Around half of all physical complaints with which people consult their family doctor have no organic cause. These are so-called functional complaints. If nothing physical is present, the psyche is usually suspected as the cause. But often neither psychotherapies nor psychopharmaceuticals lead to the desired success. What then? Do those affected not want to get better? Are they imagining the complaints?
Over the course of decades, we have gained a different view of the complaints, which leads to different therapy methods and also to gratifying changes.
What actually are "functional disorders"?
Extremely diverse
Functional disorders are complaints or clinical pictures with physical impairments, but in which no physical findings are found.
What is the characteristic of the complaints? Typical is the combination of more or less pronounced complaints with no or only slight physical findings. And as a rule, these complaints cause anxiety. Insomnia and fatigue is very common.
In other words, bodily functions (digestion, breathing, pain perception) are impaired but there is no explanatory physical impairment or physical defect.
There is a wide range from harmless everyday complaints to invalidating clinical pictures. All disorders can be found here on these pages.
Everyday complaints:
- Flushing
- Diarrhea, urinary urgency during stress
- Insomnia
- Palpitations
- Loss of appetite, "frustration eating
- Headache
Examples of clinical pictures:
- Cardiovascular complaints with feelings of anxiety, heart palpitations, feelings of pressure in the chest area.
- Respiratory complaints: Pressure on the chest, feelings of anxiety, shortness of breath, hyperventilation with anxiety or panic, irritating cough
- Gastrointestinal complaints: Irritable stomach, irritable bowel with nausea, bloating, increased flatulence, diarrhea, constipation, and abdominal pain
- Lower abdominal pain, pelvic floor pain, vulvodynia
- Bladder discomfort with irritable bladder, chronic urogenital pain, prostate pain
- Chronic pain conditions such as chronic low back pain or generalized pain as in fibromyalgia
Severe functional disorders:
- CFS
- severe postural tachycardia
The facts presented here are partly based on theguideline on functional body complaints, which is well worth reading.
Synonyms - synonymous
- Medically unexplained symptoms
- Somatoform disorder
- Bodily distress disorder
- Functional syndromes
Incredibly frequent
The complaints are markedly common:
- 20-50% in primary care practices
- 25-66% in special practices/outpatient clinics
- almost half of 70 085 GP patients have functional symptoms (40-49%)
- A GP with 40 pat. per day sees 2 pat. with functional symptoms per hour
(According to guideline functional body complaints)
What promotes functional disorders....
- Multiple complaints - not just one symptom
- Frequent or persistent complaints, hardly any symptom-free intervals
- Inner catastrophizing, helplessness/hopelessness, fear and avoidance strategies, pronounced fear regarding one's own health.
- Protective and avoidance behavior
- Increased psychosocial stress, negative stress, dejection, fear of the future, feeling of loneliness or being over/underchallenged.
- Depression, anxiety disorders, panic disorder, addictive disorders, trauma in biography
- Significantly reduced functioning, e.g., inability to work, social withdrawal, physical deconditioning
- Treater-patient relationship is experienced as "difficult" by both sides
- Incorrect treatments, passivation, unnecessary diagnostics and therapy
What protects against functional disorders...
- Positive attitude to life, humor, self-confidence
- Active coping strategies, e.g., athletic activity, but also enjoyment and relaxation skills
- Individual resources, e.g. satisfying hobbies, social commitment, career plans
- No or low psychosocial stress, e.g. stable ties, good social support, good living and working conditions
- No previous mental illness
- Stable occupation and social contacts
- Viable doctor-patient relationship
- Treatment approaches that convey confidence and positive coping strategies, avoiding unnecessary diagnosis and therapy
Diagnostics: Often too much!
Medical over- and misdiagnosis
Of course, organic causes (inflammations, tumors, genetic diseases, etc.) must be excluded from the complaints.
But the main problem is not the lack of diagnostics, the main problem with functional disorders is overdiagnosis.
In very many - actually most - patients, the same examinations (blood tests, imaging procedures such as ultrasound or X-rays) are performed over and over again. The consistent result: everything is fine. On the one hand, this is reassuring. On the other hand, a doubt arises: If everything is fine, why do I still have complaints? Not infrequently, this leads to a chain of further examinations or - worse - diagnostic interventions.
If this is compounded by disparaging remarks ("You have nothing" or even: "You're imagining things"), the uncertainty increases significantly, which usually worsens the symptoms.
In short: often medicine rather contributes to a worsening (so-called iatrogenic damage).
Naturopathic misdiagnosis
If the usual medical diagnostics do not reveal any findings, many affected persons seek advice from naturopaths or alternative practitioners. In principle, it is very welcome if disturbances of well-being are not immediately treated with medications that have many side effects. An unfortunately frequent example is the income of antibiotics with flu i.e. viral infections.
But in the case of functional disorders, naturopaths look for problems that are not the cause of the complaints:
- Amalgam exposure
- Mitochondriopathies
- Borrelia
- Food intolerances
- Scar disorders
- Vitamin deficiency
- Deficiency of trace elements
- Radiation exposure (e.g. cell phone radiation)
- Fungi/Worms/Parasites
- in former times: water veins
Of course there are real Lyme diseases, real fungal or worm diseases and - rarely - real vitamin deficiencies, but in case of functional disorders the wrong ones are suspected here.
Functional tests
Vegetative disorders are not easy to measure. Normal blood tests or imaging procedures such as X-rays fail.
However, this does not mean that this opens the door to speculation and conjecture. With a number of procedures, at least an orienting diagnosis is possible.
Examples:
- Tilt table or Schellong examination, i.e., examination of blood pressure regulation while lying and standing.
- blood flow measurements, e.g. in the brain
- Examination of heart rate variability, i.e. measurement of the natural fluctuations of the heartbeat from beat to beat.
- Sleep studies
- Examination of respiratory regulation, especially carbon dioxide levels
- Examination of thermoregulation, e.g. how fast does the skin blood flow change in response to cold and heat stimuli
- Biofeedback examinations
- functional magnetic resonance imaging
Background and causes
So how do the symptoms come about? What is the explanation for them? The most important thing first: Functional complaints are not imaginary, even if a doctor cannot make any physical findings. If you have complaints, you have them or you are lying. I.e. you can of course claim that you have pain without it being true. But if it hurts, then this pain is present, even if a doctor finds nothing.
One more thing in advance: functional complaints are also not "hysterical or hypochondriacal reactions", i.e. not a simple "shifting" of conflicts into the body.
We can usefully distinguish between:
- Acquired factors
- Congenital factors
- Sustained factors
The body does not speak in riddles or metaphors
A common explanation moves on a symbolic level. The body expresses metaphorically - in a picture language - what a person does not dare to express.
So in diarrhea - excuse me! - either someone "shits" on something or he just gets "shit".
Even if such metaphors are quite amusing at first sight, they fail with most functional complaints. Irritable bladder, prostatitis, functional respiratory problems, etc. cannot be satisfactorily explained in this way. The fact that you want "someone to cough a little" is something that people with severe irritable cough do not find plausible.
It is clear: the body reacts differently, more sensitively, often more quickly, exaggeratedly and the whole thing represents a considerable impairment in everyday life.
However, we believe, an understanding of the complaints as a "symbol", as a "ciphered message" that is not convincing.
Acquired factors
- Irritation in childhood (injuries, traumatization, operations, overprotection)
- Stressful life circumstances
- Physical/mental pre-existing conditions
We know that people with functional complaints often had a stressful childhood. Many factors come into question here: neglect, assault, trauma, as well as parental illnesses, strokes of fate, social deprivation, and more. This is probably immediately obvious.
However, overprotective parents can also be a risk factor.
In both cases, a child learns: The world is not safe! From this follows an inner organization, which is accompanied with higher attention, better observation and increased distrust. A child becomes more sensitive.
Another factor that is common to many people with functional disorders: a high willingness to perform, the will to apply oneself and to define one's inner value through performance.
But these characteristics alone by no means lead to complaints. As a rule, overstraining situations first trigger the actual symptoms. This is then not infrequently described with the formula "stress", whereby the "stress" can be of a physical, psychological or social nature. Thus infections, operations, serious illnesses, interpersonal conflicts, strokes of fate, workplace conflicts or a combination of all can be at the beginning of the symptomatology.
So, greatly simplified: a person with heightened sensitivity encounters a situation that significantly overwhelms him and that he cannot cope with using his available resources.
As an aside: In the development of functional complaints, the supporting factors - the resources - also play an essential role in addition to the stress factors. The more of these there are (emotional and financial security, social integration), the more protected a person is.
Key question: Why diarrhea instead of anger?
But now we come to the real question: If something overwhelms us, why did we react not with anger, rage, despair, sadness but with diarrhea, heart palpitations, pain or sleep disturbances?
Why does the body react in this "strange" way? This is the core question of psychosomatics!
The psychological reaction patterns (depression, anxiety) can usually be explained well on the basis of our personal biography. Especially the earlier experiences of relationships (e.g. security, uniqueness) usually influence us throughout our life. Distrust in a partnership will appear much more often if we were not allowed to experience stability as a child.
Congenital factors
We have already spoken of the personal biography of man. Strictly speaking, however, we have two biographies. A personal biography and a biography as a human being, by that I mean the history we had on this planet. In a scientific language, a distinction is made between ontogenesis (personal history) and phylogenesis (tribal history).
While the personal history is more or less well stored in your memory, of course you cannot remember the time of the Neanderthals. Nevertheless it is written down, but not in your memory but in your genes. There you can find structural information (how do we look like) as well as data that control our function.
So: how does a cell, a cell association, an organ or the whole body function. Above all, the life-sustaining functions of the body are genetically controlled: digestion, circulation, breathing, temperature regulation, immune system, muscle tone, balance, sleep-wake rhythm and much more.
There are programs that work perfectly without our conscious intervention and usually without any problems. (Computer programs could take a leaf out of our book, but nature had enough time to develop them).
Most of these programs can look back on a very, very long history. They were not "invented" by our human ancestors, but can be found practically in the same way in animals, e.g. mammals and even older creatures.
That means - and now it comes - the programs were developed in interaction with an environment, which does not exist in such a way in wide areas any more. They originate from a past prehistoric epoch, which reaches back far before the time of the agriculture and the cattle breeding: From primeval forest and savannah, in which we roamed as collectors and hunters in small groups over wide areas.
Our ancestors were threatened in ways that we can hardly imagine today. Hunger, infections, and wild animals were constant threats. For such situations, programs - genes - evolved that ensured our survival.
Let's assume that we are - like our ancestors - in such a dangerous jungle. What would be then an optimal reaction, if a tiger stands before us, which did not have breakfast yet? Essentially the following: highest attention (all seeing, hearing, smelling!), high muscle tension, fast heartbeat, increased blood pressure, accelerated breathing, restriction of unnecessary body functions (immune system, sexuality) and - at night - do not sleep, and if you do, do not sleep deeply. Innate factors
Sustaining factors
- Inappropriate treatments (overtherapy)
- Inappropriatediagnostics(overdiagnosis)
- Inappropriate theories of illness (poisoning, organ stress, neurosis, imagination)
- Increased self-observation during anxiety/stress
- Avoidance and deconditioning
Example digestion
Our ancestors were always in a precarious situation with regard to food. There was usually too little of it. People who managed to eat more and have a little fat on their ribs despite the threat lived longer. We call this "frustration eating", i.e. under stress we gain weight - actually it makes sense.
Let's stay with the food intake. Another problem in the "jungle" is the quality of the food. Most plants are inedible, prickly or really poisonous. And it was no better with animal foods. What tasted good and was nutritious either resisted or quickly ran away (hunter's rule: good meat runs fast!). Therefore, our ancestors often had to make do with the leftovers (rotten meat). In addition, we gobbled down these unappetizing morsels of meat raw for the longest time.
To deal with this less delicate cuisine, the gastrointestinal tract has developed some very successful strategies. So if there was danger from the food, it was useful to react quickly with nausea and vomiting, to produce a lot of hydrochloric acid to put an end to bacteria. If that wasn't enough, it was good to eliminate as quickly as possible....
Those who suffer from irritable bowel syndrome will already know: Nausea, bloating, rumbling in the stomach, flatulence, diarrhea - all typical signs of IBS.
Old protective reflexes
Functional disorders can usually be traced back to protective reflexes that guaranteed the survival of our ancestors. In situations that overtax us, the body falls back on programs that originate from ancient times and are now "unwound".
They were "actually" highly meaningful when we were in danger in the past. However, the reaction patterns were mostly tailored to short-term threat scenarios and not to coping with years of stress and overwhelm as we do today.
So let's summarize: We believe that functional disorders can be traced back at their core to genetically transmitted response patterns that ensured our ancestors' survival in danger. Today, they are also provoked by external danger, i.e. stress. Only: the old reactions do not fit into a daily office routine.
What does this mean for therapy?
Firstly, this changes the view a person. We believe that functional no disorders nothing is defective. The body "actually" reacts normally. It cannot help that our environment has changed too radically.
On the other hand, this also influences the therapeutic strategies. So - simplified - we assume that stress genes have been "switched on". These need to be inactivated again.
Therapy
Many ineffective drug therapy methods
In general, the success of medicinal measures for functional complaints is low. This applies, for example, to painkillers (e.g., for fibromyalgia) or antidepressants. Quote guideline: "The efficacy of tricyclic antidepressants for functional body complaints as a whole was accordingly classified as not demonstrable in a large Cochrane review (Kleinstäuber et al. 2014), compared with placebos."
In some studies and for some conditions, the situation is somewhat more favorable, i.e., complaints may subside somewhat, such as amitriptyline for fibromyalgia. The idea of taking a tablet in the evening and waking up symptom-free in the morning may be true for antibiotic therapy of bacterial infections, but unfortunately not for functional disorders.
Psychotherapy
Psychotherapy is effective for functional disorders. This has been proven. However, the effectiveness is often not very strong and may not be specific.
Very often patients report that they have been to a psychosomatic rehab (cure). There, the complaints would have subsided somewhat, but at home, the familiar symptoms would have returned quickly.
Then - after a long wait - they started psychotherapy, which also helped somewhat. Above all, they would recognize the connections with their own history more clearly, but a really fundamental improvement had not occurred.
Doubtful natural remedies
The naturopathic methods are now different e.g.
- Phytotherapy, i.e. plant substances
- Homeopathy
- Minerals
- vitamins
- Detoxifications
- Avoidance of food
- Elimination of toxins
- Bioresonance
- Mitochondrial therapy
- orthomolecular therapy
- etc.
Not all measures are basically ineffective. Some herbal remedies have a beneficial effect, but the characteristic is usually only a short-term improvement. After that, the effect wears off. A new preparation is tried with a similar procedure. Thus, there are many patients who try again and again and keep countless preparations in a box at home.
The background of the effect is mostly the - by no means bad! - placebo effect. The hope of efficacy brings about relief and calming, which thus leads to a lessening of anxiety and tension.
If the drugs are harmless, then no great harm will be done. However, inappropriate concepts can have less innocuous consequences. For example, inMCS(multiple chemical sensitivity), if the cause is thought to be "poisoning" by insulation materials, wood preservatives, or adhesives, we have seen sufferers who have had apartments or houses gutted, always looking for an external cause of their symptoms.
Equally problematic are paramedical therapies when lengthy and side-effect-laden antibiotic therapies are prescribed based on the inapplicable diagnosis of "Lyme disease".
Inaccurate theories can also cause "mental hallway damage". They create confusion about possible causes. Common misguided concepts include:
- Poisonings
- "strains" or "weaknesses" of individual organs
- "incompatibilities"
- Harmful effects from the environment (radiation, environmental toxins)
- Deficiency diseases
- Disease of mitochondria
Some patients with functional disorders suspect such dire diseases and often remain caught for a long time in a false belief that they share with their therapists. Unfortunately, the rejection of the concepts by "normal" medicine often only solidifies these beliefs.
Principles of rational therapy
From our point of view, functional disorders are based on sensory but often "exaggerated" or "inappropriate" reaction patterns. At the core, each is about protection from a real or suspected danger. On the psychological side, the reactions are immediately understandable: caution, anxiety, withdrawal or depression can be seen as a response to a threat.
On the other hand, the physical side (diarrhea, headache, heart palpitations) need to be "translated. They are explained by innate reflexes, which were highly meaningful for survival in an original form of life. Today, however, these are no longer triggered by lions but by stress.
It is essential to distinguish between the actual goal of the reflex, which always aims at protection, and the unpleasant consequences.
Here are examples and possible explanations:
Reassurance and encouragement at all levels
So, in essence, it is about protection and emergency programs, but they have become pointless. They are exaggerated and no longer work in our civilized environment.
In therapy, therefore, it must be conveyed that the world is not as threatening as it may seem. From our point of view, this must be done on three levels:
- Cognitive
- Emotional
- Physical
And in addition to reassurance, there is encouragement, i.e. those affected should learn again what they avoided when they were afraid.
Cognitive reassurance and encouragement
The easiest way is to understand the connections. In other words, what you are hopefully doing right now: taking a new look at the complaints, gaining a different understanding of the physical regulations. Details can be found in all the disease patterns described here on this page.
However, this step is not quite so easy if you have been convinced for a long time that environmental toxins or similar factors are to blame for your complaints. It is often difficult to detach yourself from such concepts, especially if a great emotional or financial sacrifice (e.g. house remodeling, moving, quitting) has already been made because of the disease theory. Then these sacrifices suddenly seem pointless, which poses a great challenge to the inner self.
Emotional reassurance and encouragement
Inner calming, the release of anxiety and tension are a second essential step in overcoming functional complaints.
Especially if they are based on serious problems from the past, psychotherapy can be extremely helpful here.
- Reduction of guilt
- Mediation of competence
- Reduction of tension
- Resolution of entanglementEmotional reassurance and encouragement
Physical reassurance and encouragement
The physical reaction is genetically controlled. Many of the stress genes we share with animals, they originate from a time when there was no language in our sense.
Therefore, in order to influence such functional complaints, a "language" must be chosen that our body understands. This "language" is physical. I.e. massages, warmth, cold, movement, breathing or nutrition reach another layer of our being than emotional touch or purely cognitive information.
Therefore, we believe that "old" physical processes (digestion, basal stimulus processing, breathing, metabolism) can be influenced mainly by "old" ways, i.e. by a "language" that even infants or animals can understand.
Some rules of experience apply to this type of intervention:
- Therapy methods that act through many sensory channels are particularly effective. Thus, if the eye, ear, nose, taste, the perception of pressure, touch, heat, cold and internal organs are addressed simultaneously. Here above all an experience is to make: there is no danger. This simultaneity of experience is one of the basic pillars of therapy.
- The therapy depends on a large number of repetitions. I.e. again and again the "heal, heal bless" experience must be sensually experienced. Probably several thousand cycles are necessary for restructuring of circuits in the nervous system.
- Calming down, relaxation, pampering are not sufficient, otherwise a stress reaction will occur again once the world is more unfriendly. Therefore, one part is also hardening. In this process, it is taught that it is not threatening if stronger stimuli ever come. So the inner system should be "recalibrated".
- So, if a treatment works repeatedly through many channels, if it also contains hardening elements, if it is understandable and takes place in a secure emotional relationship, then the duration plays a subordinate role, i.e. progress is then possible surprisingly quickly.
- Ultimately, we follow the same principles in "hardening" as we do with specific phobias, e.g. a dog phobia. Avoidance makes everything worse. Therefore, here we confront slowly. At the beginning with cute puppies, then with small harmless, playful dogs and finally with always right big yappers.
Multimodal therapy
Multimodal therapy procedures are currently considered the "gold standard" in the therapy of functional disorders.Guideline citation: "More advanced formal definitions of multimodal treatment require the inclusion of a psychosocial specialty (for psychosocial diagnosis and course assessment, not necessarily psychotherapy), and in addition the use of at least three of the following active therapy methods: Psychotherapy, physiotherapy, relaxation methods, occupational therapy, artistic therapy, (medical) training therapy or other exercising therapies (source: German Institute for Medical Documentation and Information DIMDI; German operation and procedure code OPS number 8-918.x)."
The trick now is to select the appropriate procedures:
- Which treatment methods should be combined?
- How many therapies are optimal?
- How long should treatment last per day?
- How long should the overall therapy last?
Self-help and self-efficacy
Very central is the teaching of ability to help oneself after therapy. Therefore, we have developed programs that can be continued at home after therapy.
For some existing complaints, structured online programs exist that guide step-by-step through self-help.