Functional: The Word that Works
These words were repeated over and over during my rotation in Medicine. To me, they seemed arrogant, chauvinistic and somewhat aloof and unsympathetic to a group that was experiencing genuine health symptoms deserving care, whether of a psychological or physical nature as yet undetermined, and yet regarded as psychiatric. And that became my motivation enough to delve into the depths of the word “functional”.
By definition, “functional” means “of or relating to a function”. That in itself is somewhat explanatory. Going towards the medical definition of the word, functional refers to a pathology that affects the function or bodily processes but not the structure. Hence if the structure is unaffected, there must be no pathology, and most likely the patient’s symptoms are either fictional, created to attract attention or fulfill a purpose, often referred to as “malingering” or a figment of the patient’s own imagination with no correlation to an actual disease process.
This is the general perception among physicians. The entity of functional disorders is very real. Any group of symptoms that are poorly understood or don’t tidily fit into a diagnosis are classified as functional and often regarded as undeserving of treatment, or at the most, receive symptomatic treatment. However this fails to explore the cause.
At one point in time, diseases such as epilepsy, migraine and schizophrenia were also regarded as functional, only due to the gap that was created as a lack of knowledge, and later on refuted as that when physiological evidence became available. This is a clear indication that excluding malingerers, the rest of the patients have real health issues and deserve genuine concern. Perhaps detective work eliciting a complete and proper history, viewing the patient as a whole individual to find a clue towards the nature of the etiology or discover a pattern as groundwork for further research on their symptoms.
Take tuberculosis for example. In the 18th century, it was believed that a “consumption of the lungs” could be expected in people with a tubercular personality; young, witty and precocious with a cheerful and restless disposition. Today we know the cause is far from a personality type but rather Mycobacterium Tuberculosis.
Gastric ulcers, throughout history were accepted as a consequence of psychological stress, and finally explained to be caused majorly by infection with Helicobacter Pylori. Fibromyalgia, a disorder that is characterized by chronic widespread pain, is associated with psychological stress. Despite there being a functional and structural change in the brains of patients who have it, as well as changes at the genetic level, there being no conclusive evidence as yet to the cause except response to anti-depressants and cognitive behavioural therapy, this abnormality of pain perception is largely treated symptomatically.
Irritable bowel syndrome, very commonly encountered condition and believed to be due to hyperactivity of the autonomic nervous system, is a diagnosis of exclusion, and yet for a number of symptoms that basically defied explanation. What all these “functional” disorders have in common denotes the gender bias in our society that dates back to ancient times. Indeed, these disorders are considered far more common in females.
In ancient Greece, the term “hysteria” was brought forth by the father of medicine, Hippocrates, himself. He described hysteria as a condition in which the uterus dried up and wandered the body in search of moisture, and depending which organ the uterus would press upon, symptoms would be caused pertaining to that. This definition underwent various transformations during the centuries. Today we know how illogical, infact ridiculous the initial explanation was, and yet the concept of “conversion disorder” is widely accepted.
Hysteria was renamed officially as Conversion disorder in the 1980s on the hypothesis that patients convert their subconscious anxieties into physical symptoms. Conversion disorder is characterized by a loss of neurological function in the absence of organic disease. To me, it sounds more of a cover-up of modern medicine for a baffling group of symptoms that defy explanation by a single diagnosis.
Conversion disorder belongs to a larger group of disorders known as Somatoform disorders. Somatoform disorders include somatization disorder, conversion disorder, hypochondriasis, somatoform pain disorder, chronic fatigue syndrome and body dysmorphic disorder. Somatization disorder is characterized by multiple, chronic somatoform symptoms, such as pain, vomiting, nausea, sexual dysfunction etc. without any physical cause.
Hypochondriasis is the fear of having a fatal disease. Somatoform pain disorder is a disorder characterized by severe, prolonged pain with no known cause. Chronic fatigue syndrome can be defined as excessive fatigue after minimal physical or mental exertion. Body dysmorphic disorder is the belief that one’s body is deformed in some way.
These disorders are basically not explained by a medical condition, and they have a strong association with anxiety and depression. Hence these disorders are treated on general measures with anti-depressants and cognitive behavioural therapy. Since medically unexplained symptoms are due to an absence of evidence, and not an evidence of absence, therefore they should not be trivialized by being labelled as “functional”.
This brings forth a challenge for the physicians. Whilst giving importance to functional symptoms, evaluation for the number of investigations and amount of treatment to be given is must; we need neither over-treat nor under-treat the patients. Likewise, if a cause cannot be found, unnecessary investigations need to be limited. Most importantly, before introducing the stigmata of a psychiatric condition into the patient’s knowledge and convincing them to believe that they are responsible for their own ailments, or worse, disregarding their symptoms as any ailment at all, it is important to give them possible explanations for their symptoms, to have a good patient-doctor relationship and offer counselling for any psychological issues that the patient might have, without losing the vision that there might be some among these very patients with definitive causes for their symptoms that have nothing to do with somatoform disorders.
About the Author: Madiha Viqar Usmani is a House Officer at Civil Hospital, Karachi, Pakistan. She graduated from Dow Medical College in 2013 and can be reached at [email protected]
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