Fascinating Topic: Exploring Some Thoughts On Psychogenic Illnesses

Exploring an article written about long covid and the presence of psychogenic disease in non-psychiatric medicine

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I read a great article this week about the psychogenic origins of long covid and the very real experience that people have with psychosomatic disease. The article was written by a neurologist who had a number of patients coming to appointments with a wide range of self-diagnoses which, when given a normal battery of tests, had no physical signs of actually existing. The first patient he describes reported experiencing cognitive after-effects of long covid which dampened her ability to think and remember. Brain imagery was normal, and she seemed to improve almost immediately on being asked to give the history of her new illness and other symptoms she was experiencing. A look into her medical history showed a trend of reported illnesses with no clear signs of anything clinically relevant. 

Long covid wasn’t the only example of an illness which presented without clinical signs—the doctor described another patient who claimed to have been infected by a parasite contracted overseas which damaged his nerves and skin. The patient had undergone testing for years which all came back negative, but he had a group of friends who apparently contracted the same parasite in the same place, so the inconclusive test results didn’t deter his belief in his own suffering. After some back and forth, the physician got the patient to admit that these were friends he had never actually met, but were a group of people online who had been to the same place overseas and who experienced the same problem. 

The article described the successive definitions of this kind of clinical presentation, which we now call a Functional Neurological Disorder (FND), or a conversion disorder in the recent past, and hysteria long before that. I had never heard of FND until reading this piece, and the scientific literature describes it as a common mental disorder which expresses symptoms of diseases without their “structural” counterpart, which can also cause individuals to present symptoms of diseases that others really do have in their environment, and which affects women three times as often as men. The literature emphasizes that FND causes real distress for sufferers, and the article does a good job building the same perspective for the reader, having us consider that, yes, these people might not have the exact illnesses they claim to, but very real suffering is in fact happening. 

What makes FND different from other mental disorders though, like depression and anxiety, is that the sufferers of these diseases don’t build their entire identities around being sick, which FND sufferers do, and which is a hidden subtext in the article. FND seems willful, the sufferers put much time, thought, and energy into presenting as disabled individuals, they are highly effective at it, and like the scientific literature on the subject, the article avoids exploring the undergirding incentives that may be driving the disorder. Mental disorders like the ones on the antisocial personality spectrum are often defined by the motivations which drive their sufferers, so it seems important for the goal of general understanding that the motivations in FND be defined as well. A few pieces of information from the article give some ideas, like the fact that most of the functional Illnesses have their own communities, much like the “spoonies” detailed in a piece on Bari Weiss’ substack, who are a community made up mostly of women who have undiagnosable disorders that prevent them from entering the world. Community building tendencies are present in everyone, and some people might just have a preference to bond over suffering. That might be the only way that social connection makes sense to them.

Some other hints in the article that may explain the incentives are the dismissive reactions some patients give after their illness is described as possibly having mental origins, instead of having provenance in something more serious which justifies the amount of care they’ve been seeking. This isn’t quite like the experience a lot of us have had where we visit the emergency room for some sudden issue and the ER doctor comes back saying he couldn’t find anything, but that we should make an appointment with our primary caregiver if anything new comes up. In these cases something probably could have been found with enough testing. In the case of a “functional” disease, the patient has taken every possible test over the course of years and found nothing. The news that these problems might be a consequence of stress or something else psychological in some instances garners a negative reaction because it means that the care and attention they’ve been deriving from their illness may come to an end. Like the different paths we take toward community building, people also have various ways to pursue the feeling of being cared for and attended to—functional neurological disorders are probably one of them. 

The article also describes cases of psychogenic disease spreading from the internet, from influencers, which gives us another hint, one which I think is most compelling. A situation made the news recently where high schoolers began presenting with Tourette’s syndrome en mass after seeing a popular TikToker with the disease. After learning about this event I was reminded of the myth of the Spanish king who spoke with a lisp, and who in turn inspired his subjects to do the same, eventually changing the expression of the language entirely. Who wouldn’t want to do the high status thing? Who wouldn’t like to be similar to the high status person? There are certain people who will do pretty much anything which is in vogue, say anything that’s fashionable, no matter how ridiculous, and this may explain a lot of this phenomenon. This may sound like a less-than-compassionate explanation compared to the others given, but it’s worth bearing in mind that FND patients steal attention away from people who actually suffer the diseases they’re only pretending to have, and those people can’t pick up a new disease when it becomes high status the way FND patients can.

There is some value in knowing that there may be a real disorder that causes the presentation of illnesses that aren’t there, and I think that some people with FND do have harmless incentives, but for the most part I think most of them are full of it. In my mind the disorder is more like narcissism and psychopathy than something less pernicious, and I say this from experience with people who treat others viciously while using an illness as cover for all the harm they do. I think people with FND can be serious burdens on people who are compassionate, from family members, to friends, to physicians like the one who wrote this brilliant piece. And I think we should try to promote a discourse that validates efforts to move beyond sickness, a discourse of strength and vitality, instead of a discourse which validates illness-based identities.

The whole project of compassion and care has been altered by the people like the article describes, but as culture shifts into stranger forms than we’ve seen, it’s more important than ever before to wrest it from their hands and alter it back.