Functional Neurological Disorders (FND): history of its nomenclature and modern classification.

I would like to talk today about the modern classification and the history behind the nomenclature of Functional Neurological Disorders (FND). This is a topic of vital importance because there is tremendous misunderstanding and confusion around this illness, which is directly affecting patients, friends, family members and healthcare professionals, who often ask me with a scared and disappointed look:  "What is FND?”, “Am I crazy?”, “Am I making all this up?", “Is it all in my head?”.

Initially I could not understand where those questions and ideas were coming from, and why was there so much apprehension about this diagnosis, because as I have shared previously, I have experienced certain functional symptoms throughout my life, and I certain that I am not crazy! Besides, FND is a well-recognized disorder, with clear pathophysiological mechanisms, diagnostic criteria, and clinical manifestations; all of which have been studied deeply through scientific and clinical studies. So, when, and why did we develop such apprehensions and concerns around the illness? What is the story behind them?

Well, everything started back in the 19^th century, with the term hysteria, largely introduced to the medical community and the popular belief after the publication of Sigmund Freud’s book “Studies on hysteria” in 1895. This term denoted a series of physical and mental symptoms described to happen due to “emotional excess” or temporary “altered states of mind or emotion”, mainly affecting women, and theorizing about sex-related disparities in stress management. Obviously, just reading about those characteristics, we can see that there are significant limitations related to this name, and it is understandable how the population has rejected and judged its use. Additional problems related to this label are: the lack of recognition of the neurological basis of the condition, the lack of understanding about the connection between mind- body – emotions- environment, the inaccurate assumption that men and women have significantly different stress responses.

“Hysteria” later progressed towards the terminology “Conversion disorder” and “disorder of psychogenic origin or psychoneurosis” in 1968, and these were included in the International Classification of Diseases (ICD)-6 and Diagnostic and Statistical Manual of Mental Disorders (DSM)-II. The dilemma was that this nomenclature still had its basis on the psychoanalytic theory described by S. Freud, connecting the physical manifestations to unconscious conflicts that progressed to neurological symptoms. As such, many of the same problems mentioned above remained to be present; particularly the tendency to assume that all patients with functional manifestations were turning a psychological symptom into a physical illness as a way of dealing with stress, believing that these disorders are created only by the psyche and the mind, leading the public to believe that they had some psychological illness or psychiatric problem, and that “it is all in their minds”, failing to properly describe the complex interface between neurology, psychology, the physical body, and the environment.

To be fair with our predecessors, we must recognize that at that time they did not have the availability of functional magnetic resonance studies (fMRI), PET scans, or any of the imaging studies that we have nowadays, that prove that FND is not created by the psyche alone, but on the other hand, there are many parts of the nervous system involved, many intricate pathways taking part in the origin of these disorders, connections involved in movement, vision, and sensations, just to name a few. So, yes, psychological and emotional aspects are very important and must be investigated well and taken into consideration, because we are organisms that need to live in balance with the Four Bodies: mental, physical, emotional and spiritual or environmental. Our psychology, our thoughts, and our emotions are undeniable parts of who we are, parts of our organisms, our human experiences, and it is impossible to deny them. Additionally, there are two-way relationships between these four aspects of our being, for example, many actions (behavior/physical body) that we perform are promoted by a sense of obligation or mental habits (mental body), which in turn may trigger or be the consequence of certain emotions (emotional body), all of it having a consequence in our surroundings (spirit/environment). At the same time, our physical health or lack of thereof (physical body) will trigger certain thoughts (mental body), emotions (emotional body) and it will have an effect in our environment (spirit/environment), or events on the environment such a car accident can and will affect our physical wellbeing, our emotions, and our thoughts. We should not then, overlook or separate the importance of the Four Bodies: mind, physical body, emotions, and spirit, and we must always remember that all of them together have a certain degree of influence on the presence of functional symptoms.

Conversion in the DSM-III and the ICD-9 of 1979, was grouped under the term “Somatoform Disorders”, and it still retained the important role of psychological factors, but this were no longer described as the direct cause of the problems, but were bring considered an associated manifestation.

The DSM-IV of 1994 also retained the term Conversion disorder and specified the presence of various subtypes including motor, sensory, seizures and mixed, and recognized that the presence of these symptoms caused significant distress and impairment, but eliminated and discouraged the use of “hysteria and hysterical neurosis”.

Finally, in the year 2013, the term functional neurological disorder (FND) was introduced thanks to the vast amount of research happening in the previous 10 to 15 years, in a way to better describe the characteristics of these conditions. Specifically, the goals of this new nomenclature are to:

• To create more acceptance by patients and physicians, by avoiding the judgments and misunderstandings associated with the older terminology.
• To represent the supportive empiric evidence available over the past years
• To establish that these conditions warrant a thorough medical evaluation
• To emphasize the importance of the neurological examination
• To institute that the diagnosis now relies mostly on neurological examination
• To clarify the shift from a psychiatric condition to a disorder essentially diagnosed by neurologists
• To convey that at the time of diagnosis, we may be agnostic about etiology
• To avoid mind-body dualism
• To specify that the condition is present when the physical symptoms are incongruent and inconsistent with other known neurological disease, and the manifestations should not be better explained by another disorder
• To highlight that relevant psychological factors may not be apparent at the time of diagnosis, and reaffirm the importance of identifying psychological stressors, if present.

 Despite all the advances, we must understand that it is still difficult for healthcare professionals and neurologists to understand the causes, the etiology of these conditions, mainly due to the limitations of our healthcare system, and we will talk more about this in the following sessions. So, the origins, which commonly are not apparent in the first consultations with the doctors, must be discovered through a thorough investigation by the physician and the patient, together, because the cause is unique for each of person, for each one of you. For me, for example, the functional symptoms appeared during my medical career, related to overwork, and stress. So, it is very important to study your psychological well-being, to analyze the health state of your physical body, and to review your environmental conditions as well: The Four Bodies.

As we can see, the diagnosis is nowadays made primarily by neurologists, and it is paramount to undergo a thorough history and neurological physical examination, receive all the necessary tests to determine if the symptoms are the manifestation of a problem in the structure of the organs, or if it they are functional in nature.

So, what does all this mean to you? For your journey of self-knowledge and healing? Well, to recognize that the mind is a very complex organ, and very powerful is very meaningful because the mind can sometimes be one of the factors limiting our healing, but it can also be an aspect that will facilitate your journey. It is imperative to study your mental positions, review if our mind is behaving as an ally or as an obstacle, determine if you must work on overcoming concerns about what people think, review if you have fears around this diagnosis, shame given the history behind the terms, or concerns about judgements. Then you must recognize that all misunderstandings are in the past, and we should leave them back in 1895. “Conversion disorder”, “hysteria”, “madness”, “everything is in the head” no longer applies, is not aligned with science, and whoever uses those terms and feels influenced by them, is outdated, as that nomenclature speaks mainly about the previous limitations of medical understanding. That is why it is so important that you take possession of this journey, because to heal you need to discover yourself, understand yourself, the system you are embedded in, and develop self-consciousness. I will support you as much as I can, but the biggest changes will depend on you.

We will talk more about this in our Four Directions program, during the Winter season, when we will transform the mind in an ally, removing mental limitations, studying how to overcome judgments and detrimental mental patterns.

Through these lines we should also understand the importance of knowing yourself, to take an active role in the search for the etiology of the disorder, because only you know the details, deep within, and only you can share them with your doctor or the professional involved in your path, only you can share what you know and find out what may be contributing to the cause and the perpetuation of the disease. It is very important that you do this research.

So, to finalize, I would like to recommend some practices:

• Start a diary because you will find out a lot! About you, your body, your mind, your emotions, your environment, your life’s mission, and the meaning of this whole process.

• Notice the sensations of your body, how they fluctuate during the day, daily, and notice how they are connected to your thinking, your environment, and your emotions. For example, if you are in love, notice what you feel in the chest or belly, notice the butterflies. If you're scared, realize the physical sensations that accompany that. If your boss or colleague asks you for something that you don’t wish to perform, appreciate what happens in your body. Also sense what changes when you are in a hurry, when you are resting, when you just wake up in the morning. Notice the sensations in your body!

• Make a list of any uncomfortable or pleasurable feelings that you notice during the day and reflect on what you think is causing them.

• Think, what limitations do you feel you have in your own journey? It may be time, it may be that you are busy, it may be the fear of judgment, the shame, not having time to heal because you have many obligations, many priorities.

• What resources do you have? Some strong points may be that you are determined, that you have a good support network, your dedication, your willingness to study, and to create a time to explore yourself, and the various methods I will propose.

• Write down any questions, any concerns, or experiences that you notice, because we can share and exchange during our monthly community conversations

Let us learn and grow together! I'm going to tell you everything I know and everything I continue learning, because medicine, healing and helping myself and others are my life’s missions, and I want to share everything with you, so that you get where you want and deserve to be: living a life filled with happiness, health and satisfaction!

At your service,

Yadira Velazquez, MD.

Functional Disorders Healing Ally.