Finding your own way to manage patients with functional disorders

There is a high prevalence of patients with medically unexplained symptoms (MUS) in primary and secondary care settings. Persistence of MUS is common, with a study based in secondary care identifying half of all referred patients having no clear diagnosis yet have an associated impaired quality of life.¹ Beyond the personal costs to these patients with functional disorders, there is accompanying impaired work productivity (approximated at £14 billion in the UK) and increased healthcare costs (estimated £2.9 billion to the NHS).² The irony is that the need for a multidisciplinary approach integrating physical and mental healthcare services has been established for some time, but has proved elusive in practice. The articles in this themed edition of Clinical Medicine are directed towards helping the clinician find their own style of managing these common presentations, recognising the multi-system nature of the problem and finding their own way of understanding this and communicating it with patients.

But before that integrated approach is possible, the essential first step is to diagnose the patient accurately, and that is the theme of the first paper in the series.³ While the bravely written case report can be read as the description of an unusual condition, the deeper message is the importance of taking a history with an open mind, even if you are the third or fourth person to be seeing the patient with the same unexplained symptom. There follow two papers on the assessment of patients who remain symptomatic when an organic diagnosis has been excluded. The first highlights the importance of identifying pathological health anxiety, which often takes that most precious of commodities, time.⁴ The authors make a case for a nurse with psychological training to lead outpatient management of patients with functional disorders. This potentially provides easier access to psychological input as well as removing the often-perceived taboo of an external referral to a mental health professional. The second paper provides an excellent practical approach to history taking and information-sharing with the patient, adherent to a core principle of management – namely that patient self-care depends on having an accurate understanding of the condition.⁵

Chronic pain and fatigue are often the most troubling symptoms in patients with functional disorders, and commonly the ones clinicians have greatest difficulty in manging. Eccles and Davies explore the overlap with joint hypermobility and dysregulated inflammatory processes, and present the emerging evidence suggesting a neuro-immune basis to aetiology.⁶ The same group present some original data developing the theme of hypermobility in patients with fibromyalgia and chronic fatigue, identifying high rates of misdiagnosis.⁷ The edition also features a series of reviews from clinicians active in practice and research with this patient group, organised by clinical specialty.^8–10 This may seem counter to the theme developed in the series of thinking in a multidisciplinary way, but these papers reflect the reality that patients are referred to physicians based on dominant symptoms. As such, while there are common themes that emerge in how patients are managed, what is also clear is the need to assess patients according to their presenting symptoms. These speciality-based papers all have a message to the naysayers about functional disorders – they point to aspects of aetiology that are distinctive and emerging in the literature.

Another paper in the theme is on the ‘hot topic’ of long COVID.¹¹ More than one in ten individuals who get COVID experience chronic symptoms, hence this emergent diagnostic label; we have previously published on rehabilitation following infection.¹² Now Ladds et al describe the particular opportunity presented by the proportion of healthcare workers who contracted the virus, and could potentially inform the agenda.¹¹ Their paper forms a nice bookend to the series, highlighting the importance of multidisciplinary services as well as advancing the research agenda. We hope you find much here to instruct your practice.