Clearing Misconceptions about Functional Neurological Disorders

Functional Neurological Disorders (FND) make up a significant portion of referrals to neurology, maybe as high as 30%. However, misconceptions regarding these disorders remain across medicine, and patients are frequently dismissed as “faking it.”

FND are neuropsychiatric conditions in which patients experience neurologic symptoms due to a “functional” disruption of brain networks rather than a “structural” disorder of the nervous system. 

On this episode, Drs Bigham and Omole speak with Peter Gill, a patient with FND. Mr. Gill describes his seven-year journey to diagnosis and his recent success with various approaches to therapy.

Next, Drs Bigham and Omole speak with Dr. Matthew Burke, a cognitive neurologist at Sunnybrook Hospital in Toronto and an expert in FND. They discuss the current understanding of the disorder, diagnostic criteria and therapeutic options.

Links:

Neurosymptoms.org

Functional neurologic disorder associated with SARS-CoV-2 vaccination

CMAJ

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Transcript

Dr. Blair Bigham:

I'm Blair Bigham.

Dr. Mojola Omole:

I'm Mojola Omole, and this is the CMAJ Podcast. This episode we're going to be discussing a paper in the CMAJ entitled Functional Neurological Disorders Associated with the SARS-CoV-2 Vaccine. The commentary took a case study to just talk about functional neurological disorders, and they talked about a patient who had this experience with neurological changes after getting their first vaccine, and then just talked about functional neurological disorders, how it's diagnosed and just the novel treatment options that are out there for patients.

For me, I don't see a lot of neurological disorders as a surgeon, but I see a lot of functional disorders that are GI related, and I think that even when I was in training, we diagnosed people as psychosomatic, which is quite labeling and could be demeaning to patients, almost condescending to be saying that. This was really interesting because even though this was neurological, it really gave me a great insight into just the neurobiology of functional disorders in general, so I'm really excited to talk to the author of the paper and to the patients reagarding just their experience with this and what treatment looks like and what options there are for patients with these disorders.

Dr. Blair Bigham:

Let's jump into it, Jola. We're going to speak with Dr. Matthew Burke, one of the co-authors of the paper in CMAJ, but first, we're going to hear a first-person account from someone diagnosed with a functional neurologic disorder. As a professional musician, Peter Gill had made a living off his voice and his hands. At some point, the repeated use and strain took their toll, but what started as seemingly straightforward injuries from overuse cascaded into a devastating set of neurological symptoms, and eventually a diagnosis of functional neurological disorder. Peter, thanks for joining us.

Peter Gill:

Thank you for having me. Pleasure to join you.

Dr. Blair Bigham:

Now I just said eventually you were diagnosed with Functional Neurologic Disorder. How long did that take from when your symptoms first began?

Peter Gill:

The onset of symptoms came in several stages, so I first lost the use of my voice followed by problems with my hands, and then eventually more general problems with mobility and walking as well as a lot of chronic pain and fatigue, so that probably took I'd say about 2 1/2 years to fully reach the full expression of the symptoms.

Dr. Blair Bigham:

Wow. Can you tell me a little bit about what it was like to go through those symptoms when they were at their worst?

Peter Gill:

Yeah, so when symptoms were at their worst, I was essentially unable to walk. I used a wheelchair for about a year, and had a lot of trouble with my hands. I could move my hands but they were very weak, so I had problems with grip strength and holding onto objects, and I had months at a time where I essentially could not speak or could not speak for prolonged periods of time, so I used to write in notebooks to my friends, spent a lot of time typing on laptops to people and things like that. It was pretty disabling. It was pretty serious.

Dr. Mojola Omole:

Peter, how did this all begin?

Peter Gill:

This began with a vocal injury for me. The first thing that happened was I had been out with my wife, who was my girlfriend at the time, and we were celebrating her birthday in a pub, and I had a number of concerts before that that were hard on my voice. We were out at this pub, celebrating her 25th birthday and at some point in the night, I felt my voice just give out. To be honest, I didn't think that much about it at the time. I knew that I was in a performance industry and I knew that these things could happen, and I just didn't think it was going to be that big of a deal.

I remember going home to rest and waking up the next morning and still not being able to sleep, or not being to able to speak, rather. I went to an ENT who told me that I had an injury to my vocal folds, but that it would heal in a couple weeks, and to be on voice rest in the meantime. I went on voice rest for a couple weeks and didn't speak during that time, and at the end of that couple weeks the ENT expected that my voice would return, but it really didn't. In many ways what I experienced was a sort of continuation of the ghost of that injury, as if the injury was still present when it in fact was not, but it had been sort of patterned into my brain unfortunately.

Dr. Blair Bigham:

Can you tell us how the symptoms progressed after the speech problems?

Peter Gill:

Yeah, so I had the speech problems first. I saw a speech-language pathologist for that. They gave me exercises, which helped somewhat, and as I was going through that process, recovering from one condition that seemed impactful enough at the time, I gradually noticed that I was beginning to feel a kind of tingling and pain in my hands, and then one morning I woke up and had this very electric, very bright, very sharp pain in both my wrists.

Within a couple hours of feeling that pain, I lost my ability to use my hands, so at that point I thought I was just unlucky. I thought well, I had a speech thing and now I have a hand thing because I'm using my voice and my hands so much, and I just thought I was tremendously unlucky really. It was about a year after that that I lost my ability to walk, and that was when I realized that I might be dealing with something that's a really different character than just a repetitive strain injury, which was scary.

Dr. Blair Bigham:

Peter, I come from a family of musicians. I think I'm the only one who doesn't have a musical gift, but knowing how personal their life is with music, this must have been pretty devastating to start losing some of your musical abilities. What did this do for your career as a musician, for your sort of self-identity as a musician?

Peter Gill:

Well, the effect on my career can be said pretty simply. It ended it. I never was able to fully come back from the damage that I took in the course of my experience with FND. At this point it really dramatically altered the course of my career. I had been doing quite well up until that point. I had a really successful teaching studio. I was gigging regularly. I was going on tours around the US, and I wasn't a well-known musician by any means, but I was also only 24, 25.

I felt like I was immersed in a community that I really felt like I belonged in, and I was doing the work that I wanted to be doing, and I was paying my rent and my student loans at a time when unemployment was really high, and I was doing it with a saxophone. I was super proud of that. I just loved it. I loved that life. Yeah, so being taken out of that and being in some ways incapacitated by a condition that I didn't really understand and which no one seemed to understand, caused me a great amount of emotional angst.

Dr. Mojola Omole:

Sorry, quick sidebar. What kind of saxophone? Alto, tenor? I play tenor.

Peter Gill:

Primarily alto but I play all of them.

Dr. Mojola Omole:

Oh. I used to play tenor sax.

Peter Gill:

Oh, that's awesome. It's a great instrument.

Dr. Mojola Omole:

It is. I love it. Sorry.

Dr. Blair Bigham:

No, that's fine. Peter, as you start interacting with the healthcare system, as this situation evolves, what was your experience? What happened?

Peter Gill:

There was an initial phase where the problems that I was having appeared to just be a straightforward injury. During that time it was treated that way by physiotherapists, by doctors, but then I lost my ability to walk, and it happened really fast. It was like less than a month going from being able to walk as far as I want to being in a wheelchair unable to move my legs. When that happened I went to see my primary care physician and he was very alarmed. He was not a really emotionally expressive kind of guy. He has kind of a stoicism about him, but I could tell that he was freaked, really, like it didn't seem like he saw things like this much and everything that he did suggested to me that he thought that it was really dire.

There were a lot of tests that were run. I gave an unfathomable amount of blood in terms of different immunological tests and things that I went through. I was scanned using MRIs from essentially my head to my feet, and they did find some sort of structural things along the way, like I have a syringomyelia, but ultimately those things didn't map on to the symptoms that I was having, and it didn't really seem plausible that would produce the character of the disability that I have. There was this initial rush of copious and really extreme testing, and then when they couldn't come up with a decent explanation for why this was happening, everything kind of stopped. That was when I sort of entered the wastelands of medicine, I think.

Dr. Mojola Omole:

Can you explain that to me? What was your experience in that space?

Peter Gill:

Yeah. I found that after I went through the initial testing, there was a period of almost seven years actually where it was a continual odyssey of trying the get from one doctor to another, and to find somebody who could make any kind of diagnostic progress on this thing. A lot of different doctors took swipes at it. I saw ENTs and speech pathologists, I saw a lot of neurologists. I saw rheumatologists and immunologists. I saw physiatrists. I mean, you name it, we've met, and I think a lot of people really gave it their best shot. In that way I think I did not encounter a lot of the stigma and dismissal that a lot of people with FND do.

The doctors seemed to think that what I had was clearly quite serious. They just didn't know what that was. Typically they would do everything they could as an individual doctor. They would exhaust their toolkit, and coming up with nothing they would essentially throw up their hands. If I was lucky they would refer me somewhere else, but usually not. Usually it was up to me to find the next person, and I ended up being seen at a number of top medical centers in North America. I saw this thing sort of destroy the edifice of medicinal knowledge. I saw some of the best doctors I could find try their best and come up with nothing, which I have to tell you is even scarier as a patient, when you have some idea of what they're trying to do and recognizing that it's not working.

Dr. Blair Bigham:

Tell me about the diagnosis. How did you eventually get diagnosed?

Peter Gill:

I was eventually diagnosed at the NIH's Clinical Center as part of the Undiagnosed Disease Network, and that was a really extensive neurological investigation that they did on my behalf. That actually incorporated all of my past medical history as well, so they had access to all my medical records. I think they actually knew what I had before I got there.

I think they looked at my medical history and they looked at the description of the symptoms, and likely knew what it was before I arrived because a lot of what they did once I got there seemed to be dedicated towards confirming what it seemed like they had already established, as well as ruling out other things, genetic disorders, different types of neurological dysfunction, autoimmune conditions that might be potentially in play. When they had confirmed the symptoms that I had as being functional, and when they had ruled out the major classes of other things that they were looking for, essentially the picture was set. The diagnosis happened in, it took them about three days from A to Z to get through that whole thing.

Dr. Mojola Omole:

Peter, how did you react?

Peter Gill:

I reacted really badly.

Dr. Mojola Omole:

Yeah. I imagine so. Tell us what it's like when somebody tells you that you have a functional illness.

Peter Gill:

It depends how it's explained. In my case the explanation of FND was fairly short, and I had actually brought a lot of my own bad priors to that conversation, so I hadn't heard about FND in an educated or informed way. I had heard about it as being essentially synonymous with the idea of conversion disorder and I understood conversion disorder to be a process by which a person represses their emotions or represses traumatic memories and doesn't deal with their emotional life in a mature kind of way. As a result it produces this strange kind of disability as a result of that.

I think there's a kind of sort of epistemic terror that comes with that for people who get the diagnosis under that formulation because essentially the doctor is saying you have so little knowledge of your own life that you produce your biggest problem and you don't even know it, and I'm here to tell you about it. If you deny it, that's just further evidence that you're repressing it, because of course you can't access it because you've repressed it from memory.

There's a sort of vicious cycle of explanation there that I think is really terrible and really unscientific. That was all that I knew at that time, was that was the only framework that I had to understand FND. Eventually I came to know it better and I understood that a lot of those things are not true about it. Once I came to know FND reasonably well it did fit my story and it did make sense that things played out the way that they did. But the initial experience of the diagnosis was not a great one.

Dr. Blair Bigham:

I imagine a lot of physicians out there might also feel similarly around functional disorders. I don't know if it's from a place of frustration or what it is, but did you meet physicians after your diagnosis who maybe some were more helpful and some were less helpful, and can you help guide us as clinicians, as to how we can make those functional diagnoses easier to understand and easier to get through?

Peter Gill:

Absolutely. I think the first part is just understanding what functional disorders are. To my mind, functional disorders are not a disease, as doctors would traditionally think of it. There's no misfolding proteins. We're not talking about necessarily the presence of a virus in the body or something like that. Those are the kind of things that I think doctors actually feel really comfortable with because of their education. I think there's a hidden dynamic to the way that doctors often treat people with this condition, and I just want to name it, even though it's uncomfortable.

I think sometimes doctors think that people with FND are faking and they'll treat them badly on that basis. They'll say essentially you don't really deserve to be here with my real patients. That's a real thing, and I don't want to underplay it. But actually I think there's something that's more common than that, which is that doctors will see someone with FND or some other functional symptoms and they'll recognize that this thing is real, and it's actually pretty profound, and I think that they get scared because they feel so unequipped to make sense of this in even a really basic way.

That must be frightening after you've been through all that medical education and spent a million hours as a med student when your friends were partying, and now you're supposed to know everything and yet here's something that appears to challenge just the basic foundations of all the stuff that you were taught, like the whole entire system of ideas and facts seems to be challenged by this thing in front of you. If that's true, then how much can you really know, and are you actually good at your job, and are you actually helping people? I think that would explain a lot of the sort of resentment that doctors seem to display for these patients, who again, people with FND are not doing this voluntarily. It's an involuntary disability just like anything else.

I think that when doctors run into this sort of primeval force that is FND, it sort of comes out of these ancient brain mechanisms, I think it scares them, and I think instead of doing the hard thing, which is going back to basics and saying what if there's something else out there that works different than the other things I know, they take the time that they have in the 15 minute appointment. They take the easiest way out, which is essentially either to blame the patient or say this isn't a thing. One thing I would want doctors to know is that the good news about modern FND science is that there's an answer. There's a better way to do this. You don't have to do things that way anymore. I would encourage them to embrace it.

Dr. Blair Bigham:

Peter, we're going to be talking to an FND expert in a few minutes, but before we do that I just want to ask where are your symptoms at now? How's your recovery going?

Peter Gill:

I'm doing well. Thank you. I have recovered quite a bit. I'm working full-time for the first time in almost a decade. My pain levels are much lower than they have been in a long time. At this point, I'm doing quite well and I'm also still quite a ways from being what people would call able-bodied. I can walk a mile if I have to, but I can't walk 10. I have kind of a radius, and I have to do a lot of management to keep things on track and stay healthy day to day, but it's worth it, and I feel grateful for where I've gotten to. Especially I recognize that the kind of recovery that I've had is often one that most people with FND don't have because they never get diagnosed in the first place.

Dr. Mojola Omole:

That's amazing.

Dr. Blair Bigham:

Peter, I think you used the word toolbox, and every doctor comes to work every day with a toolbox, which is the accumulation of all of that training, and if we don't have a tool in our toolbox that can fix something, I think we do get frustrated. I think there's a lot of truth to what you said, and like you said, we either refer or we ignore once our toolbox is exhausted. I'm sorry that you've gone through such a long period of illness to get to where you are today.

Peter Gill:

Thank you.

Dr. Blair Bigham:

You're a great advocate and an excellent orator, so thank you so much for joining us today and for advocating for functional neurologic disorders.

Peter Gill:

Thank you so much for taking this on. It was a pleasure to join you.

Dr. Blair Bigham:

Thank you. Peter Gill lives in Toronto. After the break we'll be speaking with Dr. Matthew Burke, an expert in functional neurologic disorders.

Dr. Mojola Omole:

Welcome back. Functional neurological disorders are the focus of a paper in the CMAJ entitled Functional Neurological Disorders Associated with SARS-CoV-2 Vaccine. The paper describes a case of FND following vaccination, but it also offers a primer on the condition that is frequently not well understood. Dr. Matthew Burke is a co-author on the paper. He's a cognitive neurologist at Sunnybrook Hospital. Thanks for joining us today, Dr. Burke. Just off the top, what were your thoughts on what you heard from Peter?

Dr. Matthew Burke:

Yeah, so it was a very interesting and eloquent account that he provided, and I really agree with much of what he said. To start, there are absolutely clinicians, including senior esteemed clinicians that do treat patients like they are faking it or it's all in their head, and really have no concept of the condition and our kind of contemporary understanding of it.

That's a huge problem, and then the second point that Peter says about the lack of knowledge and being uncomfortable and scared, that also definitely resonates. I think the root of that is the lack of medical education on the topic. In medical school in Toronto where I trained or across the country, there's really very limited teaching on this topic, despite these patients being very frequent, estimates around maybe 30% of patient neurology referrals and similar numbers probably in other medical sub-specialties.

Dr. Mojola Omole:

30%. That's high.

Dr. Matthew Burke:

Yeah, absolutely. It's very common.

Dr. Blair Bigham:

Matthew, we heard that Peter took many years to be diagnosed, and I imagine that people with these symptoms often get MRIs. They get a paraneoplastic workup. They get a rheumatologic workup. They get a [inaudible 00:20:48]. I'm just curious are there ways that we can fast track the diagnosis? Can you tell me a little bit more about the diagnostic criteria?

Dr. Matthew Burke:

Yeah, so that's a fantastic question and probably one of the most controversial ones. The diagnostic criteria, largely the one that people use as a DSM manual, which essentially is pretty vague and does not include specific objective rule-in factors that alludes to the presence of neurological symptoms that are incongruent with recognized medical or neurological diseases and emphasize the importance of neurologic exam and assessment in determining that, but unfortunately right now we don't have any objective measures like a blood test or a brain scan where we can definitively and in an objective fashion rule in a functional neurological disorder to avoid these unnecessary redundant or excessive investigations.

What we are getting much better at is for our subsets of symptom presentations, most notably the movement or motor presentations of functional neurological disorder, we are getting these clinical rule-in signs that can aid in a positive diagnosis that you don't see in other neurological conditions. We outline that in a table in the paper in CMAJ, but that's only for a subset of the types of presentations that involve abnormal movements or weakness. Depending on how much you're a lump or a splitter, there are many different types of presentations of functional neurological disorder where it is still largely diagnoses of exclusion.

There can be some kind of soft positive signs, but it's tricky. Where you draw the line on the investigations to have the confidence that this is functional neurologic disorder really varies physician to physician and it's something we all need to think about and worry about because most physicians are more worried about missing a diagnosis than making the correct functional neurological disorder diagnosis early to avoid the potential negative outcome associated with a long delay to diagnosis.

Dr. Blair Bigham:

Where does FND fall on the spectrum of neurological versus psychological disorder? Is there any settled science on that?

Dr. Matthew Burke:

Yeah, so this is a great question. The field that I'm in, in neuropsychiatry, tries to get away from these types of divisions where something's neurological or psychological or psychiatric, because in the end it's all the same organ. It's the brain, and there are very arbitrary kind of divisions that we make for practical purposes. These disorders are disorders of brain network dysfunction, and that has to do with neurons, their connections in the brain, and whether that falls under neurology or psychiatry is arbitrary and in my mind really epitomizes the interface between these fields.

I don't see how you can make a great argument to say that they're one or the other. They're both, because there are factors that are historically related to both fields, but I really think it's better to have a paradigm shift that these are brain disorders that kind of fall in between classically described disciplines. Unfortunately because of that they've largely slipped through the cracks of both fields and all of medicine, really.

Dr. Blair Bigham:

That makes sense.

Dr. Mojola Omole:

What's the typical way FND progresses in patients?

Dr. Matthew Burke:

It's quite variable, and some of the literature on prognosis of patients is surprising in how bad the prognosis can be overall, especially in more severe cases presenting to a neurologist where there have been studies showing that the prognosis in terms of measures of quality of life and impairment can be similar to other neurological diseases like Parkinson's Disease for example. But there's a very wide spectrum. One of the important things to emphasize is that these disorders are potentially completely reversible. I have seen cases of that, because it's like a software dysfunction, a circuit based dysfunction that was disrupted and it can be remedied.

But we'll see patients who make full recoveries and we'll also see patients who can really be struggling for a very long time. Trying to understand why one patient would fall into those different trajectories is obviously extremely important. I will also say that we do see a lot of comorbid symptoms across medicine sometimes with this patient population. They might present with a functional neurological disorder and that might resolve, but then maybe they present later with a chronic pain syndrome or a functional GI disorder because core in the brain is probably this disrupted circuitry that is the foundation for not only the neurologic symptoms but lots of symptoms we might see in medicine.

Dr. Mojola Omole:

What are some of the therapeutic options effective for patients who have FND?

Dr. Matthew Burke:

First and foremost, and it's often not usually described as a therapeutic option, but the education and counseling to a patient about what the disorder is and giving them an explanation of the mechanism, and that they're not crazy or faking it. That in itself is quite therapeutic, because if we can imagine that maybe part of the problem is the hyperactive stress response centers in the brain, when they're going from doctor to doctor being told I'm not sure what you have or waiting for these tests, that fuels a lot of the anxiety and uncertainty.

Being told what this is and the mechanisms for how it works, and that it doesn't equate to it's all in my head or I'm faking it, I think is extremely important, and really is the first step in management along with different resources. You can provide them with more full information like neurosymptoms.org, which is a great resource that we highlight in the paper. Then it depends on the nature of the symptoms. Motor symptoms, like in the case we present, physiotherapy is really critical and really an FND informed physiotherapy that uses specialized techniques to leverage things like the fact that distraction can improve symptoms into the therapy is critical.

Unfortunately many of our physiotherapists are as poorly educated on this topic as the doctors, and so it's an uphill battle often, especially when seeing patients in rural Ontario, to get someone from the physical therapy space that knows that. I often fax or send over the guidelines for physiotherapists with these disorders, and we recently gave rounds to our physiotherapists at Sunnybrook on these disorders as well. There's education piece with our multidisciplinary colleagues as well, and then certainly, if there are notable psychological factors at play, which is not uncommon, then psychotherapy for helping reconceptualize the nature of their symptoms, the nature of this disorder.

Maybe helping a gradual return to activities when they've previously been fearing such activities, because they exacerbate symptoms for example. CBT and other techniques can be important with psychotherapy. Then certainly for patients who do have the risk factor, which is a strong risk factor when present certainly, when it comes to childhood adverse events, histories of trauma, psychological trauma, sexual trauma, physical trauma, more focused psychotherapies on that aspect, whether it be psychodynamic techniques or other trauma based techniques, which I'm not trained in as a neurologist, are certainly important too. I would say that those are probably two of the core management aspects, and some patients might need different specialized [inaudible 00:29:06] of medical care,.

If there's functional speech or swallowing symptoms, then speech-language pathologist. If it's more functional return to work considerations, then an occupational therapist for example, but there is no magic pill unfortunately, and we're working on targeted treatments where we could identify these circuits that have become disrupted in the patient's brain, and then use, for example, non-invasive brain stimulation techniques to normalize or modulate those circuits that are disrupted. That's kind of a Holy Grail of this field that obviously isn't in primetime yet.

Dr. Mojola Omole:

That's really great. I love how you say that there's just a disruption of the circuit system. I think that's a very accessible way for people to actually understand what's going on with them, that they don't feel like A, it's all in my head. There is something that's happening that explains my symptom. It's just not something structural.

Dr. Matthew Burke:

Absolutely.

Dr. Mojola Omole:

Great. Thank you so much. I learned quite a lot. Dr. Matthew Burke is the co-author of a paper in CMAJ entitled Functional Neurological Disorders Associated with the SARS-CoV-2 Vaccine. He is a cognitive neurologist at Sunnybrook Hospital.

Dr. Blair Bigham:

Jola, this is fascinating. What are your thoughts?

Dr. Mojola Omole:

I was completely enthralled by listening to Peter just explain so eloquently his journey with functional neurological disorder and the impact that it's had on his life, and then the joyous part of him being able to make a recovery, and Dr. Burke really just kind of blew my mind open in terms of just the way to view functional disorders as there's just something that is wrong with the circuitry of your brain and it's just wiring is off.

That makes so much sense to me and I really connected with that. I guess for me, I feel like that is a much more clear way of explaining to patients that is not condescending, doesn't minimize what they're going through, but actually gives them an explanation that you know what? Yes, there's nothing structural that is wrong with you, whether it's neurological or gastrointestinal, but your circuitry is off. We just need to help you figure out how to rewire it. I thought he said that really beautifully.

Dr. Blair Bigham:

Yeah, I imagine the way you initially deliver that diagnosis kind of makes or break it. I'm sure you could really turn people off so that they would be less open to further conversations about it if you approached it in a way that made people feel dismissed. I worry that that probably happens more often than it should because I really resonated with what Peter said. We get so frustrated when we have exhausted our diagnostic pathways. We've relied on specialists who have exhausted their diagnostic pathways, and it's hard to sort of fall back on what many people would call a diagnosis of exclusion because we are always worried that we're missing something organic. But the way that Dr. Burke has worded this diagnosis is so helpful.

Dr. Mojola Omole:

Mm-hmm, 100%.

Dr. Blair Bigham:

Jola, you're a saxophone player just like Peter.

Dr. Mojola Omole:

Not like Peter, but I can play a saxophone.

Dr. Blair Bigham:

Got you. How did it make you feel hearing about this six or seven year ordeal of waiting to be diagnosed and not being able to play his music, to do his profession?

Dr. Mojola Omole:

It actually made me quite sick to my stomach in terms of hearing that it was six to seven years of his life stopping. It was just chilling, and speaking to friends who are also physicians, I actually do think a lot of us, we find functional disorders to be terrifying because it's one of those things that you're like could this happen to me?

Dr. Blair Bigham:

Absolutely.

Dr. Mojola Omole:

I'm someone who has bad reflux. As I was listening to this, I'm like hmm, maybe mine is a functional disorder because despite medication I still have days where I have really bad reflux, and I think that that's always kind of the fear of oh my goodness. What if this is quote, unquote, what they used to say, "in your head?" But the way Dr. Burke said it is that it's in your head because your circuits are off.

Dr. Blair Bigham:

Yeah.

Dr. Mojola Omole:

To me, that was actually empowering, because you're giving a solution as you're telling the problem.

Dr. Blair Bigham:

That's right. It makes it tangible. It removes the patient from the blame. This is not a patient choice as both Peter and Dr. Burke said. I love the conversation about being able to sort of shorten that time to diagnose this with some of these tests for people who have incongruent symptoms, so that we can try to speed things up and not have them go through years of specialist appointments and paraneoplastic workups and things like that.

Dr. Mojola Omole:

For sure.

Dr. Blair Bigham:

That's it for this week on the CMAJ Podcast. Please, if you can, remember to like or share our podcast wherever you download your audio. I am Blair Bigham.

Dr. Mojola Omole:

I'm Mojola Omole and until next time, be well.