@Hutan.
I agree that EEG specificity and sensitivity can be problematic but usually the pwEpilepsy have had previous EEG’s that show their seizure activity. It is possible to develop a new presentation of a seizure disorder with a new pathology. That is investigated for all known causes. We also do blood tests post seizure, there is an increase in certain blood chemistry. No FND diagnosis is made until the person is thoroughly investigated.
Unfortunately there is a difference between reading papers as a layman, or training in reading the evidence base of a paper, versus clinical training and experience. When doctors of any specialty start throwing out diagnoses like “functional disorder and psycho-social overlay”, I am afraid, I am one big sceptic of their credibility.
The amount of investigation for functional disorder is huge, in terms of man hours and technology. It is not a diagnosis you make on the history from a patient, a “feeling” the doctor has, a “I think it is this” - that is arrogant posturing, as far as I am concerned.
The clinician has to prove it, they have to rule out everything known. (Yes, not everything is known in ME/CFS…. but as retired psychiatrist and with clients I did care for) The person with ME/LC, are just like regular people, and have symptoms that vary across multiple organ systems. Can a doctor and specialist know everything? no, but it is their responsibility to learn to improve their knowledge, to take better care of their patient and to reduce stigmatisation.
I, personally, if someone had a symptom I didn’t understand, I would record it as a somatic symptom (i.e. physical) vs mental (arising from the brain) eg.thoughts, feelings, behaviour, hallucinations, unusual movements, tics…the list is quite long…
That does not mean it is psychosomatic, it is just a symptom a patient has identified when we are doing routine physical history and examination and has not been mentioned by their GP or other specialist. We read through all their specialist notes before starting our mental health assessment and often these have been identified as relating to the disease/disorder by others. Psychiatrist usually expect GP’s to have done full physical history and examination and work up for any underlying conditions, prior to referral. Of course many do not….They get a full written mental health assessment (often 8-10 pages long- sometimes up to 20) and makes for education….and hopefully a reminder to do these essential history, examination and checks.
Psychiatrists, as part of their training, have to undergo retraining and pass a post-graduate course in identifying medical disorders, on top of the medical degree that we have been practising with for the minimum, usually of two years. This is because psychiatrists, tend to do a lot of talking and not touching our clients because we have been taught to observe behaviour very carefully for signs of arousal, as that is for safety of the patient, ourselves, the mental health team and other health professionals and the public. Arousal can be from a multitude of factors and not just “stress” or feeling uncomfortable talking to a psychiatrist, there are easy to observe psychiatric symptoms and there are neuropsychiatric processes going on that must be excluded and treated.
If somatic symptoms were significant or distressing for the patient, I would have emailed, the appropriate colleague for a verbal opinion, and start investigations, usually bloods and (imaging if the hospital will allow as there is often strict criteria for getting scans and often need discussion with a radiologist around urgency and appropriateness). Usually when people come under the care of the mental health service, where the psychiatrist is responsible for a patient’s physical as well as mental health (or in more mild to moderate illness, we share the care with the person’s GP, and they care for the physical illness and we care for the psychiatric disorder and are professionally responsible for medication and education and management of side effects but inform GP they are starting medication. (but the mental health team, nurses especially, are assigned to monitor for side effects).
ME/CFS is viewed in my country as a primary care health diagnosis and only people who have troubling mental health symptoms get a referral to a community mental health team. Of course GP’s get very confused by ME/CFS symptoms as they have had no training or inadequate BPS training (and I have been a victim of that too). Also people choose to go private and for most people that can be positive, the rest is like the Wild West of prescribing and physical treatment and they get away with it by quoting low-evidenced psychiatric literature.
Actually I have seen this by some psychiatrists in the public sector and is ongoing….and hoping long covid will give them a big wake-up call. (But not holding my breathe but cautiously hopeful).
Not sure about that as our professional college that still seems to be publicly operating in the 90’s, and reflected in the appalling lack of research into ME/CFS, never respond to people questioning the BPS response so whether they change their ways, I do not know.
Getting back to functional disorders and tics. Tics are often associated with other developmental disorders eg. ADD/ADHD, and a long list. We usually take a history for all of these disorders including family, friends, work colleagues and teachers (with their consent) to ask in what situations the tics occur and other neurodevelopmental behaviour occurs. This can range from non-specific behaviour like being restless, impulsive to specific signs (related to severity and risk). We can go and observe children (not adolescents) at school on occasions.
Psychologists are trained to observe for tics but not to the level of a psychiatrist, pediatrician or neurologist. They can describe the tic in a simple fashion, but some senior child and adolescent psychologists could make a correct observation with training and clinical experience. Tics on the whole, fulfill certain criteria for a movement disorder with clear torsion of the neck, head and face (and other parts of body, shoulders etc), they may also have focal neurological signs on physical examination (abnormal plantar response and hyper-reflexia) - these are called soft signs as they are non specific to a diagnosis but indicate neurodevelopmental damage of some description due to multiple causation and often not treatable with any medication or other modality.
I do appreciate you are probably talking about all the discussion and emerging psychiatric literature on the the Tik Tok “functional tic disorders” which is being publicly discussed everywhere. I think psychiatrists and any specialist should be cautious on saying these are functional without a proper diagnostic work-up. Unfortunately, specialists do like to be quoted for the press or even appear on TV talking nonsense and make blanket statements around causation. A real concern for me, is that a lot of children have not been able to access child and youth mental health services during the pandemic (and they were very stretched prior) so saying these are pandemic “stress” is negligent.
Can a child, youth or adult learn how to imitate a tic and Tourette’s, yes they can. But they have to continue to tic in multiple different environments, home, school, work, friends and especially when they are relaxed. People can tic in their sleep for example and be observed by parents. People’s tics can worsen with eg. times of intellectual and emotional stress or lessen when doing complex activities. We question people on what aggravates and relieves the frequency of ticking. Often it is the client makes an observation of their increased tic behaviour and go “oh yeah, whenever I am with this person, they make me feel uncomfortable and I tic more” and then we talk about what makes them uncomfortable and see if we can help them. That is them describing a psychological stressor, we do not assume there is one.
Edit: typos and a few additions for clarity
