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.
What utter nonsense, resorting to blaming those naughty, naughty patients for being ill and that they dare to question the appallingly weakly evidenced theory of 'FND'. I mean how dare they? Oh but wait, asking the AIs to grade the evidence base for 'FND' according to the GRADE system used by NICE gives a result that the evidence for 'FND' is 'very poor or poor' , which is substantially worse than for example the grading of the biological evidence for ME/CFS, some of which is groundbreakingly high. OMG, if patients were to realise that they wouldn't be able to take the 'faith healing' hype approach and BELIEVE in 'FND' which we are told is needed for the talking therapy to work! Snake oil, anyone? And unprepared to face both the fact that talking therapies have almost zero effect, and that we have absolutely no reason to think the biological explanation is unlikely to be adequate on its own. I'm left speechless by the sheer absurdity of talking about 'cognitive processing' approaches to labour pain - as if that has even the tiniest possible impact on pain once strong labour sets in. Anyone out there volunteering to try it? I mean why not remove dental anaesthesia as well and give patients talking therapy instead while they're waiting in the waiting room?
Once the language shifts to "functional overlays," "functional components," triggers, and underlying causes that supposedly produce a functional disorder, the obvious question is whether this is still a primary disorder at all.
If the same features show up across many illnesses, it may just be a common presentation, not evidence of a separate entity called FND. At that point the diagnosis is doing philosophical work: it groups observations together and then treats the grouping as the cause.
That is a different claim from "these symptoms are real." Reality of symptoms does not establish that the category explains them.
I'm sure we are all aware of the cunning and manipulation beneath the word 'real' when used by the medical profession. The word 'real' when applied to symptoms is normally understood by the patient to mean the symptom is biological, it has a biological, organic reality whether or not the limited kinds of tests the health service runs picks anything up. However the word 'real' to the doctor means 'psychological', the patient is genuinely deluded into thinking they have something wrong, at best, isn't faking. I've watched this cause chaos in court, for example also in an inquest - the doctors were responding the coroner's questions - yes of course we understood M's symptoms to be 'real'. The lay audience is then misled into thinking the doctors meant the patient had a biomedical condition. The doctors meant 'they were really convinced there was something wrong', it was 'really psychological', 'real to them'. (The coroner, bizarrely, was then satisfied that the patient had not been treated as though the condition didn't exist when in fact that was the entire approach of the team treating her. ) NEVER use the word 'real' when questioning doctors or in discussion, it's a red flag for manipulation to try to get the patient's 'on side'.