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Finding Help When Your Symptoms Don’t Make Sense

Using a rehabilitation approach to understand functional neurological disorders.

Key points

  • Functional neurological disorders are not widely known and evolved from conceptions of "hysteria" and conversion disorders.
  • The unusual symptom presentation seen in functional neurological disorders can create confusion for patients and physicians alike.
  • They may be caused by underlying stress; according to psychodynamic theory, they are due to unresolved "internal conflict."
  • Any suggestion that the symptoms are "not real" or merely psychological can be distressing for patients.
Source: Fizkes/Shutterstock

You wake up one morning and find that you cannot see; suddenly—inexplicably—you are blind. For the vast majority of people, this occurrence would constitute a crisis, yet for a handful of people, it would qualify as merely "unusual." Indeed, the quality of a person’s response to a sudden loss of physical functioning is one feature neurologists and psychologists note when diagnosing a functional neurological disorder (FND). These disorders, while uncommon, occur in a small but significant group of people. However, many still struggle to get the help they need to manage their FND symptoms. It is through an understanding of this condition’s history that will help you see why.

I was in college when I first met someone with a conversion disorder, now more popularly referred to as a "functional neurological disorder." A visiting professor shared an interesting story about a strange period in his life. Following the success of a book he had written, he found his status elevated to that of a minor celebrity. As such, he was sought after to make public appearances. On one particular Saturday morning—on a day scheduled full of public appearances—he woke up blind.

Was waking up blind a crisis? Not for him. He simply said to himself, “Well, I guess blindness happens sometimes.” In a relatively calm state, he presented to the emergency department of a nearby hospital and was found to be in good health. In other words, there was no physical explanation for his sudden vision loss.

One of the interesting and defining features of a functional neurological disorder is inconsistency with symptom presentation. For example, a person who is physically blind will not react when a small object is tossed at their face. They don’t move their head out of the way for the simple reason that they cannot see it coming. With FND blindness, however, the nervous system remains intact; the person experiencing blindness will reflexively jerk their head out of harm’s way from a quickly approaching object.

There are many more examples of inconsistency like this with FND symptoms. A person with paralyzed legs might be able to walk backward, but not forward. Someone with uncontrollable jerking movements throughout their body while standing or walking might be able to run at a smooth pace. A patient unable to stand due to stroke-like symptoms will nevertheless catch themselves if pushed off balance. An individual unable to clearly write due to continual hand tremors will be able to put in their contact lenses with effortless precision. And so on.

The Hang Ups of History

Many current patients with FND are uncomfortable with the history connected to their condition. Thanks to the work of Jean-Martin Charcot, "conversion disorder" replaced the term hysteria in the 1800s. The term “hysteria” comes from the Greek hystera, meaning uterus; in the time of ancient Greece, any unexplainable physical and emotional symptoms in women were often attributed to a “wandering uterus.” Later on, Sigmund Freud developed "the talking cure" for conversion disorders based on his theory of internal conflict.

According to Freud’s theory, there are three elements of a conversion disorder:

  • The symptoms begin to develop following an internal emotional conflict within the patient.
  • The symptoms “allow” the patient to avoid some activity related to the conflict.
  • The symptoms result in additional emotional support from others.

A Case Example

Take the case of the professor from our earlier example to see how the talking cure helped. Fortunately for him, the emergency room physician treating him had seen a few cases of FND blindness before and he was familiar with Freud’s theory.

Sitting with the professor, the physician inquired about his life and work. He asked him, “I see that besides being a professor, you are a writer; I’m curious, do you consider yourself an outgoing person?” The professor explained that he loved the solitary aspect of writing—how it allowed him to be alone for great spans of time.

The next question the doctor posed reportedly served as the cure. He simply asked, “How do you feel about all your public appearances, given that you are not an outgoing person?” The professor reflected on this, and then simply stated, “I hate it!”

Within moments, the professor recalled, his vision returned.

Was Freud Right?

Consistent with Freud’s theory, there was an acute conflict in this man’s life: he was an introvert and therefore very uncomfortable with his sudden fame and the responsibilities that came with it. Left with two irreconcilable forces—his desire not to let others down and hating the personal cost that came from being in the spotlight—his mind came up with a creative solution. Blindness.

This sudden affliction benefited him in two ways. The medical emergency allowed for him to graciously cancel his appointments that Saturday, (leaving his audience more sympathetic than disappointed) and he avoided his discomfort over the larger situation.

Resolving the conflict requires identifying and expressing the two opposing desires and any associated emotions. When the professor was able to bring his underlying tension into the open, he removed the need for his mind to produce the protective symptom of blindness.

This conceptualization of FND is both fascinating and a cornerstone of psychodynamic theory. However, it is not well received by most patients nor clearly understood by healthcare professionals.

In fact, any suggestion that symptoms such as these are psychological in nature is typically only more distressing to a patient. Just imagine—if you sought care for a sudden speech impairment and partial paralysis of your right side, concerned that you had suffered a stroke, you probably wouldn’t want to hear, “Your symptoms are not real.”

Where To Start

If you or someone you know struggles with FND, know that there is help. In the blog articles to follow, you will learn about the different types of FND conditions, how to delineate FND from other medical disorders, and the rehabilitation approach to managing FND symptoms.

It’s important to recognize that a fruitless pursuit of additional diagnoses (when the most obvious possibilities have been ruled out) may not be worth your time or money. While it might be hard to accept, focusing your energy on doing the things that work will help. These are the actions that allow you to get moving, manage stress, and stay connected with the people and activities that are important to you. Above all, don’t let FND get in your way of moving forward.