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To the Editors,
Being a sufferer of Benign Fasciculation Syndrome (BFS) for more than a year, I read with great interest Professor Kiernan’s editorial (1), as well as Dr. Vercueil’s personal account of his encounter with the syndrome (2). I was relieved to see how much the “clinical course” of my case corresponded to that described by Professor Kiernan and Dr. Vercueil. They surfaced during a period of stress and sleep-deprivation, and has since kept going.
As Professor Kiernan writes, anything that increases central excitability can trigger fasciculations. This includes the fear that they form part of a prodrome to motor neuron disease (MND); a defining characteristic of Fasciculation Anxiety Syndrome in Clinicians (FASICS). Even though my diagnosis of BFS have been “confirmed” by an EMG and a neurologist, I still suffer from occasional episodes of FASICS exacerbations, surfacing like a recurrent nightmare according to its own inner logic. In other words, FASICS undoubtedly shares a quality with health anxiety, namely a jumbled relationship between symptoms and belief. The opening lines of H.P Lovecraft’s “The dreams in the witch house” captures this poetically; “Whether the dreams brought on the fever, or the fever brought on the dreams, Walter Gilman did not know”.
After years of working in hospitals you will have encountered some rare cases where the etiology of a disease have followed a non-standard pathway. These can unconsciously skew your wo...
After years of working in hospitals you will have encountered some rare cases where the etiology of a disease have followed a non-standard pathway. These can unconsciously skew your worldview, making you focus on the “non-Gaussian” cases and off-the scale reports. When I first noticed my twitching, I frantically started researching Pubmed and discovered to my horror that there indeed were scattered reports of patients with apparently benign fasciculations progressing to MND (3). Having no background in neurology, I was unable to discern the details and, indeed, how rare these cases actually were. Nevertheless, they became the fuel of my bouts of FASICS. I gazed too long into the abyss and the abyss gazed back into me. I became the case reports.
The protagonist of Lovecraft’s story, Walter Gilman, is a student of non-euclidean geometry. He soon discovers that his rented room is constructed according to outlandish geometrical principles. Would he have noticed this without being knowledgeable in mathematics? His preoccupation with these geometrical patterns propels him into a strange and nightmarish dimension that eventually consumes him. Our background in medicine can sometimes lure us into such parallel dimensions when we misinterpret symptoms in ourselves.
Unlike Walter Gilman, I was not lost in a parallel world. My bouts of FASICS are now rare and short-lived, but it has been a long journey. Enduring such a journey can bring a reward. Like a booty brought back from a nightmare, my FASICS have also become a powerful reminder for me that it is all too easy to fall into the trap of Foucault’s “clinical gaze”, were the patient becomes a process, rather than an individual.
As a clinical pharmacist I often meet patients that are overly worried about adverse effects of drugs. Their anxieties are often caused by a uniformed reading of the package leaflet and internet research. The existence of rare, but dramatic side effects creates an illusory scientific foundation for their fears. When counselling these patients I try to make use of statistics, but now I know that such anxiety transcends the world of figures and a wider cognitive approach should be sought. Exiting a witch house built upon a strange “geometry” of “singularities” can be quite time-consuming.
Studies on long-term outcomes are invaluable in mapping the “Gaussian space” of BFS and FASICS (4, 5), but dealing with a non-Gaussian dimension requires the human touch described by Professor Kiernan, as well as reassuring personal testimonials like Dr. Vercueil’s. This is something other sufferers of FASICS can attest to, for example Dr. Mert Erogul in his excellent Guardian long-read “The perils of being your own doctor”. What finally made him realize he was not on the path to MND was the fact that his own neurologist also suffered from benign fasciculations (6). Being lost in a witch house of case reports, you need the “anti-case reports” to show you the way out.
1. Kiernan MC. Fasciculation anxiety syndrome in clinicians: FASICS. Pract Neurol. 2020;20(6):433-4.
2. Vercueil L. FASICS: fasciculation anxiety syndrome in clinicians. Pract Neurol. 2020;20(6):514-5.
3. Singh V, Gibson J, McLean B, Boggild M, Silver N, White R. Fasciculations and cramps: how benign? Report of four cases progressing to ALS. J Neurol. 2011;258(4):573-8.
4. Blexrud MD, Windebank AJ, Daube JR. Long-term follow-up of 121 patients with benign fasciculations. Ann Neurol. 1993;34(4):622-5.
5. Simon NG, Kiernan MC. Fasciculation anxiety syndrome in clinicians. J Neurol. 2013;260(7):1743-7.
6. Erogul M. The perils of being your own doctor: The Guardian; 2016 [Available from: https://www.theguardian.com/news/2016/aug/04/perils-being-your-own-docto....