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Suicidality in FND: Are Researchers Overlooking the Obvious?

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Suicidal thoughts, suicide attempts and suicide deaths have been investigated in patients diagnosed with Functional Neurological Disorder (FND), particularly those with functional or dissociative seizures. Researchers have examined psychiatric comorbidities, psychological vulnerabilities and clinical risk factors associated with suicidality. But before getting lost in the statistics, there is a much more basic question worth asking: why are researchers looking for psychiatric explanations for distress in people who are already living with potentially devastating illness?

There is a glaring common-sense problem here. If someone is living with constant pain, disabling neurological symptoms, lost independence, financial hardship and no clear answers about what is happening to their body, why would anyone be surprised that they might experience suicidal thoughts? You do not need a psychiatric theory of their neurological illness to understand why they might be desperate. Their circumstances alone provide an obvious explanation worth investigating.

Yet when researchers investigate suicidality in FND, psychiatric comorbidities frequently take centre stage. Why? If the same patient had multiple sclerosis (MS), would we first consider the devastating consequences of living with a neurological disease? What changes when the diagnosis is FND? The patient's suffering has not changed. Only the diagnostic label has.


What are these studies actually investigating?

A 2024 cohort study published in BMJ Mental Health investigated suicidal ideation and suicide attempts among patients diagnosed with functional/dissociative seizures and epilepsy. The researchers examined demographic characteristics and psychiatric diagnoses, including depression and personality disorders, to identify factors associated with suicide risk.

Identifying patients at risk of suicide is an entirely understandable objective. But identifying an association between depression and suicidal thoughts tells us remarkably little about why someone became depressed in the first place. Did depression precede the neurological symptoms? Did it develop after years of disability? Was it influenced by chronic pain, financial hardship, loss of independence or repeated unsuccessful medical consultations? These are not minor distinctions. They are fundamental to understanding what the findings actually mean.

The study included patients with epilepsy, so psychiatric risk-factor research is clearly not exclusive to FND. Nevertheless, the prominence of psychiatric diagnoses raises questions about what is being measured and what is being left out. A statistical association between psychiatric illness and suicidality cannot establish that psychiatric illness caused the neurological symptoms, nor can it establish that psychological vulnerability explains the patient's underlying condition.

The distinction should be obvious: someone can become depressed because they are ill. Finding depression does not tell us why they are ill.


Compare this with multiple sclerosis

A 2025 systematic review and meta-analysis of suicidality in MS examined 64 studies involving more than 200,000 patients. It reported a pooled prevalence of suicidal ideation of approximately 22.6% and suicide attempts of approximately 3.4%. The review acknowledged the substantial challenges of living with a lifelong, unpredictable neurological disease while also examining depression and other potential risk factors.

Research involving functional seizures has likewise documented substantial rates of suicidal thoughts and attempts. However, comparing percentages across separate studies is not sufficient to establish whether the risks are equivalent. Patient populations, recruitment settings, definitions and measurement methods differ. The important observation is simpler: suicidal distress is also found in people with established neurological diseases. Its presence is not evidence that unexplained neurological symptoms have a psychiatric origin.

In MS, the burden of living with a disabling disease is an obvious part of the discussion. Why should the same reasoning not apply to FND? Patients diagnosed with FND can experience severe disability, persistent symptoms, pain, unemployment and dependence on others. Whatever the eventual explanation for their neurological symptoms, the consequences are real.

If researchers believe psychiatric factors play a particular role in suicidality among FND patients, that hypothesis needs to be demonstrated, not simply preferred over the equally plausible explanation that people are distressed because they are suffering.


Is the research agenda influenced by the psychiatric model of FND?

FND has a long history of psychiatric interpretation, and that influence has not disappeared from the literature. A 2024 systematic review by Lazzari and colleagues explicitly advanced the view that FND and psychogenic non-epileptic seizures develop on the basis of other psychiatric conditions. This is an explanatory position about the disorder itself, rather than merely an observation that some patients have coexisting psychiatric diagnoses.

That does not establish that every researcher investigating suicidality is attempting to reinforce a psychiatric explanation of FND. It does, however, demonstrate that psychiatric explanations remain an active part of the research landscape. It is therefore reasonable to examine whether existing theoretical assumptions influence the questions researchers choose to ask, the variables they measure and the explanations they consider most important.

What exactly is the motivation behind these suicidality studies? Is the primary objective to understand the psychological consequences of living with disabling symptoms? Is it to identify patients requiring suicide prevention? Or is it to investigate psychiatric vulnerabilities within an existing explanatory model of FND? These objectives can overlap, but they are not interchangeable, and the stated objectives of the studies examined do not establish a single overarching motivation.

That uncertainty matters. Research does not begin with statistics. It begins with decisions about which questions are worth asking. If investigators repeatedly prioritise psychiatric diagnoses while giving less attention to disability, pain, diagnostic uncertainty and patients' experiences of healthcare, the resulting evidence will be shaped by those priorities.


The common-sense question researchers should be asking

Imagine a patient who has spent years experiencing disabling neurological symptoms. They can no longer work, struggle with everyday activities, have lost financial security and still do not have a satisfactory explanation for what is happening to them. They may have undergone numerous investigations, received conflicting opinions and experienced treatments that have not improved their condition.

Now imagine that patient reports suicidal thoughts.

What is the first question worth investigating? Whether they have an underlying psychiatric vulnerability, or whether the circumstances of their life have become intolerable?

Both possibilities can be investigated, but there is no justification for treating the first as the default explanation while neglecting the second. The burden of illness is not an obscure alternative theory. It is an immediate, observable part of the patient's circumstances.

If someone is suffering from a disabling illness, psychological distress is not a surprising discovery. The real question is why researchers would look for explanations beyond that suffering before establishing how much of the distress it accounts for.

Nor does a lack of identified structural pathology settle the question. Failure to identify the cause of someone's neurological symptoms does not establish a psychological cause. Finding depression, anxiety or suicidal thoughts in that person does not establish one either. These observations cannot substitute for independent evidence about the mechanisms producing the neurological symptoms.

There is a serious risk of confusing consequences with causes. A patient may experience anxiety because their symptoms are unpredictable, depression because their independence has disappeared, or suicidal thoughts because they see no prospect of improvement. Those psychological responses can be clinically significant without explaining why the neurological illness began.

Researchers should therefore be examining symptom severity, chronic pain, duration of illness, functional disability, employment loss, financial circumstances, diagnostic delays, treatment outcomes and patients' experiences of medical care alongside psychiatric diagnoses. These factors are measurable, relevant and capable of influencing mental health. Ignoring or inadequately accounting for them leaves a major explanatory gap.


What has actually been established?

The studies demonstrate that suicidality is a serious concern among some patients diagnosed with FND, particularly functional seizures. They also identify associations with psychiatric diagnoses and other clinical characteristics. What they do not establish is that suicidal thoughts arise because FND has a psychological cause, or that psychiatric vulnerability is necessarily a more important explanation than the consequences of living with disabling illness.

Equally, the available evidence examined here does not establish that suicidality research is being conducted specifically to validate the psychiatric model of FND. That would require stronger evidence from research protocols, stated hypotheses, study designs and authors' interpretations. The distinction is important: identifying a psychiatric emphasis is not the same as proving why that emphasis exists.

But the unanswered question remains. Why does the investigation of suicidality in FND so readily turn toward psychiatric comorbidity when the patients' physical suffering and life circumstances offer such an obvious starting point? And are those circumstances being investigated with the same seriousness?

Patients do not need an established explanation for their neurological symptoms before the consequences of those symptoms can be recognised. They can be severely disabled, frightened about their future and psychologically distressed regardless of whether medicine has identified the underlying mechanism.

The purpose of suicide research should be to understand and reduce risk. If that is the objective, researchers need to investigate the full reality of patients' lives rather than allowing the diagnostic label to determine which explanations receive priority.

Until that happens, the question remains entirely legitimate: are researchers investigating why patients with FND become suicidal, or are they investigating the psychiatric characteristics they already expect to find?

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