The influence of culture
There is a growing recognition of the strong influence of social factors on the development, expression and treatment of FND.
Canna and Seligman (2019) describe three interrelated cultural processes that particularly confirm the effect of of cultural relevance in FND:
(1) the embodiment of cultural models and the development of so-called "interoceptive capacities";
(2) socialisation of trauma and chronic stress; and
(3) moral judgement.
Embodiment of cultural models and development of "interoceptive capacities"
Culture largely determines how the members of a given society will think and feel and thus, in addition to ensuring its own continuity through time and space, determines human action and the dominant view of life in a given historical period. Every culture develops its own rules, guidelines and precepts by which its members must abide in order to be accepted into it. These norms or guidelines are internalised by people through a process of socialisation that takes a lifetime.
Cultural meanings could be defined as a set of shared representations, models and expectations of reality that are deeply internalised from a very early age.
These models are mostly acquired through socialisation:
Primary socialisation to which we are exposed in early childhood and through which we acquire not only a human nature but also a social nature.
Secondary socialisation which introduces 'social man', through various institutions, into new strata and spheres of society.
Within socialisation, a process takes place of internalisation where the child 'takes on' the world already inhabited by his or her significant others (e.g. parents, carers...). Through identification with significant others, the child makes their world his/her own and acquires an identity. The process also takes place of social learning which is socially determined and takes place through model learning.
Anthropology and sociology suggest that diseases and/or disorders are also shaped and maintained by socially internalised models, of which we are either aware or unaware. Thus, Canna and Seligman (2019) suggest that patients with FND express their symptoms in a culturally informed way, or in other words, based on an internalised model of illness. All of this suggests that, in addition to studying FND in the context of (neuro)biology and psychology, it is crucial to study the broader cultural context that potentially contributes significantly to the initiation and maintenance of FND symptoms.
This would also help to understand 'interoceptive capacities', which can be defined as a set of interoceptive signs or signals that allow us to monitor our own physiological state and are meaningful and relevant to a given society in a given time context (Canna, 2017).Cultural meanings can alter 'interoceptive sensitivity', which is manifested in the fact that we can amplify symptoms based on a certain cultural meaning, as we have learned to perceive them as threats.
E.g. a fast heartbeat can be perceived as a trigger for a severe seizure, and even though our heartbeat is normal, the cultural meaning, due to the influence of a combination of thoughts and emotions (thoughts about cultural meaning lead to anxiety and hyper-arousal), lowers the level of 'interoceptive sensitivity', which actually makes the heartbeat faster. The result is that even though the initial stimulus was minimal (e.g. heart rate in the normal range), the abnormal reaction to it(due to cultural meaning) intensifies or even causes the expected symptom.
Techniques such as biofeedback can thus help patients to monitor their internal physiological state and learn how to distinguish between the culturally driven 'interoceptive sensitivities' that create and maintain cultural models of illness and natural physiological reactions. This is particularly useful in the case of functional seizures, where patients can learn to identify and differentiate the triggers that lead to seizures and to prevent their self-injurious patterns.
It is also important to mention the cultural environment within which cultural models of FND are formed and internalised. This is why it is important to be aware of the systemic reciprocal reinforcing relationship that takes place between the patient with FND and his/her community, which is made up of professionals, family members, relatives and friends. These can in turn amplify or transform the patient's 'interoceptive capacities' through feedback and response to the symptoms expressed.
Socialising trauma and chronic stress
Cultural models provide appropriate ways and strategies of expressing psychological trauma, which can lead to the physical expression of primary psychological distress. The cultural meaning of trauma can enable psychotherapists to reframe and manipulate personally constructed meaning.
Moral judgement
Moral judgement is a common phenomenon experienced by patients with FND. They often report feelings of being unheard, of not belonging and of being judged as 'all in their head'. In addition, due to a combination of not understanding the complexity and functional source of FND in a way that is understandable to both patients and medical staff, most patients feel ashamed of their symptoms or perceive them as humiliating and socially invalid. All this can lead to the development of avoidant behaviours, social isolation, social anxiety, lowered prosociality and self-esteem. Some symptoms and/or disorders and illnesses may thus be socially accepted in a more or less positive way, and their moral connotation and acceptability may have a strong impact on their coping and expression.
This is why it is crucial that we place greater emphasis on reducing the stigma surrounding functional neurological disorder, both at an individual and collective level. It is essential that we focus on developing and conducting studies that examine the impact of cultural norms on the perception of certain disorders, one's own body and symptoms. This will provide important insights into the impact of a non-stigmatising culture on the understanding and treatment of FND.
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Canna, M., in Seligman, R. (2020). Dealing with the unknown. Functional neurological disorder (FND) and the conversion of cultural meaning. Social Science & Medicine, 246, 112725.
Maccoby, E. E. (2007). Historical overview of socialization research and theory. Handbook of socialization: Theory and research, 1, 13-41.
van der Hulst, E. J. (2023). A Clinician's Guide to Functional Neurological Disorder: A Practical Neuropsychological Approach. Routledge.