38 CLINICAL FOCUS
38 CLINICAL FOCUS
9 AUGUST 2024 ausdoc . com . au
Therapy Update
Top down or bottom up ?
Art of medicine
Dr Gillian Deakin is a GP in Bondi , NSW . She is the author of What the Hell is Wrong with Me ? A Guide to Treating Fatigue , Pain , Weakness , and other Unexplained Symptoms , and 101 Things Your GP Would Tell You If Only There Was Time .
This second of two articles outlines different approaches to helping patients with functional disorders .
PATIENTS with functional conditions are frequently over-investigated and yet still misdiagnosed . But even with the correct diagnosis , a systematic approach to management is frequently limited .
Medical training lacks clear treatment guidelines for many functional symptoms . And yet without a careful explanation of the diagnosis , followed by individualised treatment , functional symptoms can lead to years of misery and disability .
This is the second in a series of articles on functional disorders . The first outlined the ‘ body stress systems ’ approach ( see online resources ), developed by Dr Kasia Kozlowska , an Australian child and adolescent psychiatrist with an interest in functional neurological disorders . Dr Kozlowska and colleagues have published an open access text which is an excellent resource ( see online resources ). 1 Although aimed at young patients , it outlines a practical and effective therapeutic model , which GPs can readily adapt to the broader general practice setting .
Clarity of diagnosis and communication
To ensure the patient will accept a functional diagnosis , the doctor needs to listen carefully to the history and complete appropriate examination and investigations . Over-investigation risks iatrogenic anxiety . If the provisional diagnosis is functional , testing should be contextualised within the expectation of normal results , so treatments can commence in parallel .
Experts in the field of functional neurological disorder assert that this is no longer just a condition of exclusion but should be positively diagnosed . 1
Sadly , surveys still find that a significant number of doctors believe the functional patient is malingering . 2 Functional MRI studies have demonstrated that neural centres for self-awareness , interoception and agency are often disrupted in patients with functional neurological conditions . 3 To establish rapport with the patient , it is essential that the doctor states that they accept the symptoms are real and that there is an explanation .
Murtagh ’ s Diagnostic Strategies assist in the diagnosis of functional conditions . It is estimated that 10 % of the general population and one-third of adult patients in clinical populations experience functional somatic symptoms . 4 When considering a probability diagnosis using Murtagh ’ s framework , the clinician must take into account that functional conditions are much more common than is typically recognised by doctors and patients
There are a number of signs that may be used to positively diagnose functional neurological conditions .
alike . A clinician who works in a typical general practice setting , who is not regularly diagnosing functional conditions , is most likely missing them .
It is essential to rule out serious conditions by excluding red flags . Subtle but vital clues that suggest a functional diagnosis need to be explained to the patient in clear , non-judgemental terms . There are a number of signs that may be used to positively diagnose functional neurological conditions in particular . 5 It is important to share and explain this information to help the patient accept the diagnosis .
Murtagh ’ s fifth strategy — “ Is the patient trying to tell me something ?” — needs particular attention in these patients . Functional symptoms usually have a complex pathogenesis , of which the patient may not be aware .
Having excluded physical conditions , a description of the restorative and maintenance mode versus the defensive mode , as detailed in the first article in this series , needs to be followed by a clear assertion that remaining in the defensive mode will perpetuate the condition .
By this point , the patient will have revealed , either directly or indirectly ,
NEED TO KNOW
Patients benefit from a clear , positive diagnosis of functional conditions .
Patient education , using the body stress system approach , is both acceptable and effective .
The top-down approach includes education , identifying causative factors and engaging the patient in psychotherapy to address causative factors , using the 4Ps model ( predisposing , precipitating , perpetuating and protective factors ).
The bottom-up approach allows recovery to occur through physical forms of therapy , retraining , relaxation exercises , massage , acupuncture , mindful movement and lifestyle improvements . Altering the physical stress responses helps to decouple the body from a habituated symptom .
Early therapeutic interventions may reduce the risk of chronicity and associated poorer therapeutic outcomes .
Complex , multi-system somatic stress disorders often require multidisciplinary therapies .
whether they prefer a top-down or bottom-up approach . Top-down approaches focus on exploring biopsychosocial influences and strategies for functional symptoms , using the 4Ps approach outlined below . Bottom-up approaches involve strategies directed at easing physiological symptoms , states or responses ( for example , slow-breathing and mindful movement techniques ).
Top-down approach
The top-down approach is patient-centred . This is particularly important in functional medicine , where the patient ’ s physiological coping mechanisms have been overwhelmed , activating body stress reflexes , and resulting in the symptom experience .
Many of us GPs chose our specialty because we appreciate the art of medicine as much as the science . This is where we can use our skills in artful science to engage the patient in the therapeutic process .
This can begin by providing an overview of how a functional symptom may arise using the 4Ps paradigm — that is , predisposing , precipitating , perpetuating and protective factors ( see figure 1 ).
It is worth being mindful in follow-up consultations that prognosis is determined by the ongoing influences of perpetuating and protective factors .
The line of inquiry should sensitively explore stressors : sleep quality , physical excesses ( too much or too little activity ), hormone changes , nutritional levels , challenges to the immune system ( including illness or vaccine administration ), the nocebo effect ( wherein the belief that an intervention will cause harm results in a negative outcome ) 6 and mental health