By Dr Attia Anwar
Despite our understanding of the human body and mind, we are unable to understand the root cause of many problems in our medical practice. So any well-defined disease that does not have any organic cause or we are unable to find the cause is called functional disorder. This means there is nothing wrong which can be measured by tests and investigations, available. Everything seems normal on examination and investigation. However, the patient has symptoms that are sometimes very debilitating.
Functional disorders are medical conditions that are due to changes in the function of the body. They do not affect the structure of the body and there are no measurable changes in the body by labs and examination.
Functional disorders are common, but they are difficult to diagnose. As physicians and medical students, we are not enough trained to diagnose them. They are usually called diagnoses of exclusion. This means if you do not find anything wrong in the body system you label them functional disorders. Which annihilates the symptoms and agony the patient is facing. Functional disorders were not present in the medical curriculum till 1970. Traditionally in Western medicine body is thought to be made of organs and systems. The functions of individual organs and systems are very well understood. However, it is less well understood how these systems communicate with each other.
Most symptoms that are caused by functional disorders are also caused by certain diseases. So patient has to undergo intensive investigation before we conclude. Examples of functional disorders are irritable bowel syndrome, cyclic vomiting syndrome, fibromyalgia, chronic pelvic pain, interstitial cystitis, and functional neurological disorders. Despite some progress in this area, physicians are reluctant to diagnose functional disorders, as they are afraid to miss the organic disease. Missing a disease is a problem but over-investigation, treating a patient with the wrong medicine, and delay in proper treatment pose more threats to the health of the patient and are more dangerous.
There are no measurable changes in the body. But after studying the connections of the brain we have real evidence that patients have problems. They are actually feeling the symptoms and are not feigning something. Despite all that research and evidence, people with functional disorders face a subtle and overt form of discrimination from clinicians and the public. Stigma is attached to it. They are thought to be weak, or they are making something up. Behind all this is a traditional concept of mind-body dualism.
A lot of research has been done in this area and it is clear that mind and body work together and affect each other. But it needs more awareness for doctors and the general public. It is also evident that we do not know everything about certain diseases. Maybe, if we study the functions of the brain more or we have more sophisticated tests, we will be able to measure more disorders. As epilepsy was once considered a functional disorder is now regarded as an organic medical condition. So these disorders are not at all less real.
Clinically gender bias affects the management of problems, such as dizziness, fatigue, or pain. Women are less likely to receive appropriate diagnosis, treatment, and follow-ups. Some medical disorders like chronic fatigue syndrome, anorexia nervosa, and migraine are marginalized and considered stereotypically female disorders. These implicit bias on the basis of gender has a profound impact on the management of these disorders. Functional disorders receive similar bias. People with functional disorders wait years to receive treatment. Some studies say that patients waited on average eight years before a diagnosis was made. This road to diagnosis is paved with misunderstandings, worse levels of anxiety, and unnecessary tests and imaging. Delay in diagnosis results in bad long-term outcomes. Undiagnosed patients have long-term effects on their social life. Early diagnosis is associated with improved outcomes.
The stigma around functional disorders comes in many forms. It is a psychiatric problem. A person does not have proper voluntary control which is based on an extreme dualistic model of the mind as a separate thing from the body. Although a lot of progress has been made in this area. Women still continue to describe experiences of doubt, blame, and being seen as less genuine than those who have a disorder with structural pathology.
This is because we have a problematic history in this case. The disorders that we call functional today were historically immersed in prejudice and even punishment. They were depicted as moral failing, demonic possession, hysteria, and witchcraft. Their proposed treatment at that time was uterine repositioning.
One thing that is a bit better from this historical bias is that physicians diagnose these disorders earlier in females as compared to males. Functional disorders are more common in women as compared to men before the age of 50. After the age of 50 incidence of functional disorders is equal to both sexes.
In the past hysteria was the term used for disease in female patients. It was shameful for men to have hysteria. For men by their male doctor’s terms like neurospasm, hypochondria, and shell shock were used. These terms show more respect as compared to hysteria, although symptoms were similar to hysteria.
Term hysteria was removed from medical literature in 1980. Other terminologies like psychosomatic and conversion disorders were used. Now we use the term functional disorders. But against this backdrop of changing terminology, actual progress towards proper recognition and management remained slow.
I will conclude by saying that the history of functional disorders mirrors the history of women in general. It shows inequality, dismissal, and injustice. People with functional disorders do not require pity but proper management. We need to listen to the voices of people with these disorders and take meaningful actions. In the medical curriculum, significant importance should be given to these disorders and their early diagnosis. Clinicians should know that these disorders are not failures, they exist and they should learn to diagnose, manage, and counsel these patients.
“Some women get erased a little at a time, some all at once. Some reappear”. Rebecca Solnut.
The author Dr. Attia Anwar is a consultant family physician with a postgraduate degree from the Royal College of GP UK. She is a strong advocate of health and well-being and wants patient participation in decision-making regarding health.