Functional Disorder
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‘Functional disorder’ is an umbrella term for a group of recognisable
medical conditions A disease is a particular abnormal condition that negatively affects the structure or function of all or part of an organism, and that is not immediately due to any external injury. Diseases are often known to be medical conditions that a ...
which are due to changes to the functioning of the systems of the body rather than due to a disease affecting the structure of the body. Functional disorders are common and complex phenomena that pose challenges to medical systems. Traditionally in western medicine, the body is thought of as consisting of different
organ system An organ system is a biological system consisting of a group of organs that work together to perform one or more functions. Each organ has a specialized role in a plant or animal body, and is made up of distinct tissues. Plants Plants have ...
s, but it is less well understood how the systems interconnect or communicate. Functional disorders can affect the interplay of several organ systems (for example gastrointestinal, respiratory, musculoskeletal or neurological) leading to multiple and variable symptoms. Less commonly there is a single prominent symptom or organ system affected. Most
symptoms Signs and symptoms are the observed or detectable signs, and experienced symptoms of an disease, illness, injury, or condition. A sign for example may be a higher or lower temperature than normal, raised or lowered blood pressure or an abnormali ...
that are caused by structural disease can also be caused by a functional disorder. Because of this, individuals often undergo many medical investigations before the
diagnosis Diagnosis is the identification of the nature and cause of a certain phenomenon. Diagnosis is used in many different disciplines, with variations in the use of logic, analytics, and experience, to determine " cause and effect". In systems engin ...
is clear. Though research is growing to support explanatory models of functional disorders, structural scans such as
MRIs Magnetic resonance imaging (MRI) is a medical imaging technique used in radiology to form pictures of the anatomy and the physiological processes of the body. MRI scanners use strong magnetic fields, magnetic field gradients, and radio wa ...
, or laboratory investigation such as
blood test A blood test is a laboratory analysis performed on a blood sample that is usually extracted from a vein in the arm using a hypodermic needle, or via fingerprick. Multiple tests for specific blood components, such as a glucose test or a cholester ...
s do not usually explain the symptoms or the symptom burden. This difficulty in 'seeing' the processes underlying the symptoms of functional disorders has often resulted in these conditions being misunderstood and sometimes stigmatised within medicine and society. Despite being associated with high disability, functional symptoms are not a threat to life, and are considered modifiable with appropriate treatment.


Definition

Functional disorders are mostly understood as conditions characterised by: * persistent and troublesome symptoms * associated with impairment or disability * where the pathophysiological basis is related to problems with the functioning and communication of the body systems (as opposed to disease affecting the structure of organs or tissues)


Examples

There are many different functional disorder
diagnoses Diagnosis is the identification of the nature and cause of a certain phenomenon. Diagnosis is used in many different disciplines, with variations in the use of logic, analytics, and experience, to determine "cause and effect". In systems enginee ...
that might be given depending on the
symptom Signs and symptoms are the observed or detectable signs, and experienced symptoms of an illness, injury, or condition. A sign for example may be a higher or lower temperature than normal, raised or lowered blood pressure or an abnormality showin ...
or
syndrome A syndrome is a set of medical signs and symptoms which are correlated with each other and often associated with a particular disease or disorder. The word derives from the Greek σύνδρομον, meaning "concurrence". When a syndrome is paired ...
that is most troublesome. There are many examples of symptoms that individuals may experience, some of these include persistent or recurrent pain, fatigue, weakness, shortness of breath or bowel problems. Single symptoms may be assigned a diagnostic label, for example “functional chest pain”, “functional constipation” or “functional seizures”. Characteristic collections of symptoms might be described as one of the Functional Somatic Syndromes. A
syndrome A syndrome is a set of medical signs and symptoms which are correlated with each other and often associated with a particular disease or disorder. The word derives from the Greek σύνδρομον, meaning "concurrence". When a syndrome is paired ...
is a collection of symptoms. Somatic means ‘of the body’. Examples of functional somatic syndromes include;
Irritable Bowel Syndrome Irritable bowel syndrome (IBS) is a "disorder of gut-brain interaction" characterized by a group of symptoms that commonly include abdominal pain and or abdominal bloating and changes in the consistency of bowel movements. These symptoms may ...
, Cyclic vomiting syndrome, Some persistent
fatigue Fatigue describes a state of tiredness that does not resolve with rest or sleep. In general usage, fatigue is synonymous with extreme tiredness or exhaustion that normally follows prolonged physical or mental activity. When it does not resolve ...
and
Chronic Pain Chronic pain is classified as pain that lasts longer than three to six months. In medicine, the distinction between Acute (medicine), acute and Chronic condition, chronic pain is sometimes determined by the amount of time since onset. Two commonly ...
syndromes, such as
Fibromyalgia Fibromyalgia (FM) is a medical condition defined by the presence of chronic widespread pain, fatigue, waking unrefreshed, cognitive symptoms, lower abdominal pain or cramps, and depression. Other symptoms include insomnia and a general hyp ...
(Chronic Widespread Pain), or
Chronic pelvic pain Pelvic pain is pain in the area of the pelvis. Acute pain is more common than chronic pain. If the pain lasts for more than six months, it is deemed to be chronic pelvic pain. It can affect both the male and female pelvis. Common causes in inclu ...
. Other examples include
Interstitial cystitis Interstitial cystitis (IC), a type of bladder pain syndrome (BPS), is chronic pain in the bladder and pelvic floor of unknown cause. It is the urologic chronic pelvic pain syndrome of women. Symptoms include feeling the need to urinate right aw ...
(Urology) and Functional Neurological Disorder (Neurology), and
Multiple Chemical Sensitivity Multiple chemical sensitivity (MCS), also known as idiopathic environmental intolerances (IEI), is an unrecognized and controversial diagnosis characterized by chronic symptoms attributed to exposure to low levels of commonly used chemicals. Sym ...
(Allergy Medicine).


Overlap

Most
medical specialties A medical specialty is a branch of medical practice that is focused on a defined group of patients, diseases, skills, or philosophy. Examples include those branches of medicine that deal exclusively with children (paediatrics), cancer (oncology), ...
define their own functional somatic syndrome, and a patient may end up with several of these diagnoses without understanding how they are connected. There is overlap in symptoms between all the functional disorder diagnoses. For example, it is not uncommon to have a diagnosis of irritable bowel syndrome (IBS) and chronic widespread pain/fibromyalgia. All functional disorders share risk factors and factors that contribute to their persistence. Increasingly researchers and clinicians are recognising the relationships between these syndromes.


Terminology and classification

The terminology for functional disorders has been fraught with confusion and controversy, with many different terms used to describe them. Sometimes functional disorders are equated or mistakenly confused with diagnoses like category of “somatoform disorders”, “medically unexplained symptoms”, “psychogenic symptoms” or “conversion disorders”. Many historical terms are now no longer thought of as accurate, and are considered by many to be stigmatising. Psychiatric illnesses have historically also been considered as functional disorders in some classification systems, as they often fulfil the criteria above. From now on, this article refers primarily to functional somatic disorders in which the primary troubling symptoms are generally understood as related to the body. Whether a given medical condition is termed a functional disorder depends in part on the state of knowledge. Some diseases, such as
epilepsy Epilepsy is a group of non-communicable neurological disorders characterized by recurrent epileptic seizures. Epileptic seizures can vary from brief and nearly undetectable periods to long periods of vigorous shaking due to abnormal electrical ...
, were historically catagorized as functional disorders but are no longer classified that way.


Prevalance

Functional disorders can affect individuals of all ages, ethnic groups and socioeconomic backgrounds. In clinical populations, functional disorders are common and have been found to present in around one-third of consultations in both specialist practice and primary care. Chronic courses of disorders are common and are associated with high disability, health-care usage and social costs. Rates differ in the clinical population compared with the general population, and will vary depending on the criteria used to make the diagnosis. For example, irritable bowel syndrome is thought to affect 4.1%, and fibromyalgia 0.2-11.4% of the global population. A recent large study carried out on population samples in Denmark showed the following: In total, 16.3% of adults reported symptoms fulfilling the criteria for at least one Functional Somatic Syndrome, and 16.1% fulfilled criteria for Bodily Distress Syndrome.


Diagnosis

The
diagnosis Diagnosis is the identification of the nature and cause of a certain phenomenon. Diagnosis is used in many different disciplines, with variations in the use of logic, analytics, and experience, to determine " cause and effect". In systems engin ...
of the functional disorder(s) is usually made in the healthcare setting most often by a doctor - this could be a primary care physician or family doctor, hospital physician or specialist in the area of
psychosomatic medicine Psychosomatic medicine is an interdisciplinary medical field exploring the relationships among social, psychological, behavioral factors on bodily processes and quality of life in humans and animals. The academic forebear of the modern field of ...
or a consultant-liaison psychiatrist. The primary care physician or family doctor will generally play an important role in coordinating treatment with a
secondary care Health care or healthcare is the improvement of health via the prevention, diagnosis, treatment, amelioration or cure of disease, illness, injury, and other physical and mental impairments in people. Health care is delivered by health profe ...
clinician if necessary. The diagnosis is essentially clinical, whereby the clinician undertakes a thorough medical and mental health history and physical examination. Diagnosis should be based on the nature of the presenting symptoms, and is a “rule in” as opposed to “rule out” diagnosis - this means it is based on the presence of positive symptoms and signs that follow a characteristic pattern. There is usually a process of clinical reasoning to reach this point and assessment might require several visits, ideally with the same doctor. In the clinical setting, there are no laboratory or imaging tests that can consistently be used to diagnose the condition(s); however, as is the case with all diagnoses, often additional diagnostic tests (such as blood tests, or diagnostic imaging) will be undertaken to consider the presence of underlying disease. There are however diagnostic criteria that can be used to help a doctor assess whether an individual is likely to suffer from a particular functional syndrome. These are usually based on the presence or absence of characteristic clinical signs and symptoms. Self-report questionnaires may also be used/helpful. There has been a tradition of a separate diagnostic classification systems for 'somatic' and 'mental' disorder classifications. Currently, the 11th version of the International Classification System of Diseases (
ICD-11 The ICD-11 is the eleventh revision of the International Classification of Diseases (ICD). It replaces the ICD-10 as the global standard for recording health information and causes of death. The ICD is developed and annually updated by the World H ...
) has specific diagnostic criteria for certain disorders which would be considered by many clinicians to be functional somatic disorders, such as IBS or chronic widespread pain/fibromyalgia, and dissociative neurological symptom disorder. In the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (
DSM-5 The ''Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition'' (DSM-5), is the 2013 update to the ''Diagnostic and Statistical Manual of Mental Disorders'', the taxonomic and diagnostic tool published by the American Psychiatric ...
) the older term “somatoform” (DSM-IV) has been replaced by “
somatic symptom disorder A somatic symptom disorder, formerly known as a somatoform disorder,(2013) dsm5.org. Retrieved April 8, 2014. is any mental disorder that manifests as physical symptoms that suggest illness or injury, but cannot be explained fully by a general ...
”, which is a disorder characterised by persistent somatic (physical) symptom(s ), and associated psychological problems to the degree that it interferes with daily functioning and causes distress. (APA, 2022). Bodily distress disorder is a related term in the ICD-11.
Somatic symptom disorder A somatic symptom disorder, formerly known as a somatoform disorder,(2013) dsm5.org. Retrieved April 8, 2014. is any mental disorder that manifests as physical symptoms that suggest illness or injury, but cannot be explained fully by a general ...
and bodily distress disorder have significant overlap with functional disorders and are often assigned if someone would benefit from psychological therapies addressing psychological or behavioural factors which contribute to the persistence of symptoms. Note however that people with symptoms partly explained by structural disease (for example cancer) may also meet the criteria for diagnosis of functional disorders, somatic symptom disorder and bodily distress disorder. It is not unusual for a functional disorder to coexist with another diagnosis (for example functional seizures can coexist with Epilepsy, or Irritable Bowel Syndrome with Inflammatory Bowel Disease. This is important to recognise as additional treatment approaches might be indicated in order that the patient achieves adequate relief from their symptoms.   The diagnostic process is considered an important step in order for treatment to move forward successfully. When healthcare professionals are giving a diagnosis and carrying out treatment, it is important to communicate openly and honestly and not to fall into the trap of dualistic concepts – that is “either mental or physical” thinking; or attempt to “reattribute” symptoms to a predominantly psychosocial cause. It often important to recognise the need to cease unnecessary additional diagnostic testing if a clear diagnosis has been established .


Causes

Explanatory models that support our understanding of functional disorders take into account the multiple factors involved in symptom development. A personalised, tailored approach is usually needed in order to consider the factors which relate to that individual’s biomedical, psychological, social, and material environment. Healthcare professionals might find it useful to consider three main categories of factors: predisposing, precipitating, and perpetuating (maintaining) factors.


Predisposing factors

These are factors that make the person more vulnerable to the onset of a functional disorder; and include biological, psychological and social factors. Like all health conditions, some people are probably predisposed to develop functional disorders due to their genetic make-up. However, no single genes have been identified that are associated with functional disorders. Epigenetic mechanisms (mechanisms that affect interaction of genes with their environment) are likely to be important, and have been studied in relation to the Hypothalamic-Pituitary-Adrenal Axis. Other predisposing factors include current or prior somatic/physical illness or injury, and endocrine, immunological or microbial factors. Functional disorders are diagnosed more frequently in female patients. The reasons for this are complex and multifactorial, likely to include both biological and social factors. Female sex hormones might affect the functioning of the immune system for example. Medical bias possibly contributes to the sex differences in diagnosis: women are more likely to be diagnosed than men with a functional disorder by doctors. People with functional disorders also have higher rates of pre-existing mental and physical health conditions, including depression and anxiety disorders, Post-Traumatic Stress Disorder, Multiple Sclerosis and Epilepsy. Personality style has been suggested as a risk factor in the development of functional disorders but the effect of any individual personality trait is variable and weak. Alexithymia (difficulties recognising and naming emotions) has been widely studied in patients with functional disorders and is sometimes addressed as part of treatment. Migration, cultural and family understanding of illness, are also factors that influence the chance of an individual developing a functional disorder. Being exposed to illness in the family when you are growing up or having parents who are healthcare professionals are sometimes considered risk factors. Adverse childhood experiences and traumatic experiences of all kinds are known important risk factors.


Precipitating factors

These are the factors that for some patients appear to trigger the onset of a functional disorder. Typically, these involve either an acute cause of physical or emotional stress, for example an operation, a viral illness, a car accident, a sudden bereavement, or a period of intense and prolonged overload of chronic stressors (for example relationship difficulties, job or financial stress, or caring responsibilities). Not all affected individuals will be able to identify obvious precipitating factors and some functional disorders develop gradually over time.  


Perpetuating factors

These are the factors that contribute to the development of functional disorder as a persistent condition and maintaining symptoms. These can include the condition of the physiological systems including the
immune In biology, immunity is the capability of multicellular organisms to resist harmful microorganisms. Immunity involves both specific and nonspecific components. The nonspecific components act as barriers or eliminators of a wide range of pathogens ...
and neuroimmune systems, the endocrine system, the
musculoskeletal The human musculoskeletal system (also known as the human locomotor system, and previously the activity system) is an organ system that gives humans the ability to move using their muscular and skeletal systems. The musculoskeletal system prov ...
system, the
sleep-wake cycle A circadian rhythm (), or circadian cycle, is a natural, internal process that regulates the sleep–wake cycle and repeats roughly every 24 hours. It can refer to any process that originates within an organism (i.e., endogenous) and responds to ...
, the brain and
nervous system In biology, the nervous system is the highly complex part of an animal that coordinates its actions and sensory information by transmitting signals to and from different parts of its body. The nervous system detects environmental changes th ...
, the person’s thoughts and experience, his/her experience of the body,
social situation Social organisms, including human(s), live collectively in interacting populations. This interaction is considered social whether they are aware of it or not, and whether the exchange is voluntary or not. Etymology The word "social" derives from ...
and environment.  All these layers interact with each other. Illness mechanisms are important therapeutically as they are seen as potential targets of treatment. The exact illness mechanisms that are responsible for maintaining an individual’s functional disorder should be considered on an individual basis. However, various models have been suggested to account for how symptoms develop and continue. For some people there seems to be a process of central-sensitisation, chronic low grade inflammation or altered stress reactivity mediated through the hypothalamic-pituitary-adrenal (HPA) axis (Fischer et al., 2022). For some people attentional mechanisms are likely to be important. Commonly, illness-perceptions or behaviours and expectations (Henningsen, Van den Bergh et al. 2018 ) contribute to maintaining an impaired physiological condition. Perpetuating illness mechanisms are often conceptualized as ‘vicious cycles’, which highlights the non-linear patterns of causality characteristic of these disorders. Other people adopt a pattern of trying to achieve a lot on ‘good days’ which results in exhaustion for days following and a flare up of symptoms, (sometimes called ‘Boom-Bust’), which has led to various energy management tools being used the patient community such as 'spooning'. Depression, PTSD, Sleep Disorders, and Anxiety Disorders can also perpetuate functional disorders and should be identified and treated where they are present. Side effects or withdrawal effects of medication often need to be considered. Iatrogenic factors such as lack of a clear diagnosis, not feeling believed or not taken seriously by a healthcare professional, multiple (invasive) diagnostic procedures, ineffective treatments and not getting an explanation for symptoms can increase worry and unhelpful illness behaviours. Stigmatising medical attitudes and unnecessary medical interventions (tests, surgeries or drugs) can also cause harm and worsen symptoms.


Treatment

Functional disorders can be treated successfully and are considered reversible conditions. Treatment strategies should integrate biological, psychological and social perspectives. The body of research around evidence-based treatment in functional disorders is growing. With regard to self-management, there are many basic things that can be done to optimise recovery. Learning about and understanding the condition is helpful in itself. Many people are able to use bodily complaints as a signal to slow down and reassess their balance between exertion and recovery. Bodily complaints can be used as a signal to begin incorporating stress reduction and balanced lifestyle measures (routine, regular activity and relaxation, diet, social engagement) that can help reduce symptoms and are central to improving quality of life. Mindfulness practice can be helpful for some people. Family members or friends can also be helpful in supporting recovery. Most affected people benefit from support and encouragement in this process, ideally through a multi-disciplinary team with expertise in treating functional disorders. Family members or friends may also be helpful in supporting recovery. The aim of treatment overall is to first create the conditions necessary for recovery, and then plan a programme of rehabilitation to re-train mind-body connections making use of the body’s ability to change. Particular strategies can be taught to manage bowel symptoms, pain or seizures. Though medication alone should not be considered curative in functional disorders, medication to reduce symptoms might be indicated in some instances, for example where mood or pain is a significant issue, preventing adequate engagement in rehabilitation. It is important to address accompanying factors such as sleep disorders, pain, depression and anxiety, and concentration difficulties. Physiotherapy may be relevant for exercise and activation programs, or when weakness or pain is a problem. Psychotherapy might be helpful to explore a pattern of thoughts, actions and behaviours that could be driving a negative cycle – for example tackling illness expectations or preoccupations about symptoms. Some existing evidence-based treatments include Cognitive Behavioural Therapy (CBT) for Functional Neurological Disorder; and dietary modification or gut targeting agents for Irritable Bowel Syndrome. For some patients, especially those who have lived with a functional disorder for many years, realistic treatment includes a focus on management of symptoms and improvements in quality of life. Acceptance of symptoms and the limitations they cause can be important in these situations, and most people are able to see some improvement in their condition. Supportive relationships with the healthcare team are key to this.  


Controversies/stigma

Despite some progress in the last decade, people with functional disorders continue to suffer subtle and overt forms of discrimination by clinicians, researchers and the public. Stigma is a common experience for individuals who present with functional symptoms and is often driven by historical narratives and factual inaccuracies. Given that functional disorders do not usually have specific
biomarker In biomedical contexts, a biomarker, or biological marker, is a measurable indicator of some biological state or condition. Biomarkers are often measured and evaluated using blood, urine, or soft tissues to examine normal biological processes, p ...
s or findings on structural
imaging Imaging is the representation or reproduction of an object's form; especially a visual representation (i.e., the formation of an image). Imaging technology is the application of materials and methods to create, preserve, or duplicate images. ...
that are typically undertaken in routine clinical practice, this leads to potential for symptoms to be misunderstood, invalidated, or dismissed, leading to adverse experiences when individuals are seeking help. Part of this stigma is also driven by theories around “ mind body dualism”, which frequently surfaces as an area of importance for patients, researchers and clinicians in the realm of functional disorders. Artificial separation of the mind/brain/body (for example the use of phrases such as; “physical versus psychological” or “organic versus non-organic”) furthers misunderstanding and misconceptions around these disorders, and only serves to hinder progress in scientific domain and for patients seeking treatment. Some patient groups have fought to have their illnesses not classified as functional disorders, because in some insurance based health-care systems these have attracted lower insurance payments. Current research is moving away from dualistic theories, and recognising the importance of the whole person, both mind and body, in diagnosis and treatment of these conditions. People with functional disorders frequently describe experiences of doubt, blame, and of being seen as less ‘genuine’ than those with other disorders. Some clinicians perceive those individuals with functional disorders are imagining their symptoms, are malingering, or doubt the level of voluntary control they have over their symptoms. As a result, individuals with these disorders often wait long periods of time to be seen by specialists and receive appropriate treatment. Currently, there is a lack of specialised treatment services for functional disorders in many countries. However, research is growing in this area, and it is hoped that the implementation of the increased scientific understanding of functional disorders and their treatment will allow effective clinical services supporting individuals with functional disorders to develop. Patient membership organisations/advocate groups have been instrumental in gaining recognition for individuals with these disorders.


Further research

Directions for research involve understanding more about the processes underlying functional disorders, identifying what leads to symptom persistence and improving integrated care/treatment pathways for patients. Research into the biological mechanisms which underpin functional disorders is ongoing. Understanding how stress effects the body over a lifetime, for example via the immune endocrine and autonomic nervous systems, is important Ying-Chih et.al 2020, Tak et. al. 2011, Nater et al. 2011). Subtle dysfunctions of these systems, for example through low grade chronic inflammation, or dysfunctional breathing patterns, are increasingly thought to underlie functional disorders and their treatment. However, more research is needed before these theoretical mechanisms can be used clinically to guide treatment for an individual patient.


See also

*
Idiopathic disease An idiopathic disease is any disease with an unknown cause or mechanism of apparent spontaneous origin. From Greek ἴδιος ''idios'' "one's own" and πάθος ''pathos'' "suffering", ''idiopathy'' means approximately "a disease of its own kin ...
*
Functional gastrointestinal disorder Functional gastrointestinal disorders (FGID), also known as disorders of gut–brain interaction, include a number of separate idiopathic disorders which affect different parts of the gastrointestinal tract and involve visceral hypersensitivity ...
*
Functional symptom A functional symptom is a medicine, medical symptom with no known physical cause. In other words, there is no structural or pathologically defined disease to explain the symptom. The use of the term 'functional symptom' does not assume Psychogen ...
*
Functional Neurological Disorder A functional neurologic disorder or functional neurological disorder (FND) is a condition in which patients experience neurological symptoms such as weakness, movement disorders, sensory symptoms and blackouts. Symptoms of functional neurological ...
*
Psychosomatic Medicine Psychosomatic medicine is an interdisciplinary medical field exploring the relationships among social, psychological, behavioral factors on bodily processes and quality of life in humans and animals. The academic forebear of the modern field of ...


References

{{DEFAULTSORT:Functional Disorder Diseases and disorders Medical terminology