Editorial |
Functional disorders—a cause of increasing work absence?
In this issue of Occupational Medicine, IIhlebaek et al. [1] report on health complaints and sickness absence. Against the backdrop of a 65% increase in sickness absence days over the 7 years to 2003 they discovered that the prevalence of health complaints, while high, had been stable over this period apart from allergy and asthma. Although the research is from a single Nordic country, it is likely that their findings are applicable throughout Western Europe.What might account for this apparent discrepancy? Despite conflicting trends perhaps there is a clue in another of their findings—that while their absolute numbers were relatively small, the largest increase in sickness absence was related to sleep problems, tiredness and anxiety symptoms. These are non-specific symptoms, common to each of us as individuals and certainly familiar to clinicians as a substantial part of their workload. These are also closely associated with the functional disorders.
Functional disorders are characterized by combinations of symptoms which can be associated with virtually any body system. Symptoms can be changeable, affecting different bodily systems and overlapping between one type of disorder and another. These disorders have no clear pathophysiological basis and are also not merely a surrogate manifestation of a psychological problem. The list of currently described functional disorders is long and varied—irritable bowel syndrome (IBS), non-cardiac chest pain, fibromyalgia, non-specific joint discomfort, low back pain of unidentifiable cause, pelvic disorders and dysparunia, irritable bladder syndrome and so on. A hallmark of these disorders is the presence of non-specific problems such as sleep disorder, tiredness and anxiety.
Such disorders have long been recognized. Osler in 1892 [2] referred to the ‘neuroses of the stomach’ but acknowledged his inability to explain how mental state actually affected the bowels. Present thinking, although more sophisticated, essentially encapsulates the same frustration. Despite increasing knowledge about neurotransmitters, the hypothalamic-body axis and the role of serotonin in and outside the brain, we are not much closer to defining the root of these disorders, most of which are characterized by apparent hypersensitivity of the organ ostensibly affected. For example, visceral hypersensitivity is a characteristic of IBS and pressure point hypersensitivity has been identified in fibromyalgia, both despite the absence of any structural or biochemical abnormalities. Although accepted as diagnoses, some of these labels are seen by some sufferers as an attempt to resolve the meaninglessness of a mysterious label [3]. What is clear is that these problems have an enormous effect on peoples' lives in terms of quality and in sickness and sickness absence.
IBS is well researched in this regard. The prevalence of IBS is 6–25% depending on location and definitions [4]; a recent study reported a Europe-wide prevalence of 11.5% with 9.6% suffering from current symptoms and 4.8% having received a formal diagnosis of IBS from a clinician [5]. Of IBS sufferers who responded to this large survey across eight European countries, 78% reported that the condition affected their general state of health. Among factors which impinged upon their lives were difficulties with diet, concentration, long journeys and relationships. Over the previous year, nearly 70% of sufferers reported having symptoms lasting between 1 and 9 days per month, others reported being more frequently affected. More than 50% of sufferers reported that the condition affected their work or their choice of job, caused problems with time management and affected their self-confidence. IBS sufferers reported more sickness days off work in the previous 12 months; overall, they spent 3.9 days in bed due to sickness compared with 2.7 days for non-sufferers and 5.5 sickness days off work compared with 3.1 days. They also reported 10.2 days when work activities had to be cut short because of their condition compared with 4.8 days for non-sufferers. Tellingly, although 96% of sufferers had discussed their problem with others, only 10% had told their employers about it.
These data are likely to reflect the situation in the other functional disorders. The combined effect of these problems points to them being a major contributory factor to sickness. There is increasing evidence of the impact of these conditions on the health services, for example, IBS forms the largest component of referrals seen by gastroenterologists throughout the UK. The medical symptoms (IBS, chronic pain, etc. as detailed above) will be familiar to any practising clinician and if the psychological syndromes (such as anxiety, depression and somatoform disorders) are added these probably constitute the majority of consultations in primary care. The problem is not confined to Europe or USA: the World Health Organization reports functional symptoms to be common and disabling in primary care patients in all countries and cultures studies with up to half remaining disabled by their symptoms up to a year after presentation [6].
What then are the solutions? Stress and lifestyle undoubtedly play a role in these problems and studies have confirmed associations with anxiety and depression. However, the management of these disorders is difficult and frequently complex. Management strategies need to be geared to the individual sufferer with their particular symptoms. Bass and May [7] describe a combined strategy for chronic multiple functional symptoms. This comprises a biomedical approach based on symptoms, investigations (and presumably a positive diagnosis of the functional disorder) and drugs or operations and/or a biopsychosocial approach engaging with distress, broadening the agenda and heading towards rehabilitation and coping. If IBS is used as an example, symptom-based drug therapies have proven to have only limited success with the psychotropic drugs also only having a narrow role [8]. Psychological interventions, particularly cognitive behaviour therapy [9,10] and hypnotherapy [11] are effective but are constrained because of the needs for subject selection, time and resource. There are probably two challenges: the recognition of the functional disorders and their acceptance as real problems with their impact upon sufferers' lives and work and, secondly, providing an effective clinical response, not least with regard to sickness absence.
Professor of Primary Care and General Practice, Dean of Medicine, Durham University, Queen's Campus, Stockton on Tees TS17 6BH, UK
e-mail: Dean.medicine{at}durham.ac.uk
References
- Ihlebaek C, Brage S, Eriksen H. (2007) Health complaints and sickness absence in Norway, 1996 –2003. Occup Med (Lond) 57:43–49.[Medline]
- Osler W. (1892) The Principle and Practice of Medicine(Appleton and Co, New York).
- Madden S and Sim J. (2006) Creating meaning in fibromyalgia syndrome. Soc Sci Med 63:2962–2973.[CrossRef][Web of Science][Medline]
- Gschossmann JM, Haag S, Holtmann G. (2001) Epidemiological trends of functional gastrointestinal disorders. Dig Dis Clin Rev 19:189–194.
- Hungin APS, Whorewell PJ, Tack J, Mearin F. (2003) The prevalence, patterns and impact of irritable bowel syndrome: an international survey of 40,000 subjects. Aliment Pharacol Ther 17:643–650.
- Mayou R and Farmer A. (2008) Functional somatic syndromes. ABC of psychological medicine. Br Med J 326:265–268.
- Bass C and May S. (2006) Chronic multiple functional somatic symptoms. ABC of psychological medicine. Br Med J 325:323–326.
- Brandt LJ, Bjorkman D, Fennerty MB, et al. for the American College of Gastroenterology Functional Gastrointestinal Disorders Task Force. (2002) An evidence based approach to the management of IBS in North America. Am J Gastroenterol 97:(Suppl. 11), S7–S26.[Web of Science][Medline]
- Speckens AE, van Hemert AM, Spinhoven P, Hawton KE, Bolk JH, Rooijmans HG. (1995) Cognitive behavioural therapy for medically unexplained physical symptoms: a randomised controlled trial. Br Med J 18:1328–1332.
- Kennedy T, Jones R, Darnley S, Seed P, Wessely S, Chadler T. (2005) Cognitive behaviour therapy in addition to antispasmodic treatment for irritable bowel syndrome in primary care: randomised controlled trial. Br Med J 331:435–441.
[Abstract/Free Full Text] - Whorwell PJ. (2005) Review article: the history of hypnotherapy and its role in the irritable bowel syndrome. Aliment Pharmacol Ther 22:1061–1067.[CrossRef][Web of Science][Medline]
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