Mystery illnesses reveal the power of our minds to influence health, New Scientist

[aza]

Hi guys, I'm enjoying the discussion, you are very knowledgeable. I am just an observer for the time being, until I can absorb more info and have some time to process it (menopausal aspie brain is a bit slow these days).

I thought conditions whose cause is unknown or uncertain are called idiopathic. If you call them 'functional' that would mean there's some functional abnormal evidence, like the ones you see during functional MRI studies, when areas of the brain show different patterns of activity when compared to controls. Is this another example of stigmatisation of brain issues?

I think evolution has the answer for most of nature's "mysteries", but when it comes to human evolution, there's always the problem of subjectivity, humans can't be guinea pigs for objective experimentation. When these researchers say they haven't found any physical sign of brain disease, what exactly are they calling physical? Quantum physical? Are they saying the unconscious mind is in control of the symptoms? I find it all very confusing, excuse me if I'm being simplistic.

 

[rvallee]

but cause no observable changes in organs

I think this is probably the key: observable changes to physiology. To say that there are no changes is simply unscientific. There are too many gaps in our knowledge to make such broad statements. It was just last year that medicine confirmed the existence of a previously unknown freaking entire organ because it would have to have been observed in situ while the body did its thing.

This is way too much like the faces-on-mars things. Until we have the proper resolution to make out details, we can't just have people fill in the gaps with their gut feelings. This is a terrible way to go about things, 10x so in medicine where the consequences can be impairing progress and causing harm.

 

[Hoopoe]

I find it all very confusing, excuse me if I'm being simplistic.

While the names being used for the concept changes, the concept itself has not changed much since the 18th century. The idea is there are diseases of organic origin and diseases of emotional and mental origin. Functional disorder is now used to refer to these diseases of emotional and mental origin because it hides the real meaning from the patient. If it doesn't make much sense and is confusing that's because it doesn't make sense. It's experts pretending they have a clue to avoid embarassment and healthcare systems finding it cheaper to classifiy poorly understood illness as mental problem.

Functional disorder can also mean that some disturbance of function is present.

 

[aza]

Thanks @strategist. While I understand that 'functional' is being used to refer to diseases of 'emotional' and 'mental' origin, and that some disturbance of function is present, I still find it an unscientific term, unless it points to the specific function that's altered and the cause of disturbance. If it's being used as a general term it says nothing really. I also don't understand 'functional' meat burgers, it sounds like the word has been used loosely. There must be a word that better fits what they want to advocate. If these ailments are purely routed on emotional origin shouldn't they be addressed by psychiatrists and psychoanalysts and shouldn't these treatments effectively work? Is there any evidence that by addressing the emotional origin, the symptoms disappear?

 

[Jonathan Edwards]

If you call them 'functional' that would mean there's some functional abnormal evidence, like the ones you see during functional MRI studies

The evidence of functional abnormality in this case is of the organ not doing the job it is supposed to do - not carrying outfits function. So if the person cannot stand up and the cause sin the brain, sit seems to be, then that is a problem with brain function. It does not imply that there is evidence from tests of some causal mechanism malfunctioning.

The 'functional' in functional MRI is rather confusing because it was originally meant to mean that the MRI was done while the organ was performing a function. So fMRI is done while asking people to think about playing tennis or some such. However, the methods used in fMRI tend to track functional mechanisms like oxygen uptake. So people also talk of fMRI as a tool for studying physiology, independent of whether the person is performing a special function.

When it is said that no physical abnormality can be found in FND, it means that nothing can be measured that distinguishes the FND patient from a healthy control using physical methods. All methods are physical in a sense but asking someone if they have a headache does not count as a physical measure.

 

[chrisb]

Isn't part of the problem with "functional disorder" that it is not a diagnosis, but merely a different way of describing the symptoms.

Patient says "this doesn't seem to be working properly". Doctor says "Yes, it's what we specialists call a functional disorder".

 

[Jonathan Edwards]

Isn't part of the problem with "functional disorder" that it is not a diagnosis, but merely a different way of describing the symptoms.

Patient says "this doesn't seem to be working properly". Doctor says "Yes, it's what we specialists call a functional disorder".

I see functional disorder as a perfectly reasonable term if it is being used in the straight sense without implying any 'influence of mind'. In the straight sense it is a legitimate shorthand for:

'A disorder with functional impairment in the absence of any identifiable structural cause.'

If I were to use such a term I might well explain to the patient that it is a bit like a software problem rather than a hardware problem - a malfunction without any actual damage. To that should be added a bit of discussion about whether the absence of structural damage is a good thing or not necessarily, focusing on realistic information about prognosis.

 

[aza]

Thanks @Jonathan Edwards. So, it's called functional based on lack of another explanation (ie, physical abnormality), so why not call it idiopathic? I find it hard to accept that something is being categorised without clear boundaries. I don't see how this term can render these conditions less 'mysterious'.

I have Asperger's Disorder, is it a FND?

 

[chrisb]

I accept that it has uses provided that it is not implying (or, indeed, expressing) psychological causation. My point is that it is not taking the matter any further forward other than offering an alternative description of the symptoms.

 

[aza]

'A disorder with functional impairment in the absence of any identifiable structural cause.'

Isn't part of the problem with "functional disorder" that it is not a diagnosis, but merely a different way of describing the symptoms.

Patient says "this doesn't seem to be working properly". Doctor says "Yes, it's what we specialists call a functional disorder".

Thanks. I agree, the term functional is merely descriptive.

 

[roller*]

I might well explain to the patient that it is a bit like a software problem rather than a hardware problem - a malfunction without any actual damage.

what damage do you see at all ?
why to ignore the bleeding obvious in that ?

that the technician
a) doesnt have a complete construction plan yet (how embarrasing)
b) has parts of some construction plan that are based on guesses only
c) has parts of some construction plan that have proven grossly faulty in the past
d) doesnt have the tools to diagnose even the known circuits
e) doesnt have tools to repair known issues in those circuits

you have to tell your customer.

in addition, feel free to suggest the customer has caused themselves a software problem.

 

[aza]

I see that wikipedia calls it 'Functional neurological symptom disorder'. My bolding. Even more descriptive.

One differential diagnosis is hemiplegic migraine, which runs in the maternal side of my family. I wonder if it's just a matter of time to find out the 'structural cause'.

 

[Dx Revision Watch]

Thanks @Jonathan Edwards...

I have Asperger's Disorder, is it a FND?

For ICD-11, Asperger disorder has been absorbed into and is a sub class of:

Autism spectrum disorder

and is classified as a Neurodevelopmental disorder:


https://icd.who.int/dev11/l-m/en#/http://id.who.int/icd/entity/120443468

6A02.0 Autism spectrum disorder without disorder of intellectual development and with mild or no impairment of functional language

All Index Terms

• Autism spectrum disorder without disorder of intellectual development and with mild or no impairment of functional language
• Asperger syndrome
• Asperger
• Asperger disorder
• Autism spectrum disorder without disorder of intellectual development and without impairment of functional language

 

[Dx Revision Watch]

I see that wikipedia calls it 'Functional neurological symptom disorder'. My bolding. Even more descriptive.

One differential diagnosis is hemiplegic migraine, which runs in the maternal side of my family. I wonder if it's just a matter of time to find out the 'structural cause'.

'Functional neurological symptom disorder (Conversion disorder)' is the term used by DSM-5.

ICD-11 is using "Dissociative neurological symptom disorder".


This is how the DSM-5 structures the Dissociative disorders category blocks and the Somatic Symptom and Related Disorders category blocks:

https://www.psychiatry.org/File Library/Psychiatrists/Practice/DSM/APA_DSM-5-Contents.pdf

Table of Contents

(...)

Dissociative Disorders

Dissociative Identity Disorder
Dissociative Amnesia
Depersonalization/Derealization Disorder
Other Specified Dissociative Disorder
Unspecified Dissociative Disorder


Somatic Symptom and Related Disorders

Somatic Symptom Disorder (ICD-11's equivalent is Bodily distress disorder, with Somatic symptom disorder under Synonyms to BDD)
Illness Anxiety Disorder
Conversion Disorder (Functional Neurological Symptom Disorder) (ICD-11's equivalent has been retained under Dissociative disorders and secondary parented under the Diseases of the nervous system chapter)
Psychological Factors Affecting Other Medical Conditions
Factitious Disorder
Other Specified Somatic Symptom and Related Disorder
Unspecified Somatic Symptom and Related Disorder

 

[Jonathan Edwards]

so why not call it idiopathic? I find it hard to accept that something is being categorised without clear boundaries. I don't see how this term can render these conditions less 'mysterious'.

I have Asperger's Disorder, is it a FND?

Idiopathic does not require an absence of structural change. Psoriasis remains 'idiopathic' in the sense that we do not know what causes it, but there is major structural change in the skin to explain the itching. So FND is idiopathic (if we assume it is not due to emotional trauma) but it is more specific than that - it does not even have a structural change to explain the route from cause to effect.

There are no clear boundaries in medicine. There are, strictly speaking, no illnesses, only ill people - each one different so you can categorise to the end of time and never get the next person to fit.

The term is not intended to make the illness less mysterious. And I think this may be relevant to chrisb's point too. The term is honest, as it should be. It implies that we do not know - the most important thing of all to say, if it is true. The point of giving it a name is to reassure the patient that the doctor has seen the problem before and other doctors have seen it before and people have thought about it enough to delineate it as best they can.

You might think Asperger's would qualify as a FND and it certainly seems to at first. However, the full concept of FND implies that a nervous system that is capable of functioning entirely normally is now malfunctioning. The general view of Asperger's is that it is a problem of different function based the way the nervous system has developed. In other words, although there is no specific evidence from scans etc. the assumption is that Asperger's is really a hardware problem. That might be wrong though.

I think it is important to realise that terms in medicine are pragmatic and not necessarily logical or watertight. So FND is used to cover a group of illnesses that cannot be categorised any other way and which look similar enough to give the same name. It is a bit like swallows. If you live in England swallow is a good enough name, despite the fact that there are about a hundred types of swallow other than the (barn) swallow we have here.

I thin getting hung up on medical terms is a mistake. What matters is how doctors use them. That is muddled for FND but it does not mean that FND is not as good a term as we can expect for the time being.

 

[aza]

Thank you very much, @Dx Revision Watch. I knew Asperger's wouldn't fit the category, but I just wanted to ask the question because although it's classified as a 'Neurodevelopment Disorder' it's also described as 'Autism spectrum disorder without disorder of intellectual development' so what is the neurodevelopment problem? I mean, there's no 'structural cause' either.

 

[aza]

Idiopathic does not require an absence of structural change. Psoriasis remains 'idiopathic' in the sense that we do not know what causes it, but there is major structural change in the skin to explain the itching. So FND is idiopathic (if we assume it is not due to emotional trauma) but it is more specific than that - it does not even have a structural change to explain the route from cause to effect.

There are no clear boundaries in medicine. There are, strictly speaking, no illnesses, only ill people - each one different so you can categorise to the end of time and never get the next person to fit.

The term is not intended to make the illness less mysterious. And I think this may be relevant to chrisb's point too. The term is honest, as it should be. It implies that we do not know - the most important thing of all to say, if it is true. The point of giving it a name is to reassure the patient that the doctor has seen the problem before and other doctors have seen it before and people have thought about it enough to delineate it as best they can.

Plaque Psoriasis and Psoriatic arthritis are autoimmune diseases.

I agree that categorisation of illnesses is a necessary evil, but I don't see how 'functional' is relevant to the name unless it would be called "Idiopathic Functional Neuro Disorder". That would reassure patients that the doctors acknowledge they don't know the cause of their real disease.

 

[Jonathan Edwards]

Plaque Psoriasis and Psoriatic arthritis are autoimmune diseases.

Actually they are almost certainly not. Nobody has ever found an autoantibody or auto reactive T cell to explain them. (If you are new to the forum you may not be aware that as a professor of medicine/immunology my main work was on autoimmunity.) I agree that psoriasis and the arthropathy are almost certainly mediated by T cell malfunction but we don't have any real idea how.

 

[aza]

Actually they are almost certainly not. Nobody has ever found an autoantibody or auto reactive T cell to explain them. (If you are new to the forum you may not be aware that as a professor of medicine/immunology my main work was on autoimmunity.) I agree that psoriasis and the arthropathy are almost certainly mediated by T cell malfunction but we don't have any real idea how.

Yes, I'm new to the forum. Good to know you're a Professor! I had my first episode of Plaque Psoriasis when I was 11 and the only treatment that has ever helped are TNF-alpha inhibitors so I guess it's an immune disorder, maybe not the 'classical' definition of autoimmune, ie, autoantibodies, but it certainly has a 'structural' feature of excess of specific cytokines.

 

[Mithriel]

That does not actually have to be the case. In autoimmunity B cells that produce autoantibodies are allowed to survive despite their being disadvantageous to the rest of the body. However, these B cells are not in any sense damaged or abnormal in their biochemistry. They use normal physiological mechanisms to produce unwanted signals. You could consider an analogy with machine delivered with the wrong instruction manual. You cannot get the machine to work but neither the machine nor the manual are damaged. The problem is at a higher level of organisation.

This is exactly what I mean. They imply that the brain systems are working properly so our thoughts and behaviours must be at fault, hence CBT. But like your analogy the system is not working properly because things are in the wrong place when they are needed. So the answer is to take away the wrong manual and provide the right one and no CBT is necessary to change thoughts.

My main fear is that FND as a concept is stopping any investigation into why there is the wrong manual, why systems are not lining up there components properly.

If they really meant there was a signalling problem they would not need any input from psychology, in fact they would be as incensed by it as we are.