The curious challenge of breaking good news

Abstract

Stone and colleagues (1) present useful guidance regarding assessment and management of patients with functional neurological disorder (FND). Unfortunately, clinicians caring for those with other ‘functional’ syndromes often face rather more fraught and complex challenges.

Chronic fatigue syndrome (CFS) and fibromyalgia (FM) are examples of common presentations which have also attracted the ‘functional' label due to persisting uncertainty regarding aetiology and pathophysiology; optimal management is consequently challenging (2,3). FND is typically identified by overt physical signs; even when these are absent, as in dissociative seizures, it is often possible to give significant weight to features in the history (1). By contrast, the absence of physical signs and the lack of symptom specificity in CFS and FM can be a source of doubt, dispute, and stigma for all concerned (4, 5).

As Stone et al demonstrate, clinical findings enable the positive diagnosis of FND in tandem with judicious diagnostic testing to exclude relevant pathologies (1). By contrast, many other functional syndromes are identified in a negative sense, only after often extensive physical investigations have excluded demonstrable pathology. This conclusion is generally less satisfying and a frequent source of frustration for both patients and clinicians (4, 5). Doctors thus often find themselves in the difficult position of breaking unwelcome ‘good news’ to patients hungry for a mechanistic explanation of their symptoms. Recognising and skillfully managing patients’ emotional investment in having a physical diagnosis is crucial in avoiding the dual risks of over-investigation and overtreatment (6).