One of the things that I’m learning in my neurology clerkship is how to identify “functional” symptoms versus “pathological”.
In the latter category are things that we think of as neurological disease, such as stroke, multiple sclerosis, brain tumor, epilepsy, etc. and then functional symptoms which are happening due a process which we don’t understand to be associated with a known nervous system pathology, and could even be a somatic manifestation of the patient’s psychology.
One of the good things about starting early with a clerkship in neurology is that they really put a lot of effort into teaching the skills of a neurological exam. To establish some contrast, the dermatological physical exam is examining the skin, hair and nails over the entire body (including inside the body, such as in the mouth) and is fairly fixed. You don’t really have to make the patient do a lot of particular maneuvers and participate very actively in the examine. Obviously you can’t take a history from an unconscious patient, and what makes the dermatologist’s job difficult is both differentiating all the subtle skin findings and integrating them with other symptoms of disease which can span all the body systems, so dermatologists need to know how to do a full exam (including sometimes looking for neurological or neuromuscular findings which associate with skin findings), but in terms of the actual physical exam of the skin, you are able to do a pretty decent dermatological exam on an unconscious patient (given that they are not too big to move around). The neurological exam you would do on an unconscious patient is almost completely different from what you do with a conscious patient, highlighting the range of tests you need to do. A lot of the elements of a neurological exam require large number of specific maneuvers and techniques to elicit different signs. I think the neurological exam and the musculoskeletal exam are the most difficult to learn in terms of all the maneuvers and techniques the practitioner have to do. They are also related and there some overlap in that they often both spend a lot of time trying to assess the functioning of the limbs, and you are making the patient try to move and do a large number of activities. The fact that the awake patient contributes to the neurological exam means that many of the signs and symptoms involve active participation (e.g. application of strength or performance of tasks) and/or subjective experience (e.g. reporting what is experienced). That element of subjective experience means that the mind certainly has an influence. Symptoms such as tingling, pain, or weakness all have an element of conscious involvement and processing. A big part of the neurological exam is of course not just trying to characterize symptoms, but to identify if they occur in a pattern of known organic illness or not. I won’t go into the many techniques to do this, as they are describe in many sources. However, it is worth mentioning that neurologists have developed a large number of techniques to characterize symptoms and tease out their causes, and part of that is to identify if an illness is functional.
So what is a “functional” symptom? As noted, this means an illness or symptom which does not have a known cause in terms of our understanding of the molecular/cellular/structural pathology of diseases. However, we have to be empathic and caring in all these cases. For example, a patient seeking powerful narcotics may actually have pain, there is even a type of rebound-like pain from opioid use, and the patient may certainly have strong symptoms related to drug dependency which need treatment. It is also important to keep in mind that many diseases were once considered functional, but now are better understood. Multiple sclerosis and interstitial cystitis were both considered functional at one time, before we understood their pathology. Munchausen syndrome, where a patient presents with symptoms to attract attention and receive care is more clearly a psychiatric illness than just dissembling, particularly as patients with Munchausen will harm themselves in an effort to present with symptoms, and sometimes pay large amounts to receive medical care, without any sign of clear material gain from the experience. Certainly, patients who have a somatic presentation of symptoms have very real problems that is causing them very real pain, discomfort and disability, and both psychotherapy and medication can sometimes help.
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However, where this all ends up is that a big part of the neurological exam, as complex as it is, includes assessing symptoms as being functional. And then after a presentation is assessed as having a functional component, then there is trying to identify in what way it is functional. In many ways this latter part is a lot harder as you have to collect psycho-social features to try to get an understanding of what is happening. Overall though, I want to make sure that even as I keep a skeptical part in my heart, I continue to be compassionate and an advocate for my patients and their well-being, so my heart is warm and open, with compassion. But beyond the heart, the question sometimes remans, is it in your brain or in your mind or both?