Functional symptoms in the general medical and surgical setting

A large proportion of foundation training is spent in general specialities, even for those who have the opportunity to do a psychiatry rotation. However, there is plenty of psychiatry involved in general medicine and surgery. In particular, ‘functional’ symptoms are very common, but often overlooked.

What is functional illness?

Functional symptoms are those without identifiable structural cause. They can be likened to a “software” rather than a “hardware” problem in the body. Doctors and patients can be suspicious of the diagnosis as it is often one of exclusion.

Functional symptoms have a lot of labels, reflecting different views of aetiology and with different degrees of stigma attached (table 1).

Table 1: Some disorders that involve functional symptoms

See Reference 1 and 2 for more detailed explanation.

Every speciality looks after patients with functional symptoms (table 2). However, they fall partially into the remit of psychiatry because psychological disturbance can sometimes be a cause or consequence of such disorders, and because psychological therapies can sometimes help.

Table 2: Symptoms which can be functional and are commonly encountered in foundation years

It is important to remember that all of these symptoms can also be structural in origin.

How can we help patients with functional symptoms?

Often the most helpful thing we can do for functional symptoms is to recognise them as such. This can be hard to do as inexperienced doctors. However, most illnesses have a functional component to them, even if they started off as structural, and it is rarely harmful to sensitively explore this possibility. Doing so may avoid potentially harmful investigations and greatly empower the patient. Consider the cases below.

Case 1: General surgery. You are just starting a night shift and are asked to see an angry patient on the wards who has presented with abdominal pain for the fourth time in nine months and wants to know when her operation will be. Your review her radiology investigations and note two normal CT abdomens in the last year. Her medical notes give a working diagnosis of non-specific abdominal pain and suggest no plan for surgery. When you talk with her she demands to know how the pain can go away without an operation.

Case 2: General medicine. You are asked to write a discharge letter for a man who has presented with monocular visual loss. He has had a normal CT head, and a thorough review by ophthalmology found normal visual acuity and visual fields in both eyes, despite ongoing subjective visual impairment. He has had several presentations with neurological symptoms  over the last ten years and receives outpatient neurological follow-up who has diagnosed functional neurological symptoms. When you check his discharge medications with him, he asks you what his diagnosis is.

As foundation doctors, we often find ourselves in such situations. Patients who do not have a structurally identifiable disease may be less likely to have had the opportunity to discuss their diagnosis and management with a senior doctor. A careful explanation of the concept of functional symptoms and the limitations of what can be expected from surgical and pharmacological management has the potential to be very helpful.

If someone is very disabled by their symptoms, or the symptoms are long-standing, they may benefit from input from other disciplines and specialities. For example, the chronic pain team in case 1, or a neuropsychiatrist with an interest in functional neurology for case 2. Depending on the patient’s treatment preferences and the likely presence of any comorbid mood disorder, referral to a psychologist or a liaison psychiatrist might also help.

In summary, many symptoms causing acute hospital admission can be wholly or partially functional. Caring for patients as a foundation doctor brings us into frequent contact with functional symptoms and explanations are often left to junior staff. Exploring functional symptoms with patients can be a difficult communication skill to master, but is very worthwhile. Whether or not you are interested in psychiatry, developing the skills to manage functional symptoms will benefit you and your patients.

Further Reading/References

1. The bare essentials: Functional symptoms in neurology. Stone J. Practical Neurology. 2009 Jun; 9(3):179-89. A very clear review article about functional neurology.

2. Textbook of Psychiatry 2^nd Edition. Puri BK, Laking PJ, Treasaden IH. Churchill Livingstone. Chapter 11 gives a detailed account of the psychiatric diagnoses related to functional illness. 

3. http://www.neurosymptoms.org/ An excellent website for both doctors and patients (focuses on functional neurological symptoms).

Katie Marwick, Foundation Year Two, South-East Scotland