“Functional disorders”: one of medicine’s biggest failuresBMJ 2023; 380 doi: https://doi.org/10.1136/bmj.p221 (Published 27 January 2023) Cite this as: BMJ 2023;380:p221
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An excellent and succinct commentary on 'Functional Disorders', one of the challenges in clinical practice where 'ruling out' becomes an extensive and laborious exercise, more so in an era of patient because of the consumer redressal and litigation(s) that may follow. Viewed broadly and wisely, the mind - body relation is inseparable. Unless one makes an obvious and spot diagnosis looking at the appearance, face, gait, movement; unless a wide spectrum - laboratory, imaging assessment is done, 'hypochondriasis' as a diagnosis may be difficult to make. There cannot be any bigger blunder than a ' functional' turning out and emerging to be 'organic', sometimes damaging the reputation so assiduously built. The best approach is therefore, making a 'diagnosis by exclusion' unless anxiety, panicare the only presenting symptoms, observed over sufficient time.
Whether COVID-19 pandemic has added to and aggravated the psychosomatic scenario is a moot question, but the answer is more likely to be in the affirmative; frenetic lifestyles, day-night blurring, 24/7 living linked sleep deprivation and drugs - psychedelics have been known factors before the pandemic. Psychiatrists have helped resolve many problematic situations, and their role deserves to be rightfully acknowledged.
Dr Murar E Yeolekar, Mumbai
Competing interests: No competing interests
Re: “Functional disorders”: one of medicine’s biggest failures
Richard Smith introduces a thoughtful discussion of "Functional Disorders" (1) prompted by reading Suzanne O’Sullivan’s book The Sleeping Beauties: And Other Stories of Mystery Illness:
“About a third of patients attending neurological and gastrointestinal, or almost every outpatient clinic—have functional disorders, meaning that they do not have a physical cause that can be detected with a microscope, scanners, or blood or genetic tests. … When no physical cause is found the patients may be referred to psychiatrists, with at least the implication that the patients have a psychological problem.”
He goes on to explain that O’Sullivan herself worries about this: “Like many Western doctors, I medicalise feelings and behaviour. People come to me so that I will do that for them—give them a medical explanation for their suffering—but, in truth, I worry all the time that what I’m doing, faithful as it is to my training and welcome as it may be to my patients, is wrong and potentially harmful.” And that “She draws a contrast with people with functional disorders exposed to modern medicine. Not only must they undergo many tests and pick up “diagnoses” along the way but they may also become permanent patients. Worse still, the patients may find themselves in battles with the medical establishment.”
O’Sullivan suggests that for recovery community support is needed, including “…a community that can tolerate imperfection and failure, and which has the humility to put aside its vested interests.”
The ‘functional disorders’ discussed have been the focus of my own lay research since, as a psychotherapist, I first encountered the phenomenon of ‘medically unexplained symptoms’ in 2016, and wrote in response to Allen Frances’s 2013 BMJ article ‘The new somatic symptom disorder in DSM-5 risks labelling many people as mentally ill’ (2):
“Something is going horribly wrong when it is becoming apparent that previously healthy patients are being seriously harmed and made very unwell by medicines 'taken as prescribed' - and are then being dismissed/described as troublesome heartsink patients who display “excessive” responses to distressing, chronic, somatic symptoms with associated “dysfunctional thoughts, feelings, or behaviours.””(3)
Subsequently we embarked on our own public petitions – which are formally summarised in this article 2020 “The ‘patient voice’: patients who experience antidepressant withdrawal symptoms are often dismissed, or misdiagnosed with relapse, or a new medical condition” (4)… such as ‘medically unexplained symptoms’ and ‘somatic/functional disorders’.
More recently there has been heated debate about the ‘serotonin theory’ of depression. BJGP journal published my recent letter on the topic (5) “serotonin has multiple effects — on all physiological systems as well as on feelings of overwhelm, hopelessness, and ‘depression’. These effects can include paradoxical suicidality, sexual dysfunction, blunted emotions, digestive problems, fatigue, weird dreams, and compulsions — and other apparently bizarre effects that also affect mood”
As Richard Smith says “Almost any symptom, perhaps every symptom, can result from functional disorder.” (1)
Is this a cop-out for the medical profession? Surely we need to look at what may be CAUSING the mind/body system to malfunction, and sometimes catastrophically? And not miss out the important question of ‘could it be the medicine’? Is ‘medicine’ actually causing a range of ‘functional’ disorders'? This surely needs to be squarely addressed so that appropriate action can be taken to prevent further harm to patients – and indeed doctors who are also patients.
“These are [indeed] patients whom medicine has failed more than almost any other group.”(1)
(1) “Functional disorders”: one of medicine’s biggest failures | The BMJ
(2) The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill | The BMJ
(3) Chillingly accurate prediction: The new somatic symptom disorder in DSM-5 risks mislabeling many people as mentally ill | The BMJ
(4) The ‘patient voice’: patients who experience antidepressant withdrawal symptoms are often dismissed, or misdiagnosed with relapse, or a new medical condition - Anne Guy, Marion Brown, Stevie Lewis, Mark Horowitz, 2020 (sagepub.com)
(5) The serotonin theory of depression and why we use antidepressants | British Journal of General Practice (bjgp.org)
Competing interests: No competing interests