Somatisation and functional disorders

What is somatisation?

Somatisation is a word that means that the symptoms that you are experiencing are not due to a specific disease process but are caused by other biological, social or psychological factors.

Although the word somatisation still means the same thing as it always used to, the conditions that used to be referred to as somatoform are now more commonly referred to as functional.

There are a very wide range of symptoms that can be caused by somatisation or functional disorders. They include (but are not limited to):

• Pain.

• Headache.

• Fatigue.

• Dizziness.

• Nausea.

• Vomiting.

• Fainting.

• Seizures or seizure-like activity.

These symptoms can all be caused by diseases - for example, anaemia can make you more likely to faint, arthritis can cause pain or epilepsy can cause seizures. However all these symptoms can also be caused by a complex interaction of biological, social and psychological factors - these are then referred to as functional symptoms.

Somatisation itself is extremely common and something that we all experience from time to time. We all recognise that sometimes when we feel stressed we feel more tired or get a headache. This physical symptom is caused by a condition that arises in the mind.

Somatoform or functional disorders are less common (though not uncommon). They are more complex than simple somatisation.

How can the mind cause physical symptoms?

The relationship between the mind and body is complex and not fully understood. However, we all recognise (even without noticing) the relationship between the mind and the body on a daily basis. For example, when we are feeling sad, our posture might change to be more droopy and our actions, such as walking, might become slower. We all recognise that the mind is used by both children and adults to learn new physical skills - for example, a toddler's mind helps it to learn to walk or to climb, an adult's mind helps it to learn to knit or ski. In a similar way, the mind can affect other aspects of our body. A mind can teach a person to develop unhelpful symptoms in just the same way as it can teach it useful physical skills.

How common is somatisation?

It is common. Sometimes we can relate the physical symptoms to a recent stress or mental health problem. For example, you may realise that a bout of neck pain or headache is due to stress. Anxiety and depression are also common reasons to develop physical symptoms such as a 'thumping heart' (palpitations) or bodily aches or pains. Often the physical symptoms go when emotional and mental factors ease.

However, sometimes we may not realise the physical symptom is due to an emotional, psychological or social factor. We may think we have a physical disease and see a doctor about it.

Somatisation and functional symptoms

A functional symptom means a function of the body is faulty (for example, there may be pain or diarrhoea) but the cause is not due to a disease causing that pain or the diarrhoea. The cause may be due to psychological, social or biological factors.

What are functional disorders (previously known as somatoform)?

Functional disorders are at one end of the scale of somatisation. So, the physical symptoms persist long-term, or are severe and cause significant disability, but there is no physical disease present to explain the symptoms.

They are classed as mental health disorders but this can be unhelpful. Psychological input can often help to treat functional disorders but they cannot be solely attributed to mental health conditions such as depression or anxiety. There is often a complex relationship between emotional, psychological, social and biological factors that lead to a functional disorder.

It can be hard to accept that symptoms that are severe enough to affect our quality of life can be due to a functional disorder. When pain is very severe, it is completely rational to assume initially that that pain must be due to a physical cause such as arthritis, cancer or injury.

However one of the common misunderstandings about functional disorders is that they are less severe or less significant than symptoms that are caused by disease. This is not the case. However, understanding that the symptoms are caused by a functional disorder is key to being able to manage and treat those symptoms effectively.

Functional disorder

People with this disorder may have a variety of symptoms and signs. These include, but are not limited to:

• Headaches.

• Feeling sick (nauseated).

• Abdominal pain.

• Bowel problems, particularly diarrhoea.

• Tiredness and fatigue.

• Fainting or seizures.

• Sexual problems.

• Dizziness.

• Weakness of the limbs.

• Hoarse voice or "lost" voice.

There is no single cause of functional disorders. There is often a complex interplay between social, psychological and biological factors.

Our brains are constantly affected by sensations. For example, when you are sitting in a chair, many parts of your body are being touched by the different parts of the chair. When you have a minor injury to your leg, your leg will hurt as it is recovering. When you are working and there are children playing in the park outside, they are making noises that your ears can hear. However, our brains are good at filtering out some of these things. We are not usually aware of the feeling of the chair pressing on parts of our back and legs. We often can forget about the leg pain until something brings it to our attention. We can often block out noises so that we can concentrate on our work.

It is likely that, for some reason, functional disorders tend to start when the brain starts to notice certain normal biological symptoms but perceives them as abnormal or strange.

For example, many of us might feel nauseous or light-headed if we have not eaten for some hours. We all will experience tiredness and pains in our legs if we have been for a long walk. We may notice that our voice is weaker than normal when we have a sore throat or cold. Usually we recognise these symptoms as normal and can see that they will pass if we eat some food, have a rest or wait for the cold to pass.

However, sometimes our brains stop treating these sensations or symptoms as normal and we start to become very aware of them. There may be particular reasons for this. If a family member has recently been diagnosed with a heart condition then we might be more aware of our heart beating when we are feeling a bit anxious and might be more likely to think that these "palpitations" are dangerous. If we know someone with diabetes, we might be more aware of feelings of nausea or light-headedness when we haven't eaten.

Sometimes there are no obvious reasons for the changes in the way our brain is reacting. This may be more common in situations where someone has very severe pain but where there is no underlying physical cause for that pain.

Functional neurological disorder

Previously known as conversion disorder, functional neurological disorder (or FND) is a condition where a person has neurological symptoms, such as:

• Total loss of vision (severe sight impairment).

• Deafness.

• Weakness, paralysis or numbness of the arms or legs.

• Seizures or seizure-like activity.

These might normally suggest a disease of the brain or nerves (a neurological disease) but all the tests for disease are normal. The findings on examination tend to make it clear that a disease is not the cause because the examination findings tend to not make sense anatomically or biologically.

Pain disorder

Pain disorder is a condition where a person has a persistent pain that cannot be attributed to a physical disorder.

Who gets functional disorders and what causes them?

Functional disorders can affect anyone of any age. They are commoner in women than men and slightly more common at younger ages. The exact number of people affected is difficult to determine.

It is not clear why some people develop functional disorders. Genetic makeup and environmental factors both probably play a part. Genetic makeup is the material inherited from your parents which controls various aspects of your body. This genetic makeup combined with factors such as how you were brought up, your parental and peer influences, etc, may all contribute. There are also social factors which can affect how likely someone is to develop a functional disorder - for example, they have been shown to be more common in some asylum-seeking populations in certain countries.

Misuse of alcohol and drugs is more common in people with functional neurological disorders. However, there is no evidence that use of alcohol and drugs causes FND. It is more likely that some people may turn to alcohol or other drugs to ease the distress of their somatic symptoms. Unfortunately, excess alcohol or illicit drugs may make the symptoms worse.

What is the treatment for functional disorders?

It can be difficult for a doctor to diagnose functional disorders. This is because, even if the symptoms do not fit well with a disease process, it can be difficult to be absolutely sure of this without tests. People with functional disorders tend to be referred to various specialists, and have many tests and investigations before the diagnosis is made. Unfortunately, some of the tests that are done can be potentially harmful and increase the likelihood of disease in the future (for example, chest cancers from multiple CT scans or chest x-rays).

People with functional disorders can find it a difficult diagnosis to accept as people often misunderstand the diagnosis as meaning less severe, less significant or even that it is "made up". This is absolutely not the case - functional disorders can have symptoms just as severe or more severe than symptoms caused by disease, but it can be hard to understand. Media stories about functional disorders often talk about "mystery syndromes" as though there is an underlying disease process that we just haven't found yet. This can also make it hard to accept the diagnosis.

There is good evidence that psychological treatment works well to treat functional disorders. Cognitive behavioural therapy which tries to reframe the way that our brains react to symptoms or triggers has been shown to be effective at managing short-term and long-term symptoms.

Medication does not have much of a role but can sometimes help with underlying anxiety or depression. Some specific conditions such as pain disorder have been helped by medicines called selective serotonin reuptake inhibitors (SSRIs). Normal painkillers are not of much benefit with a functional pain syndrome.

Books about functional disorders

There is a neurologist called Suzanne O'Sullivan who works with people with functional disorders and who has written books which can help explain functional disorders in much more detail.

These books are called "It's All in Your Head" and "The Sleeping Beauties" and are highly recommended as further reading.