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

Jon Stone, Michael Sharpe and others in their 2010 Editorial 'Issues for DSM-5: Conversion Disorder':

“the name “conversion disorder” has not been widely accepted by either nonpsychiatrists or patients. We therefore need a name that sidesteps an unhelpful brain/mind dichotomy, will be more widely used clinically, and will be more accepted by patients. We suggest that the term “functional neurological disorder,” as a diagnosis for symptoms such as “functional weakness,” would be practically and theoretically more useful …..

In summary, we suggest that conversion disorder be renamed “functional neurological disorder”

American Journal of Psychiatry June 2010.




And so it came to pass - Conversion Disorder (Functional Neurological Symptom Disorder) DSM-5 300.11 (2013)

The DSM5 Primer states:
'Conversion Disorder (also known as Functional Neurological Symptom Disorder or Functional Neurological Disorder [FND]) is a mental disorder characterized by neurologic symptoms (either motor or sensory) that is incompatible with any known neurologic disease'



Stone Sharpe Issues for DSM5 2010 Conversion and FND

https://ajp.psychiatryonline.org/do...NrbmUXASfhJ-JoqZErk7q0O2yn0fjT3iRQZNv6RIvvM-k

https://ajp.psychiatryonline.org/doi/pdf/10.1176/appi.ajp.2010.09101440







DSM5 Library

Somatic symptom disorder and other disorders with prominent somatic symptoms constitute a new category in DSM-5 called somatic symptom and related disorders. This chapter includes the diagnoses of somatic symptom disorder, illness anxiety disorder, conversion disorder (functional neurological symptom disorder), psychological factors affecting other medical conditions, factitious disorder, other specified somatic symptom and related disorder, and unspecified somatic symptom and related disorder.

https://dsm.psychiatryonline.org/doi/full/10.1176/appi.books.9780890425596.dsm09
 
WHY I THINK FND IS BULLSHIT

"A lot of patients, from ME, to long COVID, to post-vaccine syndrome, and MANY MORE get referred to neurology thinking they will get extensive neurological tests done demonstrating why their body has gone haywire, only to come out with “your symptoms are functional”. Et voila, you now have a functional neurological disorder, or FND.

Functional?

What the hell is functional?

Yes, that is exactly my question too. WHAT THE HELL IS FUNCTIONAL?!

In this post, I’m going to explore, in the most generous of ways I can, what functional is, and why I think it is complete and utter bullshit. "

https://dontbelievehype.co.uk/covid-&-vaccines/f/why-i-think-fnd-is-bullshit

Source:
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Andy said:
WHY I THINK FND IS BULLSHIT

"A lot of patients, from ME, to long COVID, to post-vaccine syndrome, and MANY MORE get referred to neurology thinking they will get extensive neurological tests done demonstrating why their body has gone haywire, only to come out with “your symptoms are functional”. Et voila, you now have a functional neurological disorder, or FND.

Functional?

What the hell is functional?

Yes, that is exactly my question too. WHAT THE HELL IS FUNCTIONAL?!

In this post, I’m going to explore, in the most generous of ways I can, what functional is, and why I think it is complete and utter bullshit. "

https://dontbelievehype.co.uk/covid-&-vaccines/f/why-i-think-fnd-is-bullshit

Source:
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Author's own tweet
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I am encouraged by the amount of overt push back by both patients and clinicians/researchers that seems to be happening against FND.

It increasingly seems like whatever patients do is wrong: don't try hard enough, try too hard, ask for more tests, sit and suffer ad infinitum...

https://dontbelievehype.co.uk/covid-&-vaccines/f/why-i-think-fnd-is-bullshit
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The Goldilocks theory of therapeutic failure. Finding the 'right balance', which can only be done with the careful guiding therapeutic hand of a experienced and expensive expert.

Most importantly, if isn't successful it is never the expert's fault.
 
Jonathan Edwards said:
It's nice to hear that this isn't conversion after trauma any more - although last time we had something on this it seemed to just have changed the names.

The attempts at scientific explanation do not look very coherent to me. I was intrigued by the comment - brain scans of FND patients appear to demonstrate that conscious parts of the brain have become over-involved in movement.
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If that is the case then there is enough work going on in certain parts of psychology that look at the processing involved in movement - particularly with things like stroke or brain injury or illness - for that to be significant.

I'm thinking with the forward and backward processing involving properception etc it utterly makes sense if it relates to an illness where energy is an issue and your body parts don't work the same any more then it isn't going to be 'automatic' that if you reach out your arm in the same way it will get there in the same angle, pace etc. to catch a ball. Or miss the door frame if your gait has changed. That doesn't make the issue causing it psychological, nor does it make the 'fix' psychological - because the patients are already doing all they can tenaciously from that perspective, but the underlying issues getting worse makes it a moving target if it is an illness based elsewhere?

And that's just one guessy, naff explanation that's more logical than theirs.

But yes with all the muddying of what different people and areas mean by 'unconscious'. A stroop test where you don't notice influence of colour vs reading the word and the control is unconscious because it is so fast all the way up to trauma you didn't realise you'd ever had apparently influencing your health and every decision and personality are NOT the same thing clearly, but I have actually had enough idiots trying to quote the former as proof of the latter.

And that is just one common sense way in which it's explained more simply by anything other than whatever this FND bucket nonsense is (that I'm not sure they know what it is other than a shove off to this dept to deal with). Isn't it the classic if your area isn't capable of addressing it/it's not on the list, don't imagine anything cross-disciplinary other than psych as part of the conundrum?

And start having half your staff training in the area of proving that strange assumption instead of cross-disciplinary with other medical or scientific aspects. That's the weird bit how that has grown and happened.
 
Besides all of the above (very valid) reasons, I also just find it highly unethical that "functional" is used to mean different things when speaking to patients and when speaking to clinicians -- and this is often *encouraged* by the people supposed to be on the patients' side.

From people offering psychological therapies, I find this disturbing. It's essentially gaslighting.

And what happens when the patients find out about this trickery? Why don't people who specialise in psychology (and neuropsychology) recognise the cognitive dissonance this requires and why don't they work to challenge this hypocrisy?

They are supposed to be supporting and healing patients, yet they intentionally mislead them, despite surely knowing what the intense psychological impact of that can be?

It boggles the mind. It really does.
 
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Andy said:
WHY I THINK FND IS BULLSHIT

""A lot of patients, from ME, to long COVID, to post-vaccine syndrome, and MANY MORE get referred to neurology thinking they will get extensive neurological tests done demonstrating why their body has gone haywire, only to come out with “your symptoms are functional”. Et voila, you now have a functional neurological disorder, or FND.

Functional?

What the hell is functional?

Yes, that is exactly my question too. WHAT THE HELL IS FUNCTIONAL?!

In this post, I’m going to explore, in the most generous of ways I can, what functional is, and why I think it is complete and utter bullshit. "

https://dontbelievehype.co.uk/covid-&-vaccines/f/why-i-think-fnd-is-bullshit
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This is some commentary from the blog, about Jon Stone's website:


“The most commonly used type for FND is Cognitive Behavioural Therapy (CBT). Psychodynamic therapy (‘psychoanalysis’), Dialectical Behavioural Therapy (DBT) and hypnotherapy can also be used.”

You have, once again, read that correctly. Psychoanalysis and hypnotherapy are considered valid treatments for FND. I do not know how anyone thinks this is not quackery.

CBT is used most commonly:

“In the context of FND, CBT focuses on identifying precipitants (‘triggers’) of physical symptoms (e.g. seizures) and finding ways to stop these symptoms occurring, such as using distraction or relaxation techniques”

The website claims there is stronger evidence for CBT, in the form of RCTs. Let’s take a wee look.

Citation 1: Nothing to do with FND

Citation 2: Is a pilot study. Pilot studies are conducted to assess feasibility not to assess claims. But if you don’t want to accept basic research methods, beyond that, they found similar outcomes at 3 month follow-up (despite the abstract making it sound like they found distinct improvement). For the stats nerds: OR 3.13, 95 % CI 0.85, 11.47; p = 0.086.

Citation 3: Another pilot study. The study states it was not poweredto detect between group differences...i.e. what you need to make clinical claims of efficacy, but regardless, there was no between-treatment effect anyway. In plain speak: Nothing to see here folks (plus it was focused on seizures, no idea what other so-called FND symptoms would respond like):

“The pilot study was not powered to detect between-group differences and was designed for within-group analyses…No interaction effect or between–treatment condition seizure trajectories were observed”

I think they are using the lack of power excuse to dismiss their lack of effect to be honest. But I speculate.

So in all, based on the evidence that Prof Jon Stone thinks is most convincing for his website, it is unimpressive to say the least. Let’s move on."
 
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Hutan said:
This is some commentary from the blog, about Jon Stone's website:


“The most commonly used type for FND is Cognitive Behavioural Therapy (CBT). Psychodynamic therapy (‘psychoanalysis’), Dialectical Behavioural Therapy (DBT) and hypnotherapy can also be used.”

You have, once again, read that correctly. Psychoanalysis and hypnotherapy are considered valid treatments for FND. I do not know how anyone thinks this is not quackery.

CBT is used most commonly:

“In the context of FND, CBT focuses on identifying precipitants (‘triggers’) of physical symptoms (e.g. seizures) and finding ways to stop these symptoms occurring, such as using distraction or relaxation techniques”

The website claims there is stronger evidence for CBT, in the form of RCTs. Let’s take a wee look.

Citation 1: Nothing to do with FND

Citation 2: Is a pilot study. Pilot studies are conducted to assess feasibility not to assess claims. But if you don’t want to accept basic research methods, beyond that, they found similar outcomes at 3 month follow-up (despite the abstract making it sound like they found distinct improvement). For the stats nerds: OR 3.13, 95 % CI 0.85, 11.47; p = 0.086.

Citation 3: Another pilot study. The study states it was not poweredto detect between group differences...i.e. what you need to make clinical claims of efficacy, but regardless, there was no between-treatment effect anyway. In plain speak: Nothing to see here folks (plus it was focused on seizures, no idea what other so-called FND symptoms would respond like):

“The pilot study was not powered to detect between-group differences and was designed for within-group analyses…No interaction effect or between–treatment condition seizure trajectories were observed”

I think they are using the lack of power excuse to dismiss their lack of effect to be honest. But I speculate.

So in all, based on the evidence that Prof Jon Stone thinks is most convincing for his website, it is unimpressive to say the least. Let’s move on."
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Psychoanalysis is very dated. DBT is also what they use to treat borderline personality disorder. Seems like they're making it all up as they go along. Maybe that's the true meaning of functional? It functions to give them all a job doing anything they want.
 
Lou B Lou said:
“the name “conversion disorder” has not been widely accepted by either nonpsychiatrists or patients. We therefore need a name that sidesteps an unhelpful brain/mind dichotomy, will be more widely used clinically, and will be more accepted by patients. We suggest that the term “functional neurological disorder,” as a diagnosis for symptoms such as “functional weakness,” would be practically and theoretically more useful …..
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Maybe that says it all - a term designed to 'sidestep' any meaning that might give the game away.
 
This is worth saying again:
adambeyoncelowe said:
Besides all of the above (very valid) reasons, I also just find it highly unethical that "functional" is used to mean different things when speaking to patients and when speaking to clinicians -- and this is often *encouraged* by the people supposed to be on the patients' side.

From people offering psychological therapies, I find this disturbing. It's essentially gaslighting.

And what happens when the patients find out about this trickery? Why don't people who specialise in psychology (and neuropsychology) recognise the cognitive dissonance this requires and why don't they work to challenge this hypocrisy?

They are supposed to be supporting and healing patients, yet they intentionally mislead them, despite surely knowing what the intense psychological impact of that can be?

It boggles the mind. It really does.
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Trial By Error: Does Functional Neurology Disorder Account for a Third of Outpatient Neurology Consults?

"The “positive identification” of FND is conducted through the use of strategies designed, for example, to demonstrate that patients whose attention is distracted can perform physical actions they are otherwise incapable of executing voluntarily. Assuming that these signs accurately identify FND, then the prevalence of the condition in outpatient neurology consultations is, as Carson and Lehn noted, “approximately 6%.” This data point for what they called “typical FND cases” is from a major study of Scottish neurology practices, which Carson and Lehn reference in the text of their chapter. (While they rounded up to 6% in the abstract, they used a more precise figure of 5.4% in the text of the chapter.)

But that doesn’t seem to be the most widely used estimate for this disorder. FND experts have a tendency to cite a higher figure—16%–as the prevalence among outpatient neurology consultations. Here, for example, is a statement from a 2021 paper, whose authors included Alan Carson: “FND is among the most common causes of neurological disability, diagnosed in approximately 16% of outpatient neurology consultations.”

Huh? How can the prevalence of FND diagnoses in outpatient neurology consultations be both 5.4% and 16%?"

https://www.virology.ws/2022/06/16/...for-a-third-of-outpatient-neurology-consults/
 
Good catch, noticing how explanations, from the same people, switch back and forth being "ruled in" while also being made out of (poorly) ruling out other things. The lack of consistency alone should be grounds for major concerns, and yet it almost seems to be a feature. Remaining vague, even confused, is necessary, as it avoids the whole issue with making claims that can be falsified.
 
I read the article by FND portal. I see nothing in there that would validate a diagnosis of FND. The person has some neurological illness that doctors cannot diagnose. If FND was a neutral term that meant "unexplained neurological illness" it would be acceptable but it's got all this pseudoscientific explanatory model attached to it which I just cannot take seriously. My suspicion is that a lot of FND doctors don't understand how they're injecting their own biases into their research and encounters with patients and then see their biases confirmed. e.g. The article mentions a study where children are trained to reinterpret their symptoms which I suspect as extremely high risk of bias due to it involving deliberate reinterpretation of symptoms, in children, with a marginalized disease. I also noticed how FND studies often don't have control groups but interpret effects they find as being specific to FND. If a proper control group was added they would risk discovering that some of the signs they believe are due to faulty processing in the brain might actually be normal (in chronically ill patients). They would interpret that not as lack of validity of FND but that many patients have some "functional overlay" to their symptoms.

Maybe that person is happy with FND because it's an illusory answer that gives them some hope or sense of control, or they're content with a stop to further investigations or the diagnosis gives them access to resources they find useful or helps them be more open about their disability.

I suspect it's not possible to have a conversation with FND proponents about the lack of validity of FND without them feeling invalidated and insulted.

That doesn't mean that there is nothing that is useful and valid in FND. But the overall impression is not good. The involvement of Sharpe, Carson, and attempts to bring ME/CFS into the FND category further reduces credibility. People that are incompetent in ME/CFS are probably incompetent in other areas too.
 
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For those who have been involved in the ME world longer than I, were there patient advocates who accepted and defended the deconditioned/GET/CBT paradigm in its early days in a similar way to how there currently seems to be FND patients who accept and defend FND?
 
Andy said:
For those who have been involved in the ME world longer than I, were there patient advocates who accepted and defended the deconditioned/GET/CBT paradigm in its early days in a similar way to how there currently seems to be FND patients who accept and defend FND?
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I wonder about this too. FND has some patient support now, but in 20 years, will the majority of FND patients rebel against what they perceive as a nonsensical and pseudoscientific model of care in the same way ME/CFS patients did?
 
I think fnd is completely pseudo-science and a lot of bias is expressed in both research and clinical practice.
It is also very circular.
I did like the article in tullers twitter account about a misdiagnosis and the huge payout. That should have the alarm bells ringing or will mit be glossed over and business as usual.
 
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