The function of ‘functional’: a mixed methods investigation
Richard A Kanaan1,
David Armstrong2,
Simon C Wessely1
Contributors: RK designed the study, collected the data, analysed the data, drafted the manuscript and acts as guarantor; DA designed the study, cleaned the data, analysed the data and edited the manuscript; SW designed the study and edited the manuscript. All authors had full access to all of the data in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.
Received 18 July 2011 Revised 12 October 2011 Accepted 19 October 2011
Published Online First 16 January 2012
Abstract
Objective
The term ‘functional’ has a distinguished history, embodying a number of physiological concepts, but has increasingly come to mean ‘hysterical’. The DSM-V working group proposes to use ‘functional’ as the official diagnostic term for medically unexplained neurological symptoms (currently known as ‘conversion disorder’). This study aimed to explore the current neurological meanings of the term and to understand its resilience.
Design
Mixed methods were used, first interviewing the neurologists in a large UK region and then surveying all neurologists in the UK on their use of the term.
Results
The interviews revealed four dominant uses—‘not organic’, a physical disability, a brain disorder and a psychiatric problem—as well as considerable ambiguity. Although there was much dissatisfaction with the term, the ambiguity was also seen as useful when engaging with patients.
The survey confirmed these findings, with a majority adhering to a strict interpretation of ‘functional’ to mean only ‘not organic’, but a minority employing it to mean different things in different contexts – and endorsing the view that ‘functional’ would one day be a neurological construct again.
Conclusions
‘Functional’ embodies real divisions in neurologists' conceptualisation of unexplained symptoms and, perhaps, between those of patients and neurologists: its diversity of meanings allows it to be a common term while meaning different things to different people, or at different times, and thus conceal some of the conflict in a particularly contentious area. This flexibility may help explain the term's longevity.