Unexplained (Functional) Symptoms
This is supplemental
information for this topic marked by the little computer icon in the book, Irritable Bowel Syndrome and the MindBodySpirit Connection,
by William B. Salt II, M.D. and Neil F Neimark, M.D. (Columbus: Parkview
Publishing, 2002). Click here to learn more about
the book and/or to purchase it.
issue of a prestigious medical journal, The Annals of Internal Medicine,
was recently devoted to symptoms (Ann Intern Med. 1 May 2001, volume 134,
supplement number 9).
are part of the human condition and experience. One survey of more than
one million people found that 40% to 55% were having headaches, 33% to
46% fatigue, and 15% sore throat at the moment that they were being surveyed
(Hammond ED. Some preliminary findings on physical complaints from a prospective
study of 1,064,004 men and women. Am J Public Health. 1964;54:11-23).
a person considers a symptom or symptoms to be troublesome enough to constitute
an "illness." JH Dingle prospectively followed 443 persons for
10 years, for a total of 970,036 person-days (The ills of man. Sci Am.
1973;229:76-84). There were 9.4 instances per person-year in which the
participants reported symptoms that caused impairment sufficiently severe
to be described as illnesses. But participants sought medical care for
only a minority of the "illnesses." So most people do not regard
symptoms as being illnesses or most illnesses as necessitating a visit
to the doctor.
of "minor" illnesses result in huge expenditures, even when
people do not see a doctor about them. The multiple billions of dollars
spent on over-the-counter medications that do not require a prescription
are part of the evidence for this observation. Every year in the United
States, respiratory infection symptoms result in more than 100 million
days of lost productivity. The symptoms of irritable bowel syndrome
are the second most common cause of missing work (the common cold is first).
many patients do decide to consult a doctor about symptoms, and many to
most symptoms cannot be explained by convention medical tests. The medical
term "functional" means that the cause of symptoms cannot be
explained by currently available diagnostic studies, including blood tests,
x-rays, endoscopy (esophagogastroduodenoscopy and colonoscopy), biopsy,
or surgical findings. Instead, there is an altered physiological function
(the way the body works). Kurt
Kroenke, M.D. is renowned for scientific investigation of symptoms.
In a widely quoted medical report, he showed that in a study of 1000 patient
visits for any of 14 different common acute symptoms, doctors could only
establish a clear diagnosis in 16% of cases (Kroenke K, Mangelsdorff AD.
Common symptoms in ambulatory care: incidence, evaluation, therapy, and
outcome. Am J Med. 1989;86:262-6). Click
here to read an abstract of this medical journal article.
such medically unexplained symptoms can cause functional impairment in
life that is as significant as that seen in patients who have well-defined
organic diseases (Kroenke K. Studying symptoms: sampling and measurement
issues. Ann Intern Med. 2001;134:844-53).
study, Dr Kroenke and his colleagues found that many patients with symptoms
of minor illnesses do not benefit significantly from their encounter with
the health care system (Kroenke K, Arrington ME, Mangelsdorff AD. The
prevalence of symptoms in medical outpatients and adequacy of therapy.
Arch Intern Med. 1990;150:1685-9). 410 of 500 outpatients who were prospectively
interviewed indicated that they currently had symptoms, which they regarded
as "major problems." Only 39% of patients with presenting symptoms
of fatigue, shortness of breath, dizziness, insomnia, sexual dysfunction,
depression, or anxiety reported any benefit from the visit or from the
treatments prescribed at the physician visit. Approximately one third
of patients who seek care for symptoms are dissatisfied with the outcome
(Jackson JL, Kroenke K. The effect of unmet expectations among adults
presenting with physical symptoms. Ann Intern Med. 2001;134:889-97).
unexplained symptoms are also frustrating for doctors. Hahn found that
physicians are more likely to label patients with unexplained symptoms
as "difficult," independent of any concurrent psychiatric or
organic disorders (Hahn SR. Physical symptoms and physician-experienced
difficulty in the physician-patient relationship. Ann Intern Med. 2001;134:897-904).
considerable medical evidence that psychiatric distress and disorders
(especially anxiety and depression) are found more often in patients with
medically unexplained symptoms (Kroenke K. Studying symptoms: sampling
and measurement issues. Ann Intern Med. 2001;134:844-53; Barsky AJ. Palpitations,
arrhythmias, and awareness of cardiac activity. Ann Intern Med. 2001;134:832-7;
Katon W, Sullivan M, Walker E. Medical symptoms without identified pathology:
relationship to psychiatric disorders, childhood and adult trauma, and
personality traits. Ann Intern Med. 2001;134:917-25).
colleagues argue that many symptoms, although medically unexplained, are
not necessarily unexplainable or imaginary (Katon W, Sullivan M, Walker
E. Medical symptoms without identified pathology: relationship to psychiatric
disorders, childhood and adult trauma, and personality traits. Ann Intern
Med. 2001;134:917-25). They state that "many medical symptoms without
identified pathology may actually be caused by psychophysiologic or brain-body
pathways, such as abnormalities in smooth muscle tone in the gastrointestinal
tract during stress in patients with irritable bowel syndrome … Recent
research also suggests that links between perturbations in brain physiology
and physical symptoms are bidirectional." Sharpe and Carson say the
same thing and advocate a "paradigm shift" in which unexplained
symptoms are remedicalized around the notion of a functional disturbance
of the nervous system" (Sharpe M, Carson A. "Unexplained"
somatic symptoms, functional syndromes, and somatization: do we need a
paradigm shift? Ann Intern Med. 2001;134:926-30). Click here to read an abstract of the medical journal article.
an idealized model in which symptoms are studied by independently and
simultaneously measuring various neural components of symptom perception
and formation (Barsky AJ. Palpitations, arrhythmias, and awareness of
cardiac activity. Ann Intern Med. 2001;134:832-7). These components are
1) the peripheral abnormality (for example muscle spasm) that triggers
afferent sensory fibers, 2) the ascending pathways carrying sensory messages
to the brain and the descending pathways that influence them, 3) the reception
of the sensory message in the brain, 4) the activation of perceptual and
emotional centers in the brain in response to the received sensation,
and 5) the impact of an individual’s emotional state and socially determined
belief systems on the perception of the sensation. We may be able to approach
this ideal with new scientific techniques and technologies, such as functional
brain imaging with positron emission tomography (PET) scanning.
In a medical
journal article entitled, Symptoms: In the Head or In the Brain? (Ann
Intern Med. 2001;134:783-785), Harvard’s Anthony Komaroff, M.D. says,
" While some patients seek medical care for ‘symptoms’ that are fabricated
to achieve secondary gain, most patients who seek medical care for symptoms
almost surely have what Sharpe and Carson call a ‘functional disturbance
of the nervous system.’ We need to explain this to patients, while also
recognizing the important role that a patient’s emotional state can play
in augmenting the pathology. Taking this approach is likely to make us
(doctors) more effective physicians. What will always remain ineffective
therapy, in dealing with the patient who has unexplained symptoms, is
saying, in so many words, ‘There’s really nothing wrong with you. It’s
all in your head.’ Click here to read this medical journal article.