Functional Neurological Symptom Disorder: A Continuing Conundrum for the Perioperative Physician, 2023, Chin and Kumaraswami

Abstract

Functional neurological symptom disorder (FNSD) or functional neurological disorder (FND) or conversion disorder, is a syndrome of neurological complications unexplained by neuropathology. The term FNSD or FND is now preferred, as conversion disorder is not an etiologically neutral term and is thus falling from use by researchers and clinicians in the field.

We report a case of new-onset postoperative neurological deficit in a patient who had undergone uneventful general anesthesia for a urology procedure. Postoperatively, in the post-anesthesia care unit, the patient was found to be unable to move her upper and lower limbs. Organic pathology was excluded and a diagnosis of FNSD was made. Four weeks after the surgery, the patient was only able to ambulate with the help of a mechanical walker device.

It is now suggested that procedures involving anesthesia are relatively common triggers for the development of FNSD. The occurrence of FNSD in the postoperative period is increasingly being attributed to the effects of anesthesia, the hypothesis being that it arises from the abreactive or dissociative effects of anesthetic agents. Another theory is the vulnerability of the anesthetized state which may evoke previous traumatic experiences. Psychiatric co-morbidities such as anxiety and depression may be seen in these patients. Preoperative psychological assessment may help identify patients at risk for FNSD. If postoperative neurological deficit occurs, detailed neurological, metabolic, and psychiatric assessments should be done with FNSD being a diagnosis of exclusion.

We present this case to increase awareness regarding this uncommon condition which can cause significant distress to the patient and healthcare team. Management should comprise honest disclosure, reassurance of recovery, and reinforcement of alternative coping strategies. The development of preoperative screening tools may help identify patients at risk for this disorder.

Open access, https://www.cureus.com/articles/163...-conundrum-for-the-perioperative-physician#!/

 

See also Post-operative Incomplete Quadriplegia Caused by Conversion Disorder in a Female After Gynecological Surgery: A Case Report (2022)

 

And yet —

Abreactive
n. the expression and consequent release of a previously repressed emotion, achieved through reliving the experience that caused it (typically through hypnosis or suggestion).

FNSD FFSD

 

Aside from how bleak and morally bankrupt this looks to me, it's so disappointing how medicine misses out on so many opportunities (most of them? all of them?) to learn about how the human body works, and instead defaults to trying to avoid blame for their own failures. In this case it even looks like an active one, rather than the more typical failure of figuring out what is happening at all. It's even common to do that for forgotten surgical instruments, but everything about is gagged, never recorded anywhere. So it's impossible to learn because the problem is always covered up.

It's very transparent to me that all of MUS/FND and the myriad acronyms are used as a weapon against liability and obligations, including the obligation to change past failed practices. It looks clearly to be the case here, although certainly opinions will vary.

Even worse is that people who are supposed to be scientists, although I guess in this case they are clinicians, used theory when they meant hypothesis, and even at that it's merely a suggestion at best, spitballing at worst. MDs make really bad scientists in general, they are too caught up in their immediate work and individual cases to look at the bigger picture. Especially in a case with so many obvious health problems and past procedures. It's as if their perspective is laser-focused and simply sees nothing else than whatever doesn't cause them problem. The system is very poorly built to allow for good outcomes.

It's well-established that medicine has a lot more to learn, that what they can do is still very limited. And still they will argue that if they can't figure it out easily, it can't be anything else than repressed trauma, or some imaginary nonsense that legally gets them off the hook, but binds them into immorality. In my opinion. This is very bleak reading. This antiscience absolutely doesn't belong in academic or medicine. Or in any expert profession.

 

It would be interesting if there were a male comparative case to see if the same procedures and diagnosis were found.
Sorry, but being female is part of this problem..

Are there figures for sex split in FND diagnoses ?
@dave30th

 

Yep, the past traumas quote seems a straight laugh on the following theme, surely just boundary testing to see if you can get away with blaming someone coming round having been affected by anaesthesia must instead 'have past traumas being resurrected' as their possible cause, or maybe they just need to get away with that doubt like when someone can't prove they got covid at work even though they didn't go anywhere else etc.


the functional overlay never getting removed even after a new diagnosis also looks obviously like practising political medicine and not neurology. Then building yourself a literature of how great it is to accidentally miss Parkinsons or CJD and diagnose FND first before you get too many of them. No idea why it is a good idea, because they fail to explain that part.

Also shows how the idea of the way the literature works 'sorting out these problems through back and forth' fails when one group has standards that mean they jot off manifestos from the top of their head every rainy Sunday, or each time they have an intern they need to find a task for they get them to do a retrospective cherry-picking 'findings' across select years. And the 'other', if said group even wanted to let them into the ring of the literature, actually have standards that mean they have to you know do all the ethics panels and recruiting controls and designing things in a ball ache way. Which costs money beyond their tenure and time.

But I do still wonder why we don't have any CJD or Parkinson's experts in the comments or replies saying 'erm, my first choice wouldn't be to dump them under a functional overlay because after all getting them to a proper diagnosis and clinic with support designed for that prognosis etc' and wonder whether they have had the same treatment the respondents here had when replying to Peter Denton White's recent anomolie claims manifesto ...

 

Yeah it just feels like there needs to be a new law (which I'm aware would need to be adopted by country probably) and regulation/standard for submission to journals that these items can only be submitted where the author is an assigned independent without any connections or conflicts.

I say this because there is indeed surely a safeguarding issue, imagining the way the US healthcare system works then we are talking about people being put in situations where they can't afford to survive to get to the point where they might take action they'd have a full right to without the 'deal' of rehab or care that might come with strings regarding allowing something to be written without their sign-off.

But also because these are supposed to add to the literature, and if it was done by a proper independent investigator then it would actually add useful and helpful advice and knowledge as it builds up - and if these 'second victims' were so traumatised then having such reasuring and accurate and validated information on prevalence, prognosis etc would be a game-changer.

We also wouldn't doubt why someone thought it OK for a doctor to think someone left paralysed should be put in a situation where their arm and hand would drop on their own face - which when it is 'dead' isn't light and is not a small thing so doesn't feel like the best and kindest test from an appropriateness point of view, even if they thought someone was faking (deserving) or that there were other reasons this wouldn't happen.

But I guess then you have the other layer of administrators letting said people in - and all this in a timeframe where e.g. someone having a stroke might have a critical time-period. So then you think about regulations perhaps needing to leave the situation of 'and if you didn't invite them in' would it make you look like you are hiding something vs if you did?

But surely this isn't the answer - it really doesn't feel like a typing up of the TV programmes where they apparently have a review of whatever case and all the clinicians get to learn and comment from it. And it does feel just by its nature of being post-procedure of it sitting in some twilight between medical literature and will be used legally. Which feels like it is trying to add to some sort of case law whilst getting the right to dictate what is written by it being written only by one side?

And I agree on the privacy issue. In most spheres of e.g. market research any group with less than 5 cannot even have figures published to questions as it makes them potentially identifiable (the only male under 40 with a disability doesn't like the CEOs communication strategy). Then there is GDPR on identifiability. Insinuating all sorts as well as trawling through what might be factual history seems pretty inappropriate given the implications (employment, relationships, religion)

Worrying trend I can't believe is allowed and doesn't have an easy way to have stopped it already.