Psychiatry's modern role in functional neurological disorder: join the renaissance, 2021, Begue, Perez et al

Andy

Andy

Retired committee member
Functional neurological symptom (conversion) disorder (FND) is a neuropsychiatric condition well described in the 19th century, yet largely ignored by late 20th century academics. This ‘blind spot’ is in contrast to FND's high prevalence, disability, and healthcare utilization (Espay et al., 2018). In Neurology, Mark Hallett called FND a ‘crisis’ based on a poor pathophysiological understanding and limited therapies (Hallett, 2006). Recent diagnostic improvements, an emerging neurobiology and renewed interest in treatment development are catalyzing a renaissance for FND among some neurologists. Unfortunately, many psychiatrists are less interested – related to a complex interplay of factors that include, in part, limited exposure (and education) in assessing and managing this population, and less psychotherapy training than a generation ago.

Open access, https://www.cambridge.org/core/jour...-renaissance/2E1ABDA4A3D67373E3FC8BA1A5E68FC7
 
Andy said:
limited exposure (and education) in assessing and managing this population
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Or in other words less indoctrination. FND is a proposed disease or disorder still awaiting solid evidence. Therefore its incidence is suspect. In ME cases rediagnosed as FND the objective evidence of benefit from treatments is from pathetic to harmfull to scientific misconduct.
 
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This is just bizarre, the whole concept exists mainly in psychiatry and would have been forgotten along with phrenology as a weird artifact of the past without psychiatry holding an obsession that has lasted for well over 150 years.

And "largely ignored"? I mean there are only so many things you can say about some imaginary concept based on denial of reality, just like at some point writing about angels dancing on hairpins just repeats itself endlessly. And even most of what has been said is basically parroting the same baseless arguments, different interpretations of the same beliefs. It's obviously an obsession in the field of psychiatry and there have been surveys showing that the vast majority buy into it.

So basically this is a whine that the thing the author believes in is not taken as seriously as they want. Even though it's the current default paradigm. Even the whole attention-seeking is projection, uh? "Pay attention to me, to my beliefs, look at me look at me I'm important". Of course it is. Most BPS papers seem to need to add the affirmation that the BPS model is good and important and needs to be reminded of it every day. Which is unnecessary when something really is important and validated.

Quit. Projecting. Your damn flaws onto us.
 
rvallee said:
And "largely ignored"?
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There seems to be a precedent on which that claim might be based. It might be recalled that McEvedy and Beard claimed that the case for hysteria had not had a fair hearing. This despite the fact that Acheson had set out in detail the refutations of the idea. By making that claim it enabled them to totally ignore the refutations - which honest researchers would have addressed and sought to rebut. Perhaps some similar ploy is intended here.
 
chrisb said:
There seems to be a precedent on which that claim might be based. It might be recalled that McEvedy and Beard claimed that the case for hysteria had not had a fair hearing. This despite the fact that Acheson had set out in detail the refutations of the idea. By making that claim it enabled them to totally ignore the refutations - which honest researchers would have addressed and sought to rebut. Perhaps some similar ploy is intended here.
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The fact that it has been a default explanation for several decades affecting tens of millions really puts a dent in that claim.

It's true that it's absurd that no one really takes it seriously despite this. Which must be very confusing for people who believe in it. It's in widespread use as the default explanation for every complicated ill until proven otherwise, but since there is no basis to it few people actually talk about it. It's both universal and taboo at the same time, needs to be researched all over again but is also basically done and complete and should be expanded as is. Talk about confusion, and of course always discussed with euphemisms, metaphors and other vague language.

Exactly what would be expected of pushing through a weird belief system with no basis in fact, so no surprise here. It's weird, just for the exact opposite reasons the faithful argue. But it's not hard to empathize with how weird this must feel, that this has total unchallengeable dominion over an entire category of medicine, but can't be discussed scientifically, because it's not. But it's far more wrong than weird so whatever, basic common sense should force minimal self-reflection and failing at this is just sad.
 
I personally get the impression there's a great deal of interest in "functional neurological disorder" in psychiatry. Which makes the lack of remotely good quality treatment trials on it slightly bizarre. There are many people that have dedicated their careers to this. Where are the large, properly controlled RCTs of treatments with proper long term followup? They just don't seem to exist. It's weird. I don't get it.

(There is this trial: https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(20)30128-0/fulltext for cbt for non-epileptic seizures, a subset of FND, which found no significant difference for reduction of seizures)
 
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petrichor said:
Where are the large, properly controlled RCTs of treatments with proper long term followup? They just don't seem to exist. It's weird. I don't get it.
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In my view, with ME treatment using CBT/GET as an example, they don't attempt to do that any more because 100% of trials using objective outcomes and careful design failed. Even PACE failed at long term outcome using highly biased subjective measures. If you want positive results you cannot use good study design.
 
petrichor said:
I personally get the impression there's a great deal of interest in "functional neurological disorder" in psychiatry. Which makes the lack of remotely good quality treatment trials on it slightly bizarre. There are many people that have dedicated their careers to this. Where are the large, properly controlled RCTs of treatments with proper long term followup? They just don't seem to exist. It's weird. I don't get it.

(There is this trial: https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(20)30128-0/fulltext for cbt for non-epileptic seizures, a subset of FND, which found no significant difference for reduction of seizures)
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I may be being unfair, but both in relation to FND and to MUS, I have seen articles where PACE is cited as conclusive evidence for the effectiveness of psychological and behavioural interventions and then assumed that this can be generalised to all FND and MUS patients without any evidenced rationale or empirical justification.

I don’t know how widespread this is as I may have only read unrepresentative papers, but it is very worrying if people are taking at face value very controversial research, and then using their unevidenced beliefs to justify generalising the authors’ dubious conclusions to other patient groups and to justify not researching that intervention with those other groups.
 
Peter Trewhitt said:
I may be being unfair, but both in relation to FND and to MUS, I have seen articles where PACE is cited as conclusive evidence for the effectiveness of psychological and behavioural interventions and then assumed that this can be generalised to all FND and MUS patients without any evidenced rationale or empirical justification.

I don’t know how widespread this is as I may have only read unrepresentative papers, but it is very worrying if people are taking at face value very controversial research, and then using their unevidenced beliefs to justify generalising the authors’ dubious conclusions to other patient groups and to justify not researching that intervention with those other groups.
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Same with CODES. Saw it a few times recently, generalizing CBT to FND. Without rationale or justification either, and of course ignoring the null result. Because what's a null result if not a frowny face downside up?
 
petrichor said:
I personally get the impression there's a great deal of interest in "functional neurological disorder" in psychiatry. Which makes the lack of remotely good quality treatment trials on it slightly bizarre. There are many people that have dedicated their careers to this. Where are the large, properly controlled RCTs of treatments with proper long term followup? They just don't seem to exist. It's weird. I don't get it.

(There is this trial: https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(20)30128-0/fulltext for cbt for non-epileptic seizures, a subset of FND, which found no significant difference for reduction of seizures)
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Most of the research reported in FND are confirmation trials designed to show that FND is a genuine disease. They should be looking for alternative explanations to show how robust their theory is but we a far away from science here.

There has also been a flood of trials to make the diagnosis palatable to patients and to encourage doctors to see it everywhere and accept that FND can present as anything from epilepsy, stroke, bladder and bowel diseases, movement disorders and, well almost anything they can shoehorn in.

They do not need treatment trials because there is already a treatment, CBT with physiotherapy or exercise. If only those pesky patients did not fight it.
 
Andy said:
Functional neurological symptom (conversion) disorder (FND) is a neuropsychiatric condition well described in the 19th century, yet largely ignored by late 20th century academics. (...) Recent diagnostic improvements, an emerging neurobiology and renewed interest in treatment development are catalyzing a renaissance for FND among some neurologists. Unfortunately, many psychiatrists are less interested
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Interestingly, this small study on functional movement disorders (a subset of FND) does not support a psychiatric etiology for FMD -- especially not the mechanism of conversion -- and does not suggest more psychiatric care is needed for FND patients:

"FMD patients presented a significant alteration of QoL and no increased psychiatric comorbidities compared to OMD patients. These results highlight the impact of FMD and suggest that neurologists should be as involved in the management of FMD as they are in OMD."
 
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cassava7 said:
Interestingly, this small study on functional movement disorders (a subset of FND) does not support a psychiatric etiology for FMD -- especially not the mechanism of conversion -- and does not suggest more psychiatric care is needed for FND patients:

"FMD patients presented a significant alteration of QoL and no increased psychiatric comorbidities compared to OMD patients. These results highlight the impact of FMD and suggest that neurologists should be as involved in the management of FMD as they are in OMD."
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Unfortunately, they don't even trust their own research findings and no one makes them so they will completely overlook those negative findings and in fact continue promoting them. They genuinely don't trust their own research, because it's not research, it's outcome-seeking. So when they don't get the outcome they sought, they just try again until they get the answer they want by either chance and/or cheating.

Worst case, they can just argue it's deep-seated unconscious blah blah blah. Nobody cares, least of all them. They know it's not science and no one can make them care.
 
petrichor said:
I personally get the impression there's a great deal of interest in "functional neurological disorder" in psychiatry. Which makes the lack of remotely good quality treatment trials on it slightly bizarre. There are many people that have dedicated their careers to this. Where are the large, properly controlled RCTs of treatments with proper long term followup? They just don't seem to exist. It's weird. I don't get it.

(There is this trial: https://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(20)30128-0/fulltext for cbt for non-epileptic seizures, a subset of FND, which found no significant difference for reduction of seizures)
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Excellent point. It’s one of those things that’s been grandfathered in. “Everyone knows” psychosomatic conditions exist. The purported treatments have virtually never been tested because on some level they know the results would be DEVASTATING.
 
join the renaissance
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I thought the renaissance was when we transitioned from the middle ages into a scientific revolution which included the development of the scientific method and a focus on empirical evidence. Can they use another word? Or if they must borrow the word "renaissance" for their title, how about "renounce the renaissance", or "join the retrogression"?
 
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