Ethically Engaging “Complex” Patients in the Clinic: Functional Neurological Disorders, Factitious Disorders, and the (Ethical) Importance of Knowing the Difference

Abstract: When patients present with symptoms that are difficult to correlate with clear organic causes or a known pathophysiology, management can become complex and, at times, frustrating for both healthcare professionals and patients. This is particularly the case when the impetus for a patient’s symptoms is unclear and it is suspected that they may be “self-caused” in a significant way. But there are at least two different conceptual categories of disorder that patients may be experiencing when they present in this way: functional neurological disorders (FND) and factitious disorders (FD).
FND is an evolving category that includes psychogenic non-epileptic seizures and functional movement disorders. Though these disorders often have psychological or psychiatric components, they are not understood to originate by conscious decision of patients, instead arising from dysfunctional communication between brain and body. By contrast, FD is a disorder that involves a patient deliberately inducing or feigning illness for the purpose of receiving medical care and attention.
Identifying ethically supportable approaches for engaging with patients experiencing such disorders can be challenging, and healthcare professionals often find themselves frustrated and distressed by suspicions that patients are engaging in exploitative or manipulative behaviors. As a result, such cases are commonly referred for ethics consultation. In this talk, two clinical cases are utilized to describe and distinguish the categories of disorders mentioned here, and the importance of this distinction to ethically engaging patients is clarified. Five recommendations and action steps for ethically engaging complex patients with functional neurological disorders and factitious disorders are outlined.