Functional Neurological Disorders: Challenging the Mainstream Agnostic Causative Position 2024 Scamvougeras and Castle

Introduction

The classification of the so-called “functional” psychiatric disorders has long been debated. Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV; 1994) retained the “somatoform” psychological-primacy concept but had poorly devised subdivisions with criteria that proved too loose or too tight to be useful.1 The disorders were excluded from major health surveys and clinicians simply did not use the diagnostic categories.2 Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; 2013) provided an opportunity for improvement, but instead of primarily addressing the weaknesses of DSM-IV, changes were made in a completely different direction: there was a fundamental shift away from the acknowledgement of psychological mechanisms being of central importance in functional disorders. Criteria requiring the clinician to judge conversion symptoms as being “associated with psychological stressors” were dropped; the transition from “conversion” to “functional neurological” was begun. “Somatoform” became the neutral “somatic symptom disorders”,3 and there was a move away from the idea of “medically unexplained symptoms” (MUS): the DSM-5 workgroup felt that “medically unexplained” was synonymous with “psychiatric” and was thus to be avoided.4–6 There was also a view that “…the MUS approach is not well accepted by patients who feel that MUS implies that their symptoms are inauthentic and ‘all in your head’”.7 Overarchingly, DSM-5 adopted an attitude of agnosticism regarding the causation of these disorders. In the ensuing years this has morphed into a mantra: the idea that psychological factors are integral to these disorders rather than “co-morbid” is now deemed “radical”,8 or “out of date”,9 and psychiatrists are being encouraged to join the agnostic “renaissance”.10

It would be fair to expect such a fundamental change in direction to have been informed by substantial supporting evidence, but that does not appear to be the case. Indeed, there remains much evidence that these conditions have what we would all consider psychological or psychiatric factors at their core, and little or no evidence to the contrary. The changes in approach appear to have been made largely in efforts to “destigmatize” these conditions; to define them as something other than psychiatric disorders. Although arguably well-meaning, we believe that this shift away from the psychological is short-sighted, and, most important, invalid. It hinders a clear understanding of these conditions in clinical settings and thus leads to poorer treatment outcomes. It misdirects research efforts, as we will discuss. And it is doomed to fail as it does not reflect the underlying nature of these disorders. As Feynman says, “Nature cannot be fooled”.11

In this CJP Perspective, we suggest that the DSM-5 agnostic stance has been of detriment to the functional disorder field, from the point of view of patients and clinicians, and in terms of research. We commence by presenting the psychological causation model, which in essence prevailed for more than a century before DSM-5.

Open access, https://journals.sagepub.com/doi/10.1177/07067437241245957

 

@dave30th , an 'interesting' one for you.

 

Or perhaps the described changes are simply a product of being ill (with an unexplained "organic" illness).

 

Er, no, just a recognition that the previous view had no supporting evidence.

 

This article is actually quite interesting in relation to a conversation David and I were having in the park on Sunday.

It seems that the official story about FND with DSM-5 is that it is agnostic about causation.
The pundits want to reverse that.
So although at one time it was hysterical conversion it went through a phase of being non-committal, which was to some extent my perception.

We see the pundits making claims all the time but they aren't necessarily representative. Rheumatoid pundits insisted for 40 years that it was a TH1 T cell disease, despite all that we knew being that it was autoimmune and all the evidence there was was o the B cell side. Many rheumatologists probably went along with T cells but it did not affect their conversations with patients much.

The situation for FND is probably less rosy but it may be an oversimplification to say that it was just a new synonym for hysteria.

 

Impressive jumble of logical fallacies, summed up mostly as: ackshually, sophistry is good and someone has to say the quiet part loud.

Beliefs are something to behold. They speak of overwhelming evidence, when they have none at all, at most innuendo and a heaping of logical fallacies. Neither position is actually tenable, two sides of the same ideology, the whole construct is lacking in validity, but recent attempts at fooling patients into accepting something they don't are bound to face traditionalists and reactionaries who agree that things are heading in a wrong direction, just for the complete opposite reasons. So this is more like political polling and corner pub-level discussion of things they don't understand about other people they know nothing about. So, more of the same. You can find ramblings like this all the way back to Freud, identical in their lack of substance.

The recent attempts at falsely representing the concept of conversion disorder are essentially the same thing done for the "chemical imbalance", invented largely because biopsychosocial explanations to people who had great psychosocial everything fell completely short, so they tacked on some BS pseudoscience-level bio to account for it. The "new" model attempts to associate changes in biology as the explanation for how the "conversion" occurs, trying to explain the observed changes in biology while trying to maintain the traditional myths, but that was always superficial dog whistling, a BS explanation that everyone in medicine sees through as "for the peasants".

As usual they cannot see how the problem is always taking the consequences of illness and reattributing them as cause, rather than imagined risk factors, all of which fall down perfectly to statistical noise when properly examined.

So, was the world sprung into existence because a giant cosmic cow licked some golden chalice, or did it happen when his Noodly appendages breathed life into the cosmic pasta? Experts can debate about such things on and on without ever caring about what actually goes on in real life. There used to be smarter discussion over the "faces on Mars", until higher resolution photos unblurred the shadows triggering our facial recognition wetware.

It's actually really absurd to pretend like this "new view", 99% identical to the old view, is agnostic as to cause. Biopsychosocial was always 99% psycho and that will never change, it's all pretense based on decades of failure in both theory and practice. Everything about it is pretend, they're only trying to preserve old belief systems alongside real science. It doesn't matter which way they fail at it, the problem is that the entire concept is holistically flawed, perhaps the only holistic thing about any of this.

Also imagine Feynman being brought in on a pseudoscientific argument like this. That's just disrespectful. You can't fool nature, but damn can you fool ideologues all the damn time.

 

But he also said that the easiest person to fool is yourself, buddy.
And strangely, although that is sort of psychology, psychologists never get it.

 

yes, thanks--I responded to its posting on X by an FND patient--who obviously found it to be distressing and contrary to their view--and pointed out that it was reverting to the Stone/Sharpe view from 2002--that one third of neurology patients clearly suffer from "neurosis."

 

except for the fact that they routinely declare that FND itself--as in malfunctioning brain networks--is the cause. FND itself IS the explanation, in their view. So maybe it was more agnostic in 2013 when they were getting around to popularizing the term, but they seem not to be agnostic as to cause, although they acknowledge not understanding the mechanism by which these brain malfunctions are causing whatever.

 

Interesting discussions on the tweet machine. Seems like some are getting bored of the whole dog whistle movement that pretends that it doesn't mean psychological, including the current fashionable trend making it up as some "network dysfunction":

Another one:

I guess we're supposed to pretend that "anything but psychologically driven" doesn't mean "all in the mind"? That's why I never give these people the benefit of the doubt. Building up a bunch of dog whistles to say what they mean without saying it out loud means nothing, this is what they've always believed, the rest only exists to sell the lies.

 

From Conversion to FND: An Interview With Anton Scamvougeras

"Anton Scamvougeras, MBChB, FRCPC, is a neuropsychiatrist in the UBC Neuropsychiatry Unit at the University of British Columbia in Vancouver, British Columbia. He directs the Adult UBC Tourette's Clinic and since the mid-1990s has had a special interest in helping individuals with severe functional disorders.

Mark Ruffalo: I recently had a chance to read your paper with Dr. David Castle titled, "Functional Neurological Disorders: Challenging the Mainstream Agnostic Causative Position," published in the Canadian Journal of Psychiatry. I found it to be an excellent critique of much of the modern thinking on conversion disorder, which we now call functional neurological disorder (FND). First, for our readers, can you briefly describe FND?"

https://www.psychologytoday.com/us/...n-to-fnd-an-interview-with-anton-scamvougeras

 

Some quotes:

It seems that Scamvougeras is doing what he attacks others of. Can this name be real? It seems to be.

 

Isn’t the problem with a lot of this debate around FND is that we just do not know what the aetiology is, and the evidence for treatments using subjective measures in open label trials is pretty useless?

Different people have different beliefs, but at present that is all they are, beliefs.

None of which denies that there is a core group of FND that is a clinically meaningful grouping, and that their health issues, however they arose, are very real.

 

I wondered if Scamvougeras had written about ME/CFS, and of course he has. He has co-published Understanding and Managing Somatoform Disorders - A Guide For Clinicians, which is available via Amazon, and has its own website, https://somatoformdisorders.wordpre...-somatoform-disorders-a-guide-for-clinicians/, which also offers a free PDF version, https://somatoformdisorders.wordpre...toform-disorders-scamvougeras-howard-2018.pdf

"Somatoform Disorders occur when emotional distress is unconsciously and involuntarily expressed in the form of symptoms and signs of physical illness. The clinical features cannot be explained by general medical causes and no underlying physical pathology exists. Many individuals disabled by common chronic conditions such as Fibromyalgia, Chronic Fatigue Syndrome, Irritable Bowel Syndrome, and other well-known syndromes, are suffering Somatoform Disorders under different names. Somatoform Disorders represent the ‘Elephant in the Room’ for modern medicine."

 

I could agree that in an ideal world this might be the case. But it is not an ideal world. Problems I see are:

1. Even if there are some people struggling with their mental health there is precious little evidence that psychologists know better than you or I how to help and a lot of evidence that they can do a lot of harm.

As I have said in a recent document, the least one can say is that if there are psychological factors involve nobody has a clue what they are or how to deal with them.

2. A number of scam treatments like LP humiliate people in a most unpleasant way - the very opposite of 'psychological treatment' in fact.

3. I doubt that Garner ever had any major problems with his mental health. I have recently discussed this with a pro-BPS physician and we agreed that the most likely analysis for many is that they have disabling fatigue, the origin of which lifts, and around that time a 'therapy' provides something to rationalise improvement around. In some cases it can be face-saving. In others it is just that people like to attribute effects to causes. Anything would do. There is no need to pay.

4. There are no doubt people who most of us would call malingerers. That has nothing to do with mental health.

5.There are also fantasisers, with about 18 diagnoses, changing all the time. It is easy enough to comprehend what goes on in malingerers' minds but for the fantasisers I don't think anyone has much idea how it actually works inside.

6. The Neo-Freudian 'conversion' story is actually the least plausible and least evidence based of any theory. There has been an interesting suggestion that he concocted the idea to cover up for some rather embarrassing family events of his own.

The bottom line though for me is that the conversion/FND bandwagon in reality almost certainly does much more harm than good simply because of incompetence and an obsession a significant proportion of the human race have for gratifying their own desire to be seen to be 'helping' other people. Psychology would be a nice science to have if anyone knew anything about it, but at present they don't

 

But if this was the case wouldn't we see better results in objective outcomes in GET and CBT trials?