surveys and interviews were used to explore FND as a co-diagnosis in SARDs. Quantitative analyses included group comparisons using t-tests, ANOVA and Kruskal-Wallis tests as appropriate. Qualitative data were analysed thematically. Survey responses (N = 1853 patients, N = 400 clinicians, N = 463 general population) and in-depth interviews (N = 19 patients, N = 27 clinicians), indicated substantial variation in perspectives. Patients’ agreement with their co-diagnoses was higher for depression (86%) than for FND (30%). Participants described experiences suggestive of misattribution in both directions and perceived variation in diagnostic attribution between clinicians. Communication of an FND co-diagnosis varied; when interpreted as implying symptom controllability, this was associated with increased distress and reduced acceptance. Clinicians (72.1%) were significantly more likely than patients (50.2%) and the general population (47.9%) to state that mental health symptoms were considered more acceptable/less stigmatised if they were from the direct effects of the systemic disease (Welch’s F(2647) = 135.006), p < 0.01. Clinicians often used dualistic categorisations of symptoms (e.g., functional versus “organic”). Other clinicians considered dualism particularly unhelpful in SARDs due to the multiplicity, complexity and inter-relatedness of symptoms and aetiologies. FND as a co-diagnosis in SARDs is variably understood and applied, with differing levels of clinician agreement and patient acceptance. Clear, patient-centred explanations of diagnostic attribution, including how symptoms are interpreted and how symptoms being attributed to FND differ from SARD symptoms, may improve understanding and acceptance. These findings highlight the need for improved communication, multidisciplinary approaches and holistic care to support patients with complex neuropsychiatric symptoms.
Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1007/s00296-026-06296-w.
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BibTeX
@article{sloan2026false,
title = {{“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}},
author = {Melanie Sloan and Guy Leschziner and Arjoon Arunasalam and David D’Cruz and Lucy Calderwood and Rupert Harwood and Arvind Kaul and Michael Bosley and Mervi Pitkanen and Sharmilee Gnanapavan and Max Yates and Alessandra Bortoluzzi and James A. Bourgeois},
journal = {Rheumatology International},
year = {2026},
month = oct,
doi = {10.1007/s00296-026-06296-w},
url = {https://doi.org/10.1007/s00296-026-06296-w},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - “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
AU - Melanie Sloan
AU - Guy Leschziner
AU - Arjoon Arunasalam
AU - David D’Cruz
AU - Lucy Calderwood
AU - Rupert Harwood
AU - Arvind Kaul
AU - Michael Bosley
AU - Mervi Pitkanen
AU - Sharmilee Gnanapavan
AU - Max Yates
AU - Alessandra Bortoluzzi
AU - James A. Bourgeois
PY - 2026
DA - 2026/10/16
JO - Rheumatology International
DO - 10.1007/s00296-026-06296-w
UR - https://doi.org/10.1007/s00296-026-06296-w
AB - Functional neurological disorder (FND) presentations include limb weakness, tremors, non-epileptic seizures, and sensory symptoms. FND can present diagnostic challenges in systemic autoimmune rheumatic diseases (SARDs) due to overlapping neuropsychiatric symptoms. Evidence regarding its role and impact as a potential co-diagnosis in SARDs remains limited. Mixed methods data from international surveys and interviews were used to explore FND as a co-diagnosis in SARDs. Quantitative analyses included group comparisons using t-tests, ANOVA and Kruskal-Wallis tests as appropriate. Qualitative data were analysed thematically. Survey responses (N = 1853 patients, N = 400 clinicians, N = 463 general population) and in-depth interviews (N = 19 patients, N = 27 clinicians), indicated substantial variation in perspectives. Patients’ agreement with their co-diagnoses was higher for depression (86%) than for FND (30%). Participants described experiences suggestive of misattribution in both directions and perceived variation in diagnostic attribution between clinicians. Communication of an FND co-diagnosis varied; when interpreted as implying symptom controllability, this was associated with increased distress and reduced acceptance. Clinicians (72.1%) were significantly more likely than patients (50.2%) and the general population (47.9%) to state that mental health symptoms were considered more acceptable/less stigmatised if they were from the direct effects of the systemic disease (Welch’s F(2647) = 135.006), p < 0.01. Clinicians often used dualistic categorisations of symptoms (e.g., functional versus “organic”). Other clinicians considered dualism particularly unhelpful in SARDs due to the multiplicity, complexity and inter-relatedness of symptoms and aetiologies. FND as a co-diagnosis in SARDs is variably understood and applied, with differing levels of clinician agreement and patient acceptance. Clear, patient-centred explanations of diagnostic attribution, including how symptoms are interpreted and how symptoms being attributed to FND differ from SARD symptoms, may improve understanding and acceptance. These findings highlight the need for improved communication, multidisciplinary approaches and holistic care to support patients with complex neuropsychiatric symptoms. Supplementary Information: The online version contains supplementary material available at https://doi.org/10.1007/s00296-026-06296-w.
SN - 0172-8172
SN - 1437-160X
ER -