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      What is the functional/organic distinction actually doing in psychiatry and neurology?

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          Abstract

          The functional-organic distinction aims to distinguish symptoms, signs, and syndromes that can be explained by diagnosable biological changes, from those that cannot. The distinction is central to clinical practice and is a key organising principle in diagnostic systems. Following a pragmatist approach that examines meaning through use, we examine how the functional-organic distinction is deployed and conceptualised in psychiatry and neurology. We note that the conceptual scope of the terms ‘functional’ and ‘organic’ varies considerably by context. Techniques for differentially diagnosing ‘functional’ and ‘organic’ diverge in the strength of evidence they produce as a necessary function of the syndrome in question. Clinicians do not agree on the meaning of the terms and report using them strategically. The distinction often relies on an implied model of ‘zero sum’ causality and encourages classification of syndromes into discrete ‘functional’ and ‘organic’ versions. Although this clearly applies in some instances, this is often in contrast to our best scientific understanding of neuropsychiatric disorders as arising from a dynamic interaction between personal, social and neuropathological factors. We also note ‘functional’ and ‘organic’ have loaded social meanings, creating the potential for social disempowerment. Given this, we argue for a better understanding of how strategic simplification and complex scientific reality limit each other in neuropsychiatric thinking. We also note that the contribution of people who experience the interaction between ‘functional’ and ‘organic’ factors has rarely informed the validity of this distinction and the dilemmas arising from it, and we highlight this as a research priority.

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          Epistemic Injustice

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            Post-Stroke Depression: A Review.

            Poststroke depression (PSD) has been recognized by psychiatrists for more than 100 years, but controlled systematic studies did not begin until the 1970s. Meta-analyses addressing almost all major clinical issues in the field have emerged because of the relatively small number of patients included in some stroke studies. In order to build large databases, these meta-analyses have merged patients with rigorously assessed mood disorders with major depressive features with patients scoring above arbitrary cutoff points on depression rating scales, thus missing important findings such as cognitive impairment associated with major but not minor depression. Nevertheless, PSD occurs in a significant number of patients and constitutes an important complication of stroke, leading to greater disability as well as increased mortality. The most clinically important advances, however, have been in the treatment and prevention of PSD. Recent meta-analyses of randomized controlled trials for the treatment of PSD have demonstrated the efficacy of antidepressants. Similarly, randomized controlled trials for prevention of PSD have shown that antidepressants significantly decrease the incidence of PSD compared with placebo. Early antidepressant treatment of PSD appears to enhance both physical and cognitive recovery from stroke and might increase survival up to 10 years following stroke. There has also been progress in understanding the pathophysiology of PSD. Inflammatory processes might be associated with the onset of at least some depressive symptoms. In addition, genetic and epigenetic variations, white matter disease, cerebrovascular deregulation, altered neuroplasticity, and changes in glutamate neurotransmission might be relevant etiological factors. Further elucidation of the mechanism of PSD may ultimately lead to specific targeted treatments.
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              The Patient-Centered Outcomes Research Institute (PCORI) national priorities for research and initial research agenda.

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                Author and article information

                Contributors
                Role: ConceptualizationRole: Writing – Original Draft PreparationRole: Writing – Review & Editing
                Role: ConceptualizationRole: Writing – Review & Editing
                Role: ConceptualizationRole: Writing – Review & Editing
                Role: ConceptualizationRole: Writing – Review & Editing
                Role: ConceptualizationRole: Writing – Review & Editing
                Role: ConceptualizationRole: Writing – Review & Editing
                Journal
                Wellcome Open Res
                Wellcome Open Res
                Wellcome Open Res
                Wellcome Open Research
                F1000 Research Limited (London, UK )
                2398-502X
                11 June 2020
                2020
                : 5
                : 138
                Affiliations
                [1 ]Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
                [2 ]South London and Maudsley NHS Foundation Trust, London, UK
                [3 ]Department of Sociology, Philosophy and Anthropology, Exeter University, Exeter, UK
                [4 ]Department of Sociology, Goldsmiths, University of London, London, UK
                [5 ]Headway East London, London, UK
                [6 ]Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
                [1 ]Neuropsychiatry Unit, National Institute of Neurology and Neurosurgery of Mexico, Mexico City, Mexico
                [2 ]School of Medicine, National Autonomous University of Mexico, Mexico City, Mexico
                [1 ]Department of Neuropsychiatry, St George's Hospital, South West London and St George's Mental Health NHS Trust, London, UK
                Author notes

                No competing interests were disclosed.

                Competing interests: No competing interests were disclosed.

                Competing interests: No competing interests were disclosed.

                Author information
                https://orcid.org/0000-0001-8616-4847
                https://orcid.org/0000-0002-0165-0617
                Article
                10.12688/wellcomeopenres.16022.1
                7338913
                32685699
                913d0f1e-0b6a-470a-b0c9-4a77fe8345fe
                Copyright: © 2020 Bell V et al.

                This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 5 June 2020
                Funding
                Funded by: Wellcome Trust
                Award ID: 200589
                This work was supported by the Wellcome Trust [200589]. This work was produced as part of Wellcome’s The Hub Award.
                The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Review
                Articles

                neuropsychiatry,neurology,psychiatry,functional,organic
                neuropsychiatry, neurology, psychiatry, functional, organic

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