Discussion
FND, historically known as conversion disorder or hysteria, is a disorder that presents with motor and/or sensory symptoms that have no structural origin. Multiple variants of this disorder exist with the most common variants being functional seizure disorder (psychogenic non-epileptic seizures), functional movement disorder and functional cognitive disorder. FND remains one of the most common reasons for neurological disabilities.5 FND incidence varies from 7 to 30 cases per 100 000 population per year, with women being affected more than men.3
This study found that the mean score of correct answers regarding FND was 30.4%, indicating a notable gap in knowledge. This deficit is particularly concerning given the expectation that healthcare practitioners possess a more comprehensive understanding of FND compared with undergraduates. Notably, this discrepancy in knowledge acquisition mirrors the educational gap observed in the educational system. During their preclinical years, students are exposed to extensive theoretical knowledge through lectures and readings, with minimal interactive engagement such as seminars. However, a shift occurs during clinical clerkships and residencies, where physicians transition to experiential learning, immersing themselves in authentic patient challenges that markedly diverge from the theoretical framework of their preclinical training.12 This transformation highlights the pressing need to bridge the gap between theoretical understanding and practical application.
Additionally, the assessment of medical students’ perception of their training aligns with this finding as shown in a study where 2% of students rated their medical training as excellent, with a majority considering it fair (44%) or poor (15%). Moreover, 54% of students acknowledged that faculty knowledge and dedication to teaching is lacking. These findings emphasise the need for substantial enhancements in medical education and align with the imperative for a comprehensive revision of teaching methodologies and curricular approaches, addressing the prevailing challenges in medical education.13
Differences in clinical practice might explain these results. General practitioners might not recognise FND cases as readily or may see fewer patients with FND than neurologists or psychiatrists. A cross-sectional study conducted by Lehn et al in Australia showed that neurologists had significantly greater knowledge of FND than other practitioners did, with only 14% of general practitioners reporting good knowledge of FND.14 Additionally, participants who acquired their knowledge through medical schools had a significantly higher score than those who obtained it from other sources, indicating that the quality of the taught material is high and requires only more time allocation. This is supported by the finding that teaching hours of FND positively correlated with the score of correct answers. The significance of these findings reverberates within the broader context of medical education. Students in Saleh’s et al study highlighted various priorities for enhancing teaching methods within medical college. These recommendations encompassed a spectrum of measures, including the implementation of small group teaching across study years, improvements in infrastructure and teaching facilities, continuous training of teaching staff to stay abreast of updated pedagogical methods, granting students a more active role in the learning process, and an increased emphasis on practical and clinical sessions.12 This collective call for reform underscores the pivotal role of effective teaching methodologies in bridging the gap between theoretical knowledge and practical application. The findings from these studies also explain the low confidence levels reported by participants and the recognition of the outdated term hysteria instead of FND.
The myth that ‘FND is a diagnosis of exclusion’ was found to be the least recognised among the statements, with only 7.4% of respondents correctly identifying it as a myth. A cross-sectional study assessing the knowledge of neurologists found that 51.5% of respondents viewed FND as a diagnosis of exclusion.15 While the DSM-4 required the exclusion of other diseases and the presence of a psychological factor to establish a diagnosis of FND, the most recent DSM-5 has focused on a positive diagnosis and removed the criterion of the presence of a psychological factor as a prerequisite.2 Diagnosis can be made based on positive signs found only in FND or internal inconsistency of signs and symptoms, such as Hoover’s sign and tremor entrainment.5 Believing in the outdated notion that FND is a diagnosis of exclusion may lead to delays in treatment, as physicians may spend extensive time excluding other neurological diseases, potentially causing harm to patients’ physical and psychological health, and negatively impacting their quality of life.
The statement ‘FND is exclusively a psychological problem caused by psychological factors’ is a myth that was considered by 51.2% as a fact while only 13% of respondents correctly identified it as such. This misperception may be largely influenced by the use of the outdated term ‘hysteria’, which 80.3% of respondents identified as an alternative term for FND. In a survey of UK neurologists, Kanaan et al found that 47% of participants considered ‘subconscious behaviour’ as an aetiological factor of conversion disorder.16 Similarly, Lehn et al’s study in Australia found that 56% of participants considered FND to be a primary psychiatric or psychological problem.14 However, a study from the Netherlands revealed that more than half of participating neurologists and psychiatrists viewed the aetiology of FND as a combination of disordered brain functioning and psychogenic factors.17 Additionally, Pun et al’s article studying the psychological profiles of patients diagnosed with FND found that while 73.3% of patients had a comorbid mental health condition, 14.9% of patients did not have an established mental health diagnosis.18 This supports the theory that psychological factors are not necessary for a diagnosis of FND. Furthermore, the DSM-5 removed the criterion of psychological stress as a prerequisite to diagnose FND.2 However, the statement ‘A history of adverse life experience and psychological comorbidities is necessary for the diagnosis’ was the most recognised myth, with 67.3% of respondents identifying it as such.
This study found that the statement ‘FND treatment is individualised and involves careful explanation and combinations of physical and psychological rehabilitation’ was recognised as a fact by 77.5% of the respondents, making it the most correctly identified statement. This finding is consistent with the results of a survey conducted among neurologists in the Netherlands, which reported that 55% of the participants preferred a combined approach for the management of patients with FND, including an explanation of the diagnosis, physiotherapy and psychotherapy.17
In a survey of members of the Movement Disorder Society from different countries, which aimed to evaluate their opinions and practices regarding psychogenic movement disorders, the most important factors for predicting the prognosis were the acceptance of the diagnosis and educating the patient.19 These findings highlight the importance of providing patients with a clear understanding of their diagnosis and involving them in their treatment plan.
Moreover, sharing the physical signs of FND with patients, such as Hoover’s sign, has been suggested as an effective way to improve treatment outcomes. Stone et al noted that demonstrating the basis of the diagnosis of functional motor symptoms to patients can help to persuade them that their symptoms are not due to another cause, and increase their confidence in their physician’s diagnosis. Overall, these findings emphasise the importance of individualised and multidisciplinary approaches to FND treatment that involve both physical and psychological rehabilitation, as well as clear communication and education of patients.20 Finally, exploring diverse avenues holds promise for the enhancement of Iraqi medical education. A trajectory towards globalised training opens up the possibility of forging partnerships and linkages between medical institutions in economically advanced nations and those in Iraq. Notably, the adoption of a common curriculum delivered in English confers a notable advantage, potentially facilitating cross-border collaboration in education.13
This study has several limitations that warrant consideration. First, the participants were predominantly drawn from a single medical college and healthcare practitioners from a specific online group, which could potentially limit the generalisability of the findings to a broader cross-section of healthcare professionals in Iraq. Moreover, the study did not analyse or compare the specialties or subspecialties of the practitioners, which might influence their level of exposure to and understanding of FND. Additionally, the relatively modest sample size could impact the representativeness of the results. Despite these limitations, this study provides valuable insights into the prevailing knowledge gaps and misconceptions surrounding FND among students and healthcare practitioners, thus offering a foundation for future investigations and interventions to enhance awareness and education in this area.
