A Final Commonly Missed Diagnosis: Functional Symptoms

This missed diagnosis is a bit more complicated. It’s not one specific condition, like a slightly underactive thyroid or gluten intolerance. It’s about you and your doctor’s tunnel vision, the “if your only tool is a hammer, then everything around you is a nail” sort of thinking.

Functional symptoms constitute a huge spectrum of missed diagnoses that when carried in the wrong direction can actually hurt or even kill you from inappropriate testing and surgical procedures.

And even if they don’t physically hurt, the process can definitely make you a nervous wreck.

When you go to the doctor with a problem, you present her with symptoms, from top (“I’m losing my hair!”) to bottom (“My feet hurt”) and everything in between. Despite all the possible symptoms we can experience, and there are plenty, they all boil down to essentially two types:

• Disease-based symptoms are caused by a specific illness, such as hair loss due to scalp infection or underactive thyroid, painful foot due to plantar fasciitis.
• Functional symptoms are just part of you being a human being. Parts of our anatomy can hurt without anything being actually wrong. Functional symptoms come with the territory of being a person.

It’s less difficult than you might think to separate the two. Disease symptoms usually start at a specific point in time and get progressively worse, often fairly quickly. Likely disease: “My stomach hurt a bit last month and now it’s all the time and keeps me from sleeping.” Functional symptoms, on the other hand, come and go, often for years. Likely functional: “I was just about to go to a doctor with my stomach pain, but then it just vanished. I remember I had this same thing a couple of years ago.”

Stress and diet underlie functional symptoms

If there are two buzzwords for the underlying cause of functional symptoms, they are stress and diet. No matter what your functional symptom happens to be, the path most of the time can be traced back to one of the two (or both). We say “follow the money or the sex” for political chicanery. It’s “follow the stress or the diet” for functional symptoms.

When you present symptoms to your doctor, she should be deciding if they seem disease-based or functional. Disease-based symptoms need prompt investigation (tests) to make a diagnosis and initiate treatment. Functional symptoms can be approached in a more relaxed manner, as in “Let’s play detective. Let’s find out what sets off your symptoms and then you make lifestyle changes so you don’t have this symptom anymore.

If your doc were to treat all your symptoms–even those that sound blatantly functional–as disease-based, she’d be guilty of Tunnel Vision 101.

All this seems pretty straightforward, right? You, the patient, go to your doctor with a symptom. She listens to your history, examines your body, performs some tests, determines your symptom is either disease-based or functional, and treats you appropriately. In fact, if you’re basically healthy the odds will always be that your symptoms are functional. Especially when you hear the ubiquitous phrase “All your tests are normal.” And the very reason patients do hear this so often is, thank heaven, because most symptoms are functional. You might want to say that aloud: “Most symptoms are functional.” Louder, all together now: “MOST SYMPTOMS ARE FUNCTIONAL!”

But let’s say you’re not satisfied (“I don’t care that everything we’ve done so far is normal and that my symptoms are actually a little better, I want more tests or I want to see a specialist”). Alternatively, something shows up mildly abnormal, likely of zero consequence (“Your blood pressure is a little low,” “I think there’s a shadow on your chest x ray,” or “Your platelets are a little off”). Your physician then orders still more tests, or sends you off to a specialist.

And here’s where real trouble begins

Specialists themselves acknowledge their training renders them susceptible to serious tunnel vision. If you present yourself to a cardiologist with chest discomfort (even though your primary care doctor is pretty confident your pain is from pulling a chest muscle at the gym), you can expect an EKG, possibly a stress test, and an echocardiogram.

If you report having felt a skipped beat (like when you drink too many espressos) expect a Holter monitor. If your stress test is a tad abnormal, expect a coronary angiogram. All this for your pulled chest muscle.

In addition, and unfortunately, the financials of specialist health care are driven by “procedures.” The more stuff done to you the more money for your doctor. Yes, the specialists say, they don’t want to miss anything and they moan about the malpractice crisis, but there is an undeniable financial incentive to do more and more.

Functional vs disease-based

I’m going to end this health tip with a short but disturbing list I’ve prepared from patients telling me their medical histories. Underlined you’ll see common symptoms that are almost always functional, usually stress-related or dietary, and temporary. They’re annoying but harmless. Underneath each symptom is a list of the diagnostic and surgical procedures patients have told me they’ve undergone in an attempt to further diagnose, treat, or cure these largely harmless symptoms. Their personal view on the effectiveness of these procedures? A big fat zero.

Hair loss (stress-related)
Scalp biopsy, cortisone injection, Rogaine.

TMJ (stress-related jaw-grinding)
Dental reconstruction of molars, steroid injections into the jaw, insanely expensive mouth guards.

Fatigue (misdiagnosed as sleep apnea, stress-related)
Surgical reconstruction of uvula and palate, CPAP machine (frequently discarded).

Sinusitis (usually diet)
Multiple sinus endoscopies, surgical repair of sinuses (often repeated every three or four years), countless courses of antibiotics.

Heartburn (diet and/or stress)
Repeated (and normal) gastroscopies, surgical reconstruction of esophagus, years of medication.

Chest pain (stress induced)
Coronary angiogram, surgical intervention for minimal coronary artery plaque.

Palpitations (diet and/or stress)
Holter monitor, surgical ablation (destruction) of rhythm center of heart.

Back pain (stress-induced with minor MRI abnormalities)
Spinal surgery (often multiple), steroid injections.

Irritable bowel syndrome (stress, diet)
Multiple colonoscopies (the record being set by a 25-year-old woman with six normal colonoscopies starting at age 14), unnecessary surgeries including gallbladder and appendix removal.

Pelvic pain (stress)
Hysterectomy, cystoscopy.

Painful feet (bad shoes—stressful nonetheless)
Unnecessary and expensive orthotics, podiatric surgery.

Here’s what I suggest: before finding yourself on the verge of being aestheticized and wheeled into an operating room, ask yourself, “Could all this be stress? Could it be my diet? Do I really need this?”

Be well,
David Edelberg, MD