Remote delivery of cognitive behavioral therapy to patients with functional neurological disorders: Promise and challenges, 2021, Lin & Espay

Highlights


• CBT is a promising treatment for patients with FND.

• Remote delivery of CBT can potentially increase access to care for patients with FND.

• Remote CBT can be integrated into clinical practice using a stepwise approach.

• Remote CBT can be integrated into practice using patient predictive factors.
Abstract

Functional neurological disorders (FND) are an important source of healthcare utilization and morbidity. While there are no formal guidelines for treating these disorders, cognitive behavioral therapy (CBT) is emerging as a safe and effective treatment. Currently, there is a global shortage of CBT providers, with only a small subset trained in and comfortable with treating patients with FND.

We highlight four types of remote CBT delivery to patients with FND to alleviate the access obstacle: workbooks, internet-guided CBT, app-based CBT, and teletherapy. CBT workbooks and teletherapy have been studied in FND, with preliminary studies suggesting efficacy; internet-guided CBT and app-based CBT have not but have been effectively used in patients with psychiatric disorders, particularly depression, anxiety, and post-traumatic disorders. As these disorders are often comorbid and share overlapping neurobiology with FND, internet-guided CBT and app-based CBT represent promising delivery options of CBT for FND. Although remotely-delivered CBT is unlikely to replace in-person CBT and there are technical and logistical challenges to overcome prior to widespread deployment, it holds promise as an adjunct treatment when in-person CBT is inaccessible. We propose a rational approach to future allocation of remote CBT treatment options and highlight important research gaps to bridge beforehand.

Open access, https://www.sciencedirect.com/science/article/pii/S2589986421000435

 

this should only be allowed after they actually prove fnd is a thing show us the evidence .

 

Precisely. They argue that CFS is not a real disease at every level, and the same with other poorly understood diseases, but want to replace these diseases with disease categories that have even less evidence than CFS, and much less than ME and many other disease categories. Even ME may fracture into many diseases in time as we learn more, but FND is much worse, a hodgepodge of everything they can cram in together.

 

Am I being stupid, but if a group of disorders are described as functional is it rational to assert they have a ‘neurobiology’? If a condition (or group of conditions) has (have) distinct biomarkers, why are these not used as diagnostic tools, and surely they raise a possibility/probability they are biomedical conditions.

Also if we are looking at identifiable neurobiological abnormalities this also raise the question which is the more appropriate target of any intervention, behaviour or the neurobiology, given we have little or no evidence on the direction of any hypothetical causal relationship?

 

I think they're referring to the very nonspecific and highly variable findings from resting state fMRI. Some studies of depression point to increased functional connectivity within the default mode network, which is the network engaged when we are lost in our inner thoughts (a finding often, rather stupidly, interpreted as evidence of excessive rumination, but of course the method can't distinguish between positive and negative inner thoughts). Some generalised anxiety studies point to increased functional connectivity in the salience and limbic networks. The salience network is involved in upregulating our ANS to gear up for an important challenge. PTSD is a bit all over the place, but never let the facts get in the way of a good story, right?

Its all a bit like the Rorshach inkblot test, because people will tend to impose upon the findings whatever preconceptions they had in the first place. And sometimes its heads-we-win-tails-you-lose, because excessive connectivity and weak connectivity are both interpreted in much the same way - as evidence of whatever "badness" you most fancy.

The whole business has been a bit of a mess, which is probably not a surprise, when you think of what a mess those diagnostic categories are in the first place (major depression is probably dozens of different things all lumped together). Lately the generalisations have given way to attempts to sort people into subgroups (and that might turn out to be actually useful, because it at least offers a new source of information). But the big problem is that weak thinkers and unscrupulous researchers try to make reverse inferences from the fMRI findings to the nature of the psychological processes that are implicated.

 

This is a very strange statement considering CBT has been used as a treatment from the start.

Also the study of outcomes of patients with "functional epilepsy" (using some name or other, there are so many!) at a clinic from 2011 to now showed that the number of seizures did not decrease with treatment

It looks like they are using "functional" to sound scientific with brain scans yet also using it to mean a "disease which serves a function" as in hysteria.

Watching all these studies it is obvious that they started out with a belief that certain neurological diseases (spreading out to anything else they can lay their hands on) and are now busy trying to put a scientific spin on everything by twisting all they write.

It is going to be very difficult to disentangle the story to get back from this cultish nonsense.