Recognising and explaining functional neurological disorder, 2020, Stone et al

Woolie said:
Sorry, perhaps I wasn't clear. The "algorithms" view I was referring to above is in fact the predictive coding model of functional movement disorders that is described in the paper at the top of this thread.
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Right, but you quoted my post, and for criticism, and I originally only wanted to point out, that algorithms and the likes are by far not bound to BSP models and the likes.

Also the interpretation of illnesses which present in a way FND might present themselves, is by far not bound to any BSP approach, instead it could be indeed any dysfunctional algorithms in nerve cells (or whatever).

I find it pretty important that researcher would know this, and would mention this in an effort to think logically. Also for patients it could be very important not too loose recognition on this possibility.


The paper discussed here somehow suggests such an interpretation when it comes to treatment, though doesn´t seem to rely on it theoretically, and this is of course a dangerous mixture. Indeed.
 
Re: Functional neurological disorder - Patients' experience & research
People are developing ‘functional neurological’ issues downstream of having taken GP prescribed antidepressants, benzodiazepines, etc. (on- or off-label, sometimes long-term) for various ‘indications’. As these prescribed drugs are designed to cross the blood-brain barrier and to act on the central and autonomic nervous systems this must surely be significant? We know from recently published work by Hengartner, Davies & Read 2020 (2) that a high percentage of people (46%) experience ‘severe’ withdrawals from antidepressants.
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https://www.bmj.com/content/371/bmj.m3745/rapid-responses
 
Sly Saint said:
Re: Functional neurological disorder - Patients' experience & research


https://www.bmj.com/content/371/bmj.m3745/rapid-responses
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Thanks for posting, @Sly Saint. I read through the letter, and felt pretty angry at Stone et al. for giving patients the false impression that they believe FND is a neurological disorder ("corruption of the brain-generated predictions and interference from the limbic system and amygdala"). If you strip off the layers, its clear they think the key determinant of who gets FND and who doesn't is personality and psychopathology. These are the characteristics they believe to be the root cause of the "interference from the limbic system and the amygdala" that is at play. The proposed solutions are entirely behavioural (therapy and exercise).

I remember a book that came out in the 70s called "how to lie with statistics", and it struck me that this is the modern equivalent "how to lie with neuroscience".

Stone et al have clearly succeeded, because this group sees hope that their illness will now be taken seriously. And maybe they are partly right, because this new language might prove more acceptable to friends and family (let's face it, its a way more acceptable story than having to tell people you have ME or CFS). But at the end of it is just therapy and retraining and the same old cycles of hope and then self-blame when it all fails. Plus, each iteration of this new model takes us further and further away from actually understanding what's at the bottom of these various movement disorders and how we might actually treat them successfully.
 
Woolie said:
Thanks for posting, @Sly Saint. I read through the letter, and felt pretty angry at Stone et al. for giving patients the false impression that they believe FND is a neurological disorder ("corruption of the brain-generated predictions and interference from the limbic system and amygdala"). If you strip off the layers, its clear they think the key determinant of who gets FND and who doesn't is personality and psychopathology. These are the characteristics they believe to be the root cause of the "interference from the limbic system and the amygdala" that is at play. The proposed solutions are entirely behavioural (therapy and exercise).

I remember a book that came out in the 70s called "how to lie with statistics", and it struck me that this is the modern equivalent "how to lie with neuroscience".

Stone et al have clearly succeeded, because this group sees hope that their illness will now be taken seriously. And maybe they are partly right, because this new language might prove more acceptable to friends and family (let's face it, its a way more acceptable story than having to tell people you have ME or CFS). But at the end of it is just therapy and retraining and the same old cycles of hope and then self-blame when it all fails. Plus, each iteration of this new model takes us further and further away from actually understanding what's at the bottom of these various movement disorders and how we might actually treat them successfully.
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In a funny twist, I don't think the effort will ever work out because no matter how they coat and distort what they mean, other physicians understand very well that this means psychosomatic and thus not medically relevant, so will pay little attention to it.

It may get taken seriously as a psychological thing of nebulous vagueness (yes, it's that fuzzy), but never as a legitimate medical condition, precisely because of their own arguments. I don't think anyone with an MD is fooled by the weird mumbo jumbo, they understand very well it's a BS explanation and still roughly the same as when Freud came up with it.
 
Andy said:






Thread continues for a few more posts on Twitter.
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This "change of position" seems very similar to the "change of position" BACME did. As in it changes absolutely nothing, it's simply a reframing/recycling of the same claims with a slightly different emphasis. As is tradition. The emperor has new clothes. Again. This time they're real. Again. This time they're waterproof. Maybe.
 
The brilliant insight of Mark Edwards referred to in the twitter thread -- that insight came at the precise moment that the BPS became aware that their position as it stood was no longer defensible. Because there was a tipping balance of awareness that the theory as previously defined was made of pure conjecture.

Enter (and I'm quoting now) "incorporating neurobiological factors as key drivers". It's laughable and sad NOT brilliant.

Thus rescuing a nonsense theory by making it scientific because they include 'neurobiological factors'. Or so they believe.

The thing is, it may be when the biology is really investigated with actual scientific research the key driver may not be neurobiology at all but something that is affecting neurology whether that be an environmental toxin or a chemical signalling problem or a epigenetic change.

But the BPS continues to be a closed system that has the answers if only the details still need to be tweeked. There is no need for science only the appearance of for the sake of credibility.
 
chrisb said:
Would there not need to be a prospective study before one could assert that FMD patients have a body-focused attentional bias? Has there ever been such a study?
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No, apparently not. And even if the results were negative, this group's appraoch means that they would not see a need to revise the model. There have been a number of recent attempts to link FND with psychological characteristics or adverse life exepriences, and all have failed - - and this group have used that, not to challenge their conceptions, but to argue for using an even looser set of criteria to diagnose it.
 
I haven't followed this thread, but people may or may not be interested in the following rapid response:

https://www.bmj.com/content/371/bmj.m3745/rr-1

Rapid Response:
The curious challenge of breaking good news

Stone and colleagues (1) present useful guidance regarding assessment and management of patients with functional neurological disorder (FND). Unfortunately, clinicians caring for those with other ‘functional’ syndromes often face rather more fraught and complex challenges.

Chronic fatigue syndrome (CFS) and fibromyalgia (FM) are examples of common presentations which have also attracted the ‘functional' label due to persisting uncertainty regarding aetiology and pathophysiology; optimal management is consequently challenging (2,3). FND is typically identified by overt physical signs; even when these are absent, as in dissociative seizures, it is often possible to give significant weight to features in the history (1). By contrast, the absence of physical signs and the lack of symptom specificity in CFS and FM can be a source of doubt, dispute, and stigma for all concerned (4, 5).

As Stone et al demonstrate, clinical findings enable the positive diagnosis of FND in tandem with judicious diagnostic testing to exclude relevant pathologies (1). By contrast, many other functional syndromes are identified in a negative sense, only after often extensive physical investigations have excluded demonstrable pathology. This conclusion is generally less satisfying and a frequent source of frustration for both patients and clinicians (4, 5). Doctors thus often find themselves in the difficult position of breaking unwelcome ‘good news’ to patients hungry for a mechanistic explanation of their symptoms. Recognising and skillfully managing patients’ emotional investment in having a physical diagnosis is crucial in avoiding the dual risks of over-investigation and overtreatment (6).

1) Stone J, Burton C, Carson A. Recognising and explaining functional neurological disorder. BMJ. 2020;371:m3745. doi: 10.1136/bmj.m3745.
2) Missailidis D, Annesley SJ, Fisher PR. Pathological mechanisms underlying myalgic encephalomyelitis/chronic fatigue syndrome. Diagnostics (Basel). 2019;9:80. doi: 10.3390/diagnostics9030080.
3) Schmidt-Wilcke T, Clauw DJ. Fibromyalgia: from pathophysiology to therapy. Nat Rev Rheumatol. 2011;7:518-27. doi: 10.1038/nrrheum.2011.98.
4) Boulton T. Nothing and everything: Fibromyalgia as a diagnosis of exclusion and inclusion. Qual Health Res. 2019;29:809-819. doi: 10.1177/1049732318804509.
5) Houwen J, Lucassen PL, Stappers HW, Assendelft WJ, van Dulmen S, Olde Hartman TC. Improving GP communication in consultations on medically unexplained symptoms: a qualitative interview study with patients in primary care. Br J Gen Pract. 2017;67:e716-e723. doi: 10.3399/bjgp17X692537.
6) Williams N, Wilkinson C, Stott N, Menkes DB. Functional illness in primary care: dysfunction versus disease. BMC Family Practice. 2008;9:30.

Competing interests: No competing interests

13 November 2020
David B Menkes
academic psychiatrist
Sean L Davidson
University of Auckland

Waikato Hospital, Hamilton, New Zealand
@davidmenkes
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As Stone et al demonstrate, clinical findings enable the positive diagnosis of FND in tandem with judicious diagnostic testing to exclude relevant pathologies (1). By contrast, many other functional syndromes are identified in a negative sense, only after often extensive physical investigations have excluded demonstrable pathology. This conclusion is generally less satisfying and a frequent source of frustration for both patients and clinicians (4, 5). Doctors thus often find themselves in the difficult position of breaking unwelcome ‘good news’ to patients hungry for a mechanistic explanation of their symptoms. Recognising and skillfully managing patients’ emotional investment in having a physical diagnosis is crucial in avoiding the dual risks of over-investigation and overtreatment (6).

It is not a scientific conclusion to presume that because nothing is found after extensive tests that the problem is FND. There is no scientific proof that a person is experiencing what has been termed and then reassigned a half dozen times at least and is now called FDN. Which is essentially the mind creating illness that the body experiences. The theoretical construct itself is a mere belief on the part of the people who have invested their careers in it.

People are not looking for a materialistic explanation they are experiencing a failure of therapists to understand that their treatment is not working.

And the longer this goes on the more people will die of treatable illnesses that get shunted to FND because of the "judicious" use of what medicine has to offer.

As is mentioned by others in plenty of posts elsewhere -- the system is broken. FDN is not a cure or treatment for anything. It is a symptom of this brokenness.
 
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