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Figure 1 . The seven body stress systems and associated symptoms .

Tremor Weakness Paralysis Gait disturbance Tics Postural disturbance Muscle spasm

Skeletomotor

Immune – inflammatory

Microbiome – gut – brain

Pain Swelling Rash

Complex regional pain syndrome

Gut disturbance Abdominal pain Flatus

Vomiting

Irritable bowel syndrome

Box 3 . Illuminating the triggers

• What was going on in your life around the time your symptoms first arose ?

• How did you feel about what was happening ? How did you respond ?

• What about the situation troubles you most ? What did it bring up for you ?

• How are you handling that ? Did you seek further information and advice from friends or Google ?

Management

Management will be covered in more detail in a subsequent Therapy Update , but a simple summary of an approach to treating functional conditions follows .

Step 1 : Give a clear diagnosis Functional conditions should be treated like any other disorder : provide a clear positive diagnosis followed by the encouraging statement that , with the right treatment , it is manageable .

It is important not to presume psychogenic factors are at play . For example , only one in five patients with functional neurological disorder believe ( a priori ) that stress has anything to do with it . 4 Making assumptions about the role of stress implies that the patient has contributed to their condition or is somehow responsible . This is shaming and alienating and will harm the therapeutic relationship .

Try to avoid negatives , such as , “ Your tests show nothing wrong ,” or ‘ We cannot find a medical explanation for your symptoms .” A functional diagnosis is a medical diagnosis . Functional neurological disorder is listed in DSM-5 , and a number of functional conditions are listed in the ICD-11 . How this diagnosis is given is critical to recovery .

Step 2 : Use the body stress system model This approach can help to shift the diagnostic paradigm .

Step 3 : Clarify which body stress systems have been activated Talk through any questions with the patient to ensure you have a shared understanding , and then draw up a management plan that is suited to the patient ’ s situation , using the factors listed in figure 2 .

A common feature of functional symptoms is they tend to worsen when attention is given to them . One of the clinical challenges is to help the patient to focus instead on re-establishing a sustained restorative and maintenance mode . Outline that this is a key management goal . The means to achieve this should incorporate the patient ’ s preferred method or methods that can be accessed readily and used preferably on a daily basis to reduce the body stress response .

Step 4 : Build a team to enable healing It should be evident that functional conditions are highly individual and arise as a result of a unique congregation of factors . Similarly , not only is treatment individualised but a strongly patient-centred approach to recovery is also needed . The less psychologically minded may do better with physical therapies , such as yoga / tai chi / qi gong or simply time in nature .

If your patient has a relationship with any therapist practising a modality that can reduce sympathetic activation , encourage a course of therapy and review . Engaging a psychologist , physiotherapist , occupational therapist , massage therapist , exercise physiologist or counsellor who can work with the patient to achieve balance is a helpful adjunct .

Many people are using wearable devices to track sleep , heart rate and , especially useful , heart rate variability . It may help them

Figure 2 . What causes functional symptoms ?

Illness / injury Genetics Epigenetics Pain Trauma Anxiety Depression Sleep disturbance Cultural stressors Environmental stressors Overwork Financial stressors Interpersonal stressors Personality vulnerabilities

to observe symptomatology in response to their interventions .

While remaining in the workforce may be beneficial , patients need to consider adopting a lifestyle that prioritises the restorative mode .

Step 5 : Arrange timely review Agree to review symptoms as often as is necessary to assure the patient of ongoing support while they focus on the best way to achieve the agreed goal .

ACTIVATED BODY STRESS SYSTEMS

Conclusion

The diagnosis and treatment of functional conditions may require a radical shift in approach by both doctor and patient alike . The focus of this Therapy Update has been communication of the diagnosis and a general management approach to patients . A subsequent article will outline the top-down and bottom-up approaches to management .

References on request from kate . kelso @ adg . com . au

Symptoms