A Shift in Approach: Assessment and Treatment of Adults With Functional Neurological Disorder, 2022, Keatley & Molton

Abstract

Functional neurological disorder (FND) is a complex condition involving an interaction of psychological, physiological, and social factors. Despite high utilization of medical services, people with FND often suffer from poor long-term health and psychosocial outcomes, and experience stigmatization and marginalization within the medical community. Health service psychologists are well positioned to help patients with FND through the lens of the biopsychosocial model of health. Psychologists can facilitate appropriate assessment and treatment, and advocate for the needs of patients diagnosed with FND within multidisciplinary teams. This article reviews best practices for assessment and treatment of individuals diagnosed with or suspected of having FND and presents some clinical and ethical challenges associated with this complex population.

Open access, https://link.springer.com/article/10.1007/s42843-022-00061-w

 

Sarah Waters is a music teacher in her 30s who recently returned to full-time in-person work following a long period of unemployment due to the COVID-19 pandemic. One day, while at work, her legs gave out and she collapsed to the floor in front of her students. She was taken to the emergency room and admitted for workup.

On interview, she reported a four-month history of progressive leg weakness, tremors, and fatigue that was interfering with her daily functioning. She underwent extensive diagnostic testing including spine and brain MRI and bloodwork for toxin exposure. Results revealed a minor disc bulge but were otherwise unremarkable. Neurology was consulted and physical examination demonstrated that tremors were distractible and “give way” leg weakness was intermittent and inconsistent with known disease. The neurologist described her symptoms as having “functional overlay” and told Sarah her symptoms were caused by stress. She was told to rest for several days and she was discharged from the hospital with a referral for psychological evaluation.

Several weeks later, Sarah arrived at her psychology appointment in a wheelchair and appeared frustrated stating, “they think it’s all in my head.” She described hesitancy to engage with psychology given she did not perceive herself as having any psychological difficulties or stress. In fact, she could not link any stressor to the onset of her symptoms, except for a minor gastrointestinal illness that preceded the onset of leg weakness by a few days.


Hmmmm

 

Maybe authors should have read this one, for example.

The Enterovirus Theory of
Disease Etiology in Myalgic Encephalomyelitis/Chronic Fatigue Syndrome: A Critical Review

https://www.frontiersin.org/articles/10.3389/fmed.2021.688486/full

 

Very, very strong "beatings will continue until morale improves" energy. To continuously advise the problem as the solution to the problem. Like mindlessly trying the same key thousands of times, just in case it works the next time.

And as always: it's brand new, never been tried before. Every time I see this I am reminded of a tweet Gerada made, during a discussion of ME, about how UK physicians have been trained biopsychosocially for many years. It's both the current paradigm, running strong for years, but also never-been-tried-before, a novel idea for a problem that is always new and unknown, despite having an explicit description and treatment plan in the BPS model. It's both old and new, always has been.

Guy! I figured it out! The solution to climate change. It's so obvious: we burn ALL the coal, so there will be no coal left to burn. It's a flawless plan. The logic is flawless: we burn far less coal than we used to (well, by % only but whatever) and the problem is worse than ever. Therefore it's obviously burning less coal over the years that is responsible. Wow, thinking biopsychosocially is really easy, you don't even have to bother with anything. Not even common sense.

Either very foolish, or delusional. Or, well, they probably just mean "multidisciplinary teams" that don't feature any medical specialty, only rehab and other alternative medicine.

 

I was curious about the ethical challenges and oh boy does it make it clear how ethically challenged these people are:

It's well-documented, in the FND/conversion disorder literature itself, that patients reject those diagnoses. This has always been the main reason they were withheld, because the patients point out it's BS. I don't know if they genuinely believe in the lie that was to protect the patients, but this is as ethically challenged as it gets.

We can't lie to them without them being able to find out about it. This is a great example of why such legislation are so critical, they literally enable ethics, as otherwise unethical decisions are simply done without restraint.

It's widely acknowledged, in the literature itself, that the term FND is used because fewer patients object to it. So FND is literally coded and vague language itself. Most papers explicitly acknowledged it is merely a rebranding of conversion disorder and overlaps perfectly with the old concepts of hysteria, or neurasthenia in our case.

Those two are mutually exclusive with one another. So they do the latter. The unethical choice. Because they can, because although legislation exists in some countries to give patients access to their records, there is no such legislation obliging physicians to tell the truth. So they don't, they instead use coded language and vague terminology like FND.

That's about the extent of the ethical issues. It revolves around the fact that physicians can't effectively lie anymore because of patients' rights to access their records, and how to effectively work around it by using coded language and vague rhetoric.

Ethics truly are relative. To someone who needs to lie in their official capacity, it is difficult to continue lying while the person being lied to as the means to find out about it. That's the ethical challenge here. Straight from the unethical source.