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Hello and welcome to the neuro transmitters, a podcast about everything neurology with the goal of reducing your neur a phobia. I'm Doctor Michael countries. And today we're talking about functional neurologic disorders. Today, we are joined by the host of FND portal where he runs a very informative and deep dive oriented website as well as a very active Twitter account focused on education and advocacy. Thank you. Pleasure to join you. Thanks for having me and thank you for taking the time to talk with me today. One thing that I read really noticed was just these very detailed tweet Orioles about the history and science of F and D that you kind of put out on Twitter from time to time and they're always incredibly well referenced. And my understanding is that you don't come from a healthcare background. That's correct. I have no medical training whatsoever. And that is just amazing because a lot of the information you present is so well put together um so well cited. Uh It's always very educational and uh I spent a lot of time on your website uh several weeks ago, kind of reading some of the primary literature that you had reference there as well. So just tell me a little bit about how you kind of ended up diving into this research as much as you have. Sure. Um Well, thank you for the, for the kind words. Firstly, um you know, it means a lot to me as somebody who doesn't come from a medicine or even a stem background um to know that it's, the work is being well received And I always have that sort of uh paranoia of the self taught that I've put a foot wrong somewhere, you know, and, and not realized it yet. But um but thank you. Um So the reason that I got so into this is, I mean, first, I should say that I am a person with functional neurological disorder. So that gives me a good reason to care about it in the first place. Um But in terms of the specific reason why I do things the way I do them, I think it was really an emotional need. Um When I got diagnosed, I wasn't immediately finding a lot of great resources about how to understand the disorder. And I had absorbed a lot of um half formed sort of problematic assumptions from society about what having this condition means. And I can tell more about that in a little bit. But um but in essence, I started off as uh a an undiagnosed patient for a long time. I was assumed to be uh you know, a so called zebra like a rare disease patient for many, many years. And uh and when I did get diagnosed with FND, it came as a complete surprise. And so I felt really personally compelled to dive into the history and the biology of the disorder because I needed to understand it just to make sense of my own world. So for people who are listening, who may not be as familiar with functional neurologic disorders, would you care to give a sort of working up to date definition? Sure. So, functional neurological disorder, well, it is what it says on the tin, it's a neurological disorder, but it's one that is different from what many neurologists are used to seeing. I think many neurologists are trained to think about illness principally as disease. You know, we're familiar with these disease processes in disorders like Parkinson's, Huntington's MS, things like that. And uh FND is a, is a bit of a different beast. It's not a disease process in the sense of proteins, MS folding or it's not uh it's not like a chromosomal disorder or something like that. It's probably a kind of overtraining of the brain or it's a kind of uh training of the brain with bad data. So for example, it's really common to see people with FND who got in uh an accident of some kind of skiing accident, a car accident and maybe they lost the use of a limb due to an initial, you know, arm, arm injury or something and some time passes and that, that wound heals, but they're still unable to move. And what's happened is that the brain has sort of taken in that salient sensorimotor data and essentially reprogrammed itself biologically, uh such that the person loses the ability to command and interface with their body in the way that they normally would. And it's kind of interesting how this can be similar to how I say a dystonia might develop in a professional musician or a high level athlete. Uh because they have the same kind of overtraining areas that go on. And similarly, dystonia is also thought to be a psychologic disorder for a while. I listen to another podcast called Thank you for this consultation, has a neurologist and a psychiatrist talking with one another about seeing things sort of at the juncture between the two specialties. And uh they had another psychiatrist on who said that oftentimes once a marker for organic disease is found, neurology, kind of takes the diagnosis away from psychiatry. Uh And it seems that may be something that's happening with FND as well. Yeah, I think that's, that's fair and that certainly has been the pattern, right? Um So to, to sort of give a little historical perspective, this condition was, it actually has a pretty long history with medicine that has been mostly forgotten and it was once known uh Grossly as hysteria back in the 17, 18 hundreds. And uh for some time in the 19 hundreds, it was kind of tentatively known as Conversion Disorder, which is, uh kind of, I think how a lot of clinicians learn about it in passing even to this day, you know, where it's like they mostly don't learn about FND in medical school. And my understanding is that often, if you do learn about it, it's kind of in passing of like, you know, here's the neurological disorders and, oh, well, there's also this other thing where sometimes people's emotions can cause their body to do weird stuff and, and you know, it sort of gets thrown in as a, as a, as a footnote. Um And what's complex about FND is that, um you know, it's, it's in some ways not a strictly neurological disorder, like there definitely are psychiatric, psychological elements to it. Um People notice that, you know, where you put your attention can really make a difference. Um People will notice that certain stressful events may cause the symptoms generally to flare. Um or some of the comorbidities that come with FND like chronic pain can, can flare with those kind of things. Um And what you sort of come to is uh this, this realization at a certain point that these things are interlocked in the brain in a way that is really different from what most of us would have grown up. Assuming, you know, you, you assume that there are biological disorders on one side and then sort of psychological psychiatric disorders on the other. And FND kind of laughs in the face of that distinction. You know, it sort of shows you that the brain is really working in a really non dualistic way and attempts to put it in one box or another, invariably fail when reading a little bit about some of the historical things, you kind of come across this mind body dualism, you know, where, where does the brain stop? Where does the mind begin? And, um, it's kind of an artificial division between the two. I think we're coming to learn more and more. And, but unfortunately, there is that division that still exists. It would probably be traced back to kind of like Charcot and Freud and have those really early neurologists and, uh, psychiatrist back in the day. Absolutely. Yeah. And, and, you know, it's probably too much to, you know, we could have a long conversation just on the history of the disorder. But what's funny is that, you know, uh FND has sort of been the victim of its own history in some ways where like if you go back and look at, you know, the history of psycho psychiatry in the history of neurology, and you look at the moment where they really kind of split for good over the last 100 years, it was over the issue of hysteria. So, you know, it seemed to be at first a neurological disorder, you know, as characterized by um Jean Martin Charcot, and then Freud came along with a completely different conception of how it was thought to work. And when that happened, the combination of Freud sort of laying claim to it as well as a very ambitious wave of neurologists who came right after Charcot that, that basically really wanted his spot, like they wanted his preeminence. Um They, they sort of rejected the, you know, the, the neurological concept of hysteria. And um and at that moment, not only did hysteria sort of become considered an exclusively psychological phenomenon, but the disciplines themselves really split. And uh ironically that sort of rendered brain science as a whole, much less capable of reckoning with functional disorders because they couldn't bring the integrated perspective that you sort of need to see it in its true dimensionality. Yeah. And that, that was one of the challenging things in training, you know, we'd uh get these patient's with these, you know, unusual symptoms and we did eventually, you know, get the testing done, we'd identify the, you know, symptoms that would lead us down one way or another and say like this is probably a functional neurologic disorder of some kind, whether that's, you know, functional movement disorders or uh functional seizures, nonepileptic seizures, etcetera. And um in my particular case, I, I've kind of come up through the epilepsy uh line as opposed to a lot of other neurologists who are perhaps more on the movement disorder side of things. So we had a lot of times, you know, when I would work in the epilepsy Monitoring unit, we'd bring these folks in, we would capture their spells on eeg there's no epileptic activity happening during the spell and there'll be certain, you know, clinical signs and we go in and talk with the patient and you know, like these aren't epileptic seizures. And so then we would go through and explain what nonepileptic seizures were. And you know, sometimes people were very understanding of that. Uh sometimes happy, sometimes not other people were very resistant, would be kind of opposed to that diagnosis. Uh Thinking we must have gotten something wrong. Very interesting. Can I actually ask you a question? Of course. Um So were you taught about, you know, when you encounter cases like that where you're like, okay, this thing is looking epilepsy esque and yet something is telling me, you know, we're not registering the sort of epileptiform activity or the different things that indicate that it's epilepsy. And you know that there's this other thing out there, were you taught explicitly about functional disorders or even conversion disorders in school or was this something you sort of encountered in the practice and started to kind of figure out? So, yeah, it's uh it's something that we, we were taught about a lot of times it was kind of in the paradigm of conversion disorder typically. Although later on, kind of like when I was, you know, to wait towards the end of my training, early as a junior attending, uh I started to hear more and more about like functional neurologic disorder specifically, uh came across John Stones work his website neuro symptoms dot org and kind of got more educated from that perspective, um, in that sort of newer paradigm of the cluster of symptoms. And it's always been something that uh well, where there was instruction, it wasn't focused as much on the treatment. And so a lot of times you'll have these patient's whether they're in the, in the outpatient or inpatient setting. And, you know, I think this is what you have and I may or may not have a good treatment protocol or recommendations on how to help this person. And so that can be of course, very frustrating both to the person who, you know, maybe you've accurately given a diagnosis to. But then you're saying like, well, there's nothing I can do for you. And so that can be very frustrating and understandably. So I would say for, for both the patient as well as the person trying to, again, assuming best intentions, trying to help them. Yeah. And um and that's really tricky for both the patient and the doctor, right? Because when you're looking at these questions of, you know, the patient's trying to make sense of why is this happening to me just as much as you are, like, everybody's seeking that resolution. And I think one of the things that's been really frustrating about the sort of traditional ad hoc way that clinicians have handled functional disorders is so from what I hear from the community, it tends to go and kind of one of two ways assuming that a doctor has said this is conversion or this is stress or this is functional, like however rigorously defined. Um it tends to kind of go in one of two directions. One would be that the doctor just straight out comes and says this is stress. You don't have a quote unquote organic disorder. You don't have epilepsy, you don't have something that we recognize and uh stress is behind this. And the best thing you can do is, you know, deal with that stress and it'll be fine, it'll go away. And the other one that I hear, which I, I guess I would consider more progressive. Um if still insufficient is for a doctor to look at something like the situation you described and say, okay, well, there may or may not be things here that sort of predispose you to it. But to be clear, we don't really exactly know what it is. We know it's not epilepsy, but we were not prepared to make, you know, a really firm statement on what exactly that this is that's happening to you. And I think that was kind of the boat that I was in, um I was undiagnosed for almost a decade. And, um you know, fortunately I did not have a lot of the experiences of abuse that many other patient's have had until, until the end. But I did get a lot of, you're not my problem. Um So, and that happened across multiple neurologists, rheumatologists, immunologists, allergists, you know, it was like, you become very conscious of the fact that you're being ruled out. And uh and, and they're occurs a split, right? Because from the from the practitioners perspective, they're like, well, I've done my job. It's not neuro neurological supposedly. And yeah. And right. Yeah. And you know, from a really impoverished perspective of what neurology is. Um And, and from my perspective, it's like, yeah, but you didn't, you didn't tell me anything like you didn't do, you didn't do anything for me and not only did you not do anything for me, but you know, we're both American, which means I just got charged like $8000 for, you're not doing anything for me. So like this really sucks, actually. Yeah. And, and so uh the way that that came to an end for me personally was um I submitted a long shot application to the NIH is Undiagnosed Disease program. Very interesting. And yeah, so for folks who may not be familiar with this, um this is an extremely selective program where basically you have to submit your entire medical history you know, whatever you've got since you were born and you have to be able to demonstrate that not only has no one else figured it out but that no one else could figure it out. Like you have to be able to demonstrate that the door has been closed in your face and that you have nowhere else to go. And, uh, for me, after going to major medical centers in several different cities that was very easy to do, um I had been told explicitly by doctors, we're never going to figure this out, just go home and, you know, you're never going to have a job again, just learn to live with this, the disability and, and kind of deal with it. And so I applied to the NIH, it was the only shot I had left and uh they accepted me and I was seen there by Mark Hallet who has had uh interest in FND since, you know, the early two thousands. And um I was seen by him and a group of, I would say maybe two dozen neurologists and other specialists. We're all sort of assembled together at the Human Motor control Unit. Um It was pretty amazing to, like, be in a situation where, like, you know, the, the NIH Clinical Center is, I think the biggest building of any kind of ever been in my life. Like it's just massive like you. Yeah, I've only seen pictures. Yeah. Enormous. Yeah. Right. And it's like the resources that the US federal government can bring to bear when it wants to on something is pretty incredible. And, um, I was seen there and I was told by a sort of junior doctor that, you know, we've gone through everything. We're pretty confident on this. We're confident enough to say you have functional neurological disorder. And, um, I didn't take it very well because I, I had heard about the concept of conversion disorder somewhere and I understood it to me and that, you know, if, if they're saying I have this thing that used to be called conversion disorder. I understood that to mean a condition in which someone is so sort of unaware of their own emotionality that they repress those emotions and transform it into physical disability without even realizing that they're doing it. And so it's something that you've like done to yourself that like I had disabled myself and, and not known that I was the author of my own affliction. And uh I couldn't, I couldn't deal with that. Like I had, I had a really, really, like, I freaked out basically, I left the, I left the appointment. I went back to the hotel room and I just freaked out like I just let myself, like, let that stress out for a little bit. And then when I was done, I kind of sat down and thought about it and I was like, okay, well, the easiest thing to do would be to say, you know, forget these people, they don't know anything, they're just making stuff up. I'll keep looking. Um, but I had to be honest with myself where I was like, you know, first of all, I've come to the best undiagnosed Disease program in the world. I saw them working with kids who have like, rare genetic disorders. You know, this isn't like some sort of, you know, Backwater Clinic and they're not obligated to give me a diagnosis. Like they let me know before I come there that only 15% that's 15 of the people who get into this program get a diagnosis because they're already dealing with the hardest cases, you know, in the world. And so if they told me that I have this thing, I'm obligated to take that seriously. And uh so I sat down with my laptop and I went on Google scholar and um I had been kind of studying neurology on my own at home uh for a number of years in the hope that I could figure it out because doctors had said no one's ever gonna be able to get this. And, um, you know, I had maybe like a sort of quasi late undergrad understanding of neurology. And um and I went online and googled functional neurological disorder. And the first thing that came up was a series of studies by uh Doctor David Perez in Boston. And uh it was talking about the functional and structural micro structural changes that happened in the brains of people with FND. And what I saw there was a blueprint of all the brains of all the brains blueprint, of all the brain areas in the brain networks that I would have expected would produce my symptoms if you had asked me, you know, three weeks before I got the diagnosis. And so I, I saw the thing that I had been looking for and I was like, this makes complete sense, but I just didn't know what the name of that thing was. And so that was the kind of beginning of my engaging with that neurobiology and sitting down and trying to really understand it. And that's, that's sort of the long version of how I ended up getting so into the particulars of FND. Yeah, a lot of the research that's come out does look into a lot of these kind of like interest Cept Ivanov networks, a lot of network research in general and kind of how does one perceive one's body? How do you think of yourself? How does your mind perceive itself? So all these kind of really deep, almost metaphysical kind of ancient types of questions that are now being translated more into these different manifestations in different subtypes of FND. Absolutely. Yeah. Which makes it actually even interesting just beyond the question of, you know, what is happening to my body, right? Or like why are people having these seizures and stuff like it, it, it almost does become a question that goes a little bit beyond medicine. Like when you start looking at, you know, to get into the neurology of it a little bit, when you start looking at the brain systems that are involved in FND, you have things like the temporal parietal junction which is involved with feelings of agency. You know, the that that felt identification with your own body where you just wake up in the morning and you know, you don't, you don't have to cognitively reason about your own in your body. You just feel it right. You're like this is mine and I can move it if I want to. And the, the TPJ and some of the posterior parietal areas are are things that are involved in that. And we know because of studies, some of which were done by, you know Markowitz group at that at the NIH where I was that some of these brain areas are disrupted and it starts raising questions of like what is a self? Because it, it very much appears that you know what we're looking at an FND is, is kind of like a, a sort of fractured consciousness. It's like a fractured, a fractured mind, body self, you know where um you have these different brain areas that should be talking to each other in a certain way that helps you manage your body in the way that healthy people are used to and that you would expect and when that gets thrown off, it's really, it's really startling. You know, I can, I can tell you just subjectively as, as a person that has a disorder that, uh, you feel the same in terms of, like, when, I mean, to move my legs, I will it consciously in exactly the same way as I always have. It just doesn't feel any different, but it's like sitting there with a keyboard and a frozen computer. You know, you're like hitting the space bar and like, nothing's happening and you're, you expect that it's going to get through and it just doesn't. And it's, it's so, it's so weird. It's so unnerving. It feels kind of like being amputated inside your body. You know, it's just, it's, it's, it's so, so strange and it, it does have things in common with like conditions like, uh you know, Phantom limb syndrome and hemi spatial neglect and stuff like that. And, uh, and, and it, it does get to the spooky area of like free will and the self and these things that science has sort of traditionally declined to approach to directly because it felt like they weren't ready. And, but FND is kind of a window into where that stuff lives, I think. Yeah, it definitely ties into that whole mind body connection kind of the, the, uh analogy issue often here is like software and hardware and how much of the mind itself is this emergent phenomenon from, from the hardware of the brain itself? And how much does it circle back to cause changes on its own hardware? Right. So to speak with this whole model of neuroplasticity. And while we are seeing a lot of evolving ways in terms of like identifying like, yes, there are structural changes going on and people with different types of FND, uh we're still not, at least as far as I'm aware, fully explaining a lot of the things that are going on and we still don't have like ideal treatment regimens. So while things are progressing, there is this lag in the diagnostics and treatments if FND as compared to some other areas of neurology perhaps. Absolutely. And you know, just from like, uh you know, from the perspective of being a like a disabled person living with the condition, um you know, in some ways, it's, it can be really frustrating when the pace of progress feels slow. But on the other hand, I'm just super glad that I wasn't living with this condition like 40 years ago because, you know, before you had this sort of uptick in F MRI studies and everything like that, um It was just really bleak honestly for people with this condition. And so I'm hoping that um you know, that one of the things that neurology practitioners and trainees will take away from this is that there's actually a huge uh potential gain here, right where it's like this is a whole population of people with a pretty common disorder that really has not, has not been helped, like at all, like it would be kind of like not knowing Parkinson's exists or something um which like that would be bad. Um And you know, so just getting the basic stuff in place, you know, not even super advanced solutions or anything like that, but just getting a basic standard of care um could make just such a massive difference. And um I sort of sense I'd be interested in what you think about this too, but I get the sense from doctors that they kind of know that this thing is out there, like, even if it, it may be hasn't been directly acknowledged where, you know, you're like, okay, I've got my epilepsy patients', I've got my movement disorder patients' and there's this other thing that just doesn't really line up and the patient's that have it keep coming back, their symptoms seem to be particularly bad. They don't really seem to get better. Sometimes they have a trauma history, sometimes they don't. And um I get the sense that this is a crisis for your side of the table almost as much it is as it is for mine. Um What do you think? So, I think neurology in general is aware of these patient's, I think historically, it's just been a problem that a lot of neurologists aren't uh trained to provide treatment for, for folks with FND. Uh you know, we do see a lot of people and they'll get, you know, work up for whatever kind of the presenting uh problem is, you know, weakness uh episodes concerning for seizures, etcetera. And, you know, like you said, you kind of get through the work. I was like, well, you don't have epilepsy, you don't have myasthenia gravis or what, what have you, what, you know, whatever diagnosis um or diagnoses were kind of on your differential. And so then you're left with while I think this is FND or, you know, if there are the positive signs that can guide your diagnosis, you kind of maybe have that on your list earlier than later. And so a lot of neurologists still traditionally consider this to be kind of a uh psychologic diagnosis. And so it does lead to a lot of people with FND or things, you know, in that kind of neck of the woods being released from neurology clinics at that point, once they don't find a quote unquote true uh neurologic problem. And so you wind up with these people who are kind of left in the lurch, you know, it's like maybe they do, maybe they don't have any co morbid uh psychiatric problems. But a lot of times treating that in isolations in isn't going to be sufficient. So you really do need that kind of, um, you know, multidisciplinary care from that perspective. And I know a lot of my patient's that I would see uh in the epilepsy monitoring unit, you know, we might diagnose a functional seizure disorder, but a lot of these people would still follow up because there is still this risk of, you know, injury that is comparable to someone with epilepsy. And a lot of times they can get mistaken as having epilepsy by, by other uh doctors or clinicians who are taking care of them. So there is still that utility to stay in touch with these people to keep them in your practice. Um But that's not necessarily always the case as far as what I've just seen anecdotally. And I think the other important thing to keep in mind is that looking at the literature, you do see uh some studies depending what numbers you look at anywhere from 10 to 20% of people with FND do have a co morbid traditional neurologic diagnosis and that will still need management uh from a neurologic perspective. So I think there is still benefit that can be offered to these people by remaining in touch with the neurologist, even if they're not super familiar with FND. Sure. Sure. Um You know, I think we've touched on this a little bit, but I think one of the, one of the really nice things about the current wave of research on FND is that it offers a sort of um a sort of specificity that wasn't really there before, you know, where uh like, just to put it bluntly, I've met a lot of people who were diagnosed with, um, either conversion disorder, you know, if the doctor called it that or they might have even been diagnosed with FND and the doctor may have done it correctly. Like they may have done it technically correctly on the basis of okay, this appears to be epilepsy, but it's actually not and we can see specific things that, you know, tell us. It's, it's, it's not epilepsy. And so they'll say, okay, well, it's not epilepsy. That means it's functional and ergo that means it's psychological and not really like a neurological condition. And so go see a psychiatrist. And I think that's actually where a lot of patient's experience the stigma and experience the sort of violation of their own narrative is that um you make this jump from it's not epilepsy therefore, and then all of a sudden, like three other assumptions are linked to that all at the same time. And um you know, there are, you know, there are people who have functional disorders that it clearly does come primarily from some kind of psychological trauma. And in those cases, when I meet people where that's the case, it's almost always something where I could never argue with it, you know, where they'll, they'll tell me like I think it is, you know, they did say, I think it is trauma because XYZ happened to me and I, I'm like, wow, that's, that's really horrible. Like that would deeply affect me to potentially in my body if that happened to me. Um But like, you know, in my own example, um I had kind of a series of workplace injuries that I think, you know, combined to uh sort of trip my brain into this, into this FND state, you know, the probabilities sort of shifted me out of my habitual brain patterns and into this other thing. And there may have been psychological components that contributed to that, but it would be a serious reach in my case. And in many other people's cases to say, well, there's a psychological thing that happened, right when you got this and that's why it's happening. And I think what's powerful about the sort of current thinking on FND is it doesn't need that like you can just look at it and say, okay, based on these characteristics, it's a functional disorder and that also makes sense biologically because it maps onto the things that the implicated systems are known to do, like it acts like the Salience network because it comes from the Salience network, it acts like the insulin, the Amygdala because those things are participating in the formation of FND. So you've got this sort of like link between biology and explanation that totally, totally makes sense and is also supported from a bunch of other areas of brain science at once. And then after you've established that you can then go to, is there a role for sort of classic trauma or classic stress or depression in this for the specific person? And if so, what is that? And can we help? But you don't have to start from this place of insisting that everybody has trauma and that it specifically your childhood and that it specifically sexual trauma, like this is a ridiculous way to look at brain disorders and we don't need it anymore, you know. Right. And that's still how a lot of, a lot of people do think about uh functional urologic disorder, especially kind of through the old paradigm of conversion disorder, but just anecdotally, right? I, I have these folks and we don't find any of those risk factors when we kind of dive into what might be going on from a psychosocial perspective. Yeah, I think, I think there can be um you know, among people who have experienced trauma, there can be aspects of this that are, that are sort of violating as well, like um you know, especially the sort of repression explanation for conversion disorder, right? Where in the classic Freudian, you know, narrative, it's that you've repressed your emotions and therefore it's popping out on the other side of the equal sign as physical disability. But, you know, myself and other people who have trauma as some percentage component of FND. Uh most of us actually remember exactly what happened and how much it sucked. And, you know, the idea that while this is happening because you're repressing, it is like, well, I kind of wish I was repressing. It. Like that would be nicer actually in some ways. Um, yeah, and so I just, I think it's great that we're sort of turning a page to a more, um, a, more evidence based and more humane approach to this really common thing, right? And yeah, uh diagnostic delay is a big problem with a lot of people with FND. Um I think the average number is about seven years if you get diagnosed with epilepsy and end up having functional seizures. But, you know, you end up with a lot of testing that may be unnecessary exposure to medications that are likely doing more harm than good. Um you know, costs for lots of different, probably repeat redundant Mri's things like that. But I know one of the things I'm always kind of harping on about with like trainees who are working with me is that, you know, like again, I can come back to functional seizures, but just because it's not epileptic doesn't mean that it's volitional. And I think that's one concept that in the medical community at large still isn't uh super well established. And so you do sometimes see some less than ideal perceptions in the medical community. Absolutely. Um You know, there's some debate about this among people who have FND because I think also there's um there's unfortunately still a lot of distrust in the wider disability community about functional neurological disorder. And um it's unfortunate because where there should be solidarity, there's actually been kind of a lot of distrust of, of people with FND. And one of the issues is that people with other conditions are concerned that if they have a rare disorder or something, the doctors aren't used to seeing that doctors will use FND as a convenient waste bin to sort of throw them in rather than doing the testing that is going to turn up the thing that they actually have. And, um, I don't, I don't know that we have great stats on this issue really, but my sort of personal take on it, you know, having just sort of sat with it for a little while is I really don't mind the additional testing, you know, medication might be one thing, right? Like we don't want to put people on epilepsy meds that will make them worse. But when it comes to Mri's and stuff like that, um I don't feel as sort of precious about the cost of that because the lifetime cost of undiagnosed FND are so, so high that it's like if you diagnose FND and then you run, you know, five or six tests after that anyway, it may seem expensive in the moment, but it's really not compared to just getting the right answer. You know, in that, in that time frame and, you know, I leave it to neurologists and specialists who have training in these things, you know, to, to make those decisions. But like my personal take is I'm not really worried about the cost of the initial testing um because that so pales in comparison to the hundreds of thousands of dollars that it costs over the lifetime of having an undiagnosed illness, you know. Right. And you know, that is one of the things that uh that you sometimes run into, you know, I'll see someone with a tremor, various movement problem of some kind. And I can tell them like, hey, I think I see these signs on your exam. I think it's FND or what have you. Um But definitely, uh I, I think one of the important things is for the person in question to make sure that they feel confident that they have the right answer. And so getting a second opinion is always a good idea. I think if you don't feel confident as the person having the symptom that you have the right answer, so I think it's always reasonable to get that, especially if you say you have a movement problem and you saw a general neurologist and you want to go see a movement sub specialist. I think that's entirely reasonable to make sure that you kind of covered those bases. Have, you know, an expert in that particular field. Look at it, particularly if it's something a little off the beaten path, so to speak. Yeah. Absolutely. And, you know, I think it's a challenging thing to where, you know, in the United States we don't really have like, a national health care system in the way that they have, you know, the NHS in the UK. Um, so I've, I've heard a lot about people running into those kinds of situations where you're like, I think it's this, I'm not totally 100% sure what to do about it, you know, and there may be sort of a limited group of people that you can reach out to for, for advice or guidance. Um And I think that's one of the big challenges that sort of facing FND advocates and people on the medical side who want to see this uh progress in advance is you sort of run into the question of how do we do that when the system in some ways seems to be so kind of balkanized, you know, it's sort of a different hospital in every city and they have nothing to do with each other, like, you know, yeah, it can be very challenging from that perspective. You know, we have all these electronic medical records and sometimes they talk to each other, sometimes they don't, sometimes they do, but it's still kind of not super great. Um I remember one case in particular, I saw a young woman a few years ago and, you know, she looked like she had a functional gate disorder where she kind of have some unusual movements and you'd be able to change the pattern a little bit depending on how you asked her to walk and the symptoms would come and go kind of, you know, good days, bad days, kind of pattern. And I told her, I think this is a functional neurologic disorder. Um, but I was fortunate where I was practicing at the time, was close to the University of Cincinnati with Dr Sp and his group and I was able to, to send her there and get a second opinion um where they will confirm that. But I know that's not, that's not always an option. And I think where things can get really kind of complicated. As you know, like we mentioned earlier, those folks who have both a functional neurologic disorder as well as a traditional neurologic disorder um like epilepsy per se, you know, I, I see a lot of those folks in the clinic or at least I used to when I was practicing outpatient. And so they have a new spell, say we have to bring into the epilepsy unit, capture the spell because we need to figure out do we need to increase the seizure meds? Do we need to focus on something else? So it it can be challenging depending on kind of the the individual and the constellation of symptoms they're having at that time. But to your earlier point, if someone had been diagnosed with FND and you're, you're evaluating them and things have changed in a way that doesn't make sense. Or there's new symptoms that are coming up that don't really fit with that pre existing diagnosis. I think it is important to keep that door open for alternative diagnoses or new diagnoses that may not fit with FND or maybe they're in addition to FND. Absolutely. And, um, you know, I'm very fortunate in that I don't, I don't have that, that combination. Um But I imagine that must be really difficult on a personal level to understand how do I manage this on a day to day basis? Like, how am I supposed to sort of keep this under control? Um But I've, I've also been surprised that, um you know, given that there, there has been some resistance uh from other areas of the disability community. Um I've, I've still been surprised by how different people have reached out to me and other folks with FND. Um, like, I've found a lot of really great allies among the Parkinson's community who came to FND all on their own. You know, where they started to realize because of research that was being done over there that, oh, actually, like a lot of people that have Parkinson's also have FND on top of it probably as a result of these brain system changes that they're, that they're going through and you know, so their outlook on it was basically, well, I mean, Parkinson's takes its course, we try to medicate it but everybody knows where that's going and you can't really change it yet. And so then it becomes a quality of life issue where it's like if you have Parkinson's and if you're stuck with that and you have FND on top of it, then it behooves you to get interested in FND because at least that's something you can do something about and, you know, enjoy your life a little more than you would have given that the disease progression is going to be what it's going to be. Um And that was something that was completely new to me. But as soon as they, you know, as soon as I got to talk with them about it, I was like, oh yeah, this makes total sense and, you know, you start seeing some of those, you know, perspectives from different disability communities coming together and really good things happen when you can do that. Yeah, I can imagine that, you know, adding more voices is always going to be more helpful and kind of getting a message across so to speak. Absolutely. Um And, you know, I never knew that there were these, these sort of interesting things about those conditions, you know, where we're used to hearing things, you know, in the FND community, like, well, your symptoms can come and go, which means it's not like a structural disorder or, you know, they can be, they can recede with distraction, which is how we know. Uh, but there's, there's elements of that and other things too, right? Like freezing of gait in Parkinson's and the way that, you know, somebody might try to walk and then their, their, their brain sort of pitches and stops them from doing it. And the way that they can make it go is to walk in a semicircle, you know, towards their intended destination. And yeah, changing kind of a perspective in terms of how they uh think about the movement itself um rather than the kind of what they've been doing most of their life. And you kind of see a similar thing like kind of a visual spatial perspective where you also see that freezing kind of changing from, you know, carpet to tile or maybe going through a doorway where there's a kind of perceptual barrier where, you know, in someone who doesn't have Parkinson's, it wouldn't be a barrier at all. But you get this again, this kind of perception shift that causes this change in their functional abilities briefly. Absolutely. And um you know, just, just from my perspective like that, that stuff is really um in some ways reassuring because it can be easy with FND to think like, well, this is me like this is I'm some way responsible for this. But when you see people who have other brain conditions and their brains are doing weird transient things like that. You know, the change from carpet to tile or, um, you know, the, the freezing of gait that can be, that can be circumvented by literally walking in a semicircle around your intended path. It's like, okay, so, you know, the brain is always sort of making these perceptual guesses about how to move and how to do things and, you know, even what it's perceptions are and that's not really something that's unique to people with FND. It just comes to the surface for us, but it's kind of the brains mo all the time. It just looks at stuff and kind of makes guess is like, it's like, how about this and then it, you know, tries something, you know, based on that and yeah, and just for us, it sort of happens in kind of a pathological way, unfortunately. Yeah. And that, that kind of brings me to uh thing I wanted to ask about, which is as far as like some of the treatment modalities, you know, one of the one that has been uh written about a fair amount in the FND literature is cognitive behavioral therapy. From my perspective as a non neurologist, non psychologist, non therapist, um I don't administer CBT or other types of behavioral therapy or anything like that. So I do try and read a little bit about it, but I was curious because I had heard a criticism on another podcast. I was listening to that said a lot of the reason CBT was so studied in so many different conditions was because, like, there's basically a worksheet workbook that you can follow. So it doesn't necessarily require as much individualization as a lot of other types of therapy. Uh, might ouch. No, I'm just kidding. Um, yeah, I know. I mean, that's interesting. I hadn't, I hadn't heard that before. Um, if I had to make a completely uninformed guess, I would say, I would guess that CBT is popular just because it's a dominant paradigm. And I mean, I, you know, I, I think, well, of CBT, you know, I think it's, it's good for a lot of things. Um, but I, I think, you know, one thing that sort of snuck up on me recently is I feel like there are some areas where that works better than others and I haven't seen a lot of evidence that says that sort of classic CBT is so great for functional seizures specifically. And my suspicion is that we're missing something and I think the thing that were missing is, um, is embodiment basically. I think that, you know, especially psychologists are used to thinking of conditions like FND, using the traditional tool set of like, you know, they think about quote unquote psychological stuff which is basically like thoughts, feelings, beliefs, emotions, right? And those, those things definitely matter in FND. But, you know, the, the central dynamic of FND is one of interaction with the body and ownership of it. And I think that that's a sort of middle ground between traditional neurology and traditional psychology psychiatry that hasn't been so directly addressed. And um I think that there's a lot to be learned there. You know, if we can better suss out the way that people interact with their bodies and the feelings from their bodies, those are still technically kind of a psychological process, but it's not psychological on the way that I think many clinicians are used to thinking about it. And I kind of have a feeling that specifically with, you know, um with functional seizures, I I think there's a lot to be, to be gained there. You know, you can, you can sort of see it, right? Because they're called dissociate of seizures where they're, they're defined by like a sort of unlinked king of the normal self with the body where you're still kind of conscious, but you've lost control and things are happening and it's all just kind of going berserk and it's like, okay, so like what is the mind body inference ing that is specifically happening to drive that process? And I could believe that anxiety has something to do with it for some set of people, but I'm not sure that it's just that simple because if it was that simple, then traditional CBT would have fixed functional seizures by now and it clearly hasn't. Yeah, I mean, a lot of the literature does show, you know, some improvement in functional seizures with CBT. But there's that sub population that doesn't really seem to respond and there's also a population that tends to have a tendency towards relapsing even after treatment with CBT. So it does, like you said, kind of begs the question of who are the people who respond? What's the best therapy for certain types of FND? Uh why do some people respond? Why don't others and kind of trying to develop that model a little more thoroughly? And I know, you know, just anecdotally before, before I had moved from my last position, I've been kind of reaching out to the local psychiatry and psychology programs in the area to see if we could put something together with the neurology department in terms of kind of that traditional multidisciplinary clinic for FND, just to get people who are more comfortable with other aspects of FND, kind of on board because like you said earlier, I would get a lot of these patient's and I'd be struggling to find another psychiatrist or psychologist who was trained in the appropriate therapy is so my goal is to try and try and build something from the ground up. Unfortunately, didn't really materialize thanks to COVID and life happening. Yeah, absolutely. Um Yeah, I mean, you know, unfortunately, the pandemic has made everything that much harder as it is, you know, every everywhere. Um and I do think that, um, you know, it's, it's really easy to get distracted by what is the best possible care that we could get for people. And, I mean, as a patient, I want that, like, I want to have access to the best care in the world, you know, who, who wouldn't really, um, but when it comes to the question of, you know, sort of triage or, or thinking about what do we do next? Um, you know, I did a little sort of closed door outreach to folks with FND that I know, uh, earlier this year because, um, I felt like we had kind of gone through a couple of cycles of advocacy together and, um, had gotten some things done and what I really wanted to know is what do you think is the top priority that we should be looking at next? And what I actually heard was we need to stop the medical abuse of people with FND in emergency care settings. And I don't know what I expected to hear but that wasn't what I expected to hear and I should have known better. Um, because I had gotten a little bit too far into, you know, what's on the cutting edge and for a moment there lost sight of the fact that actually the first thing we need to do is help, er, doctors understand that somebody coming in with a dissociative seizure is not faking and, you know, not to dismiss them or? Yeah. Yeah. And this is something, uh, I definitely kind of harp on about, like I, I mentioned, um convincing your own staff, uh, you know, even as the neurologist on service that these, you know, are not, like you said, not faking, these are non volitional uh episodes. So, you know, you can't really talk people out of it per se. Although certainly you can kind of provide some supportive, you know, calming, almost like a semi guided meditation uh to some people during a dissociative seizure. Um but we do see a lot of these folks who come in through the emergency department and they've gotten just tons of benzodiazepines for what they think are epileptic seizures. Uh in severe cases. I'll see people intubated on ventilators and you get the story from someone who is there like a family member, a friend who witnessed the spells. I'm like, well, this kind of sounds like a non epileptic seizure and like who the heck is intubating these people. Uh So it's kind of interesting. There's, there's been some data uh looking at this over the years and, and there was a study looking at uh ems is ability and no, not against ems. I got a lot of stuff to deal with. But their accuracy in identifying epileptic versus non epileptic seizures was something around 46%. And then we also see data looking over about the last 10 to 20 years that shows the rate of intubation and this is just for epileptic seizures is increasing by about 20% in the emergency department. So we are seeing kind of this escalation of treatment on the emergency side of things specifically for, you know, epileptic and non epileptic types of spells. So, you know, that is obviously a safety issue and I've certainly had folks who I would follow in the clinic in the past who we found that most of the events they were having were nonepileptic seizures. And like, unless you've fallen and injured yourself or the, you know, the something's gone wrong where the person is not coming around appropriately afterwards, stay away from the emergency department because a lot of times they're not going to recognize these events and might treat, might treat it incorrectly. So that does happen. But to that point, I I've been very happy. Actually, in my current position, we do have emergency medicine residents who choose to rotate through. And I know one of the lectures I I like to do with them is just a series of videos. And the only question for each video is, is it an epileptic seizure or not? So I like to think that that helps a little bit in terms of kind of at least the next generation of physicians trying to further educate as far as that goes. And then in the past, I have done similar lectures for, for ems uh service lines as well. Where we kind of take some, take some videos and just review them uh for educational purposes to get people looking for certain signs so they can help differentiate, you know, what is the appropriate treatment for this person? So we can hopefully avoid uh any unnecessary treatments and reduce harm. Yeah, absolutely. And um, this is something that we, you know, we do hear about a lot unfortunately. And um, you know, I have to be, have to be careful, I talk so much with other people with FND and also with people who treat it that I have to be careful that I'm not disclosing certain, like private medical information, but suffice it to say that. Um, yeah, this is definitely something that comes up a lot and I think it's fair to say that if people with FND have experienced an unusually high amount of trauma as a group before getting FND, that, that is almost then inflicted again once they enter the medical system. Um, I know people who treat FND, who, when they first got into it, they were surprised to hear that, um, you know, at the first appointment with the patient, what they really needed to do was get through talking about the abuse and neglect and mistreatment that had happened to that patient post entering the medical system. You know, that, that was the sort of most acute stressor at, at that time. And that's certainly, that's certainly true for me, like I, in some ways I mentioned earlier, I'm lucky to have escaped the brunt of it. Um, but I've certainly, I've certainly gone through that and, um, you know, it's, it's really, really, really difficult is that stuff is, is hard to deal with because you are in such a vulnerable position as a, as a patient. And, um, that's actually something that informed my decision recently to, um, to actually always disclose an FND diagnosis when I go to a new doctor. Because for a long time, I had to do a lot of mental calculus on whether that would expose me to risk uh of harm, like physical harm or if it would just make the doctor say, you know, go away. Like, I don't really believe any symptoms you have. And uh at a certain point, I got confident enough with what I know about FND that I decided, like I'm gonna be the snowplow, you know, I'm going to go in and even if I'm just seeing the dermatologist, like I'm going to bring up FND on purpose because I want them to hear about it for the next person who comes along, you know, and um there's a lot of doctors who are welcoming and interested or, you know, or are just basically okay with it. And in the cases where they are skeptical or in some cases, sort of like outright scornful of the, of the label. Um, you know, I've sort of reached a point in my advocacy where I'm like, well, I mean, if you want to sit down and debate me about like the functions and connectivity of the anterior insula, we can do that like otherwise, right? Should probably take my word for it and take this seriously. Um But I mean, I recognize that most people are not in that position and I wasn't even in that position for most of the time that I've, that I've had this. Um And so for that reason, what I'd really love to see would be uh serious sort of systemic effort to undertake including FND education as part of the medical curriculum. Um because I think that, um for the most part, it can be really difficult to change institutions and even individual minds when they've sort of ascended the strata to a certain point. Um But, you know, but people who are just coming into medical school, like if you tell them, hey, there's this disorder of brain physiology that has to do with like agency and volition and embodiment and emotion and how you manage your body and interception. That stuff is really interesting and, and there's a really good research basis for it and, and they'll, you know, they totally, you know, they'll be interested. Um It's much harder I think in my experience to reach a skeptical doctor who has been in practice for 15 years and like, feels quite confident, you know, wrongly that like FND is not a thing. So. Right. And you know, I would say 15 years might be a little on the conservative side as well. But over the last few years, I've been trying to kind of re engage with the humanity side of things. And one of the phrases I've come across, you know, from Plato's apology is uh to paraphrase. You know, the only thing I know is that I know nothing. And so just being aware of my own ignorance and uh the way that we are continuing to further identify things in the way the brain functions I think is just one of the most humbling parts of practicing in this field. And so I don't, if there's something that comes up that I don't understand, it doesn't mean that doesn't exist, just means that we may not know what it is or how it works yet. Absolutely. And I mean, I, I love that mindset and I would love for um more neurologist to sort of embrace that ethos, you know, that would be, I think that's just such a, such a positive and healthy outlook. And, you know, I would love to see that spread. Yeah. Over the, over the years, I've tried to emphasize that a mindset to a lot of the med students and residents who have worked with me just to, you know, question everything, question yourself, question, question me. Don't trust me. Uh You have to make up your own mind uh, with respect to a lot of these things and, you know, just don't, don't act on the assumption that everything's been done correctly before you've assumed care of somebody that whole question everything. Trust. But verify, I think is a very good perspective to have, you know, in medicine and probably life at large. Yeah, absolutely. When you've been around FND long enough it starts to, um, I don't know how to phrase this Exactly, but it sort of dawned on me recently that these are like extremely powerful forces that we're, we're talking about, you know, where the sort of idiosyncrasies of FND, you know, that it can change with attention, um, that it can be shaped by prior experience and belief. Um I think in some ways some neurologists are inclined to look at that and say, well, it's kind of a silly thing, like if you can just change your mind about it, you know, can't be that serious. And it's like, well, first of all, you can't just change your mind out of FND, it doesn't really work like that. Um But I mean, more to the point, the only reason these things are possible is because we evolved them, right, like, out of, out of the, you know, our whole evolutionary lineage. And, um, you know, just making a sort of a guess on this one, I would have to guess that FND has been part of human experience for as long as we've had the sort of modern architecture and connectivity of the brain. I would think that makes sense to me. Yeah. And like, so, you know, it's when you're dealing with conditions like epilepsy or, you know, um or, or FND you're talking about something that far predates not only medicine but all of, all of human sciences. You know, you're, you're looking at something that to me is like a redwood tree or like a, you know, it's like a, like a great white shark or something that's just been around like all this time. And, um I really, I really uh feel the need to respect it on that basis, you know, because it's a, it's a sort of, it's evolved with the, the sort of core of what a human brain is and, and it's, it's very hard not to take that seriously when you, when you sort of check it out in perspective. Yeah. Anything that kind of goes back that far, you, you almost get this mythical character to it, you know, legends of the mind emerging. Um You know, kind of we wind up again with that kind of back to that dualism, you know, the ghost in the machine manifesting itself. And then in this case, maybe even causing changes to the machine. So we wind up with these phenomena that for hundreds thousands of years, we couldn't really explain why they were happening to a large extent and are only now starting to pull back the veil to a degree to understand them a little bit more from a more materialistic sense. Although I still feel like the metaphysical aspect is important. Yeah. And it can get kind of spooky, you know, sometimes like, it's a, it's, there's a weird kind of like, sort of poltergeist esque kind of quality to this disorder, you know, where? Um, I mean, I, I recall many times like that when I, when I would feel symptoms happen, for example, um I have a functional voice disorder as part of my symptom cluster and it's in remission now, um, as you can tell because you can hear me. Um, but, you know, that felt very much like my, my muscles inside my larynx sort of choking myself. You know, it felt like it felt like a foreign entity in my body doing this thing that I have, I can no longer directly sort of get my mental control over. Um And you do end up with these really sort of spooky phenomenon about like the components of the self. And, you know, like you said, all this different stuff, it does sort of enter this kind of like 90 mythical territory and, um I can see why it freaks doctors out to. Do you think, um, do you sort of see a path forward for, you know, working clinicians on this? Like, what do you think clinicians would need um from, from you, from your, you know, point of view um to have confidence in helping with this. Yeah. So I think we're starting to see some movement in that direction. I think with greater awareness of FND promoted by folks like yourself as well as a lot of good research being done out there in terms of the sort of different clinical uh phenotypes that we can see in practice as well as kind of what the risk factors are. So I think that's changed kind of like, well, we rule out all these other neurologic problems. Now we're left with functional neurologic disorder. I think we're able to use these clinical symptoms and signs and kind of move that higher up the list of possible diagnoses and come to a diagnosis faster, which may in turn, get people diagnosed sooner and you know, kind of prevent this diagnostic delay where we have people languishing in this unknown limbo for ages and ages and they're, they're at least, you know, again in functional seizures, there is data that shows the longer someone goes with without a confirmed diagnosis, the harder is for them to go into remission. And whether that is due to kind of the further in French Mint of those maladaptive pathways or if it's due to some other uh psycho social phenomena that we just haven't elucidated yet, I don't know, but I think that does certainly have a role to play. You know, you can get these traits ingrained into kind of that, that intraseptal theory of self model and that could of course cause some longstanding problems um in those circuitry. So I think that certainly plays a role. So I think making sure that people are well educated about what are the signs and symptoms. And then secondly, I shouldn't as a neurologist, be just washing my hands of these people and be working in tandem with someone if there's a co morbid mental health issues, uh things like that, working in tandem with the psychiatrist, psychologist, physical therapist, occupational therapist, etcetera, etcetera, you know, get the whole gamut for whatever the symptoms the person is having and working on a uh multidisciplinary plan to get these things together, which is of course, easier said than done in terms of, you know, kind of the amount of resources it may take and whether or not uh these things will be readily available in the community that the person is living in. So if it is one of those settings, then we wonder if you know, some sort of telemedicine type thing for some aspects of that care might be feasible, particularly if that increases access to two people in those disciplines who have more experience with different types of FND, then we could kind of expand that expertise to a wider number of people. Um Again, these are some things that I think have been trialed in different select settings. But uh I think it would be overall a good for a lot of these people and not just for FND, but for a lot of different neurologic disorders. Sure. Yeah, that makes a lot of sense to me to, um, you know, I've often wished for, um, some kind of a real like bootstraps kind of program. Like this is not a, this is not a great comparison, but I actually think, do you know about, like, the barefoot Doctors of China? I'm not familiar now. So this was like a Maoist initiative back in, I don't know, maybe the fifties or something sixties. Um And I mean, obviously I'm not like endorsing like authoritarian communism on this podcast. But um but this was, this was like one of the great public health stories of all time as far as I know. And basically what they did was they looked at the public health situation in China and they said, well, uh first off, it's really bad and the things that seem to be needed are actually pretty basic. Like there were people, you know, because it's such a massive country, there were people out in the country, you know, living on farms and so forth who had like zero access to medical care. And so they would die of things like infections, just routine stuff, right? And um so what they did was they spun up this um this sort of paramedical court um and train them in emergency medicine and, you know, field medicine essentially. And um and just rolled it out and just, just had it go sort of serve the community here there and everywhere and uh it resulted in an in credible increase in uh lifespan and like a whole bunch of measurable stuff. And um I sort of wonder if there needs to be some kind of an initiative like that for FND where it's like, maybe not necessarily like a massive public health works thing cause I know we're not going to get that. But like, is there some kind of way that we can sort of establish, like what is the basic standard of care? You know, what is, what is the baseline that we can offer and then roll it out as many places as possible. Um So that we sort of get people up to that just, you know, serviceable, not great but better than before level and, and then we can, you know, worry about scaling up to the, you know, vertiginous heights of the greatest academic medical centers and stuff like that. But you know, I mean, most people, like I get emails from people every week that are like, hey, there's like literally no doctor within 1000 miles of where I live that treats this condition. What should I do? And I don't know what to tell them. Um It's just a problem that needs to be solved, you know. Yeah. And you know, we, we are seeing a, just like in, in my field of neurology's in general, there is a shortage of neurologist and that's only uh by the most recent studies I've read expected to further increase. And I think it's similar amongst other specialties like psychiatry. So I know that we're looking down the barrel of a physician shortage just in general and you know, those gaps in care are obviously a big problem. And the further away from cities you get, the harder it is to find people who might have experience, particularly you start talking about, you know, rarer diseases or things that require more specialized treatment. So it definitely is a problem. And I wonder if uh you know, kind of like some of the academic centers are taking kind of a hub and spoke model with respect to rotating some of their subspecialists into more underserved areas and things of that nature. So I wonder if that might be something that could even be further extended with, with telemedicine. Um You know, we've seen a lot of that dynamic changing in the uh in the COVID era. So I wonder if that's something that would be feasible because, you know, we definitely do have that lack of experienced personnel to, to provide care, especially like you said, and people who are hundreds of miles away from the nearest center or experienced clinician. Yeah. Excuse me, I, I hope it's possible. Um I think it's more likely that things will work the way they usually do, which is you know, it propagates out from the major academic centers, other places sort of pick it up, you know, so almost stochastic Lee. Um, but, you know, again to sort of come back to something that we, we talked about towards the beginning, this is, uh, this is an area that has huge potential gain, you know, for a neurologist. Like, you know, if, if you're dissatisfied with the large proportion of patient's who are coming in whose symptoms are, you know, functional. Um, and if you'd like a better definition of that than, oh, it's all just stress, go see a psychiatrist. You know, we're, we're there now and there are things that you can do to help and, you know, even honestly, even just checking out a couple of the more recent, uh, review articles on Google scholar, like most of the stuff that comes up when you search for FND now, uh, on a scholarly basis is pretty reputable and, you know, you can grab those major review articles and, uh, and have much more to work with than you would have otherwise, I hope that people do. Yeah, I think that's exactly right there. There's definitely been some, some excellent articles written in recent years, even just in the last couple of months. And, uh, you know, in the lead up to the Functional Neurologic Disorder Society meeting, there's also been some, uh, excellent podcast being put out from them as well, which have been just excellent, uh, Doctor Alan Carson interviewing a lot of kind of luminaries in the FND research field. And, you know, I could just listen to that calming Scottish accent uh indefinitely. So those have been a great resource also on my long commutes. But to your point, you know, it really is important for clinicians of all stripes to really, you know, stay up on the literature. And this, this is an area that has been changing uh pretty rapidly over the last, you know, 20 years or so. And uh it's funny, one of my colleagues at work, he says that uh any neurologist who doesn't keep up on the literature has a shelf life of about 10 years before they are out of date and their practice is archaic. So I, I do kind of subscribe to that uh that thought that it is important to keep up to date and make sure that you're providing the most up to date and best care that you can. Sure. But I mean, I'm sure that that um that adds another dimension to your practice, right? Like I'm sure that, you know, you'll, you'll really benefit from that as a clinician. And so will your patient's? Yeah, because I know, I think back to when I was a trainee and you know what, I would encounter a patient with a functional urologic disorder, I would be frustrated because I'm like, you know, the traditional deny, this isn't a neurologic problem. And as I've learned more and more you learn more like, well, yeah, there are these abnormal connections, these abnormal circuits and you wind up like diving into these kind of really basic neuroscience concepts. Like what itself, where does our perception of our ourselves come from? How is that related to the clinical scenario playing out in front of my eyes? It's kind of brought some of that basic sciences back into my clinical practice in terms of the things that I need to think about and learn about, that's really cool. And, you know, I, I have to say that I didn't expect in learning about this disorder to find that, you know, that I would, I would also be re examining these sort of basic assumptions that I didn't even know I had about how, you know, what does it mean to have a mind and stuff like that? And, um, you know, FND has a really reorienting effect in that way. And um FND the disorder is terrible, but it also kind of shows you some of that scaffolding of, you know, embodiment and consciousness uh in a way that can actually be beautiful at certain moments. And I hope that that's something people can see as well. I hope so. Uh This has certainly been a very interesting conversation, very illuminating on a number of aspects of FND. And thank you again for taking the time to talk with me at such a length today. Uh if folks want to learn more or find you online, where should they be looking? Uh Thank you. I mean, so, first of all, thank you so much for having me. I also really enjoyed this and, and really appreciate you uh taking an interest in this disorder. Um So again, I'm a pseudonymous person with FND I go by FND portal online. And um my website is FND portal dot org and I'm more active on Twitter at the handle at FND portal. And thank you again so much. It was a fascinating conversation. It was a pleasure. Thank you. Also to our listeners. If you enjoyed this podcast, please leave a five star review on Apple itunes, Spotify or wherever you're getting your podcast and please don't forget to share and subscribe for future episodes. You can reach me on Twitter as well at Dr Ken Trees. That's Drkentris or by email at the Neuro transmitters podcast at gmail dot com.