The natural history of terms describing functional (neurological) disorders in the medical literature of the last 60 years 2022 Bratanov et al

Andy

Andy

Retired committee member
Abstract

Background
Functional neurological disorders (FND), a subtype of functional disorders (FD), are a frequent motive for neurology referrals. The various presentations and the unknown physiopathology of FD have led to the multiplication of terms describing these disorders over the years.

Methods
We examined the FD-related articles published from 1960 to 2020 in PubMed and PsycINFO databases. We searched for: psychogenic, somatization, somatoform, medically unexplained symptoms, hysteria, conversion disorder, dissociative, functional neurological disorder, and functional disorder. Use rates in the title, abstract, keyword, or MeSH fields were collected over successive 5-year periods. After correcting for off-topic results, we examined proportional distribution over time, term associations, and disciplinary fields (neurology and psychiatry). Term impact was estimated via H-index and number of citations.

Results
We found that none of the terms is prevailing in the recent medical literature. We observed three trends in the use rates: stability, increase, and decrease of use over time. While most of the terms were present in a stable proportion of the publications, hysteria and psychogenic lost popularity over time. We found a differential preference for terminology between disciplines. Functional neurological disorder showed the highest citation impact, yielding 10% of highly cited publications.

Conclusion
We found a dynamic and evolving use of the different terms describing FD in the last 60 years. Despite the tendency to use the term functional in the recent highly cited publications, its low prevalence and coexistence with several other terms suggest that a precise, explanatory and non-offensive term remains yet to be found.

Paywall, https://link.springer.com/article/10.1007/s00415-022-11526-9
 
Despite the tendency to use the term functional in the recent highly cited publications, its low prevalence and coexistence with several other terms suggest that a precise, explanatory and non-offensive term remains yet to be found.

I'd be questioning the whole FND concept at this stage, if I was them.
 
Yes, that's the downside of a propaganda strategy aimed explicitly at obscuring the meaning of words and relies on swapping out terms periodically in order to keep fooling people. There are only so many combinations that can be used. There's also the fact that it's mind-numbingly dumb and built entirely out of logical fallacies. Even the lack of effort at abusing their power shows up, it's obvious that their heart isn't really in it because it's been too easy to simply abuse secrecy and the fact that until recently, the victims of this con could not share or communicate with others. Social media put a timer on this strategy and as usual they can't adapt. Normal for people stuck with 19th century ideas.

You can see a similar phenomenon in conspiracy theory crowds where they have their own language to refer to their various concepts, but unless you're very familiar with the culture it's basically an incomprehensible idiom. It works until you try to use those terms in public, where people don't know what the hell you're even talking about.

Even in the conclusion they can't pretend to respect our intelligence. They speak of finding a term that is not offensive, when the problem has nothing to do with the terms themselves, it's the idea behind. They're trying to find the equivalent of a n-word that doesn't sound offensive but is understood to mean the same thing. Not a thing. This is the same kind of hubris that lead to suspect X, likely Wessely, to genuinely argue that they could publish the NICE guidelines without the evidence review and we would be happy anyway. The danger with making up convenient caricatures of one-dimensional behavior is that you can end up believing in it. They've made us out to be so stupid they can't imagine we can see right through them, even though the vast majority of patients always did.

This reads to me like Bigoted Magazine trying to figure out why their ever-changing racist/bigoted terms keep getting them in trouble and banned from social media. Dog whistling, using benign words to mean offensive things, is not a unique problem to medicine, it's one of many things psychosomatic ideology shares with bigots.

There are dozens of those constructs around and they missed out most. There are even a few that are local, like the exhaustion syndrome in Norway or Sweden and the dozen of functional disorders Fink managed to sucker their healthcare authorities to adopt. And they all mean the exact same thing. Usually that's a big tell that this is all made-up. And it sure is.
 
Andy said:
Functional neurological disorders (FND), a subtype of functional disorders (FD), are a frequent motive for neurology referrals.
Click to expand...

The first sentence sets the tone. FD are ‘a frequent motive for neurology referrals’ sounds rather like prejudging the issue. The motive for referrals to neurology is surely finding an answer to and hopefully a treatment for presenting neurological symptoms.
 
Peter Trewhitt said:
The first sentence sets the tone. FD are ‘a frequent motive for neurology referrals’ sounds rather like prejudging the issue. The motive for referrals to neurology is surely finding an answer to and hopefully a treatment for presenting neurological symptoms.
Click to expand...
Yeah I noticed that one too. And it's especially weird coming from... neurologists who want to make FND a legitimate thing. It just shows the underlying lack of respect for the patients. No matter how much they pretend, they don't.
 
Peter Trewhitt said:
The first sentence sets the tone. FD are ‘a frequent motive for neurology referrals’ sounds rather like prejudging the issue. The motive for referrals to neurology is surely finding an answer to and hopefully a treatment for presenting neurological symptoms.
Click to expand...
We had a neuro consult this month. Although my daughter has many symptoms that could be neuro based ( Like many pwME) she wanted to focus on headaches ( a couple of types) as she felt if she brought up everything she'd simply be written off with FND. Sadly.

She's had migraines earlier in her teens and made it plain that these headaches did not match her experience of migraine

she's going for 3 types of MRI , but the letter confirming the consultation and MRI referral sent to GP stated that if nothing is found on scans it's basically migraine and to prescribe prophelactics
 
Amw66 said:
We had a neuro consult this month. Although my daughter has many symptoms that could be neuro based ( Like many pwME) she wanted to focus on headaches ( a couple of types) as she felt if she brought up everything she'd simply be written off with FND. Sadly.

She's had migraines earlier in her teens and made it plain that these headaches did not match her experience of migraine

she's going for 3 types of MRI , but the letter confirming the consultation and MRI referral sent to GP stated that if nothing is found on scans it's basically migraine and to prescribe prophelactics
Click to expand...


Well MRI finally reported back as normal. So bittersweet.
That sensation of relief that nothing serious has been found , but disappointment that once again nothing validates her experience and medics think she's imagining it and is a nutter.

She thought it a bit odd that none used contrast ( previous MRI years ago for pituitary had contrast)
I don't know parameters for use of contrast ?

@SNT Gatchaman
 
The three types of MRI were likely to have been acquired in one appointment. For this indication I would expect that they were a basic brain MRI (anatomical structural sequences + evaluation for blood and ischaemia: susceptibility and diffusion-weighted imaging); MRA (time-of-flight angiography/arteriography to look for thrombosis or vascular anomalies, esp. aneurysms or AV malformations); and MRV (time-of-flight venography, to look for thrombus and narrowed outflows as a marker of raised intracranial pressure).

For the indication of "headaches", it's highly unlikely they would do MR spectroscopy, and even less likely they would have interrogated the ventricles, but in ME that might have shown abnormally raised lactate levels. (I would like more research on this and it would be an easy translation into clinical practice, if valid).

Due to the high contrast resolution of MRI, the basic principle is one would see a lesion or abnormality and give contrast to characterise it. CT is different as you've only got density to work with so things can hide a lot more easily. For MRI, if there's nothing to see there's no point giving contrast for something that isn't there. In the brain, a lesion will usually show enhancement due to abnormal vascular supply, localised breakdown of the BBB etc, eg abscess, large primary tumour or smaller metastases, large MS lesions.

As your daughter found previously, sometimes contrast can be used up-front. That's often a dynamic assessment, particularly when looking at vascular flow eg in a malformation. In her case they would have been assessing for a pituitary adenoma, which is a common referral. Adenomas can be large or small: the arbitrary cut-off is 10 mm, defining macroadenomas and microadenomas. Microadenomas can be tricky to see, but they show slightly delayed contrast enhancement compared to the normal pituitary gland (~100 ms vs ~70 ms). So if you do a dynamic sequence you'll just catch it as an area of lower signal that then fills in.

While still in the early research phase, the future could see dynamic-contrast enhanced evaluation for global BBB impairment, although other non-contrast techniques would be better if they can pan out. Final comment, it's possible her MRI shows a few more than usual perivascular spaces. These are relatively commonly seen and have always been considered non-specific. They would generally not be mentioned in a report unless large or weird-looking (to use the technical term). In that case they might "mention to dismiss" for the benefit of a non-expert looking and wondering "what's that obvious abnormality they've missed?". It may turn out that perivascular spaces too are actually a marker for previous or current BBB dysfunction. Again, if proven that would be an easy and useful change to clinical practice, not even requiring more sequences - just a change in analysis and reporting.
 
SNT Gatchaman said:
The three types of MRI were likely to have been acquired in one appointment. For this indication I would expect that they were a basic brain MRI (anatomical structural sequences + evaluation for blood and ischaemia: susceptibility and diffusion-weighted imaging); MRA (time-of-flight angiography/arteriography to look for thrombosis or vascular anomalies, esp. aneurysms or AV malformations); and MRV (time-of-flight venography, to look for thrombus and narrowed outflows as a marker of raised intracranial pressure).

For the indication of "headaches", it's highly unlikely they would do MR spectroscopy, and even less likely they would have interrogated the ventricles, but in ME that might have shown abnormally raised lactate levels. (I would like more research on this and it would be an easy translation into clinical practice, if valid).

Due to the high contrast resolution of MRI, the basic principle is one would see a lesion or abnormality and give contrast to characterise it. CT is different as you've only got density to work with so things can hide a lot more easily. For MRI, if there's nothing to see there's no point giving contrast for something that isn't there. In the brain, a lesion will usually show enhancement due to abnormal vascular supply, localised breakdown of the BBB etc, eg abscess, large primary tumour or smaller metastases, large MS lesions.

As your daughter found previously, sometimes contrast can be used up-front. That's often a dynamic assessment, particularly when looking at vascular flow eg in a malformation. In her case they would have been assessing for a pituitary adenoma, which is a common referral. Adenomas can be large or small: the arbitrary cut-off is 10 mm, defining macroadenomas and microadenomas. Microadenomas can be tricky to see, but they show slightly delayed contrast enhancement compared to the normal pituitary gland (~100 ms vs ~70 ms). So if you do a dynamic sequence you'll just catch it as an area of lower signal that then fills in.

While still in the early research phase, the future could see dynamic-contrast enhanced evaluation for global BBB impairment, although other non-contrast techniques would be better if they can pan out. Final comment, it's possible her MRI shows a few more than usual perivascular spaces. These are relatively commonly seen and have always been considered non-specific. They would generally not be mentioned in a report unless large or weird-looking (to use the technical term). In that case they might "mention to dismiss" for the benefit of a non-expert looking and wondering "what's that obvious abnormality they've missed?". It may turn out that perivascular spaces too are actually a marker for previous or current BBB dysfunction. Again, if proven that would be an easy and useful change to clinical practice, not even requiring more sequences - just a change in analysis and reporting.
Click to expand...
Thank you for your comprehensive reply.
It was a single appointment in a mobile MRI unit .
We don't normally get the report , just a summary letter which has still to pop through letterbox . GP had their letter emailed and could advise on Friday.
Fascinating.
 
Our copy of neurology letter came through letterbox this morning.
Date of scan wrong and no reporting of venous MRI.
I double checked direct with neurology admin and this is as yet unreported ( so why issue a letter ?)

Despite giving detailed symptom description of not being anything like experienced migraines , migraine has been decided .

Suggested prophylactics with no particular recommendation ;beta blockers, amitriptyline/ nortriptyline (caution re fatigue side effects) , topiramate, pizotifen or candesartan.
So ball passed back to GP.

Hypoperfusion fits with a lot of symptoms, and intermittent " brain in fire" might tie up with lactate/ glial activity?

GP however may think she's nuts if these are mentioned.

Oh for some decent research and replication
 
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