The Spiral – when the search becomes a burden

At the beginning stands a question: where do the symptoms come from? Examinations, appointments and waiting times follow – and at the end often a sentence that stays: “We can’t find anything.” For many people with Functional Neurological Disorders (FND), this sentence is not the end of the search, but its beginning.

When “nothing” becomes a burden

When no cause is named, the feeling easily remains of not being taken seriously. This is deeply understandable: you feel the symptoms every day – and yet hear that it is “nothing”. Out of this hurt, over time, often comes disappointment, and out of disappointment can come bitterness. A thought sets in: there must be something – I just have to let them search long enough.

The fallacy: “only what is found is real”

At the core of this spiral lies a conviction that hardly anyone says openly, but that has enormous power: “My symptoms are only real once a physical damage can finally be demonstrated.” Out of this assumption, the search for a structural cause entrenches itself – because a finding promises what one needs most: confirmation that everything is real and that one has not imagined it.

The fallacy lies in the equation itself. In FND there is no damage, but a disturbance in the interplay of control and perception – the symptoms are therefore real, but not measurable as structural damage.⁵ “Real” and “demonstrable” come apart here. Whoever keeps hunting for damage is searching for something that does not exist in this form – and in doing so overlooks what really helps. Why “real” does not mean “demonstrable” is explored in the article “Body and mind”.

How the spiral turns

From then on, much revolves only around the next finding. One more referral, one more scan, one more test – in the hope that finally something becomes visible. But the longer the search lasts, the greater the exhaustion and frustration become. Repeated, normal examinations rarely bring reassurance; they can even intensify the worry and narrow the gaze ever more onto the body. The spiral holds one captive: it costs energy, time and confidence without coming any closer to an answer.

Empathising is not the same as agreeing

This spiral does not end at the examination table – it continues as soon as others react to what has been experienced. The first, understandable reaction is often compassion: encouragement, the feeling of finally being understood. This is important and right – no one should be left alone with the feeling of having been overlooked.

Here a fine but decisive distinction is worthwhile – between empathy and confirming the content. Empathy means perceiving and acknowledging a person’s feelings: the exhaustion, the fear, the hurt. In psychotherapy this is called validation. Decisive – as dialectical behaviour therapy teaches – is that validation refers to the feeling, not to every belief connected with it: one honours the experience, not automatically its interpretation.⁶ One can therefore fully empathise – “I understand how wearing and unjust this feels” – without reinforcing the assumption that an overlooked damage must still be found. Exactly here empathy (which is directed at the person) and agreeing (which is directed at an interpretation that can hold one captive) part ways.

How well-meant confirmation becomes bitterness

At the beginning stands a genuine experience of injustice: one is not taken seriously, feels rejected. The lasting reaction to this has a name and is well researched – bitterness (the psychiatrist Michael Linden described it as “post-traumatic embitterment disorder”). Bitterness is a persistent emotional state that arises from experienced injustice, humiliation or breach of trust – and, unlike passing anger, it does not disappear on its own.⁸ That is exactly what makes it so tenacious:

Those affected are “trapped in a vicious circle of strong negative emotions that continually reinforce one another”.— on the self-reinforcing course of bitterness (after M. Linden)

Now precisely what is meant to help can bring about the opposite. If the hurt is talked through again and again and the content is thereby confirmed – the assumption that something must still be found – a pattern arises that psychology calls co-rumination: the “excessive, repeated discussion of problems with a strong focus on the negative feelings”.⁷ The insidious thing about it is a paradox:

Co-rumination strengthens connection – and at the same time makes one more susceptible to inner distress: closeness and risk lie close together here.— in the sense of A. Rose (2002)

Thus the circle closes. The experience of injustice is reinforced instead of placed in context, the basic assumption “only real if something is found” entrenches itself – and the bitterness settles in. Research on chronic illness points in the same direction: a strong, repeatedly ruminated sense of injustice goes together with more pain, anger and depressive symptoms.⁹ This is not a reproach to those affected – on the contrary: it is a deeply human reflex of comfort that simply does not carry further at this particular point.

What the new guidelines say

The understanding of FND has changed – and with it the diagnostics. The current DGN guideline (2026) understands functional movement disorders as an independent condition that is recognised by positive clinical signs, not by the absence of other findings.¹² The classification ICD-11 (6B60) has also dropped the old assumption of a psychological cause.⁴ In short: a robust diagnosis arises from evidence – not from the search for a gap. In more detail, see the article “The new guideline 2026”.

The diagnosis as a turning point

A well-communicated, positive diagnosis is more than a label – it is the first step of treatment. When those affected understand what FND is and why the symptoms are real, the search for the “missing finding” loses its urgency. Experts therefore describe the neurological examination and the understandable explanation as themselves part of the therapy.³ It is not the diagnosis that is missing – what is often missing is an understanding that takes the symptoms seriously and places them correctly. How FND is diagnosed positively – by typical signs – is explained in the article “Causes & diagnosis”. And how FND can develop over time is under “Prognosis in FND”.

Why connection leads out of the spiral

The way out of the spiral is rarely the next appointment alone. What helps is: being taken seriously, finding reliable information and meeting people who have experienced the same. Exactly here lies the opportunity of connection – when it brings both together: the compassion that breaks through the isolation in which bitterness grows, and the factual level that shows that FND is recognisable, explainable and treatable. Connection brings those affected, their families and professionals together and makes visible where there are points of contact that know FND. Knowledge and exchange take the spiral’s power away.

Sources

1. Deutsche Gesellschaft für Neurologie (DGN). S2k guideline “Functional Movement Disorders”, 2026 (AWMF register 030/148).
2. Aybek S, Perez DL. Diagnosis and management of functional neurological disorder. BMJ. 2022;376:o64. PMID 35074803.
3. Stone J. Functional neurological disorders: the neurological assessment as treatment. Practical Neurology. 2016. PMID 26715762.
4. World Health Organization (WHO). ICD-11, 6B60 Dissociative neurological symptom disorder.
5. Prof. Jon Stone et al. Patient information on FND. neurosymptoms.org.
6. On the concept of validation (honouring the feeling, not necessarily confirming the interpretation): dialectical behaviour therapy after M. M. Linehan; experimental review on validation/invalidation of emotions.
7. Rose AJ. Co-rumination in the friendships of girls and boys. Child Development. 2002;73(6):1830–1843. PMID 12487497.
8. Linden M. Posttraumatic embitterment disorder. Psychotherapy and Psychosomatics. 2003;72(4):195–202. PMID 12792124.
9. Sullivan MJL, Adams H, Horan S, et al. The role of perceived injustice in the experience of chronic pain and disability. J Occup Rehabil. 2008;18(3):249–261. PMID 18536983.

This article serves general education and does not replace medical advice, diagnosis or treatment. It does not judge individual persons, groups or their decisions.

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