Understanding the Care Pathway in Iranian Patients with Functional Neurological Symptom Disorders

Understanding the Care Pathway in Iranian Patients with Functional Neurological Symptom Disorders | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Understanding the Care Pathway in Iranian Patients with Functional Neurological Symptom Disorders Neda Masjedi, Lida Shafaghi, Sana Eybpoosh, Mohammad Arbabi, Mohammad Javad Ziaa, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5461333/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background : The vague pathology of conversion disorders (Functional Neurological Disorders (FNDs)) creates diagnostic and therapeutic challenges and uncertainties, requiring individuals to navigate various medical specialties and treatments. This study aims to explore pathways individuals with FNDs take in seeking care, uncovering factors influencing their healthcare journey. Methods : Conducted at Roozbeh and Imam Khomeini Educational Hospitals in Tehran from 2019 to 2022, this cross-sectional study included 101 FND-diagnosed patients. They were interviewed using a validated questionnaire by a trained psychiatrist to explore their care-seeking journey, diagnosis delay, and related factors retrospectively. Results : Participants, averaging 36.9 years in age (SD: 12.98), were predominantly female (66.3%) and married (55.0%). Initially, most participants sought consultation from neurologists (40.2%), then general practitioners (36.3%), with subsequent referrals mainly to neurologists in the 2 nd (71.2%) and 3 rd (72.7%) visits. Alongside with the low rates of visiting a general physician in first exposure that is a pronounced deviation from the hierarchy of care (primary, secondary, and tertiary), referral to psychiatrists was minimal in the whole reported visits (2.9%, 3.4%, and 9.1%, respectively). On average, participants had 1-5 specialist visits before visiting with a psychiatrist, with average disorder duration of 37.1 months. Movement disorders were found in 31.7%, and major depressive disorders in 42.6% of this population. A majority of patients (n=79, 78%) experienced at least one stressor before FND onset, with family conflict being the most significant one (17.1%). Conclusion : Our study highlights the significant challenges in the care pathway for Iranian adults with FNDs. Individuals sought consultations with a varying number of medical specialists before ultimately being referred to a psychiatrist. This is especially notable given the high prevalence of psychiatric comorbidities and associated stressors, which emphasize the crucial role of psychiatrists in addressing these complexities. However, both patients and healthcare providers seem to perceive the symptoms with a tendency toward more organic origins, indicating a potential gap in understanding and communication. Enhancing awareness and collaboration among healthcare providers, advocating for early intervention and routine psychiatric evaluation for individuals with FNDs, and addressing perceptions of symptoms through targeted education is recommended. Further research is needed to explore the pathway to care for patients experiencing each type of FND symptoms. Health sciences/Health care/Health policy Health sciences/Health care/Health services Health sciences/Health care/Public health Conversion disorder FNDs FNSDs diagnosis course prognosis comorbidity referral system care treatment Iran Figures Figure 1 Figure 2 Introduction Functional Neurological Disorders (FNDs), also known as Functional Neurological Symptom Disorders (FNSDs) or conversion disorders, constitute a significant subset of neuropsychiatric conditions characterized by complex symptomatology and uncertain pathophysiology 1 . The term "functional," as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) 2 , 3 , underscores the absence of structural neurological abnormalities 4 . Although increasing recognition and advancements in explanatory models have enhanced understanding 5 , significant variability in incidence and prevalence due to methodological differences across studies challenges comprehensive recognition 6 – 9 . In a recent report, the incidence of FND was estimated to be between 10 and 22 per 100,000, with a minimum prevalence ranging from 80 to 140 per 100,000 9 ; with higher occurrence in females 8 , 10 and variations across age groups 11 , 12 and regions 7 . However, diagnostic ambiguity, misclassification, and delays in referral persist, prolonging the diagnostic trajectory and limiting access to appropriate care 10 , 13 – 17 . The complexity of FND symptomatology is a key driver of these delays. Neurological manifestations—including tremors, dystonia, somatosensory impairments 18 , 19 , and psychogenic nonepileptic seizures (PNES)—frequently lead patients to seek neurological rather than psychiatric care, resulting in misdirected referrals and prolonged diagnostic uncertainty. This misalignment between clinical presentation and appropriate specialist care is further compounded by the high prevalence of psychiatric comorbidities, including depression 20 , 21 , anxiety 22 , and dissociative disorders 23 , 24 , which affect symptom expression, healthcare utilization, and treatment outcomes. Additionally, systemic disturbances such as chronic pain 25 , 26 , fatigue 21 , 27 , and cognitive deficits 8 , 28 not only worsen functional impairment but also increase healthcare-seeking behaviors, reinforcing the need for an integrated, multidisciplinary approach to optimize referrals and patient management. Beyond its clinical burden, the fragmented FND care pathway imposes a significant economic strain on healthcare systems. Repeated specialist consultations, unnecessary tests, and delayed psychiatric interventions drive rising healthcare costs, yet financial analyses often overlook pediatric FND cases 29 , 30 . In the UK, healthcare costs associated with somatization disorders reach £18 billion annually, with inpatient care exceeding £600 million 31 , 32 , while in the US, the estimated economic burden of somatization is $ 256 billion per year 7 . A systematic review of sixteen studies further underscores this financial strain, reporting annual costs ranging from $ 4,964 to $ 86,722 (2021 USD), encompassing both direct medical expenses and indirect costs related to lost productivity and long-term disability 6 , 9 . The intersection of diagnostic inefficiencies, clinical complexity, and economic burden highlights an urgent need for improved diagnostic strategies and streamlined treatment pathways. Addressing these challenges requires an optimized, structured model for FND care. The diagnostic process is complex and inefficient, starting with symptom recognition, followed by multiple specialist consultations, and ideally leading to timely treatment 33 , 34 . However, prolonged diagnostic uncertainty not only delays intervention but also exacerbates patient and caregiver distress, worsening prognosis. To mitigate these inefficiencies and improve patient outcomes, a standardized referral framework, enhanced interdisciplinary collaboration, and earlier psychiatric integration are essential to ensuring timely access to appropriate care. This study aims to examine the healthcare trajectory of FND patients, focusing on diagnostic classifications, psychiatric and medical comorbidities, and sociodemographic determinants. Specifically, it will assess whether distinct FND subtypes (e.g., somatosensory vs. motor-related) influence the initial point of care contact whether patients first seek general medical or specialist consultations and how these choices shape subsequent referral pathways. Furthermore, the study will investigate the role of psychiatric comorbidities in diagnostic delays and treatment trajectories, while also evaluating sociodemographic factors such as gender, socioeconomic status, education, family history, and childhood trauma to determine their impact on healthcare access and clinical outcomes. By identifying key determinants of diagnostic and treatment pathways, this study seeks to bridge existing gaps in FND management, inform evidence-based clinical practices, and optimize healthcare resource allocation, ultimately enhancing patient care and long-term outcomes. Methods Since Augst 10th 2019 to May 6th 2022, a cross-sectional study was undertaken involving residents of Tehran diagnosed with functional neurological disorders. The research was conducted in educational hospitals affiliated with Tehran University of Medical Sciences, namely Imam-Khomeini Hospital and Roozbeh Psychiatry Hospital. These two hospitals are situated in Tehran, the capital of Iran, where the population is heterogeneous and encompasses a variety of backgrounds, including diverse urban and socioeconomic conditions. Additionally, these referral hospitals boast other significant features. Primarily, they offer low medical costs, making them accessible to individuals across socioeconomic strata. Also, they attract patients from diverse parts of the country and backgrounds due to the high skill level of their practicing physicians. So, the participants recruited for this study can be regarded as a reasonably representative cohort of individuals with functional neurological disorders. Eligible individuals, who were at least 16 years old, included those with confirmed FND diagnoses based on the psychiatrist’s diagnosis while excluding those whose diagnosis underwent changes during or after the interview setup. Data collection utilized a made-researcher questionnaire comprising five sections: demographic characteristics and socioeconomic status; comprehensive neuropsychiatric assessments; care and treatment-seeking history; self-treatment records; and medical diagnoses and treatments. The questionnaire underwent evaluation and adjustments by the research team, preceded by a pilot study involving ten patients. Trained psychiatrists conducted the interviews and filled out the questionnaires. Written informed consent was obtained from all patients or their first-degree guardians/relatives before participation. The consent process included clear information on study objectives, procedures, potential risks, and benefits. Participants were informed of their right to withdraw from the study at any time without affecting their treatment, and they were provided with the option to request the study results along with contact details for further inquiries. Confidentiality was strictly upheld, with all identifying information removed from research data and materials. Privacy measures were enforced to ensure the protection of participant information. Participants were assured that their involvement would not result in harm and that compensation would be provided for any adverse effects. The study adhered to ethical standards, including the Declaration of Helsinki (1964), and national and international regulations. It was approved by the Ethics Committee of Tehran University of Medical Sciences (IR.TUMS.MEDICINE.REC.1398.229). All study procedures, including informed consent, confidentiality protocols, and data management, complied with the relevant guidelines for research involving human participants. The research did not involve the use of identifying images or information, and any publication of such data would be contingent on obtaining prior informed consent from participants. Statistical analyses were performed using SPSS software (version 26), with graphical representations generated using Excel. Categorical variables were described in terms of absolute and relative frequencies, while quantitative data were characterized by range, mean, and standard deviations. Additionally, statistical tests such as t-tests and logistic regression were performed to further examine the data. Results Participants’ Demographic and Clinical Profile Totally, 101 individuals with a confirmed FND diagnosis participated in the study, 66.3% of which were female, and a mean age of 36.0 years (SD: 13.0). On average, patients reported having 4.8 family members (range: 2-12 individuals). The majority of patients were married (54.5%), unemployed (56.4%), and did not possess a university-level educational background (64.4%; Table 1). Table 1. Demographics of Study Participants Variable n (%) Age (year) Mean (SD) 36 (13.0) Min, Max 17, 68 Gender Female 67 (66.3) Male 34 (33.7) Family Members (number) Mean (SD) 4.8 (1.7) Median (IQR) 5 (4, 6) Min, Max 2, 12 Marriage Status Single 45 (45.5) Married 55 (54.5) Insurance Type Social Security 42 (41.6) Other 59 (58.4) Having Supplementary Insurance Yes 21 (20.8) No 73 (72.3) Occupational Status Unemployed 53 (56.4) Part-time 17 (18.1) Full-time 24 (25.5) Educational Level High school diploma or lower 65 (64.4) College/University 27 (26 . 7) Post graduate 9 (8.9) Table 1. Table presents the demographic characteristics of the study participants, including their age, gender, family size, marital status, insurance type, and educational level. The average duration of perception of FND symptoms (the duration of suffering from symptoms) was 37.1 months (SD: 51.6 months, range: 0.1 - 300 months). The average duration between taking the primary actions for seeking diagnosis and treatment averaged 35.7 months (SD: 46.2, range : 1 - 275 months). Among those who responded on the outcome of the treatment (68 participants), 61.8% claimed it was useless, while 26.5% reported partial improvement. Notably, individuals without comorbid psychiatric disorders had a significantly longer mean duration of illness compared to those with psychiatric comorbidities (73.0 ± 64.0 vs. 35.8 ± 26.6 months; p = 0.003). The FND symptoms were persistent in 40.6% of patients. Based on the table 2 and fig 1, Movement Disorders were the most common symptom, affecting 31.6% of participants, mostly younger females (62%), and were strongly linked to major depressive disorder (87%) and family stressors. Sensory Problems (15.8%) also predominantly affected females (68%) and were associated with depression and panic disorder. Fainting (13.8%) was observed mainly in females (92%), with high rates of depression (87.5%) and family-related issues. PNES (12.8%) had an even gender distribution and was seen in younger individuals, all of whom had major depression. Pain (10.8%) affected both genders equally, with 75% having depression, along with common OCD and trauma diagnoses. Multiple Symptoms (5.9%) involved complex psychiatric comorbidities like phobias. Less common symptoms included Aphasia (4.9%), Visual Problems (2.9%), and Cognitive Impairments (0.9%), primarily in females, and were associated with borderline personality disorder, panic, PTSD, and phobias. Table 2. Distribution of FND Symptoms, Comorbidities, and Recent Stressors Among Study Participants Variable n (%) Periodicity of FND Symptoms Intermittent 59 (58.4) Persistent 41 (40.6) Type of FND Symptom Movement Disorders 32 (31.7) Sensory Problems 16 (15.8) Faint 14 (13.9) PNES 13 (12.9) Pain 11 (11.0) Vision-Related Problems 3 (3.0) Aphasia 5 (5.1) Cognitive Impairments 1 (1.1) Multiple Symptoms 6 (5.9) Accompanying Psychiatric Disorders Yes 75 (74.3) No 26 (25.7) Type of Psychiatric Comorbidity Major Depressive Disorder 32 (42.6) Generalized Anxiety Disorder 15 (20.1) Mixed Mood Disorders 7 (9.4) Bipolar Mood Disorder 5 (6.6) Panic Disorder 4 (5.4) Specific Phobias 3 (4.2) Borderline Personality Disorder 2 (2.6) Adjustment Disorder 2 (2.6) Social Anxiety Disorder 2 (2.6) Post-Traumatic Stress Disorder 1 (1.3) Obsessive-Compulsive Disorder 1 (1.3) Transient Psychotic Disorder 1 (1.3) Type of Recent Stressor* Family conflicts 13 (18.0) Loss of a loved one 12 (16.6) Divorce 9 (12.5) Emotional stress 7 (9.7) Workplace conflicts 6 (8.3) Financial problems 5 (6.9) Illness of family members 3 (4.8) Exams 2 (2.8) Burglary 2 (2.8) Property Loss 1 (1.4) Deployment to the military services 1 (1.4) Fears and phobias 1 (1.4) Accidents 1 (1.4) Receiving negative news 1 (1.4) Guarantor unemployment 1 (1.4) None 7 (9.7) Table 2. Table illustrates the distribution of Functional Neurological Disorder (FND) symptoms, psychiatric comorbidities, and recent stressors reported by study participants. Fig 1. Distribution of Functional Neurological Disorder (FND) symptoms among participants. The Figure illustrates each symptom separately, Movement Disorders (31.6%), Sensory Problems (15.8%), Fainting (13.8%), Psychogenic Non-Epileptic Seizures (PNES) (12.8%), Pain (10.8%), Multiple Symptoms (5.9%), Aphasia (4.9%), Visual Problems (2.9%), and Cognitive Impairments (0.9%). Each pie chart represents the prevalence of the symptom among participants, accompanied by demographic and psychosocial characteristics, including gender, age group, psychiatric comorbidities, and significant stressors. The p-values indicate the significance of associations between the demographic factors and the presented symptom. The mean treatment cost per patient from the onset of symptoms until the diagnosis of FND amounted USD 63.3. There was no significant difference in mean treatment costs between individuals with and without psychiatric comorbidities (87.7 ± 32.8 vs. 62.7 ± 48.7 USD; p = 0.49). Pathway to Care of FND Patients The overall referral pattern revealed that in the first step, 40.2% of FND patients visited a neurologist or neurosurgeon, 36.3% visited a general practitioner, 20.6% visited other specialties, and merely 2.9% initially visited a psychiatrist or psychologist. Thereby, neurologist visits were prominent among first exposures to the healthcare system, followed by consultations with general physicians. In the second visit, nobody referred to the GPs anymore or to other specialties. Instead, 71.2% referred to neurologists/neurosurgeons, and 3.4% to psychiatrists/psychologists. In the third visit, the pattern of referral remained the same, with a slightly more cases visiting psychiatrists/psychologists than visit 1 and 2 (Fig 2 and Table 3). Altogether, most individuals had visited a neurologist on all three visits . Traditional healer visits were specifically investigated during each visit. Patients only sought traditional healers during their third visit. Fig 2. Pathway of specialist consultations and frequency of visit locations for patients diagnosed with Functional Neurological Disorders (FNDs). Panel (a) visualizes the referral network showing connections between various medical specialists, with the thickness of the lines representing the number of referrals between specialists. The specialists include general practitioners, neurologists, psychiatrists, and others involved in the patient's care pathway. Panel (b) illustrates the frequency of visits by specialist type and location in terms of visit order (1st, 2nd, and 3rd). The top heatmap shows the frequency of specialist visits, with neurologists and general practitioners being the most visited. The bottom heatmap shows the frequency of places visited, such as doctors’ offices, emergency departments, and hospitals, with doctor’s offices being the most common location for initial visits. Table 3. Medical specialization sought by FND patients Psychiatry* Neurology** GP Traditional therapies Other § Total Visit Order n (%) n (%) n (%) n (%) n (%) n (%) OR (95% CI) p -value Overall 1 st 3 (2.9) 41 (40.2) 37 (36.3) 0 (0.0) 21 (20.6) 102 (100) - - 2 nd 2 (3.4) 42 (71.2) 0 (0.0) 0 (0.0) 15 (25.4) 59 (100) 3 rd 2 (9.1) 16 (72.7) 0 (0.0) 3 (13.6) 1 (4.6) 22 (100) - - Based on FND symptom Movement Disorder 1 st 2 (6.3) 14 (43.8) 7 (21.9) 0 (0.0) 9 (28.1) 32 (100) 3.4 (0.9, 12.9) 0.08 2 nd 0 (0.0) 17 (89.5) 0 (0.0) 0 (0.0) 2 (10.5) 19 (100) 3 rd 1 (12.5) 6 (75.0) 0 (0.0) 1 (12.5) 0 (0.0) 8 (100) Faint 1 st 0 (0.0) 6 (42.9) 5 (35.7) 0 (0.0) 3 (21.4) 14 (100) 1.9 (0.4, 0.7) 0.45 2 nd 1 (11.1) 7 (77.8) 0 (0.0) 0 (0.0) 1 (11.1) 9 (100) 3 rd 1 (33.3) 2 (66.7) 0 (0.0) 0 (0.0) 0 (0.0) 3 (100) Sensory Disorders 1 st 0 (0.0) 5 (31.3) 8 (50.0) 0 (0.0) 3 (18.8) 16 (100) 0.2 (0.1, 1.8) 0.14 2 nd 0 (0.0) 6 (60.0) 0 (0.0) 0 (0.0) 4 (40.0) 10 (100) 3 rd 0 (0.0) 4 (100) 0 (0.0) 0 (0.0) 0 (0.0) 4 (100) PNES 1 st 1 (7.7) 7 (53.9) 5 (38.5) 0 (0.0) 0 (0.0) 13 (100) 0.5 (0.1, 5.7) 0.59 2 nd 0 (0.0) 6 (100) 0 (0.0) 0 (0.0) 0 (0.0) 6 (100) 3 rd 0 (0.0) 1 (100) 0 (0.0) 0 (0.0) 0 (0.0) 1 (100) Pain 1 st 0 (0.0) 4 (36.4) 4 (36.4) 0 (0.0) 3 (27.3) 11 (100) 0.4 (0.03, 6.3) 0.54 2 nd 0 (0.0) 3 (37.5) 0 (0.0) 0 (0.0) 5 (62.5) 8 (100) 3 rd 0 (0.0) 2 (66.7) 0 (0.0) 1 (33.3) 0 (0.0) 3 (100) Cognitive Impairments 1 st 0 (0.0) 1 (100) 0 (0.0) 0 (0.0) 0 (0.0) 1 (100) - - 2 nd 2 (3.4) 42 (71.2) 0 (0.0) 0 (0.0) 15 (25.4) 59 (100) 3 rd 2 (9.1) 16 (72.7) 0 (0.0) 3 (13.6) 1 (4.6) 22 (100) Visional Problems 1 st 0 (0.0) 0 (0.0) 3 (100) 0 (0.0) 0 (0.0) 3 (100) - - 2 nd 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 3 (100) 3 (100) 3 rd 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 3 (100) 3 (100) Aphasia 1 st 0 (0.0) 0 (0.0) 4 (80.0) 0 (0.0) 1 (20.0) 5 (100) 3.1 (0.3, 35.6) 0.35 2 nd 1 (33.3) 2 (66.7) 0 (0.0) 0 (0.0) 0 (0.0) 3 (100) 3 rd 0 (0.0) 0 (0.0) 0 (0.0) 1 (100) 0 (0.0) 1 (100) Multiple Symptoms 1 st 0 (0.0) 4 (66.7) 1 (16.7) 0 (0.0) 1 (16.7) 6 (100) 2.6 (0.3, 20.4) 0.37 2 nd 0 (0.0) 1 (100) 0 (0.0) 0 (0.0) 0 (0.0) 1 (100) 3 rd 0 (0.0) 1 (100) 0 (0.0) 0 (0.0) 0 (0.0) 1 (100) Table 3. table categorizes the medical specializations sought by patients with Functional Neurological Disorder (FND), classified by the visit number (1st, 2nd, 3rd) and type of symptom. Among the 101 participants, 59 (58.4%) recalled details of their next visit (the 2nd visit). Notably, the majority of these patients (71.2%) were directed to neurologists, while in 11 (10.9%) cases, the general practitioners initially suggested consultations with psychiatrists. Of these, 9 patients did not recall if they visited the psychiatrist, and the remaining 2 patients opted for neurologists instead. The referral rate to psychiatrists in the second visit remained consistent compared to the first visit (3.4% vs. 2.9%, respectively). Only 2 patients were re-referred by neurologists to their respective areas of expertise during the second visit. The remaining referrals to the neurologist in the second visit were initiated by the patients themselves, disregarding the advice of the initial clinician. Also, none of the participants sought traditional therapies during their second visit (Table 3). Among the 101 participants, 22 (21.8%) patients recalled details of their third visit. By the third visit, a similar trend as the second visit emerged, with 72.7% of respondents being referred to neurologists, two patients to psychiatrists, and none to general practitioners. Additionally, three respondents visited traditional therapists at this step due to perceived inefficacy of previous treatments (Table 3 & Figure 1). Notably, 64% of patients who initially consulted general practitioners were primarily directed towards neurologists or neurosurgeons with subsequent referrals predominantly to specialists other than psychiatrists. On average, participants visited between one and five different medical specialists before being referred to the psychiatrist. Individuals with movement disorders, faint, and PNES, were more likely to visit the neurologist/neurosurgeon at the first visit, however, patients with sensory problems, visional issues, and aphasia more frequently preferred to visit GP at first (Table 3). Patients with intermittent symptoms were more likely to be referred to a general practitioner for their initial visit compared to those experiencing chronic suffering. Logistic regression models showed that after controlling for demographic factors, comorbidities, and stressors, patients whose symptoms were movement-associated and faint were respectively 3.4 and 1.9 times more likely to go to a neurologist at the first visit and actually considered and perceived the origin of their problem to be neuronal. However, these associations were not statistically significant. People whose symptoms were in the sensory disorders category, PNES, and aphasia group were less likely to see a neurologist at the first visit. Instead, these people were more likely to see a general practitioner than a neurologist or other specialists. These associations were not statistically significant as well. Regarding the vision and cognitive problems, since all participants have examined by the neurologists, regression analysis was not possible (Table 3). Moreover, the results revealed no significant association between neurologist referral and underlying demographic variables, as shown in table S1. Discussion Our study highlights significant challenges in the diagnosis and management of Functional Neurological Disorder within the Iranian healthcare system. The findings reveal a prolonged diagnostic delay, considerable economic burden, and a preference among patients and referring physicians for non-psychiatric specialties, even when psychiatric care would be the most appropriate. These results align with international literature suggesting similar diagnostic obstacles across diverse healthcare settings, emphasizing the need for improved awareness, multidisciplinary collaboration, and revised clinical protocols for FND management. Diagnostic Delay and Healthcare Utilization One of the most striking findings of our study was the considerable delay between symptom onset and definitive FND diagnosis, averaging 37.1 months. This delay is not unique to Iran, as previous research has consistently reported prolonged diagnostic timelines in various healthcare systems. Studies from the UK and US have found that FND patients often undergo extensive medical evaluations and referrals before receiving an accurate diagnosis, with delays frequently exceeding two years 35,36 . Our results reinforce the notion that the lack of early recognition of FND, compounded by skepticism regarding its legitimacy as a neurological disorder, significantly hampers timely intervention 37 . Additionally, the delay in diagnosis translates into increased healthcare costs, a concern also reported in other studies where patients accumulate unnecessary imaging, laboratory tests, and specialist consultations before appropriate referral to psychiatric care 38 . Referral Patterns and the Role of Neurologists Our findings demonstrate that the majority of patients initially sought care from neurologists (40.2%) or general practitioners (36.3%), with only 2.9% visiting a psychiatrist during their first medical consultation. This referral pattern mirrors global trends wherein FND patients are predominantly managed within neurology rather than psychiatry 39 . Patient and provider reluctance to involve psychiatrists early reflects persistent misconceptions about the psychiatric nature of FND and a broader resistance to integrating psychiatry into neurology 34 . Neurologists often hesitate to make a definitive FND diagnosis, opting instead for extensive neurological workups, further delaying psychiatric referral and prolonging patient distress 40 . Moreover, neurologists’ reliance on exclusionary diagnoses rather than positive identification criteria for FND has been widely criticized 41 , indicating a pressing need for structured training programs emphasizing early FND recognition. Symptom Profiles and Psychiatric Comorbidities Our study further reinforces the high prevalence of psychiatric comorbidities in FND patients, with depression, anxiety, and trauma-related disorders being the most commonly associated conditions. Previous literature has extensively documented the strong correlation between FND and psychiatric disorders, with rates of comorbidity often exceeding 70% 42 . In our study, individuals presenting with movement disorders, sensory symptoms, and fainting episodes were particularly prone to psychiatric comorbidities, consistent with prior research indicating that these symptoms frequently coexist with affective disturbances and trauma histories 43,44 . The high prevalence of depression (87%) among patients with psychogenic non-epileptic seizures (PNES) in our sample mirrors findings from Reuber et al. (2018) 45 , who reported that PNES is strongly associated with a history of adverse life events and emotional dysregulation. Despite this well-established link, psychiatric conditions did not appear to significantly influence treatment costs, suggesting that while psychiatric comorbidities may facilitate earlier recognition in some cases, they do not necessarily increase direct financial burdens. This finding diverges from some international studies, such as Vroegop et al. (2023) 46 , which reported higher healthcare expenditures among FND patients with comorbid psychiatric conditions. This discrepancy may be due to differences in healthcare coverage and accessibility between countries, warranting further investigation into region-specific cost determinants. Healthcare System Barriers and Missed Opportunities The reluctance to refer FND patients to psychiatric services reflects broader systemic barriers within the Iranian healthcare framework. Psychiatric referrals remained low across multiple consultations, increasing only slightly from 2.9% in the first visit to 9.1% by the third visit. This trend underscores a critical gap in mental health integration within general and specialty care, a challenge not limited to Iran but observed globally 47,48 . The low psychiatric referral rates suggest potential physician biases, patient reluctance due to stigma, and structural deficiencies in mental health services, all of which warrant targeted intervention. Study Limitations and Potential Biases Several limitations must be acknowledged. First, our study relied on self-reported data regarding medical consultations, which introduces recall bias and potential inaccuracies in reported referral patterns. Although medical records were consulted where available, discrepancies between patient-reported and documented referrals could not be entirely ruled out. Second, our sample was limited to Iranian patients, and while the findings align with global studies, the results may not be entirely generalizable to other healthcare contexts. Cultural factors, including stigma associated with psychiatric disorders, may have uniquely influenced our participants’ healthcare-seeking behaviors. Third, our study did not assess the impact of specific interventions or physician training programs on referral patterns, limiting our ability to propose evidence-based solutions to identified challenges. Finally, the relatively small sample size may have affected the statistical power of some analyses, particularly subgroup comparisons regarding specialist referral patterns and treatment costs. Implications for Clinical Practice and Policy Our findings have important implications for improving FND diagnosis and management. To reduce diagnostic delays, healthcare providers—particularly neurologists and general practitioners—must receive specialized training on the early identification of FND. International guidelines emphasize the importance of a "rule-in" approach, which prioritizes positive clinical features rather than exclusionary criteria 49 . Additionally, improved communication strategies between neurologists and psychiatrists could facilitate earlier psychiatric referrals, addressing the persistent gap between neurology and mental health services. Beyond physician education, patient-directed interventions are also needed. Given the widespread misconceptions about FND, public awareness campaigns emphasizing its legitimacy as a neuropsychiatric disorder may help reduce stigma and encourage timely psychiatric engagement. Furthermore, healthcare policymakers should consider implementing integrated FND clinics, as successfully piloted in the UK and US, where multidisciplinary teams provide comprehensive assessments and tailored treatment plans 44 . Conclusion Our study underscores the urgent need to address diagnostic delays, referral biases, and systemic healthcare barriers in the management of FND within Iran. The predominant reliance on neurologists and general practitioners, coupled with the minimal engagement of psychiatric services, reflects both physician reluctance and patient misconceptions regarding the disorder’s psychiatric underpinnings. High rates of psychiatric comorbidity highlight the necessity for an integrated care model that bridges the gap between neurology and mental health services. By adopting evidence-based diagnostic criteria, fostering interdisciplinary collaboration, and implementing targeted educational interventions, we can enhance the efficiency of FND diagnosis and treatment, ultimately improving patient outcomes. Future research should explore the impact of structured training programs on referral trends and investigate patient perspectives to further elucidate barriers to timely psychiatric engagement. Only through such multi-pronged efforts can we ensure that FND patients receive the timely, effective, and multidisciplinary care they deserve. Declarations Author Contribution N. M designed the study, collected the data, contributed to the primary conceptualization and design of the framing the analysis and writing/editing the manuscript and submission process; MT. Y contributed to the primary conceptualization and design of the study, edited the manuscript; S. E contributed in the primary conceptualization and design of the study, developed and contributed to questionnaire validation, supervised the project, performed the analyses, and wrote and edited the manuscript; L. SH contributed in the data entry and categorization, participated in the analysis process, wrote and edited the manuscript; A. M played roles in the analysis design, data categorization and editing the manuscript; M.J. Z participated in the data entry process and categorization, writing the manuscript; M. A, as the supervisor of the current project, designed the study frame and protocol, supervised the whole project and analysis planning, editing the manuscript and submission process. Acknowledgement We express our sincere appreciation to Roozbeh Psychiatry Hospital and Imam Khomeini Complex Hospital for their collaboration and assistance. We are also deeply grateful to the participants and their families for their invaluable contributions and willingness to take part in this research. Data Availability The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request. We are committed to providing access to the data for non-commercial purposes, in accordance with ethical guidelines and participant confidentiality agreements. Data will be made available promptly to researchers who meet the necessary criteria for non-commercial use. Please note that the datasets may not be publicly available due to privacy concerns, but access can be granted through a formal request. For further information regarding data access, please contact the corresponding author at [ [email protected] ]. References Fobian, A. D. & Elliott, L. A review of functional neurological symptom disorder etiology and the integrated etiological summary model. Journal of Psychiatry and Neuroscience 44 , 8-18 (2019). https://doi.org:10.1503/jpn.170190 Ding, J. M. & Kanaan, R. A. A. Conversion disorder: a systematic review of current terminology. General hospital psychiatry 45 , 51-55 (2017). https://doi.org:10.1016/j.genhosppsych.2016.12.009 Girouard, E., Savoie, I. & Witkowski, L. C. Functional Neurological Symptom Disorder: A Diagnostic Algorithm. Behav Neurol 2019 , 3154849 (2019). https://doi.org:10.1155/2019/3154849 Tinazzi, M. et al. Functional motor disorders associated with other neurological diseases: beyond the boundaries of “organic” neurology. European journal of neurology 28 , 1752-1758 (2021). https://doi.org:10.1111/ene.14674 Raynor, G. & Baslet, G. A historical review of functional neurological disorder and comparison to contemporary models. Epilepsy & Behavior Reports 16 , 100489 (2021). https://doi.org:https://doi.org/10.1016/j.ebr.2021.100489 O'Mahony, B., Nielsen, G., Baxendale, S., Edwards, M. J. & Yogarajah, M. Economic Cost of Functional Neurologic Disorders: A Systematic Review. Neurology 101 , e202-e214 (2023). https://doi.org:10.1212/wnl.0000000000207388 Stephen, C. D., Fung, V., Lungu, C. I. & Espay, A. J. Assessment of Emergency Department and Inpatient Use and Costs in Adult and Pediatric Functional Neurological Disorders. JAMA Neurology 78 , 88-101 (2021). https://doi.org:10.1001/jamaneurol.2020.3753 Hallett, M. et al. Functional neurological disorder: new subtypes and shared mechanisms. The Lancet Neurology 21 , 537-550 (2022). https://doi.org:10.1016/s1474-4422(21)00422-1 Finkelstein, S. A., Diamond, C., Carson, A. & Stone, J. Incidence and prevalence of functional neurological disorder: a systematic review. Journal of Neurology, Neurosurgery & Psychiatry (2024). https://doi.org:10.1136/jnnp-2024-334767 Bennett, K. et al. A practical review of functional neurological disorder (FND) for the general physician. Clinical Medicine 21 , 28-36 (2021). https://doi.org:10.7861/clinmed.2020-0987 Harris, S. R. Psychogenic movement disorders in children and adolescents: an update. European journal of pediatrics 178 , 581-585 (2019). https://doi.org:10.1007/s00431-019-03317-8 Chouksey, A. & Pandey, S. Functional movement disorders in elderly. Tremor and Other Hyperkinetic Movements 9 , 10.7916/tohm. v7910. 7691 (2019). https://doi.org:10.7916/tohm.v0.691 Kozlowska, K. et al. Changing the culture of care for children and adolescents with functional neurological disorder. Epilepsy & behavior reports 16 , 100486 (2021). https://doi.org:10.1016/j.ebr.2021.100486 Aybek, S. & Perez, D. L. Diagnosis and management of functional neurological disorder. Bmj 376 (2022). https://doi.org:10.1136/bmj.o64 Scamvougeras, A. & Castle, D. Functional neurological disorders: Challenging the mainstream agnostic causative position. The Canadian Journal of Psychiatry 69 , 487-492 (2024). https://doi.org:10.1177/07067437241245957 Mason, X. L. Challenges to the diagnosis of functional neurological disorder: feigning, intentionality, and responsibility. Neuroethics 16 , 2 (2023). https://doi.org:10.1007/s12152-022-09509-8 Mavroudis, I. et al. Understanding functional neurological disorder: Recent insights and diagnostic challenges. International Journal of Molecular Sciences 25 , 4470 (2024). https://doi.org:10.3390/ijms25084470 Butler, M. et al. International online survey of 1048 individuals with functional neurological disorder. European Journal of Neurology 28 , 3591-3602 (2021). https://doi.org:10.1111/ene.15018 Thomsen, B. L. C., Teodoro, T. & Edwards, M. J. Biomarkers in functional movement disorders: a systematic review. Journal of Neurology, Neurosurgery & Psychiatry 91 , 1261-1269 (2020). https://doi.org:10.1136/jnnp-2020-323141 Araújo Filho, G. M. d. & Caboclo, L. O. S. F. Anxiety and mood disorders in psychogenic nonepileptic seizures. Journal of Epilepsy and Clinical Neurophysiology 13 , 28-31 (2007). https://doi.org:10.1590/S1676-26492007000500006 Carle-Toulemonde, G. et al. Overall comorbidities in functional neurological disorder: a narrative review. L'encephale 49 , S24-S32 (2023). https://doi.org:10.1016/j.encep.2023.06.004 Calma, A. D. et al. The impact of depression, anxiety and personality disorders on the outcome of patients with functional limb weakness–individual patient data Meta-analysis. Journal of psychosomatic research 175 , 111513 (2023). https://doi.org:10.1016/j.jpsychores.2023.111513 Patron, V. G., Rustomji, Y., Yip, C. & Jenkins, L. M. Psychiatric comorbidities in functional neurologic symptom disorder. Practical Neurology (Fort Washington, Pa.) 21 , 71 (2022). https://doi.org:10.1136/practneurol-2021-003042 Campbell, M. C. et al. Dissociation and its biological and clinical associations in functional neurological disorder: systematic review and meta-analysis. BJPsych Open 9 , e2 (2023). https://doi.org:10.1192/bjo.2022.597 Steinruecke, M. et al. Pain and functional neurological disorder: a systematic review and meta-analysis. Journal of Neurology, Neurosurgery & Psychiatry 95 , 874-885 (2024). https://doi.org:10.1136/jnnp-2023-332810 Mason, I. et al. Functional neurological disorder is common in patients attending chronic pain clinics. European Journal of Neurology 30 , 2669-2674 (2023). https://doi.org:10.1111/ene.15892 Ducroizet, A. et al. Functional neurological disorder: clinical manifestations and comorbidities; an online survey. Journal of Clinical Neuroscience 110 , 116-125 (2023). https://doi.org:10.1016/j.jocn.2023.02.014 Alluri, P. R. et al. Cognitive Complaints in Motor Functional Neurological (Conversion) Disorders: A Focused Review and Clinical Perspective. Cogn Behav Neurol 33 , 77-89 (2020). https://doi.org:10.1097/wnn.0000000000000218 Magee, J. A., Burke, T., Delanty, N., Pender, N. & Fortune, G. M. The economic cost of nonepileptic attack disorder in Ireland. Epilepsy Behav 33 , 45-48 (2014). https://doi.org:10.1016/j.yebeh.2014.02.010 Porta, M. A Dictionary of Epidemiology . (Oxford University Press, 2016). Barsky, A. J., Orav, E. J. & Bates, D. W. Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity. Arch Gen Psychiatry 62 , 903-910 (2005). https://doi.org:10.1001/archpsyc.62.8.903 Bermingham, S. L., Cohen, A., Hague, J. & Parsonage, M. The cost of somatisation among the working-age population in England for the year 2008-2009. Ment Health Fam Med 7 , 71-84 (2010). Varley, D., Sweetman, J., Brabyn, S., Lagos, D. & van der Feltz-Cornelis, C. The clinical management of functional neurological disorder: A scoping review of the literature. Journal of Psychosomatic Research 165 , 111121 (2023). https://doi.org:10.1016/j.jpsychores.2022.111121 Keatley, E. & Molton, I. A Shift in Approach: Assessment and Treatment of Adults With Functional Neurological Disorder. J Health Serv Psychol 48 , 79-87 (2022). https://doi.org:10.1007/s42843-022-00061-w Stone, J. et al. Who is referred to neurology clinics?—the diagnoses made in 3781 new patients. Clinical neurology and neurosurgery 112 , 747-751 (2010). Perez, D. L. et al. Decade of progress in motor functional neurological disorder: continuing the momentum. Journal of Neurology, Neurosurgery & Psychiatry 92 , 668-677 (2021). https://doi.org:10.1136/jnnp-2020-323953 Edwards, M. J., Adams, R. A., Brown, H., Pareés, I. & Friston, K. J. A Bayesian account of ‘hysteria’. Brain 135 , 3495-3512 (2012). https://doi.org:10.1093/brain/aws129 Sajin, V. & Macerollo, A. in Prevention in Mental Health : From Risk Management to Early Intervention (eds Marco Colizzi & Mirella Ruggeri) 277-307 (Springer International Publishing, 2022). Laukaityte, U. The Scope of Functional Neurological Disorder: Symptom Perception, Inference, and Psychiatry , UC Berkeley, (2024). Espay, A. J. et al. Current Concepts in Diagnosis and Treatment of Functional Neurological Disorders. JAMA Neurology 75 , 1132-1141 (2018). https://doi.org:10.1001/jamaneurol.2018.1264 Aybek, S. & Perez, D. L. Diagnosis and management of functional neurological disorder. Bmj 376 , o64 (2022). https://doi.org:10.1136/bmj.o64 Gelauff, J., Stone, J., Edwards, M. & Carson, A. The prognosis of functional (psychogenic) motor symptoms: a systematic review. Journal of Neurology, Neurosurgery & Psychiatry 85 , 220-226 (2014). https://doi.org:10.1136/jnnp-2013-305321 Velazquez-Rodriquez, Y. & Fehily, B. Functional Neurological Disorder: Historical Trends and Urgent Directions . (2023). Pick, S., Goldstein, L. H., Perez, D. L. & Nicholson, T. R. Emotional processing in functional neurological disorder: a review, biopsychosocial model and research agenda. Journal of Neurology, Neurosurgery & Psychiatry 90 , 704-711 (2019). https://doi.org:10.1136/jnnp-2018-319201 Walsh, S., Levita, L. & Reuber, M. Comorbid depression and associated factors in PNES versus epilepsy: Systematic review and meta-analysis. Seizure 60 , 44-56 (2018). https://doi.org:10.1016/j.seizure.2018.05.014 de Jong, T. J., van der Schroeff, M. P., Achterkamp, M. D. & Vroegop, J. L. First results of the Strengths and Difficulties Questionnaire, applied as a screening tool for psychosocial difficulties in pediatric audiology. European Archives of Oto-Rhino-Laryngology 280 , 4467-4476 (2023). https://doi.org:10.1007/s00405-023-07979-x Woodward, E. N. et al. Impact of Primary Care–Mental Health Care Integration on Mental Health Care Engagement Across Racial and Ethnic Groups. Psychiatric Services 75 , 369-377 (2024). https://doi.org:10.1176/appi.ps.20220631 Moitra, M. et al. Global mental health: Where we are and where we are going. Current psychiatry reports 25 , 301-311 (2023). https://doi.org:10.1007/s11920-023-01426-8 Espay, A. J. et al. Current Concepts in Diagnosis and Treatment of Functional Neurological Disorders. JAMA Neurol 75 , 1132-1141 (2018). https://doi.org:10.1001/jamaneurol.2018.1264 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5461333","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":437731742,"identity":"8ccad163-e1ea-4db5-a293-0c48b993d5ea","order_by":0,"name":"Neda Masjedi","email":"","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Neda","middleName":"","lastName":"Masjedi","suffix":""},{"id":437731743,"identity":"aa7317a0-ac6d-46d2-a0df-0557edb01b78","order_by":1,"name":"Lida Shafaghi","email":"","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Lida","middleName":"","lastName":"Shafaghi","suffix":""},{"id":437731744,"identity":"3f1dcaab-8142-4fb5-9feb-8c8801dcebbb","order_by":2,"name":"Sana Eybpoosh","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYBAC+QYInQAimBkqQCRzA14tBgdQtJwBkYwEtDAga2FsA1GEtLCfPfiBoeJwnjl78+HPhfNqo/nbgVp+VGzDqUW+Jy9ZguHM4WLLnmNp0jO3Hc+dcZixgbHnzG3c1hzIMZBgbDucuOFGjhkz77ZjuQ1ALUAX4tFy/o3xD8Z/YC3Gn3nnHMudT1AL0HAJxgawFgNp3oaa3A2EtBjceGNmkXAsHeIXnmMHcjcCtRzE5xf5/hzjGx9qrCEhxlNTlzvv/OGDD35U4HEYCCQwNMMi6DCYPIBfPRjUwbTUEaF4FIyCUTAKRhoAABWiX7zJ/ajaAAAAAElFTkSuQmCC","orcid":"","institution":"Pasteur Institute of Iran","correspondingAuthor":true,"prefix":"","firstName":"Sana","middleName":"","lastName":"Eybpoosh","suffix":""},{"id":437731745,"identity":"3a731b73-a880-4f93-923d-3bfe34a9176a","order_by":3,"name":"Mohammad Arbabi","email":"","orcid":"","institution":"Farnham Road Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"","lastName":"Arbabi","suffix":""},{"id":437731746,"identity":"df4a7de6-1882-4679-8880-ef7495190cc8","order_by":4,"name":"Mohammad Javad Ziaa","email":"","orcid":"","institution":"Tehran University","correspondingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"Javad","lastName":"Ziaa","suffix":""},{"id":437731747,"identity":"519fbcee-896d-47c0-8588-65e9cde0d17d","order_by":5,"name":"Aria Motamedi","email":"","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Aria","middleName":"","lastName":"Motamedi","suffix":""},{"id":437731748,"identity":"8d183c9c-1cf1-4777-8047-8694781ae50d","order_by":6,"name":"Mohammad Taghi Yasamy","email":"","orcid":"","institution":"Taleghani Hospital, Shahid Beheshti University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Mohammad","middleName":"Taghi","lastName":"Yasamy","suffix":""}],"badges":[],"createdAt":"2024-11-15 14:53:17","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5461333/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5461333/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":79904799,"identity":"c5881aaa-e95e-46ac-a535-567e83e335b0","added_by":"auto","created_at":"2025-04-04 10:49:48","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":953709,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eDistribution of Functional Neurological Disorder (FND) symptoms among participants. \u003c/strong\u003eThe Figure illustrates each symptom separately, Movement Disorders (31.6%), Sensory Problems (15.8%), Fainting (13.8%), Psychogenic Non-Epileptic Seizures (PNES) (12.8%), Pain (10.8%), Multiple Symptoms (5.9%), Aphasia (4.9%), Visual Problems (2.9%), and Cognitive Impairments (0.9%). Each pie chart represents the prevalence of the symptom among participants, accompanied by demographic and psychosocial characteristics, including gender, age group, psychiatric comorbidities, and significant stressors. The p-values indicate the significance of associations between the demographic factors and the presented symptom.\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5461333/v1/30643056b739343cab4b5257.jpg"},{"id":79905625,"identity":"efe65be2-e496-4b6d-a7b3-4f892012243f","added_by":"auto","created_at":"2025-04-04 10:57:48","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":598274,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePathway of specialist consultations and frequency of visit locations for patients diagnosed with Functional Neurological Disorders (FNDs).\u003c/strong\u003e Panel (a) visualizes the referral network showing connections between various medical specialists, with the thickness of the lines representing the number of referrals between specialists. The specialists include general practitioners, neurologists, psychiatrists, and others involved in the patient's care pathway. Panel (b) illustrates the frequency of visits by specialist type and location in terms of visit order (1st, 2nd, and 3rd). The top heatmap shows the frequency of specialist visits, with neurologists and general practitioners being the most visited. The bottom heatmap shows the frequency of places visited, such as doctors’ offices, emergency departments, and hospitals, with doctor’s offices being the most common location for initial visits.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-5461333/v1/0356ac59aa73137612a627b8.jpg"},{"id":92067599,"identity":"9d618d92-b2fd-4fe3-b622-a61f6e19631b","added_by":"auto","created_at":"2025-09-24 09:11:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2955657,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5461333/v1/8c4cefd5-7727-4340-a9fb-78c4f76c7e85.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Understanding the Care Pathway in Iranian Patients with Functional Neurological Symptom Disorders","fulltext":[{"header":"Introduction","content":"\u003cp\u003eFunctional Neurological Disorders (FNDs), also known as Functional Neurological Symptom Disorders (FNSDs) or conversion disorders, constitute a significant subset of neuropsychiatric conditions characterized by complex symptomatology and uncertain pathophysiology\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. The term \"functional,\" as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e,\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e, underscores the absence of structural neurological abnormalities\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. Although increasing recognition and advancements in explanatory models have enhanced understanding\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e, significant variability in incidence and prevalence due to methodological differences across studies challenges comprehensive recognition \u003csup\u003e\u003cspan additionalcitationids=\"CR7 CR8\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. In a recent report, the incidence of FND was estimated to be between 10 and 22 per 100,000, with a minimum prevalence ranging from 80 to 140 per 100,000\u003csup\u003e9\u003c/sup\u003e; with higher occurrence in females\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e and variations across age groups\u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e\u003c/sup\u003e and regions\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. However, diagnostic ambiguity, misclassification, and delays in referral persist, prolonging the diagnostic trajectory and limiting access to appropriate care\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan additionalcitationids=\"CR14 CR15 CR16\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThe complexity of FND symptomatology is a key driver of these delays. Neurological manifestations\u0026mdash;including tremors, dystonia, somatosensory impairments\u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e,\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e, and psychogenic nonepileptic seizures (PNES)\u0026mdash;frequently lead patients to seek neurological rather than psychiatric care, resulting in misdirected referrals and prolonged diagnostic uncertainty. This misalignment between clinical presentation and appropriate specialist care is further compounded by the high prevalence of psychiatric comorbidities, including depression\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e,\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e, anxiety\u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e, and dissociative disorders\u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e,\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e, which affect symptom expression, healthcare utilization, and treatment outcomes. Additionally, systemic disturbances such as chronic pain\u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e, fatigue\u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e,\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e\u003c/sup\u003e, and cognitive deficits\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e not only worsen functional impairment but also increase healthcare-seeking behaviors, reinforcing the need for an integrated, multidisciplinary approach to optimize referrals and patient management.\u003c/p\u003e \u003cp\u003eBeyond its clinical burden, the fragmented FND care pathway imposes a significant economic strain on healthcare systems. Repeated specialist consultations, unnecessary tests, and delayed psychiatric interventions drive rising healthcare costs, yet financial analyses often overlook pediatric FND cases\u003csup\u003e \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e,\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e \u003c/sup\u003e. In the UK, healthcare costs associated with somatization disorders reach \u0026pound;18\u0026nbsp;billion annually, with inpatient care exceeding \u0026pound;600 million\u003csup\u003e \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e,\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e \u003c/sup\u003e, while in the US, the estimated economic burden of somatization is \u003cspan\u003e$\u003c/span\u003e256\u0026nbsp;billion per year\u003csup\u003e \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e \u003c/sup\u003e. A systematic review of sixteen studies further underscores this financial strain, reporting annual costs ranging from \u003cspan\u003e$\u003c/span\u003e4,964 to \u003cspan\u003e$\u003c/span\u003e86,722 (2021 USD), encompassing both direct medical expenses and indirect costs related to lost productivity and long-term disability\u003csup\u003e \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e \u003c/sup\u003e. The intersection of diagnostic inefficiencies, clinical complexity, and economic burden highlights an urgent need for improved diagnostic strategies and streamlined treatment pathways.\u003c/p\u003e \u003cp\u003eAddressing these challenges requires an optimized, structured model for FND care. The diagnostic process is complex and inefficient, starting with symptom recognition, followed by multiple specialist consultations, and ideally leading to timely treatment\u003csup\u003e\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e,\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u003c/sup\u003e. However, prolonged diagnostic uncertainty not only delays intervention but also exacerbates patient and caregiver distress, worsening prognosis. To mitigate these inefficiencies and improve patient outcomes, a standardized referral framework, enhanced interdisciplinary collaboration, and earlier psychiatric integration are essential to ensuring timely access to appropriate care.\u003c/p\u003e \u003cp\u003eThis study aims to examine the healthcare trajectory of FND patients, focusing on diagnostic classifications, psychiatric and medical comorbidities, and sociodemographic determinants. Specifically, it will assess whether distinct FND subtypes (e.g., somatosensory vs. motor-related) influence the initial point of care contact whether patients first seek general medical or specialist consultations and how these choices shape subsequent referral pathways. Furthermore, the study will investigate the role of psychiatric comorbidities in diagnostic delays and treatment trajectories, while also evaluating sociodemographic factors such as gender, socioeconomic status, education, family history, and childhood trauma to determine their impact on healthcare access and clinical outcomes. By identifying key determinants of diagnostic and treatment pathways, this study seeks to bridge existing gaps in FND management, inform evidence-based clinical practices, and optimize healthcare resource allocation, ultimately enhancing patient care and long-term outcomes.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eSince Augst 10th 2019 to May 6th 2022, a cross-sectional study was undertaken involving residents of Tehran diagnosed with functional neurological disorders. The research was conducted in educational hospitals affiliated with Tehran University of Medical Sciences, namely Imam-Khomeini Hospital and Roozbeh Psychiatry Hospital. These two hospitals are situated in Tehran, the capital of Iran, where the population is heterogeneous and encompasses a variety of backgrounds, including diverse urban and socioeconomic conditions. Additionally, these referral hospitals boast other significant features. Primarily, they offer low medical costs, making them accessible to individuals across socioeconomic strata. Also, they attract patients from diverse parts of the country and backgrounds due to the high skill level of their practicing physicians. So, the participants recruited for this study can be regarded as a reasonably representative cohort of individuals with functional neurological disorders. Eligible individuals, who were at least 16 years old, included those with confirmed FND diagnoses based on the psychiatrist\u0026rsquo;s diagnosis while excluding those whose diagnosis underwent changes during or after the interview setup.\u003c/p\u003e \u003cp\u003eData collection utilized \u003cem\u003ea made-researcher questionnaire\u003c/em\u003e comprising five sections: demographic characteristics and socioeconomic status; comprehensive neuropsychiatric assessments; care and treatment-seeking history; self-treatment records; and medical diagnoses and treatments. The questionnaire underwent evaluation and adjustments by the research team, preceded by a pilot study involving ten patients. Trained psychiatrists conducted the interviews and filled out the questionnaires.\u003c/p\u003e \u003cp\u003e Written informed consent was obtained from all patients or their first-degree guardians/relatives before participation. The consent process included clear information on study objectives, procedures, potential risks, and benefits. Participants were informed of their right to withdraw from the study at any time without affecting their treatment, and they were provided with the option to request the study results along with contact details for further inquiries. Confidentiality was strictly upheld, with all identifying information removed from research data and materials. Privacy measures were enforced to ensure the protection of participant information. Participants were assured that their involvement would not result in harm and that compensation would be provided for any adverse effects. The study adhered to ethical standards, including the Declaration of Helsinki (1964), and national and international regulations. It was approved by the Ethics Committee of Tehran University of Medical Sciences (IR.TUMS.MEDICINE.REC.1398.229). All study procedures, including informed consent, confidentiality protocols, and data management, complied with the relevant guidelines for research involving human participants. The research did not involve the use of identifying images or information, and any publication of such data would be contingent on obtaining prior informed consent from participants.\u003c/p\u003e \u003cp\u003eStatistical analyses were performed using SPSS software (version 26), with graphical representations generated using Excel. Categorical variables were described in terms of absolute and relative frequencies, while quantitative data were characterized by range, mean, and standard deviations. Additionally, statistical tests such as t-tests and logistic regression were performed to further examine the data.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003eParticipants\u0026rsquo; Demographic and Clinical Profile\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTotally, 101 individuals with a confirmed FND diagnosis participated in the study, 66.3% of which were female, and a mean age of 36.0 years (SD: 13.0). On average, patients reported having 4.8 family members (range: 2-12 individuals). The majority of patients were married (54.5%), unemployed (56.4%), and did not possess a university-level educational background (64.4%; Table 1).\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003cthead\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 1. Demographics of Study Participants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003en (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/thead\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u0026nbsp;\u003c/strong\u003e(year)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e36 (13.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Min, Max\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17, 68\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Female\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e67 (66.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Male\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e34 (33.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eFamily Members\u0026nbsp;\u003c/strong\u003e(number)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Mean (SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e4.8 (1.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Median (IQR)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e5 (4, 6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Min, Max\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e2, 12\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eMarriage Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Single\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e45 (45.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Married\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e55 (54.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eInsurance Type\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Social Security\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e42 (41.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Other\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e59 (58.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eHaving Supplementary Insurance\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e21 (20.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e73 (72.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eOccupational Status\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Unemployed\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e53 (56.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Part-time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e17 (18.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Full-time\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e24 (25.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u003cstrong\u003eEducational Level\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;High school diploma or lower\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e65 (64.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;College/University\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e27 (26\u003cspan dir=\"RTL\"\u003e.\u003c/span\u003e7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Post graduate\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd\u003e\n \u003cp\u003e9 (8.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 1.\u003c/strong\u003e Table presents the demographic characteristics of the study participants, including their age, gender, family size, marital status, insurance type, and educational level.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe average duration of perception of FND symptoms (the duration of suffering from symptoms) was 37.1 months (SD: 51.6 months, range: 0.1 - 300 months). The average duration between taking the primary actions for seeking diagnosis and treatment averaged 35.7 months (SD: 46.2, range\u003cspan dir=\"RTL\"\u003e\u0026nbsp;:\u003c/span\u003e1 - 275 months). Among those who responded on the outcome of the treatment (68 participants), 61.8% claimed it was useless, while 26.5% reported partial improvement. Notably, individuals without comorbid psychiatric disorders had a significantly longer mean duration of illness compared to those with psychiatric comorbidities (73.0 \u0026plusmn; 64.0 vs. 35.8 \u0026plusmn; 26.6 months; \u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 0.003).\u003c/p\u003e\n\u003cp\u003eThe FND symptoms were persistent in 40.6% of patients. Based on the table 2 and fig 1, Movement Disorders were the most common symptom, affecting 31.6% of participants, mostly younger females (62%), and were strongly linked to major depressive disorder (87%) and family stressors. Sensory Problems (15.8%) also predominantly affected females (68%) and were associated with depression and panic disorder. Fainting (13.8%) was observed mainly in females (92%), with high rates of depression (87.5%) and family-related issues. PNES (12.8%) had an even gender distribution and was seen in younger individuals, all of whom had major depression. Pain (10.8%) affected both genders equally, with 75% having depression, along with common OCD and trauma diagnoses. Multiple Symptoms (5.9%) involved complex psychiatric comorbidities like phobias. Less common symptoms included Aphasia (4.9%), Visual Problems (2.9%), and Cognitive Impairments (0.9%), primarily in females, and were associated with borderline personality disorder, panic, PTSD, and phobias.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"71%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 100px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2. Distribution of FND Symptoms, Comorbidities, and Recent Stressors Among Study Participants\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePeriodicity of FND Symptoms\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Intermittent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e59 (58.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Persistent\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e41 (40.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of FND Symptom\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Movement Disorders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e32 (31.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Sensory Problems\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e16 (15.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Faint\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e14 (13.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;PNES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e13 (12.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Pain\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e11 (11.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Vision-Related Problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e3 (3.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Aphasia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e5 (5.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Cognitive Impairments\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e1 (1.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Multiple Symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e6 (5.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAccompanying Psychiatric Disorders\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Yes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e75 (74.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;No\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e26 (25.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of Psychiatric Comorbidity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Major Depressive Disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e32 (42.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Generalized Anxiety Disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e15 (20.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Mixed Mood Disorders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e7 (9.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Bipolar Mood Disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e5 (6.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Panic Disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e4 (5.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Specific Phobias\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e3 (4.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Borderline Personality Disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e2 (2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Adjustment Disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e2 (2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Social Anxiety Disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e2 (2.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Post-Traumatic Stress Disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e1 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Obsessive-Compulsive Disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e1 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Transient Psychotic Disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e1 (1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eType of Recent Stressor*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Family conflicts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e13 (18.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Loss of a loved one\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e12 (16.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Divorce\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e9 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Emotional stress\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e7 (9.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Workplace conflicts\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e6 (8.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Financial problems\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e5 (6.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Illness of family members\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e3 (4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Exams\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e2 (2.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Burglary\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e2 (2.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Property Loss\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e1 (1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Deployment to the military services\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e1 (1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Fears and phobias\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e1 (1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Accidents\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e1 (1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Receiving negative news\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e1 (1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;Guarantor unemployment\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e1 (1.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 46px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;None\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 53px;\"\u003e\n \u003cp\u003e7 (9.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2.\u003c/strong\u003e Table illustrates the distribution of Functional Neurological Disorder (FND) symptoms, psychiatric comorbidities, and recent stressors reported by study participants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFig 1. Distribution of Functional Neurological Disorder (FND) symptoms among participants.\u0026nbsp;\u003c/strong\u003eThe Figure illustrates each symptom separately, Movement Disorders (31.6%), Sensory Problems (15.8%), Fainting (13.8%), Psychogenic Non-Epileptic Seizures (PNES) (12.8%), Pain (10.8%), Multiple Symptoms (5.9%), Aphasia (4.9%), Visual Problems (2.9%), and Cognitive Impairments (0.9%). Each pie chart represents the prevalence of the symptom among participants, accompanied by demographic and psychosocial characteristics, including gender, age group, psychiatric comorbidities, and significant stressors. The p-values indicate the significance of associations between the demographic factors and the presented symptom.\u003c/p\u003e\n\u003cp\u003eThe mean treatment cost per patient from the onset of symptoms until the diagnosis of FND amounted USD 63.3. There was no significant difference in mean treatment costs between individuals with and without psychiatric comorbidities (87.7 \u0026plusmn; 32.8 vs. 62.7 \u0026plusmn; 48.7 USD; \u003cem\u003ep\u0026nbsp;\u003c/em\u003e= 0.49). \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePathway to Care of FND Patients\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe overall referral pattern revealed that in the first step, 40.2% of FND patients visited a neurologist or neurosurgeon, 36.3% visited a general practitioner, 20.6% visited other specialties, and merely 2.9% initially visited a psychiatrist or psychologist. Thereby, neurologist visits were prominent among first exposures to the healthcare system, followed by consultations with general physicians. In the second visit, nobody referred to the GPs anymore or to other specialties. Instead, 71.2% referred to neurologists/neurosurgeons, and 3.4% to psychiatrists/psychologists. In the third visit, the pattern of referral remained the same, with a slightly more cases visiting psychiatrists/psychologists than visit 1 and 2 (Fig 2 and Table 3). Altogether, most individuals had visited a neurologist on all three visits\u003cspan dir=\"RTL\"\u003e.\u003c/span\u003e Traditional healer visits were specifically investigated during each visit. Patients only sought traditional healers during their third visit.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFig 2. Pathway of specialist consultations and frequency of visit locations for patients diagnosed with Functional Neurological Disorders (FNDs).\u003c/strong\u003e Panel (a) visualizes the referral network showing connections between various medical specialists, with the thickness of the lines representing the number of referrals between specialists. The specialists include general practitioners, neurologists, psychiatrists, and others involved in the patient\u0026apos;s care pathway. Panel (b) illustrates the frequency of visits by specialist type and location in terms of visit order (1st, 2nd, and 3rd). The top heatmap shows the frequency of specialist visits, with neurologists and general practitioners being the most visited. The bottom heatmap shows the frequency of places visited, such as doctors\u0026rsquo; offices, emergency departments, and hospitals, with doctor\u0026rsquo;s offices being the most common location for initial visits.\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"100%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"10\" style=\"width: 57.4635%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3. Medical specialization sought by FND patients\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePsychiatry*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNeurology**\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTraditional therapies\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOther\u003c/strong\u003e\u003cstrong\u003e\u003csup\u003e\u0026sect;\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.0986%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.6004%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVisit Order\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e\u003cstrong\u003en (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.0986%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOR\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.6004%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverall\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.0986%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.6004%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e1\u003csup\u003est\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e3 (2.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e41 (40.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e37 (36.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e21 (20.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e102 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.0986%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.6004%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e2\u003csup\u003end\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e2 (3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e42 (71.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e15 (25.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e59 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.0986%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.6004%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e3\u003csup\u003erd\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e2 (9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e16 (72.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e3 (13.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e1 (4.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e22 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.0986%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.6004%;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"10\" style=\"width: 57.4635%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBased on FND symptom\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 7.9462%;\"\u003e\n \u003cp\u003eMovement Disorder\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e1\u003csup\u003est\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e2 (6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e14 (43.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e7 (21.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e9 (28.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e32 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 4.0986%;\"\u003e\n \u003cp\u003e3.4\u003c/p\u003e\n \u003cp\u003e(0.9, 12.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 4.6004%;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e2\u003csup\u003end\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e17 (89.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e2 (10.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e19 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e3\u003csup\u003erd\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e1 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e6 (75.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e1 (12.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e8 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 7.9462%;\"\u003e\n \u003cp\u003eFaint\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e1\u003csup\u003est\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e6 (42.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e5 (35.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e3 (21.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e14 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 4.0986%;\"\u003e\n \u003cp\u003e1.9\u003c/p\u003e\n \u003cp\u003e(0.4, 0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 4.6004%;\"\u003e\n \u003cp\u003e0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e2\u003csup\u003end\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e1 (11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e7 (77.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e1 (11.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e9 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e3\u003csup\u003erd\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e1 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e2 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e3 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 7.9462%;\"\u003e\n \u003cp\u003eSensory Disorders\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e1\u003csup\u003est\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e5 (31.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e8 (50.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e3 (18.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e16 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 4.0986%;\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003cp\u003e(0.1, 1.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 4.6004%;\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e2\u003csup\u003end\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e6 (60.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e4 (40.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e10 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e3\u003csup\u003erd\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e4 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e4 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 7.9462%;\"\u003e\n \u003cp\u003ePNES\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e1\u003csup\u003est\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e1 (7.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e7 (53.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e5 (38.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e13 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 4.0986%;\"\u003e\n \u003cp\u003e0.5\u003c/p\u003e\n \u003cp\u003e(0.1, 5.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 4.6004%;\"\u003e\n \u003cp\u003e0.59\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e2\u003csup\u003end\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e6 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e6 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e3\u003csup\u003erd\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e1 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e1 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 7.9462%;\"\u003e\n \u003cp\u003ePain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e1\u003csup\u003est\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e4 (36.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e4 (36.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e3 (27.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e11 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 4.0986%;\"\u003e\n \u003cp\u003e0.4\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(0.03, 6.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 4.6004%;\"\u003e\n \u003cp\u003e0.54\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e2\u003csup\u003end\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e3 (37.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e5 (62.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e8 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e3\u003csup\u003erd\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e2 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e1 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e3 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 7.9462%;\"\u003e\n \u003cp\u003eCognitive Impairments\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e1\u003csup\u003est\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e1 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e1 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 4.0986%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 4.6004%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e2\u003csup\u003end\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e2 (3.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e42 (71.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e15 (25.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e59 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e3\u003csup\u003erd\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e2 (9.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e16 (72.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e3 (13.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e1 (4.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e22 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 7.9462%;\"\u003e\n \u003cp\u003eVisional Problems\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e1\u003csup\u003est\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e3 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e3 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 4.0986%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 4.6004%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e-\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e2\u003csup\u003end\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e3 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e3 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e3\u003csup\u003erd\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e3 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e3 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 7.9462%;\"\u003e\n \u003cp\u003eAphasia\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e1\u003csup\u003est\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e4 (80.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e1 (20.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e5 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 4.0986%;\"\u003e\n \u003cp\u003e3.1\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e(0.3, 35.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 4.6004%;\"\u003e\n \u003cp\u003e0.35\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e2\u003csup\u003end\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e1 (33.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e2 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e3 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e3\u003csup\u003erd\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e1 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e1 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" style=\"width: 7.9462%;\"\u003e\n \u003cp\u003eMultiple Symptoms\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e1\u003csup\u003est\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e4 (66.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e1 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e1 (16.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e6 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 4.0986%;\"\u003e\n \u003cp\u003e2.6\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;(0.3, 20.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" style=\"width: 4.6004%;\"\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e2\u003csup\u003end\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e1 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e1 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 4.4331%;\"\u003e\n \u003cp\u003e3\u003csup\u003erd\u003c/sup\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.9462%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 8.5317%;\"\u003e\n \u003cp\u003e1 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.1822%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 7.6116%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 4.7677%;\"\u003e\n \u003cp\u003e0 (0.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 3.8476%;\"\u003e\n \u003cp\u003e1 (100)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"10\" style=\"width: 58.0491%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 3.\u003c/strong\u003e table categorizes the medical specializations sought by patients with Functional Neurological Disorder (FND), classified by the visit number (1st, 2nd, 3rd) and type of symptom.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eAmong the 101 participants, 59 (58.4%) recalled details of their next visit (the 2nd visit). Notably, the majority of these patients (71.2%) were directed to neurologists, while in 11 (10.9%) cases, the general practitioners initially suggested consultations with psychiatrists. Of these, 9 patients did not recall if they visited the psychiatrist, and the remaining 2 patients opted for neurologists instead. The referral rate to psychiatrists in the second visit remained consistent compared to the first visit (3.4% vs. 2.9%, respectively). Only 2 patients were re-referred by neurologists to their respective areas of expertise during the second visit. The remaining referrals to the neurologist in the second visit were initiated by the patients themselves, disregarding the advice of the initial clinician. Also, none of the participants sought traditional therapies during their second visit (Table 3).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAmong the 101 participants, 22 (21.8%) patients recalled details of their third visit. By the third visit, a similar trend as the second visit emerged, with 72.7% of respondents being referred to neurologists, two patients to psychiatrists, and none to general practitioners. Additionally, three respondents visited traditional therapists at this step due to perceived inefficacy of previous treatments (Table 3 \u0026amp; Figure 1). Notably, 64% of patients who initially consulted general practitioners were primarily directed towards neurologists or neurosurgeons with subsequent referrals predominantly to specialists other than psychiatrists. On average, participants visited between one and five different medical specialists before being referred to the psychiatrist.\u003c/p\u003e\n\u003cp\u003eIndividuals with movement disorders, faint, and PNES, were more likely to visit the neurologist/neurosurgeon at the first visit, however, patients with sensory problems, visional issues, and aphasia more frequently preferred to visit GP at first (Table 3).\u003c/p\u003e\n\u003cp\u003ePatients with intermittent symptoms were more likely to be referred to a general practitioner for their initial visit compared to those experiencing chronic suffering. Logistic regression models showed that after controlling for demographic factors, comorbidities, and stressors, patients whose symptoms were movement-associated and faint were respectively 3.4 and 1.9 times more likely to go to a neurologist at the first visit and actually considered and perceived the origin of their problem to be neuronal. However, these associations were not statistically significant. People whose symptoms were in the sensory disorders category, PNES, and aphasia group were less likely to see a neurologist at the first visit. Instead, these people were more likely to see a general practitioner than a neurologist or other specialists. These associations were not statistically significant as well. Regarding the vision and cognitive problems, since all participants have examined by the neurologists, regression analysis was not possible (Table 3). Moreover, the results revealed no significant association between neurologist referral and underlying demographic variables, as shown in table S1.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eOur study highlights significant challenges in the diagnosis and management of Functional Neurological Disorder within the Iranian healthcare system. The findings reveal a prolonged diagnostic delay, considerable economic burden, and a preference among patients and referring physicians for non-psychiatric specialties, even when psychiatric care would be the most appropriate. These results align with international literature suggesting similar diagnostic obstacles across diverse healthcare settings, emphasizing the need for improved awareness, multidisciplinary collaboration, and revised clinical protocols for FND management.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDiagnostic Delay and Healthcare Utilization\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOne of the most striking findings of our study was the considerable delay between symptom onset and definitive FND diagnosis, averaging 37.1 months. This delay is not unique to Iran, as previous research has consistently reported prolonged diagnostic timelines in various healthcare systems. Studies from the UK and US have found that FND patients often undergo extensive medical evaluations and referrals before receiving an accurate diagnosis, with delays frequently exceeding two years\u003csup\u003e35,36\u003c/sup\u003e. Our results reinforce the notion that the lack of early recognition of FND, compounded by skepticism regarding its legitimacy as a neurological disorder, significantly hampers timely intervention\u003csup\u003e37\u003c/sup\u003e. Additionally, the delay in diagnosis translates into increased healthcare costs, a concern also reported in other studies where patients accumulate unnecessary imaging, laboratory tests, and specialist consultations before appropriate referral to psychiatric care\u003csup\u003e38\u003c/sup\u003e.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eReferral Patterns and the Role of Neurologists\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur findings demonstrate that the majority of patients initially sought care from neurologists (40.2%) or general practitioners (36.3%), with only 2.9% visiting a psychiatrist during their first medical consultation. This referral pattern mirrors global trends wherein FND patients are predominantly managed within neurology rather than psychiatry\u003csup\u003e39\u003c/sup\u003e. Patient and provider reluctance to involve psychiatrists early reflects persistent misconceptions about the psychiatric nature of FND and a broader resistance to integrating psychiatry into neurology\u003csup\u003e34\u003c/sup\u003e. Neurologists often hesitate to make a definitive FND diagnosis, opting instead for extensive neurological workups, further delaying psychiatric referral and prolonging patient distress\u003csup\u003e40\u003c/sup\u003e. Moreover, neurologists’ reliance on exclusionary diagnoses rather than positive identification criteria for FND has been widely criticized\u003csup\u003e41\u003c/sup\u003e, indicating a pressing need for structured training programs emphasizing early FND recognition.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSymptom Profiles and Psychiatric Comorbidities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur study further reinforces the high prevalence of psychiatric comorbidities in FND patients, with depression, anxiety, and trauma-related disorders being the most commonly associated conditions. Previous literature has extensively documented the strong correlation between FND and psychiatric disorders, with rates of comorbidity often exceeding 70% \u003csup\u003e42\u003c/sup\u003e. In our study, individuals presenting with movement disorders, sensory symptoms, and fainting episodes were particularly prone to psychiatric comorbidities, consistent with prior research indicating that these symptoms frequently coexist with affective disturbances and trauma histories\u003csup\u003e43,44\u003c/sup\u003e. The high prevalence of depression (87%) among patients with psychogenic non-epileptic seizures (PNES) in our sample mirrors findings from Reuber et al. (2018)\u003csup\u003e45\u003c/sup\u003e, who reported that PNES is strongly associated with a history of adverse life events and emotional dysregulation. Despite this well-established link, psychiatric conditions did not appear to significantly influence treatment costs, suggesting that while psychiatric comorbidities may facilitate earlier recognition in some cases, they do not necessarily increase direct financial burdens. This finding diverges from some international studies, such as Vroegop et al. (2023)\u003csup\u003e46\u003c/sup\u003e, which reported higher healthcare expenditures among FND patients with comorbid psychiatric conditions. This discrepancy may be due to differences in healthcare coverage and accessibility between countries, warranting further investigation into region-specific cost determinants.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eHealthcare System Barriers and Missed Opportunities\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe reluctance to refer FND patients to psychiatric services reflects broader systemic barriers within the Iranian healthcare framework. Psychiatric referrals remained low across multiple consultations, increasing only slightly from 2.9% in the first visit to 9.1% by the third visit. This trend underscores a critical gap in mental health integration within general and specialty care, a challenge not limited to Iran but observed globally\u003csup\u003e47,48\u003c/sup\u003e. The low psychiatric referral rates suggest potential physician biases, patient reluctance due to stigma, and structural deficiencies in mental health services, all of which warrant targeted intervention.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStudy Limitations and Potential Biases\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Several limitations must be acknowledged. First, our study relied on self-reported data regarding medical consultations, which introduces recall bias and potential inaccuracies in reported referral patterns. Although medical records were consulted where available, discrepancies between patient-reported and documented referrals could not be entirely ruled out. Second, our sample was limited to Iranian patients, and while the findings align with global studies, the results may not be entirely generalizable to other healthcare contexts. Cultural factors, including stigma associated with psychiatric disorders, may have uniquely influenced our participants’ healthcare-seeking behaviors. Third, our study did not assess the impact of specific interventions or physician training programs on referral patterns, limiting our ability to propose evidence-based solutions to identified challenges. Finally, the relatively small sample size may have affected the statistical power of some analyses, particularly subgroup comparisons regarding specialist referral patterns and treatment costs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplications for Clinical Practice and Policy\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur findings have important implications for improving FND diagnosis and management. To reduce diagnostic delays, healthcare providers—particularly neurologists and general practitioners—must receive specialized training on the early identification of FND. International guidelines emphasize the importance of a \"rule-in\" approach, which prioritizes positive clinical features rather than exclusionary criteria\u003csup\u003e49\u003c/sup\u003e. Additionally, improved communication strategies between neurologists and psychiatrists could facilitate earlier psychiatric referrals, addressing the persistent gap between neurology and mental health services. Beyond physician education, patient-directed interventions are also needed. Given the widespread misconceptions about FND, public awareness campaigns emphasizing its legitimacy as a neuropsychiatric disorder may help reduce stigma and encourage timely psychiatric engagement. Furthermore, healthcare policymakers should consider implementing integrated FND clinics, as successfully piloted in the UK and US, where multidisciplinary teams provide comprehensive assessments and tailored treatment plans\u003csup\u003e44\u003c/sup\u003e.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study underscores the urgent need to address diagnostic delays, referral biases, and systemic healthcare barriers in the management of FND within Iran. The predominant reliance on neurologists and general practitioners, coupled with the minimal engagement of psychiatric services, reflects both physician reluctance and patient misconceptions regarding the disorder\u0026rsquo;s psychiatric underpinnings. High rates of psychiatric comorbidity highlight the necessity for an integrated care model that bridges the gap between neurology and mental health services. By adopting evidence-based diagnostic criteria, fostering interdisciplinary collaboration, and implementing targeted educational interventions, we can enhance the efficiency of FND diagnosis and treatment, ultimately improving patient outcomes. Future research should explore the impact of structured training programs on referral trends and investigate patient perspectives to further elucidate barriers to timely psychiatric engagement. Only through such multi-pronged efforts can we ensure that FND patients receive the timely, effective, and multidisciplinary care they deserve.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eN. M designed the study, collected the data, contributed to the primary conceptualization and design of the framing the analysis and writing/editing the manuscript and submission process; MT. Y contributed to the primary conceptualization and design of the study, edited the manuscript; S. E contributed in the primary conceptualization and design of the study, developed and contributed to questionnaire validation, supervised the project, performed the analyses, and wrote and edited the manuscript; L. SH contributed in the data entry and categorization, participated in the analysis process, wrote and edited the manuscript; A. M played roles in the analysis design, data categorization and editing the manuscript; M.J. Z participated in the data entry process and categorization, writing the manuscript; M. A, as the supervisor of the current project, designed the study frame and protocol, supervised the whole project and analysis planning, editing the manuscript and submission process.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eWe express our sincere appreciation to Roozbeh Psychiatry Hospital and Imam Khomeini Complex Hospital for their collaboration and assistance. We are also deeply grateful to the participants and their families for their invaluable contributions and willingness to take part in this research.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request. We are committed to providing access to the data for non-commercial purposes, in accordance with ethical guidelines and participant confidentiality agreements. Data will be made available promptly to researchers who meet the necessary criteria for non-commercial use. Please note that the datasets may not be publicly available due to privacy concerns, but access can be granted through a formal request. For further information regarding data access, please contact the corresponding author at [[email protected]].\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eFobian, A. D. \u0026amp; Elliott, L. A review of functional neurological symptom disorder etiology and the integrated etiological summary model. \u003cem\u003eJournal of Psychiatry and Neuroscience\u003c/em\u003e \u003cstrong\u003e44\u003c/strong\u003e, 8-18 (2019). https://doi.org:10.1503/jpn.170190\u003c/li\u003e\n\u003cli\u003eDing, J. M. \u0026amp; Kanaan, R. A. A. Conversion disorder: a systematic review of current terminology. \u003cem\u003eGeneral hospital psychiatry\u003c/em\u003e \u003cstrong\u003e45\u003c/strong\u003e, 51-55 (2017). https://doi.org:10.1016/j.genhosppsych.2016.12.009\u003c/li\u003e\n\u003cli\u003eGirouard, E., Savoie, I. \u0026amp; Witkowski, L. C. Functional Neurological Symptom Disorder: A Diagnostic Algorithm. \u003cem\u003eBehav Neurol\u003c/em\u003e \u003cstrong\u003e2019\u003c/strong\u003e, 3154849 (2019). https://doi.org:10.1155/2019/3154849\u003c/li\u003e\n\u003cli\u003eTinazzi, M.\u003cem\u003e et al.\u003c/em\u003e Functional motor disorders associated with other neurological diseases: beyond the boundaries of \u0026ldquo;organic\u0026rdquo; neurology. \u003cem\u003eEuropean journal of neurology\u003c/em\u003e \u003cstrong\u003e28\u003c/strong\u003e, 1752-1758 (2021). https://doi.org:10.1111/ene.14674\u003c/li\u003e\n\u003cli\u003eRaynor, G. \u0026amp; Baslet, G. A historical review of functional neurological disorder and comparison to contemporary models. \u003cem\u003eEpilepsy \u0026amp; Behavior Reports\u003c/em\u003e \u003cstrong\u003e16\u003c/strong\u003e, 100489 (2021). https://doi.org:https://doi.org/10.1016/j.ebr.2021.100489\u003c/li\u003e\n\u003cli\u003eO\u0026apos;Mahony, B., Nielsen, G., Baxendale, S., Edwards, M. J. \u0026amp; Yogarajah, M. Economic Cost of Functional Neurologic Disorders: A Systematic Review. \u003cem\u003eNeurology\u003c/em\u003e \u003cstrong\u003e101\u003c/strong\u003e, e202-e214 (2023). https://doi.org:10.1212/wnl.0000000000207388\u003c/li\u003e\n\u003cli\u003eStephen, C. D., Fung, V., Lungu, C. I. \u0026amp; Espay, A. J. Assessment of Emergency Department and Inpatient Use and Costs in Adult and Pediatric Functional Neurological Disorders. \u003cem\u003eJAMA Neurology\u003c/em\u003e \u003cstrong\u003e78\u003c/strong\u003e, 88-101 (2021). https://doi.org:10.1001/jamaneurol.2020.3753\u003c/li\u003e\n\u003cli\u003eHallett, M.\u003cem\u003e et al.\u003c/em\u003e Functional neurological disorder: new subtypes and shared mechanisms. \u003cem\u003eThe Lancet Neurology\u003c/em\u003e \u003cstrong\u003e21\u003c/strong\u003e, 537-550 (2022). https://doi.org:10.1016/s1474-4422(21)00422-1\u003c/li\u003e\n\u003cli\u003eFinkelstein, S. A., Diamond, C., Carson, A. \u0026amp; Stone, J. Incidence and prevalence of functional neurological disorder: a systematic review. \u003cem\u003eJournal of Neurology, Neurosurgery \u0026amp; Psychiatry\u003c/em\u003e (2024). https://doi.org:10.1136/jnnp-2024-334767\u003c/li\u003e\n\u003cli\u003eBennett, K.\u003cem\u003e et al.\u003c/em\u003e A practical review of functional neurological disorder (FND) for the general physician. \u003cem\u003eClinical Medicine\u003c/em\u003e \u003cstrong\u003e21\u003c/strong\u003e, 28-36 (2021). https://doi.org:10.7861/clinmed.2020-0987\u003c/li\u003e\n\u003cli\u003eHarris, S. R. Psychogenic movement disorders in children and adolescents: an update. \u003cem\u003eEuropean journal of pediatrics\u003c/em\u003e \u003cstrong\u003e178\u003c/strong\u003e, 581-585 (2019). https://doi.org:10.1007/s00431-019-03317-8\u003c/li\u003e\n\u003cli\u003eChouksey, A. \u0026amp; Pandey, S. Functional movement disorders in elderly. \u003cem\u003eTremor and Other Hyperkinetic Movements\u003c/em\u003e \u003cstrong\u003e9\u003c/strong\u003e, 10.7916/tohm. v7910. 7691 (2019). https://doi.org:10.7916/tohm.v0.691\u003c/li\u003e\n\u003cli\u003eKozlowska, K.\u003cem\u003e et al.\u003c/em\u003e Changing the culture of care for children and adolescents with functional neurological disorder. \u003cem\u003eEpilepsy \u0026amp; behavior reports\u003c/em\u003e \u003cstrong\u003e16\u003c/strong\u003e, 100486 (2021). https://doi.org:10.1016/j.ebr.2021.100486\u003c/li\u003e\n\u003cli\u003eAybek, S. \u0026amp; Perez, D. L. Diagnosis and management of functional neurological disorder. \u003cem\u003eBmj\u003c/em\u003e \u003cstrong\u003e376\u003c/strong\u003e (2022). https://doi.org:10.1136/bmj.o64\u003c/li\u003e\n\u003cli\u003eScamvougeras, A. \u0026amp; Castle, D. Functional neurological disorders: Challenging the mainstream agnostic causative position. \u003cem\u003eThe Canadian Journal of Psychiatry\u003c/em\u003e \u003cstrong\u003e69\u003c/strong\u003e, 487-492 (2024). https://doi.org:10.1177/07067437241245957\u003c/li\u003e\n\u003cli\u003eMason, X. L. Challenges to the diagnosis of functional neurological disorder: feigning, intentionality, and responsibility. \u003cem\u003eNeuroethics\u003c/em\u003e \u003cstrong\u003e16\u003c/strong\u003e, 2 (2023). https://doi.org:10.1007/s12152-022-09509-8\u003c/li\u003e\n\u003cli\u003eMavroudis, I.\u003cem\u003e et al.\u003c/em\u003e Understanding functional neurological disorder: Recent insights and diagnostic challenges. \u003cem\u003eInternational Journal of Molecular Sciences\u003c/em\u003e \u003cstrong\u003e25\u003c/strong\u003e, 4470 (2024). https://doi.org:10.3390/ijms25084470\u003c/li\u003e\n\u003cli\u003eButler, M.\u003cem\u003e et al.\u003c/em\u003e International online survey of 1048 individuals with functional neurological disorder. \u003cem\u003eEuropean Journal of Neurology\u003c/em\u003e \u003cstrong\u003e28\u003c/strong\u003e, 3591-3602 (2021). https://doi.org:10.1111/ene.15018\u003c/li\u003e\n\u003cli\u003eThomsen, B. L. C., Teodoro, T. \u0026amp; Edwards, M. J. Biomarkers in functional movement disorders: a systematic review. \u003cem\u003eJournal of Neurology, Neurosurgery \u0026amp; Psychiatry\u003c/em\u003e \u003cstrong\u003e91\u003c/strong\u003e, 1261-1269 (2020). https://doi.org:10.1136/jnnp-2020-323141\u003c/li\u003e\n\u003cli\u003eAra\u0026uacute;jo Filho, G. M. d. \u0026amp; Caboclo, L. O. S. F. Anxiety and mood disorders in psychogenic nonepileptic seizures. \u003cem\u003eJournal of Epilepsy and Clinical Neurophysiology\u003c/em\u003e \u003cstrong\u003e13\u003c/strong\u003e, 28-31 (2007). https://doi.org:10.1590/S1676-26492007000500006\u003c/li\u003e\n\u003cli\u003eCarle-Toulemonde, G.\u003cem\u003e et al.\u003c/em\u003e Overall comorbidities in functional neurological disorder: a narrative review. \u003cem\u003eL\u0026apos;encephale\u003c/em\u003e \u003cstrong\u003e49\u003c/strong\u003e, S24-S32 (2023). https://doi.org:10.1016/j.encep.2023.06.004\u003c/li\u003e\n\u003cli\u003eCalma, A. D.\u003cem\u003e et al.\u003c/em\u003e The impact of depression, anxiety and personality disorders on the outcome of patients with functional limb weakness\u0026ndash;individual patient data Meta-analysis. \u003cem\u003eJournal of psychosomatic research\u003c/em\u003e \u003cstrong\u003e175\u003c/strong\u003e, 111513 (2023). https://doi.org:10.1016/j.jpsychores.2023.111513\u003c/li\u003e\n\u003cli\u003ePatron, V. G., Rustomji, Y., Yip, C. \u0026amp; Jenkins, L. M. Psychiatric comorbidities in functional neurologic symptom disorder. \u003cem\u003ePractical Neurology (Fort Washington, Pa.)\u003c/em\u003e \u003cstrong\u003e21\u003c/strong\u003e, 71 (2022). https://doi.org:10.1136/practneurol-2021-003042\u003c/li\u003e\n\u003cli\u003eCampbell, M. C.\u003cem\u003e et al.\u003c/em\u003e Dissociation and its biological and clinical associations in functional neurological disorder: systematic review and meta-analysis. \u003cem\u003eBJPsych Open\u003c/em\u003e \u003cstrong\u003e9\u003c/strong\u003e, e2 (2023). https://doi.org:10.1192/bjo.2022.597\u003c/li\u003e\n\u003cli\u003eSteinruecke, M.\u003cem\u003e et al.\u003c/em\u003e Pain and functional neurological disorder: a systematic review and meta-analysis. \u003cem\u003eJournal of Neurology, Neurosurgery \u0026amp; Psychiatry\u003c/em\u003e \u003cstrong\u003e95\u003c/strong\u003e, 874-885 (2024). https://doi.org:10.1136/jnnp-2023-332810\u003c/li\u003e\n\u003cli\u003eMason, I.\u003cem\u003e et al.\u003c/em\u003e Functional neurological disorder is common in patients attending chronic pain clinics. \u003cem\u003eEuropean Journal of Neurology\u003c/em\u003e \u003cstrong\u003e30\u003c/strong\u003e, 2669-2674 (2023). https://doi.org:10.1111/ene.15892\u003c/li\u003e\n\u003cli\u003eDucroizet, A.\u003cem\u003e et al.\u003c/em\u003e Functional neurological disorder: clinical manifestations and comorbidities; an online survey. \u003cem\u003eJournal of Clinical Neuroscience\u003c/em\u003e \u003cstrong\u003e110\u003c/strong\u003e, 116-125 (2023). https://doi.org:10.1016/j.jocn.2023.02.014\u003c/li\u003e\n\u003cli\u003eAlluri, P. R.\u003cem\u003e et al.\u003c/em\u003e Cognitive Complaints in Motor Functional Neurological (Conversion) Disorders: A Focused Review and Clinical Perspective. \u003cem\u003eCogn Behav Neurol\u003c/em\u003e \u003cstrong\u003e33\u003c/strong\u003e, 77-89 (2020). https://doi.org:10.1097/wnn.0000000000000218\u003c/li\u003e\n\u003cli\u003eMagee, J. A., Burke, T., Delanty, N., Pender, N. \u0026amp; Fortune, G. M. The economic cost of nonepileptic attack disorder in Ireland. \u003cem\u003eEpilepsy Behav\u003c/em\u003e \u003cstrong\u003e33\u003c/strong\u003e, 45-48 (2014). https://doi.org:10.1016/j.yebeh.2014.02.010\u003c/li\u003e\n\u003cli\u003ePorta, M. \u003cem\u003eA Dictionary of Epidemiology\u003c/em\u003e. (Oxford University Press, 2016).\u003c/li\u003e\n\u003cli\u003eBarsky, A. J., Orav, E. J. \u0026amp; Bates, D. W. Somatization increases medical utilization and costs independent of psychiatric and medical comorbidity. \u003cem\u003eArch Gen Psychiatry\u003c/em\u003e \u003cstrong\u003e62\u003c/strong\u003e, 903-910 (2005). https://doi.org:10.1001/archpsyc.62.8.903\u003c/li\u003e\n\u003cli\u003eBermingham, S. L., Cohen, A., Hague, J. \u0026amp; Parsonage, M. The cost of somatisation among the working-age population in England for the year 2008-2009. \u003cem\u003eMent Health Fam Med\u003c/em\u003e \u003cstrong\u003e7\u003c/strong\u003e, 71-84 (2010).\u003c/li\u003e\n\u003cli\u003eVarley, D., Sweetman, J., Brabyn, S., Lagos, D. \u0026amp; van der Feltz-Cornelis, C. The clinical management of functional neurological disorder: A scoping review of the literature. \u003cem\u003eJournal of Psychosomatic Research\u003c/em\u003e \u003cstrong\u003e165\u003c/strong\u003e, 111121 (2023). https://doi.org:10.1016/j.jpsychores.2022.111121\u003c/li\u003e\n\u003cli\u003eKeatley, E. \u0026amp; Molton, I. A Shift in Approach: Assessment and Treatment of Adults With Functional Neurological Disorder. \u003cem\u003eJ Health Serv Psychol\u003c/em\u003e \u003cstrong\u003e48\u003c/strong\u003e, 79-87 (2022). https://doi.org:10.1007/s42843-022-00061-w\u003c/li\u003e\n\u003cli\u003eStone, J.\u003cem\u003e et al.\u003c/em\u003e Who is referred to neurology clinics?\u0026mdash;the diagnoses made in 3781 new patients. \u003cem\u003eClinical neurology and neurosurgery\u003c/em\u003e \u003cstrong\u003e112\u003c/strong\u003e, 747-751 (2010).\u003c/li\u003e\n\u003cli\u003ePerez, D. L.\u003cem\u003e et al.\u003c/em\u003e Decade of progress in motor functional neurological disorder: continuing the momentum. \u003cem\u003eJournal of Neurology, Neurosurgery \u0026amp;amp; Psychiatry\u003c/em\u003e \u003cstrong\u003e92\u003c/strong\u003e, 668-677 (2021). https://doi.org:10.1136/jnnp-2020-323953\u003c/li\u003e\n\u003cli\u003eEdwards, M. J., Adams, R. A., Brown, H., Pare\u0026eacute;s, I. \u0026amp; Friston, K. J. A Bayesian account of \u0026lsquo;hysteria\u0026rsquo;. \u003cem\u003eBrain\u003c/em\u003e \u003cstrong\u003e135\u003c/strong\u003e, 3495-3512 (2012). https://doi.org:10.1093/brain/aws129\u003c/li\u003e\n\u003cli\u003eSajin, V. \u0026amp; Macerollo, A. in \u003cem\u003ePrevention in Mental Health : From Risk Management to Early Intervention\u003c/em\u003e (eds Marco Colizzi \u0026amp; Mirella Ruggeri) 277-307 (Springer International Publishing, 2022).\u003c/li\u003e\n\u003cli\u003eLaukaityte, U. \u003cem\u003eThe Scope of Functional Neurological Disorder: Symptom Perception, Inference, and Psychiatry\u003c/em\u003e, UC Berkeley, (2024).\u003c/li\u003e\n\u003cli\u003eEspay, A. J.\u003cem\u003e et al.\u003c/em\u003e Current Concepts in Diagnosis and Treatment of Functional Neurological Disorders. \u003cem\u003eJAMA Neurology\u003c/em\u003e \u003cstrong\u003e75\u003c/strong\u003e, 1132-1141 (2018). https://doi.org:10.1001/jamaneurol.2018.1264\u003c/li\u003e\n\u003cli\u003eAybek, S. \u0026amp; Perez, D. L. Diagnosis and management of functional neurological disorder. \u003cem\u003eBmj\u003c/em\u003e \u003cstrong\u003e376\u003c/strong\u003e, o64 (2022). https://doi.org:10.1136/bmj.o64\u003c/li\u003e\n\u003cli\u003eGelauff, J., Stone, J., Edwards, M. \u0026amp; Carson, A. The prognosis of functional (psychogenic) motor symptoms: a systematic review. \u003cem\u003eJournal of Neurology, Neurosurgery \u0026amp;amp; Psychiatry\u003c/em\u003e \u003cstrong\u003e85\u003c/strong\u003e, 220-226 (2014). https://doi.org:10.1136/jnnp-2013-305321\u003c/li\u003e\n\u003cli\u003eVelazquez-Rodriquez, Y. \u0026amp; Fehily, B. \u003cem\u003eFunctional Neurological Disorder: Historical Trends and Urgent Directions\u003c/em\u003e. (2023).\u003c/li\u003e\n\u003cli\u003ePick, S., Goldstein, L. H., Perez, D. L. \u0026amp; Nicholson, T. R. Emotional processing in functional neurological disorder: a review, biopsychosocial model and research agenda. \u003cem\u003eJournal of Neurology, Neurosurgery \u0026amp;amp; Psychiatry\u003c/em\u003e \u003cstrong\u003e90\u003c/strong\u003e, 704-711 (2019). https://doi.org:10.1136/jnnp-2018-319201\u003c/li\u003e\n\u003cli\u003eWalsh, S., Levita, L. \u0026amp; Reuber, M. Comorbid depression and associated factors in PNES versus epilepsy: Systematic review and meta-analysis. \u003cem\u003eSeizure\u003c/em\u003e \u003cstrong\u003e60\u003c/strong\u003e, 44-56 (2018). https://doi.org:10.1016/j.seizure.2018.05.014\u003c/li\u003e\n\u003cli\u003ede Jong, T. J., van der Schroeff, M. P., Achterkamp, M. D. \u0026amp; Vroegop, J. L. First results of the Strengths and Difficulties Questionnaire, applied as a screening tool for psychosocial difficulties in pediatric audiology. \u003cem\u003eEuropean Archives of Oto-Rhino-Laryngology\u003c/em\u003e \u003cstrong\u003e280\u003c/strong\u003e, 4467-4476 (2023). https://doi.org:10.1007/s00405-023-07979-x\u003c/li\u003e\n\u003cli\u003eWoodward, E. N.\u003cem\u003e et al.\u003c/em\u003e Impact of Primary Care\u0026ndash;Mental Health Care Integration on Mental Health Care Engagement Across Racial and Ethnic Groups. \u003cem\u003ePsychiatric Services\u003c/em\u003e \u003cstrong\u003e75\u003c/strong\u003e, 369-377 (2024). https://doi.org:10.1176/appi.ps.20220631\u003c/li\u003e\n\u003cli\u003eMoitra, M.\u003cem\u003e et al.\u003c/em\u003e Global mental health: Where we are and where we are going. \u003cem\u003eCurrent psychiatry reports\u003c/em\u003e \u003cstrong\u003e25\u003c/strong\u003e, 301-311 (2023). https://doi.org:10.1007/s11920-023-01426-8\u003c/li\u003e\n\u003cli\u003eEspay, A. J.\u003cem\u003e et al.\u003c/em\u003e Current Concepts in Diagnosis and Treatment of Functional Neurological Disorders. \u003cem\u003eJAMA Neurol\u003c/em\u003e \u003cstrong\u003e75\u003c/strong\u003e, 1132-1141 (2018). https://doi.org:10.1001/jamaneurol.2018.1264\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Conversion disorder, FNDs, FNSDs, diagnosis, course, prognosis, comorbidity, referral system, care, treatment, Iran","lastPublishedDoi":"10.21203/rs.3.rs-5461333/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5461333/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: The vague pathology of conversion disorders (Functional Neurological Disorders (FNDs)) creates diagnostic and therapeutic challenges and uncertainties, requiring individuals to navigate various medical specialties and treatments. This study aims to explore pathways individuals with FNDs take in seeking care, uncovering factors influencing their healthcare journey.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e: Conducted at Roozbeh and Imam Khomeini Educational Hospitals in Tehran from 2019 to 2022, this cross-sectional study included 101 FND-diagnosed patients. They were interviewed using a validated questionnaire by a trained psychiatrist to explore their care-seeking journey, diagnosis delay, and related factors retrospectively.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e: Participants, averaging 36.9 years in age (SD: 12.98), were predominantly female (66.3%) and married (55.0%). Initially, most participants sought consultation from neurologists (40.2%), then general practitioners (36.3%), with subsequent referrals mainly to neurologists in the 2\u003csup\u003end\u003c/sup\u003e (71.2%) and 3\u003csup\u003erd\u003c/sup\u003e (72.7%) visits. Alongside with the low rates of visiting a general physician in first exposure that is a pronounced deviation from the hierarchy of care (primary, secondary, and tertiary), referral to psychiatrists was minimal in the whole reported visits (2.9%, 3.4%, and 9.1%, respectively). On average, participants had 1-5 specialist visits before visiting with a psychiatrist, with average disorder duration of 37.1 months. Movement disorders were found in 31.7%, and major depressive disorders in 42.6% of this population. A majority of patients (n=79, 78%) experienced at least one stressor before FND onset, with family conflict being the most significant one (17.1%).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e: Our study highlights the significant challenges in the care pathway for Iranian adults with FNDs. Individuals sought consultations with a varying number of medical specialists before ultimately being referred to a psychiatrist. This is especially notable given the high prevalence of psychiatric comorbidities and associated stressors, which emphasize the crucial role of psychiatrists in addressing these complexities. However, both patients and healthcare providers seem to perceive the symptoms with a tendency toward more organic origins, indicating a potential gap in understanding and communication. Enhancing awareness and collaboration among healthcare providers, advocating for early intervention and routine psychiatric evaluation for individuals with FNDs, and addressing perceptions of symptoms through targeted education is recommended. Further research is needed to explore the pathway to care for patients experiencing each type of FND symptoms.\u003c/p\u003e","manuscriptTitle":"Understanding the Care Pathway in Iranian Patients with Functional Neurological Symptom Disorders","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-04-04 10:49:43","doi":"10.21203/rs.3.rs-5461333/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7fb84662-1da3-4b6d-ba9c-3afeb4c16d86","owner":[],"postedDate":"April 4th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":46610590,"name":"Health sciences/Health care/Health policy"},{"id":46610591,"name":"Health sciences/Health care/Health services"},{"id":46610592,"name":"Health sciences/Health care/Public health"}],"tags":[],"updatedAt":"2025-09-24T09:11:38+00:00","versionOfRecord":[],"versionCreatedAt":"2025-04-04 10:49:43","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-5461333","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5461333","identity":"rs-5461333","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}