Functional neurological disorder in Saudi Arabia: A retrospective study, 2023, Tayeb

[Andy]

Abstract

Objectives
To describe the clinical profile of a sample of Saudi patients with Functional Neurological Disorder (FND).

Method
A retrospective review of charts of FND patients seen from 2021-2023 at a neuropsychiatry clinic at an academic tertiary care center in Jeddah, Saudi Arabia.

Results
Out of 473 patients seen in the clinic, 52 (11%) had FND. Their mean age was 34 (standard deviation = 10.7), and 77% were female. Family disputes (39%) were the most reported risk factor, followed by sexual abuse (15%). The most common FND symptoms were nonepileptic seizures (61.5%) and abnormal movements (30.8%). Pain was reported by 57.7% and cognitive symptoms by 36.5%. FND symptoms were frequently attributed to supernatural causes (67.3%). During the last follow up visit, 53.9% of patients reported FND symptom improvement, whereas 21.2% reported no change, 10.2% reported worsening, and 15% were lost to follow-up. The proportion of patients without symptom improvement was higher among patients with cognitive symptoms (45.5% vs 18% respectively, X2 = 10.08, df = 3, P = .018). The mean number of visits was highest in patients reporting worsening and lowest among patients reporting no change (F = 4.21, P = .017).

Conclusion
The role of family disputes in FND in the Middle East, the role of supernatural concepts in how FND is perceived, and the relatively high rate of subjective improvement within this sample of Saudi FND patients merit exploration. Cognitive symptoms may be a prognostic indicator. Prospective multicenter research using standardized assessment scales is needed.

Paywall, https://journals.sagepub.com/doi/10.1177/00912174231215908

 

[SNT Gatchaman]

the role of supernatural concepts in how FND is perceived

Are we talking about the neurologists or the patients?

 

[SNT Gatchaman]

Another notable finding is that more than two thirds of the sample reported that they or their social circles interpreted FND symptoms to be supernatural.

It’s also consistent with how FND-like symptoms have lent themselves to supernatural interpretations since Greek times, including how it was interpreted in Muslim civilizations. The prevailing notion that external forces may influence a person’s psyche and lead to involuntary behaviors and undesirable experiences can be attributed, in part, to a cultural emphasis on mind-brain dualism. This philosophical stance allows attribution of mental and behavioral phenomena to non-organic causes. It was shown that this philosophical belief may form the cognitive basis linked to stigma against neurological and mental conditions.

[...] it may be worthwhile to address the supernatural beliefs as needed during clinical encounters with FND patients while educating patients about the biopsychosocial underpinnings of the disorder. Patients outcomes may be improved if physicians are guided by the principles of patient centeredness, cultural competence, and the importance of spiritual wellbeing in the overall wellbeing of individuals.

 

[SNT Gatchaman]

Counseling Saudi FND patients in the clinic may commence by validating the patient’s symptoms and suffering, followed by introducing the neurobiological processes assumed to underlie these symptoms and the potential role of psychosocial stressors. Physicians may consider discussing how patients understand their symptoms and explore whether supernatural causes contribute to this understanding, particularly if patients raise this issue. In these cases, it is important to listen respectfully, acknowledge that we do not fully understand supernatural phenomena, and state that we do not have evidence directly linking them to the pathophysiology of FND. The approach may then pivot back to the biopsychosocial approach, emphasizing how it provides a framework that informs diagnosis and management from a medical point of view and also encourages approaches to improve spiritual health and wellbeing as an integral aspect of overall health.

 

[rvallee]

Are we talking about the neurologists or the patients?

Yes

 

[rvallee]

Counseling Saudi FND patients in the clinic may commence by validating the patient’s symptoms and suffering, followed by introducing the neurobiological processes assumed to underlie these symptoms and the potential role of psychosocial stressors. Physicians may consider discussing how patients understand their symptoms and explore whether supernatural causes contribute to this understanding, particularly if patients raise this issue. In these cases, it is important to listen respectfully, acknowledge that we do not fully understand supernatural phenomena, and state that we do not have evidence directly linking them to the pathophysiology of FND. The approach may then pivot back to the biopsychosocial approach, emphasizing how it provides a framework that informs diagnosis and management from a medical point of view and also encourages approaches to improve spiritual health and wellbeing as an integral aspect of overall health.

Ha! Beyond parody.

No, not those beliefs, those other beliefs.

 

[SNT Gatchaman]

One reason contributing to patients presenting without seeing a primary care doctor and resorting to supernatural causes and treatments may be the lack of a well-defined clinical care pathway for FND. In fact, a significant proportion expressed dissatisfaction with clinical that they had had before following up in the neuropsychiatry clinic. A proportion of these patients perceived that they had not properly cared for as they bounced from one practitioner to another, hearing different, at times dismissive, explanations for their condition.

The author postulates based on clinical experience that a substantial proportion of Saudi FND patients are receptive to the idea that psychological distress may lead to bodily or neurological symptoms. This receptiveness may be rooted in mind body dualism. Within this perspective, a person is seen as composed of both mental (soul) and physical (brain and body) components that interact with one another. Hence, it is conceivable that disruptions in this interaction may manifest with bodily symptoms. As such, dualistic thinking may predispose patients to attribute their symptoms to supernatural causes, potentially leading to stigma. However, it may also facilitate acceptance of a connection between the mind and the body. Exploring these concepts with patients through appropriate psychoeducation about the biopsychosocial underpinnings of FND may pave the way for patients to develop insight into their illness and facilitate their engagement in the recovery process.

If anyone else is also confused by what is meant by mind-body dualism we have the thread I need a good summary of the problems with mind-body theory to help.

The author has also written Mind-Body dualism and medical student attitudes toward mental illness in Saudi Arabia (2022, The International Journal of Psychiatry in Medicine, paywall) which maybe explains their framing of this.

 

[SNT Gatchaman]

The introduction for Mind-Body dualism and medical student attitudes toward mental illness in Saudi Arabia is —

The biopsychosocial model of mental illness is the predominant paradigm through which mental illnesses are viewed in modern mental health care. This integrated model emphasizes the role of neurobiological causation for mental disorders without neglecting the roles of psychological, social, and environmental factors. This view of mental disorders embraces mind-brain monism, the philosophical stance that all mental phenomena are ultimately brain-based. The opposite philosophical stance is mind-brain dualism (MBD). As articulated by Rene Descartes, Mind-body dualism claims that mental phenomena are separate and independent of physical ones. This view is largely incompatible with modern neuroscience in an era where great advancements in neuroimaging and other techniques has bolstered a cerebro-centric approach to explaining mental disease.​

I don't think I've seen it written elsewhere that BPS emphasises neurobiological causation — quite the opposite.

Mind-body dualism beliefs are also potentially harmful in the clinical context as previous research has shown that such beliefs are associated with undue blame and stigmatization of patients with mental illness. Nevertheless, some mental health professionals and trainees continue to use MBD as a framework for understanding mental illnesses, which may lead them to conceptualize some disorders as “more biological” than others.
​

So here, the framing is mind-body dualism is bad. Whereas in the thread's paper mind-body dualism "may also facilitate acceptance of a connection between the mind and the body".