Academic critique of the "functional" concept

Liie

Liie

Senior Member (Voting Rights)
I have for a long time been wondering about academic criticism about the term "functional" from withing medicine itself.

The psychosomatic proponents try to launch this distinction between "functional" and "structural" aspects of the body. This seems to clearly be just a way to obscure the fact that they see medical conditions as psychosomatic. In factual terms the distinction seems more or less nonsensical.

I came across an article with the title "Avoid the concept 'functional' in pain healthcare" by processors and physicians (sorry, only Swedish):

lakartidningen.se

Undvik att använda begreppet »funktionell« vid smärttillstånd

Denna webbplats vänder sig till läkare
lakartidningen.se lakartidningen.se

The term "functional" has different meanings along a spectrum, the extremes of which consist of a fairly unproblematic emphasis on how the patient "functions" in their everyday life (a biopsychosocial perspective) on the one hand, to a problematic "psychiatrating" of long-term pain on the other. We interpret the text from Maroti et al as leaning strongly towards the latter. Underlying this, the terms "pathology" and "pathophysiology" are used unclearly and without connection to the state of research on pain conditions.
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In order for a scientific discussion to be able to take place and confusion and controversy to be avoided, it is necessary to agree on definitions of basic concepts within the academic subject in question. A considerable conceptual fog surrounds the term “functional” and its underlying assumptions, and we therefore suggest that it not be used for common pain conditions, such as fibromyalgia, chronic non-specific back pain, or IBS, as it risks misleading thinking.
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This is a bit like what I was interested in. But there is probably a lot more like this.

Maybe for example Brian Hugues has published something about this?

Please post discussion and links to other academic criticism of the concept "functional"!
 
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Richard Sykes (of Westcare), in one of his publications, addressed use of the term 'Functional'. He identified something like 14 separate definitions/interpretations of the term Functional across various medical and therapy disciplines. I have the book somewhere here, but all my papers are in boxes atm. So I may be able to find it, but it will take some time.
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how the patient "functions" in their everyday life (a biopsychosocial perspective)
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I have never seen anything out of biopsychosocial ideology that has anything to do with how a person "functions", and none of this is a spectrum of any kind. It's just generic propaganda gobbledygook. This is a completely imaginary version of what biopsychosocial means.
 
rvallee said:
I have never seen anything out of biopsychosocial ideology that has anything to do with how a person "functions", and none of this is a spectrum of any kind. It's just generic propaganda gobbledygook. This is a completely imaginary version of what biopsychosocial means.
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Yes, I also think that part was a bit confusing. Maybe the authors are not aware of how the term "biopsychosocial" has been used to simply camouflage psychosomatic theories, in the same way as "functional".

When I myself first saw that term I thought it sounded okay. That for example it could mean to also consider how a biomedical condition influences a patients psychological health and social situation. I have since learned that it is constructed specifically to mean "psychosomatic".

But the authors are active in pain research so they should know better.
 
In our household, the word “functional” has become something of a swear word. In medicine, it can mean very different things depending on context. Sometimes it just means measurable physiology, like functional MRI or liver function tests (ALT, AST). Sometimes it’s a polite way of saying there’s no identifiable pathology, as in functional dyspepsia or functional chest pain. Sometimes it’s used to imply a psychogenic explanation, as in functional movement disorders or functional neurological disorder. And then there’s functional medicine, where it’s mostly a marketing term for supplements, diets, and lifestyle tweaks. I’m very much in the “call a shovel a shovel” camp — if something isn’t supported by evidence, just say so.
 
There is Bob Souhami's comment in:
using 'functional' as if it meant something other than ignorance.

cstruter said:
functional MRI
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A bit off topic but I remember a conversation with Lynne Turner Stokes in which she claimed that 'functional MRI' meant imaging someone while they were 'functioning' - as in recognising a picture or talking, or some other behaviour. I tried to point out that it has always just meant (I am pretty sure) imaging physiological events like blood flow rather than structure. As such it can be useful regardless of any behaviour.

The discussion was in the context of the meaning of 'consciousness' (a pet interest of mine), which she claimed was a type of behaviour indicating certain brain activities - like eye or limb movements in response to stimuli. On this basis fMRI could not demonstrate consciousness by finding that a person with no behaviour at all showed specific shifts in brain blood flow when asked to think of playing tennis, or even to use thinking of playing tennis as a way of answering 'yes' to a question.

I found this quite disturbing as an attitude in an intelligent colleague. Consciousness is, to my mind, and most people who study it, a state of being aware, which may be reflected in certain behaviours, but is not in itself those behaviours.

Maybe this is the way rehabilitationists think. Everything is exercising limbs. An inner life of joy or suffering simply does not exist?
 
Nightsong said:
This is, I think, the Sykes paper on the "functional" term & psychogenicity:

https://philpapers.org/rec/SYKFRN
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This seems to be great!

It's apparently part of an exchange:

First article by Richard Sykes: Medically Unexplained Symptoms and the Siren “Psychogenic Inference”

Reply by Stephen Tyreman : MUSings on Functional Disorders

Reply by Michael Loughlin: Psychologism, Overpsychologism, and Action

Final reply by Richard Sykes (the one @Nightsong linked): “Functional,” Reasons, Neuroscience and the Psychogenic Inference

Unfortunately all are behind paywall. If anyone know where I can get hold of them, please tell me!

There should be more like this, no?
 
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I've (very briefly) glanced through a few of the papers in this exchange. Sykes introduces the concept of what he calls the "psychogenic inference":
What I am calling “the psychogenic inference” is the inference that: If there is no known physical cause for a symptom or disorder, the cause must be psychological. Although this inference is commonly made when thinking about patients with MUS, this paper aims to show that the inference is not justified: that it is in fact the seductive song of a dangerous Siren and leads to damaging “overpsychologizing”.
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I certainly don't agree with all of what he has written (he gives rather too much credence to psychology, even writing at one point that "[p]sychodynamic psychiatrists have a most important role in caring for patients with MUS"). And I suspect that some of the problems Sykes alludes to are less common now, e.g. his example of
a boy with CFS who insisted on wearing his cap in school lessons was diagnosed as needing some defense against the outside world, for which his cap was a symbol. In fact, the boy suffered from photophobia, a not uncommon symptom of CFS, and was using his cap to give himself some relief.
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That kind of 'symbolic' neo-Freudian thinking is less common now in psychology than it was decades ago, having been replaced with more behaviouralistic formulations.

Tyreman seems quite confused:
Sykes quite rightly highlights the ambiguity of the words “functional,” “nonorganic,” and “somatization.” He concludes that where there is no evidence that the problem is psychogenic, these terms should be replaced with more precise ones that do not imply psychogenic. He suggests the word “idiopathic” as a replacement, although to my mind idiopathic infers psychogenic just as much as functional does, and worse, may bamboozle the patient into thinking either that they have a real medical condition, or that the clinician understands the problem, when they do not.
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and then goes on to mount a defence of the "biopsychosocial model". Tyreman is also wrong about "idiopathic" being synonymous with "psychogenic"; it is regularly used in medicine to simply mean "not understood" (e.g. "idiopathic pulmonary fibrosis"). He appears to be an osteopath so would not understand that.

These kinds of debates & epistemological questions really don't interest me any more but may be of interest to some other philosophically-minded members here.

I also wasn't aware of some of the history related by Richard Sykes - e.g. there was a time when the Lancet was more sceptical of the psychologisation of ME/CFS:
Overpsychologizing can easily lead to the alienation of patients. This seems to have happened with large numbers of patients with CFS. When the Royal Colleges of Physicians, Psychiatrists and General Physicians produced a report on CFS in 1996 (Royal Colleges 1996), the report was greeted by a patients’ petition with over 10,000 signatures asking for its repeal. The main ground for the opposition was that the report overpsychologized CFS, a sentiment that was echoed in a contemporary Lancet editorial (Lancet Editorial 1996).
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