Medically Unexplained (Functional) Symptoms

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.

An entire 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).

Symptoms 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).

Sometimes 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.

The symptoms 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).

However, 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.

Furthermore, 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).

In another 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).

Medically 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).

There is 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).

Katon and 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.

Barsky proposes 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.