“Functional Disorders”: One of Medicine’s Biggest Failures | Marion Brown

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From The BMJ: “Richard Smith introduces a thoughtful discussion of ‘Functional Disorders’ 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’:

‘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.”’

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8 COMMENTS

  1. Thank you Marion.

    The problem of misdiagnosed adverse drug reactions to prescription medicines is an area that might have been addressed in greater detail in my own experience of undergraduate medical training and perhaps this was limited in depth and detail in a lifetime of continuing medical education during forty years of medical practice. Perhaps there is a greater awareness developing now?

    I have witnessed the misdiagnosis of SSRI/SNRI/AD induced AKATHISIA as ‘Serious Mental Illness”: leading to inappropriate detention and forced, unnecessary psychotropic poly-drugging with apparent prescriber-inability to recognise and react to a cascade of serious (and/or life-threatening) adverse drug reactions (ADRs) and withdrawal syndromes.

    The resulting multi-systems morbidity may last for years, even for life, and becomes vulnerable to the future label of “Functional Disorder”, “Medically Unexplained Symptoms” (MUS) – or even further alleged ‘psychiatric disorder’.

    The perceived physician-rejection of such disabling prescription-drug injuries adds to the isolation and heartache endured by the ‘heart sink patient’.

    What about the heart sink prescriber?

    Discussing ADRs such as AKATHISIA and PSSD, (et al) as a vital part of achieving fair, full and informed consent in prescribing, might reduce avoidable suffering and decrease the perplexing problem of ‘MUS’?
    I recognise that it would be challenging to try to achieve this during a 10 – 15 minute consultation.

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  2. I haven’t read the book reviewed in the refered letter, pointed from this post to it’s reply. But:

    A medical complaint, even a set of them is not a medical problem.

    Im me old days the textbooks taught, I’m getting all mystical, that many medical complaints, i.e. signs and sypmtoms, as: diarrhea, headaches, neck pain, lumbar pain, heartburn, reflux, tinnitus, dizzyness, and some others, actually occured in healthy people in surprising frequency.

    And they also taught, that many improved on their own, rarely became a “disease”, and indirectly, that treating them, as mere signs and symptoms, was more harm than good. Just the thought a real disease came up after several years of wrong treatment! and now it’s deadly!. Beyond the treatment risks/complications.

    For me, back then, unless after carefull review there was enough suspicion to warrant another intervention, best was to explain the frequency of symptoms in normal people.

    If asked what else could be, or bring it if there was a “risky”, albeit infrequent, sometimes even a frequent one, disease that could be investigated, then discuss which diseases could present themselves like that, in order of probability. Stressing that those are the most likely.

    And claim that most likely is not a disease, and if there is still a concern, then suggest things to look for if the disease would seem to appear. And what now and then, diagnostically could be done.

    With the caveat that doing that now, had false positives, false negatives, and expense. And some anxiety, depending.

    The only patients I remember ever asking treatment were people with migraine. And second line treatment for migraine was dangerous back then, it could cause a stroke and/or brain bleeding.

    To put an example: I might have said that given the age, gender, medical stuff, there is less than 1-5% chance there is one of the most frequent diseases that could present like that. Now, this one might be serious. Unfortunately, doing now some tests to diagnose it, probably will pick something that is not the disease. And that could lead to treatment, which is this, and this treatment can cause, blah, blah, blah. So, what do YOU want us to do?.

    Put like that it’s to me no wonder almost no one asked neither for treatment, nor for further tests. And they asked it for almost everything else. Similar routine though. No apparent disease is also a diagnosis, I filled those pieces of papers a lot for work, sports and schools, at the request of the patient of course.

    I’ve read lawsuits are a driver of testing, lack of time in the office with each patient too.

    But what I read in the original letter, seems more like “medical education” or “medical culture”.

    And at the beginning does refer that becoming a functional disordered patient, pun intended, is constructed: the patient learns to be diseased, and the “society” teaches how to be diseased.

    Worrisome is that Ms. O’Sullivan says she is worried about the harm she could bring patients, but apparently, apparently, she still moves in the mainstream.

    One caveat, Ms. O’Sullivan is a neurologist, so she likely sees patients refered to her, mostly I guess, and those patients are filtered, usually. So her patient population is different, way different, than mine was decades ago.

    Without intruding, for me, outside neurology, as a former practitioner in diagnostic medicine to whom patients were refered to, was the same dynamic, but many/some patients might have something below the “diagnostic horizon”, that is, with a disease of enough severity, that now, cannot be diagnosed. Now in the “stage” of the disease, or now as we have no sensitive/specific enough test. Even if it causes symptoms now.

    And her patients probably have more severe complaints that mine, as GP and as go to doc for limited diagnostic intervention. So the pressure on her might be more, at least because she has definitively to do better than a GP.

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  3. As an example of a disease previously hard or impossible to diagnose, still now for some, with lots of symptoms, simplifying, is this artcile:

    https://www.nytimes.com/2023/10/04/magazine/esophagitis-allergic-inflammation.html

    And yeah, more than 30yrs ago someone with eosinophilic esophagitis might have had it for decades before being diagnosed. There are people with it without “feline oesopahgus”, some have it and don’t meet biopsy criteria, etc.

    So, symptoms and signs could be a disease, could be not, could be in the future, etc. Not complex, but complicated.

    But the linked article does go to the “learned disease” hypothesis in vivid detail. And reading that, if there is no other interest, could save from buying the book. Not encouraging nor discouraging.

    And the NYTimes does have a column I think called “Can you guess the diagnosis?”. That might exemplify what might be in the refered book by Ms. O’Sullivan.

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  4. Of interest:
    “One of the world’s foremost experts on the problems with MUS is the philosopher and bioethicist Diane O’Leary. Studies of MUS put its prevalence at anywhere between 10 and 86 percent of outpatient visits; O’Leary splits the difference at 50 percent, still a remarkably high number.
    So how are these enormous numbers of patients viewed by clinicians? In a scholarly article, O’Leary gives the example of a hypothetical general practitioner who looks up the term in Macleod’s 2013 Clinical Examination Handbook and finds the following entry: “MUS cause similar levels of disability to those resulting from disease and are often associated with emotional distress. ”
    The implication here is that MUS do not result from disease, and therefore their explanation must be psychosocial—an implication consistent, O’Leary notes, with the classification of MUS as “psychiatric” in the Oxford Textbook of Medicine.

    “In medicine, the leap between ‘doctor doesn’t know’ and ‘problem is in the mind’ is instant,” O’Leary told me. “They are the same thing.”
    The medical literature offers endless evidence to support her assertion. Last May, for instance, while COVID long haulers were struggling with dismissive doctors, a case report was published with the title “Medically Unexplained Symptoms in the Times of COVID-19 Pandemic.” The authors proceed by assuming MUS means psychosocial, and caution that “extreme anxiety reactions to COVID-19 may elicit unexplained medical symptoms in predisposed individuals.”
    Source: The Medical System Should Have Been Prepared for Long COVID. Alan Levinovitz. March 18/21. Vice – https://www.vice.com/en/article/qjpywp/the-medical-system-should-have-been-prepared-for-long-haul-covid-patients-symptoms

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  5. Picked up GERD, was attributed to ‘anxiety.’ Got nexium, which didn’t fix the problem and which I couldn’t get off of. Later on got discoid lupus from being on nexium and Mynocycline, which no doctor told me both increase the risk of discoid lupus, and which increase the risk that discoid lupus becomes systemic. Once I got sleep apnea treated GERD went away. Must be that cpap cured my ‘anxiety’ which cured my GERD, right? Or they just didn’t know so they told me it was in my head. Anyway, got off the nexium, but the withdrawal was the worst thing I’ve ever experienced. Admittedly I’ve been addicted to hard substances, and this withdrawal was worse. A month of what felt like the flu, completely disoriented, witn rebound reflux that felt like my whole body was on fire. If I was working I’d never have been able to do it. Something is pretty wrong with this system. Nobody was even telling me about the med risk of the cocktail I had to find out on my own.

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    • I agree there is no limit in one’s life.

      But for explaining and doing experiments, the psychological, the sociological, the psychiatrical, and let alone any mix of them, provide no rationality.

      They have no theory, as in beyond doubt, as necessarily true, as always true, to do logical arguments to make hypothesis that predict the results of experiments.

      They lack explanatory power, and therefore predicting power for empirical research. That’s why they are called humanities, not sciences.

      An experiment might become the extension of an argument starting with a false premise, that sometimes gives positive experimental results, and sometimes negative experimental results. Sounds familiar?.

      No amount of experimentation can overcome faulty logic, bad logic. Let alone that which starts from false premises. Circular logic is just one form of that kind of fallacy. Reductio, not a fallacy, is another, but they are not the only ones.

      The same as logical arguments DO when at least ONE false premise is used. Experiments just extend that faulty, useless, counterproductive logic into the pseudoscientific camp. Sounds familiar?.

      So lacking theoretical basis, they RATIONALY provide no positive benefit beyond physicial.

      Granted, one might feel better with the non-physical, sometimes because physical treatment provides no benefit or is harmfull.

      And generally, but not in each case, that can be explained because the physical treatment is based on empirical research with at least one false premise.

      One false premise as in not necessarily true, not always true and identical in logical terms to false. True is alwas true. Not always true is FALSE. As in not true…

      So I agree with you, but I have my reasons to agree and disagree…

      And sociological research, economic research, psychological research, historical research, were not called scientific because “proper” experiments could not be carried out.

      And the more fundamental reason was because, to carry them out, you have to start to argue, before designing experiments, ONLY from TRUE premises. Otherwise one would be chasing one’s tail thinking it was a positive result.

      But somehow the why empirical scientific research in the humanities was not doable as science got lost.

      Everyone thought, as far as I perceive, it was because the technical part, not the fundamental logical part. As in “we cannot do experiments with the whole economy, or the whole country”.

      No, there was a more fundamental problem of starting by necessarily, always true premises.

      PS: Constructs mean they are not necessarily true and therefore false and one cannot do scientific experiments with that.

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