In this installment, we delve into the crucial function of the medical expert witness in cases of Functional Neurological Disorder (FND). Addressing issues like misdiagnosis and stigma, along with the difficulties of articulating FND’s intricate nature within legal contexts, expert witnesses are tasked with transforming subtle clinical observations into understandable courtroom presentations. Join us as we dissect how neurologists and psychologists assess symptoms, distinguish FND from malingering, and advocate for just resolutions in legal disputes and insurance matters. Whether you are a healthcare professional, attorney, or an interested listener, this episode provides an insightful glimpse into the convergence of neuroscience and legal proceedings.
Welcome to another episode of Beyond the Impact, the podcast where we explore the intersections of neuroscience, law, and human experience. I’m your host, Dr. Mavroudis, consultant neurologist, academic, and medicolegal expert. Today, we delve into a fascinating and often misunderstood area of medicine—Functional Neurological Disorder, or FND—and the vital role played by neurologists when called as expert witnesses in these complex cases.
What is Functional Neurological Disorder?
Functional Neurological Disorder is a condition where patients experience neurological symptoms—like weakness, seizures, tremors, or cognitive impairment—that are not caused by identifiable structural damage to the nervous system. Instead, they arise from altered brain function. Importantly, these symptoms are real, often disabling, and can severely impact quality of life.
FND is not a diagnosis of exclusion; it is a positive diagnosis, made based on specific clinical signs and patterns. And this distinction—between what is not there (organic disease) and what is there (positive functional signs)—is critical when it comes to courtrooms, compensation claims, and disability assessments.
Why Do FND Cases End Up in Court?
There are several scenarios where a case involving FND may enter the legal system:
- Personal Injury Claims: Following trauma—like a car crash or fall—patients may develop neurological symptoms that are ultimately diagnosed as FND.
- Medical Negligence: Allegations that a healthcare provider failed to detect or properly manage symptoms that later evolved into functional symptoms.
- Insurance & Disability Disputes: Determining whether a claimant is entitled to benefits or compensation when the symptoms are functional rather than structural.
- Criminal or Fitness-to-Work Evaluations: Rarely, FND may feature in cases assessing criminal responsibility or professional capacity.
In all of these contexts, expert medical testimony becomes crucial to help judges and juries understand what FND is—and what it is not.
Role of the Neurologist as Expert Witness
When acting as an expert witness in FND cases, the neurologist must bridge clinical science with legal clarity. The role is multifaceted and involves:
- Diagnosis & Differentiation:
Providing an opinion on whether the person’s symptoms meet the diagnostic criteria for FND, and distinguishing FND from mimicking conditions like epilepsy, multiple sclerosis, stroke, or neurodegenerative diseases. - Causation:
Is there a link between the precipitating event—like a road traffic accident—and the onset of symptoms? Did the trauma cause the disorder, or was it a trigger in a person already predisposed? - Prognosis:
Offering evidence-based opinions about likely outcomes, particularly in the presence of risk factors for chronicity such as co-existing pain, PTSD, maladaptive beliefs, or lack of access to multidisciplinary care. - Functional Impact & Capacity:
Clarifying how symptoms affect everyday functioning, employment potential, and capacity for decision-making. Is the person likely to return to work? Are they genuinely impaired? - Psycho-Social Vulnerability and Risk Assessment:
Identifying predisposing and maintaining factors, such as early trauma, perfectionism, illness beliefs, or family dynamics that may influence recovery.
Challenges in the Legal Context
1. FND and the “Invisible Illness” Problem
Unlike conditions with visible pathology—like a brain tumor or a fractured spine—FND doesn’t show up on conventional scans. The absence of structural abnormalities often creates skepticism, especially in court.
2. Misconceptions about Feigning
A common but dangerous myth is that people with FND are faking their symptoms. The neurologist must educate the court on the difference between functional disorders, factitious disorders, and malingering—each with distinct psychological and behavioral markers.
3. Differing Standards of Proof
In clinical medicine, we operate on probabilities and evolving hypotheses. In court, the question is often binary—yes or no, with a burden of proof that depends on the context (e.g., balance of probabilities in civil cases, beyond reasonable doubt in criminal trials).
4. Communication Pitfalls
Expert reports must be accessible, clear, and jargon-free. In court, the neurologist must be able to explain complex concepts—such as neuroplasticity, dissociation, or functional neuroimaging—in plain English.
The Ethical Imperative
As expert witnesses, neurologists must walk a fine line:
- We are not advocates for the claimant or defendant.
- Our duty is to the court, not the party instructing us.
- We must be guided by evidence, not emotion or speculation.
- Importantly, we must acknowledge the limits of current science where appropriate.
Being impartial is not the same as being indifferent. We must present the evidence with empathy but also with scientific integrity.
Real-World Application, Courtroom Practice & The Future of Expert Testimony in FND
Expert Report Writing in FND Cases
Writing an effective medicolegal report is both an art and a science. Here are essential components tailored to FND cases:
1. Clarity of Diagnosis
Use DSM-5 or ICD-11 language where appropriate. Clarify whether diagnostic criteria are met positively (not just “no other explanation”).
2. Timeline of Events
Be specific. When did symptoms begin? Were they immediate or delayed post-event? Was there a latent period? What psychosocial events were present?
3. Explanation of Functional Symptoms
Include educational content for the court. Describe the distinction between structural and functional disorders. Use analogies where helpful (e.g., “a software glitch in a healthy computer”).
4. Risk Factors and Maintenance Mechanisms
Discuss any trauma history, comorbid mental health conditions, prior functional symptoms, or maladaptive illness beliefs.
5. Prognosis and Recovery Potential
Use published literature to support recovery expectations—especially if prognosis is guarded due to lack of treatment or ongoing legal stress.
6. Avoiding the Pitfalls
Avoid:
- Speculative links without support
- Emotional tone or advocacy
- Pathologizing claimants unfairly
Always remember: the report is for the court, not your instructing solicitor.
Giving Evidence in Court
Appearing in court as a neurologist can be intimidating but impactful.
Key Skills Include:
- Staying Within Your Expertise: Be honest about what is unknown or controversial in the field.
- Translating Medical Jargon: Use simple language to explain things like dissociation, attention networks, or the limbic system.
- Handling Cross-Examination: Maintain calm. If challenged on FND’s legitimacy, lean on its recognition in major diagnostic manuals and professional guidelines.
- Challenging Malingering Claims: When applicable, explain why inconsistency does not equal feigning. Emphasize that most patients with FND are not consciously producing symptoms.
Often, your calm, informed presence is more persuasive than any single fact.
When to Decline a Case
Not every instruction should be accepted. As an expert, you should refuse or return a case when:
- The claimant hasn’t been examined personally, and remote records are insufficient.
- The diagnosis is unclear, and further investigation is needed.
- The legal question is outside your expertise (e.g., psychiatric causation, forensic psychology).
Maintaining professional boundaries preserves the integrity of your role—and your reputation.
Future Directions – FND in the Legal System
Education Is Key
Too often, lawyers and judges are unfamiliar with FND. Experts have a duty not only to answer the legal question but also to educate. Resources like NeuroSymptoms.org, FND Hope, and position papers from professional bodies should be included in appendices or referenced where relevant.
Towards Standardization
Efforts are ongoing to create standardized templates and checklists for reporting on functional disorders in medicolegal contexts—helping to ensure consistency and fairness.
The Need for Multidisciplinary Testimony
In many cases, expert neurologists work alongside psychologists, occupational therapists, and psychiatrists to form a complete picture. The expert must understand the limits of their own view and advocate for a team-based understanding of recovery.
Final Thoughts
FND sits at the crossroads of neurology, psychiatry, trauma, and identity. As such, it challenges both clinicians and the legal system. But when approached with empathy, evidence, and clarity, neurologists can play a transformative role—not just for the court, but for the patients whose voices so often go unheard or misunderstood.
Whether you’re a clinician entering the medicolegal world, a lawyer handling your first FND case, or a policymaker shaping disability criteria, understanding this condition is no longer optional—it’s essential.
