[FND]: Extending the diagnosis to other disorders, and proposing an alternate disease term—Attentionally-modifiable disorder, 2022, Mark

Full title: Functional neurological disorder: Extending the diagnosis to other disorders, and proposing an alternate disease term—Attentionally-modifiable disorder

Abstract:

BACKGROUND:The term “Functional Neurological Disorder,” or “FND,” applies to disorders whose occurrence of neurological symptoms fluctuate with the patient’s attention to them. However, many other disorders that are not called “FND” nonetheless can also follow this pattern. Consequently, guidelines are unclear for diagnosing “FND.”

OBJECTIVE:To review the neurological conditions that follow this pattern, but which have not so far been termed “FND,” to understand their overlap with conditions that have been termed “FND,” and to discuss the rationale for why FND has not been diagnosed for them.

METHOD:A systematic review of the PubMed literature registry using the terms “fluctuation,” “inconsistency,” or “attention” did not yield much in the way of these candidate disorders. Consequently, this review instead relied on the author’s personal library of peer-reviewed studies of disorders that have resembled FND but which were not termed this way, due to his longstanding interest in this problem. Consequently, this approach was not systematic and was subjective regarding disease inclusion.

RESULTS:This review identified numerous, diverse conditions that generally involve fluctuating neurological symptoms that can vary with the person’s attention to them, but which have not been called “FND.” The literature was unclear for reasons for not referring to “FND” in these instances.

CONCLUSION:Most likely because of historical biases, the use of the term “FND” has been unnecessarily restricted. Because at its core FND is an attentionally-influenced disorder that can respond well to behavioral treatments, the field of neurological rehabilitation could benefit by extending the range of conditions that could be considered as “FND” and referred for similar behavioral treatments. Because the term “FND” has been viewed unfavorably by some patients and clinical practitioners and whose treatment is not implied, the alternative term attentionally-modifiable disorder is proposed.

Paywall, https://content.iospress.com/articles/neurorehabilitation/nre228003

 

It’s perhaps not unhelpful if the concept of functionality gets this (at face value, offensive and infuriating) notion “attention dependence” tagged on, as it takes the lived experience of chronic illness even further away from the definition.

However, as there are no autophenomological states which aren’t in some way attention dependent, this chap’s attempted contribution to the literature seems unlikely to catch on.

 

Aren't all symptoms by definition modifiable by attention?

Symptoms are by definition self-reported. Self-reporting of symptoms is well known to be affected by various contextual factors like attention or the interaction with the clinician.

 

My tinnitus is attention dependent
My carpal tunnel symptoms are attention dependent
My postural kyphosis is attention dependent
My sciatica is attention dependent
My melancholy is attention dependent (when its there)
My scalp itching is attention dependent
My eye floaters are attention dependent

There. They can add lots of things to FND, making it even more absurd a category.

 

They are going to keep renaming FND/conversion disorder/hysteria every time patients discover what doctors really mean by them.

It is an ego trip.

 

I love the parallel track of FND nonsense accentuated by this paper. On one hand, the exhaustive efforts to render it a “rule in” diagnosis. On the other, let’s just attach the label to any symptoms in the most slapdash, cavalier fashion possible. In practice, I’m guessing the later is what actually transpires.

 

so all these other disorders are categorized and described so differently that they do not come up with any of the search terms he used, but he himself has dug them out of the literature and is pretty sure they are the same as whatever FND is because he's really read a lot about it out of personal interest. Ok, then. Sure. Why not?

 

Is this gent kidding in his methodology, it sounds like a spoof or parody or Monty Python sketch for someone claiming their labels they give people are scientific and not based at all on his presumptions or discrimination.

What would possess someone to approach 'research' like this ["my personal library" come on mate that is ripe for mickey-taking, is that really OK these days?] - with seemingly no 'cover' for why he is picking things then other than it could be reasonably claimed his prejudice or gut feeling or what, most people at least 'grab something else as cover' to avoid that. What happens when someone else decides to research his personal list and finds they are all female-prevalent illnesses? or common in certain protected characteristics? And if there is little other rhyme or reason between what is on there or not beyond that?

Lest we forget that Functional Neurological Disorder + his claim of 'attentionally-modifiable' by paper-based personal judgement call based on what a limited history taken with a focus on something else? = man calling random numbers/individuals neurotic or hypochondria by the sounds. 'if you don't pay attention to your symptoms they will go away'...

It's not 'rehabilitation' in any kind or helpful terms. How on earth did a journal pick this up? Is it 'comment-based' research this time?

This sounds like 'hawking for work' when you start trawling for how far you can expand something which is pretty frivolous as a 'subjectively judged fuzzy-edged concept' such as 'fluctuation'? Don't most illnesses and indeed well people characteristics fluctuate day to day? How is he when he hasn't had his coffee, stared at a screen too long or had a 'big night' before? Where is his 'proof of consistency' in what he has done? Maybe on another day he'd change his feelings towards some of the illnesses he put on his personal library and his 'diverse' end list/output would change?

Or is it 'fishing' if it is producing a suggestion list 'starter for ten' for where those who might want to expand the whole think might look to start (like when newpapers publish a story to see if people object and then tweak it before it becoming policy)? How low can science go if this 'citation' gets used by others as a weak excuse to begin work on one of these?

Maybe comedy is the direction we should go in and start getting some decent comedians in to begin a few sketches on these things - sometimes that is the only thing that gets things across for a variety of reasons. One of which is there is so much wrong with these studies (and the logic of those behind them) sometimes that refuting requires more than the 5 seconds any bystander would be prepared to give as eartime if you said the technical stuff with seriousness. Being able to use 'all sensory modes' rather than just written might get across the 'it doesn't matter what name they are using this week' issue - it's all just wink wink nudge nudge code. It would nice for the butt of the joke not to be whoever the patient is for a change.

 

And how is he defining and assessing what is and isn't 'attention dependent' without context or understanding of the condition itself? Ie someone might technically have incontinence, TMJ (jaw issue where you need to avoid overusing it and chewing lots for a while) or another condition specifically when they don't pay attention to help minimise the issue, a comorbidity such as dementia that means that they are unaware of it but it doesn't lessen the issue, or a job that relevantly increases the attention paid. Even dandruff can be a relevant issue to focus on if you are a hairdresser or giving a make it or break it presentation.

Some things come to your attention for reasons that are far from subjective e.g. you tend to notice if you can't do something you needed to, others the attention is expected and required/useful. I also used to say to my physio that I can only ever tell you how the thing that hurts the most is that day with any accuracy, because it is hard to work out if your frozen shoulder has improved in pain since the week before when you've spent the week tending to a back spasm whilst having ME.

I'd be able to tell them if I could reach the tea bags without noticing I was automatically going onto tiptoes though. And what is waiting at the top priority on my to-do list as it is normally reasonably urgent and I'm working out how to manage it. So are they doing an assessment of the 'actual' vs 'attention paid' vs 'necessary' to see if there is a difference the wrong way given the assumption in the treatment/rehab proposed?

 

This is intended to be mildly sarcastic.

It's seems clear to me that psychologists, psychotherapists, psychiatrists and other people with a job title that starts with "psych" want to classify all chronic medical conditions as FND. This won't improve anyone's health, but then that isn't the point. It's purpose can only be to reduce costs for certain interest groups and raise the career possibilities for the "psychs". The government wants this to reduce welfare/benefit costs. The insurance industry wants this to aid them in denying payouts to people with certain types of insurance. GPs have been complaining about being overworked for ever. Now they can reduce their workload by declaring someone's symptoms as being caused by FND and passing them over to the psychs. After all, this is so easy it doesn't appear to involve any training, even I could do it.

It won't save any money though, because having a huge proportion of the population classified as having FND and therefore "mentally ill" will just pass many costs to other groups. Shrinks and their underlings don't come cheap. A population living with chronic pain and untreated physical illness won't be very productive and so having a healthy workforce is going to get harder.

And any society which demonises the sick is not likely to be a mentally healthy society. Euthanasia will be next.