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

Abstract

<ns4:p>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.</ns4:p>

Magical thinking and moral injury: exclusion culture in psychiatry

“…We ask medical colleagues to ‘exclude organic causes’ of a disturbed mental state, as if it is always possible to do this acutely or to precisely isolate which symptom arises from which condition; as if conditions cannot coexist. In their detailed analysis of the incoherent distinction between ‘organic’ and ‘functional’, Bell et al 13 conclude that ‘the functional–organic distinction often seems like a tool that helps determine treatment priority dressed up in the language of causation’. Neurologists and other specialists may be as guilty of this as psychiatrists, 14 but we should surely have a greater interest in challenging what is essentially another form of stigma.…”

“…Stigma towards people with mental illness in medical settings is well-documented and tackling it a slow process; it was only in January 2020 that the Side by Side consensus statement was published 13 but the COVID-19 pandemic that hit us just a month later jeopardises its intentions. Driven by the pandemic, there is a vogue for developing acute psychiatric assessment sites away from emergency departments.…”

Interpretable deep learning of myelin histopathology in age-related cognitive impairment

“…Weakly supervised learning approaches using multiple instance learning have had remarkable success thus far in digital pathology, especially in oncology [ 13 , 14 ]. However, unlike cancer pathology, where a gold standard diagnosis can be ascertained, the neuropathologic etiologies of cognitive impairment are poorly understood, graded rather than categorical, overlapping, and dynamically interacting [ 15 – 17 ]. Moreover, clinical measures of cognitive function available for clinicopathologic correlation in neuropathology are frequently imprecise, non-standardized, ephemeral, and collected at distant time points prior to death [ 18 – 20 ].…”

The role of the electroencephalogram (EEG) in determining the aetiology of catatonia: a systematic review and meta-analysis of diagnostic test accuracy

“…In terms of terminology, we note there is controversy over the use of the traditional functional-organic distinction, as it artificially dichotomises complex disorders. 30 For the purposes of this study, we are interested in the pragmatic clinical distinction between cases of catatonia where there is considered an identifiable neuropathological process (which we term ‘medical’ catatonia) and those where catatonia is considered part of a primary mental disorder (which we term ‘psychiatric’ catatonia). While we acknowledge the imperfections of this terminology, we can benefit from a common language within this paper.…”