Topical Review
Functional Neurological Disorder
A Common and Treatable Stroke Mimic
Stoyan Popkirov , MD; Jon Stone, PhD; Alastair M. Buchan, DSc
T he hyperacute clinical diagnosis of stroke remains a
major challenge, as 1 in 4 suspected cases turns out to
be a stroke mimic.1 In large registries, among patients who
are treated with intravenous thrombolysis, the upward-trend-
ing rate of misdiagnosis is 3.5% to 4.1%.2,3 Considering the
safety of thrombolysis in stroke mimics (complication rate:
1.5%)3 and its potential benefit in acute ischemic stroke,
it seems permissible to err on the side of overtreatment.
As strategies to reduce the door-to-needle time are being
implemented, the rate of thrombolysis of stroke mimics has
increased noticeably.3–5 This problem will not be overcome
by optimizing clinical pathways or emerging technologies
but by focusing on clinical skills.
A common type of stroke mimic is functional neurological
disorder presenting with limb weakness, numbness, or speech
disturbances (previously known as psychogenic or conversion
disorder).1 Two recent studies from large centers in London,
United Kingdom, and Doha, Qatar, demonstrate rates of func-
tional stroke mimics of 8%.6,7 Functional stroke mimics are
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often considered elusive, since they have traditionally been
seen as diagnoses of exclusion, characterized by psychiatric
comorbidities such as anxiety, neuroticism, or traumatization.
However, the diagnostic criteria for functional neurological
disorder have fundamentally changed with the last revision
of the Diagnostic and Statistical Manual of Mental Disorders,
replacing what was a principle of exclusion with a phenotype-
based diagnosis supported by specific clinical signs that dem-
onstrate inconsistency, reversibility, and top-down modulation
of symptoms.8 As the utility of examination techniques and
clinical signs to identify functional weakness, numbness, and
speech disorders are increasingly established, it is now timely
to provide a state-of-the-art review, tailored to the needs of the
clinician working in acute stroke care.
Functional Limb Weakness
and Sensory Deficits
Presentations with limb weakness and sensory disturbances
comprise about 70% of all functional stroke mimics.1 Like
Received January 14, 2020; final revision received March 4, 2020; accepted March 13, 2020.
From the Department of Neurology, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Germany (S.P.);
Wissenschaftskolleg zu Berlin–Institute for Advanced Study, Germany (S.P., A.M.B.); Centre for Clinical Brain Sciences, University of Edinburgh,
Royal Infirmary of Edinburgh, United Kingdom (J.S.); and Acute Stroke Programme, Radcliffe Department of Medicine, University of Oxford, United
Kingdom (A.M.B.).
Correspondence to Stoyan Popkirov, MD, Universitätsklinikum Knappschaftskrankenhaus Bochum, In der Schornau 23-25, 44892 Bochum, Germany.
Email popkirov@gmail.com
(Stroke. 2020;51:1629-1635. DOI: 10.1161/STROKEAHA.120.029076.)
© 2020 American Heart Association, Inc.
Stroke is available at https://www.ahajournals.org/journal/str
1629
stroke syndromes, functional motor and sensory deficits are
typically lateralized, often as hemiparesis.9–11 Between-group
differences in demographic characteristics can be found in
large studies but cannot differentiate between etiologies at the
individual patient level. On the contrary, stereotypical biases
based on sex, age, or social background are typical pitfalls
for misdiagnosis. Similarly, the medical history regarding the
acute problem or comorbidities is unlikely to help with ascer-
taining the diagnosis. For example, although panic accompa-
nies acute-onset functional paresis in 59% of cases and could
be taken as a red flag for a functional disorder,12 it is also re-
ported at symptom onset by 64% of patients with stroke.13
Similarly, migraine or peripheral injury are common precipi-
tants of acute-onset functional limb weakness12 but are also
found in acute ischemic stroke.14,15
Clinical features such as anxiety and age will inevitably
alter pretest probability of stroke, but ultimately the diagnosis
of functional motor or sensory symptoms relies primarily
on characteristic clinical signs. A large variety of examina-
tion techniques and signs that aim to differentiate functional
from pathophysiological weakness and numbness have been
described since early work on "hysteria." Those signs are
passed on through clinical mentoring and are dutifully collated
in literature reviews, but only a few of them are sufficiently
specific and reliable to contribute to the differential diagnosis
(Table 1). Many signs are not proven to be helpful (or are
proven to be unhelpful) and should thus be explicitly discour-
aged for emergency decision-making, as they lead to misdiag-
nosis (Table 2).
In functional limb weakness, the patient’s motor deficit is
chiefly determined by an abnormal (computational) prediction
of weakness that can be encoded at various levels of the motor
control pathway.19 The presentation is thus determined by
attention and expectation, with voluntary movements affected
more so than automatic ones. Most bedside tests aim to tease
out this difference and demonstrate the inconsistency between
voluntary and involuntary movements. However, in stroke-
related paresis, movement can also be modulated by attention
or emotion, harboring the potential for false positives. It is
DOI: 10.1161/STROKEAHA.120.029076
 1630  Stroke  May 2020

Table 1. Examination Techniques for the Diagnosis of Functional Stroke Mimics With Motor Symptoms

Sign Description Comment PPV*

Hoover's sign Hip flexion and extension testing reveals
inconsistency in attended vs unattended
movement in affected leg
Hip abductor sign Hip abduction testing reveals inconsistency in
attended vs unattended movement in affected
and unaffected leg
Drift without pronation The affected arm drifts downward without
pronation
Unilateral facial lip pulling/platysma Functional facial spasm or dystonia typically
contraction/jaw deviation presents with contraction of platysma, which
may pull the lip down or the jaw to one side
Give-way weakness Sudden loss of tone or strength during strength
(collapsing weakness) testing
Global or inverse pyramidal pattern of Weakness of upper limb with extensors weaker
weakness than flexors and vice versa in lower limbs
NA indicates not available; and PPV, positive predictive value.
*PPV to be interpreted with caution; based on studies from various settings.
Data derived from Stone and Aybek.16
False positive in patients with supplementary 67%–100%
motor area or parietal lobe strokes possible
Limited evidence for utility in clinical 100%
practice
Only testable in mild-to-moderate upper 93%–100%
limb weakness
May be accompanied by orbicularis oculis NA
activity and ipsilateral convergent spasm,
which can mimic a sixth nerve palsy
False positive in patients with joint/limb pain 60%–100%
or when instructions are unclear
No formal studies but good evidence that NA
such a pattern is not found in structural
disorders causing limb weakness

thus advisable to seek confirmation from several clearly posi-
tive signs before reaching a final diagnosis.
Give-way weakness describes the sudden loss of tone or
strength during isometric muscle strength testing. It has good
interrater reliability, as well as excellent specificity and pos-
itive predictive value for functional limb weakness.16,18 In
patients with leg weakness, it can manifest during gait assess-
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A pattern of global or inverse pyramidal weakness is com-
mon in functional limb weakness instead of the usual pattern
of stronger flexors in the arms and extensors in the legs. In
studies of patients with a variety of upper and generalized
lower motor neuron weakness (eg, Guillain-Barré syndrome),
this pattern is consistently found. Achieving global or inverse
pyramidal weakness requires a process that preferentially

ment as knee buckling. An important caveat is that it can occur affects the strongest voluntary muscles, in keeping with a dis-
due to joint or limb pain, especially in patients with preexisting order of willed movement.
conditions. Moreover, patients might want to help out during For functional leg weakness, Hoover's sign has the best
assessment or demonstrate their symptom to the examiner. clinical utility.16 It can be conducted when the patient is
seated or lying down (Figure) and reveals a normalization of
Table 2. Examination Techniques Not Suited for Acute Stroke Workup hip extension on the weak side during hip flexion of the non-
Due to Insufficient Specificity, Reliability, Evidence or Practicability (See paretic lower limb. In a prospective study of 124 patients
References16–18 for Descriptions) with suspected stroke and leg weakness, Hoover's sign was
Abduction finger sign positive in 5 of 8 functional stroke mimics and in none of
the definite stroke cases, yielding a sensitivity of 63% (CI,
Arm drop test
24%–91%) and specificity of 100% (CI, 97%–100%).20 The
Atypical distribution of weakness positive predictive value was 100% (CI, 46%–100%); the
Thigh trunk test negative predictive value was 99% (CI, 96%–100%). This
prospective study found no false positives, but those defi-
Bowlus-Currier test
nitely occur in acute stroke, particularly in supplementary
Co-contraction sign motor area lesions,21,22 or in cases of so-called pseudopare-
Forced choice/systematic failure sis due to parietal lobe lesions.23
La belle indifférence The hip abductor sign is similar to Hoover's sign and
describes weakness of voluntary hip abduction, which returns,
Midline splitting of sensory loss
through automatic movements, to normal during contralateral
Monrad-Krohn test hip abduction against resistance24 (Figure). In a study of 33
Non digiti quinti sign patients with lateralized leg weakness (16 functional and 17
organic, of whom 8 with stroke), this sign achieved 100% sen-
Nonanatomic distribution of sensory symptoms
sitivity and specificity.24
Pseudo-waxy flexibility Downward drift with pronation indicates cortical weak-
Sensitivity to suggestion ness. Drift without pronation is a typical finding in patients
Splitting of vibration sense with functional arm weakness (Figure). In a study of 26
patients with functional arm weakness and 28 controls with
Sternocleidomastoid test
organic paresis (23 due to stroke), drift without pronation
 Popkirov et al   Functional Neurological Disorder Mimicking Stroke   1631
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Figure. Positive clinical signs of functional neurological disorder. A, Hoover's sign: right hip extension is weak but normalizes during contralateral flexion
(gray and white arrows indicate examiner’s and patient’s active movements, respectively; striped arrows indicate patient’s automatically/involuntarily gener-
ated movement in the affected limb). B, Hip abductor sign: right hip abduction is weak but normalizes during contralateral abduction (arrows same as above).
C, Drift without pronation in functional arm weakness, with pronation in stroke. D, Unilateral lip pulling with ipsilateral platysma contraction in functional facial
dystonia. With permission from the person pictured.

identified functional arm weakness with a sensitivity of 100%
(CI, 84%–100%) and a specificity of 93% (CI, 76%–98%).25
Functional motor disorders of the face are generally easy
to distinguish from facial symptoms of stroke. The unilat-
eral lip-pulling sign (Figure) reveals a characteristic func-
tional dystonic movement disorder of the face that may give
a superficial appearance of weakness but is actually caused
by overactivity, typically of platysma or the muscles of jaw
deviation.26 Ipsilateral orbicularis oculis contraction may be
an accompanying feature. Other facial or axial signs include
the trunk-thigh test,27 which has a low interrater reliability,18
and the wrong-way tongue deviation away from paretic side28
(toward hemiparesis in most strokes29), which remains to be
evaluated systematically and can be false positive in medullary
infarctions.30 The proposed sternocleidomastoid muscle test, in
which head rotation is more likely to be weak toward the side
of hemiparesis in patients with functional paresis,31 is prob-
lematic as it is documented as a common finding in stroke.32,33
In most cases, functional limb weakness is accompanied
by sensory deficits. However, sensory testing in general has
low interrater reliability,34,35 and most diagnostic signs that
have been suggested for identifying functional sensory distur-
bance do not have the required specificity. For example, non-
anatomic distributions of acute sensory symptoms, such as a
glove-like distribution, are found in patients with distal arm
paresis due to cortical stroke.36 Another proposed feature of
functional hemisensory disturbance is so-called midline split-
ting. Since cutaneous nerves of the trunk typically overlap
a couple of centimeters at the midline, an exact splitting of
deficits is often attributed to a functional disorder. However,
midline splitting can be found in patients with clear organic
causes of sensory loss,37–39 particularly in pure sensory stroke,
which can remain magnetic resonance imaging (MRI) neg-
ative.40 Other proposed signs for functional sensory symp-
toms, such as splitting of vibration sense (vibration is felt less
on the numb side of the forehead or sternum despite intact
bone conduction), similarly lack specificity for use in stroke
workup.38,39 It should be noted that these clinical signs may
show better specificity when combined with the above men-
tioned motor signs.16
 1632  Stroke  May 2020
In conclusion, clear positive signs of inconsistency of
deficits should support the diagnosis of functional neurolog-
ical disorder. Diagnosis based solely on psychosocial factors,
psychiatric comorbidity, or negative imaging is not clinically
indicated and a common source of error in the diagnosis of
functional neurological disorder.41 Even minor symptoms that
indicate acute cerebrovascular pathology, such as clear upper
motor neuron facial weakness,21 should discourage acute diag-
nosis of a functional disorder.
Functional Speech and Language Disorders
An acute isolated voice (phonation) disorder would be a rare
stroke presentation, although partial vocal cord paralysis can
often accompany other deficits. Functional aphonia or dys-
phonia can usually be diagnosed by demonstrating normal
sound production on prompted coughing or throat clearing or
other signs of inconsistency of presentation.
One of the commonest kinds of functional speech dis-
order is stuttering.42 It can accompany functional movement
disorders43 and dissociative (nonepileptic) seizuires44 or occur
in isolation. The following features can help to distinguish it
from (rare45) acute stroke-related neurogenic stuttering: exces-
sive variability of presentation; excessive consistency (stut-
tering on every syllable/word); struggling behaviors such as
grimacing and neck extension (though articulatory groping
can accompany apraxia of speech); absence of accompany-
ing dysarthria, aphasia, or apraxia of speech; agrammatic or
telegraphic speech without aphasia.42 One of the most reliable
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distinguishing features of functional stuttering is its quick and
complete response to therapy, though that will not be available
in the emergency setting.
Dysarthria (difficulty with articulation) is a common
symptom of stroke but occurs in isolation in only 1.3% to
2.8% of cases.46,47 In cases of moderate-to-severe isolated
dysarthria, the patient will always report some degree of dys-
phagia as well, since the motor components of speaking and
swallowing overlap. In functional dysarthria, patients might
complain of a globus sensation but will rarely have any other
swallowing difficulties. Functional dysarthria is only rarely an
isolated presenting symptom, so diagnosis can usually be de-
termined by its variability and by close examination of accom-
panying symptoms.
An inability to produce language, aphasia, is another com-
mon presenting sign of stroke, usually in the context of clearly
identifiable anterior circulation stroke syndromes. When
aphasia presents without limb motor deficits, additional signs
such as facial weakness, hemianopia, or sensory disturbance
are usually found.48 Truly isolated aphasia accounts for only
3% of acute stroke presentations and has an 86% likelihood
of being a stroke mimic.49 Functional aphasia is also rare and
usually presents as nonfluent aphasia with preserved compre-
hension and naming.50 Its agrammatism can sound like broken
English or baby talk ("me sleepy"), compared with Broca tele-
graphic speech ("I sleepy"), and speech patterns are generally
more inconsistent than in stroke aphasia. There is some evi-
dence that a proportion of patients with foreign accent syn-
drome have a primary functional neurological disorder.51
Neuroimaging
Although advanced structural and functional neuroimaging
techniques can detect subtle statistical alterations in groups of
patients with functional neurological disorder compared with
controls,52 routine imaging cannot at present establish (or dis-
prove) the diagnosis. When clinical assessment strongly sug-
gests a functional stroke mimic, the role of neuroimaging is
to detect concomitant (cerebrovascular) pathology. Normal
scans can only serve as evidence against acute ischemia when
there is a clear incongruence between imaging features and
observed symptoms. Since lacunar strokes can remain unde-
tected in all available imaging modalities, incongruous find-
ings can only relate to presentations that suggest nonlacunar
(ie, territorial) infarcts. Examples of such findings would be
lack of early ischemia signs in late presentations, normal MRI
in someone with a dense hemiparesis, and lack of dense ar-
tery sign or conjugated eye deviation on computed tomog-
raphy when large vessel occlusion is suggested clinically.53,54
Perfusion computed tomographic imaging can visualize
territorial ischemia in cases when nonenhanced computed
tomography is normal, but false negative findings are not un-
common. Atypical perfusion changes can reveal other stroke
mimics such as focal epileptic seizures.55
If available, emergency MRI with diffusion-weighted im-
aging (DWI) can be used to visualize ischemic brain damage.
However, according to a recent meta-analysis, about 7% of
acute ischemic stroke cases have no detectable DWI lesions.56
In a study of 701 acute ischemic stroke cases who had under-
gone acute MRI, 31 had no DWI lesion, and 6 (19%) of those
were retrospectively determined to have had functional symp-
toms.57 True DWI-negative stroke cases all corresponded to la-
cunar or posterior circulation stroke syndromes such as ataxic
hemiparesis or isolated internuclear ophthalmoplegia.57 Thus,
a DWI-negative stroke that does not correspond to a known
stroke syndrome58 should prompt specific reexamination re-
garding functional neurological deficits.
In summary, neuroimaging can only support but not prove
the diagnosis of functional neurological disorder, and it can
detect an acute infarction but cannot exclude it with absolute
certainty. Although it cannot thus establish the diagnosis of a
functional stroke mimic on its own, it can tip the scales suffi-
ciently to guide treatment.
Deciding on a Diagnosis
The diagnostic decision of acute-onset functional neurolog-
ical disorder versus imaging-negative/atypical stroke has to be
reached as quickly as possible. While the above mentioned ex-
amination techniques can be incorporated into the neurolog-
ical examination without significant delay, further information
from collateral history or short-term observation might not be
available acutely, leading to variable levels of diagnostic con-
fidence at the end of the emergency workup.11 Considering
the proven safety of thrombolysis for stroke mimics, only a
high level of certainty regarding the phenotype-based diag-
nosis of a functional stroke mimic, supported by positive clin-
ical signs and normal neuroimaging, can justify withholding
acute stroke treatment, that is, thrombolysis. In all other cases,
the possibility of a functional disorder can be communicated
 Popkirov et al   Functional Neurological Disorder Mimicking Stroke   1633
early on, but a competing suspicion of acute ischemia should
prompt stroke treatment algorithms in consideration of the
short therapeutic windows. Follow-up examinations will usu-
ally settle the final diagnosis. Studies of functional motor dis-
order including stroke-like presentations suggest a low rate of
misdiagnosis (<1%) at follow-up,59–61 although more studies
from a hyperacute setting are required.
Management
Treatment begins with an open and clear communication of
the problem (Table 3).62 A simple explanation of the disorder
can be offered, making clear that the loss of motor control or
sensation results from abnormal brain functioning rather than
structural damage (software, not hardware); as such, it is po-
tentially reversible through appropriate therapy. It is important
to keep in mind that a functional neurological disorder is just as
real, worrisome, and disabling as stroke can be. Terms such as
hysteria, psychogenic, and conversion imply an unproven path-
ogenesis and are likely to offend.63 Psychological risk factors,
when present, should not be ignored but are best addressed later
in treatment once patients have a secure understanding of their
condition. This is similar to addressing smoking or lifestyle
issues in relation to ischemic stroke later as part of rehabilita-
tion. If patients have been managed under the working diag-
nosis of stroke to date, the distinction should be made clear, as
Table 3. Principles of Treatment for Functional Neurological Disorder
Presenting to the Stroke Service
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Positive clinical diagnosis and communication
 Make a diagnosis based on positive diagnostic features, not on normal
investigations
 Explain diagnosis clearly, preferably demonstrating positive features
 Provide accessible material to allow the patient to understand the diagnosis
Physiotherapy
 Link principles of physiotherapy to ideas of brain retraining: promotion
of normal automatic movements and suppression of abnormal voluntary
movement
 Emphasis on goal-directed task-specific movement, eg, kick a football,
rather than specific limb movements
 Use of full-length mirror or video for visual feedback
Psychological therapy
 Assessment/formulation of potential predisposing, precipitating, and
perpetuating factors
 Treatment of comorbid anxiety, depression, and other psychiatric
disorders
 Retraining of aberrant cognitions and behaviors in relation to movement
Occupational therapy
 Careful use of aids and appliances, only as short-term solutions;
requires planning to stop using
 Focus on goal-directed activities, which may often involve overcoming
fear avoidance
Speech and language therapy
 Identification and promotion of normal automatic sounds and
identification of aberrant involuntary speech sounds
well as the fact that the diagnosis is based not just on normal
imaging but primarily on specific clinical signs. There may be
particular value in showing patients the positive clinical signs
that establish the diagnosis: it emphasizes that the diagnosis is
not reached by exclusion and reveals the nature of the problem
(a deficit of voluntary but not automatic movement), as well as
the potential for improvement.64 Provision of information, for
example, from websites such as www.neurosymptoms.org or
patient organizations such as www.fndhope.org may be helpful
but should not be regarded as a substitute for treatment.
As the patient achieves a degree of confidence in the di-
agnosis, treatment is more likely to be helpful. Patients with
functional limb weakness have been shown to benefit from
specialized physiotherapy that relies on retraining movement
emphasizing the promotion of automatic movements with
diverted attention.65 A feasibility trial of this approach com-
pared to a standard neurophysiotherapy showed high rates of
improvement,66 and a multicenter randomized controlled trial
of specialized physiotherapy for functional motor disorder is
currently underway.67 Importantly, physiotherapy is different
than that for stroke. Techniques that focus attention on the im-
pairment, such as strengthening or balancing exercises, are un-
likely to help, and walking aids should be avoided. Instead,
normalization of movement is aimed for through distraction
techniques and task-oriented exercises.65 Functional dysarthria
or aphasia responds well to specialized speech therapy.42 Stroke
clinicians are well suited to manage acute multidisciplinary
treatments and initiate appropriate long-term rehabilitation.
If acute psychiatric symptoms such as severe anxiety or
suicidality are present, (neuro)psychiatric assessment is nec-
essary. Some patients with functional disorders will benefit
from psychotherapy, exploring how risk factors may have
contributed to vulnerability and perpetuation of symptoms,
but clinicians should avoid the idea that all patients need or
benefit from such treatment, and it is typically best delivered
after some improvement in motor function has occurred. As
with stroke, successful treatment of functional neurological
disorder is a multidisciplinary endeavor, which may include
occupational68 and speech therapy42 in addition to modali-
ties already mentioned. It should be stressed that functional
motor and sensory symptoms have a prognosis comparable to
that of neurological control cases, with about half of patients
showing no improvement in the long term.59 The associated
disability should not be underestimated, and the rate of spon-
taneous remissions should not be overestimated.
Acknowledgments
We thank Dr Natalie Zadrozny for assistance with the Figure.
Disclosures
Dr Popkirov received a speaker’s honorarium (Novartis). Dr Stone is
supported by an National Health Service (NHS) National Research
Scotland Career Fellowship and reports independent expert testi-
mony work for personal injury and medical negligence claims, royal-
ties from UpToDate for articles on functional neurological disorder,
and runs a free nonprofit self-help website, www.neurosymptoms.
org. A.M. Buchan is a cofounder of Brainomix, which is developing
eASPECTS.
 1634  Stroke  May 2020
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Key Words: conversion disorder ◼ diagnosis ◼ functional neurological
disorder ◼ imaging ◼ psychogenic ◼ stroke mimic