Jon Stone has written an excellent response to Scamvougeras and Castle’s argument that FND is fundamentally psychiatric. I agree with all of it. The neurology vs psychiatry framing itself gets in the way of understanding patients and providing effective care. The patients I evaluate and treat vary considerably. Some have relatively straightforward presentations, with habitual, involuntary movement patterns that respond very well to sensorimotor retraining. Others have no diagnosable psychiatric condition, but psychosocial factors such as fear, shame, cognitive rigidity, etc appear to contribute substantially to symptom onset and persistence. Others have multiple psychiatric comorbidities, and psychiatric or psychological treatment is central to their progress. Across these presentations, I find coordinated multidisciplinary care most useful, with the balance of treatment reflecting each person’s needs. These differences don’t require placing patients on a line between “neurological” and “psychiatric.” Each person has their own combination of interacting biological, psychological, and social/environmental factors. As Stone explains, describing the brain mechanisms involved in a symptom is different from explaining why that person developed it. Understanding altered motor control doesn’t exclude psychological contributions, and identifying psychological distress doesn’t fully explain how someone develops a particular movement, weakness, or seizure. A psychological contribution also doesn’t require a psychiatric diagnosis, and having a psychiatric diagnosis doesn’t establish the cause of someone’s neurological symptoms. This is why I love the pie chart analogy created by Julie Hershberg and her team at re+active. I explain to patients that we can think about their condition through the interaction of factors that increased their vulnerability, events that may have triggered symptoms, and things that now keep those symptoms going. Picture a pie divided into slices representing psychosocial, lifestyle, physical impairments, motor control, sensory processing, and autonomic factors. For some people, psychosocial and lifestyle factors appear to make up much of the pie. For others, sensory and physical impairment do. For many, several areas contribute equally. The slices interact, their relative importance can change, and what maintains symptoms may (and often does) differ from what initially triggered them. The pie is a shared working formulation, rather than a precise measurement of causation. Patients often respond very well to having this visual representation of their difficulties and understanding why we’re recommending particular treatments. It also helps us identify what we may have overlooked. I find it difficult to imagine treating this population well without some version of this individualized, integrated approach. I see the consequences of narrower thinking in both directions. Some clinicians and patients emphasize neurological mechanisms so heavily that psychological and social contributors go unexplored. Others assume a psychiatric explanation is sufficient and overlook the need for neurological assessment or rehabilitation. In either case, the explanation can start determining what the clinician is willing to see. One particularly troubling mistake I encounter, especially from mental health professionals but sometimes from neurologists, is concluding that symptoms are too severe to be functional. Patients report being told, “This is clearly neurological; your mind can’t make you have these symptoms.” Symptom severity doesn’t distinguish FND from another neurological condition. Establishing the diagnosis requires neurological expertise, an appropriate examination, and positive clinical evidence. This is why I believe neurologists need to take a central role in diagnosis and remain involved in management where needed.