Functional Neurological Disorders - discussion thread

Trial By Error: Shaky Evidence for Signs of Functional Neurological Disorders

http://www.virology.ws/2019/12/30/t...r-signs-of-functional-neurological-disorders/

30 December 2019

By David Tuller, DrPH

One of my goals next year is to write more about so-called “medically unexplained symptoms,” also known as MUS. The term MUS might be useful as a descriptive name for the large category of phenomena that lack a proven pathophysiological pathway. But in the medical literature, and in the minds of those who present themselves as experts in the field, it is framed as an actual diagnosis that can be delivered with full confidence rather than a provisional construct based on the current state of medical understanding.

Different specialties have their own sub-categories of MUS. In neurology, these are called “functional neurological disorders,” or FND. This term has generally replaced older ones for this concept, including “conversion disorders” and “psychogenic disorders.” As with MUS overall, the evidence for these conditions has resided primarily in the absence of standard signs indicating organic dysfunction. The phrases “conversion disorder” and “psychogenic disorder” mean exactly what they say–the idea is that unexpressed psychological distress is transformed into physical symptoms, although how this “conversion” would occur is not really clear...

 

In gynaecology the preferred diagnosis for those irritating women who won't go away is (or was - I could be out of date) primary dysmenorrhea. When I was diagnosed with this I was just told to go away and get pregnant to cure pain.

In hypothyroidism the preferred diagnoses for MUS is Chronic Fatigue Syndrome, depression, or anxiety, or some combination of the three. The idea that TSH being in range equals perfect health is rampant throughout the medical profession. If the TSH range is (0.5 - 4.5) then doctors pretend that a TSH of 1 will be as good as, and give the same results for the patient as, a TSH of 4. In real people this isn't true. It only seems to be true in medical education, medical guidelines, and doctors' heads.

In gastroenterology the preferred diagnosis for MUS is IBS i.e. Irritable Bowel Syndrome, or anxiety.

I'd be interested in knowing the go-to diagnosis for other parts of the body or in other circumstances when doctors want to fob off their patients.

 

@dave30th In your article this sentence

takes people to post #7 in the S4ME thread you refer to rather than the beginning of the thread. Was that intentional?

 

Nicely written and I like that you'll write more about MUS.

I think this idea exists to cover up the fact that nobody actually has a clue and that it would be too expensive to investigate in depth every patient with difficult to explain symptoms.

And also because of Freud. The "complete works of Freud" can be found on the internet and various ideas of him will feel familiar.
For example, in the image above, Freud proposes that patients are generally unaware of the psychological cause of their hysteria. Is this why we patients are not considered a reliable witness to our own condition? Is this why BPS people ignore our feedback when we say it's not psychological?

Also I might add that the procedure of hypnosis to recover memories of the traumatic event that supposedly caused the illness is very similar to the discredited recovered memory therapy, which is now considered to be a method to implant false memories in patients.

 

No, thanks for pointing it out. should be fixed now.

 

Paper discussed in Dave's article is discussed here, https://www.s4me.info/threads/youve...cal-disorder-now-what-2018-perez-et-al.12970/

 

Spot on.

The admission that evidence is being back-filled to prove things already 'known' is bizarre. It is really an acknowledgement that there has never been any justification for the 'theories', or the interventions used; that being the case, then the only ethical and scientific way forward is to scrap the entire heap of pseudo-knowledge generated since Freud et al.

It's very strange that we keep seeing scientists more or less admitting to pseudoscientific and unethical practices. I guess in this domain if you just pretend like it's normal, and decry criticism as 'anti-science', you can pretty well rely on the wagons to circle. Of course this just gives credence to actual bad-faith anti-science rhetoric.

 

[my bold]

This is the crunch point. It's astonishingly arrogant; presuming to know the root cause of all these unknowns. Let alone presuming that root cause to be psychological. I strongly suspect there are political shenanigans behind the scenes, with health care costs being a significant factor.

 

About time this got more attention. Its common knowledge in our community, but hardly known in the general population ... even the general population of doctors.

 

Its actually a fallacy, and has been formally published as a fallacy.

 

I don't have the reference offhand and I don't feel strong enough to plough through the dross to find it but one paper suggests that FND should be considered if a woman turns up with a supportive husband with her.

The old mysogynist ideas of women using their health to chain a man are underlying a lot of these assumptions.

(posted before I was finished, oops)

FND is accepted easily by medics because of underlying cultural assumptions of hysterical women feigning illness which are not examined.

There is also a feeling that the signs of neurological illness are obvious but even in the early papers about FND there are lots of caveats about movement disorders and genetic studies have shown how bad neurology is at picking up some things.

Basically, standard neurological tests are great when they work but some disease is much more subtle. At one time, neurology was aware of that but it is being lost to quick judgements of FND.

 

That's what I meant when I said it really.

 

Hm. What do you mean that it has been "formally published" as a fallacy?

 

I think this is the best representation of how both the BPS and FND ideologies have worked up their "evidence base", inventing models that fit then looking back wistfully at how the models they invented to fit actually do fit if you look at them from the right angle and beliefs.

Just like the Copernican spheres. Except much, much dumber.

 

Unfortunately, that's kind of the point. The whole thing basically keeps a large patient population out of medicine by making us not patients. So doctors not knowing about us is precisely the whole point, they are spared the "distress" of having to deal with unsolved problems, we are out of sight and out of mind, then out of existence as a result.

It's sad but not really stretching satire too much to say that all patients are equal, some are much less equal than others.

 

I wrote a blog on this on Phoenix Rising. There were a series of papers written by, if I recall correctly, Richard Sykes. Something with Siren in the title, both in my blog and one of the papers. I will see if I can get a link to it. The papers point out the reasoning in simple syllogisms. They then show its a fallacy.

I keep having to reset my password to get on Phoenix Rising, and am no longer well enough to spend time on two forums (and am spending less here) so it may take me a little while to find it.

If I were going to oversimplify the argument, to give the flavour of it without a formal breakdown, it would be they use the reasoning that if it might be true it is.

 

I wrote a blog on this too, but not a great blog. This is nineteenth century science, and overthrown for nearly all science by the theories of Karl Popper on falsification. Early science was about amassing data to show you are right, and never ever really test your theories. That is the responsibility of others, and of course you then argue with them, pointing out how much data you have. One name this went under in philosophy was verificationism.

 

Darn, my Siren blog is completely gone. I wonder how many others are missing after the forum change last year? I will have to investigate further.

This blog on Verificationism cites my next blog, the one that is missing - https://forums.phoenixrising.me/blog-articles/part-one-verificationism.1148/

The blog was entitled The Witch, The Python, The Siren and The Bunny.

A second blog is also missing, I think it was called The Pacificist's Version of Nuclear Hand Grenade. There may be others missing.

PPS False alarm. For some reason it was not displaying properly (or my brain was glitching again). Here is the blog link https://forums.phoenixrising.me/blog-articles/the-witch-the-python-the-siren-and-the-bunny.1149/

 

Here is the relevant section of the blog -

Sykes has pointed out that the diagnosis of CFS as a mental disorder makes use of what he calls the psychogenic inference. The psychogenic inference uses the following "logic":

"Premise 1. If there is no known physical cause for a
condition, there is no actual physical cause for the
condition.

Premise 2. If there is no actual physical cause for the
condition, the cause must be psychological.

Conclusion (The psychogenic inference). If there is no
known physical cause for the condition, the cause must
be psychological."
(p. 312 Functional,Reasons, Neuroscience and the Psychogenic Inference )


Sykes' paper Medically Unexplained Symptoms and the Siren Psychogenic Inference targets the first of these premises. Its not a defensible position. Its also possible, from a strictly logical standpoint, that there is a physical cause that has not been discovered yet. Or that there is a physical cause that has been wrongly dismissed. Or that there are both physical causes and mental causes - so why do they then proceed to ignore the physical?

The psychogenic inference relies either on unexplained symptoms or the lack of a known disorder causing the symptoms. The problem is that most CFS symptoms have physical explanations - you just have to do testing that goes beyond what the hospital system typically provides. So a very real alternative to mental causation is a simple lack of diagnostic and investigatory tests. This is defended on two grounds:

1. It costs too much and often comes up empty, so it is a waste of money.
2. Even if physical problems are found they do not know how to treat it anyway - again a waste of money.

The third through fifth unspoken points are:

3. Its not their problem that the lack of such testing means that patients cannot receive appropriate social support including financial support.
4. Its not their mandate to fund tests to support social claims - OK, maybe it is, but there isn't any funding, what can they do?
5. Its not their fault that they can't treat many of these problems - that requires cutting edge medicine, is often not well validated, requires a better understanding of systems biology which is not taught at medical school, and is often seriously expensive ... where is the money coming from? Who is going to fund this expensive research?

What Sykes does not discuss is the possibility the majority of current psychosomatic medical thinking is wrong. This is a whole other debate, one I will return to later. Sure there are mental issues that cause physical symptoms ... oh, wait, depression is closely associated with physical problems, as is anxiety. It couldn't be that those physical issues are driving the symptoms? No, surely not! Thats buying into the biomedical model, heresy! Sorry to point it out, but the biopsychosocial model does have a bio- part ... oh, and a social part too.

This is not to refute the importance of cognition, mood and behaviour on modifying brain induced symptoms. The brain is plastic, it can change. The physical issues in the brain might therefore be modifiable by various techniques including CBT - but that doesn't necessarily mean the problem is mental. It might be - or not.

So the basis of a psychiatric diagnosis is this: A patient has a psychiatric reason for their CFS unless a known physical cause is found - in which case even a diagnosis of CFS cannot be made as its diagnosed by exclusion. Therefore by definition, not evidence and reason, if they have CFS then they have a psychiatric illness. Case closed.

Or put another way: If you can't prove your not crazy then you must be crazy. They do not have to prove they are right, only that you can't disprove them - but no you can't do any tests. Its a presumption of craziness without evidence. Oh wait, yes, they use a symptom checklist. Presumed psychosomatic patients have these symptoms. If you have these symptoms you must therefore have a psychosomatic illness. Its only invalid if a known alternative illness explains the symptoms, like MS. If you have a physical illness with these symptoms that is not understood ... gosh, no, that could never happen! Sorry to point this out, but how many former psychosomatic illnesses are now known to be physical?