Hypothesis A global neuronal workspace model of functional neurological disorders 2024 Naccache and Munoz-Musat

[Andy]

Abstract

We introduce here a general model of Functional Neurological Disorders based on the following hypothesis: a Functional Neurological Disorder could correspond to a consciously initiated voluntary top-down process causing involuntary lasting consequences that are consciously experienced and subjectively interpreted by the patient as involuntary. We develop this central hypothesis according to Global Neuronal Workspace theory of consciousness, that is particularly suited to describe interactions between conscious and non-conscious cognitive processes. We then present a list of predictions defining a research program aimed at empirically testing their validity. Finally, this general model leads us to reinterpret the long-debated links between hypnotic suggestion and functional neurological disorders. Driven by both scientific and therapeutic goals, this theoretical paper aims at bringing closer the psychiatric and neurological worlds of functional neurological disorders with the latest developments of cognitive neuroscience of consciousness.

Open access, https://www.tandfonline.com/doi/full/10.1080/19585969.2024.2340131

 

[NelliePledge]

so now they’re saying people are hypnotising themselves………

 

[rvallee]

 

[rvallee]

I tried to skim this and I just can't make it. It's just self-important rambling.

 

[Jonathan Edwards]

It's just self-important rambling.

Not just self-important rambling, but global neuronal working space self-important rambling.
You need to get the full nuance!
And bad science while we're about it.

 

[Joan Crawford]

 

[Joan Crawford]

so now they’re saying people are hypnotising themselves………

 

[Joan Crawford]

I've read a bit. Enough for one evening.

The inclusion of the words 'could' and 'may' pop up frequently.

Yup their clever clogs ideas could or may be useful/meaningful etc. But on the other hand, it could just be a load of unfalsifyable mumbo jumbo nonsense. The unease that clinicians can experience as evidence of somesuch made me laugh out loud

Have a pleasant evening.

 

[Hutan]

If people with FND are actually achieving something with their self-hypnosis, then, as far as I can see, they are doing better than hypnosis practitioners.

e.g. this post refers to the Cochrane Review that found that hypnosis was of no use in getting people to stop smoking.
Hypnosis and hypnotherapy (also Rapid Transformational Therapy)
Which seems pretty poor, given that the people going to a hypnotist to stop smoking clearly want to stop smoking and believe hypnosis can help.

 

[Sean]

Which seems pretty poor, given that the people going to a hypnotist to stop smoking clearly want to stop smoking and believe hypnosis can help.

Good point.

 

[Hutan]

While Functional Neurological Disorders (FND) rank among the most frequent category of diagnostics of both acute and chronic neurological or psychiatric conditions (up to ∼10-20% of neurology outpatients (Stone et al. Citation2009; Carson and Lehn Citation2016), and see (Garcin et al. Citation2021) for a focus on motor FND), our understanding of their mechanisms is still very limited, as well as our therapeutic efficacy for the affected patients (Espay et al. Citation2018).

So, they are still acknowledging that they can't fix these patients. Perhaps that is useful to remember for advocacy.

First, we identified an apparent form of residual dualism inherent to the conceptualisation of FND, at least since the end of nineteenth century and the iconic figure of Jean-Martin Charcot and the ‘Ecole de la Salpêtrière’ (Charcot Citation1875; Ellenberger Citation1965). This residual dualism is best captured by the weird opposition between diseases of ‘CNS structure’ on the one hand (i.e.: the concept of ‘organicity’), and diseases of ‘CNS function’ on the other hand that include FND. This original residual dualism seems to have spread until today, as evidenced by the current name of this clinical category that refers to an idea of cleavage: the adjective ‘Functional’ of ‘Functional Neurological Disorders’ clearly points to their radical distinction from organic diseases. As if function and structure of a biological system were two independent and divided attributes. At the contrary of this division, modern biology demonstrated that ultimate resolution of discrete natural objects reveal the strong entanglement of function and structure (e.g.: allosteric transitions of a protein with a tight relation between fine molecular structure and corresponding enzymatic functions (Monod et al. Citation1965). This dualistic aporia is also present in the previous names of FND, - that changed across time and space -, from ‘conversive disorders’ (i.e.: a conversion from the mind to the body) up to ‘Dissociative Neurological Symptom Disorder’ (i.e.,: a dissociation within the same mind) according to the ICD-11 (World Health Organisation International Coding manual).

All that is to make a point that I think is valid - of course function is a result of structure at some level. So they are accusing people naming this supposed clinical category of dualism. Also a point that might come in handy.

So far, surprisingly so good.

One may consider this dualism being driven either by a motivation of reassuring patients about the absence of severe underlying disease (e.g.: multiple sclerosis, brain tumour, stroke, neurodegenerative disorder…), of by a kind of ‘diagnostic humility’: as if clinicians dissociated diseases with identified physical causes from those that remain out of reach. However, none of these two reasons justifies the need to translate this dichotomy into such a dualist perspective.

Interesting points. It's possible that 'functional' is supposed to be reassuring to the patient. I don't think it arose out of a 'diagnostic humility' though - in fact, I think the real reason is quite the opposite. I think it came to be out of diagnostic hubris. If no physical cause is identified, the clinician assumes there can't possibly be one and that the patient just thinks they are not well. That suggests that FNDs should be able to be fixed by better thinking, but it's been an ongoing frustration that efforts to achieve that have failed.

 

[Sean]

our understanding of their mechanisms is still very limited, as well as our therapeutic efficacy for the affected patients​

If they still have not demonstrated adequate, reliable, and safe efficacy under strict research conditions, then they cannot be claiming effectiveness at the practical clinical, and policy and medico-legal advice levels.

Yet they are rolling out implementation at those levels as fast as they can.

Exactly as happened with the GET/CBT rehab model for ME/CFS.

 

[Hutan]

Second, FND also raise the issue of agentivity of symptoms. Up to which point the large repertoire of FND symptoms, that can include both positive (e.g.: various types of movements and behaviours) and negative phenomena (e.g.: sensory-motor deficit, memory impairment, etc…), correspond to voluntary or to involuntary processes? It is noteworthy that this issue remains at stake even after clearly differentiating FND from pretending or malingering. Indeed, specificities of neurological examination of FND include various suggestive manoeuvres, distraction of voluntary attention to modulate positive symptoms such as the famous Hoover manoeuvre and related signs (Garcin Citation2018). What type of agentivity should we attribute to a symptom distinguished from malingering, but still sensitive to distraction of patient’s voluntary attention?

A last argument stems from the subjective experience reported by many clinicians in charge of FND patients, and that we may coin as an ‘uncanny mixed feeling of voluntary/involuntary symptoms’: this irrepressible feeling of a certain form of voluntary participation in the symptoms, in a patient who is not malingering.

I think that excerpt is worth reading. The authors are grappling with the question of whether an FND is voluntary or not. These conditions exist, in the clinicians' minds I think, in some half-way house between pretending and a mental illness. I think that last description in the excerpt of an 'uncanny mixed feeling of voluntary/involuntary symptoms' is quite revealing and demonstrates the major role that prejudice could play in the ready assignment of an FND label to a patient.

The authors say that their hypothesis allows both voluntary and involuntary aspects of FND to be true.

Main Hypothesis: A FND could correspond to a consciously initiated voluntary top-down process causing involuntary lasting consequences (i.e.,: FND symptoms), that are consciously experienced and subjectively interpreted by the patient as involuntary.

Also, the apparent ‘residual dualism’ conceptualisation of FND could be interpreted as a failed attempt to dissociate diseases that are not depending on voluntary top-down cognitive processes (i.e.: so-called ‘organic’ diseases), from those who would require a voluntary top-down triggering (i.e.: FND).

That last quote seems to agree with the reason I suggested for the 'functional' label. Essentially the FND patient can be blamed for their initial, voluntary poor thinking, while excusing the clinician for not being able to fix the involuntary consequences by helping their patient think better.

 

[rvallee]

Interesting points. It's possible that 'functional' is supposed to be reassuring to the patient

Having seen thousands of people discussing being told they have FND over the years, a small fraction of which was definitely positive, I say, with all due respect: Horse. Shit.

They can pretend if it makes them sleep better at night but the only way to know this is to ask and they don't want to know otherwise so they almost never ask, and the few studies of this tell exactly the opposite.

So, absolutely not it's not supposed to be reassuring to patients.

 

[rvallee]

For what it's worth, there was a recent discussion on the LC sub-reddit over someone being told by two MDs that LC was psychosomatic that it was explained to them that psychosomatic means that their central nervous system is malfunctioning, which of course is a complete bullshit explanation that obviously the clinician doesn't even believe. So things are sort of morphing into something like this.

There were several comment saying they were told something like this. The profession is trying to bridge facing mounting evidence that the whole concept is BS but simply cannot face the truth, while at the same time we are seeing a push to expand further than ever before, driven largely by neurologists, while most in the specialty don't even want to see those patients.

Honestly it's easy to see why we are so easy to dismiss. When you explain plainly and clearly all of this is all sounds so completely insane that no, well, sane person could ever accept this, continue to play along. And yet here we are. This has been a tradition for well over a century. Hundreds of millions of people, probably north of a billion to a lesser degree, have been subjected to this ideology, with real-life clinical decisions affecting, and in the case of tens of millions at least, ruining our lives.

As a scandal it rivals, and with time will outdo, what the tobacco companies did. Accounting for doing it knowingly, it probably already does. And it all feels like nothing. It's just words, for the most part. Words from people in a position of authority in a context in which failure to act is harmful.

I really fear that even with mounting overwhelming evidence, it will take a while to break this. It's too much, no one wants to take responsibility and it's all so much worse in that it's all rapidly expanding, and it's already more influential and widespread than ever before. It's by far the worst failure of expertise in human history, so much that it probably outdoes them all, combined. Like how Jupiter is 2.5x more massive than all the planets combined. It's so big that it can't be accepted.

 

[Hutan]

Having seen thousands of people discussing being told they have FND over the years, a small fraction of which was definitely positive, I say, with all due respect: Horse. Shit.

Well, of course 'supposed to be reassuring' and 'actually being reassuring' are two quite different things. It's a bit like a doctor saying 'Good news! All the tests came back clear!' - some doctors probably genuinely think that is good news. Of course, it is not, as you still have no explanation for feeling rubbish.