To the Editor In a report on 21 US diplomatic staff who became unwell in Cuba,1 the authors rejected the possibility of a functional neurological disorder as the etiology. We disagree. The accompanying Editorial pointed out that functional neurological disorders are genuine and not malingering.2 Patients with functional disorders typically pass cognitive tests of effort,3 and there is no epidemiological evidence to suggest that they seek time away from the workplace. Functional disorders are typically persistent and commonly coexist with, or are triggered by, minor pathophysiological or psychophysiological processes. In many functional neurological disorders, initial sensory discomfort together with anxiety and heightened attention trigger maladaptive processes that lead to persistent symptoms. For example, persistent postural perceptual dizziness usually has a vestibular trigger. Acoustic shock,4 described in professional telephone operators, is triggered by an unexpected loud noise and includes persistent ear pain, headache, tinnitus, dizziness, imbalance, noise sensitivity, and anxiety at similar frequencies to the Cuban cohort. Long duration suggests nothing about etiology.
Stone J, Popkirov S, Carson AJ. Neurological Symptoms in US Government Personnel in Cuba. JAMA. 2018;320(6):602–603. doi:10.1001/jama.2018.8706
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