Functional, Fashionable or Toxic?

BNPA stands for British Neuropsychiatry Association.  I emailed its officers almost 4 months ago, about their annual meeting coming up in slightly over 4 months time.

This post goes hand in hand with Ariadne’s Thread on RxISK.

From: David Healy
Date: Fri, 3 Jul 2026 at 10:29
Subject: BNPA Meeting
To: Vaughan Bell, Ingrid Hoeritzauer

Dear Drs. Bell and Hoeritzauer

I’ve been approached by a patient who has a medication induced peripheral sensory nervous system disorder. She is concerned that a diagnosis of FND has slipped into her medical records.  A growing number of patients, with medication triggered disorders that have a variety of sensory neuropathic elements in common, have similar concerns.

SSRIs are the common medication element. Acting on sensory receptors these can be of benefit but given in excessive doses and for too long they can disrupt sensory systems leading to disorders that in the absence of reliable tests, and perhaps given a background of nervous problems for which these drugs were given, can lead to the word functional slipping into the frame.

I’ve been writing about the effects of SSRIs on sensory receptors for some time and have several articles on these effects currently in press. Thinking about how misunderstandings arise at the intersection between SSRI related problems and FND diagnoses, it occurred to me that a BNPA meeting might be the best venue to start a conversation. Hence this note.

I’ve given two prior talks at BNPA meetings. I’m offering to give another focused on SSRI sensory system effects, which if misread risk alienating patients and generating pushback against the FND concept.

When a patient can take a hard-bristled brush and rub it up and down her genitals and feel nothing, and this clearly started with a drug and endured after stopping treatment, but she gets an ‘of course this is real for you’ message, it impacts on confidence in the medical system.

Beyond FND, the effects of SSRIs on sensory systems can shed light on complaints like Brain Fog and how, if you know what to look for, can support a Not Guilty by reason of Toxicity plea in legal settings. A lecture with a focus on sensory system effects, I hope might be of general interest but given an FND intersection I’d be more than open to BNPA having a linked FND talk and would share the articles mentioned and slides for the talk with whoever is involved in that aimed at making the session as fruitful as possible for everyone.

I hope to hear back from you at some point.   David Healy

From: Ingrid Hoeritzauer
Date: Mon, 6 Jul 2026 at 08:22
Subject: Re: BNPA Meeting
To: David Healy, Vaughan Bell

Dear Prof Healy,

Thanks for your email and topic suggestion. We have already organised most of next years meeting as it’s the 40^th anniversary of the BNPA and we are keen to celebrate that.

As you’ll know, the BNPA benefits from encouraging new speakers. We try to ensure that those you’ve spoken several times make way for new speakers so that the line up is always exciting and novel. It’s part of what brings back people year after year to the meeting and expands the learning for all of us.

We are sorry to turn your suggestion down and hope to see you in March next year at the 40^th celebrations.

Kind Regards Ingrid

Images of Uncertainty

Images of Trauma was published over 30 years ago.  The publishers insisted on a title change from Images of Uncertainty. Its early chapters dug into the prehistory of psychotherapy – mesmerism and hypnosis. Followed by the emergence of what we now view as psychotherapy in the work of Pierre Janet and Sigmund Freud with the uncertainty element cropping up when touching on the then Recovered Memories crisis of the 1990s.

Janet’s work was and remains very impressive.  Unlike Freud, he did not switch from being an advocate of trauma as the cause of everything at one point and shortly afterwards to a view that trauma is irrelevant – it causes nothing. Janet focused on phenomena like dissociation and was the first ‘explorer’ of states like alien hand today that now would possibly support the concept of a functional neurological disorder (FND). He described experiments and reported results still viewed as valid today. He made no attempt to explain Civilization and its Discontents or The Future of an Illusion.

His work, however, did migrate into the science of crowd behavior, fashions and propaganda, as a recognition grew that just as with individuals crowds can be governed by the same dynamics he, and not Freud, had described.

Facing the images of uncertainty that clinical situations throw up and leaning more to Janet’s approach than Freud’s, it’s difficult not to accept that there is some validity to the concept of a functional neurological disorder (FND). The BNPA describe FND in flowery language that could well apply to a fashion (like Adult ADHD etc). They say there has been a “transformation in our understanding of functional neurological disorder during the history of neuropsychiatry – one of the most remarkable in the history of medicine”.

We unquestionably from time to time display unintended and not readily explained automatic behaviors.  Some of these we can now link to Tourettism (not the same as saying you have Tourette’s Syndrome), some are linked to Narcolepsy, Parasomnias linked to the stages of sleep, others to epileptiform conditions, and some to catatonia, the most dramatic and seemingly willful of all, despite us viewing it as involuntary.

These states generally can be triggered or aggravated by any one of the following – physical illnesses, medication or emotional shocks.  There can be real problems working out where the boundaries of any of these states begin and end. Is neuroleptic malignant syndrome part of catatonia?  Should serotonin syndrome be viewed as part of catatonia?  When conditions like PSSD, or similar conditions after finasteride, or isotretinoin, or related states after mefloquine and many anticonvulsants, endure for years after treatment stops has the problem become a functional one – a psychological one?

The word functional is a weasel word.  Catatonia is a disorder of function but is clearly not a psychological problem in the sense of a neurosis or something ‘put-on’ as we loosely understand those words – See Feedback Loop Disorders.

If catatonia and tardive dyskinesia and diabetes are not FND – all can be made worse by stress – what exactly is FND?.  (Diabetes up to 1920 was viewed by many doctors as a form of male hysteria – see Are Diabetes and Depression Linked). Does FND or does it not involve automatisms – reflex unintended behaviors?  Are its behaviors to some extent intended unlike those of automatisms?

These are not easy matters to settle.  But there comes a point when some degree of settling is needed.  We have got to that point when people taking SSRIs end up with PSSD or Visual Snow Syndrome or Persistent Postural Perceptual Dizziness (PPPD) are told they have FND – without anyone doing the tests supposedly specific for FND. We have got to that point when people PSSD, VSS or PPPD get referred for psychotherapy – aka trauma therapy – for their FND.  We have got to that point when they get put on SSRIs, which unrecognized by their doctors have caused the original problem, in order to manage the person’s anxiety which according to the doctor is manifesting as FND.

We have got to that point when FND enters a person’s medical record and they can’t get it removed and everyone, either consciously or unconsciously knows that FND in a medical record is a kiss of death and nothing this person says about their symptoms is ever likely to be taken seriously again. Functional can be and has become for many a toxic word. We have got to a point where something needs doing.

Reclaiming FND

This is not all the fault of the originators of modern day FND. The concept sits on a slippery slope between Janet and Freud.  While the label may be applied by some neurologist in a specific sense to a specific patient, once let loose in the wider world and exposed to the fertilizing interests of many varied health system stakeholders, its growth always risked taking off.

While the great harm these developments can do is not all of the fault of the originators, they are in a better place than anyone else to put a brake on things – if only to save their baby.  Otherwise, FND risks going the way of medically unexplained symptoms (MUS), somatization, illness behavior and other initially helpful framings of important points, which end up being viewed as ‘hysteria’ in disguise and abandoned as pejorative.

A key thing is to ensure FND does not get diagnosed until the diagnostician has ruled out the possibility of a prior drug induced toxic state. This may not be easy as we have a culture that rushes to embrace new diagnostic fashions like FND, adult ADHD and adult ASD but flees possible diagnoses of treatment induced problems – such as toxic physical states in response to medicines or toxic psychological states such as recovered memories of abuse that never happened.

We are quick to blame patients for failing to recognize the illnesses they have – saying they have an additional condition we call anosognosia (although this is a drastic misuse of that word) but we are glacially slow to recognize professional Venomagnosia – See Horrendous Investigations.

Although dressed in scientific jargon such as anosognosia, these are indecent manifestations of defenses against science rather than ‘decent’ contributions to science or clinical care.

A central point that needs nailing down that MHRA last week – MHRA Warnings – were dragged toward recognizing is that many bizarre conditions can continue for years, even decades, after the triggering drug is out of the patient’s system.

It was semi-understandable that some doctors would ridicule people for thinking a drug they had been off for a year or more could be causing a real physical problem – this had to be something functional.  There were similar initial responses to Tardive Dyskinesia.

Neurologists are not just in appropriately branding people who have real and serious problems, they are passing up a chance to make neurological discoveries by not taking seriously what people tell them in good faith.  Discoveries linked to drugs they use like anticonvulsants.  Anticonvulsants cause real problems that can endure for years after stopping. Exploring what is happening could help patients, make a neurologist’s job more exciting and lead to scientific breakthroughs.

In clinical trials, anticonvulsants double the rate of suicidal events compared to placebo and likely homicidal events but the timeframe differs from the increases in suicidal events on antipsychotics and suicidal events on antidepressants.  Why?  The mechanisms linking antidepressants and antipsychotics to suicides and homicides are well worked out – is there any input from neurologists as to how anticonvulsants ends up causing effects like these?

Science is empirical.  This means that like law it is about observing what happens in front of a jury aimed at coming to a consensus – a diagnosis or verdict.  The jury members who have equal weight when it comes a consensus. We who have the problem should not feel under any onus to defer to the ‘beliefs’ of a doctor. The onus is on doctors to keep a door open to their beliefs being wrong.

Decency requires not entering into a patient’s record a label on which doctor and patient have not arrived at a consensus – or at the very least making it very clear in the record the patient does not accept the doctor’s view.