Functional neurological disorder: new subtypes and shared mechanisms, 2022, Hallett, Dworetzky, Stone et al

[Andy]

Summary

Functional neurological disorder is common in neurological practice. A new approach to the positive diagnosis of this disorder focuses on recognisable patterns of genuinely experienced symptoms and signs that show variability within the same task and between different tasks over time.

Psychological stressors are common risk factors for functional neurological disorder, but are often absent. Four entities—functional seizures, functional movement disorders, persistent perceptual postural dizziness, and functional cognitive disorder—show similarities in aetiology and pathophysiology and are variants of a disorder at the interface between neurology and psychiatry.

All four entities have distinctive features and can be diagnosed with the support of clinical neurophysiological studies and other biomarkers. The pathophysiology of functional neurological disorder includes overactivity of the limbic system, the development of an internal symptom model as part of a predictive coding framework, and dysfunction of brain networks that gives movement the sense of voluntariness.

Evidence supports tailored multidisciplinary treatment that can involve physical and psychological therapy approaches.

Paywall, https://www.sciencedirect.com/science/article/pii/S1474442221004221

ETA: Change "open access" to "paywall".

 

[Arnie Pye]

Psychological stressors are common risk factors for functional neurological disorder, but are often absent.

If there are no psychological underpinnings to a patient's medical condition how can doctors diagnose them as suffering from a functional condition? They are playing silly b*****s with their own stupid definitions now.

 

[duncan]

I can almost hear Rod Serling now:

a disorder at the interface between neurology and psychiatry...

...the middle ground between light and shadow... between science and superstition...an area that we call....The Twilight Zone.

 

[rvallee]

Four entities—functional seizures, functional movement disorders, persistent perceptual postural dizziness, and functional cognitive disorder—show similarities in aetiology and pathophysiology and are variants of a disorder at the interface between neurology and psychiatry

Notably absent: immunology. Those are all widely reported in LC. Literally all of those I see commonly reported: non-epileptic seizures, limb weakness and difficulty controlling movements, POTS obviously and of course brain fog. And I have no idea how they can seriously argue for "new subtypes" when those have featured heavily in psychosomatic medicine for decades. This is basically medicine on brain damage, or Memento medicine.

Immunology isn't just where intuition goes to die, it's where scientific thinking and the basic duties of the medical profession die a very premature death. So much it can't even be voiced. Immunology is basically Voldemort.

Seriously, how can immunology be missing given how commonly those issues are associated with infectious diseases and the massive surge following Long Covid? It's completely insane that medicine in the 21st century has ideological taboos. We are being destroyed by myths and traditions from the 19th freaking century, exempt from any safeguards or basic accountability.

This is just pure horseshit:

the development of an internal symptom model as part of a predictive coding framework

It's the new quantum woo stuff, basically applying Deepak Chopra depth of thinking onto medicine. It was bad enough in alternative medicine, it's far worse when the worst features of pseudoscience are mixed in with the completely unaccountable power of the mental health exemption in healthcare.

 

[Mithriel]

I can almost hear Rod Serling now:

...the middle ground between light and shadow... between science and superstition...an area that we call....The Twilight Zone.

Years ago now, early 90s or so it was said that ME (CFS) "is a strange, new type of disease which sits at the interface of biomedical disease and psychological disease"

At the time I felt that such a claim needed iron clad evidence to show it was not just a disease that fitted the usual categories but was not fully understood. In the last thirty years this has not appeared, in fact the evidence they put forward is all of low or very low standard, weaker not stronger.

It does not even reach the normal levels of proof usual in other areas and further undermined by the gross amounts of spin put on the results and the way bias seems to be written into the designs of trials.

 

[Jonathan Edwards]

The pathophysiology of functional neurological disorder includes overactivity of the limbic system, the development of an internal symptom model as part of a predictive coding framework, and dysfunction of brain networks that gives movement the sense of voluntariness. Evidence supports tailored multidisciplinary treatment that can involve physical and psychological therapy approaches.

This is plain make-believe.
My colleagues should be ashamed of producing this sort of thing.
They may have developed a model based on predictive coding, but until that model is coherent and testable saying that the patients' brains have a model is just fabrication.

Edit: As the man said; Deepak Chopra deep fried mars bars.

 

[duncan]

It does not even reach the normal levels of proof usual in other areas and further undermined by the gross amounts of spin put on the results and the way bias seems to be written into the designs of trials.

Why is this kind of thinking allowed?

Aside from cost-cutting benefits, why have functional anything, somatic anything, this gruesome psych charade that is wrecking lives already in shambles?

Who walks away a winner? Insurance companies and state agencies and miscellaneous zealots responsible for bottom lines, sure. The psych industry, of course. Lazy neurologists.

Ethics is a big casualty, whoever manages to benefit. A whole lot of sick people impaled as well, on this spike.

It's worse than a tragedy. A tragedy seems accidental. I cannot think of a word.

 

[rvallee]

They may have developed a model based on predictive coding, but until that model is coherent and testable saying that the patients' brains have a model is just fabrication.

My understanding of this word salad is that it is the patients who are developing a model of predictive coding about symptoms and blah blah blah. I don't think they're claiming they have a model, rather they have a claiming that building this (cognitive) model is part of somatization, it changes the brain, or whatever, predicting symptoms following from, doing something I guess, which then "somatizes" emotions into the symptoms. Or whatever.

That's how it's phrased anyway, as it's put on the same level as overactivity of the whatever, that this cognitive model leads to symptoms. The whole emotional channeling of something into emotions. Conversion disorder is the conclusion that was established over a century ago, all this pseudoscience is doing is trying to fill it with stuff that can explain the 19th century conclusions. Exactly like flat Earth, faith in the conclusion is the basis, everything that happens exists to support the belief system.

At this point frankly the only comparable thing in academia is theology. This is basically medical theology, except the existence of a god has been replaced by the infallibility of medicine, starting in the late 19th century, since that's when the "all tests are normal" trope began.

 

[Amw66]

And so FND expands . Reframing district symptoms ( eg POTS) as somatic.
I am too cynical nearly 6 years in...would this be preparing the way for the insurance denials for LC in the same way CFS rebranding did for ME .....the sheer weight of numbers has knock ons. Not all of which will be positive

 

[Jonathan Edwards]

I don't think they're claiming they have a model, rather they have a claiming that building this (cognitive) model is part of somatization, it changes the brain, or whatever, predicting symptoms following from, doing something I guess, which then "somatizes" emotions into the symptoms. Or whatever.

Yes they are. Mark Edwards published it about three years ago I think. It is all based on Karl Friston and Jacob Hohwy stuff but as far as I could see Edwards's 'model' would predict the opposite of what he said. It is all very hand-waving because nobody actually has any evidence for this predictive coding stuff much beyond the obvious implications of oculomotor studies from sixty years ago.

And the idea is to imply that patients' brains are making use of the unconscious Fristonian predictive coding and so this is a real software problem. But then, as we know, the same people send patients off for psychotherapy as if that would help.

It is all a complete word salad as you say.

 

[Snow Leopard]

They may have developed a model based on predictive coding, but until that model is coherent and testable saying that the patients' brains have a model is just fabrication..

It is funny that their model of "predictive coding" works backwards to how predictive coding works in other fields.

They have no scientific explanation as to why their model works backwards.

 

[alex3619]

Woo Report : Conversion woo version 3.16 failed. Produce a paper for version 3.2 . Engage.

(Whispers heard in background - I hope nobody figures out we still don't have a clue.)

 

[Sean]

symptoms and signs that show variability within the same task and between different tasks over time.

So therefore psychosomatic?

Because no physiological pathology ever does that?

Really?

I am genuinely lost for words at that extraordinary claim.

My understanding of this word salad is that it is the patients who are developing a model of predictive coding about symptoms and blah blah blah. I don't think they're claiming they have a model, rather they have a claiming that building this (cognitive) model is part of somatization, it changes the brain, or whatever, predicting symptoms following from, doing something I guess, which then "somatizes" emotions into the symptoms. Or whatever.

Yes, the basic claim underneath all the ever shifting verbiage and sophistry, ever since Freud, remains that there is nothing but some form of learned mind/brain/neurology misperception, and the only task for the mind/brain/neurology experts is to figure out the details of making patients unlearn it.

A self-appointed task at which they have failed miserably from day one.

Yet here we are, over a century later, having to deal with exactly the same nonsense, with exactly the same appalling consequences for patients.

 

[Mithriel]

Why is this kind of thinking allowed?

Aside from cost-cutting benefits, why have functional anything, somatic anything, this gruesome psych charade that is wrecking lives already in shambles?

Who walks away a winner? Insurance companies and state agencies and miscellaneous zealots responsible for bottom lines, sure. The psych industry, of course. Lazy neurologists.

Ethics is a big casualty, whoever manages to benefit. A whole lot of sick people impaled as well, on this spike.

It's worse than a tragedy. A tragedy seems accidental. I cannot think of a word.

When you read in the dark psychosomatic histories series of blogs how the tobacco companies manipulated the science you do not have to be a conspiracy theorist to see a hand behind the treatment of ME. When CFS was first bandied about it was made explicit that there was a great worry that treating fatigue as a serious disease and handing out benefits to anyone who claimed to be tired with no validated tests was a "Malingerers Charter" So the insurers who had tried since the 30s to make ME a mental illness so there would be time limited pay outs were now joined by government.

They got ordinary people on side by making fatigue the only symptom and who doesn't get that. Tube fed, bedridden children were taken from the narrative and CFS became sloth, a deadly sin.

Move on and the backlash to pharmaceutical companies has made non pharmaceutical treatments attractive and part of the way medicine has moved to "lifestyle" as the main part of ill health so we pay the price for our sins.

I read a book years ago now and can't find it to recheck it but it said something like psychologists need to work so when psychotherapy was falling out of favour they leapt on the recovered memories bandwagon. When that was discredited they moved on to medical CBT which has just kept on giving.

It all builds up. The more they claim CBT cures illness (if only people would accept it) the more people not directly involved think it is a good way to look at the world. It is fashionable.

FND seems to have patients who are happy to be told it is caused by the psychological effects of trauma. They maybe find it more acceptable than we do because they are innocent victims with their hurt made manifest whereas we have been told that we are so wimpy that we are frightened to do any exercise because it might hurt. We are weak, self indulgent, parasitical and whiny. Thank you Wessely, White and Sharpe.

The way FND is claiming diseases makes me think of a big chomping machine destroying everything it its path.

 

[dave30th]

It is funny that their model of "predictive coding" works backwards to how predictive coding works in other fields.

Can you elaborate? How does it work in other fields? I just don't get how anyone could know or prove that the brain has developed a pattern of faulty predictions, if that's what it means in English.

 

[dave30th]

And also, they keep talking about software problems, but then they also have written papers about structural changes as well in various areas of the brain. And yet for some reason they continue talking about software/hardware in their more public presentations, like the neurosymptoms site. Have others noticed this, and have they themselves given any explanation of this apparent contradiction?

 

[Andy]

I believe that they use the existence of structural abnormalities as proof of the 'power' of the patients thoughts to cause these changes, and therefore they are proof of the legitimacy of FND as a diagnosis.

Which obviously ignores the more sensible logic that the structural abnormalities might just be the cause of the patients symptoms, not their thoughts or emotions.

Presumably this will in time allow them to claim any symptom that is caused by abnormalities in the brain as an FND.

 

[Lilas]

One of the authors, the neurologist and prof. Jon Stone (University of Edinbugh), created a website to " learn all about FND ", promoting this uncertain disorder. This is what the proof on which he builds his whole theory looks like:

Can I have a scan to ‘prove’ that my brain isnt working properly?
At the moment all of these techniques are only suitable for research studies. We are not in a position to do functional neuroimaging to diagnose or ‘prove’ FND.

I understand why people with FND would like some evidence of whats wrong. It might help reduce stigma or people not believing this is REALLY happening to them.

But as a neurologist seeing people with FND I dont need a scan to believe my patients. Lots of my patients with other disorders have normal scans too.

https://www.neurosymptoms.org/en_GB/causes/how-has-it-happened/

And yet he says, still on his website under the heading " How has it happened "?

When the patients symptoms improved then their scans improved too.

For a simple understanding of this unproven theoretical model:

Patients with FND do not have damage to their nervous systems so its not surprising you can’t see it on a scan. Instead the nervous system is not functioning properly.

If you were a computer it’s like having a software problem rather than a hardware problem. If you have a software bug on your computer, it might keep crashing or work really slowly. You wouldn’t solve that problem by opening up the computer and looking at the components. You wouldn’t see anything if you did an x-ray of that computer.

You’d have to solve it by reprogramming the computer, working out which programs were causing the problem.

And the treatment part obviously requires the magical BPS approach...! But what gibberish!!

 

[Jonathan Edwards]

Can you elaborate? How does it work in other fields? I just don't get how anyone could know or prove that the brain has developed a pattern of faulty predictions, if that's what it means in English.

The predictive coding theory of Hohwy, Friston and others says that what we experience is what the brain calculates to be the difference between what it expects to sense and what comes in from sense organs. So if the brain thinks it is going to sense being by the third platform bench and what comes in is past the end of the bench the brain senses that one's train has started to move.

If this is applied to 'false beliefs 'about e.g. pain or fatigue then the story doesn't seem to work. The brain is supposed now to predict pain, despite there being nothing wrong. The sense organs should send in no signal. So the brain should perceive minus pain. Or for fatigue it should experience boundless energy. After all that is what happens when you finally get over flu. You wake up with your brain thinking you are going to feel God-awful like yesterday and amazingly you don't. So you think 'hey, today life is worth living'.

I may have missed a trick but I doubt it. Predictive coding is a mantra widely used by the brain dead. It is vague enough for people to think it says the backwards of what it does to these people.
And of course this is another example of what I bang on about. You need two explanations for a disease of regulation. You need an explanation of normal regulation and a completely different explanation of why that does not apply in a disease.

 

[Art Vandelay]

One of the authors, the neurologist and prof. Jon Stone (University of Edinbugh), created a website to " learn all about FND ", promoting this uncertain disorder.

On his website, Stone promotes a fellow quack and the Lightning Process: