Table 3 Ingredients of a successful explanation for patients with functional symptoms
Explain what they do have…“You have functional weakness”
“You have dissociative seizures”
Emphasise the mechanism of the symptoms rather than the causeWeakness: “Your nervous system is not damaged but it is not functioning properly”
Seizures: “You are going into a trance-like state a bit like someone being hypnotised”
Explain how you made the diagnosisShow the patient their Hoover’s sign or dissociative seizure video.
Explain what they don’t have“You do not have MS, epilepsy” etc
Indicate that you believe them“I do not think you are imagining/making up your symptoms/mad”
Emphasise that it is common“I see lots of patients with similar symptoms”
Emphasise reversibility“Because there is no damage you have the potential to get better”
Emphasise that self-help is a key part of getting better‘This is not your fault but there are things you can do to help it get better”
Metaphors may be useful“The hardware is alright but there’s a software problem”; “It’s like a car/piano that’s out of tune”; “It’s like a short circuit of the nervous system” (dissociative seizures)
Introducing the role of depression/anxiety“If you have been feeling stressed/low/worried that will tend to make the symptoms even worse” (often easier to achieve on a second visit)
Use written informationSend the patient their clinic letter. Give them some written information
Stop the antiepileptic drug in dissociative seizuresIf you have diagnosed dissociative seizures and not epilepsy, stop the antiepileptic drug. Leaving the patient on the drug is illogical, makes no sense to the patient and will hamper recovery
Suggesting antidepressants“So-called antidepressants often help these symptoms even in patients who are not feeling depressed. They are not addictive.”
Making the psychiatric referral“I don’t think you’re mad but Dr X has a lot of experience and interest in helping people like you to manage and overcome their symptoms. Are you willing to overcome any misgivings about their specialty to try to get better?”
Involve the family/friendsExplain it all to them as well