Covid, FND, and models

“Helping the Public Understand Adverse Events Associated With COVID-19 Vaccinations. Lessons Learned From Functional Neurological Disorder.” (here) Published today (9th April 2021), I think this viewpoint is brave; mentioning Covid-19 and functional disorders in the same title; challenging, because it suggests the bravery is warranted; and, to me, fascinating because it shows how the biomedical model remains an insidious influence however biopsychosocial we think we are.

The viewpoint above was stimulated by videos on the internet showing movement disorders which show all the hallmarks of functional movement disorders. The videos attribute these disorders to recent vaccination against Covid-19. There is no way of knowing whether the individuals had actually been vaccinated, nor what the time course was. Nonetheless, it is probable that some people do develop and will develop functional neurological disorders and, by implication, other functional disorders after vaccination.

Reflection on functional illness and Covid

Long-Covid symptoms, and symptoms seen after Covid vaccination, raise a few interesting issues.

First, will functional symptoms and illnesses be recorded as potential ‘side-effects’ of the vaccination. If a vaccine is associated in time with the development of a relatively rare disorder, such as Guillan-Barre syndrome, then it will be listed as a side-effect. If there is a reasonably certain biological link between an event, such as vaccination, and the development of any symptom, then it is classified as a side-effect. But I wonder if the occurrence of a functional neurological disorder would be reported, and if reported would be accepted as a side-effect.

Also, will functional disorders be recorded as one of the many complications of Covid, or will they instead be relegated to being one of differential diagnoses that need to be identified. Will its connection be denied and discounted, despite the temporal link.

Second, the whole terminology and most thinking still takes the view that a symptom or problem is either functional or not-functional (sometimes termed ‘organic’). For example, a person with Long-Covid may be diagnosed as having a ‘functional illness’, or as having a problem ‘due to Covid-19 virus’, as if these were alternatives and as if the functional illness had no relation to Covid.

A holistic analysis would be more discriminating.

The first step is to agree that the patient had an infection with Covid virus, or the patient had symptoms that they attributed to the Covid virus. As proving that the patient did, or did not actually have an infection is impossible, and will certainly be disputed if not proven, there is little point in differentiating these two.

The next step is to identify and list all the symptoms and other problems the person reports as arising at the time of or since their infection.

Then, it must be acknowledged that all the reported symptoms are related to the infective episode, directly or indirectly. At the same time, it must also be acknowledged that each symptom or problem may have both direct, tissue-damage related mechanisms and indirect, other mechanisms and factors contributing to it.

Last, one has to discuss the symptoms and problems in a manner that allows that a given percentage of a symptom or problem is most likely to be related to continued tissue-damge or dysfunction, while the remaining proportion of each symptom or problem will have other factors that are causing and/or maintaining and/or exacerbating them. These factors may be anywhere else within the biopsychosocial model of illness.

The only prediction one can make is that a significant proportion of the symptoms and problems reported by people attending clinics after an episode of Covid will not be directly due to tissue damage, but will arise from other causes and will occur through other mechanisms. The challenge is to know which symptoms (not which people) are primarily functional in nature.

Reflection on language used.

When reading the article, I was struck be this sentence: FND is a real, brain-based disorder at the intersection of neurology and psychiatry whereby patients develop a range of neurological symptoms precipitated and perpetuated by biological, psychological, and/or environmental factors, reflecting the biopsychosocial model for clinical formulation described by George Engel, MD” (FND = Functional Neurological Disorder) I have highlighted in bold the part that interested me.

In one respect, this phrase is similar to distinguishing between ‘real pain’ and … unreal pain? or pain that is not due to tissue damage. (see here). What would constitute an unreal disorder?

However the sentence then goes on to say ‘brain-based disorder‘. Why? The rest of the sentence allows that both the precipitants of and the perpetuating factors of the disorder are not necessarily biological. Why is ‘brain-based’ added.

My interpretation of this is that the authors wish to anchor the article firmly within a biomedical context. The authors know that, whatever their own beliefs, a great proportion of readers will not accept any disease, condition or illness as real unless there is a biological explanation at the level of anatomical damage and/or abnormal physiological function.

It is still begs the question, what does real mean? The only real I can think of is that the healthcare professional thinks: “I, on behalf of society, accept and validate that you are ill, and that you may therefore claim the privileges given by society to people who are ill.

In other words, I think that some of the words, phrases and sentences used in this article reveal how insidious and pervasive the concepts and ideas associated with the biomedical model of illness are.

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