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The function of 'functional': a mixed methods investigation (Wessely 2012)

Discussion in 'General ME/CFS News' started by oceanblue, Mar 17, 2012.

  1. oceanblue

    oceanblue Guest

    Free full text


    Objective The term functional has a distinguished history, embodying a number of physiological concepts, but has increasingly come to mean hysterical. The DSM-V working group proposes to use functional as the official diagnostic term for medically unexplained neurological symptoms (currently known as conversion disorder). This study aimed to explore the current neurological meanings of the term and to understand its resilience.

    Design Mixed methods were used, first interviewing the neurologists in a large UK region and then surveying all neurologists in the UK on their use of the term.

    Results The interviews revealed four dominant usesnot organic, a physical disability, a brain disorder and a psychiatric problemas well as considerable ambiguity. Although there was much dissatisfaction with the term, the ambiguity was also seen as useful when engaging with patients. The survey confirmed these findings, with a majority adhering to a strict interpretation of functional to mean only not organic, but a minority employing it to mean different things in different contexts - and endorsing the view that functional would one day be a neurological construct again.

    Conclusions Functional embodies real divisions in neurologists' conceptualisation of unexplained symptoms and, perhaps, between those of patients and neurologists: its diversity of meanings allows it to be a common term while meaning different things to different people, or at different times, and thus conceal some of the conflict in a particularly contentious area. This flexibility may help explain the term's longevity.
  2. alex3619

    alex3619 Senior Member

    Logan, Queensland, Australia
    I have another name for terms that are used deceptively within a supposedly scientific context: babble.

    Here are others: Chronic Fatigue Syndrome, Chronic Fatigue, Adaptive Pacing, normal, cure, evidence-based, effective.

    Bye, Alex
    ahimsa and WillowJ like this.
  3. Sean

    Sean Senior Member

    Took you supposedly a world leading expert on 'functional' medicine a quarter century to realise and admit that fact?

    As I recall, the trait Sir Humphrey most valued in his minister was 'flexibility'.
  4. Snow Leopard

    Snow Leopard Hibernating

    South Australia
    This study is actually quite interesting, it shows you that a majority (~60%) still have old prejudices (conversion disorder is non-organic), whereas a minority (~25%) believed in a mind-body link and believed that conversion disorder would one day be able to be explained physiologically.
    oceanblue likes this.
  5. Mark

    Mark Former CEO

    Sofa, UK
    So: the fact that the term is proposed for use in DSM-V indicates that deliberate ambiguity is sometimes useful to certain people in the psychiatric field.

    Refreshingly frank, but I didn't spot any particular explicit value-judgments in the paper regarding the ethics of this deception...or should I say, I didn't spot any ethical concerns about deceiving patients by using deliberately ambiguous words to gain their trust. Why not just come straight out and lie to them and say you believe they have a physical illness, when really, you don't? Isn't it even more cowardly to use weasel words that allow you to maintain some kind of spurious sense of your own honesty by appearing to say to patients - or, indeed, to other scientists and decision-makers - the very opposite of what you actually mean?
    Wonko, WillowJ, Enid and 2 others like this.
  6. SOC

    SOC Senior Member

    That is what struck me first -- aren't there ethical concerns about deliberately communicating deceptively? The attitude of these people towards patients is extremely condescending, arrogant, paternalistic... I imagine we can come up with plenty more unpleasant, but true, adjectives. I find this paper very disturbing.
    Wonko, being and Desdinova like this.
  7. Desdinova

    Desdinova Senior Member

    More ethical perversion through obfuscation. All I can say is doctor heal thyself.
    being likes this.
  8. Esther12

    Esther12 Senior Member

    I've started to use 'functional' in everyday conversations to mean all sorts of things. It's quite good fun, and it has an impeccable pedigree.
    oceanblue and Sean like this.
  9. alex3619

    alex3619 Senior Member

    Logan, Queensland, Australia
    I have a functional hatred toward psychobabble: it makes me feel better. ;)
    ahimsa, WillowJ, Enid and 2 others like this.
  10. SOC

    SOC Senior Member

    As in, "I have to go see on of those functional medical professionals and put up with their functional psychological treatment in order to get other services"?
    Enid and being like this.
  11. Snow Leopard

    Snow Leopard Hibernating

    South Australia

    I especially like the term "functional leadership" when referring to politicians and the like.
    WillowJ likes this.
  12. Don Quichotte

    Don Quichotte Don Quichotte

    what makes you think they don't? more than that they have a "manual" which is freely accessible on the internet on how to do that in the most efficient way (and surprisingly it seems to work, because some patients seem to be quite happy with this diagnosis).

    Surprisingly, they don't have any ethical problems with this approach.
  13. Enid

    Enid Senior Member

    Whenever I see his name appear I wonder if he hasn't got something better to do than sit in his ivory tower and play with words and ideas. Seems he is playing with/trying to work out his own problems.
  14. SilverbladeTE

    SilverbladeTE Senior Member

    Somewhere near Glasgow, Scotland
    LOL! *applause* :)

    Actually, as reading somehting recently showing the , oh DSM-V what ya call it thingy, most of those working on it have massive conflicts of interests as they work for/have major financial links to the pharma corps...

    So, you either have it that these assclowns are:
    mentally deluded like they claim their patients are
    profiteering frauds, and when it comes to dispensing toxic drugs without due cause and preventing medical care, that is a serious crime

    Snow Leapord
    "Functional" politicians? damn, only thing functional about our politicians in the UK is their backsides: for sitting on or selling out! :p
  15. Dx Revision Watch

    Dx Revision Watch Suzy Chapman Owner of Dx Revision Watch

    "Objective The term functional has a distinguished history, embodying a number of physiological concepts, but has increasingly come to mean hysterical. The DSM-V working group proposes to use functional as the official diagnostic term for medically unexplained neurological symptoms (currently known as conversion disorder). This study aimed to explore the current neurological meanings of the term and to understand its resilience."

    A few notes:

    The revision of the existing DSM-IV category "Conversion Disorder" has been the purview of both the DSM-5 Work Group for "Somatic Symptom Disorders" and the Work Group for "Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders."

    None of the authors of this paper (Richard A Kanaan, David Armstrong, Simon C Wessely) are members of either of these two Work Groups.

    The paper was

    Received July 18, 2011;
    Revised October 12, 2011;
    Accepted October 19, 2011.
    Published March, 2012.

    So the paper was first submitted last year, shortly after the second DSM-5 stakeholder review and comment period closed (May 4-July 15) and was likely in preparation* at the time of the second stakeholder review and based on proposals as they had stood when released in May 2011 for public review.

    *Before the publication, on May 4, 2011, of the "Disorders Description" PDF that accompanies proposals, an interim PDF was posted on the DSM-5 Development site, dated January 14, 2011. A number of edits had been made to the February 2010 version of this document, including the proposed term "Functional Neurological Disorder" to replace "Conversion Disorder." So the term "Functional Neurological Disorder" had been proposed by the SSD Work Group since at least January 2011.

    Current proposals for the revision of "Conversion Disorder" can be found here on the DSM-5 Development site:

    A new name for "Conversion Disorder" has remained under discussion. But the name proposed in May 2011, at the point of the second stakeholder review, was "Functional Neurological Disorder" and remains as such on the DSM-5 Development site.

    The "Somatic Symptom Disorders" Work Group and the "Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders" Work Group have been discussing whether "Functional Neurological Disorder" (or whatever name is eventually decided upon) would be better placed under "Dissociative Disorders" rather than under "Somatic Symptom Disorders." ("Conversion Disorder" is currently located under "Dissociative Disorders" in ICD-10.)

    The discussion paper below, which addresses the naming, location and criteria for "Conversion Disorder" was published in the December issue of the Journal of Psychosomatic Research.

    Journal of Psychosomatic Research
    Volume 71, Issue 6 , Pages 369-376, December 2011

    Conversion Disorder: Current problems and potential solutions for DSM-5

    Jon Stone, W. Curt LaFrance, Richard Brown, David Spiegel, James L. Levenson, Michael Sharpe.

    Conversion disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) describes neurological symptoms, including weakness, numbness and events resembling epilepsy or syncope, which can be positively identified as not being due to recognised neurological disease. This review combines perspectives from psychiatry, psychology and neurology to identify and discuss key problems with the current diagnostic DSM-IV criteria for conversion disorder and to make the following proposals for DSM-5: (a) abandoning the label conversion disorder and replacing it with an alternative term that is both theoretically neutral and potentially more acceptable to patients and practitioners; (b) relegating the requirements for association of psychological factors and the exclusion of feigning to the accompanying text; (c) adding a criterion requiring clinical findings of internal inconsistency or incongruity with recognised neurological or medical disease and altering the current disease exclusion criteria to one in which the symptom must not be better explained by a disease if present, (d) adding a cognitive symptoms subtype. We also discuss whether conversion symptoms are better classified with other somatic symptom disorders or with dissociative disorders and how we might address the potential heterogeneity of conversion symptoms in classification.


    I have a copy of this discussion paper.

    James Levensen and Michael Sharpe are members of the Somatic Symptom Disorders Work Group.

    Jon Stone and W. Curt LaFrance are external advisors to the Somatic Symptom Disorders work group.

    W. Curt LaFrance is an external advisor to the Dissociative Disorders work group. Richard Brown and David Spiegel are members of the Dissociative Disorders work group.

    So two of the co-authors of this paper are members of the DSM-5 SSD Work Group and two co-authors are external advisors to the DSM-5 SSD Work Group.

    But this paper (like the Kanaan, Armstrong, Wessely paper) is not published on behalf of the DSM-5 SSD or Dissociative Disorders Work Group and does not represent the position of either Work Group.

    This paper was received on January 17, 2011 (which predates the second DSM-5 stakeholder review of proposed changes to DSM-IV categories and criteria). It was resubmitted in revised form on July 10, 2011 (that is, towards the end of the second stakeholder review). It was accepted for publication on July 19, 2011, and published in the December edition of the Journal of Psychosomatic Research.

    In the Introduction to the discussion paper, "Conversion Disorder: Current problems and potential solutions for DSM-5" it states:

    "In this article we discuss the diagnostic criteria for Conversion Disorder as described in the DSM-IV-TR [1] from the perspective of psychiatry, neurology and psychology and offer potential solutions for its description and classification in DSM-5. The article is authored by members of, and advisors to, DSM-5 work groups on somatoform and dissociative disorders. Whilst the article reflects discussion and debate that has taken place in these groups, it is not an official position statement of the American Psychiatric Association. The article highlights areas of agreement but is also intended to stimulate further discussion and debate [25] regarding those areas where there is no consensus."

    The article discusses what term the current category "Conversion Disorder" might be renamed to.

    In Box 1, the article sets out the current diagnostic criteria for Conversion Disorder in DSM-IV-TR.

    It discusses the use of the term "medically unexplained symptoms," a term it considers problematic, in general, and also in the context of "conversion symptoms."

    The SSD Work Group has already reported (in a progress report published in mid 2009 and in its first and second published draft proposals) that it proposes that the concept of "medically unexplained" should be "de-emphasized" for the SSD categories, for DSM-5.

    The paper's authors propose that a new term should be considered for "Conversion Disorder," make various suggestions but consider that more discussion is required.

    The article goes on to discuss where "Conversion Disorder" might best be placed within the classification and sets out that significant changes are being proposed to the existing "Somatoform Disorders" by the DSM-5 SSD Work Group (of which we have been aware since the publication of the first draft, and prior to that).

    That these changes involve not just relabeling the "Somatoform Disorders" categories in DSM-IV to "Somatic Symptom Disorders," but merging somatization disorder, hypochondriasis, pain disorder, and undifferentiated somatoform disorder into a new category "Complex Somatic Symptom Disorder (CSSD)"; that discussion of the consequence of such a change for conversion disorder was deferred in a recent preliminary report but that others have proposed that "Conversion Disorder" be moved to the "Dissociative Disorders" section, where it resides in ICD-10; sets out the arguments for and against retaining "Conversion Disorder" in the equivalent of the "Somatoform Disorders," versus reclassifying it as a "Dissociative Disorder."

    The authors considered that placing "Conversion Disorder" under "Somatic Symptom Disorders" would reduce the potentially useful associations with "Dissociative Disorders," which will be in a separate category in DSM-5.

    The authors also noted that location under SSD would not be congruent with ICD-10 (and ICD-11 if it is not changed).

    The authors discuss whether "Conversion Disorder" would be better placed within the "Dissociative Disorders" but do not reach consensus.

    In conclusion, the authors propose that the following changes to the DSM-IV category of conversion disorder be considered for DSM-5: they set out their own proposals for criteria (but not those of the DSM-5 Work Group for ease of comparison);
    propose that the name should be changed; that "Conversion Disorder" is not considered a useful term for this group of symptoms;
    a number of alternative names ("Functional Neurological Symptom Disorder", "Dissociative Neurological Symptom Disorder" and "Psychogenic Neurological Symptom Disorder") are suggested as possible alternatives to the existing proposal, "Functional Neurological Disorder."

    If readers obtain a copy of this paper, it needs to be read with the following in mind: like the Kanaan paper, the Stone et al paper is a discussion paper; whilst the article reflects discussion and debate that has taken place in the "Somatic Symptom Disorders" and the "Dissociative Disorder" Work Groups, it is not an official position statement of the Task Force or Work Groups.

    Until the third draft is published (currently expected no later than May 2012), it won't be known what further decisions the Work Group for the "Somatic Symptom Disorders" section may have made for the categories currently proposed for DSM-5, since last May, which are here:

    J 00 Complex Somatic Symptom Disorder (CSSD)
    J 01 Simple Somatic Symptom Disorder (SSSD)
    J 02 Illness Anxiety Disorder
    J 03 Functional Neurological Disorder (Conversion Disorder) (which may potentially be classified under Dissociative Disorders)
    J 04 Psychological Factors Affecting Medical Condition
    J 05 Other Specified Somatic Symptom Disorder
    J 06 Unspecified Somatic Symptom Disorder

    Also of interest may be this Scottish report on "Functional neurological symptoms":


    PDF: http://www.healthcareimprovementsco...302668-ff12-4f53-b547-72c19531e37a&version=-1

    Stepped care for functional neurological symptoms

    A new approach to improving outcomes for a common neurological problem in Scotland

    Report and recommendations February 2012

    This report aims to support NHS boards improve neurological health services and achieve the Clinical Standards for Neurological Health Services.

    These recommendations are published as part of the Neurological Services Implementation and Improvement Support Programme and contains some management recommendations that NHS boards may wish to consider in respect of their local position.
  16. Dx Revision Watch

    Dx Revision Watch Suzy Chapman Owner of Dx Revision Watch

    SilverbladeTE may be referring to this Essay published on PLoS Medicine last week by Cosgrove and Krimsky:

    "A Comparison of DSM-IV and DSM-5 Panel Members Financial Associations with Industry: A Pernicious Problem Persists"

    Full text of Essay available here on PLoS site under Open-access:

    A number of stories followed the publication of the Cosgrove and Krimsky PLoS Medicine Essay. Links for selected reports in this March 14 Dx Revision Watch post:

    Cosgrove, Sheldon: 69% of DSM-5 task force members report pharmaceutical industry ties review identifies potential COIs


    On March 15, APA issued this statement in response to the PLoS Medicine Essay:

    Statement from John M. Oldham, M.D.

    PDF format:

    PDF statement John M Oldham, M.D., March 15, 2012

    or full text below:

    March 15, 2012

    Statement for John M. Oldham, M.D., President of the American Psychiatric Association:

    In their article, A Comparison of DSM-IV and DSM-5 Panel Members Financial Associations with Industry: A Pernicious Problem Persists, which appeared in the March issue of the journal Public Library of Science, and which ABC and other news outlets quoted, Cosgrove and Krimsky question the work of DSM-5s volunteer Task Force and Work Group members because of publicly disclosed relationships with the pharmaceutical industry. Although we appreciate that Cosgrove and Krimsky acknowledge the commitment the American Psychiatric Association (APA) has already made to reducing potential financial conflicts of interest, we strongly disagree with their analysis and presentation of APAs publicly available disclosure documents. Specifically, the Cosgrove-Krimsky article does not take into account the level to which DSM-5 Task Force and Work Group members have minimized or divested themselves from relationships with the pharmaceutical industry.

    In 2012, 72 percent of the 153 members report no relationships with the pharmaceutical industry during the previous year. The scope of the relationships reported by the other 28 percent of member varies:

    12 percent reported grant support only, including funding or receipt of medications for clinical trial research;

    10 percent reported consultations including advice on the development of new compounds to improve treatments; and

    7 percent reported receiving honoraria.

    Additionally, since there were no disclosure requirements for journals, symposia or the DSM-IV Task Force at the time of the 1994 release of DSM-IV, Cosgrove and Krimskys comparison of DSM-IV and DSM-5 Task Force and Work Group members is not valid. In assembling the DSM-5s Task Force and Work Groups, the APAs Board of Trustees developed an extensive process of written disclosure of potential conflicts of interest. These disclosures are required of all professionals who participate in the development of DSM-5. An independent APA committee reviews these disclosure documents, which are updated annually or whenever a members financial interests change. Individuals are only permitted to serve on a work group or the Task Force if they are judged to have no significant financial interests.

    The Board of Trustees guiding principles and disclosure policies for DSM panel members require annual disclosure of any competing interests or potentially conflicting relationships with entities that have an interest in psychiatric diagnoses and treatments. In addition, all Task Force and Work Group members agreed that, starting in 2007 and continuing for the duration of their work on DSM-5, each members total annual income derived from industry sources would not exceed $10,000 in any calendar year. This standard is more stringent than requirements for employees at the National Institutes of Health and for members of advisory committees for the Food and Drug Administration. And since their participation in DSM-5 began, many Task Force members have gone to greater lengths by terminating many of their industry relationships.

    Potential financial conflicts of interest are serious concerns that merit careful, ongoing monitoring. The APA remains committed to reducing potential bias and conflicts of interest through our stringent guidelines.



    Board of Trustee Principles for DSM-5 Task Force members here:

    DSM-V Task Force and Work Group Acceptance Form here:

    Approved by BOT July2006 Amended and Approved by BOT October 2007 Member Acceptance Form.pdf

    DSM-5 Task Force members bios and disclosures here:

    DSM-5 Work Group members bios and disclosures here:

    (All 13 DSM-5 Work Group Chairs are members of the Task Force, which totals 29 members.)

    Suzy Chapman
  17. Dx Revision Watch

    Dx Revision Watch Suzy Chapman Owner of Dx Revision Watch

    Current DSM-5 proposed criteria: Functional Neurological Disorder

    Below are the current proposed criteria and rationale for "Functional Neurological Disorder" (Conversion Disorder in DSM-IV). Note these are not criteria for "Complex Somatic Symptom Disorder," which are here:


    Updated May 4, 2011

    03 Functional Neurological Disorder (Conversion Disorder)

    Criteria A, B, C, and D must all be fulfilled to make the diagnosis:

    A. One or more neurologic symptoms such as altered voluntary motor, sensory function, cognition, or seizure-like episodes.

    B. The symptom, after appropriate medical assessment, is found not to be due to a general medical condition, the direct effects of a substance, or a culturally sanctioned behavior.

    C. The physical signs or diagnostic findings are internally inconsistent or incongruent with recognized neurological disorder.

    D. The symptom causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

    Please see full disorder descriptions here

    * The final name of this disorder is still under active discussion

    * Both the Somatic Symptom Disorders Work Group and the Anxiety, Obsessive-Compulsive Spectrum, Posttraumatic, and Dissociative Disorders Work Group are discussing how conversion disorder relates to the dissociative disorders



    Major change #1: Rename Somatoform disorders to Somatic Symptom Disorders and combine with PFAMC and Factitious Disorders

    The workgroup suggests combining Somatoform Disorders, Psychological Factors Affecting Medical Condition (PFAMC), and Factitious Disorders into one group entitled Somatic Symptom Disorders because the common feature of these disorders is the central place in the clinical presentation of physical symptoms and/or concern about medical illness. The grouping of these disorders in a single section is based on clinical utility (these patients are mainly encountered in general medical settings), rather than assumptions regarding shared etiology or mechanism. Alternatively, Factitious Disorders could continue to be listed under the category Other Disorders.

    Major change #2: De-emphasize medically unexplained symptoms

    Remove the language concerning medically unexplained symptoms for reasons specified above. The reliability of such judgments is low (Rief, 2007). In addition, it is clear that many of these patients do in fact have considerable medical co-morbidity (Creed, Ng). Medically unexplained symptoms are 3 times as common in patients with general medical illnesses, including cancer, cardiovascular and respiratory disease compared to the general population (OR=3.0 [95%CI: 2.1 to 4.2] (Harter et al 2007). This de-emphasis of medically unexplained symptoms would pertain to somatization disorder, hypochondriasis, undifferentiated somatoform disorder, and pain disorder. We now focus on the extent to which such symptoms result in subjective distress, disturbance, diminished quality of life, and impaired role functioning.

    Major change #4: Modify criteria for conversion disorder

    Changes are made in an effort to simplify the criteria for conversion disorder. First, we suggest removing the requirement that the clinician actively establish that the patient is not feigning. This is because (a) it is probably clinically impossible to prove that a patient is not feigning (Sharpe, 2003) and (b) there is no evidence that feigning of conversion symptoms is more common than feigning of other mental disorders. However as with other disorders positive evidence of feigning remains an exclusion, thereby differentiating conversion from factitious disorder and malingering.

    Second, we suggest removing the requirement that the clinician has to establish that there are associated psychological factors . This is because (a) as with feigning, it is very difficult to reliably establish that relevant psychological factors are present in all cases and (b) the research evidence suggests that psychological factors can often be found but are not specific and have only a weak association with the diagnosis (Roelofs, 2005). The association with psychological factors has therefore been relegated to accompanying text rather than remaining a clinical requirement for diagnosis.

    Third, we emphasize the importance of obtaining positive evidence of the diagnosis from appropriate neurological assessment and testing. Current diagnostic criteria require that the symptom, after appropriate medical assessment, is found not to be due to a general medical condition. In contrast to most other somatic symptoms, it can be usually be reliably determined whether neurological symptoms are due to an organic disease (Stone et al 2009). Additionally there are also findings on neurological assessment and investigation that positively suggest the symptoms are those of conversion (such as Hoovers sign for motor weakness or absence of seizure activity on an EEG during apparent seizures for seizures) (Hallett 2005; Reuber 2004; Stone 2005).

    We suggest retaining Conversion Disorder in the Somatic Symptom Disorders section of the DSM. Conversion remains a condition defined by a somatic symptom that causes disability or distress and therefore sits comfortably in the new Somatic Symptom Disorders category that replaces somatoform disorders on grounds of utility. The alternative placement of this diagnosis is with dissociative disorders. The argument for moving conversion there is that the mental mechanisms involved are similar. However dissociation is a hypothetical process and moving conversion would (a) risk making an unjustified assumption about cause (b) lose the utility of grouping with other conditions that present with a somatic symptom.

    Please see the full rationale document here

    Caveat: The third and final stakeholder review is expected in May, this year, for a two month comment period. Proposals as they currently stand on the DSM-5 Development site may be subject to change for the third draft or in the interim.

    Suzy Chapman
  18. WillowJ

    WillowJ คภภเє ɠรค๓թєl

    WA, USA
    I read an article about court cases where doctors made up meanings for the various shorthand they use to say things about patients that they don't want the patients to be able to decipher, and didn't want to own in court either.

    I have actually had something like that happen to me. I wasn't happy. It didn't correct my problem and I was back in ER the next day. Spending two days in ER being shunned because the doctors are convinced you have a functional disorder and don't need them, is not recommended.
    Snow Leopard likes this.

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