A Case of Functional Neurological Disorder With Cognitive Symptoms: Emotion-Focused Psychotherapeutic Insights 2023 Millstein, Perez and Langfitt

Section snippets

Case Report
A 59-year-old woman, Mrs. A, was referred for an outpatient telemedicine psychotherapy consultation in the department of neurology at a large academic medical center. Five years earlier, she had begun experiencing neurological symptoms including gait and balance difficulties, confusion, difficulty concentrating, and cognitive fatigue. She had received a diagnosis of FND 1 year earlier through her neurologist based on “rule in” signs for a functional gait disorder. Her gait and balance...

Discussion
This case highlights the potential for emotion-focused psychotherapy in the treatment of FND with cognitive symptoms. Here, both the initial interview and subsequent therapy targeted in-session emotional experience guided by both Mrs. A's reporting and observable physical signs of anxiety discharge. Through tracking patterns of anxiety (and affect) manifesting in outwardly presenting bodily symptoms (e.g., muscle tension), the therapist and Mrs. A were able to identify potential nonconscious...

Paywall, https://www.sciencedirect.com/science/article/abs/pii/S2667296023000010

 

Without fail, those FND papers merely recount what they do. They describe the steps they took and what they think of it. And that's it, it's assumed that it must be good and that all it takes is simply to describe it in order to make it valid.

Very guru-like. They even ascribe themselves absurd powers close to mind-reading. And they describe things they do in clinical practice, then talk about how it has potential, or is promising. Which essentially admits that they're just winging it and aren't actually interested in any evidence, they consider merely describing what they do as evidence for doing what they do. The only truly circular discipline: it exists because it has existed before, and continues to exist simply by describing its existence and promoting its aspirations as accomplished facts. One of the biggest and most harmful cons in history.

 

is the cliffhanger approach normal for the abstract to what tantalise the reader into what happened next. It only seems to be something I see with FND papers so I guess that defines them as 'the next level in storytelling-focused 'researchers' vs the CFS stuff. Pay to read more and find out if the patient lived type stuff?

 

Step 1: Decide that somebody’s persistent physical symptoms are the product of some psychological process.

Step 2: Manufacture evidence for Step 1 by observing anodyne bodily sensations and deeming them an expression of the psychological processes you’ve already asserted exist; I.e. exactly what a medium, clairvoyant, or other charlatan would do.

Step 3: Reassert the conclusion, ignoring the fact that you randomly assigned normal actions as proof of psychological distress, and you still failed to connect your fictitious distress to the troublesome symptoms.

All this garbage does is get allegedly “heartsink” patients away from the medical establishment. Nobody reasonable is reading what these quacks have to say.

 

Presumably imaged 5 years prior with her initial symptoms and therefore able to be judged as stable. "Cavernoma" is an outdated term, more correctly a slow-flow venous malformation. See Radiopaedia and Wikipedia.

From Functional Neuroanatomy of the Basal Ganglia (2012) —

Back to the case report —

The supplementary data contains a post-treatment video interview between therapist and patient.

 

An "action-oriented coping style" does not seem pathological. From Resilience Factors Contributing to Mental Health Among People Affected by the Fukushima Disaster: Development of Fukushima Resilience Scale (2020) —

 

It does seem that this post hoc psychologising is used to explain radically diverse outcomes. An explanation that can be used to explain contradictory outcomes is not a meaningful explanation. I am reminded of a homeopath I saw (when I was at the trying anything and everything stage) who said if my symptoms seemed to have improved that the tincture was doing its job, but my symptoms seemed to worsen then the tincture had successfully done its job and now was the time to move on to a different dilution of brandy that may or may not have any molecules of the supposed active ingredient.

Also the fact that an intervention appears to have an effect does not mean that it is doing what the practioner believes it to be doing. For example, under the old NICE guidelines, people going through the UK specialist services may report in the short term that GET has helped them, but what outcome measures for the UK services we have from then suggest following intervention patients worked on average fewer hours and claimed more benefits. Further I have come across a number of people making comments on social media along the lines of, ‘my ME/CFS seemed to be getting worse, so I did a couple of weeks of GET to get myself back on track’. Given GET starts with establishing a stable activity base line, a reasonable explanation of these findings could be that rather than being curative, any subjective improvement comes from people doing less and being given a structure that unconsciously encourages pacing.

Similarly physiotherapy for a motor problem might provide a context for a patient to better manage their presenting symptoms without it actually having any impact on the underlying condition, for example someone with one leg shorter than the other may learn to walk better with physiotherapy but it would be unreasonable to state that the intervention has resulted in the shorter leg growing without objective measurements of changes in length.

In such situations post hoc explanations might give hints for future research, but they do not enable firm conclusions without a theoretical model that allows predictions that can be then confirmed by changes in objective measurements. What we are seeing here is a lot of conjecture and possibilities that are never subjected to meaningful validation.

 

For anyone interested, here are a couple of references looking at the neurological effects and BBB disruption associated with these lesions. The literature retains the terms "cavernoma" and "cerebral cavernous malformations". Possibly the lesions visible on imaging are only the tip of the iceberg, with a more generalised cellular problem in handling inflammation and redox that I could imagine might lead to symptoms variable in time and (neurological) space — i.e. could underlie a subset of what is called FND. At the very least I don't think it's reasonable to dismiss a positive imaging finding in this patient as "something we feel is incidental."

Oxidative stress and inflammation in cerebral cavernous malformation disease pathogenesis: Two sides of the same coin (2016)

mPR-Specific Actions Influence Maintenance of the Blood–Brain Barrier (BBB) (2022, International Journal of Molecular Sciences)