Briquet syndrome revisited: implications for functional neurological disorder, Maggio et al, 2021

[Andy]

With the creation of the Somatic Symptom and Related Disorders category of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition in 2013, the functional neurological (symptom) disorder diagnostic criteria underwent transformative changes. These included an emphasis on ‘rule-in’ physical examination signs/semiological features guiding diagnosis and the removal of a required proximal psychological stressor to be linked to symptoms. In addition, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition somatization disorder, somatoform pain disorder and undifferentiated somatoform disorder conditions were eliminated and collapsed into the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition somatic symptom disorder diagnosis. With somatic symptom disorder, emphasis was placed on a cognitive-behavioural (psychological) formulation as the basis for diagnosis in individuals reporting distressing bodily symptoms such as pain and/or fatigue; the need for bodily symptoms to be ‘medically unexplained’ was removed, and the overall utility of this diagnostic criteria remains debated.

A consequence of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition restructuring is that the diagnosis of somatization disorder that encompassed individuals with functional neurological (sensorimotor) symptoms and prominent other bodily symptoms, including pain, was eliminated. This change negatively impacts clinical and research efforts because many patients with functional neurological disorder experience pain, supporting that the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition would benefit from an integrated diagnosis at this intersection.

We seek to revisit this with modifications, particularly since pain (and a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition somatization disorder comorbidity, more specifically) is associated with poor clinical prognosis in functional neurological disorder.

As a first step, we systematically reviewed the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition somatization disorder literature to detail epidemiologic, healthcare utilization, demographic, diagnostic, medical and psychiatric comorbidity, psychosocial, neurobiological and treatment data.

Thereafter, we propose a preliminary revision to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition allowing for the specifier functional neurological disorder ‘with prominent pain’.

To meet this criterion, core functional neurological symptoms (e.g. limb weakness, gait difficulties, seizures, non-dermatomal sensory loss and/or blindness) would have ‘rule-in’ signs and pain (>6 months) impairing social and/or occupational functioning would also be present. Two optional secondary specifiers assist in characterizing individuals with cognitive-behavioural (psychological) features recognized to amplify or perpetuate pain and documenting if there is a pain-related comorbidity. The specifier of ‘with prominent pain’ is etiologically neutral, while secondary specifiers provide additional clarification.

We advocate for a similar approach to contextualize fatigue and mixed somatic symptoms in functional neurological disorder. While this preliminary proposal requires prospective data and additional discussion, these revisions offer the potential benefit to readily identify important functional neurological disorder subgroups—resulting in diagnostic, treatment and pathophysiology implications.

Open access, https://academic.oup.com/braincomms/article/2/2/fcaa156/5910543

A related question not yet addressed is how to also contextualize other prominent physical symptoms in patients with FND, most notably but not limited to fatigue (Aybek et al., 2020; Gelauff et al., 2020). Like pain, fatigue is a common symptom in FND that is also linked to reduced quality of life and reduced treatment engagement (Věchetová et al., 2018). We suggest that the same approach taken for pain can also be used to categorize FND patients with prominent fatigue symptoms. This would include using the specifier ‘with prominent fatigue’ for those individuals that endorse fatigue (>6 months) is limiting their occupational and/or social functioning. Optional secondary specifiers can denote the presence or absence of cognitive-behavioural (psychological) features and the co-occurrence with a contributing comorbidity known to be associated with fatigue (e.g. multiple sclerosis, chronic fatigue syndrome). Lastly, for patients with prominent pain and fatigue, or those exhibiting a combination of two or more non-sensorimotor symptoms (e.g. widespread body pain and gastrointestinal distress), the diagnostic specifier FND ‘with prominent mixed somatic symptoms’ can be recorded (see Fig. 3).

 

[Sean]

The arrogance and callousness of these people is just as breathtaking as when I first encountered it a few decades back.

They have learned nothing, and grow ever more resistant to doing so every day. Their act consists of ever finer hair splitting with definitions and statistical thresholds, and withdrawing deeper into their theoretical bubble.

...these revisions offer the potential benefit to readily identify important functional neurological disorder subgroups—resulting in diagnostic, treatment and pathophysiology implications.

And a lifetime of employment, power, and status for FND researchers and clinicians.

Lastly, for patients with prominent pain and fatigue, or those exhibiting a combination of two or more non-sensorimotor symptoms (e.g. widespread body pain and gastrointestinal distress), the diagnostic specifier FND ‘with prominent mixed somatic symptoms’ can be recorded (see Fig. 3).

Once again, heads they win, tails you lose.

If you are not psychologically ill before they get a hold of you, you sure as shit will be after they have ground you through their mill, and then blamed you for not 'engaging' and 'responding'.

Better stop there.

 

[Mithriel]

Surely the only point to categorizing patients is to work out which treatments lead to recovery in each type.

Since CBT is the answer to everything it hardly seems worth the effort.

 

[rvallee]

the functional neurological (symptom) disorder diagnostic criteria underwent transformative changes

Right. Totally. Transformed entirely. Sure. Uh uh. Those are truly serious people talking about serious things.

Not even smart enough to not point out they are proposing a change, a finality, despite having no evidence for it, as if the process of fabricating the evidence is just a formality. This could literally be rewritten as "let's fabricate the evidence for it".

While this preliminary proposal requires prospective data and additional discussion, these revisions offer the potential benefit

This is Facebook quizz level of pseudoscience and these people want, need, to enforce this, coercively, onto millions of people. With force of law, which medicine fully has. It's not even coherent enough to use for trivial matters such as what to wear, and they want to control millions of people's lives, without any afterthought or even a basic quality assurance mechanism. Borderline criminal insanity to actually argue that in the context of medicine.

The "new" FND, totally different from the old "FND". It has a new hat!

 

[Invisible Woman]

i think I'll out all the striped deckchairs together and separate from the solid colour ones...... Hmmmm perhaps it would be better to do them by colours.

Iceberg? Is that a shade of blue?

 

[mat]

I really wonder if they don't have any other priorities. I mean, I would understand if the lead author was a psychiatrist and needed to publish something. But why are neurologists so fixated on psychosomatism?

 

[MSEsperanza]

The senior author seems to be David Perez who has already earned some criticism by some forum members...
.
see this thread:

Towards an Outpatient Model of Care for Motor Functional Neurological Disorders: A Neuropsychiatric Perspective https://www.dovepress.com/towards-a...rological--peer-reviewed-fulltext-article-NDT

The senior author, David Perez in Boston, wrote the commentary accompanying the CODES trial that substituted his clinical experience as providing evidence for the benefits of CBT in treating so-called "dissociative seizures," even though the findings of the trial found the opposite.

edited to add https://www.s4me.info/threads/trial...cbt-for-medically-unexplained-symptoms.15535/

 

[rvallee]

I really wonder if they don't have any other priorities. I mean, I would understand if the lead author was a psychiatrist and needed to publish something. But why are neurologists so fixated on psychosomatism?

Honestly, same reason why some people are fascinated by stuff like telekinesis. It's magic. People want to believe in magic, even smart people. Magic is amazing. Sufficiently advanced science is indistinguishable from magic, but science is hard. Just magic is so much easier.