I had an interesting discussion on Youtube with a medical resident, and as you know if you’ve been following my blog regularly I am very interested in opening the minds of new doctors just getting their feet wet in the field of neurology. This guy was educated in the typical way most neurology residents are taught and after viewing a woman’s video who was having facial spasms while she was watching TV he posted that he thought her disorder was “functional”.
The model used currently to differentiate “functional” from organic neurological disease/disorder is usually to check whether;
1) symptom patterns coincide with known patterns associated with “organic” neurological diseases/disorders.
2) a presenting symptom or group of symptoms stops during a period of distraction, thus appearing inconsistent.
(Keep in mind that distraction tricks are often used by patients with established Dystonia not considered “functional” such as touching the area involved or nearby which have the same effect of disrupting faulty brain signals and often do stop the symptoms temporarily).
I responded back that such a mindset does a real disservice to patients and often stands in the way of early detection and treatment of a neurological disorder.
He posited to me that there is a real category of Somatoform Disorders at the same time acknowledging neither Psychiatry nor Neurology wants to deal with those, but likens the stigma to that of diseases such as Major Depression or Bipolar Disorder. This was my response to that statement of his;
“Your second sentence spells out what makes it different from Major Depression or Bi-polar disorder. Psychiatrists don’t brush off those two conditions and they don’t confuse those with “feigning”. A functional diagnosis is way more stigmatizing because unlike the two mood disorders you used as examples they don’t believe functional diagnoses have a biological basis. There are imaging studies and neurotransmitter studies pointing to an underlying neurochemical basis for mood disorders, and now genetic research linking certain genes to them. The same has not been researched in those categories labeled as “functional”.
When you really think about it just about all the “mental” disorders are now thought to be brain diseases (AKA; neurologically based). That is exactly why psychiatrists prescribe medication for them. There was a time when Schizophrenia was believed to be behavioral and caused by bad parenting. As long as doctors treated it accordingly patients didn’t recover. It was only when enough research money was put into it to investigate its biological basis that advances were made and patients improved through more targeted medications. Dr. E. Fuller Torrey was instrumental in uncovering alot of the biology behind that disease. He continues to research now through a private research center and is finding out that the disease is not only characterized by a disordered Dopamine receptor system, but that there are intracellular pathogens involved in its cause which are not detected by commercial testing methods. While I must state that I disagree with Torrey’s focus on involuntary commitment of such patients, he was one of the first to hypothesize and quantify with research that Schizophrenia is in fact a true brain disease, removing it from the realm of “it’s all in the patient’s mind.”
I would bet that if enough research were put into studying what they call “functional disorders” scientists would find a biological/neurological basis for it. I’ve been reading lots of research papers and I think I have an idea what it really is. If you read some of the latest studies on Fibromyalgia and on Dystonia you’ll be very intrigued at what you’ll find. Apparently there are studies that have elucidated some very good data suggesting that these disorders involve faulty signals and neural pathways.
The same areas of the brain involved in emotions are activated in disorders such as Fibromyalgia, Chronic Fatigue Syndrome, and Dystonia as well as other disorders currently called “functional”. This doesn’t mean these are “mental illnesses” although people can experience mental symptoms (but not always). It merely means that the signals coming through those brain regions involving pain and/or movement are often impaired and become crossed with emotion-bearing pathways.
If you are going into either the field of Neurology or Psychiatry I hope you will dedicate yourself to these “gray area” diseases/disorders and look for these quantifiable markers. You can do that with PET, fMRI, and a number of other state-of-the-art imaging methods, as well as on a more micro level look for genetic and neurochemical markers involved. If you look and put in the time you will find them eventually (and maybe make a name for yourself in the process if you should publish your findings in established medical journals).
Taking on such an endeavor would go a long way toward doing justice to these patients with such orphan diseases/disorders and remove the stigma associated. I’m sure in time researchers will identify a physical basis, and targets will be found for which they can develop medications that really work (as long as doctors care enough and are unbiased enough to look and believe patients are worth it).
I really believe “mental” as opposed to “physical” illness is an old paradigm and that the future of science will bear that out as more research comes out. Think of a computer as a model for instance; no software can function properly in a computer if the hardware is dysfunctional.
Autism is a human model that illustrates this quite well. While you may or may not find any structural differences in the brain, it is known and pretty widely accepted that it is a difference in the way these people are “hard-wired”. It is listed in both the DSM and the ICD. Although it has “mental” or “behavioral” manifestations, it is not a “mental illness” per se, but a neurodevelopmental disorder. Autism is also associated with disordered brain signaling/processing of sensory input; same as the diseases/disorders I mentioned in my 4th paragraph. You will notice that many interventions recommended for autism are not covered by health insurance. This is a particular type of “othering” supported by insurance companies.
The same goes for delineating “Dental” from “Medical” for purposes of health coverage. Take a look at what some dentists are doing for people with movement disorders (for the most part private pay and unfortunately out of reach of many most in need who could really benefit). Look up Dr. Stack/Dr. Jeffrey Brown, Demerjian, and several others doing some very cutting edge work in that subspecialty.
In Dystonia, look up Juaquin Farias PhD. and his work in neuroplasticity. He is Director of the Neuroplastic Training Institute Toronto and adjunct professor at the University of Toronto at the Music and Health Research collaborative. He started out working only with focal dystonia in musical and performing artists, but now has had some success with Parkinson’s patients.
All of these things should be under the same umbrella as “physical”. The insurance industry has alot more of a stake in keeping these divides than most people realize because they can justify not covering them or charging higher premiums for them as add-on coverage. The way these things are structured and coded is often for their benefit, not the benefit of patients.
Follow the thread and see where it leads. I think you will be surprised that much of what you’ve been taught in medical school doesn’t line up with the latest research.”
So far he has not responded, but maybe that gave him food for thought and the idea will grow on him once he thinks more deeply about it later.
One very important point I forgot to make in my response to the neurology resident is that the woman watching TV was distracted and yet her facial movements continued anyway. This is definitely not consistent with a “functional” etiology, as watching TV is a very absorbing activity often causing a person to tune out all else going on in the environment. (I will add that point to the thread next chance I get).
Perhaps where doctors tend to misinterpret a patient’s symptoms as “functional”, especially in such disorders or diseases involving brain signaling/processing or in such cases in which a condition is caused by intracellular pathogens too small or evasive to be seen by most commercial imaging techniques is that one may have a disorder that involves faulty brain function yet it is not “functional” in the derogatory sense of the word, but is in fact truly neurological and can be quantified in ways other than structural.
In a study published in the medical journal Current Opinion in Neurology in August 2013, the hypothesis of authors, Mark J. Edwards , Aikaterini Fotopoulou , and Isabel Pareés is that attentional processes in the brain are most likely disordered.
An experiment using “Functional” Distonia patients versus familial Dystonia patients yielded the following results;
1) Both groups had increased bloodflow in the right dorsolateral prefrontal cortex to an abnormal degree
2) In the “Functional” Dystonia group bloodflow in the primary motor cortex was decreased and blood flow in basal ganglia and cerebellum increased.
3) The reverse pattern was found in the genetic Dystonia patients.
The big picture suggests that both groups of Dystonia patients have abnormal prefrontal involvement, but that those patients labeled “functional” may have additional abnormalities in frontosubcortical circuitry which regulates motor attention and likely surrounding limbic areas .
The authors of the research paper also hypothesize that certain movement patterns may become ingrained by a precipitating trigger (often physical in nature) which the brain erroneously associates with certain abnormal movements. Although this processed information is converted into abnormal movement it is not “hysterical conversion disorder” nor is it purposely initiated by the patient.
The article illustrates beautifully that what is often mistaken for a psychological phenomenon is actually a disorder of brain processing, encoding, and wiring!
So patients; next time you are told by a doctor “this is all in your mind” point him/her to this research (listed in the last link I’ve provided at the bottom), or better yet, print it out and hand it to the doctor. You are not crazy, and don’t let anyone tell you that you don’t have anything physically wrong! It is time that clinical practice caught up to the most up-to-date research and throw out the old outdated concept of “Hysterical conversion /Somataform disorders”. It is no longer relevant, and only adds insult to injury preventing or delaying your getting the real and compassionate healthcare to best treat your neurological condition.
And to doctors; Remove that discounting “Psychogenic” label from your mindset (and from your vocabulary). It’s not helpful to you in rendering effective treatment and it does nothing positive for the doctor/patient relationship (which is a necessary bond to maintain if you want to be of any real service to those you treat). If you value your reputation you must extend the same courtesy to that of your patients’ reputation. Do not chart things that invariably cause other doctors (who may ultimately have a pivotal role in your patients’ best outcome) to question your patients’ credibility. These patients’ lives are hard enough without this added burden which not only causes emotional distress but can also be quite costly to the patient financially to correct. It’s important to remember that those people in any field who’ve made the biggest strides were individuals who dared to challenge the status quo. Why be just an OK doctor, playing it safe following trails blazed for you by others when you can be a great doctor by blazing trails for those that come later! If you choose the latter your patients will thank you and you will have contributed something valuable to your specialty!
References used for this article;
Update on Fibromyalgia; Dr. Sean Mackey – Assistant Professor of anesthesia at the Stanford University Medical Center
Dr. G. Gary Demerjian –The TMJ Connection and Dental Appliances for Neurological Disorders
Dr. Brendan Stack/Dr. Jefferey Brown – Patient Case Studies-Neurological Disorders Treated With Dental Appliances
Dr. Nick Yiannios/Dr. Tom Coleman – Dental Treatment for Muscular TMD Patients
Dr. E. Fuller Torrey and other Researchers – Biological Basis and Schizophrenia Gene Identified