“The Doctor Said I’m Crazy”

This last week of work, I had a lot of patients with functional disorders, and it has motivated me to help more people in this world understand functional disorders and the people who experience them, which will probably be all of us at one time or another.

First, let’s start with my favourite thing: an exhaustive, mutually exclusive categorization.

I categorize all symptoms into three broad groups: organic, functional, and malingering.

Organic symptoms are caused by the body. For example, if you have a bowel obstruction and your stomach is super distended, that will trigger the nausea receptors in your GI tract, and you will have significant nausea.

Functional symptoms are caused by the mind. These symptoms are felt just as surely as organic symptoms are, it’s just their source is different. For example, if you have a major psychological stressor, it will activate nausea receptors in your cerebral cortex, and you will feel nausea just like if you had a bowel obstruction. The common symptoms of functional disorders that I see all the time are pain (anywhere, but often abdominal pain, chest pain, back pain, headaches), generalized symptoms (fatigue, weakness), psychological symptoms (brain fog, depression, anxiety), GI symptoms (nausea, diarrhea), and neurologic symptoms (altered sensation, focal weakness). Any of those symptoms could come from an organic source or a functional source.

Malingering is straight up lying. The person doesn’t have symptoms, they’re just making them up so they can get something. For example, if someone really likes the high some IV diphenhydramine plus promethazine can give them, they’ll say they have nausea and itching and that the oral versions of those meds don’t work.

I believe malingering is rare. But functional symptoms are very common.

Sometimes symptoms are a mix of organic and functional. And sometimes the symptoms started out as organic but perpetuate as functional.

Functional disorders are diagnoses of exclusion, meaning we have to exclude the other likely organic causes before we can give the diagnosis of a functional disorder. This is because we currently have no lab test or imaging modality that will be definitively diagnostic for a functional disorder. Sure, we can find objective things as a result of functional disorders; people will truly get diarrhea, which is pretty objectively identifiable. And people will get metabolic alkalosis if their functional nausea has been causing them to throw up all their body’s acid. But no test will be able to definitively identify the cause of that diarrhea or that nausea.

Because functional disorders are diagnoses of exclusion, patients will first get worked up for increasingly rare organic disorders until, eventually, the doctor determines that even though there’s still a small chance they’ve missed something organic, the likelihood of the patient’s symptoms being from an organic disorder is small enough that it’s no longer worth further testing, and they should instead proceed with trying to treat the functional disorder to see if that resolves the symptoms. This means that, sometimes, the diagnosis of a functional disorder will be wrong. That’s the nature of the statistics of diagnoses of exclusion.

When a doctor gives a functional diagnosis, they’ll usually say something like, “All of your tests came back negative; I think it’s being caused by stress. You need to see a psychiatrist or a therapist.” And what the patient hears is either, “I don’t believe you’re having nausea,” or, “I think you’re crazy.”

And what does the patient do next? They find another doctor. The workup starts all over again. Increasingly rare causes are tested for. The patient Googles their symptoms and finds all sorts of things online that lead them to request testing for rare disorders, which are often expensive and/or invasive.

Sometimes, if the second round of testing turns something up, they are even more convinced the first doctor was horrible. And they latch onto that diagnosis, even if there’s a good chance it was a false positive or only explains a part of their symptoms.

I try to avoid all of that by explaining to patients the three categories of disease and then being very clear about two things. First, that functional disorders are not malingering; I tell the patient I am absolutely not saying they are making up these symptoms. I tell them functional symptoms are felt just as truly as organic symptoms are felt. Second, I tell them that it’s normal for our minds and bodies to cope in any way they can with something, and often that means creating physical symptoms. And with that understanding that it’s caused by the mind, the treatment is to see a professional who can pull that stress/trauma/hurt out of their mind and help them process and resolve it. That is the only effective treatment for what they have, and it will resolve their symptoms after that core cause is treated.

The challenge is finding a professional who can accomplish that because there’s still so much we don’t understand about the mind and how to help people process those things. Finding the right one and the right treatment modality may take several tries. But it is possible to cure functional disorders!