Mind and Body in the Guardian again

[rvallee]

I get that feeling any time I read a meta-discussion about psychology. It’s essentially just philosophy described with a different language. Which is really concering, given how much resources and faith society gives the field.

But also it's very, very bad philosophy. The kind that can serve as a how-to of what philosophy isn't. If at least it were any good, but instead philosophy is used here with the same intent and purpose as they use science: as a cover for what are just a bunch of personal opinions.

 

[Hutan]

My optometrist once got frustrated when my prescription changed as soon as I put on a pair of glasses. He would measure precisely, get me the correct glasses, and then my corrected vision would be worse than it should be. My eyes automatically adjusted as soon as I put on the glasses making the prescription inaccurate. It wasn't something I was doing consciously. I didn't need perfect vision, so I didn't bother to fix the problem. But I later found that I could see better if I wear my glasses upside down. I'm no expert on FND, but something like that has got to be functional.

Just wanted to pick up on this.

I think a lot/all of what people attribute to 'functional' i.e. the product of thought, is actually the result of other things that the attributors don't know yet. For example, here's an AI view on why someone might have better vision when glasses are placed upside down:

If your vision appears better when you turn your glasses upside down, it likely means your current glasses prescription isn't perfectly aligned with your eyes, potentially due to the optical centre not being positioned correctly on your face, or your prescription may be slightly outdated, causing the slight tilt of the lens to provide a better correction when turned upside down; this is not a normal situation and you should consult an optometrist to get your glasses properly fitted.

 

[Utsikt]

I think a lot/all of what people attribute to 'functional' i.e. the product of thought, is actually the result of other things that the attributors don't know yet.

Everyone wants to know why things happen, even though we can’t. Some make educated guesses, others just make thing up. We’ve always done that.

We also like to know how to fix things.

 

[Jonathan Edwards]

Yes, it is pretty weird to see better with glasses upside down, although it might occur if there is different astigmatism in each eye. (I am not that convinced of the AI story.)

And this would definitely be structural, not functional. The shape of the lenses - either the ones in the eyes or the ones the optician didn't quite get right in his test frames!

 

[Hutan]

Yes, it is pretty weird to see better with glasses upside down, although it might occur if there is different astigmatism in each eye. (I am not that convinced of the AI story.)

It sounds as though there are a few possible things going on. I'm not an optometrist; I may very well have written things below wrong.

The glasses won't fit so well on your face upside down, so the lens is held a bit further away - so perhaps the prescription was just straight out wrong. And you might be looking through a different part of the lens, which is ground differently across the lens to work when the angle of vision is different. And the glasses would be held on a different tilt, and that might help with an astigmatism correction. So the astigmatism correction might have been wrong.

And also, for sure we can make errors of prediction in the moment. It sounds like if you get a new glasses prescription (or even are just looking through the optometry machine), it can take a little while for the brain to realise that it is getting new signals that need to be made sense of in a new way, that it doesn't need to keep trying to correct the signals as it was before. So, there is advice to give it a little time to see if new glasses work.

Another example of an error of prediction is if you thought that you had filled the electric kettle, it can be a surprise when you pick it up and it is much lighter, because you hadn't filled it up. The kettle can jerk upwards because you applied enough lifting force for the expected heavy kettle.

But, these prediction errors are momentary things. Perhaps there are cases where someone would go on making errors of prediction for months and need some help to change their predictions. But it's hard to believe that that is the mechanism for something like ME/CFS, where the consequence of exertion is so delayed and where the symptoms are so varied.

 

[poetinsf]

I don't understand that sentence. I meant that the term is universally used to imply that the clinical features are due to inappropriate thoughts, secondary gain, so-called conversion disorder or whatever. That is what doctors mean. That has nothing to do with what is actually wrong - which we don't know. And there are no reliably validated treatments as far as I know.

So, it sounds like you are saying there is no legit functional disorder. Is that right? I'll have to differ in that case. There indeed are cases that brain is trained (or mis-trained) to respond abnormally to inputs or generate abnormal outputs, and threated by various means of retraining.

What does 'legit' mean here?

To me a disease is legit if the disorder can be diagnosed and treated/prognosticated. And there are FND cases can be diagnosed and treated. Aside from accepted medical practices, I've read a few poignant accounts by FND patients how they were freed from vision loss or mobility problems.

We all agree that there are just too many misuses and abuses of "functional disorder" label. But we shouldn't throw out the baby with the bath water. My personal experiences are no more than annoyances, but there indeed are people who suffered greatly for years and then found relief through non-somatic modifications.

 

[poetinsf]

Just wanted to pick up on this.

"If your vision appears better when you turn your glasses upside down, it likely means your current glasses prescription isn't perfectly aligned with your eyes, potentially due to the optical centre not being positioned correctly on your face, or your prescription may be slightly outdated, causing the slight tilt of the lens to provide a better correction when turned upside down; this is not a normal situation and you should consult an optometrist to get your glasses properly fitted."

How did we ever live without AI for so long? Thanks for digging that out, that thought also occurred to me. It still doesn't explain why my vision automatically worsens when I put the glasses on. Only difference between the measuring machine and the glasses that I could think of was the lack of the arms, so I tried it upside down with arms over my ears rather than behind. I'll have to admit though, it's not scientific and there could be other factors like misalignment of lenses.

 

[poetinsf]

And this would definitely be structural, not functional. The shape of the lenses - either the ones in the eyes or the ones the optician didn't quite get right in his test frames!

That still doesn't explain why my vision automatically worsens when I put on the glasses. Consider this functional possibility: I had been wearing prescription that was slightly off for years. My eyes compensated for years by "squinting" and got trained to do so whenever I put on the glasses. When I finally got the correct prescription, it still compensated and therefore threw off the prescription.

Also consider the known experiment with glasses that switches left and right. Subjects live with the switch for a week, their brains get rewired, and they get severely disoriented when they are finally off the glasses. Now imagine such rewiring happening for whatever reason and brain getting stuck in that state. Wouldn't you call that a functional disorder?

[edit: added the last paragraph]

 

[Hutan]

That still doesn't explain why my vision automatically worsens when I put on the glasses. Consider this functional possibility: I had been wearing prescription that was slightly off for years. My eyes compensated for years by "squinting" and got trained to do so whenever I put on the glasses. When I finally got the correct prescription, it still compensated and therefore threw off the prescription.

Also consider the known experiment with glasses that switches left and right. Subjects live with the switch for a week, their brains get rewired, and they get severely disoriented when they are finally off the glasses. Now imagine such rewiring happening for whatever reason and brain getting stuck in that state. Wouldn't you call that a functional disorder?

As I said, we know that it can take a little while to get used to new inputs. In the examples you give, the adaption period is short. Just perhaps, adaption doesn't happen at all for a very small number of people. But, that impact would be very specific. Do we have any credible evidence that it happens (not just personal accounts or case studies from clinicians, often with a conflict of interest?)

Where is the evidence that thinking differently solves, for example, some of the gait problems, or the seizures, labelled with FND?

Do you agree though, that to take the concept and suggest that the brain is generating the full range of symptoms of ME/CFS simply because it is stuck in a thinking rut, and that we can fix ME/CFS by thinking 'there is nothing actually wrong with me. I can safely ignore the feelings of fatigue and power on through' is wrong?

 

[Peter T]

Where is the evidence that thinking differently solves, for example, some of the gait problems, or the seizures, labelled with FND?

Even if an intervention helps some, there is no guarantee that it does so in the way those undertaking the intervention think. That is the point of an active control condition and objective outcome measures.

 

[Sean]

And the glasses would be held on a different tilt,

I have had prescription glasses that worked noticeably better when I slightly tilted the angle of the lenses relative to the face. In this case by raising the frame arms 2-3mm at the ears with some wraps of elastoplast type tape. But the arms on most frames can be adjusted too.

I don't think this means the lens were incorrectly made. More likely that the relationship between the lens, the frame, and the geometry of the individual face/head is also important.

 

[dave30th]

Functional has a bad name because it was devised and is universally used by doctors to mean behavioural/psychological despite the fact that they deny this in writings they know may be read by patients.

I think the term "functional" was useful in the sense that it also means "having to do with function," so on its face it comes across as neutral and would be neutral if that's how it were used by clinicians. As Jo says, that's not how it's generally understood. "Functional" has more or less replaced "MUS." So the main "functional" syndromes are said to be IBS, ME (they often still prefer CFS), and fibromyalgia. Any other symptoms not parts of syndromes are "functional" if they're "uexplained" by which is meant "unexplainable in perpetuity because it's 'functional.'"

FND is somewhat different and more specific, because they have given it actual diagnostic criteria. It is the current name for what was conversion disorder. And conversion disorder in 20th century generally fell into three categories--motor, sensory, and seizures. Leg paralysis, "hysterical" blindness/deafness, and "psychogenic non-epileptic seizures," for example. In the 2010 Stone et al study of neurology diagnoses, these were the conversion disorder categories and they constituted 5.5% of visits to the neurology clinics they examined. (That doesn't mean the diagnoses were accurate!!--that's just what the diagnoses were.)

In 2013, the DSM added "functional neurological symptom disorder" to the conversion disorder category, and changed the criteria. It no longer required a psychological trauma to be identified as the cause, but there had to be a positive clinical "rule-in" sign indicating a mismatch between neurological disease and the symptoms. Since then, FND has been in expansion mode, with the experts laying claim to cases of "dizziness" (many likely from orthostatic intolerance of some kind) and cognitive impairment as sub-groups of FND. Given the pandemic, FND is in a state of "diagnosis creep" but the creep has been quite rapid.

ADDED: This is all as I understand it. I don't pretend to be an expert here.

 

[shak8]

Fibromyalgia was termed Fibromyalgia Syndrome (FMS) back decades. Why it's bumped down in the pecking order to functional is beyond me.

Another instantly assumed meaning of functional is something that works, functions.

In FMS, the opposite happens. Pain being a huge inhibition of normal F.

Generational categorization games per the academies.

 

[Sean]

Any other symptoms not parts of syndromes are "functional" if they're "unexplained" by which is meant "unexplainable in perpetuity because it's 'functional.'"

Therefore does not need any further research of any kind on it that might show an alternative explanation, especially biomedical.

Who needs falsification? That way only leads to lofty eminence being called into question.

 

[Jonathan Edwards]

That still doesn't explain why my vision automatically worsens when I put on the glasses. Consider this functional possibility: I had been wearing prescription that was slightly off for years. My eyes compensated for years by "squinting" and got trained to do so whenever I put on the glasses. When I finally got the correct prescription, it still compensated and therefore threw off the prescription.

That is still structural. You would be changing the shape of your lens or eye muscles.
I also think it fairly unlikely that this would occur. When one is reading the eye charts with different lenses the optometrist relies on very rapid optimisation by your brain to a better selection.

Accommodation and focal plane can change for other reasons relating to hydration etc. - something that happens in diabetes. Again a structural problem. I have recently had such a change probably relating to lens stiffening with early cataract formation.

I am not sure that any of this has much to do with the diagnosis of functional neurological disorder.

 

[poetinsf]

As I said, we know that it can take a little while to get used to new inputs.

Yes, that's why some people get dizzy when they put on a new pair of glasses. Worse-than-expected vision is not one of them, I don't think. Practitioners wouldn't get surprised by that if that were the case.

Where is the evidence that thinking differently solves, for example, some of the gait problems, or the seizures, labelled with FND?

Would you agree that it's enough evidence if the (non-somatic) FND treatments are effective? A quick search for FVL turned up this: "A 2016 systematic review of the prognosis of functional visual loss included 5 studies (between 1966 and 1989) with 132 patients, mostly adults, with a follow up over several years. Between 46 and 78% of patients had improved or remitted at follow up [4]. A further study of 8 cases in children showed that 25% had recovered in 1 month [5]." Or, this: "In addition, although not a DSM criteria, any demonstration of reversibility of a deficit is characteristic of FND". I'm not an expert on FND by any means, nor is it a particular interest of mine; I'll have to rely on Google.

Do you agree though, that to take the concept and suggest that the brain is generating the full range of symptoms of ME/CFS simply because it is stuck in a thinking rut, and that we can fix ME/CFS by thinking 'there is nothing actually wrong with me. I can safely ignore the feelings of fatigue and power on through' is wrong?

Absolutely. I don't think anybody here is arguing that FND applied to ME/CFS is valid in any shape or form. I'm simply saying FND diagnosis may be valid in some other cases, and we shouldn't be against FND as whole.

 

[poetinsf]

That is still structural. You would be changing the shape of your lens or eye muscles.

The point is though, that "structural" change is happening without somatic modification or intention, hence it is functional.

I also think it fairly unlikely that this would occur. When one is reading the eye charts with different lenses the optometrist relies on very rapid optimisation by your brain to a better selection.

The problem occurs not during the measurement, but when I put on the glasses. The lenses are the same; the delta here the machine vs the frame on the face.

I am not sure that any of this has much to do with the diagnosis of functional neurological disorder.

I'm just using my experience as an example of possible FND, albeit a minor one. If my eyes are trained to contract eye muscles as soon as I put on glasses, that would be a functional, not somatic, problem.

 

[Jonathan Edwards]

"A 2016 systematic review of the prognosis of functional visual loss included 5 studies (between 1966 and 1989) with 132 patients, mostly adults, with a follow up over several years. Between 46 and 78% of patients had improved or remitted at follow up [4].

That tells us sweet FA. These are not controlled trial data. Of course people will improve with time. It is hard to credit just how bad the research I this field is but it is. This is worse than the Cochrane exercise review.

 

[Jonathan Edwards]

The point is though, that "structural" change is happening without somatic modification or intention, hence it is functional.

Where does that come from. What is somatic modification if not strudel change? Or by somatic are you meaning psychosomatic? Structural change in cancer occurs without intention and isn't functional so what has intention got to do with it?

 

[Jonathan Edwards]

The problem occurs not during the measurement, but when I put on the glasses. The lenses are the same; the delta here the machine vs the frame on the face.

I suspect you need a better optician. I have had similar problems in the past.