Podcast: A guide to Functional Neurological Disorder

Lee Cook: I'm Lee Cook, and I'm a partner over at Weightmans Manchester large loss team. I'm joined today by Luisa Lamb, who's also a partner in our Large loss Manchester team. Good morning, Luisa.

Luisa Lamb: Morning.

Lee Cook: Morning.

Lee Cook: Luisa and I are relatively new to Weightmans. Luisa joined at the start of November.

I started at the, the start of this year. And when we both started, we thought it'd be a good idea to get our heads together and produce a guide in relation to functional neurological disorder of what we'll refer to as FND.

And we thought we'd put together a podcast just as a bit of a whistle stop tour of that guide.

So, hopefully, people are gonna find that that useful.

Luisa Cook: Yeah. Absolutely, Lee. So what we wanna talk about today is what is FND and what the diagnostic criteria are, also some of the symptoms, the issues that we all have to deal with as solicitors and insurers together with the ever helpful tactics around that.

So, really, we need to look at what the modern day understanding of the condition is, and I think, you know, if Lee can provide an explainer of that for everybody to make it all crystal clear, that would be helpful.

Lee Cook: Yeah. Sure. I'll certainly I'll certainly try.

So in March 2022, the diagnostic criteria changed from what was, known as conversion disorder to what was, relatively new phrase to people of functional neurological symptom disorder, which we'll refer to as FND.

So, anecdotally, we've seen since that day arise in cases where, FND has been alleged by claimants. So I think it's useful, first and foremost, to see how we have got to the present position. And I know Luisa and I, since we both started over here at Weightmans, have become quite clear that we're both, keen fans of our history podcast. So I thought that we would, start off with within the guide as well with a brief history, of what FND is.

Luisa Lamb: Yeah, Brace yourself.

Lee Cook: So yeah. So we, without going into too much detail, you know,  although it is a new concept from a diagnostic criteria perspective, FND is actually, has been around for quite a while. So as far back as four thousand years ago, the Ancient Egyptians, wrote about, somatic symptoms.

And, you know, we then got into the eighteen hundreds where neurologists like Jean Martin Charcot, had, you know, discussed topics such as Hysteria, which were distinctive neurological disorders, which showed no structural, lesions. And then we then got into the nineteenth century with Freud, doing on about, psychiatry psychiatric theories of origin and concepts such as conversion, which then led to conversion disorder, and then, you know, right up into the modern day in terms of conversion disorder, and then into recent conceptions and the diagnostic criteria that we have today. So I suppose the question everyone has is, what is what is FND?

And I like to use, a phrase from a book that I read created by or written by, should I say, doctor Susanna Sullivan called 'It's All in Your Head'  and she describes it as the nervous system is like a computer, that my hardware is intact, and the wires are all in the right place.

But I have a software problem that stops my legs from receiving the instructions to move. So I'd I'd highly recommend anyone who's interested in this topic to, to pick up, doctor O'Sullivan's book.

But it's always like I say, with the historic, understanding of it and the present day understanding of it, it's always been something that's been quite prevalent and quite costly, hasn't it, Luisa?

Luisa Lamb: Absolutely. Yeah. And and the issue now we have in in the modern world is the number of people who are now suffering from this, and there's a third of patients in neurological departments who are suffering some, form of somatoform disorder.

And the diagnosis in 2021, there were eight thousand new cases of FND, which is rising and will continue to do so. We already know we've got issues with chronic pain that have been around for years. We've got increased mental health issues in society. So those figures are only going to go up. And if we're looking overall at the cost, we're looking at eighteen billion for unexplained symptoms, which will include what isn't just limited to FND. So it's it's really important for us in our, you know, working lives to be aware that this is something that's going to increase, really.

Lee Cook: Yeah. Absolutely. So what are some of the symptoms associated with FND, Luisa?

Luisa Lamb: This is this is where it gets really tricky because there are so many symptoms. It can be more or less anything because you can have anything from tremors, weak limbs, gait disorders. There can be paralysis even in some of the more serious cases. You can lose your sight. There can be all sorts of issues with sensory overload. You often see that about people who think things are too bright, things are too loud, and the usual that we we tend to see a lot of fatigue and memory and concentration issues.

The other one that we see and I've seen in in quite a lot of my cases is seizures.

Seizures that people often will think are epileptic fits but are actually different, nonepileptic attack disorder as it's called.

So it could be more or less anything, and that's the problem for us in actually trying to to to understand these cases from the beginning.

In terms of who it affects, of course, it can be anyone. But when we're looking at the the prevalence of what we've seen to date, it's more likely to be women. That's outnumbered more women than men's three to one, and the likely ages are thirty seven to fifty. And it's really hard to predict the outcomes of these cases as well. It doesn't follow a a path that you have an injury, it heals and you're better. It there can be all sorts of different results. You know, some people have the symptoms forever.

So that's depressing news for us really, Lee, isn't it? So Yeah. To that, in light of everything we've said and how difficult it is, what do you consider the challenges for insurers and defendants generally, Lee?

Lee Cook: Yeah. I suppose I think you've in in the main part, answered that in terms of, you know, the the variation in the symptoms. It's so widely different, claimant to claimant, case by case. So they're very difficult to, to manage from a defendant or insurer perspective. And I suppose from a from a from a claimant solicitor and claimant perspective as well, it's very difficult. So, I think I covered off at the start just saying, you know, anecdotally, given there's a broader diagnostic criteria, criteria, which we go in a bit more detail in the guide, there's a we've seen, haven't we, an increase in FND claims year on year. We're just seeing more and more of them.

Yep.

You know, it rewrites the rules really on what you might consider traditionally expect from a claimant's presentation that you've outlined in terms of the symptomology. And the these symptoms can come about from relatively minor accidents such as rear entrance. So something you might have considered as a, you know, relatively low value with plus claim, let's see, then can become quite a significant claim with, what, you know, defendant and the insurers might see as disproportionate damages and costs.

So, you know, relatively minor claims become much more significant claims. You've got late development of symptoms.

The causes of the condition are ill understood.

And we go in the guide a little bit in terms of, you know, the in terms of prognosis. A lot of the time, you're met with a very uncertain prognosis, and there's a two thousand and twenty three systematic review that we put in the guide, which sort of outlines the wildly varying prognosis, and outcomes in claims. So that's really what, you know, I think we both consider as, significant, problems that both defendants and insurers face with these type of claims and and why, we've written the guide, to help people through it. So as part of the guide as well, we we've outlined some red flags for people to look out for.

So some useful red flags, and this isn't this isn't exhaustive as well. There's there's more within the guide, but, you know, such as, the, party's response at the accident scene. Is it out of proportion to the events? So if you got a rear end shunt where someone's, you know, acting hysterical on the on the side of the road, inconsistent timing of symptoms and the onset, Obviously, much like pain cases, you've got abnormal illness behavior, history of somatic issues, family history of these type of issues.

So, yeah, those are sort of the some of the red flags. There's much more within the guide that we, that we outline there just to say, as an easy, thing to to pick up on. So yeah.

Luisa Lamb: I'd say on those red flags, it's it's very interesting because it it highlights we need to get in there early.

Handlers or anyone dealing with these cases needs to be aware of those red flags so you can Yeah. Case appropriately. Can't they can't they really? It's very important.

But so what do we do then, Lee? What's your view? You think this may be an FND case. You potentially haven't got medical evidence or anything to prove it as yet.

So what what tactics shall we deploy?

Lee Cook: Yeah. So we we within the guide, we've set out three key, things to sort of focus on. So early identification, like you say, is just really key. So it's picking up on those red flags within cases, identifying this may not be what it seems.

And, you know, the added bonus of that is that you can really start managing these cases from an early onset.

So, yeah, early identification is key. And then the second point is, validation. So it's just being able to validate the claim like you would do with any claim. And I think within the FND arena, it's, mostly expert led. So, you know, you're looking at documentation, which, you know, we we we outline within the guide, and there's some useful validation tests that the experts use, which we've outlined within the guide to sort of help those who are reading it to understand what sort of things the the experts pick up on when through examination or through reviewing of the records. So validation is quite key after early identification.

And then I suppose that leads us on to the trickiest aspects of of FND cases. Once you've identified a case, once you're in the process of validating it, the hottest topic at the moment is treatment, isn't it? So what do what what's our approach in terms of in terms of treatment? I know it's quite a general question, Luisa, but what what absolutely.

Luisa Lamb: Really, really difficult because you you'll see these cases where sometimes there's just a huge list of absolutely everything you can imagine, in no particular order and, obviously, at great expense. So from our point of view, it's how do we get the relevant treatment for the relevant claimant.

And the guide will go into this in more detail and is helpful. But the the main point is for the claimant to accept their diagnosis, which is often a key issue because there's often other issues as well around their life or comorbidities as well. And then they need to be seen that they are getting some control of their life. So it's very, very difficult for them to do and then can take some time. Then we get into the actual treatment in terms of experts or pain relief, neuropsychiatry, neurophysiotherapist, neuropsychologist, occupational therapist.

Everything can be on the table, basically. Absolutely. And I think we've seen cases with a mix of all of those, so it's not necessarily everything should apply to all cases, but very much looking at those symptoms we looked at earlier in terms of the type, of issues that, somebody may be experiencing.

What we do know, and it's also common with, pain cases, is that you're more likely to be treated as an outpatient or as a home based community program rather than as an inpatient, which I think is key.

And then the usual support thereafter with vocational help in getting back to work. And, again, I know we've said that you keep saying it late, early treatment. Anything that you can get in there at an early stage is more likely to be beneficial.

But just be aware of the huge shopping list. And and if we can try and control that or direct it in the right way for that right claimant, then that obviously helps us.

Yeah. So it it's with FND, it's like where you're saying with validation. It's the same sort of treatment and obviously getting on to medical causation. It's very expert led, isn't it?

Absolutely. The experts are a key and also problematic in the sense that, yes, from our point of view, we need the medical experts and legal advisers working closely from a relatively early stage.

And we need to look at those preexisting conditions, which are more or less always there, aren't they? There's always a there's a there's a full sort of cocktail of issues in these cases.

So early liaison with your full legal and medical team, but also really think carefully about which experts you want to instruct and their experience in diagnosing and treating the condition from whichever angle that they're looking at, which is really important.

Because what we often get is claimant evidence saying, yes. This is FND because of the accident. And they haven't necessarily looked at all at any of the other factors, pre-accident conditions or any stresses or comorbidities, which we need to assess because FND is a very complex medical condition. And what we can find with some of our experts is they can be robust there when you have a conference going, oh, no. This isn't an FND at all, but they're quite reluctant to put that in writing. So in their report, they may say it could be FND or something else. So we what we need is a strong expert who can back up their arguments, their opinion with literature, and to look at all those various aspects, which is important.

Lee Cook: Yeah. No. Absolutely. And I think it's following on from the expert, aspect of it, I suppose, like any large loss case, documentation's just always gonna be key.

More so probably in FND cases, you know, disclosure exercises often is often key in unlocking cases.

So, you know, we view it as it's essential to obtain and forensically review the records. Again, like most large loss cases that you deal with, but, you know, you're looking for those, pre-accident history.

I'm yet to really deal with a case where FND, may or may not be involved, and it's you there's always something in the record, you know, be it, you know, a history of, unfortunately, abuse, to some sort of, psychiatric condition, be it historic or leading right up to the accident. That that's my general experience is, because there's always something there within the, within the records, which is which is useful for both parties to understand. And then, you know, we should always just pay careful attention to, the additional treatment records, those sort of things as well. So it's always useful in these type of cases.

And it goes in the guide in a little bit more detail about this just to have those detailed chronologies of the relevant entries within the records to just understand the claimant, just to understand the claimant as a person and as a as a patient pre and post accident. So, again, it's I've said it before, and I'll say it again. It's it's like most large loss cases where you're gonna be doing that sort of exercise anyway, but just bit more of a focus in these type of cases generally.

Luisa Lamb: Yeah.

Lee Cook: So at the end of the guide, just to sort of wrap things up a little bit, we put some useful cases in there, some case law to consider should anyone want to delve into the book.

Luisa Lamb: Bed time reading there.

Lee Cook: A bit of bedtime reading and a little bit of more bedtime reading with some articles that we've referenced throughout the guide as a bit of suggestive reason. So if you're struggling to sleep, can't get to, can't get to sleep, then, then give some of the, the articles that we put at the the back of the guider a read. The guide is is full enough for everybody.

That should be all they need.

Luisa Lamb: Absolutely. Well, hopefully, that has been although we said at the beginning, it's a whistle stop tour. Obviously, there's more detail within the guide, which would be helpful for you to download, and read and have a look through. And if you still got any questions, then Lee or myself would be really happy to answer them. We've we've had many of these cases, which all follow a different path. So it there there'll be some interesting anecdotes we can give you anyway. So anything you need, we're here to help. Thanks a lot.

Lee Cook: Thanks for that, Luisa, and, thanks everybody for listening.