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Functional disorders

" Be merciful to me, O Lord, for I am in distress; my eyes grow weak with sorrow, my soul and my body with grief..."
The Bible (psalm 31-9).


The term "functional disorders" gathers together the set of symptoms that have no clearly identifiable medical cause (on the opposite of lesional disorders which express an "organic" disease).

That diagnosis, called "eliminatory", is difficult because it is only carried out at the issue of expensive check-ups imposed by the "obligation of means" (stated in the deontological code).

Here, despite the pain and handicap, the complementary examinations are not contributive and the "symptomatic" treatments are often deceiving.

This failure of the "biomedical" logics in front of worrying, disabling and capricious symptoms leads to the implication of "stress" and psycho-somatic or alternative theories but the role of sleep remains widely underestimated, all the more since the natural evolution (apart from "iatrogenic disorders") is very favorable.

"These "bad" sick people who always hurt somewhere ..." ;
"These "good" sick people who want an a bit too long prescription..."

On 1 000 adults, 800 present symptoms, 327 think about seeing a doctor, and 217 really do, in first intention medicine, 13 ckeck-in in emergency room, and 8 are hospitalized.


Functional disorders present very evocative clinical and somnological characteristics.

These characteristics are common with the data issued from sleep research where everything looks as though the decompensation of a lack of sleep efficiency expresses physically through a functional disorder, which we suggest to describe as a "somnosomatic" symptom.

Taking the implications of sleep in general medicine into account could (in our opinion) allow to gather together the set of functional disorders in a new syndrome : the "hypo-sleep syndrome". [1]

Functional disorders can affect any part of the body :

(They are described as "ubiquitary")

  • The head : is the place of a lot of functional disorders : ocular disorders, dizzy spells, migraines, tinnitus, dystonia...
  • The chest is the place of supposed cardiac pains and the sensations of lacking from air.
  • The abdomen is very rich of symptoms that the common sense relates to tiredness. These intestinal functional disorders are the subject of many medical publications but sleep is not taken enough into account.
  • The pelvic area is, like the abdomen, the place of numerous disorders whic concern the urinary (unstable bladder), sexual, or digestive (haemorrhoids, itching, crevice...) functions.
  • The locomotor system gathers pains from the rachis (lumbalgia, dorsalgia, sciatica) and numerous rheumatisms and tendinitis that are difficult to relieve and of capricious evolution: carpal tunnel, Naffziger syndrome (scalenus anterior syndrome) , Osgood Schlatter disease, spondylolisthesis, Tietze’s syndrome (costochondritis), Arnold’s neuralgia ...
  • The skin expresses tiredness (like all richly innervated organs do), with swarming sensations, itches, skin eruptions, acne, hair loss, hyperhydrosis, Raynaud’s syndrome...

They gather together the four following clinical characteristics :

  • They are worrying: even the most refractory subjects against the medical profession (who often do not even have a "family doctor") end up consulting (often in emergency), when their reticences collapse.
    Cf. "The alarm system".
  • They are disabling : they induce a multiplication of specialized consultations (expensive and/or painful), which leads to a "therapeutic escalation" often responsible for surgical or medication induced complications.
    Cf. “The Train of the «hypo-sleep» syndrome”.
  • They are capricious : the absence of objective signs and the normality of the complementary explorations (but beware of the possible bias...) implies that, sooner or later, a "psycho-somatic" anxio-depressive or even "imaginary") mechanism is mentioned.

    Besides, that failure of conventional medicine (the absence pf results of the "hippocratic model" : a symptom expresses a lesion), explains the mistrust of the patient and his/her fascination for the socalled "alternative" medicines.

    Listening more to these really sick people, the pseudo-sciences do not, objectively, reveal more to be efficient but some subjects find some real "relief" in them because it is preferable to invent a pseudo-answer than to sink into despair.

  • They are of good prognosis : fortunately, and to the opposite of most chronic diseases (like diabetes, arthrosis, or artériosclérosis...), the functional disorders never get worse and almost all heal on the long term.

    Migraine, colopathy, chronic lumbalgy, stiff neck, palpitations and tinnitus (etc.) spontaneously disappear with age (they are no longer causes of consultation in old people’s homes).

They gather together the following somnologic characteristics :

clinophilia witnesses for the intensity of tiredness (Pichot’s scale) . That tiredness contrasts with the absence of sleepiness (Epworth scale).

sleep disorders are of very different kinds, in concordance with the stage of the illness, but the sensation that sleep is no longer "restful" translates the feeling, that is common to the sick persons.

  • Clinophilia :

    This term describes the constant need of lying down to get rest every time it is possible. We observe that the tired subjects feel particularly "forced to settle down" at moments of the day which are paradoxically in counterphase with the "natural gates to sleep" (these "sleep gates") which correspond to physiological reductions of arousal and body temperature).

    Clearly :

    • a subject who lacks sleep will yawn and feel the need to sleep (sensation of sleepiness) rather around 1 to 3 PM, or during the night;
    • while the one who suffers of tiredness often says that he/she has to lie down in the end of the morning or around 6 or 7 PM, in a period of the day when the body is normally at its highest and he/she will be in a better shape during the night. (have to sleep).

    It is necessary to insist, here, on the essential differences that exist between the sensation of "sleepiness" and that of "tiredness". The scales that are used in sleep medicine to measure their respective intensities do not at all contain the same items.(See the "tests").

  • Sleep disorders : present under three different forms:
    • either pseudo-hypersomnia (in the start), because the subject tends to extend his/her sleep time in order to try to compensate the tiredness of the morning. When the disordre goes back to childhood, the sick person erroneously thinks he/she is a "long sleeper". Besides, he/she agrees to think that sleep is "very important" to him/her. It is the start of the performance seeking insomnia.
    • or an insomnia of maintaining sleep with frequent urination and a too early awakening (aggravated by a tendency to go to bed more and more early in order to manage to get some rest);
    • or a sleep onset insomnia, at a more advanced stage of the "wanting to sleep". The necessity to sleep becomes such an obsession that the motivation to sleep becomes, in itself, awakening.

What we know in sleep medicine :

Fibromyalgia (an illness mentioned in the international classification of sleep disorders since 1992) is the subject of many scientific papers.

The sleep labs make studies in collaboration with the businesses that are concerned by atypical work rythms (aviation, transport, military ...).

  • The sick persons who suffer of fibromyalgia or chronic fatigue all present a great number of functional disorders. Moreover, it is known that their sleep (systematically felt like "not being restful") often shows structure abnormalities. The (EEG) recordings of cerebral activity show the presence of signals of arousal (Alpha waves) which add themselves to slow wave sleep (Delta), resulting in an «Alpha-Delta» pattern.  [2]
  • Some somnological situations cause a close chart that combines, at different degrees, tiredness, functional disorders and multiple pains. It is known under the term of "internal desynchronieation syndrome".

    The workers who are badly adapted to delayed schedules (night or shift work), suffer of that desynchronisation of the biological clocks and complain of numerous functional disorders.

    The people who face time zone changes in repeated transmeridian flights (airline pilots, air hostesses, stewards) suffer of an identical chart : the «jet lag» syndrome.

  • Experimentally, some sportsmen and women on training interruption show a degradation of their slow wave sleep which goes with the same functional disorders. (Heavy sportsmen and women often admit that they can’t stop training).
  • Expérimentally, the situations of "bed rest", (recently carried out for space research), lead to similar charts of functional disorders.
  • Night workers (emergency physicians, for example), often observe minor similar functional disorders (digestive disorders, hemorrhoid eruptions, muscle and tendon pains, palpitations or headaches ) that follow every difficult gesture.

Sleep and general medicine ?

Cf: "Tiredness or sleepiness?"

In our opinion, most of the functional disorders encountered in general medicine are related to a problem of sleep inefficiency.

The concept of "hypo-sleep" that we introduce here stipulates that sleep is the engine of the illness. A perturbation in sleep efficiency would show through the appearance of functional disorders in a row of successive charts, quite stereotypical, going from the simple seeking for tonics to the chronic fatigue syndrome.

This point of view has been put forwards since the first descriptions of the illness by Pr. Modolwsky (1981) and it can be observed in the case of "jet lag". [3]

There seems to exist a true physiopathological continuum between the first functional disorders (signs of tiredness) and the apparition of more worrying symptoms like Fibromyalgia, «spasmophilia» attacks and/or chronic fatigue.

We descrive that succession of alarm signs like a "train" of clinical steps, characteristic to the assault course of those really sick people who someone called "homeless of the medicine".

This concept sets the basis of "somnicology" : the application of the rules of sleep and chronobiology medicine to the understanding and taking care of functional disorders.

Taking elements of sleep hygiene and balance is a therapeutic alternative susceptible to help the sick people to understand better a large number of their symptoms.

The efficiency of the caretaking relies on the understanding of the mechanisms of sleep.

A step of the patient’s education ("learn to sleep") is indispensable befor using "somnications" (the medications of sleep : light, sport, pleasure, heat) capable to influence the settings of the sleep’s balance.

The nap) is, here, rather contraindicated (on the opposite of excessive daytime sleepiness situations).

This care approach, centered on chronobiology, places the doctor-patient relationship on a more pragmatic and efficient collaboration ground than that of the placebo medication or conforting words.

That approach is still used too often in these functional pathologies, considered as "benign", but which witness for a real problem of tiredness and carry in them the germs of insomnia.

Footnotes

[1NB. The "hypo-sleep syndrome" is not an official and validated medical term.

It is one of the neologisms that we suggest to fill some vocabulary gaps in sleep medicine.

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[2The Alpha-Delta sleep is not specific to fibromyalgia patients. It has been observed in other situations (in subjects who lacked sleep or with depression).

This type of result is therefor no sufficient criteria for a diagnosis but should guide the patient in the direction of sleep medicine.
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[3The chicken or the egg?

In the actual medical litterature, the "sleep disorders" are often mentioned amongst the list of clinical signs "caused by" the illness.
According to that point of view, which we do not share, diseases like "Chronic Fatigue Syndrome", "Fibromyalgia" or "Depression" would be the root of a sleep disorder (insomnia or sleepiness?).
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Auteur | Contact | Copyleft | Traductions | derniere modif 13 October 2008.