The neuroimaging evidence of brain abnormalities in functional movement disorders, 2021, Sasikumar and Strafella

So when properly investigated physical abnormalities are found in people diagnosed with a functional condition, and somehow that supports the idea of functional conditions, rather than highlighting how flawed it is?

 

And yet we have What Does Neuroscience Tell Us About the Conversion Model of Functional Neurological Disorders? (2019)

(TLDR: it's totally conversion disorder you guys, don't worry about the name.)

As Hutan notes, the neuromancers have really managed to tie themselves into a Gordian knot. In this analogy, perhaps MRI will be Alexander's sword.

 

I am not aware of a single thing supporting this, other than ideologues saying this on a loop for years without any basis. What are they even talking about? Other than when something is found it's no longer "functional"/conversion disorder. Other than the relatively recent and egregious BS about "functional overlays", which is basically "heads I win, tails you lose".

And if nothing else, findings invalidate the entire premise since despite the Big Lie, the only relevant factor here is "none of our current tests tell us anything relating to some known pathologies and we've been doing things this way for over a century and cannot possibly stop with our credibility intact".

How in the hell do they somehow manage to cram through "agency" here?

 

We can expect to see quite a bit of this scrambling to reposition now that updated technologies like 7 tesla MRI scanners are becoming available. Any new diagnostic procedure in neurology puts a lot of psychobabble careers at risk.

 

This infamous study should send a chill down anyone’s spine. Despite clear evidence of organic disease and a fatal outcome, they still would not admit that they were wrong about FND. I hear this a lot anecdotally as well. Cases where someone was told they had FND, then a real diagnosis is made and the neurologist refuses to remove FND from the chart. Instead of mea culpa you get told you have both. “Functional overlay.”

 

Many people are misdiagnosed so why can’t the same be the case for people with FND?

 

Another thing that seems contradictory about the whole thing is that every article on diagnosis/management says how challenging it can be to diagnose. At the same time, they claim the purported rule-in clinical signs (Hoover's sign, entrainment, etc) are highly specific. If a test or sign is highly specific, how can the entity also be hard to diagnose accurately?

 

Because tests such as hoovers are circular and false positives exist

 

The culture of disdain is very deeply rooted within medicine. I remember reading a literature review on autoimmune encephalitis, which is an illness with autoantibodies directly attacking your brain, where you can easily die within weeks if not treated. When I read that 30% of those patients have a negative MRI, I asked myself how the hell it is possible for neurologists to be so confident in knowing nothing is wrong with you when their diagnostic tools have such severe limitations. Surely, any rational person couldn't not have doubts about their judgement, especially considering the huge amount of harm it would do to the patient. Eventually, I learned that this way of thinking is the standard and nobody really cares that these patients are a playground for certain doctors to dish out abuse.

In this context, the mental gymnastics that are happening to justify the coexisting of FND and neurodegenerative illness as diagnostic tools improve are not that surprising.

 

How often does their literature indicate they are diagnosing FND/overlay without rule-in signs? Is it the case that they can no longer make the diagnosis without positive rule-in signs?

If those signs aren't actually present in many patients, but they still want to give them a diagnosis of FND, that would tend to make things challenging...

 

I'm sure my ME diagnosis was referred to what is now called FND without rule-in signs - if that even makes sense.

I was told since I have ME, which is not neurological, it meant I have a non-organic illness. What happened to the lovely neuropsychological evaluations used at the time to decide if symptoms were simply organic or not?

Now it is roll out the neuro-psych tests on certain patients because now they can diagnose FND.

 

I remember the toy one and chuckled to myself, thinking there is no way this BS will catch on and now look at where we are. The acceptance was abnormally rapid. One day FND was about toys, the next day it was in the first acquired brain injury & neuro conditions guideline. Which reminds me, how did it get in there without structural brain abnormalities being a feature of the illness at the time?

 

I'm getting a bit lost about one thing: functional disorders vs FND. Is FND supposed to be some different thing from the general use of "functional disorders", which means the same thing, and under which all chronic illness has been classified by many?

Seems like there's recently been this creation of a separate but equal thing here, where ME, fibromyalgia, IBS, POTS and other stuff is considered generically "functional", meaning conversion disorder, meaning psychosomatic/stress/trauma/anxiety/whatever, but FND is the same thing, but they added this recent bit about a "rule in" sign, one that clearly doesn't matter anyway since if it's not there it's still "functional", and it means the same thing, has the same "definition", if one can call it that, and the exact same treatment approach.

Really seems like they're eating their cake and having it too here. Because the broader generic idea of "functional" remains the modern label for psychosomatic. And obviously FND is functional neurological disorder, so quite obviously the same as functional disorder. It's like it's all the same thing, but at the same time there's this big pretense of a separation that is, somehow, a subset, one that is equal to the whole. Mathematicians would puzzle endlessly at how that's supposed to make any sense at all.

And things will keep getting more and more ridiculous as new technology brings out results that invalidate the whole thing, such as better imaging that shows changes that older technologies simply did not have the capacity to identify.

 

Another mind-boggling thing for me is this.

From what I am currently aware of, when a patient complains of cognitive symptoms linked to the brain, e.g. attention, memory and concentration, the causes are; organic factors, false pretence or psychological disorder. An MRI should be carried out if a patient doesn't have a psychiatric history. If the MRI is clear, the next step in making a confident diagnosis because all three causes require very different interventions and treatments, is a neuropsychological evaluation, as it tests for structural deficits, malingering and psychological disorders. The test carefully evaluates all three possibilities causing someone to complain of varying cognitive symptoms.

For the most part, pwME complain of nervous system (neurologic) symptoms that a range of medical evaluations can determine.

At some point, ME symptoms have been understood to result from malingering. A neuropsych test can determine the likelihood.

As it stands, symptoms are alluded to be some form of converting emotional distress. A neuropsych test can assess the presence of psychological disorder.

Some argue ME is neurological. A neuropsych test can determine if cognitive symptoms arise from structural problems.

The Neuropsychological evaluation will also determine if a combination of the above is present.

https://www.ncbi.nlm.nih.gov/books/NBK513310/

Neurologists have been using neuropsychological assessments to refer patients without organic abnormalities to mental health services following careful evaluation since, forever. If a patient has significant early childhood trauma causing maladaptive beliefs, shouldn't that be established while undergoing a thorough mental health evaluation?

In some cases, what has been established as FND seems backwards, in that, the patient presents with neurological symptoms but there is a refusal to screen for in-depth structural abnormalities.

TO ADD: I doubt just having early childhood negative/traumatic experiences is enough to justify maladaptive thoughts, there should be some other traits including behavioural ones that point towards a significant level of distress that a neuropsychologist is able to identify during the long period of interaction with the patient. They also work with patients suffering from lots of established neuro-brain conditions so they understand the symptoms and can interrogate them very well.