Why psychiatrists need to know about FND

At present, the diagnosis of FND is based on ‘rule-in’ signs diagnosed by a neurologist. Treatment may require the collaboration of a multidisciplinary team including professionals such as physiotherapists, psychologists, psychiatrists, and occupational and speech and language therapists. However, such teams, which can address the complexities of FND, are sometimes available only in tertiary centres. For patients who cannot access such services, psychiatrists (especially in liaison settings) can still play a large role in diagnosis and formulation: providing brief, short-term management solutions for patients suffering from functional symptoms. ^{Reference Jasmin, Walker, Guthrie, Trigwell, Quirk and Hewison5}

There are many other reasons why psychiatrists need to know about FND. A psychiatric assessment for a newly presenting patient with FND is useful, as comorbid psychiatric disorders are common. Mood disorders occur at double the rate in equivalent neurological disorders. ^{Reference Hallett, Stone and Carson6} Emerging literature also suggests a higher than expected co-occurrence of autistic traits and FND, highlighting the need for mental health expertise. ^{Reference Gonzalez-Herrero, Happé, Nicholson, Morgante, Pagonabarraga and Deeley7} Furthermore, it is important for psychiatrists – especially those working in forensic settings – to be able to differentiate between FND and factitious disorder or malingering. ^{Reference Edwards, Yogarajah and Stone8} In fact, a recently developed optimal treatment pathway for FND explicitly mentions the roles of liaison psychiatry and community mental health teams in the management of the disorder. ⁹ These reasons highlight the importance for psychiatry trainees to learn about FND.

FND in the core psychiatry curriculum

From a training perspective, viewing FND as solely ‘neurology’s territory’ serves only to broaden the gap between physical and mental health. Disorders that are more traditionally considered ‘neurological’, such as Parkinson’s disease, dementias and cerebrovascular disease, heavily feature in the Royal College of Psychiatrists’ (RCPsych’s) core psychiatry training curriculum – and yet FND is absent. The knowledge-based MRCPsych Papers A and B include broad categories such as medically unexplained symptoms, somatisation and dissociative disorders, but they do not explicitly reference FND or reflect contemporary neurobiological models of the disorder. At present, the MRCPsych neuroscience syllabus prioritises ‘a locationist approach’ to neurology and neuropsychiatry, resulting in trainees memorising the functions of individual lobes and structures, and how their respective lesions may clinically present. Although such topics help identify the basics of brain function, contemporary cognitive neuroscience has shifted the focus towards studying large-scale intrinsic brain networks. These networks involve areas of the brain that may be geographically distant but likely have functional connectivity. Neuroscientific models such as predictive processing are also rarely featured in the MRCPsych curriculum. Although these concepts remain somewhat theoretical, they are relevant to both FND and core psychiatric disorders such as schizophrenia.

Similarly, psychotherapy training within the core curriculum outlines modalities potentially applicable to FND, yet it fails to acknowledge their relevance to this patient group. In practice, this lack of specificity means that trainees receive little structured teaching on the recognition, formulation and multidisciplinary management of FND, despite encountering such patients regularly in liaison psychiatry and general adult services. The MRCPsych Clinical Assessment of Skills and Competencies (CASC) examination also illustrates this gap. Although its scope allows for assessment of any ICD disorder, FND is not represented in standard scenarios, unlike more established conditions, for example eating disorders or dementias. This lack of assessment emphasis sends an implicit message that FND is peripheral to psychiatry, reinforcing a cycle where supervisors do not prioritise teaching and trainees are likely to have low confidence in managing these complex cases. We would encourage psychiatry curricula to acknowledge the positive ‘rule-in’ signs of FND (such as Hoover’s sign), ^{Reference Stone, Burton and Carson10} allowing for future psychiatrists to become more confident in diagnosis alongside neurologists.

Training opportunities

Compounding these weaknesses in the core curriculum is the absence of training opportunities in the UK. Anecdotally speaking, liaison psychiatry jobs are highly competitive, and many trainees miss out on seeing psychiatric patients in the general hospital setting. More striking is the lack of neuropsychiatry opportunities, despite surveys showing considerable trainee interest. ^{Reference Costello, Baum, Watson, Badenoch, Burchill and Rogers11} Although FND is explicitly mentioned in the syllabus for higher training in neuropsychiatry jointly produced by the RCPsych’s Faculty of Neuropsychiatry, the Association of British Neurologists and the British Neuropsychiatry Association, this remains only advisory. Neuropsychiatry is not recognised as a GMC-approved subspecialty, it has no formal certificate of completion of training (CCT) pathway, and deaneries are under no obligation to provide structured training in this area. As a result, exposure to FND depends heavily on local opportunities and individual supervisors, creating wide variation in clinical experience. The lack of a formal training pathway mirrors the fragmented service provision for FND across the UK, reinforcing the marginal position of the disorder within psychiatry. Taken together, these omissions risk perpetuating outdated explanatory models and terminology, widening the gap between psychiatry and neurology, and leaving future psychiatrists ill-prepared to provide evidence-based, compassionate care for a large and neglected patient population.

Suggestions for the future

As a group of psychiatry trainees, we suggest that FND could be more explicitly represented within the MRCPsych curriculum. Organisations such as the Functional Neurological Disorders Society (FNDS) and the British Neuropsychiatry Association (BNPA) are replete with resources that can shape future examination questions and e-learning material.

One way of bringing about change within existing assessment structures would be the inclusion of FND-related content in the CASC examination. For example, a station could involve a focused history and brief neurological examination of a patient presenting with limb weakness. This would assess a range of skills, including a candidate’s ability to identify positive clinical signs consistent with FND (this includes symptom variability, inconsistency on distraction and Hoover’s sign), to communicate findings clearly and to demonstrate an understanding of FND. This type of assessment would be associated with learning outcomes, including: (a) recognising common presentations of FND; (b) eliciting and interpreting positive clinical signs; (c) integrating neurological and psychiatric formulations; and (d) communicating a diagnosis of FND in a clear and non-stigmatising manner.

We hope that greater curricular visibility would also support the inclusion of FND within local teaching programmes for residents, specialty and specialist (SAS) doctors and consultants, and facilitate exposure to FND cases for psychotherapy training. Locally, we would encourage trusts to organise joint teaching with neurology trainees. We also advocate for the addition of a neuropsychiatry case-based discussion (CBD) to core psychiatry training (similar to the addictions CBD) to help expose trainees to neuropsychiatric presentations such as FND. Such a CBD could involve the supervised discussion of a neuropsychiatric case, for example FND. The emphasis of these CBDs should be on diagnostic formulation, use of positive clinical features, multidisciplinary working and reflective practice. More broadly, we would advocate for the development of more liaison and neuropsychiatry training opportunities, with the possibility of psychiatry trainees joining neurology teams and vice versa, a collaboration that would benefit both training curricula and may influence the development of future services.