Functional Neurological Disorder (FND) - articles, social media and discussion

[SNT Gatchaman]

Starts off referencing A practical review of functional neurological disorder FND for the general physician (2021, Clinical Medicine) —

FND is a common neurological condition and it is the second most common neurology referral after a headache.

And proceeds to describe the disease model per Stone and Carson. Includes a table detailing risk factors: psychologic stress; adverse childhood event; female biological sex; genetic factors; physical injuries. Also co-morbidities: depression, PTSD, chronic pain; irritable bowel syndrome; cluster B personality traits*.

However, despite all this initial framing, the main point of the paper is very reasonable. How to manage the dental care of patients with these symptoms. The FND formulation is irrelevant to this and mainly the example cases and discussion are around how to support the patient through a difficult dental procedure with special care and extra time and other accomodations. There is also an example of a particular dental problem termed oromandibular dystonia.

Patients with functional dystonia may present with involuntary jaw movements resulting in tooth surface loss or tooth fractures. This has been termed oromandibular dystonia and it can interfere with chewing, swallowing, talking, and in severe cases, breathing.

---
* Cluster B personality types are: antisocial, borderline, histrionic, narcissistic. (Noted without further comment.)

 

[SNT Gatchaman]

Chiari Malformation Type 1 In An Adolescent With Conversion Disorder (2023)

Which is a case report which describes a complete failure to fix the presenting problem. "The monthly follow-up of the case continues"

In psychiatric assessment, we learned that she did not have good school success, had bad peer relations, and had no close friends. Moreover, she had no good relations with her father, felt pressure from him, and occasionally argued with him. Her complaints began four months ago following a severe argument with him. She had an age-appropriate appearance; her mood was euthymic, her affect was compatible with her mood. In her thought content, she had no concerns about her condition. She was pleased that her family had fallen on her and taken care of her and that their interest had increased. It wasn't a problem for her not to go to school (secondary gains).

After the psychiatric interview, she was diagnosed with conversion disorder. Medical treatment was adjusted as fluoxetine 20 mg/day and lorazepam 1 mg/day. Follow-up after one month, she had no fainting during this time, and she experienced none of these symptoms, but tremor on her right hand was continuing on the second and third fingers.

In her subsequent follow-up, the tremor on her hand was again in her whole hand, and she had started experiencing a feeling of tightness in the heart, shortness of breath, tremors, and numbness in the entire body again. But it wasn't accompanied by fainting. Lorazepam treatment was stopped, and fluoxetine treatment increased to 30 mg per day. The monthly follow-up of the case continues in our outpatient clinic.

 

[Hutan]

cluster B personality traits*.

* Cluster B personality types are: antisocial, borderline, histrionic, narcissistic

It feels as though this label could well be the price patients pay for having a problem that the doctor doesn't know how to fix, and for having the temerity to turn up in a clinic, wanting an answer. And, when there isn't a real answer and they are, instead, told that if they thought differently, they wouldn't have the problem, for being a bit upset and telling the doctor what they can do with their CBT.

Histrionic Personality Disorder - StatPearls CPD activity

A histrionic personality disorder, or commonly known as a dramatic personality disorder, is a psychiatric disorder distinguished by a pattern of exaggerated emotionality and attention-seeking behaviors. A histrionic personality disorder is categorized within the "Cluster B" of personality disorders. Cluster B personality disorders include conditions such as narcissistic personality disorder, borderline personality disorder, and antisocial personality disorder. These personality disorders are commonly described as dramatic, excitable, erratic, or volatile. Specifically, people with histrionic personality disorder are typically characterized as flirtatious, seductive, charming, manipulative, impulsive, and lively. This activity reviews the evaluation, treatment, and management of histrionic personality disorder and highlights the role of the interprofessional team in managing patients with this condition.
Access free multiple choice questions on this topic.

Given ME/CFS is typically included under the FND umbrella, it raises the question of how we can be simultaneously lively and fatigued.

 

[Baseit]

There was so much to keep track of while I was reading up on the history of ME that it was hard to recall who did what when, so I tried to make a timeline of everything that happened by year to help myself remember, but it became clear very quickly that it would be a bloated mess so I scrapped the idea. It gave me the idea to make a timeline of particularly relevant articles about FND listed in documents by topic and date though, both to see how the construct evolved and gained popularity over time and as an easy arguing resource given how many people online go to bat for FND as a useful diagnosis, particularly how many of them insist that it isn't a psychosomatic diagnosis. I didn't see anything like it on here, so maybe you'll get some use out of it. Let me know if there's any problems with the documents or if there's any useful changes I could make. I'll add any especially relevant articles that come out or I find.

Researchers/institutions etc. calling FND conversion disorder, hysteria etc.
https://docs.google.com/document/d/1RMyX6T-ZkVMPD0NyoErTo_EZOyFpVpVePC7VRNzmXac/

FND Diagnosis With Neurological Issues etc.
https://docs.google.com/document/d/1GbiMr5vLUXcZH8Pnc8t9ibM-1w12zkIdxFr-0fibUT4/

Acute Illnesses and Injuries at Onset of FND
https://docs.google.com/document/d/1w5N_ErP_-HIn9zuWKPAptrbU64j-Wx3Fzu3kQQEf0n8/

Especially bad/strange logic
https://docs.google.com/document/d/1AaSlWLTIvYK8uDADg52FPFCGNq4SLcoUa7UI8JrHUlo/

Admissions That There's No or Limited Evidence For Claims/Diagnostic Signs/Treatments
https://docs.google.com/document/d/1MIgdDMU-qraAI34Mk8BWwkKM079Haitz-JwAfj48xrQ/

Especially Egregious Cases
https://docs.google.com/document/d/1wcSkiEs8URMf_WVE_ymLLHKlZR5hlBR_gQaD7CDCQI0/

Somatoform Disorder, Parkinson's, Functional Parkinson’s etc.
https://docs.google.com/document/d/1zDjlMUL5CAXXlHGN3AafXKNEs9beKu5HrBz0BafEhnA/


Also, while doing a timeline of the whole ME controversy by date wouldn't work, timeline documents by subtopic would probably be manageable and I'd like to do it so that I can be sure I'm not forgetting anything important. Is there anything people would find particularly useful to have a dated list of to begin with? If not I'll probably start with the PACE trial controversy as a practice run given that there's so much written about it and so many summary articles already.

 

[Trish]

I'm pretty sure others will be able to point you to such histories already written and starting well before the PACE trial. There's an awful lot of it, and easy to miss the background going back into the 1980s and earlier. PACE is relatively late in the story.

 

[Hutan]

It gave me the idea to make a timeline of particularly relevant articles about FND listed in documents by topic and date

Great quotes on FND, thanks Baseit.
The use of 'functional' as a smokescreen, a palatable way of saying 'psychogenic', is very clear from the quotes in the first item.

 

[dave30th]

Don't think this deserves a thread of its own, but thought it should be noted in case @dave30th wants to check the claims made

Gee, thanks! (I think!)

 

[ToneAl]

There was so much to keep track of while I was reading up on the history of ME that it was hard to recall who did what when, so I tried to make a timeline of everything that happened by year to help myself remember, but it became clear very quickly that it would be a bloated mess so I scrapped the idea. It gave me the idea to make a timeline of particularly relevant articles about FND listed in documents by topic and date though, both to see how the construct evolved and gained popularity over time and as an easy arguing resource given how many people online go to bat for FND as a useful diagnosis, particularly how many of them insist that it isn't a psychosomatic diagnosis. I didn't see anything like it on here, so maybe you'll get some use out of it. Let me know if there's any problems with the documents or if there's any useful changes I could make. I'll add any especially relevant articles that come out or I find.

Researchers/institutions etc. calling FND conversion disorder, hysteria etc.
https://docs.google.com/document/d/1RMyX6T-ZkVMPD0NyoErTo_EZOyFpVpVePC7VRNzmXac/

FND Diagnosis With Neurological Issues etc.
https://docs.google.com/document/d/1GbiMr5vLUXcZH8Pnc8t9ibM-1w12zkIdxFr-0fibUT4/

Acute Illnesses and Injuries at Onset of FND
https://docs.google.com/document/d/1w5N_ErP_-HIn9zuWKPAptrbU64j-Wx3Fzu3kQQEf0n8/

Especially bad/strange logic
https://docs.google.com/document/d/1AaSlWLTIvYK8uDADg52FPFCGNq4SLcoUa7UI8JrHUlo/

Admissions That There's No or Limited Evidence For Claims/Diagnostic Signs/Treatments
https://docs.google.com/document/d/1MIgdDMU-qraAI34Mk8BWwkKM079Haitz-JwAfj48xrQ/

Especially Egregious Cases
https://docs.google.com/document/d/1wcSkiEs8URMf_WVE_ymLLHKlZR5hlBR_gQaD7CDCQI0/

Somatoform Disorder, Parkinson's, Functional Parkinson’s etc.
https://docs.google.com/document/d/1zDjlMUL5CAXXlHGN3AafXKNEs9beKu5HrBz0BafEhnA/


Also, while doing a timeline of the whole ME controversy by date wouldn't work, timeline documents by subtopic would probably be manageable and I'd like to do it so that I can be sure I'm not forgetting anything important. Is there anything people would find particularly useful to have a dated list of to begin with? If not I'll probably start with the PACE trial controversy as a practice run given that there's so much written about it and so many summary articles already.

Nice articles here just here
Sone of the poisitive signs discused in the article can be false negatives false positives which can cloud judgement and show bias.
But they never give a theoretical point on why phych based disease can give physical symptoms

 

[Jaybee00]

Just incredible. Researchers in neurology find that 88.1% of their pts have an identifiable ANS issue, & 27.1% have anti-gAChR antibodies signifying AAG, a supposedly v rare neuropathy.

All those pts were originally dxed with FND/"conversion disorder".

Response moved here

 

[SNT Gatchaman]

See also Pediatric de novo movement disorders and ataxia in the context of SARS-CoV-2 (2023)

Here, we identified CSF antibodies against structures of the basal ganglia, but details on the pathophysiology are yet to be discovered.

The rising incidence of functional movement disorders during the COVID-19 pandemic was recently linked to the “Charcot’s Era at the Salpêtrière” and discussed in the scope of governments’ measures and their profound psychological impact. Therefore, it is even more important to characterize and identify the non-functional de novo movement disorders associated with COVID-19.

FND proponents might wish to consider yet another renaming: perhaps to "idiopathic movement etc disorder". There's not going to be much left as "FND" once all the subgroup causes are demonstrated.

 

[Hutan]

Some posts on this paper have been moved to the dedicated thread:
Anti-ganglionic acetylcholine receptor antibodies in functional neurological symptom disorder/conversion disorder, 2023, Nagata et al

 

[Gradzy]

A lot of that sounds like making stuff up.

The way he writes, the way they all write about this issue, is maddening.

Where is the acknowledgment that emerging physical evidence could possibly invalidate the whole supposed theoretical basis for FND?

If the vague and expansive set of symptoms that they call FND (including common symptoms) can sometimes be caused by previously undiscovered physical abnormalities that completely destroys the software analogy they like to use.

They can’t have it both ways. It’s either software problems caused by magic beams from dimension X or mental trauma or it’s a, y’know, hardware problem - one that you couldn’t immediately detect with your crude tests and even cruder, short-hand and short-cut filled diagnostic approach.

 

[Gradzy]

Nice articles here just here
Sone of the poisitive signs discused in the article can be false negatives false positives which can cloud judgement and show bias.
But they never give a theoretical point on why phych based disease can give physical symptoms

The mechanism(s) of action in FND is just presented as a black box. They say they don’t know what happens in the box.

Yet they project total confidence in their construct of FND. While simultaneously calling for further research.

 

[Ash]

The way he writes, the way they all write about this issue, is maddening.

Where is the acknowledgment that emerging physical evidence could possibly invalidate the whole supposed theoretical basis for FND?

If the vague and expansive set of symptoms that they call FND (including common symptoms) can sometimes be caused by previously undiscovered physical abnormalities that completely destroys the software analogy they like to use.

They can’t have it both ways. It’s either software problems caused by magic beams from dimension X or mental trauma or it’s a, y’know, hardware problem - one that you couldn’t immediately detect with your crude tests and even cruder, short-hand and short-cut filled diagnostic approach.

Absolutely incorrigible.

 

[rvallee]

They can’t have it both ways. It’s either software problems caused by magic beams from dimension X or mental trauma or it’s a, y’know, hardware problem - one that you couldn’t immediately detect with your crude tests and even cruder, short-hand and short-cut filled diagnostic approach.

Unfortunately, they really can. All of this should have been stopped a long time ago, but it keeps going because it's too embarrassing for the whole profession. In the end there will be only a few things left and there will still be loud insistence that it's still a massive thing, since they can now freely attribute it in parallel to anything that isn't fully biologically explained, which is almost everything. They call it a "functional overlay", where even with a diagnosis they can attribute symptoms to suit their fancy.

I still don't see any actual pushback from within the profession. It's not even dozens, there really isn't any at all. No speaking truth to power in a heavily regulated profession, it's a career-ender. All the pushing is in the wrong direction, into making things worse.

They painted themselves in a corner with psychosomatic ideology and are willing to keep ruining lives simply to avoid facing reality, they're completely in denial over the massive harm they're doing. Which, ironically, is a serious mental illness, errors of thinking and beliefs leading to harmful behavior. But who will diagnose the mentally ill mental illness doctors with a mental illness they can't recognize?

Only technology will pave the way out of this. Fortunately, it's going to happen within years. Without this, it could be going for decades more.

 

[Gradzy]

I came across this article sometime in the last 2 years while researching FND.

Functional Neurological Disorder – Pushing the boundaries of medical credibility?

I’m not sure what to do in terms of reproducing it here or quoting parts; I’m not sure of the usual approach here to sources, I’m out of practice with forum posting and I’m also not at my pc.

Whilst doing my ward round I came across a patient who was being attended to by one of the junior doctors, a 12 year old boy who had been admitted with “seizures”, a relatively common condition which most paediatric trainees should feel comfortable in managing.

The patient, let’s call him Peter (not his name), had a previous diagnosis of “functional neurological disorder” (FND for short) and my junior was about to discharge this patient home despite the fact that the parents had brought their child to hospital because of the severity of his symptoms, because they were desperate and had been desperate for the past three years with a child who was house bound, unable to function on a day to day basis, unable to attend school and unable to experience a normal childhood.

The patient raised my curiosity but before I discuss the management let’s take a look at FND, what it is and how the term came into being

It’s worth reading. It was one of the few things that I ever read about FND and the attitudes of medical professionals towards it that ever gave me hope.

Should I just quote the whole thing? That gets more uptake.

 

[Andy]

Should I just quote the whole thing? That gets more uptake.

No, please don't. From our Forum Rules,

"Rule 7: Do not violate copyright law
It is not permitted to post entire copyrighted articles or PDF files, but full abstracts from research papers may be quoted so long as the original source is credited or linked to. Under "fair use" doctrine, it is also permitted to quote sections of copyrighted material, but it should be the minimal amount necessary to support or illustrate your commentary regarding the content. Linking to sci-hub or other third-party sources is also permitted."

 

[Gradzy]

No, please don't. From our Forum Rules,

"Rule 7: Do not violate copyright law
It is not permitted to post entire copyrighted articles or PDF files, but full abstracts from research papers may be quoted so long as the original source is credited or linked to. Under "fair use" doctrine, it is also permitted to quote sections of copyrighted material, but it should be the minimal amount necessary to support or illustrate your commentary regarding the content. Linking to sci-hub or other third-party sources is also permitted."

I wondered. Thanks.

 

[SNT Gatchaman]

It’s worth reading. It was one of the few things that I ever read about FND and the attitudes of medical professionals towards it that ever gave me hope.

TLDR: 12yo boy unable to attend school, with pre-existing FND diagnosis, presents with escalating seizure disorder. Previous MRI/EEG = no abnormality detected. Junior staff about to discharge "because FND" but consultant paediatrician says "hold", run more tests. They diagnose an immune-mediated pathology (maybe anti-NMDAR encephalitis??), start treatment and patient now lives normally and goes to school.

As one of my colleagues put it: “I have yet to meet a patient who has benefitted from receiving a diagnosis of FND”.

 

[Hutan]

It's a great article, thanks for posting it @Gradzy. Well done to Dr Tim Ubhi.

Some of my juniors joke that FND=finding no diagnosis. It would be funny if it wasn’t for the tragedy associated with this condition. Protagonists of FND recommend a “bio-psychosocial” approach to manage these patients with input from CAMHS and the use of CBT etc etc. This unfortunately is not the real world where patients are often waiting months or years for a CAMHS review and even if they are reviewed they are often directed to self-help websites on parenting skills. As one of my colleagues put it: “I have yet to meet a patient who has benefitted from receiving a diagnosis of FND”. My concern is that once a child receives a diagnosis of FND, the diagnostic process stops and people stop being inquisitive.

I would estimate that there are at least another 20 cases around the UK right now which are like Peter and most of whom have previously been given a diagnosis of FND.

The boy and his parents must have gone through hell during those 3 years when his symptoms were being labelled as FND. The thought of more parents and children going through that, it's horrendous.

There are comments under the article, some examples:

I've lost just over 4 years to these three letters which were given very quickly along with an instant discharge from neurology and a website scribbled on a piece of paper, largely, I suspect due to a history of anxiety and depression since adolescence. There has been *no treatment* as if these three letters magically make it disappear. I am fortunate to have a listening and determined GP who is investigating other endocrine, rheumatic and neuromuscular possibilities, most recently seeing a big improvement with pyridostigmine bromide, so its looking increasingly like myasthenia gravis, which was dismissed on a single negative blood test, negative in up to 50% of cases of ocular myasthenia.

I cannot tell you how damaging those three letters are, both psychologically and physically. It is a hugely worrying trend and this "rule in" tendency is easily exploited. Thank you so much for looking beyond those three letters and championing the cause of those too easily labelled with this "Emperor's New Clothes" diagnosis.

My child was taken by child ‘protection’ because of this presentation and I am urgently trying to get them home and safe. Are there specific tests or advice you could give to pass to my lawyer at all? They accused me of FII even though psychiatrist denied it and they are ignoring all her symptoms and says she makes it up. It is torture and the damage is so great.

My son presented exactly as the patient you described. He was 11, sudden onset vocal and motor tics, (well over 200 per day and complex), then jerking seizure like movements of arm and leg on one side. Next came collapsing and what looked like loosing consciousness, (eyes were closed) but would come to and could describe what we had been saying to him. He was given a conversion disorder diagnosis despite no trauma. He then developed paranoia and attachment issues, followed by amnesia that looked like delirium plus poor cognition. The last stage was debilitating fatigue, POTS (resting >90 bpm, standing >180bpm), profuse sweating and inability to regulate temperature, joint pain, constant severe headache (described as brain to big for skull), light sensitivity due to dilated pupils, chronic digestive issues and skin sensitivities. He now receives IVIg ... and is regaining his life.

Thank you for writing about this. We had a very similar experience indeed with seizures and mention of an FND diagnosis. Luckily we found an infectious cause, treating that and the inflammation led to huge improvement. FND diagnosis would have got us nowhere and no help. It's a meaningless diagnosis too easily given out when an anwser can't easily be found. This definitely needs calling out so thank you.

My daughter has exactly these issues, sudden onset tics and FND diagnosis. Currently in a psych unit last 2 years and little to no progress. Am struggling to get her professionals to listen to the possibility of immune mediated disease causing her problems and act accordingly. The system needs to change. When information is staring them in the face they still dismiss it.