Anonymous Neurologist
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Anonymous
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11 May 2026
I’m a neurologist with over 15 years of experience, and I have no personal or professional stake in the FND field. However, I do encounter these patients frequently in my clinic. Skepticism is healthy, but it shouldn’t be driven by a complete lack of understanding of what we already know about medicine, the nervous system, and FND.
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9I did address several of her concerns. I did not address all concerns, but I addressed several. I did not address the concerns you mentioned because they shouldn’t be concerns in the first place and I have little doubt her medical team has already addressed these concerns with her if she brought them up.
- “omitted symptoms in the notes”: this doesn’t change anything and we have no proof it’s actually true.
- “ignored positive Hoffmann's sign” - positive Hoffmann’s sign would not be helpful in explaining her many symptoms and she has no experience or training in assessing for it so she might just think she has a positive Hoffmann’s sign but does not. It’s positive in some healthy adults and needs to be interpreted in the overall context.
- “family history of autoimmune disease”: this isn’t important given her symptoms. Just because she thinks it’s important doesn’t make it so. Her presentation is not consistent with an autoimmune disease/process.
- “explicit refusal to pursue autoimmune workup”: there’s no reason to pursue an autoimmune workup. She has a classic textbook example of FND. There needs to be a clinical reason to run tests and her history/symptoms do not indicate a need for autoimmune workup.
I’ll address your other points as you got many things wrong:
1. She describes a fluctuating course of many neurological symptoms. Onset was fast and she quickly reached high severity. That’s consistent with FND. People with FND can have some constant symptoms too with fluctuations in the moment. When people do not accept their diagnosis and keep going to the doctor to be told the same thing again and again it is very stressful and not uncommon for them to get more and more symptoms from this distress and not engaging in treatment.
2. She has no “prominent encephalopathic features”! She is using terms like delirium, psychosis and catatonia but she clearly does not have those symptoms. Have you ever worked with someone with true psychosis and catatonia? They aren’t sitting online coherently writing their medical journey. These symptoms also don’t come and go day to day. If her medical team thought she was having those symptoms they would test or treat her for them just like the do with everyone actually experiencing those symptoms.
3. FND is not a diagnosis of exclusion no matter how many times you say it or try to convince yourself by misinterpreting the research and not having an understanding of clinical practice. A Hoffmann’s sign and non-specific hyperintensities on brain MRI doesn’t rule out FND. Those can be incidental findings with no clinical relevance and that is clearly true in her case.
4. We don’t know her medical team’s thought process and we have no proof of her documentation so we don’t know. It’s not common for neurologists to always write the specific signs, although they should. If they weren’t documented, it doesn’t mean they didn’t identify them though.
5. Autoimmune encephalitis is ruled out because she clearly doesn’t have symptoms of it. Have you ever actually seen a patient with true AE? She would not be writing online or even alive right now if she has had untreated AE for this long. There is recent research showing large numbers of people being misdiagnosed with AE, with FND being the correct diagnosis in many of those cases.
6. Healthcare professionals can blame the FND on her trauma but that doesn’t mean it’s true or the full story. Unfortunately it’s easy for her to see a psychiatrist & tell them everything is mentally fine so that they don’t get a psychiatric diagnosis. She has already been diagnosed with PTSD though. She also mentioned agoraphobia. She clearly has psychiatric problems. If anything, the psychiatrist helped rule out psychosis and catatonia, but that’s not necessary because a neurologist can easily determine that. Psychiatrists tend to focus on biological aspects of mental illness so they would have told her if they thought her claimed psychiatric symptoms were being caused by a medical problem like AE.
This is all so basic. She has had many clinicians diagnosis and reaffirm the FND diagnosis. She claims because it’s already in her chart but clinicians tend to do their own evaluation and come to their own conclusions when seeing the patient. Many of you think clinicians just blindly rely on a medical history and always accept it as fact but that’s not true.
She is only making this worse for herself and her family. This is a clear cut case. Not all cases are so clear cut but her case is. I’ve addressed all concerns now but I’m going to assume you’ll just keep thinking you’re right and offer more nonsense explanations that do not fit her case. You claim you want to be able to debate these things and that clinicians can’t admit when they are wrong. The problem is that you don’t seem to think you can ever be wrong despite you being the one without any training and experience in this.
As I read this, I can’t help but wonder what the common denominator is here. The answer is you. Why can’t you see and accept that you’re the problem in your situation? Yes, it’s uncomfortable and frightening to admit that, but ignoring it will only lead to more suffering. It’s not a judgement.
You wouldn’t be symptomatic for this long and wouldn’t be writing this post if you had untreated autoimmune encephalitis. That’s not possible. What else could you possibly have other than FND? This is a textbook case. You have a wide range of neurological symptoms that have fluctuated and evolved over time. That’s characteristic of FND. You had a clear MRI with very common incidental findings. Healthcare professionals usually don’t accept a previous diagnosis as fact if they don’t agree with it. Although EEG is the “gold standard” for seizure-like episodes, they’re not always necessary depending on the presentation of the episode. Your doctors likely recognized that you’re having episodes consistent with your already established FND diagnosis. It’s not appropriate to order test after test. Testing is based on your history and physical exam and should only be performed when indicated. Your doctors aren’t dumb; they’d order testing if they thought it was necessary.
Your history of abuse, trauma, and PTSD is a common risk factor for FND. It’s also common for FND symptoms to start appearing as the PTSD symptoms seem to improve. Sometimes, the treatments for PTSD cause significant distress and trigger the FND. Psychiatrists cannot rule in/out FND because they do not know the wide range of neurological presentations. FND also does not require a co-morbid mental illness so your psychiatrist ruling that out doesn’t mean anything.
It appears that you have a very competent medical team. You’ve been diagnosed with FND, which seems to meet the criteria for the condition (even if they didn’t fully explain them to you). You’ve undergone appropriate medical work-up (you don’t determine what’s appropriate), and you’ve been offered treatment at a specialized center. However, you’re resisting your medical team and refusing to accept your diagnosis of FND. This resistance is causing you distress, which is why your symptoms are worsening.
FND is not an accusation or a shameful condition. It’s an involuntary, disabling illness. Why can’t you accept it? It can’t be because you believe psychiatric conditions aren’t real or are a person’s fault, as you seem to accept your PTSD diagnosis. PTSD, anxiety, and many other psychiatric conditions can cause physical symptoms. FND is a neuropsychiatric condition where psychology and neurology intersect. The way forward is to do the difficult work of genuinely accepting your diagnosis and choosing to focus on recovery rather than being right. I have been harsh in this response, but sometimes people need that.
I’m not here to play your games. Did the patient in this scenario have a positive Hoover’s sign or not? Yes or no.
It’s like you didn’t read what I wrote. You keep doing this…you ignore what I say and just repeat yourself as if I didn’t address it when I did. I’m not going to repeat myself. Actually read what I wrote and don’t repeat the same thing. I’ve already addressed it.
Also, this is not how cases are presented. You include minimal information so that you can back track and fill in information to refute any challenges. In real life there will always be much more clinical information available to the clinician than what you have provided. I’ve already told you why it’s reasonable to assess for Hoover’s sign in this case based on the little information you provided.
You said “Patient X (a 100m sprinter) initially reported decreased muscle strength”, but then you said “The patient reports fatigable weakness in the right side.” You only say the patient had fatiguable weakness after reviewing the isokinetic data. So you were a bit unclear.
Regardless, the patient reports unilateral weakness and arrives in a wheelchair. That is enough to warrant testing for Hoover’s sign, but additional information in the history would likely contribute to that decision as well. The history is used to generate hypotheses which guide the physical exam and testing to strengthen or weaken each hypothesis. The Hoover sign result is just one of many pieces of data. It is not interpreted in isolation, just like the isokinetic test results should not be interpreted in isolated.
You seem to have missed my point though. If the Hoover’s sign was positive in this case, the patient clearly does have weakness on movement initiation, specifically when asked to move the leg. If they did not, the test would have been negative. There’s no arguing that.
Two things can be true at the same time. This patient can have fatiguable weakness evidenced by isokinetic testing and functional weakness evidenced by a positive Hoover’s sign. Those could be two separate types of weaknesses or both can be functional weakness in two different contexts/tasks.
You are assuming functional weakness should always lead to weakness at movement initiation. That’s not true though. People can and often do experience functional weakness with repeated or sustained movement. You would know this with the appropriate training and experience. Majority of FND signs have low sensitivity so the absence of the same findings from the 1985 paper do not rule out the diagnosis.
Your analysis does not hold up.
The reasoning you applied is flawed. The patient told the neurologist they have unilateral weakness, so assessing for Hoover’s sign is appropriate. Just because one study used isokinetic testing in FND does not mean those results have been validated or can be generalized to all patients with FND. What are the sensitivity and specificity of those isokinetic test results in FND? If that information is not available, then the findings are not clinically useful. Therefore, the absence of findings in this patient that match those of the study participants does not tell you much.
The isokinetic test results do not carry much weight in this case. If the patient has a positive Hoover’s sign in the clinic, the isokinetic results are largely irrelevant. A positive Hoover’s sign indicates that the leg appears weak when the patient is asked to move it voluntarily, but strength returns when the movement becomes automatic by focusing on contralateral hip flexion against resistance. The isokinetic findings you described do not change the fact that the patient demonstrated weakness with voluntary movement but not with automatic movement during the neurologist’s physical exam.
FND is a disorder of voluntary movement, and the more a person focuses on voluntarily moving a limb, the more difficult the movement becomes. It is possible that this explains the decline in strength when demand increased.
Proper clinical reasoning and pattern recognition require years of education and experience. It is not a hobby that anyone can simply pick up.
I’m a neurologist with over 15 years of experience, and I have no personal or professional stake in the FND field. However, I do encounter these patients frequently in my clinic. Skepticism is healthy, but it shouldn’t be driven by a complete lack of understanding of what we already know about medicine, the nervous system, and FND. You can’t argue what we don’t know when you don’t know what we do know.
“As a result, a person may struggle to push a leg down voluntarily, but when the opposite leg is lifted, the nervous system automatically generates extension, and some force appears. This difference can resemble a positive Hoover’s sign, even when a structural problem exists.”
- No, what you described is the Hoover’s sign. That’s the point. To lift a leg against resistance, the other leg must automatically extend. This demonstrates impaired voluntary movement with intact automatic movement, which is consistent with FND annd supports a diagnosis of FND when used in conjunction with the clinical history and the rest of the examination. Impairments caused by structural problems will persist with both voluntary and automatic movement. You can sit there all day and claim that perhaps we haven’t discovered the mechanism for that yet because we still have a lot to learn, but you can do that for everything in medicine. That ignores the fact that these yet-to-be-discovered mysterious mechanisms would be incompatible with what we already know, making them unlikely to exist. We already have a sufficient explanation for it.
“Regarding my wife’s facial asymmetry, this is not a theory. It was verified by a neurosurgeon through examination of her biokinetics. The facial nerve branches, particularly the marginal mandibular branch, control muscles that pull the jaw and lower lip downward, and this movement can be easily demonstrated and reproduced on demand. Therefore, your assessment here is a serious overreach, since you lack the context of our situation.”
- What do you mean by “examination of her biokinetics” in this context? Are you saying your wife has unilateral lip pulling downward? A structural lesion to the marginal mandibular branch causes paralysis or paresis of the innervated muscle, leading to an inability to pull the lip downward. In the context of FND, a downward lip pull is commonly mistaken for facial droop due to a stroke.
I see you’re claiming your wife was diagnosed with MS, but then clarify it as CIS MS. CIS is not MS but has the risk of developing into MS. You state your wife has had several relapses with progression over the years, starting back in 2019, without any lesions in the brain or spinal cord. That’s not consistent with CIS or MS, so I’m not sure who told you she has CIS or why you’ve stated she was diagnosed with MS when you meant CIS. However, the extensive evidence you’ve provided about her condition demonstrates that she doesn’t have CIS or MS. I suspect one neurologist said CIS, the other said FND, and you decided the CIS must be correct despite all evidence suggesting otherwise. Regardless of what you say, you’re clearly not interested in honest constructive critique and skepticism to improve care for all patients, including those who do have FND.
It’s just an analogy. Trying to delve deeper into it doesn’t offer any benefit because the nervous system isn’t actually like a computer. The analogy is meant to help patients understand that it’s different from conditions like Parkinson’s, stroke, MS, etc.
“For instance, fluctuating neurological deficits caused by structural issues (such as dynamic compression) could potentially mimic patterns interpreted as inconsistency.”
- Please explain how. While sitting or lying down, the patient is asked to extend their right hip (press down into the clinician’s hand placed under the right heel). If there’s no pressure, the clinician places their hand on top of the left leg and asks the patient to lift the left leg against the clinician’s resistance. The clinician feels pressure pushing down on their hand from the patient’s right heel. This is a positive test. How can that possibly be explained by a structural issue, especially “dynamic compression”?
“For example, the facial asymmetry sometimes attributed to FND. In my wife’s case, we found actual reproducible mechanical actions that are directly responsible for what’s seen.”
- This doesn’t mean anything. It’s like someone in a clinical trial experiencing remission after receiving only a placebo. Beliefs and expectations (conscious and unconscious) from past experiences shape our current perceptions of the world, movement generation, and more. Clearly, you and your wife reject the FND diagnosis (despite having substantial evidence supporting it). Consequently, both of you will seek out evidence and modify your behavior to support your belief. However, since you lack education in anatomy, physiology, and clinical care, you don’t realize that something mechanical cannot directly cause the characteristic facial motor symptoms seen in FND. This is common. For instance, a person might press on their palm, and their leg starts jerking. They believe there’s a direct mechanical causation, but that’s not possible. We know enough to confidently conclude that. Perhaps you don’t, but people with the proper education and training do.
“Why take the presentation of symptoms, give it a name, and push patients into therapy?”
- Um, that’s the whole point of medicine. Diagnostic labels are essential for organizing complex symptoms into recognizable patterns, enabling tailored treatment plans, predicting prognosis, and facilitating communication between providers. It’s quite absurd to argue that FND is at risk of being a label that stifles investigations. If someone is diagnosed with Parkinson’s Disease (which can only be confirmed through an autopsy), they won’t undergo endless and extensive testing that’s not relevant to their presentation. We have so much more to learn about Parkinson’s disease (and most other conditions, including FND) but we know enough to reliably diagnosis and treat it with evidence-based treatments. FND is not different.
It’s easy for someone like you, lacking formal clinical education, training, and experience, to claim that we don’t know everything. Of course, there’s always more to learn, but you can’t possibly know the things healthcare professionals do know. You don’t, but others do. There’s something quite narcissistic about acting like you understand medicine and neurology more than neurologists.
Ha! You really believe you know more than a neurologist? The Dunning–Kruger effect describes when people with limited knowledge in a domain (you) greatly overestimate their knowledge. If you choose to cosplay as a clinician online, you should expect to be called out. This entire website is offensive and insulting, so forgive me if I’m not concerned that you feel insulted by my comment.
The person provided a detailed history of their symptoms, signs and progression. Any clinician knows that a diagnosis can often be narrowed significantly just from the history and confirmed with an examination and testing.
Yes, hemisensory syndrome can occur in organic conditions such as stroke or MS, but it is rare and would require a clear lesion. The person confirmed their brain MRI is normal. Most cases of complete hemisensory syndrome with a normal MRI are functional.
They also stated: “I took the course and everything went away.” Muscle relaxants can modestly reduce spasticity, but they do not eliminate it entirely. If hypertonicity were caused by an organic lesion, it would not completely resolve with medication. You would know that if you were a clinician.
You also cited hypotonia transitioning to hypertonia (e.g., spinal shock or cerebral palsy), but those scenarios are irrelevant here. In CP, that evolution can happen as the child ages and this person clearly does not have spinal shock. This case involved hypertonia that fully resolved, then hypotonia, then hypertonia again within a month. Organic neurological diseases do not produce rapid, fully reversible fluctuations like this. Degenerative conditions progress very gradually and they do not switch back and forth.
Hemisensory symptoms with hypertonia that fully resolve, followed by hypotonia and speech/swallow issues, then return of hypertonia and gait disturbance on the same side within a month is not consistent with organic neurological disease.
So it is you who is lacking clinical knowledge, especially since you are not a clinician so you have zero clinical knowledge! Reading papers and anecdotes online does not substitute for clinical training or experience. Some of the points you raised are technically true, but they are irrelevant to this clinical case. You do not understand how to look at the bigger clinical picture and clinically reason because you are not a clinician. I’m not trying to be rude, it’s just the truth.
This sounds like you wrote this or it’s a fabricated story by someone else. If this is truly from a medical student, they clearly lack fundamental clinical knowledge or are completely blinded by their bias. None of the history provided suggests an organic disease. Firstly, an organic cause of numbness from head to toe on one side of the body would be evident on imaging. It also doesn’t make anatomical sense. Secondly, hypertonia that was “treated” with muscle relaxers until it resolved doesn’t make sense either. Muscle relaxers don’t heal organic lesions, Then, the condition changed to hypotonia, and then back to hypertonia. Hypertonia and hypotonia have completely different causes, and it’s not possible for it to switch between them, so this explanation is also flawed. Lastly, the symptoms evolved to speech issues and finally gait issues. Symptoms caused by lesions don’t spread and change so drastically like this. They clearly lack basic clinical knowledge, but that seems to be on brand for “FND Nope”.
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