As more than once, I have encountered this "diagnosis" as an ultimate explanation for at times life-endangering symptoms, I decided to try and understand where it stems from and what is its utility in the management of neurological diseases. This is at least my opinion:
A diagnosis based on ignorance and
deception.
The Diagnostic and statistical manual of
psychiatry (DSM-5) has a relatively new psychiatric entity-"functional
neurological symptom disorder". In order to make this diagnosis it is
enough that: 1.The patient suffers from disabling neurological symptoms. 2. The
physician taking care of the patient (or the entire field of neurology) has no
explanation for the patient's symptoms or those are inconsistent with the current
knowledge and understanding. Even a patient with a known illness can have a
functional disorder as well, if he/she has an unusual presentation or less
common symptoms that do not fit with the knowledge and understanding of his or
her physician regarding that illness. (Stone et al., 2012)
This is the only diagnosis I am aware of,
which is based entirely on the inability of a physician or an entire field to
find a reasonable explanation for a certain ailment or symptom. Had we taken
this approach in medicine in general we would be left with very little
knowledge and ability to treat numerous disease, which were all initially
unexplained and required careful clinical observation and thought process of
numerous physicians before they were understood. We would also dismiss numerous
patients who have less common presentations of known diseases or ignore
significant symptoms which are less typical, but caused by a serious underlying
disorder or response to a commonly used treatment.
Unless there are major advances in the
field of neurology up to 30% of patients attending neurological clinics around
the world are going to satisfy those criteria1 and even more if patients with functional symptoms in
addition to a known neurological illness are taken into account. This entity is
no more than a disguise for the old term coined by Charcot and Freud-"Hysteria".
Yet, as the presumed pathogenesis of this disorder has been seriously questioned,
emotional symptoms, behavioral
abnormalities or personality traits are no longer required for this diagnosis
in the DSM-52. Furthermore, this vague and ambiguous term, deliberately
chosen to be more acceptable to patients, creates an atmosphere of deceit, even
if unintentionally3.
Numerous papers, case reports and books4-5 have warned against the use of this diagnosis. Eliot Slater has been
repeatedly cited for his highly influential study in 19651 "The diagnosis of hysteria is a disguise for
ignorance and a fertile source for clinical error. It is in fact not only a
delusion but also a snare" But also others, 20 years later were aware of
its pitfalls. "Its dismissive
potential coupled with its negative sociocultural
connotations from which physicians are not exempt…offers an expedient solution
for a diagnostically confusing patient and provides a release of negative
emotions or even punitive actions under the guise of a respectful medical label"4. and "Hysteria lends itself most readily to the
needs of physicians who have their concepts challenged and thus need to dismiss
the "problem patient" for emotional needs of their own… sometimes
with horrific results"
This diagnosis of a "functional
disorder" indeed satisfies the emotional needs of physicians while
encouraging ignorance and dismissal of at times seriously ill patients, as well
as lack of curiosity to understand the currently unexplained.
The
deceptive nature of this diagnosis undermines the foundations of the
physician-patient relationship which must be based on mutual trust and respect.
It is ill-defined and therefore prone to numerous errors which could seriously endanger
patient's well beings and lives. Even in patients with a known neurological
illness, attributing significant symptoms to this entity can lead to underestimation
of the severity of the illness, inadequate or partial treatment or inadequate
assessment of response to treatment as well as ignoring significant
side-effects of that treatment.
Even when an empathic relationship is
created, there can be dire consequences to this approach if it leads to an
illusion of adequate treatment for physician and patient alike. Just like in
any other disease, empathy, dedication and care should come with and not
instead of adequate medical treatment. Based, on this and my personal experience
with quite a few patients with “functional symptoms” that upon more elaborate
evaluation had numerous conditions such as a rare presentation of leukemia, a
rare response to a commonly used medication and a rare presentation of
myasthenia, I think that the medical community should seriously question the
validity of this diagnosis.
I think it is OK to admit to ourselves
and our patients that with all the significant advances in medicine there is
still much that we do not know and need to study and learn, without creating a
diagnosis or explanation for symptoms which in the long term create more harm
than good for patients and the medical community alike.
1 Stone, J., Hewett, R., Carson, A.,
Warlow, C., and Sharpe, M., The 'disappearance' of hysteria: historical mystery
or illusion?, J R Soc Med 101 (1), 12, (2008).
2 Stone, J., LaFrance, W.
C., Jr., Brown, R., Spiegel, D., Levenson, J. L., and Sharpe, M., Conversion
disorder: current problems and potential solutions for DSM-5, J Psychosom Res 71 (6), 369.
3 Kanaan, R. A.,
Armstrong, D., and Wessely, S. C., The function of 'functional': a mixed
methods investigation, J Neurol Neurosurg
Psychiatry 83 (3), 248.
4 Kutz, I., Garb, R., and
Kuritzky, A., Diagnosis of misdiagnosis: on some of the origins and functions
of psychophysical misdiagnosis, Gen Hosp
Psychiatry 5 (3), 197, (1983).
5 Chloe G, K. A., My Imaginary illness: a journey into
uncertainty and prejudice in medical diagnosis. (Cornell university press,
Ithaca and London, 2010).
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