Recognising and explaining functional neurological disorderBMJ 2020; 371 doi: https://doi.org/10.1136/bmj.m3745 (Published 21 October 2020) Cite this as: BMJ 2020;371:m3745
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I was pleased to see this helpful practice pointer on Functional Neurological Disorders (FNDs) (1). Especially useful to emphasise the importance of neuroscience, not requiring a history of trauma and allowing for expecting co-existing disease.
I would argue however that they have gone too far in suggesting that FNDs should be positively diagnosed as definitive disorders and not far enough in helping patients and clinicians understand the varied and likely complex multicomponent origins of symptoms. At the heart of our dis-ease as doctors at ‘functional’ presentations is our as yet primitive understanding of how they come to be. The little we do know in terms of patho-physiology does not allow us to pin point what is happening for the individual. While the specific symptom suggests an imbalance of functioning of the relevant part of the brain-body, it does not help us understand what combination of insults, or genetic predispositions are relevant for the patient in front of us.
However, we do know that Adverse Childhood Events, viral infections (most recently COVID-19), and prescribed and other substances acting on the brain (or being suddenly withdrawn) can contribute to the symptoms found in FND and other ‘functional’ conditions. And that there are a number of potential pathological pathways from viral or emotional insult, (e.g. HPA axis dysfunction, cytokines, glial cell changes) which together can be seen as Psycho-immuno-neuro-endocrine dysfunction(2,3,4). Furthermore there are good arguments and increasing evidence (eg re depression and inflammation) for a unified approach not just to all ‘functional’ ‘disorders’ but also to many psychiatric ‘disorders’. While confident doctors and diagnostic labels are appreciated by some patients, many of my patients appear to prefer to understand their Emotionally Unstable Personality Disorder as an imbalanced amygdala resultant from years of trauma. Technically disorder does mean a disordered physiology (as opposed to disease), but I would argue we too often present disorders as substantive fixed entities.
So, I would go further than the authors in bringing in neuroscience to help patients understand their conditions as complex but real, and propose we work across primary care, out-patient specialties and psychiatry and psychology to agree on some scientifically accurate ways to describe (bio-psycho-social) aetiology, underlying brain-body dysfunction and rationale for the array of management strategies we are in early stages of developing for what is a very wide range of overlapping and changing syndromes.
1. Stone J, Burton C, Carson A. Recognising and explaining functional neurological disorder. BMJ. 2020;371:m3745. doi: 10.1136/bmj.m3745.
2. Anda RF, Felitti VJ, Bremner JD, et al. The enduring effects of abuse and related adverse experiences in childhood. A convergence of evidence from neurobiology and epidemiology. Eur Arch Psychiatry Clin Neurosci. 2006;256(3):174-186. doi:10.1007/s00406-005-0624-4
3. Rasa, S., Nora-Krukle, Z., Henning, N. et al. Chronic viral infections in myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS). J Transl Med 16, 268 (2018). https://doi.org/10.1186/s12967-018-1644-y
4. Danese, A., J Lewis, S. Psychoneuroimmunology of Early-Life Stress: The Hidden Wounds of Childhood Trauma?. Neuropsychopharmacol 42, 99–114 (2017). https://doi.org/10.1038/npp.2016.198
Competing interests: No competing interests
Please may we add an important update to our previous response (1)
Our ‘Patient Voice’ paper, research commissioned by the All Party Parliamentary Group for Prescribed Drug Dependence (2), has now been published (9 November 2020) in the peer reviewed Sage journal ‘Therapeutic advances in Psychopharmacology’ (3). This paper tracks – we believe for the very first time in a scientific paper – 158 collated actual patient accounts of the aetiology of the development of all manner of prescribed drug-related ‘symptoms’ which have been variously mis-diagnosed as (or led to?) other illnesses, ‘unexplained symptoms’ and/or ‘functional’ disorders.
“In this sample [of 158 cases] 25% of patients with antidepressant withdrawal presenting to their GP were diagnosed with MUS, a ‘functional neurological disorder’ or ‘chronic fatigue syndrome.’ Many of the signs and symptoms associated with these medically unexplained disorders, captured in the often used PHQ-15, overlap with the symptoms of antidepressant withdrawal, including insomnia, feeling tired, nausea, indigestion, racing heart, dizziness, headaches and back pain.”(3)
The raw evidence for the Sage journal paper (3) is publicly available for anyone to read – the collections of extremely harrowing personal accounts are openly publicly accessible as individual PDFs on the Scottish and Welsh Parliaments’ websites (4 and 5). We urge everyone to read at least some of these patient experience accounts – each and every individual account revealing yet another alarming apparent mis-attribution of ‘symptoms’ leading to yet more (presumably unintended) mis-treatment, personal anguish and physical disability. Each individual contributor is desperate to somehow ‘get the word out’ about what is happening to people. All around us. No way has previously been found to get these patient voices heard as published ‘scientific evidence’. The Scottish and Welsh Petitions have revealed this serious ‘feedback’ flaw in the healthcare systems (systems ‘Failure Point 8’ in the Patient Voice paper (3)).
The Daily Telegraph published a feature article on 9 November 2020 (6) quoting the new original research paper (3), and this is also being picked up in the news in other countries. The public response is clearly revealing that countless others are likewise affected and now many more individuals are coming forward to share their own struggles to be heard and believed.
The Welsh Petition issued a formal report and recommendations on 19 March 2019 (7) and this was debated in plenary session at the Welsh Senedd in May 2019. Recommended actions are still outstanding.
The Scottish Petition has logged (11 November 2020) a new formal Written Petitioner Submission recording the new published work - based on the evidence published in the Written Submissions for Scottish Public Petition PE01651(8). The progress of Scottish Petition PE01651 is currently deferred (since March 2019) pending the outcome of a Scottish Government Short Life Working Group on Prescribed Drug Dependence and Withdrawal.
To repeat our previous closing statement (1): we strongly urge that the clues to the aetiology of FND (contained in our “Patient Voice” evidence further detailed above and referenced below) be fully recognised and investigated with utmost urgency. It is time to openly acknowledge that drugs which are prescribed specifically to alter the functioning of the central nervous system may be the very reason why that nervous system is now presenting as malfunctioning.
(1) Brown et al Rapid Response Patient research FND Oct 2020 https://www.bmj.com/content/371/bmj.m3745/rr
(2) All Party Parliamentary Group Prescribed Drug Dependence – Research & Reports http://prescribeddrug.org/research/
(3) Guy A, Brown M, Lewis S, Horowitz M. “Patient Voice…” Therapeutic Advances in Psychopharmacology Nov 2020 https://journals.sagepub.com/doi/10.1177/2045125320967183
(4) Scottish Parliament Public Petition PE01651: Prescribed drug dependence & withdrawal
(5) Welsh Parliament Public Petition P-05-784 Prescription drug dependence and withdrawal
(6) Levy M. “Coming off Antidepressants..” Daily Telegraph Nov 2020 https://www.telegraph.co.uk/health-fitness/mind/broke-loose-truth-coming...
(7) REPORT for Senedd: Welsh Parliament Public Petition P-05-784 Prescription drug dependence and withdrawal
(8) Petitioner Submission 11 November 2020 : Scottish Public Petition PE01651 http://www.parliament.scot/S5_PublicPetitionsCommittee/Submissions%20202...
Competing interests: No competing interests
Stone et al. describe a common and important clinical syndrome, with a large impact on the patients and everyone around them. They have often had unsatisfactory experiences of healthcare and changing this is important for all involved.
The old fashioned named GP who regularly checks in with the person affected has incredible value, ensuring different consultants and hospitals talk and write to each other, that the management plans are enacted and links to local OT and physiotherapy and in particular between physical and mental health services are made. Ideally an empowered patient or secondary care do this automatically but too often it does not occur.
In my work as a general neurologist and doing a tertiary FND clinic I find that monitoring for newly emergent disorders is extremely important for quality of life, and the feeling that any new and persistent symptom is taken seriously. General practice has an extremely important role to play in this.
A common scenario is weight gain with medication and immobility and other causes and its complications. I frequently diagnose OSAS in this context. Another common scenario is evolving musculoskeletal problems as a result of altered movement, and frozen shoulder, carpal tunnel, trochanteric bursitis and many other tendonitis and bursitis are common.
A previous response raises the issue of akathisia. As discussed by Stone et al. co-morbid neurological and psychiatric conditions are common and it is important not to diagnose FND just based on distractibility, but in, for example, tremor (a regular oscillation) this is extremely helpful. An experienced movement disorder neurologist should be able to differentiate however if patient has one or the other or both.
Another response raises the important issue of side-effects of medication. I agree this can be sometimes be the trigger of FND (small literature on levatiracetam inducing functional seizures, and functional seizures can improve with stopping this and other antiepileptics) but more commonly possible side effects co-exist with FND. Certainty is however hard and nocebo and placebo rates are high in many neurological and psychiatric conditions. Medication use however can be an important perpetuating factor. It requires a slow approach and thorough conversation with patients but I have seen dramatic improvements in patients with FND when stopping e.g. valproate (sleepiness/weight gain/cognitive), topiramate (word fluency/cognitive/mood), pizotifen (mood, weight gain and sedation) and often a very slow reduction of pregabalin, opiates and gabapentinoids are helpful (or no change occurs, but benefit of medication reduction regardless) since people have often tried a fast withdrawal and conclude they can't come of the medication. Being positive to patients about the potential to feel better with medication reduction is important in this context and general practice has an extremely important role to play. Changing and stopping TCA/SSRIs and other psychiatric medications are often possible, but sometimes might need more discussion with neurologists, pain management and psychiatrists.
All these examples illustrate that in this often complex biopsychosocial condition close relationships between general practice and secondary care are of vital importance and I thank Stone et al. for their open-minded and comprehensive review of this.
Competing interests: No competing interests
Stone and colleagues (1) present useful guidance regarding assessment and management of patients with functional neurological disorder (FND). Unfortunately, clinicians caring for those with other ‘functional’ syndromes often face rather more fraught and complex challenges.
Chronic fatigue syndrome (CFS) and fibromyalgia (FM) are examples of common presentations which have also attracted the ‘functional' label due to persisting uncertainty regarding aetiology and pathophysiology; optimal management is consequently challenging (2,3). FND is typically identified by overt physical signs; even when these are absent, as in dissociative seizures, it is often possible to give significant weight to features in the history (1). By contrast, the absence of physical signs and the lack of symptom specificity in CFS and FM can be a source of doubt, dispute, and stigma for all concerned (4, 5).
As Stone et al demonstrate, clinical findings enable the positive diagnosis of FND in tandem with judicious diagnostic testing to exclude relevant pathologies (1). By contrast, many other functional syndromes are identified in a negative sense, only after often extensive physical investigations have excluded demonstrable pathology. This conclusion is generally less satisfying and a frequent source of frustration for both patients and clinicians (4, 5). Doctors thus often find themselves in the difficult position of breaking unwelcome ‘good news’ to patients hungry for a mechanistic explanation of their symptoms. Recognising and skillfully managing patients’ emotional investment in having a physical diagnosis is crucial in avoiding the dual risks of over-investigation and overtreatment (6).
1) Stone J, Burton C, Carson A. Recognising and explaining functional neurological disorder. BMJ. 2020;371:m3745. doi: 10.1136/bmj.m3745.
2) Missailidis D, Annesley SJ, Fisher PR. Pathological mechanisms underlying myalgic encephalomyelitis/chronic fatigue syndrome. Diagnostics (Basel). 2019;9:80. doi: 10.3390/diagnostics9030080.
3) Schmidt-Wilcke T, Clauw DJ. Fibromyalgia: from pathophysiology to therapy. Nat Rev Rheumatol. 2011;7:518-27. doi: 10.1038/nrrheum.2011.98.
4) Boulton T. Nothing and everything: Fibromyalgia as a diagnosis of exclusion and inclusion. Qual Health Res. 2019;29:809-819. doi: 10.1177/1049732318804509.
5) Houwen J, Lucassen PL, Stappers HW, Assendelft WJ, van Dulmen S, Olde Hartman TC. Improving GP communication in consultations on medically unexplained symptoms: a qualitative interview study with patients in primary care. Br J Gen Pract. 2017;67:e716-e723. doi: 10.3399/bjgp17X692537.
6) Williams N, Wilkinson C, Stott N, Menkes DB. Functional illness in primary care: dysfunction versus disease. BMC Family Practice. 2008;9:30.
Competing interests: No competing interests
The purpose of this response is to shed light on the significant harm that can be caused by a functional neurological disorder (FND) misdiagnosis, especially in the case of akathisia, and to challenge the authors' claim that it is rarely misdiagnosed.
In Psychogenic Explanations of Physical Illness: Time to Examine the Evidence (2016) , Wilshire and Ward state what should be obvious, “Medical practitioners simply cannot assume that the current knowledge of disease and its markers is 100% perfect or that all complaints not otherwise accounted for must have a psychological origin.” Stone, et al. cite a "systematic review" from 2005 , also co-authored by Stone, which concluded that only 4% of patients diagnosed with FND are misdiagnosed. This was based upon the fact that the patients included in the study had not later been diagnosed with an established organic neurological disorder. Although the authors seemingly use this statistic to purport the accuracy of the FND clinical assessment, it simply proves there was still no medical explanation for the patients' symptoms years later, not that one did not exist.
As founder of the Akathisia Alliance for Education and Research, I represent thousands of people who are being misdiagnosed with FND by clinicians who have little to no knowledge of medication-induced akathisia. This is causing catastrophic harm in many cases. Already suffering from the suicidality inherent in akathisia, the FND misdiagnosis can result in loss of family support, abandonment, mistreatment, homelessness, involuntary hospitalizations, and forced drugging with medications that exacerbate the symptoms and increase the likelihood of suicide.
Patients with akathisia are being misdiagnosed by neurology as psychogenic/functional primarily because their motor symptoms can be distractible and suppressible, yet these are positive, documented features of this medication-induced disorder (Factor, Jankovic, 2020) . It is well documented that certain neurotransmitters and neuropeptides affect physiological as well as psychological processes (Shu-Heng, Li-Peng, Xu, et al., 2020; Bamalan, Al-Khalili, 2020) [4,5]. Thus, it stands to reason that side effects and withdrawal symptoms of commonly prescribed medications such as antiemetics, antipsychotics, antidepressants, benzodiazepines, etc., could be multi-systemic and organic, and undetectable upon clinical assessment.
On behalf of the many people being harmed by the FND diagnosis, I hope the authors and their colleagues will begin spending more time looking for an explanation for "medically unexplained symptoms" and less time training clinicians based on the assumption that every possible neurological disorder has already been discovered. Many lives could be saved.
1. Wilshire CE, Ward T. Psychogenic explanations of physical illness: time to examine the evidence. Perspect Psychol Sci. 2016 11(5) 606-631
2. Stone J, Smyth R, Carson A, et al. Systematic review of misdiagnosis of conversion symptoms and “hysteria". BMJ 2005 331(7523):989
3. Factor S, Jankovic J. Akathisia. 2020. https://medlink.com/article/akathisia
4. Shu-Heng J, Li-Peng H, Xu W, et al. Neurotransmitters: emerging targets in cancer. Oncogene 2020 39(3):503-515
5. Bamalan OA, Al-Khalili Y. Physiology, serotonin. StatPearls Publishing, 2020
Competing interests: No competing interests
In their BMJ ‘Practice Pointer’ (1) for General Practitioners (GPs) the authors describe the “Growing evidence … ” around explanations and findings for Functional Neurological Disorder (FND). For patients with experience of FND this evidence raises the question “What could have caused the described corruption of the brain-generated predictions and interference from the limbic system and amygdala?”.
Contributing possibilities must be explored, and there is an obvious one that is not covered: prescribed medications which alter the functioning of the nervous system.
People are developing ‘functional neurological’ issues downstream of having taken GP prescribed antidepressants, benzodiazepines, etc. (on- or off-label, sometimes long-term) for various ‘indications’. As these prescribed drugs are designed to cross the blood-brain barrier and to act on the central and autonomic nervous systems this must surely be significant? We know from recently published work by Hengartner, Davies & Read 2020 (2) that a high percentage of people (46%) experience ‘severe’ withdrawals from antidepressants.
On ‘Comorbidities’ Stone et al mention (in addition to IBS & fibromyalgia)
“Other functional symptoms and disorders, especially those involving chronic pain, fatigue, and memory symptoms” and
“Psychological comorbidities—especially anxiety, panic, and depression … affecting over 50% of patients”
There is a high probability that these patients will have been prescribed antidepressants for ‘anxiety, panic and depression’ (and chronic pain, fatigue etc). Our 2018 ‘Patient Voice’ analysis of public petition evidence (3) has shown that the commonest persistent multiple ‘unexplained symptoms’ of FND overlap strongly with those experienced in antidepressant withdrawal, including dizziness, nausea, pain, fatigue, gastrointestinal problems, palpitations, sleep issues and so on – and these symptoms can persist for months or years, and do not cease (may become worse) once ‘the drug is no longer detectible’ in the system.
This raises important questions (for practitioners and patients) – which do not feature in the list of questions in the article –
• what is the person’s medication history – from the very first prescribed medications, and then over the long term?
• when did the ‘unexplained’ symptoms first become apparent, especially in relation to prescribed medications (i.e. the possibility of adverse medication effects or withdrawal)?
• what other factors may have caused damage to the functioning of the nervous system?
SSRI and SNRI ‘antidepressants’ (taken by 7.3 million people - 17% of the adult population in England, per Public Health England Review 2019 (4)) alter the essential serotoninergic systems – profoundly affecting brain and bodily functions, directly and indirectly via the fight/flight limbic activity. The effects of serotonin are multiple, as described in ‘Serotonin, Amygdala and Fear: Assembling the Puzzle’ by Marco Boccio et al (5) and ‘The Expanded Biology of Serotonin’ by Miles Berger et al (6).
It has been known for decades that antidepressants cause neurological problems; for example, Foster & Lancaster 1959 cases of ‘Disturbance of motor function during treatment with imipramine’ (7), and Peter Haddad et al ‘Antidepressant discontinuation (withdrawal) symptoms presenting as ‘stroke’’(8).
Grosset wrote in 2004 ‘Prescribed drugs and neurological complications’ (9), concluding that “A wide spectrum of neurological presentations may be caused or precipitated by drugs, prescribed and non-prescribed. Doctors have a responsibility in preventing iatrogenic symptoms by careful prescribing, and in identifying drug induced syndromes”.
People who have developed all manner of apparently bizarre symptoms, particularly movement disorders, visual and balance issues, ‘functional’ seizures etc. have been referred to neurology and acquired diagnoses of ME/CFS, MUS, FND, etc. Patients have been researching to try to understand what has happened to them. It seems that they have suffered neurotoxicity, described by Peter Breggin (psychiatrist) in ‘What should we really call psychiatric drugs?’ (10) and Raymond Singer (neurotoxicologist) in ‘Recognising Neurotoxicity’ (11).
In April 2018 we wrote ‘Is the BMJ – and the medical profession that it represents – really ‘listening to patients’ and the public?’ (12) “..it is becoming abundantly clear that ‘the evidence’ of prescribed harm is being actively attributed to vague psychiatric diagnoses such as ‘medically unexplained’, ‘functional’ and ‘somatic’ disorders. Patients suffering complex, serious and disabling symptoms - from prescribed drug damage and neurotoxicity - are being directed to websites such as http://www.neurosymptoms.org/ and encouraged to engage in Cognitive Behavioural Therapy (CBT) and acceptance of their mysteriously acquired disability. There is emphasis on locating problems in the patients’ own early life experiences – and socio-economic circumstances - without any reference whatsoever to the all-important life-time ‘medication history’ and its own trail of havoc in the life and health of the patient.”
Our Public Petition ‘Patient Voice’ evidence was included in the Public Health England Review (3) and features in the ‘Patient evidence’ for the National Guideline Centre (13). In their petition evidence, a number of patients (25%) describe MUS or FND diagnoses following antidepressant adverse effects.
If patients ask their GPs or neurologists about the possible cause of their acquired symptoms and disabilities, any suggestion of a link to the ‘effects of medicines, taken as prescribed’ is usually strongly denied, and the patient’s ‘beliefs’ called into question. This, of course, adds further to their distress. The Cumberlege review (14) has highlighted the folly of doctors ‘not believing patients’ – and the resulting ongoing risks to patient safety. “The review panel found that healthcare providers’ dismissive attitude toward patients was underpinned by a reluctance in all parts of the system to collect evidence on potential harms, by a lack of coordination that would allow clinicians and agencies to interpret and act on that information, and by a culture of denial that failed to acknowledge harm and error, impeding learning and safety.”
There will be various reasons why a person may develop functional symptoms; however, in the interests of reducing risks of further harm, and to explore avenues for healing those already harmed, we strongly urge that these clues to the aetiology of FND be fully recognised and investigated with utmost urgency. It is time to openly acknowledge that drugs which are prescribed specifically to alter the functioning of the central nervous system may be the very reason why that nervous system is now presenting as malfunctioning.
(1) Stone J, et al. ‘FND’ BMJ Oct 2020 https://www.bmj.com/content/371/bmj.m3745
(2) Hengartner M et al 2020 ‘Antidepressant withdrawal’ https://www.cambridge.org/core/journals/epidemiology-and-psychiatric-sci...
(3) Guy A et al. ‘Voice of Patient’ 2018 http://prescribeddrug.org/wp-content/uploads/2018/10/Voice-of-the-Patien...
(4) PHE Review Summary report 2019 https://www.gov.uk/government/publications/prescribed-medicines-review-r...
(5) Boccio M, et al. ‘Serotonin, Amygdala & Fear’ 2016 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4820447/
(6) Berger M, et al. ‘Biology of Serotonin’ 2009 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5864293/
(7) Foster & Lancaster. ‘Imipramine’ 1959 https://www.bmj.com/content/2/5164/1452
(8) Haddad P. ‘Stroke’ 2001 https://journals.sagepub.com/doi/10.1177/026988110101500210
(9) Grosset & Grosset. ‘Neurological Complications’ 2004 https://jnnp.bmj.com/content/75/suppl_3/iii2
(10) Breggin P. ‘Neurotoxins’ 2018 https://www.madinamerica.com/2018/01/what-really-call-psychiatric-drugs/
(11) Singer R. Neurotoxicity 2015 http://neurotox.com/wp-content/uploads/2015/07/Recognizing_Neurotoxicity...
(12) Brown M et al. ‘Listening to patients?’ 2018 https://www.bmj.com/content/360/bmj.k1408/rr-0
(13) National Guideline Centre. ‘Patient Experience’ 2019 https://www.rcplondon.ac.uk/projects/outputs/patients-experience
(14) Haskell H. BMJ Report Cumberlege Review 2020 https://www.bmj.com/content/370/bmj.m3099
Competing interests: No competing interests
Re: Recognising and explaining functional neurological disorder: Further response
A year has passed since this ‘BMJ Practice Pointer’ article ‘Recognising and explaining functional neurological disorder’ (1) was published and many more questions are being asked – especially by patients who are finding themselves described (or diagnosed) as having developed functional neurological disorders (FND) downstream of having taken prescribed medications - including very commonly prescribed antidepressants.
A relevant new article about Functional Cognitive Disorder (FCD) by McWhirter, Ritchie, Stone and Carson has been recently published (2) which “aimed to identify positive clinical markers of FCD”. It is noticeable that, once again, no mention is made of specific ‘medication history’ of the participants of the study, although there is mention of clinical histories of depression, anxiety and psychiatric diagnoses, as well as physical symptoms.
GP Richard Byng’s rapid response last year (3) acknowledges that, amongst other factors, “prescribed and other substances acting on the brain (or being suddenly withdrawn) can contribute to the symptoms found in FND and other ‘functional’ conditions”.
A further article citing the 2020 BMJ ‘practice pointer’ (1), and our previous rapid responses to the same, was published by the Journal of Critical Psychology, Counselling and Psychotherapy (4) and this article is shortly to be published within a book: “Withdrawal from prescribed psychotropic drugs” (2021) edited by Peter Lehmann and Craig Newnes (5).
In the past year we have written to FND experts (who mostly do not acknowledge or reply) and have watched a number of publicly accessible webinars on the topic of FND, including several 2021 FND Society webinars (6) and others (7,8), contributing our own questions to open Q & A sessions following the speaker presentations. This has confirmed that ‘effects of medications’ are being mostly overlooked altogether or alarmingly misunderstood.
A new case study paper, Psychotherapy for Functional Neurological (Conversion) Disorder: A Case Bridging Mind, Brain and Body (2021), once again confirms that ‘effects of medications’ are apparently being disregarded or overlooked – and instead a painful trawling of the case study patient’s life history is seen as ‘psychotherapy’ and being recommended for FND treatment (9). “While ‘one size fits all’ formulations of the ‘conversion’ of psychological distress into physical symptoms are no longer widely accepted, emotion processing and related psychological constructs (eg, alexithymia, dissociation, threat avoidance) remain central to the conceptual understanding of FND. Furthermore, the biopsychosocial model (foundational to psychiatry) is the prevailing model through which to guide longitudinal treatment, with psychotherapy as an emerging first line intervention for FND.” (9)
Although they apparently do indeed ‘take note’ of the patients’ clinical history, it seems that, just like GPs, neurologists and psychiatrists – and indeed psychotherapists - don't recognise adverse drug reactions and withdrawal. Until they do, they will remain blind and ignorant – and patients' health will be further sacrificed. Giovanni Fava, whose 2015 paper about antidepressant withdrawal (10) brought matters into the open, has said “Regrettably, psychiatrists … are unable to think “iatrogenic” in interpreting clinical problems, simply because they have not been exposed to the concept, which has been submitted to tight censorship by mainstream psychiatry.”(11)
Please – can the ‘effects of medications’ – including the mind, brain and body effects of extremely commonly prescribed ‘safe and effective’ [sic] antidepressants – be fully explored and recognised. Countless people are suffering whilst this medical ignorance is apparently being ever further extrapolated.
(1) Stone J, Burton C, Carson A. Recognising and explaining functional neurological disorder. BMJ 2020;371:m3745 Recognising and explaining functional neurological disorder | The BMJ
(2) McWhirter L., Ritchie C, Stone J, Carson A. (2021). Identifying functional cognitive disorder: A proposed diagnostic risk model. CNS Spectrums, 1-10. doi:10.1017/S1092852921000845 Identifying functional cognitive disorder: a proposed diagnostic risk model | CNS Spectrums | Cambridge Core
(3) Byng R. BMJ Rapid response (2020) Re: Recognising and explaining functional neurological disorder Re: Recognising and explaining functional neurological disorder | The BMJ
(4) Brown M, Lewis S (2020). The patient voice Antidepressant withdrawal, medically unexplained symptoms and functional neurological disorders. The Journal of Critical Psychology, Counselling and Psychotherapy, 20 (4) pp14-20. Full Text: (7) (PDF) JCPCP v20 i04 Brown&Lewis (researchgate.net)
(5) International Institute for Prescribed Drug Withdrawal (2021): Special issue on Withdrawal from Prescribed Psychotropic Drugs - (iipdw.org)
(6) Past Webinar Topics FND Society 2021: Past Webinar Topics | FNDS (fndsociety.org)
(7) Dr Wendy Phillips. Nuffield Health Webinar; Functional Neurological Disorder 2021 Dr Wendy Phillips - Consultant Neurologist, Addenbrooke's Hospital Functional Neurological Disorder - YouTube
(8) Maudsley Philosophy Club, Seminar 1 Autumn 2021. The organic-functional distinction in psychiatry and neurology – Vaughan Bell. The organic-functional distinction in psychiatry and neurology - Vaughn Bell | Seminar 1 Autumn 2021 - YouTube
(9) Godena EJ, Perez DL, Crain LD, et al. Psychotherapy for functional neurological (conversion) disorder: a case bridging mind, brain, and body. J Clin Psychiatry. 2021;82(6):21ct14246. Psychotherapy for Functional Neurological (Conversion) Disorder: A Case Bridging Mind, Brain, and Body | Psychiatrist.com
(10) Fava G et al. (2015) Withdrawal Symptoms after SSRI discontinuation: A systematic review. Psychotherapy and Psychosomatics Vol. 84, No. 2 Withdrawal Symptoms after Selective Serotonin Reuptake Inhibitor Discontinuation: A Systematic Review - FullText - Psychotherapy and Psychosomatics 2015, Vol. 84, No. 2 - Karger Publishers
(11) Aftab A and Fava G. Psychiatry’s Intellectual Crisis. (2020) Psychiatric Times. Vol 37, Issue 9, Volume 37, Issue 9 Psychiatry’s Intellectual Crisis: Giovanni Fava, MD (psychiatrictimes.com)
Competing interests: No competing interests