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• The biography of functional disorders
  Jonathon P Tomlinson
  Published on: 27 October 2016

• Published on: 27 October 2016

  The biography of functional disorders

  • Jonathon P Tomlinson
  • Other Contributors:
    • London

  This sensitive review is very welcome, as in our experience, most patients with functional disorders are told by specialists what they do not have. I would be much more inclined to refer patients if this kind of approach was more common. It is one reason why relatively few of the patients we see in primary care are referred for specialist attention. Specialists are seeing only the tip of the primary care functional iceb...

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  This sensitive review is very welcome, as in our experience, most patients with functional disorders are told by specialists what they do not have. I would be much more inclined to refer patients if this kind of approach was more common. It is one reason why relatively few of the patients we see in primary care are referred for specialist attention. Specialists are seeing only the tip of the primary care functional iceberg. Referral rates vary widely depending variously on levels of experience, resilience, tolerance of uncertainty and access to peer or specialist support.

  One advantage GPs have over our specialist colleagues is that we get to know our patients over many years - which is how long it may take to discover the biography behind their functional symptoms. A second advantage we have is a knowledge of their family and social context within which they experience their symptoms enabling us to take a systemic approach. We have more in common with Oliver Sacks- who rediscovered the importance of narratives divulged slowly, and used to visit his patients at home like his father, a London GP, than we do with our younger neurological colleagues.

  It's worth remembering that a clinical history is not narrative and biography is not psychology. Stone warns against framing functional neurological symptoms in psychological terms, which I would agree with - mental illness, if it co-exists ought to be seen as a co-morbidity rather than a primary cause. But Stone's approach is still biomedical and lacks the systemic approach that time, continuity and contextual factors illuminate. I recently invited older GPs to talk to trainees about their favourite patients. Many described patients who were struck with their functional symptoms for years, decades even - in a state of narrative chaos, before something changed and they found some kind of peace with themselves and were much better able to live with their symptoms. In narrative medicine this is a shift from chaos to quest, where making sense takes over from searching for a cure. There are many ways of making sense of functional symptoms and my main concern about Stone's approach is that usually it's most honest to admit we just don't (yet) know.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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