10 Suspicious Things You Apparently Shouldn't Do Around an FND Specialist

Quackademic

13 Oct 2026 0 comments

Planning a visit to a neurologist? You might want to reconsider your outfit, your transport arrangements and whether to bring a notebook. Apparently, even your choice of music could become interesting. The medical literature surrounding functional neurological disorder (FND) and related functional conditions contains some remarkable observations about how patients look, move, behave and respond to their surroundings.

The real concern isn't that these behaviours are necessarily used as formal positive signs of FND. It's that they can contribute to the larger clinical picture. A pair of sunglasses here, a wheelchair there, perhaps a handwritten symptom list for good measure. Before long, a collection of ordinary behaviours may start looking like a pattern. Whether that pattern actually distinguishes FND from other conditions is another question entirely.

Here are ten examples from published medical literature, along with some alternative explanations that apparently deserve their own research funding.

1. Wearing Sunglasses Indoors: The Sunglasses Sign

   In 2008, researchers published a study examining whether wearing sunglasses during a neuro-ophthalmology appointment could predict what they called nonorganic visual loss. Of 1,377 new patients, 34 wore sunglasses, and seven of those 34 had organic visual loss. The authors concluded that wearing sunglasses without an apparent ophthalmic explanation was strongly associated with nonorganic visual loss in their clinical population. Yes, somebody actually studied the diagnostic significance of wearing sunglasses.

   Alternative explanation: Migraine, photophobia, eye disease, medication-related light sensitivity, or hospital lighting powerful enough to interrogate prisoners. Alternatively, the patient might be Bono. Perhaps ask why they're wearing the sunglasses before inviting the eyewear to participate in the diagnosis.

   Reference: The "sunglasses sign" predicts nonorganic visual loss (2008)

2. Using a Wheelchair: Suspicious Transportation

   A 2025 review of FND clinical signs describes someone walking without assistance from the parking lot but requiring a wheelchair inside the clinic as an example of apparent inconsistency. The proposed clue is the difference between the two situations, not wheelchair use itself. Nevertheless, it's an interesting scenario. Apparently, the neurological examination may begin in the car park, and nobody bothered to inform the patient.

   Alternative explanation: Pain, fatigue, weakness, dizziness, fluctuating mobility, or the radical possibility that walking a short distance doesn't mean someone can walk indefinitely. Wheelchairs have been known to transport people who have difficulty walking. Medical science continues to grapple with this astonishing coincidence.

   Reference: Positive Clinical Signs in Functional Neurological Disorders (2025)

3. Bringing a List of Symptoms: The Crime of Being Organised

   A 2023 systematic review and diagnostic meta-analysis of functional cognitive disorder examined 30 studies involving 8,602 participants. Among the findings was an association between bringing a handwritten list of problems and increased odds of a functional cognitive disorder diagnosis in the populations studied. Imagine having memory problems, writing things down so you don't forget them, and discovering that the notebook has become a clinical clue. You arrived prepared for your appointment. What were you thinking?

   Alternative explanation: Memory difficulties, preparation, anxiety about forgetting important information, or the unreasonable expectation that a doctor might appreciate an accurate medical history. Differential diagnosis: patient owns a pen. Perhaps next time write everything on a napkin and eat it before the consultation.

   Reference: Clinical signs in functional cognitive disorders (2023)

4. Attending a Memory Clinic Alone: Independent Travel Is Suspicious

   The same 2023 systematic review identified attending a memory clinic unaccompanied as another feature associated with functional cognitive disorder rather than neurodegeneration. You remembered the appointment, arranged transport, found the building and arrived independently. Congratulations, your ability to get to the doctor has now become part of the research literature.

   Alternative explanation: Independence, privacy, lack of available family members, or simply owning a car. More research is urgently needed into the relationship between car keys and functional cognitive disorder. Next time, bring three relatives, a neighbour and the family dog. Nobody can accuse you of attending unaccompanied then.

   Reference: Clinical signs in functional cognitive disorders (2023)

5. Huffing and Puffing: Please Struggle More Quietly

   There is an actual clinical sign called the "huffing and puffing sign". Researchers have examined behaviours such as grunting, grimacing, breath-holding and conspicuous demonstrations of effort during standing and walking. A 2016 review discusses research reporting relatively high specificity for functional gait disorder in selected patients, particularly when pain was excluded as a confounding explanation. The proposed sign concerns effort judged disproportionate to the observed impairment.

   Alternative explanation: Pain, exhaustion, cardiopulmonary disease, deconditioning, muscle weakness, or the extraordinary physical effort involved in walking when walking is difficult. Differential diagnosis: walking is bloody hard. Please struggle quietly, preferably without grimacing, groaning or otherwise disturbing the neurological atmosphere.

   Reference: Clinical signs in functional (psychogenic) gait disorders (2016)

6. Walking Like You're on Ice: Gravity Is Suspicious

   Functional gait literature describes a "walking on ice" pattern involving unusually cautious, hesitant steps. The 2016 review by Sokol and Espay specifically discusses walking as though navigating a slippery surface. Evidently, trying very hard not to fall can produce a gait pattern interesting enough to acquire its own description.

   Alternative explanation: Vestibular dysfunction, neuropathy, weakness, impaired balance, fear of falling, or previous experience with gravity. The patient may have discovered that hitting the floor hurts and would prefer not to repeat the experiment. Perhaps every neurology department should install an ice rink so the walking pattern finally matches the environment.

   Reference: Clinical signs in functional (psychogenic) gait disorders (2016)

7. La Belle Indifférence: You're Not Miserable Enough

   This may be the most spectacular entry. La belle indifférence, roughly translated as "beautiful indifference", is the historical notion that appearing unusually unconcerned about serious physical symptoms might suggest conversion disorder. Paralysed but calm? Interesting. Unable to walk but still making jokes? Suspiciously cheerful. Apparently, there's a correct amount of visible misery, and somebody forgot to give patients the instructions.

   In 2006, Jon Stone and colleagues reviewed the evidence. The median reported frequency of la belle indifférence was 21% among patients with conversion symptoms and 29% among patients with organic disease. Yes, the supposedly characteristic behaviour was reported more frequently in the organic disease groups. The authors recommended abandoning it as a clinical sign until its definition and usefulness were clarified. A 2017 case report also described progressive supranuclear palsy initially misdiagnosed as conversion disorder, with the patient's apparent emotional indifference contributing to the interpretation.

   Alternative explanation: Acceptance, resilience, exhaustion, depression, neurological changes in facial expression, or a personality that doesn't involve performing Shakespearean tragedy at every medical appointment. Alternative diagnosis: British. Imagine being encouraged to cope with serious illness, only to discover that coping too convincingly might once have been considered suspicious.

   Reference: La belle indifférence in conversion symptoms and hysteria (2006) | Progressive supranuclear palsy misdiagnosed as conversion disorder (2017)

8. Bumping Into Furniture: The Coffee Table Has Entered the Chat

   A 2022 review of functional visual disorders discusses exaggerated movements and collisions with objects that appear inconsistent with the reported degree of visual impairment. It also describes observing patients as they enter the clinic and interact with their surroundings. Apparently, the waiting room furniture may have been recruited into the assessment without receiving any formal medical training.

   Alternative explanation: Visual impairment, depth-perception problems, visual field loss, coordination difficulties, or a coffee table positioned by someone with an obvious disregard for human life. Alternative diagnosis: IKEA. One can only imagine the clinical notes: "Patient collided with chair. Chair declined to comment."

   Reference: Functional Vision Disorders in Adults (2022)

9. Walking Better With Music: Spotify Neurology

   A 2022 case report described rhythmic auditory stimulation during rehabilitation for a 24-year-old woman diagnosed with functional gait disorder. Researchers reported improvements in walking following the intervention. This was a treatment report, not a diagnostic study, but it illustrates how a response to an intervention can become interesting in discussions of neurological function. Rhythmic auditory stimulation has also been studied in Parkinson's disease, stroke and other neurological conditions. Apparently, the nervous system sometimes responds to rhythm. Who knew?

   Alternative explanation: Rhythmic cueing, improved motor timing, attention, motivation, or a nervous system doing what nervous systems sometimes do when presented with a beat. Alternative diagnosis: the patient has discovered the Bee Gees. If walking improves during ABBA, should we investigate the mechanism or prescribe a disco ball?

   Reference: The use of rhythmic auditory stimulation for functional gait disorder (2022)

10. Moving Around on an Office Chair: The Swivel-Chair Examination

    In 2007, researchers published a study examining the "chair test". Nine patients diagnosed with psychogenic gait disorders were asked to walk and then propel themselves forwards and backwards while seated in a wheeled swivel chair. Eight of the nine performed better on the chair task relative to walking, while the nine comparison patients showed no comparable discrepancy. The authors acknowledged that further research was needed to establish the test's diagnostic performance.

    Alternative explanation: Reduced weight-bearing, different balance requirements, less demand for upright postural control, or the fairly obvious distinction between walking and moving while seated. Alternative diagnosis: gravity has been temporarily negotiated with. Perhaps the next study can investigate whether patients improve when the chair has lumbar support, adjustable armrests and free delivery.

    Reference: The "chair test" to aid in the diagnosis of psychogenic gait disorders (2007)

The Larger Clinical Picture: Where the Joke Stops Being Funny

The real concern with these examples isn't that clinicians necessarily diagnose FND because someone wears sunglasses, uses a wheelchair or brings a notebook. It's that observations can influence diagnostic suspicion without being presented as formal evidence. Imagine a patient arriving in a wheelchair, wearing sunglasses because of photophobia, carrying handwritten notes because of memory difficulties, and speaking calmly about their illness. Each behaviour has appeared somewhere in functional-symptom literature. A clinician already considering FND might interpret the combination as a recognisable pattern, despite each observation having a separate, plausible explanation.

This is where confirmation bias and diagnostic anchoring become dangerous. Once a particular explanation becomes prominent, subsequent information risks being interpreted through it. The wheelchair may be seen as inconsistent with a previous ability to walk, the notebook as a feature of functional cognitive disorder, and emotional composure as something psychologically meaningful. None needs to be declared a positive sign. Each can simply reinforce an impression already forming. Worse, the observations may not even be independent: dizziness, fatigue, visual sensitivity and cognitive difficulties could all arise from an underlying illness, with the wheelchair, sunglasses and notebook merely being practical responses to those symptoms. Counting them as separate evidence for FND risks confusing accommodations with diagnostic clues.

A documented association isn't automatically a useful diagnostic discriminator. Research conducted in selected patient groups doesn't necessarily establish how reliably a behaviour distinguishes conditions in ordinary clinical practice, and several weak or correlated observations don't become strong evidence merely because they appear together. La belle indifférence is an excellent historical warning: an impressive French name, a plausible psychological interpretation, decades of clinical familiarity, and ultimately a systematic review finding little justification for its diagnostic use. The question isn't whether clinicians should observe patients. It's whether the meaning assigned to those observations is actually supported by evidence.

Calling something a "clinical clue" instead of a "positive sign" doesn't magically eliminate the need for evidence. If an observation influences the diagnosis, its diagnostic relevance matters. Otherwise, we've simply given confirmation bias a white coat and a medical vocabulary.

Patients shouldn't have to abandon their sunglasses, wheelchairs, notebooks or sense of humour to avoid appearing suspicious. Nor should they need to perform the correct amount of distress, walk with an approved level of confidence, or switch off the Bee Gees before entering a hospital. These things may be observations, accommodations, coping strategies or responses to symptoms. Their presence alone doesn't explain the underlying illness.

Because if a pair of sunglasses, a wheelchair, a notebook and an office chair start looking like a coherent neurological diagnosis, perhaps the most important thing to examine isn't the patient.

Perhaps it's the reasoning.