The Proto piece treats “Functional Neurological Disorder” (FND) with a kind of wounded indignation.  Finally, we know it’s not all in your head!

But careful here.  Sure, there have been imaging findings.  But there are imaging findings for everything.  All thought involves cerebral activity that can be visualized in sophisticated imaging.  The reality of the history of FND is a bit less glamorous.

A frame:  Doctors have always known symptoms to exist without apparent lesions.  What do we call them?  “Hysteria” was probably the classic term for women who had these symptoms, although the diagnosis is deeply wounding to female patients and should disappear from medicine.  (Interestingly, most FND patients are women.)

What else do we call them?  “Functional” is a good candidate, since patients do not understand that the usage and the term, with a knowing wink, means no organicity here.   That is why the major psychiatric illnesses — schizophrenia, melancholia, and catatonia — were called “functional.” No organicity that we can find, yet there is almost certainly something wrong with these patients’ brains.

Psychoanalysis (Freud’s doctrine) did not have a lot of interest in physical symptoms of any kind.  Yet when the odd patient with hysterical blindness or a hysterical tremor staggered into the consulting room, Freud invented the term “conversion disorder” for them, as though stray psychic energy was somehow being deflected into the body.  This is largely nonsense, yet the term “conversion disorder” has lingered on.

How do we understand “hysterical” symptoms today?  FND is a much more polite term and makes it sound as though we are “doing” science.  Yet there’s that old term, “functional,” to which we crawl back like a dog to its vomit.

Let’s expand the frame a bit:  The piece treats psychiatry with suspicion (it’s “all in your head”) and leans towards neurology and neuroimaging.  Yet the boundary between psychiatry and neurology is disappearing.  The practical difference is that most neurologists do not feel comfortable managing patients with major illnesses that involve psychosis or melancholia.  As a management issue, these  are what psychiatry is there for.  Psychiatry actually should not be there for managing the “worried well,” which is what most “FND” is.  Family medicine comes into its own here:  If you had “FND,” your family doc would do a great job of managing you — if only we had not abolished almost all of them!

What is the best approach to patients?  Don’t encourage them to think they have “FND,” because they will obsess over it and become difficult to treat.  There are other phrases in medicine–“medically incoherent symptoms,” for example.  Or “psychosomatic symptoms,” an old chestnut that still does us good service.  But keep them away from neuroimaging!  Unless they have some occult brain disease they are slowly growing up, neuroimaging findings will be inconclusive, and will simply lead the patient to believe that she has a disease that is somehow very special.