Healthcare employment as a risk factor for functional neurological disorder: A case–control study 2023 Vanini et al

Background and purpose

Female gender, younger age and stressful life events are known predisposing factors for functional neurological disorders (FNDs). Employment in a healthcare profession has also been suggested to be a predisposing factor. We set out to conduct a large-scale case–control study to estimate the rate employment in a healthcare profession among people with FND.

Methods
We included 200 consecutive patients with a confirmed diagnosis of FND, referred to our clinic at University Hospital Bern Switzerland between October 1, 2016, and August 1, 2019. In addition, we included a control group of 200 patients with a confirmed neurological disorder, matched for age and gender, seen during the same period. The primary endpoint was to compare the prevalence of healthcare professionals between the groups. We also describe the clinical manifestations and concomitant psychiatric diagnoses in the FND cohort.

Results
Female gender was predominant (70%), and the participants’ mean age was 37 years. The proportion of healthcare professionals in the FND patients was 18% (33/186), which was significantly higher than in the control group, in which it was 10.6% (17/189; p = 0.019, 95% confidence interval odds ratio 1.168–4.074). Most healthcare professionals in both cohorts were nurses (21/33 among FND patients, 10/17 among controls). Among FND patients, 140 (70%) had motor symptoms and 65 (32.5%) had a concomitant psychiatric diagnosis.

Conclusion
This case–control study confirmed a higher rate of employment in healthcare professions in patients with FND, suggesting two potential mechanisms of FND: exposure to models/specific knowledge about neurological symptoms or stress-related professional factors. This warrants further studies on underlying mechanisms and prevention.

Open access, https://onlinelibrary.wiley.com/doi/10.1111/ene.16056

 

Firstly it sounds like they are looking at FND diagnoses and not 'FND' given I don't see a bit where they thoroughly checked alternatives.

But pretty importantly what was the point of this - I'm not sure what these people think their 'research question' is underneath their methodology. I'm not sure it is a method for anything:

- pick out 200 FND diagnosed people,
- match them by gender and age to find 200 other mostly female, young people who have been diagnosed with a different neurological disorder not much other detail on how they picked them and how this wouldn't have been biased to have exclude healthcare professionals - given this was the one measure, so to be meaningful the same needed to have something that made it either very random or very representative based on a non-underlying factor.
- calculate the % in each group who are healthcare professionals

What does that actually tell anyone? How is either sample representative of anything?

And... unless they believe FND is conversion disorder and ergo in their heads think 'these young women who see people with illnesses start subconsciously imitating their symptoms' I can't imagine why they think the healthcare professional bit is relevant or makes sense?

So it isn't just the being women and young they target? But other things make for more juicy and tempting priming - or maybe it just happens to be a profession where it is harder to hide your symptoms so given these FND mills are of recent years more who have been working in healthcare have got pushed through a diagnosis process that shoved the women into FND. Were these 200 controls diagnosed over the same time period as those with FND were as a sample? Had they taken longer to get through the system?

Did these controls see the same physicians as the FND sample to be diagnosed and who were they? How is 33 people out of 189 vs 17 out of 183 mixed other diagnoses selected telling us anything?

Because of the nature of the age group and gender that they've been diagnosing heavily with FND this meant that this wasn't 'random' across neurological diseases but is going to be people who either have ones that present in younger females more often but also are diagnosed within that timeframe. MS, stroke/vascular and migraine seem to be predominant. Even then you are looking at people with early onset and early diagnosis to match the age groups, and from what I'm sensing about FND being a fob-off that is never removed and frustrates future diagnoses e.g. that eventually become obvious for things like CJD, they are comparing relatively new 'FND patients' with a certain young-onset sample of new and follow-ups from a department that has been running for many years.

So one could say the 'tested' and in later stage vs the 'never tested' poentially early stage (if it is being encouraged that 'diagnosing FND first' is a good thing these days) when you compare regimes, that maybe some of those could in their early presentation have been missed had their been a different approach rather than wait and see or testing.

Anyway, to me the authors suggesting the 'only two explanations' they have is surely nonsense. Are they being deliberately unself-aware or is it tongue in cheek to not think maybe them doing the follow-up with the same people and checking for other neurological conditions through an independent assessor e.g. in 3yrs time for those in the FND sample would be the real answer - to check it isn't healthcare professionals perhaps picking up on early onset whatever and a system tending to shove those people into the FND box? or of course there is also the possibility of it indeed being pure priming (those who made said assessments think female healthcare professionals and think FND) ?

How is this any more scientific than writing abstracts telling GPs that 10% of their patients will have FND as priming in order to end up with those GPs following such orders and looking out for 10% of their patients and the characteristics of female, young and find a trauma?

Did it even include the laugh of saying they tested everyone with the 'hoover's sign'? I mean even if you believed in all of that surely you'd make it time-stamped, not rule anyone out, do the hoover's sign or whatever on them all and then present all of the data without having to only use the matched-pairs for the different diagnoses. So we could see whether if e.g. 2000 people entered the dept in a year at what stage people 'pathwayed' into different areas of diagnosis based on what and whether it was gender,age and job or actual tests coming first.

 

I'm probably repeating some of @bobbler's comments, but this paper is ridiculous.

You've got the apparently well recognised relationship between healthcare worker and FND, such that it has been considered a diagnostic criterion.

So then they retrospectively look at those diagnosed with FND and see how many are healthcare workers. Amazing.

OK, so let's say that the above has no bearing and there is no such bias in the diagnosis and this is all done objectively via the much-vaunted "rule-in signs". So what has this study done?

It's a retrospective case-control study, matching by age and sex those with an FND diagnosis and those with a non-FND neurological diagnosis. The mean age is 37. The majority are female.

The profession is listed as healthcare (which is sub-categorised) or "other". I note no medical doctor had an FND diagnosis - zero.

The non-FND neuro diagnoses are largely vascular (stroke, TIA, carotid dissection), epilepsy and MS. If you have already acquired one of these diagnoses by a mean age of 37, I'd hazard that you are less likely to have wanted to apply to become, or successfully qualify as, a healthcare professional: particularly one that is doing overnight shift work of 10 hours.

OK, on to their hypothesis. The poor dear poppets are modelling neurological disorders they see in patients. Not deliberately mind you, it's that Bayesian prediction again - all unconscious you know.

The implication being that this only happens if you have a certain degree of knowledge. Which is why the doctors themselves would not be at risk, because they're too clever and know too much. Even though it's all unconscious prediction "software" somehow.

Or maybe it's because they're female and nurses —

Oh wait perhaps it's teh personalitees —

I don't know whether (female) nurses or (male) doctors might tend to have more emotional intelligence - oh wait I do know this one. So I guess don't be too empathic kids, or you'll be modelling the patients and then you gets the FND.

I can only imagine what symptoms veterinary nurses would present with. Functional hairballs maybe?

 

you've hit the nail on the head there i'd say

My cat started having something similar to non epileptic seizures (myoclonic jerks) she had all kinds of tests and they said they couldnt figure out what was causing it. I said to the vet & nurse, oh do you think its psychosomatic/behavioural then? like is she unhappy & its manifesting somatically?
They looked at me like i was either insane or stupid. "of course not, we just dont know why its happening to her"

I mentioned that if she was a human she'd definitely be referred to psych. He again looked at me with an expression that said 'are you stupid' & said "why?"... i replied that 'well because everything that doesnt have an abnormality showing up on a test must be psychological problem manifesting itself through the body & i know this from personal experience'.

He shook his head and raised the side of his lip "what about things we dont know how to test for yet"... lol i dont think he even believed me!

 

Since being female and young is a "known predisposing factor" for FND, I'm not surprised that such patients struggle to get any treatment for their illnesses of any kind. The decision about what is wrong with them has probably been decided before they've even got through the door of the doctor's surgery. And in the NHS in its current method of working it is probably the receptionist who will pass this on to the doctor when the patient requested an appointment.

 

Hmmm. I wonder if there might be some other factor that healthcare professionals are exposed to more than the average person and may explain this. Especially nurses, as this sample obviously massively skews toward.

Some kind of factor in their workplace, one that causes acute illnesses, spreads though all sorts of means and ways, including the air. Some sort of... theory... about very tiny things causing... diseases...? Invisible to the naked eye, but knowable and, in fact, known?

Oh well, can't think of anything so it must be the magical mind bits. Or maybe healthcare professionals are the only people who work hard and experience "stress", whatever is meant by that. Well, nurses anyway. That sure is an explanation, of some sort.