Function versus behaviour

In some respects, you might consider the divide between function and behaviour a niche branch of health and social care, alternatively, or, as I hope to explain, this has broader implications for everyday life, into how we interact with one another.

With respect to function, I am talking about the entity of ‘functional illness’ – this is a branch of medicine, psychology and psychiatry that remains poorly understood despite it being a component of Freud’s philosophy over 100 years ago.

What is functional illness?

This is when a patient has a symptom or symptoms which are not caused by physical disease. The list is long; indeed, people can have or produce any symptom you might imagine from pain to weakness, numbness, blindness through vomiting, incontinence and headaches.

Think of any symptom which may have a physical basis and there is likely to be a functional equivalent.

The interpretation for functional illness which I prefer to use relates to the manifestation of psychological symptoms without underlying physical abnormality or disease. In other words, an arm that doesn’t work is physically intact ‘normal’ – the systems that make an arm move – from the brain through the spinal cord to the blood vessels and nociceptors on the skin are all in what might be considered working order – if you place them under a microscope or test how they work, for example, checking nerve impulses, everything will look OK.

Despite everything looking OK – the MRI says ‘normal’ as does the CT, X-ray, biopsy and electrophysiology, if you are the patient, you still find that your arm is not working.

My interpretation, or how I choose to understand and explain to patients, despite the anatomy and physiology being intact (I don’t usually use those words), the arm is not working, and this is often a physical representation of other problems, those frequently being psychological in nature – depression, anxiety, stress.

Sometimes, after providing this explanation the patient will tell me, ‘Doctor, I feel fine, I don’t have anything to worry about, my life is great.’

I will then explain that sometimes we (that is people), don’t see what is affecting or upsetting us and instead of an individual experiencing anxiety, the body (whatever that is (mind/spirit/psyche/soma) opts to represent a symptom in a physical fashion – arm weakness.

As we know from Frankl, suffering is sizeless. What causes one person extreme distress might be considered an inconvenience for another. Yes, suffering and associated symptoms are infinite or they can be finite.

In Freud’s day, the arm weakness might have led to years of intensive Psychoanalysis (with associated high hourly rate of $$$), nowadays you would be hard-pressed to find a therapist or psychiatrist who would take you on; they might undertake an initial assessment – if they can’t find evidence of depression or anxiety, for example, often on a 50 or 100-point Likert scale, they may take you on if they are working privately, and, what the heck, we all have things to talk about or they may explain you don’t meet their criteria and politely send you on your NHS or occupational health way.

For many functional illnesses this is the experience of care – frequently ping-ponging between doctors and therapists (physical and psychological), the more obscure the symptoms and the more obscure the specialist who sees you, the more fanciful the investigations and potential treatments.

Frequently such disorders get better with time, sometimes the weak arm, or rather the normal arm that isn’t working becomes weak because of disuse and a person has a double disorder, this is something the healthcare system also struggles to support although they tend to find it easier to treat a weak arm that is weak than than a weak arm that has normal strength but not working.

Essentially, we don’t know – I was going to write ‘fully’ what causes functional illness, instead I’ll say, ‘We don’t know’ full stop, what causes functional illness, for example, where do the complexities of health – physical and mental stop or overlap? Where is a condition social as opposed to physical (thinking of West-Side Story here & Officer Krupke)?

100 years ago, it was thought people died of TB because they had artistic temperaments. Now we know it is the bacillus Mycobacterium tuberculosis. Last year people thought you could catch Covid from 5G telephone towers.

Much of our behaviour and understanding of life is little beyond witchcraft.

When a person has a functional symptom, the onlooker might interpret their situation in one of three ways:

The person has a diseased arm because of an associated physical problem – fracture, infection, stroke. When this is the perception, the person or patient is considered unfortunate, they are a victim and not to blame for their situation, they are even offered sympathy and compassion.

The arm is normal, it is a good, healthy arm, yet it does not work because of past or present psychological or psychiatric trauma or upset (Freud called this hysteria, thinking it was a particularly female condition) – these patients receive sympathy, usually so long as the weak arm or leg or headache or blindness isn’t causing too much inconvenience for another person.

The arm is normal, the person who says their arm can’t move is ‘putting it on’ maybe looking for sympathy or avoidance of an activity, this is the realm of behavioural, which in some circles might be considered malingering, although I believe this is separate.

There is no doubt that some people fake or fain illness – you’ll have seen documentaries where the insurance company secretly film the person claiming disability benefits whose limping leg or damaged arm miraculously recovers as soon as they leave the benefits office.

For the most however, it is more complicated than this.

I would probably classify the folk who conduct elaborate pantomimes for financial or other gain to be in the realm of psychopathy or perhaps the psychiatric nether-land of complex PTSD or personality disorder (both of which will take a more qualified person than I to describe.)

For me, ‘behavioural’ is a condition I encounter when dealing with colleagues who appear to apportion a degree of, let’s call it, moral judgment to the behaviour of others.

I find this area most difficult in relation to some of my patients who have dementia.

It is not uncommon for their behaviour, I say this in terms of ‘what they do’ to be described as ‘behavioural’.

I appreciate the last sentence does sound like an obfuscation – I’ll explain.

Picture a made-up old lady, let’s call her Florence.

Florence is 91 years old.

She has Alzheimer’s disease. She has been living at Windy Acres Care Home for the past six months.

Staff find that on occasion, when they offer Florence her meals, she will sit with her eyes closed. When the staff try to encourage or support her, even to the extent of trying to offer her food on a spoon, she keeps her mouth shut. Sometimes she has her eyes screwed tightly closed at the same time.

Nothing works with Florence, distraction, diversion, joking, cajoling, all the old tropes fail. You have to accept that Florence isn’t eating and leave her alone.

Sometimes, if you go away and leave some sandwiches on a plate in her room and return a couple of hours later, they may have disappeared, all with Florence still sitting with eyes and mouth tightly closed.

At other times staff will find that Florence is lying on the floor beside her chair. They never see her falling, they just find her on the ground. Trying to get Florence back in the chair is a struggle; it is as if her body is made of lead, floppy lead that doesn’t try to help the carers or herself.

Most of the time Florence is fine. She is friendly, she jokes with staff, she is able to walk around the care home with or without her walking stick.

In the past Florence has been taken to hospital after being found on the floor – the hospital doctors, despite their blood tests, ECGs, X-rays, CTs and even MRI’s can never find anything wrong.

These ‘funny dos’ are considered part of Florence’s dementia and people move-on.

And this is the thing.

Some of the staff think that Florence is pretending.

‘She knows exactly what she is doing,’ Says one carer, ‘It is behavioural.’

In this context, which I have heard nurses, doctors and therapists use when describing patients, the situation shifts from one of sympathy or understanding to either frustration or acceptance and occasionally judgment.

It is the judgment that is the problem and really why I set out to write all of this.

A doctor or nurse should (in my mind) try to understand, and, when they don’t understand, opt to accept that they do not understand. When people opt to judge, they are applying an assessment based upon their values and experience as to whether something or someone is good or bad.

When a patient is described as behavioural this is often in the context of apportioning a judgment.

‘Florence sometimes puts herself on the floor,’ is what you might hear.

The interpretation of this is Florence somehow intentionally being problematic, causing the staff extra work, in getting her back into her chair or bed (hoist required) or in the compiling of the incident form, ‘Florence has fallen again’.

Florence is not seen as a vulnerable woman with dementia who is in her 90’s, instead as a nuisance, someone who makes more work, someone who doesn’t play by the rules, behave normally or do what they should.

Is it OK for a doctor or nurse to judge a patient?

I guess the answer is that we can’t help judging. We are humans after all (despite the government wanting us to be heroes – a cunning mechanism for tricking people to go above and beyond again and again for a one per cent pay rise).

The thing for me, is that we should not allow our judgments to alter our treatment, support or assessment of patients.

We can judge but only in our own heads, and, more importantly, we need to acknowledge that we are judging and are victims of judgment when we apportion moral blame to those who have situations that are more complex than we can imagine.

And this, what is it?

It is person-centred care.

It is seeing the patient as ourselves.

Walking a mile in their moccasins.

When we are in their shoes, or, slippers, our interpretations change, the focus of our good or bad alters. We seek to understand rather than apportion blame.

Florence isn’t a bad old woman who causes extra work, she is a person, albeit with a terrible neurological disease – dementia, who is as much a victim of her situation as we the staff who are trying to support or care for her.

What does Florence gain from lying on the floor? Some will say she does it for ‘attention’ – an alternative question might be why Florence feels the need to attract attention, why is she willing to lie on the floor, what or how is she thinking?

We don’t always have to apportion blame or find a diagnosis. Sometimes we need to accept the situation for what it is and, move-on.

One day everything will be clear, everything will be explained, perhaps in another hundred or a thousand years, until that time, let’s hold on to our humility.