Functional disorders: top-down or bottom-up?
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.
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 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 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 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, 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 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 situation.
When taking a top-down approach, avoid fixating on symptom management. Symptoms often mutate if the underlying conditions or contributors that led to their development are not addressed.
Keep in mind that the symptom is not a disease process but a result of disrupted allostasis.
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 physical explanation for their symptoms.
In such cases, it is best to avoid the two extremes of confrontation or dismissiveness. Instead, it can be helpful to focus on and explore what predisposing and precipitating factors the patient agrees are having a negative effect on them.
Conversely, the more psychologically minded patient may express an early clear preference to explore psychosocial contributors. In such cases, it can be very helpful to work with a psychologist with skills in functional medicine.
The predictive processing model may need to be explained.7 This proposes that symptoms may arise because the brain has anticipated a response that will arise in certain situations.
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.
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 extremes of confrontation or dismissiveness and, instead, focus on what predisposing and precipitating factors they agree are having a negative effect upon them.
In some cases, it may not be an option to address ‘top-down’ elements first-line. When this approach is not an option, it is suitable to focus instead on what strategies may ease their symptoms, using a bottom-up approach.
It may help to use a technology ana-logy to explain. Rather than a hardware problem (physical illness), functional conditions reflect a software disruption. Functional conditions occur when the brain and nerves need reprogramming, which is something our allied health colleagues can assist with.
In practical terms, functional motor-skeletal symptoms can respond well to physiotherapy. Swallowing, speech and communication problems can be aided with speech therapy.
Mindful movement practices such as yoga, qi gong or tai chi may help to return the body stress systems to the restorative mode, to reduce the symptom threshold. Massage and acupuncture are passive therapies that may also promote the restorative mode.
Dietary and lifestyle measures may 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 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 pushed him into the pool, forcing him to use his leg.
While I personally do not endorse such an approach, it does speak to the potential benefit of offering some form of active treatment to a patient, even if they do not believe it is needed.
Motivational interviewing skills can be helpful to engage the patient and keep them engaged.
Fostering recovery and avoiding stigma
Language is key in minimising stigma. Take care with the word ‘but’, which may add to the stigma.
Instead of saying, “You have a functional condition, but you might like to try this treatment,” consider phrases such as, “So, we have explored some of the reasons why you have a functional condition. Now, would you like me to go through the treatment options that can be effective?” or “Functional conditions arise in unique ways, and there are many different means to improve them.”
Avoid focusing specifically on symptom resolution so much as how the individual successfully navigates life with or without their condition. Fixating on symptoms can lead to discouragement if relapses occur; in this situation, re-evaluate the 4Ps and seek to address what is 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.
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 cause. If there is no agreed cause, focus on retraining neural networks.
Try to avoid simply sending patients a website link and leaving it at that. Instead, enhance a mutually respectful relationship with timely follow-up. If therapy is offered early in the illness, the results can be very rewarding.
Many of these patients have experienced 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 ameliorate all symptoms is encouraging.
Given the unfamiliar nature of functional conditions, patients need time to understand and encouragement to commit to treatment, as recovery can take longer than they expect, with setbacks often arising unexpectedly.
Support through these times can foster commitment to persevere. Motivational interviewing techniques may allow the patient time to accept the diagnosis and means to restore health.
Read more:
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.
References on request from Dr Kate Kelso.
