Functional Disorders are real
The biggest misconception out there is that someone can’t have a functional disorder if they also have an organic medical disease, disorder, or condition.
The reality, of course, is that very, very rarely do functional disorders develop without an underlying physiological trigger. The reality is that most functional disorders are found to be a “functional overlay” or “functional component“ layered on top of and interwoven into physiological distress.
People don’t like hearing how involved the mind body connection is and interpret that doctors are saying that their physical symptoms are “all in their head“ when most physicians are using speech to text software when communicating the diagnosis to patients, and many, if not most of these diagnoses are also occurring in epilepsy monitoring units, where the patient is being video and audio recorded, when the diagnosis is made - patience are coming away from the diagnostic conversation, saying that the doctor told them that their problems were all in their head, while transcribed, notes and audio, and video recordings are truly showing that the doctors are delivering the diagnosis with care and complexity and are rarely saying that the symptoms are “all in one’s head.”
To be sure there probably are a few callous doctors out there who may have said something so myopic, but the vast majority of the time, the patients are hearing that there may be a psychological interplay with the severity of the symptoms and are coming away, only hearing that.
Even Lamaze techniques in childbirth are known to use cognitive processing to reduce and manage physiological pain, but unfortunately, when it comes to functional symptoms, patients are intolerant of hearing, synthesis, and incorporating the recommended therapeutic techniques to help ameliorate their physiological symptoms.
Thank you for taking the time to write this and for sharing your perspective.
The literature suggests, as you pointed out, that comorbidity is extremely common in functional disorders, with some studies reporting rates approaching 80%. That is important because it demonstrates just how frequently functional symptoms exist alongside other medical conditions. It also makes it particularly important that a functional diagnosis isn't interpreted as an explanation for every symptom a patient subsequently experiences.
I would also add an important caveat to the discussion: we need to distinguish between what we observe, how we classify it, and what the evidence actually allows us to conclude about it.
This is essentially the distinction I explored in my previous post between ontology and epistemology. We can define and recognise a clinical pattern without necessarily knowing what produces that pattern. The existence of a recognisable phenotype does not, by itself, establish its underlying mechanism or cause.
That distinction matters particularly in functional disorders. There may be recognisable clinical patterns and positive signs, but the mechanisms underlying them remain incompletely understood. There are numerous proposed models involving brain and body interactions, attention, prediction, cognition, stress, trauma and other physiological processes, but many of these remain hypotheses or partial explanations rather than established causes that can confidently be applied to an individual patient.
This is where I think we sometimes allow the strength of the classification to imply a strength of explanation that the evidence does not necessarily support. In other words, being confident that we recognise a pattern is not the same thing as being equally confident that we know why that pattern exists.
This also connects directly with the issue I raised in my latest post. Clinicians themselves can misunderstand what “functional” means. The literature has documented that some clinicians still associate functional symptoms with feigning or intentional production, while others continue to rely on older psychological narratives. So although I absolutely agree that some patients may misunderstand what their clinician is saying, we also have to acknowledge that the misunderstanding does not always originate with the patient.
A clinician can genuinely believe they are explaining a sophisticated brain and body model while still communicating an interpretation that is more certain than the evidence warrants. And a patient can understandably hear that as “your symptoms are psychological” or “they're all in your head,” particularly if they have previously experienced dismissal.
That doesn't mean clinicians are acting in bad faith, and it doesn't mean patients can never misunderstand. Both things can be true.
For me, the more constructive approach is to hold these distinctions together: functional symptoms are real, recognisable patterns can be clinically useful, organic disease can coexist with them, and psychological or cognitive factors may be relevant, but none of that removes the need to distinguish what has actually been demonstrated from what is currently inferred or hypothesised.
That epistemic humility becomes especially important when a patient's condition progresses, changes character, or produces new objective findings. A useful clinical framework should help us investigate reality, not become a reason to stop looking at it.
Thank you again for contributing to the discussion. I think this is exactly the kind of nuance that is needed if we're going to move beyond the persistent “it's either physical or it's psychological” debate.
Since you mentioned that you are a nurse, I would also be very interested in your perspective on a post I wrote: When Nursing Education Reinforces a Diagnosis.
It looks at an Australian FND nursing education guide that explicitly encourages nurses to reinforce the diagnosis and discusses patient scepticism, pursuit of alternative diagnoses and further investigation largely as barriers to recovery. My concern is that it gives considerably less attention to diagnostic uncertainty, reassessment, or recognising when new symptoms or progression might justify questioning the original diagnosis.
Given your nursing background, I would genuinely be interested to know how you view that kind of educational approach, particularly whether you think reinforcing the diagnosis is an appropriate role for nurses, and how that should be balanced against remaining alert to changes that might warrant reassessment.