Functional neurological symptoms — OSCE: diagnosis conversation and coordinated plan

Candidate brief

You are the general paediatrician. Mia is a 14-year-old referred for three weeks of a fluctuating abnormal gait after a minor ankle twist. Examination shows internally inconsistent weakness with a positive Hoover sign, non-dermatomal sensory loss split at the midline, and a gait that improves with distraction. MRI brain and spine are normal. She has missed two weeks of school and is increasingly withdrawn. Her parent is frightened, convinced "something has been missed", and is asking for more scans. [1]

You have eight minutes for Station A (the diagnosis conversation) and eight minutes for Station B (the coordinated plan). [1]

Station A — The diagnosis conversation

Task. Explain the diagnosis to Mia and her parent in a validating, stigma-reducing way, respond to their request for more scans, and establish a shared understanding that enables rehabilitation. [2] [13]

Marking domains. [2] [13]

• Information giving (3). Names the diagnosis explicitly as functional neurological disorder; states the symptoms are real and involuntary; explains that the nervous system is structurally intact and that the brain–body signals are disrupted; offers a hopeful, recovery-oriented message. [2] [13]
• Language (2). Uses validating terms; avoids "medically unexplained", "all in your head", "fake", "psychosomatic", "attention-seeking". [13]
• Responding to scan requests (2). Acknowledges the fear; explains that further imaging without new red flags perpetuates harm; agrees a clear investigation stop-point; does not dismiss the family. [2]
• Shared decision and alliance (3). Checks understanding; invites questions; agrees next steps; does not promise to "find the cause"; sets up the rehabilitation plan. [2]

Examiner prompt if the candidate falters. "The parent asks: 'So you're saying it's all in her mind?'" [13]

Strong response. "No — these symptoms are real and not in any way put on. The signals between Mia's brain and body have become disrupted, even though the structure of her nervous system is intact. This is a recognised condition called functional neurological disorder. It is common, it is not her fault, and it improves with the right rehabilitation." [2] [13]

Station B — The coordinated plan

Task. Formulate and communicate a single, coordinated, multidisciplinary plan with a named coordinator, a graded school-return strategy, and a relapse safety-net. [3] [9]

Marking domains. [3] [9]

• Coordinator and shared plan (3). Names the general paediatrician as coordinator; commits to a single written plan shared with neurology, physiotherapy, psychology, the school and the family; delivers one consistent message. [3] [9]
• First-line treatment (3). Physiotherapy-led functional rehabilitation for the motor symptoms; psychological support for mood/sleep/stress; treats comorbid pain without opioids; states clearly that no drug treats FND itself. [5]
• School and function (2). Negotiates a graded, structured return to school with a modified timetable and a written relapse strategy so a bad week does not collapse the plan. [9]
• Follow-up and safety-net (2). Reviews in two to four weeks; normalises relapse; gives a clear contact and a safety-net for new red flags (progressive signs, self-harm, safeguarding). [9]

Examiner prompt if the candidate falters. "What if she gets worse again in a month?" [9]

Strong response. "Relapse is common and not a failure. We re-engage early with the same plan and coordinator rather than starting a new investigation cycle. If new red flags appear — progressive focal signs, self-harm, or a safeguarding concern — I reassess for a different cause. Otherwise we hold the plan, adjust the rehabilitation, and keep her in school." [3] [9]