Somatoform disorders are a group of symptoms that can cause problems in the doctor-patient relationship. Patients are often disappointed by the results of repeated requests for further tests, as they believe that their illness is somatic and are desperate for treatment, with ineffective explanations. Symptoms and resulting behaviors can cause some impairment of social and family functioning.
Somatoform disorders are a group of neurological disorders characterized by persistent fears or beliefs about the predominance of various somatic symptoms. Patients repeatedly seek medical attention for these discomforting symptoms, and various medical tests that are normal as well as explanations from physicians fail to dispel their doubts. Some patients do have a somatic disorder, but the nature and severity of the symptoms, the patient’s distress, and the predominant perception are grossly inconsistent with the somatic disorder. It is often assumed that these somatic symptoms arise as a result of psychological conflicts and personality tendencies, and even though the symptoms are closely related to psychological factors, the patient is reluctant to accept them and refuses to explore the possibility of a psychological etiology, and the patient often has significant anxiety or depression.
Somatoform disorders include hypochondriac disorder, undifferentiated somatoform disorder, somatization disorder, somatoform autonomic dysfunction, somatoform pain disorder, and many other forms. It is more common in women and most of them start before the age of 30.
I. Etiology and pathogenesis
1.Heredity
Some existing studies suggest that somatoform disorders are genetically related. For example, Cloninger et al. in 1984 and Sigvardsson et al. in 1986 showed that genetic factors may be related to the onset of somatoform disorder. However, there is no conclusive evidence yet.
2.Personality characteristics
Many studies have shown that most patients tend to have personality traits of stubbornness, sensitivity and suspiciousness, and excessive concern for health. They pay more attention to their own psychosomatic state, so that their sensory threshold is lowered, especially the sensitivity to somatic sensation is increased. Therefore, they are prone to various somatic pains and discomforts, etc.
3.Neurophysiology
Patients with somatoform disorders may have dysfunction of the brainstem reticular formation. It may be caused by the dysfunction of integration filtering such as brainstem reticular formation or limbic system, and the enhanced perception of inner changes in the self. Prolonged sensory changes may then be experienced by the patient as symptoms of somatic discomfort.
4. Psychosocial factors
The attitude of parents or other elders towards the disease, living with a chronic disease patient for a long time is more likely to develop the disease. For example, early experience of illness, overprotective or lack of care in childhood are all contributing factors to somatization disorder. The influence of cultural factors: prejudice and discrimination against psychiatric patients and even against some psychiatric symptoms make people willing to show somatic symptoms rather than psychological symptoms. Also, because some somatic symptoms are more likely to be cared for and attended to.
According to the cognitive school, most patients are sensitive, suspicious, and overly self-conscious because they think they are suffering from some undiagnosed disease and are nervous and anxious. Then, repeated visits to the doctor are followed by increased anxiety and lead to selective perception of somatic changes, which can be felt at the slightest change or discomfort. This can lead to a vicious cycle of hypersensitivity to changes in oneself, triggering more anxiety and more discomfort or worsening of symptoms.
Parsons (1951) believed that patients could benefit from avoiding unwanted responsibilities by being ill, changing roles, enjoying privileges, and obtaining care and attention.
II. Clinical manifestations
1.Somatization disorder
Somatization disorder is also known as Briquet’s syndrome. The clinical manifestation is a variety of frequently changing or recurring somatic discomfort symptoms-based neurosis. The symptoms can involve any part or organ of the body, and various medical examinations cannot explain its somatic symptoms with organic lesions, patients repeatedly seek medical attention, have obvious anxiety and depression, and social function is obviously impaired. It is more common in women, most of them have an early onset (before the age of 30), and the course of the disease is often prolonged (more than 2 years). Common symptoms are as follows.
(1) Pain symptoms are common symptoms. The pain is usually not severe, and the pain is reduced or not when the mood is good.
(2) Gastrointestinal symptoms are common symptoms. Most of the symptoms include abdominal distension, abdominal pain, constipation, diarrhea, belching, nausea, vomiting, etc.
(3) Genitourinary system symptoms The common ones are frequent urination or difficulty in urination; genital discomfort; sexual dysfunction (such as coldness, erection or ejaculation disorder); menstrual irregularities. Abnormal vaginal secretions, etc.
(4) Respiratory and circulatory symptoms Such as shortness of breath, inability to lift the breath, chest tightness, discomfort in the precordial area or palpitations.
(5) Some patients show pseudo-neurological symptoms such as ataxia, limb weakness or paralysis, pharyngeal obstruction or dysphagia, deafness, blindness, skin sensory loss, etc. .
2.Undifferentiated somatoform disorder
Undifferentiated somatoform disorder: It is often manifested by one or more variable somatic symptoms, and its clinical manifestations are similar to those of somatization disorder, but the symptoms are not as abundant, the areas involved are not as extensive as those of somatization disorder, and the symptoms are not typical. The duration of the disease is between six months and two years.
3. Hypochondriasis
Also known as hypochondriac disorder, the main clinical manifestation is the fear or belief that one is suffering from a serious physical disease, and the degree of concern is very disproportionate to the actual health status. Patients repeatedly go to the doctor because of this symptom, and the conclusion of various negative medical tests and the doctor’s explanation cannot eliminate the patient’s concern. Some patients do have certain somatic disorders that do not explain the nature and extent of the patient’s stated symptoms or the patient’s perception of distress and dominance. Most patients are accompanied by anxiety and depression. Suspicions of body dysmorphic disorders (also known as body dysmorphic disorders) are also part of this disorder, although they are not well founded or even unfounded.
Symptoms vary from patient to patient, with some presenting primarily as suspicious discomfort, often accompanied by significant anxiety and depression; others with prominent suspicion, but not significant somatic discomfort, or mood changes; some with vague or widespread suspicion of disease, and others more singular or specific. Whatever the case, the patient’s suspicion never reaches the level of absurdity or delusion. Patients mostly know that there is insufficient evidence of their illness and thus want repeated tests to clarify the diagnosis and demand treatment.
4.Physical form of pain disorder
Somatoform pain disorder: It is a persistent and severe pain that cannot be reasonably explained by physiological processes or somatic disorders, and patients often feel distressed and have impaired social functioning. Emotional conflicts or psychosocial problems directly contribute to the onset of pain, and medical examination does not reveal corresponding organic changes at the site of pain. The course of the disease is often prolonged and lasts for more than 6 months. Common sites of pain are headache, atypical facial pain, low back pain, and chronic pelvic pain. The pain can be located on the surface of the body, in deep tissues or in internal organs. The nature of the pain can be dull, swelling, aching or sharp. The peak age of onset is 30 to 50 years old, and it is more common in women. Patients often repeatedly go to the doctor with complaints of pain and take many kinds of drugs, some even lead to sedative and pain medication dependence, accompanied by anxiety, depression and insomnia.
Diagnosis and differential diagnosis
Diagnostic points
1.Key points of Western medicine diagnosis
Where the patient has one or more somatic symptoms as the main manifestation, but medical examination cannot find evidence of corresponding organic lesions; or although there is the presence of physical disease, but the severity or duration of its symptoms is very disproportionate, we should consider the possibility of somatoform disorders. The diagnosis is mainly based on clinical features, and in addition, pre-morbid personality characteristics are considered. Although each clinical type has its own prominent symptoms, the following general diagnostic criteria of CCMD-3 for somatoform disorders need to be met when making the diagnosis of each subtype.
(1) Symptom criteria
(1) Symptom criteria
②Predominantly somatic symptoms with at least one of the following: excessive concern for somatic symptoms (severity clearly disproportionate to the actual situation), but not delusional; excessive concern for physical health, such as excessive concern for commonly occurring physical phenomena and abnormal sensations, but not delusional.
(3) Repeatedly seeking medical treatment or requesting medical examination, but the negative result of the examination and the reasonable explanation of the doctor cannot dispel their concerns.
(2) Severity criteria
Impaired social function.
(3) Disease duration criteria
At least 3 months have elapsed since meeting the symptom criteria (at least 2 years are required for somatoform disorders, at least half a year for undifferentiated somatoform disorders and somatoform pain disorders).
(4) Exclusion criteria
Exclude other neurotic disorders, depression, schizophrenia and paranoid psychotic disorders, etc.
2, Chinese medicine diagnosis points.
To determine the diagnosis based on symptoms, heart, liver, spleen, lung, kidney, gallbladder, stomach, small intestine, large intestine, bladder, triple jiao, all five internal organs can be affected, also pay attention to the patient’s emotional changes, and social and family factors.
Fourth, the differential diagnosis
1, somatic diseases: some somatic diseases may be difficult to find objective medical evidence in the early stage, therefore, the diagnosis of various types of somatic form disorders requires at least 3 months of disease duration, some even require more than 2 years, in order to naturally exclude the somatic discomfort caused by various types of somatic diseases. Clinically, for those who are over 40 years old and show somatic discomfort as the main symptom for the first time, we must be cautious and do not make the diagnosis of somatoform disorder easily based on the patient having psychological triggers, no positive signs found in the preliminary examination and certain suggestibility, but observe carefully to avoid misdiagnosis and mistreatment.
2, depression: depression is often accompanied by somatic symptoms, while somatoform disorders are also often accompanied by depressed mood. The differentiation should consider the sequence of symptom occurrence on the one hand; on the other hand, the characteristics of the symptoms should be analyzed. If the depression is severe, there are still some biological symptoms, such as early awakening, morning heavy night light rhythm changes, weight loss and psychomotor retardation, self-guilt and self-blame, suicidal speech and behavior, and the mood for treatment is not as strong as that of somatoform disorders, and the effect of medication is better, etc. can be distinguished.
3, schizophrenia: early symptoms of suspicion, but its content is more bizarre, not fixed, there are thought disorders and common hallucinations and delusions, the patient does not actively seek treatment, can be distinguished.
4. Other neurological disorders: various neurological disorders may present with somatic discomfort or symptoms of hypochondriasis, but these symptoms are secondary and are not the main clinical phase.
V. Treatment
1.Treatment principles
Emphasize the doctor-patient relationship At the beginning of treatment, the establishment of the doctor-patient relationship should be emphasized. We should treat the patient’s pain and complaints with patience, sympathy and acceptance, and understand that they are indeed sick, not just “imaginary problems” or “pretending to be sick”. Because most patients have had a long history of seeking medical care, their symptoms and suffering may have been denied by other doctors. In fact, many patients do come back to the clinic with a sense of anger after being dismissed by other doctors.
A thorough medical evaluation and appropriate tests should be done in the early stages of the management of these patients, and the physician should give a clear report of the findings and give additional verbal explanations. A reckless request to see a psychiatrist is only likely to cause resentment in the patient. Treatment can begin with medication, but emphasis should be placed on psychological and social aspects of the assessment.
Introduce the topic of psychosocial factors contributing to illness as early as possible Once a diagnosis of somatoform disorder has been made, the physician should choose the appropriate time to bring up the issue of the relationship between psychosocial factors and somatic illness to the patient as early as possible. Patients should be encouraged to view their illness as involving somatic, emotional, and social aspects.
Give appropriate explanations, reassurance Giving explanations and reassurance based on medical findings is in itself therapeutic. However, reassurance should be given at the appropriate time, not just before the tests and before the patient is able to appropriately describe their distress.
Appropriate control of patient requests and treatment measures Doctors should avoid committing to scheduling too many tests to avoid reinforcing the patient’s disease behavior, but should also pay attention to tests to avoid missing diagnoses. Doctors can make regular appointments to provide necessary tests but not too often, which can avoid misdiagnosis on the one hand and reduce the patient’s anxiety on the other. It is important to educate the patient’s family members about the disease, because family members may also reinforce the patient’s disease behavior.
2.Western medical treatment
(1) Psychotherapy
Psychotherapy is the main form of treatment, which aims to let patients gradually understand the nature of the disease, change their misconceptions, remove or reduce the influence of mental factors, and make patients have a relatively correct assessment of their physical condition and health status. Currently, psychotherapy includes psychoanalysis, hypnosis and suggestion therapy (placebo is available), behavioral therapy and cognitive therapy, etc. Morita therapy may have a good impact on eliminating the concept of suspicion and is worth trying.
Medication: Not only should we pay attention to the performance of drugs, but also to the dosage and duration of medication, and pay attention to individuality and flexibility on the basis of mastering the principles; this is not only a technical issue but also an art.
Available benzodiazepines such as: Valium, Clonidine, Clorazepam (Lorazepam), tricyclic antidepressants such as: Amitriptyline, selective pentazocine reuptake inhibitors (SSRIS) such as: Paroxetine, Fluoxetine, Sertraline, etc. Application of small amounts of antipsychotic is also an option such as: Sulpiride, Olanzapine, Quetiapine, as well as symptomatic treatment of analgesics, sedatives, etc. The patient should be informed of the possible side effects and the time of onset of action to increase the patient’s compliance with the treatment.
(2) Physical therapy
Biofeedback therapy, cerebral microcurrent therapy (CES).
(3) Chinese medicine treatment
The uniqueness of Chinese medicine cannot be explained by “psychological effects” alone.
Acupuncture, physiotherapy and qigong are effective for some patients and can be tried.
Prognosis
For the prognosis of suspected disease, it is generally believed that there are obvious mental triggering factors, and the prognosis of acute onset is better. The prognosis for chronic onset and duration of the disease lasting more than 2 years is poor.