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problems . Sexuality and gender issues may also play a role .
Beyond the individual , a good understanding of the family , workplace and educational environment may help to place the person in their biopsychosociosexual
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Bottom-up approach
Given the heavy dependence on the biomedical
paradigm in our society , the patient may react to the suggestion that there is not a physical explanation for their symptoms . It is best to avoid the two
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functional diagnosis . As an example , the brilliant neurologist Oliver Sacks documented this in his autobiographical A Leg to Stand On , where he wrote that he recovered the use of his leg through group support and a cheeky swim instructor who |
Once the patient understands how functional symptoms can be triggered , the task is to explore which methods work best for them to return to restorative and maintenance mode . Diagnosis and treatment do not rely on having an identifiable |
Figure 1 . The 4Ps model for understanding functional symptoms . |
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situation . |
extremes of confrontation or dismissive- |
pushed him into the pool , forcing him |
cause . If there is no agreed cause , focus on |
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When taking a top-down approach , |
ness and , instead , focus on what predis- |
to use his leg . While I personally do not |
retraining neural networks . |
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avoid fixating on symptom management . |
posing and precipitating factors they agree |
endorse such an approach , it does speak |
Try to avoid simply sending patients a |
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Symptoms often mutate if the underlying |
are having a negative effect upon them . |
to the potential benefit of offering some |
website link and leaving it at that . Instead , |
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conditions or contributors that led to their |
In some cases , it may not be an option |
form of active treatment to a patient , even |
enhance a mutually respectful relation- |
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development are not addressed . |
to address ‘ top-down ’ elements first-line . |
if they do not believe it is needed . |
ship with timely follow-up . If therapy is |
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Keep in mind that the symptom is not |
When this approach is not an option , it is |
Motivational interviewing skills can |
offered early in the illness , the results can |
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a disease process but a result of disrupted |
suitable to focus instead on what strate- |
be helpful to engage the patient and keep |
be very rewarding . |
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allostasis . |
gies may ease their symptoms , using a bot- |
them engaged . |
Many of these patients have experi- |
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Given the heavy dependence on the biomedical paradigm in our society , it is not surprising that some patients react negatively to the suggestion that there is not a |
tom-up approach .
It may help to use a technology analogy to explain . Rather than a hardware problem ( physical illness ), functional
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Fostering recovery and avoiding stigma
Language is key in minimising stigma .
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enced shame about their condition . They may withhold information on a number of symptoms because they have so many . The idea of a unifying therapeutic approach to |
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physical explanation for their symptoms . |
conditions reflect a software disruption . |
Take care with the word ‘ but ’, which |
ameliorate all symptoms is encouraging . |
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In such cases , it is best to avoid the two |
Functional conditions occur when the |
may add to the stigma . Instead of saying , |
Given the unfamiliar nature of func- |
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extremes of confrontation or dismissive- |
brain and nerves need reprogramming , |
“ You have a functional condition , but you |
tional conditions , patients need time to |
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ness . Instead , it can be helpful to focus on |
which is something our allied health col- |
might like to try this treatment ,” consider |
understand and encouragement to com- |
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and explore what predisposing and precip- |
leagues can assist with . |
phrases such as , “ So , we have explored |
mit to treatment , as recovery can take |
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itating factors the patient agrees are hav- |
In practical terms , functional |
some of the reasons why you have a func- |
longer than they expect , with setbacks |
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ing a negative effect on them . |
motor-skeletal symptoms can respond |
tional condition . Now , would you like me |
often arising unexpectedly . Support |
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Conversely , the more psychologically |
well to physiotherapy . Swallowing , speech |
to go through the treatment options that |
through these times can foster commit- |
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minded patient may express an early clear |
and communication problems can be |
can be effective ?” or “ Functional condi- |
ment to persevere . Motivational inter- |
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preference to explore psychosocial con- |
aided with speech therapy . |
tions arise in unique ways , and there are |
viewing techniques may allow the patient |
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tributors . In such cases , it can be very |
Mindful movement practices such |
many different means to improve them .” |
time to accept the diagnosis and means to |
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helpful to work with a psychologist with |
as yoga , qi gong or tai chi may help to |
Avoid focusing specifically on symp- |
restore health . |
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skills in functional medicine .
The predictive processing model may need to be explained . 7 This proposes that symptoms may arise because the brain has
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return the body stress systems to the restorative mode , to reduce the symptom threshold . Massage and acupuncture are passive therapies that may also promote |
tom resolution so much as how the individual successfully navigates life with or without their condition . Fixating on symptoms can lead to discouragement if |
References and further reading on request from kate . kelso @ adg . com . au |
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anticipated a response that will arise in certain situations . |
the restorative mode . Dietary and lifestyle measures may |
relapses occur ; in this situation , re-evaluate the 4Ps and seek to address what is |
Online resources |
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As an example , for a patient with functional arm pain , the predictive processing response may be “ If I move my arm , I will get pain .” The anticipated experience of pain in response to movement can then become a self-fulfilling prophecy . |
have positive effects on gut disturbance and pain levels . Patient commitment is required , sometimes for months , before the benefits are maintained .
The bottom-up approach can be used without the patient agreeing with a
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most pressing .
For more serious and disabling conditions , involvement of a multidisciplinary team , along with family members and carers , helps to unify the therapeutic approach and identify potential perpetuating factors .
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• An approach to functional disorders , part 1 : bit . ly / 4bjhWh5
• Kozlowska et al , Open Access : bit . ly / 3UroYJZ
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