When Dramatic Symptoms Are Dismissed: The Problem with Rule-In FND Diagnosis
Christoff Truter
Spousal caregiver
In the world of FND diagnosis, observation is the primary tool used to positively identify cases caused by non-organic
"functional" factors, rather than by physical damage to the spinal cord, nerves, or brain.
Since we are told that FND is a concrete rule-in diagnosis, the philosopy boldly suggests that true organic or structural damage would always produce predictable and repeatable symptoms every single time. After all, clinicians would not play dice with your health, would they?
Effectively, the clinician looks for unpredictable, variable, inconsistent symptoms that do not fit known neurological disorders. In other words, patterns that do not align with how nerves, muscles, or normal movement function when true damage is observed.
Clinicians may make this assessment by observing that, depending on distraction or attention, the patient’s symptoms lessen or even disappear completely, which they view as a smoking gun.
In previous posts I discussed the reliability of Hoover’s sign in the context of dynamic spinal cord compression. In this post, however, we are going to look at the Romberg test.
Generally, the Romberg test is used to assess vestibular or proprioceptive issues, and a positive result suggests a possible problem along those pathways.
In the FND context, however, this test is applied differently. The clinician specifically looks for incongruent, inconsistent, or overly theatrical responses (as some clinicians would describe it), such as exaggerated or dramatic reactions.
This is where our personal story comes into play. When my wife's symptoms first began escalating several years ago, she initially presented with vestibular issues (still present to this day). Sure enough, she had a positive Romberg test; however, it was so severe that the testing itself made her nauseous and even triggered migraines.
Over time, some of these possible vestibular symptoms improved somewhat, only to relapse years later, then improve again, and relapse once more. In the current cycle, she starts her mornings fairly symptomatic, but as the day progresses into the evening, she experiences great difficulty walking along with fatigue. See video below:
Which leaves one to wonder if their observations, which are highly subjective, lead them to conclude that her strong reactions to their tests, rather than strongly suggesting a vestibular problem, indicate that her responses are theatrical and therefore functional in nature.
Dear reader, do you see the problem here?
Her positive Romberg test, which provokes real symptoms like nausea and migraines, can be dismissed as “theatrical” simply because the reactions appear dramatic.
Here is another example, at the dentist, my wife starts shaking, trembling, and jerking to the point where they have to hold her down and place blocks in her mouth to work on her teeth.
Clinicians may call the reactions in the clip functional because they look dramatic, fluctuate, and can’t be easily measured. These are real neurological or sensory responses, but nobody bothered to investigate the vestibular system further.
If we want to make rule-in FND diagnosis claims, we have to conclude that true organic damage always produces predictable, repeatable symptoms. Any variability is then interpreted as functional, meaning dramatic, real neurological reactions like my wife’s positive Romberg or shaking at the dentist can be dismissed as theatrical, based on an untested philosophical assumption rather than biology.
