There are various reasons why health professionals or others may question the legitimacy of your symptoms. Initially, the mechanisms behind functional neurological disorders are not fully understood, causing confusion among patients, their loved ones, friends, and professionals. Diagnostic hurdles arise as FND symptoms do not show up on standard neurological tests like functional MRI scans. FND presents with diverse symptom combinations, underscoring the need for professionals to be knowledgeable in this area. Additionally, FND is sometimes inaccurately associated with other terms, rooted in the historical conversion model, which links physical symptoms to emotional stress. The lack of a clear organic cause and the assumption that FND is solely psychologically driven can lead to patients feeling undervalued and misunderstood by healthcare providers. Encouragingly, recent years have seen significant progress in FND research, education, diagnosis, and treatment, offering hope for improved understanding and care for FND patients.

Positive signs indicate that normal function is present in FND patients, which means that the symptoms are due to a difficulty in controlling the body normally, which of course raises the question of whether these symptoms are genuine or merely simulated. It is possible that someone is simulating their symptoms, but such cases are extremely rare. The following reasons also support the authenticity of the symptoms:

• New neuroscience evidence suggests that patients with FND have different structural and functional brain activity

• Patients with FND are often tireless in their search for answers to their symptoms and are more than willing to participate in medical procedures.

• Symptoms often persist for several years. Simulating symptoms may have a short-term advantage, but it is unlikely that someone would simulate their symptoms for 14 years or more.

• During the course of treatment (e.g. specialist physiotherapy), symptoms are consistent in FND patients, whereas patients simulating symptoms are likely to vary their onset in order to maintain their cover.

• There are experimental studies demonstrating differential neural activity in FND patients compared to healthy controls asked to simulate symptoms.

How to identify simulation?

• The use of performance validity testing (PTV), the main purpose of which is to distinguish between genuine cognitive decline and 'symptom exaggeration'. It is important to note that patients with FND can also fail such tests, suggesting that poor performance on neuropsychological tests is present in a wide range of neurological and neuropsychiatric conditions, not exclusively in patients with FND.

• The use of symptom validity testing (SVT), the premise of which is that if an individual reports symptoms after a specific injury (e.g. traumatic brain injury) that people who have had or are suffering from the injury in question do not, this is indicative of symptom simulation. We must be careful when interpreting the results, as these symptoms, in the absence of an organic (e.g. structural changes in the brain) cause, may also be credible and possibly suggest a diagnosis of FND. In any case, we must be careful not to equate poor performance with malingering.

• Dramatic differences between reported and observed function. Subjective reports should be as consistent as possible with medical history and/or relatives' reports. It is important to note that the inability to assess the severity of symptoms does not mean that the person is malingering.

FND is a functional disorder, meaning that abnormal symptoms and changes in function cannot be explained by measurable changes in organ and body systems. Nevertheless, certain neuroscientific studies suggest that FND patients have distinctive structural and functional activity in the areas of emotion regulation, agency of the self, interoception and attention. E.g. a key characteristic of FND is a partial loss of voluntary control over the body, where patients do not perceive themselves to be the actors of the abnormal movement (e.g. patients report that they give the signal for the correct movement, but the abnormal movement is triggered nonetheless). In the future, many practitioners working with FND, either clinically or academically, are seeking to identify potential biomarkers that would facilitate the diagnosis of the disorder and their presence would have an impact on better understanding and management of patients with FND.

This does not mean that the cause of your problems is absolutely psychological. More modern models try to explain FND within a biopsychosocial (spiritual) perspective, within which the disorder is triggered and maintained by a range of biological, psychological and social factors. Psychological factors thus represent only one piece of the puzzle. The insistence that the cause of FND is purely psychological is the result of the historical burden and stigma, the failure to understand the disorder in a way that is clear to professionals and patients alike, the creation of a strict mind-body divide and, unfortunately, the still stigmatised and non-normalised psychological treatment in the general public. Psychological treatment is and must remain part of multidisciplinary treatment, with careful consideration of the individual characteristics and preferences of each person. Some patients will not need longer psychological treatment and a shorter intervention will suffice, while some will need but not necessarily recognise it. Forcing psychological treatment and persisting in the face of strong patient resistance may do more harm than good in such a case. Nevertheless, it is important to remember that FND is an 'in-and' disorder and not a 'to-or-from' disorder. This means that the patient's condition should always be viewed from a broader perspective, which includes a combination of the factors mentioned above.

The success of psychological treatment depends on the patient's acceptance of the diagnosis and his or her commitment and active involvement in the therapy. It is particularly important for the population of patients diagnosed with FND who also have comorbid psychiatric disorders such as depression, anxiety, PTSD, panic attacks, etc. Before referral for psychological treatment, it is a good idea to describe to the patient the course and timing of the psychological treatment, as well as a general outline of the topics that will be addressed in the course of the therapy (e.g. emotions/thoughts/behaviours and their impact on symptoms).

Psychotherapy can be useful for the vast majority of patients diagnosed with FND, but there is no standardised psychological treatment for functional neurological disorder. Most research supports the effectiveness of cognitive behavioural therapy (CBT), especially for patients with functional seizures. For other subtypes FND , there is a lack of studies examining its effectiveness, so conclusions are limited. Although CBT is effective for the treatment of associated psychological disorders such as depression and anxiety disorders. There are few studies confirming the effectiveness of psychodynamic therapies. However, there is a consensus that psychological treatment is always individually tailored to each patient and that an eclectic treatment approach is used.

Over the last two decades, there has been a renaissance in the understanding of the structural and functional changes in the brain that result in and/or cause functional neurological symptoms. In general, research has found that patients with FND have impairments in areas related to emotion regulation, attention, sense of control over movement, perceptual reasoning and perception of states within the body (interoception). Although the studies have limitations, the clinical findings support their conclusions. Nevertheless, we do not know whether the functional neurological symptoms are caused by the changes in brain structure and functional connectivity or whether they are the cause of the onset and maintenance of the functional neurological symptoms. However, the development and planning of multidisciplinary treatments based on neuroscientific evidence is increasingly recommended.

As mentioned above, the diagnosis is not made on the basis of exclusion factors, but on the presence of positive clinical signs, such as Hoover's sign. Diagnosis is complex and requires a comprehensive formulation of the patient's condition and placing the positive clinical signs in a broader context. In other words, none of the signs suggestive of any neurological and/or psychiatric disorder are reliable when interpreted in the absence of a broader formulation of the patient's condition.

There is still a lack of studies examining the effectiveness of treatment in a large sample of patients with FND. In general, prognosis depends on:

• Time elapsed before the patient was diagnosed

• Accepting the diagnosis and being actively involved in treatment

• The severity and effectiveness of treatment for associated disorders and/or symptoms

• Psychological factors that maintain the disorder (e.g. secondary benefits, psychological fear of recovery)

If you suspect you have FND, see your GP who will refer you to an appropriate specialist (e.g. a neurologist) who can confirm your suspicions with a formal diagnosis. The support of your GP is very important, so if he have not heard of FND, please refer him to the appropriate educational sites.

Diagnosing a functional neurological disorder is difficult and requires clinical experience and extensive knowledge. In addition to FND, there may be comorbid disorders (e.g. anxiety or depression) or comorbid symptoms (e.g. sleep disturbances, fatigue, pain) that also need to be diagnosed and their appropriate treatment planned. The material on this website and on foreign websites does NOT REPLACE the treatment. It is intended only to raise awareness and educate about FND based on scientifically validated information. If the relevant specialist does not believe you and you strongly believe that you may have FND, please refer him to the relevant expert web links, which can be found, among others, on this website.

If you already have a confirmed diagnosis of a functional neurological disorder and are waiting for treatment, the first step is definitely to educate yourself about the disorder. You can find relevant materials in Slovenian, English and Spanish on this website, but you can also read a number of materials in foreign languages under the 'links' tab . Encourage family members, relatives and friends to educate themselves about the disorder, as social support will make a big difference to your wellbeing and treatment outcomes.