You've made the diagnosis of functional neurological disorder: now what? (2018) Perez et al

Hoopoe

Senior Member (Voting Rights)
I am posting this because I think it clearly shows that FND is just a rebranding of the old conversion disorder with a touch of the PACE trial approach.

Patients with functional neurological disorders (FND)/conversion disorder commonly present to outpatient clinics. FND is now a 'rule in' diagnosis based on neurological examination findings and semiological features. While neurologists may be more comfortable diagnosing patients with FND, there is only limited guidance as to how to conduct follow-up outpatient visits. Using clinical vignettes, we provide practical suggestions that may help guide clinical encounters including how to: (1) explore illness beliefs openly; (2) enquire longitudinally about predisposing vulnerabilities, acute precipitants and perpetuating factors that may be further elucidated over time; (3) facilitate psychotherapy engagement by actively listening for potentially unhelpful or maladaptive patterns of thoughts, behaviours, fears or psychosocial stressors that can be reflected back to the patient and (4) enquire about the fidelity of individual treatments and educate other providers who may be less familiar with FND. These suggestions, while important to individualise, provide a blueprint for follow-up FND clinical care.

https://www.ncbi.nlm.nih.gov/pubmed/29764988

But now they're trying to show, with what appears to be poor quality studies, that this idea has a scientific basis.
 
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Question: You've made the diagnosis of functional neurological disorder: now what?
Answer: Make it someone else's problem!

Alternatively, you could blame the patient!

A patient’s hesitancy to accept the diagnosis, whether overt or indirect, can present a barrier to treatment. Some providers may worry that differences of opinion regarding the diagnosis will escalate into an argument. As such, we recommend the following suggestions with such a patient:

  1. Ask the patient for their current understanding of their diagnosis. If they remain unclear or ambivalent, ask what they remember about the initial visit and discussion of the diagnosis. If details are incorrect, revisit the diagnosis and rationale behind treatment recommendations.

  2. For those who clearly articulate an alternative diagnosis despite recalling the initial encounter, directly—but non-judgmentally—bring up their hesitancy. For example, ‘It seems to me that you are not quite sure we are on the right track’. Alternatively, state, ‘I see that you have some doubts; it is okay that you do, and I would like to hear your concerns’. This approach encourages patients to express their illness beliefs and allows clinicians to address concerns and recount the neurological examination and adjunct tests that ruled-in the FND diagnosis.

  3. After encouraging an open discussion, ask the patient to report back what they heard.

  4. Transition to treatment by emphasising that, ‘Your condition is real and common and you play an active role in the process of getting better’.

Is the patient still resistant to the diagnosis? Don't worry, blame it on psychological stress. Only don't call it stress!

Patients commonly deny psychiatric symptoms and/or psychosocial stressors during the initial encounter. The reasons include time constraints, the actual absence of stressors, lack of awareness and concerns that acknowledging emotional disturbances and/or ongoing stressors will discredit neurological complaints.

Vignette 2 said:
Here, the physician acknowledges the patient’s affect and explores barriers to physical therapy attendance by leading with an empathic stance. By suggesting to the patient that she may be ‘overloaded’, a relatable term without stigma, the clinician can elicit relevant mood symptoms and psychosocial difficulties.

Patients not improving, despite psychotherapy? Don't worry, there is no true Scotsman! Wait, I mean the psychotherapy has not been done correctly.

having started psychotherapy, some patients report little or no improvement in seizure severity or frequency. At this point, it is useful to enquire about the details of psychotherapy sessions to ensure the fidelity of treatment and identify what can be improved. While some non-mental health clinicians may not be delivering psychotherapy directly, he or she may act as a facilitator of patient engagement in therapy. Also, discussing neurological symptoms during office visits allows a ripe opportunity to assist patients in exploring connections between seizures and maladaptive thoughts, behaviours, emotions and psychosocial factors.

Likewise, for occupational therapy, because the neurologist always knows better than the occupational therapist!

Despite apparent adherence to physical therapy and/or occupational therapy, patients with functional movement disorders may claim that the ‘treatment is not working’. For such people, it is important to enquire about the details of each treatment modality. This requires that providers are familiar with core elements of physical and occupational therapies for FND as outlined in published recommendations to enable physicians to make a ‘big-picture’ determination about the fidelity of a given treatment.

Conclusion, if you cannot work out what is wrong with a patient, make it someone else's problem with a FND diagnosis. If the patient is reluctant to accept this diagnosis, simply blame the patient. If the treatments don't work, just blame the therapists. Remember, fixing FND is not your job as a neurologist, it is someone else's problem!
 
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It is very helpful of them to indicate that they regard functional neurological disorder and conversion disorder as synonymous. I tremoves the confusion of the possibility that "functional" might be descriptive rather than aetiological.
When talking among themselves, there is zero ambiguity that this is what FND means. It's when communicating with the public and patients that they raise the wall of deceit where they pretend they mean something else. That's been the "innovation": deceit, it's hysteria with a transparent plastic wrapping.

It's one of the world's worst-kept secret and it's really disappointing that people pretend otherwise, will talk all day about the print, color and texture of the transparent plastic wrapping. Made worse off that there is a pretense of listening to the patient, when in truth it's about gaslighting them, making them reject their own life experience as invalid.

Dishonest medicine, one of the worst ideas ever but all the rage lately. Many professionals are not allowed to lie to their clients. By law they could be stripped of their professional title. Not medicine, they can lie all they want as long as the lie is widely accepted.
 
One more for the file of "do they even read the stuff they write about? no, they do not":
Patients commonly deny psychiatric symptoms and/or psychosocial stressors during the initial encounter. The reasons include time constraints, the actual absence of stressors
Heads they win. Tails they win. Sideways they win. No coin they win. A rock instead of a coin they win. A coin with two identical sides they win.

I'm bothered that so few people find problem with a thought process that yields the same outcome no matter what the input is, even when there is no input at all. Basically it's like a psychic with a thingamajig that they tell the client that if it lights up it means they are right and the thingamajig is always lit so they are always right. That's not even close to be how any of this should work, in fact it's pretty much perfectly representative of exactly how not to do anything, in all circumstances ever.

As far as I am aware, actual psychiatric patients rarely deny the reality of their psychiatric symptoms. Even other psychiatric patients are very good at telling fakers apart. This should tell them something. Actually, it is screaming something at them. But reality plays no role whatsoever in this belief system, they begin by not listening and end by still not listening.
 
Trial By Error: Shaky Evidence for Signs of Functional Neurological Disorders
One of my goals next year is to write more about so-called “medically unexplained symptoms,” also known as MUS. The term MUS might be useful as a descriptive name for the large category of phenomena that lack a proven pathophysiological pathway. But in the medical literature, and in the minds of those who present themselves as experts in the field, it is framed as an actual diagnosis that can be delivered with full confidence rather than a provisional construct based on the current state of medical understanding.

Different specialties have their own sub-categories of MUS. In neurology, these are called “functional neurological disorders,” or FND. This term has generally replaced older ones for this concept, including “conversion disorders” and “psychogenic disorders.” As with MUS overall, the evidence for these conditions has resided primarily in the absence of standard signs indicating organic dysfunction. The phrases “conversion disorder” and “psychogenic disorder” mean exactly what they say–the idea is that unexpressed psychological distress is transformed into physical symptoms, although how this “conversion” would occur is not really clear.
http://www.virology.ws/2019/12/30/t...r-signs-of-functional-neurological-disorders/
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Moderator note: New thread on David Tuller's article about FND here:
https://www.s4me.info/threads/trial...nal-neurological-disorders.13050/#post-228230
 
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Patients with functional neurological disorders (FND)/conversion disorder commonly present to outpatient clinics. FND is now a 'rule in' diagnosis based on neurological examination findings and semiological features.

So what exactly are these signs, what is their history in the medical literature and what have these signs previously denoted prior to MRI machines, xrays and scans?

It seems to me they are about to take the neurological examination that has a hundred years or more of validity in spotting neurological organic causation and are about to do a history revision on them and claim that they always in the past pointed at a functional disorder.

Or do they have some magic power to claim that a separate list of signs upon neurlogical examination prove a functional disorder? In which case what scientific validity do they have for such a claim?


What happens if you have their magical functional signs and also the organic neurological signs upon examination do they just ignore the organic neurological signs or not even bother doing them?

How many autopsies etc have proven no organic causation matched against people diagnosed with functional disorder using such signs upon their death?

How often do they review such people with these magical functional signs they claim using PET scans x-rays and MRIs etc?

Or is it the obvious get out once they claim their magical diagnosis you are never real worthy of a test again?

I wonder how they match this up and ever wonder why in the UK we have the worst rate of cancer detection in Europe and one of the worst rates in the whole world?
 
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How many autopsies etc have proven no organic causation matched against people diagnosed with functional disorder using such signs upon their death?

They've largely solved the problem of autopsies showing up that the doctor was wrong and the patient was really ill by cutting down dramatically on the number of autopsies that are done in the UK. I'm sure that someone diagnosed with FND would be bottom of the pile for an autopsy if they had apparently died of natural causes with no suspicious circumstances.
 


eta:
see twitter thread
btw this was a MS retweet

eta2:

FND Portal
@FndPortal

Putting the “fun" in "functional neurological disorder. Sharing news, info, and musings about FND. When we work together, we can change things for the better.


I see that FND Portal overcomes his/her lack of replies to his/her tweets by replying to him/herself over and over and over again.
 
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