Somatoform disorder is a neurological disorder characterized by persistent fears or beliefs about the predominance of various somatic symptoms. Patients repeatedly seek medical attention for these symptoms, and various negative medical tests and physician explanations fail to dispel their doubts. These somatic symptoms are thought to be the result of psychological conflicts and personality tendencies, and patients often have semi-anxious or depressed moods.
Although the onset and persistence of symptoms are closely related to unpleasant life events, difficulties, or conflicts, patients often deny the presence of psychological factors. They also refuse to explore the possibility of a psychological etiology, even when there is significant depression and anxiety. Understanding the cause of symptoms, both physically and psychologically, is difficult. Patients often exhibit some degree of attention-seeking (performative) behavior and believe that their disorder is somatic in nature and requires further examination, and if they cannot convince their physician of this, they become indignant and are more likely to engage in attention-seeking behavior. The disorder is present in both men and women and has a chronic fluctuating course. Somatoform disorders include somatization disorder, hypochondriac disorder, undifferentiated somatoform disorder, somatoform autonomic dysfunction, somatoform pain disorder, and other forms.
I. Etiology and pathogenesis
The exact etiology of this group of disorders is unknown. Psychodynamic theory suggests that patients with this disorder tend to be awkward in exploring their inner psyche and therefore often insist on some somatic etiology. It is believed that this group of disorders is mainly caused by psychological factors.
1, Genetic: There are some studies that suggest that somatoform disorders are associated with genetic predisposing qualities. For example, the foster child studies by Cloninger et al. (1984) and Sigvardsson et al. (1986) suggest that genetic factors may be associated with the onset of functional somatic symptoms. However, with respect to the current data, no conclusions can be made about the strength of the influence of genetic factors on such disorders.
2. Personality traits: Many studies have shown that such patients mostly have neurotic personality traits of sensitivity and suspicion, stubbornness, and excessive concern for health. They focus more on their own somatic discomfort and its related events, resulting in a lower sensory threshold, increased sensitivity to somatic sensations, and easy to produce a variety of somatic discomfort and pain.
3, neurophysiology: It is believed that patients with somatoform disorders have brainstem net condition structural filtration dysfunction. Individuals are generally unable to perceive the normal activities of the body’s internal organs because they are filtered out in integrated bodies such as the reticular formation or limbic system. This is to ensure that the individual directs his or her attention to the outside world without being distracted by the various physiological activities in the body. Once the filtering function is dysfunctional, the patient’s sense of internal excitement is enhanced, and information about various physiological changes is constantly felt, and over time these physiological changes may be experienced by the patient as somatic symptoms.
4, psychosocial factors: parents’ attitude towards the disease, early living with patients with chronic diseases is a predisposing factor for the occurrence of somatization disorder. The symptoms of adult patients with somatization disorder and hypochondria are often the same patterns of symptoms seen in their childhood by their chronically ill family members. Early childhood illness, excessive parental care and protection during the same years, or lack of care all contribute to the development of somatization disorder in adulthood.
5. Cultural factors: There may be several influences on somatization symptoms: firstly, language influence, and secondly, certain cultures are less accepting of overt expression of emotions, care and attention given to those with somatic symptoms; in addition, most countries hold prejudice and discrimination against the mentally ill, which potentially encourages people to display somatic symptoms rather than psychological disorders. The psychoanalytic view is that somatic symptoms are a substitute for the individual’s fear of his or her own internal or external environment, a disguised emotional outburst. parsons (1951) proposed the concept of patient role, emphasizing the privileged, compensatory and other reinforcing effects of the socially acquired patient role, i.e., through illness, one can avoid unwanted responsibilities and obtain care and attention, also known as secondary benefits.
6. Cognitive effects: Because patients are sensitive, suspicious and overly concerned about their own personality characteristics, many patients develop the view that they are suffering from some undiagnosed disease. This is followed by increased anxiety and frequent visits to the doctor. This increased anxiety leads to a selective increase in the patient’s perception of somatic conditions, and the patient can feel their heartbeat and gastrointestinal motility. This can lead to a vicious cycle in which increased selective perception leads to repeated visits to the doctor, self-monitoring of blood pressure, pulse, urine and stool, etc., and any abnormalities trigger more anxiety, which in turn may lead to more somatic complaints.
II. Clinical manifestations
1.Somatization disorder
The most important feature of somatization disorder is that stress-induced unpleasant moods appear in the form of somatic symptoms.
(1) The most common are gastrointestinal discomfort (e.g., pain, hiccups, acid reflux, vomiting, nausea, etc.), abnormal skin sensations (e.g., itching, burning, tingling, numbness, soreness, etc.), skin blotches, and sexual and menstrual complaints are also common.
(2) Significant depression and anxiety are often present.
(3) Multiple symptoms may co-exist.
(4) The patient has undergone many tests for this purpose, but no positive findings, even surgical exploration, have been found.
(5) The disease is often chronic and fluctuating, with severe and long-standing social, interpersonal and family behavioral disorders that rarely resolve completely.
(6) Females are far more likely than males to develop the disease in early adulthood, and the earliest symptoms in females may be related to sexual difficulties or marital or romantic problems. Some patients can become drug dependent or abuse (mostly sedatives and painkillers) due to frequent treatment.
2.Divergent somatoform disorder
This type should be diagnosed if the duration of the disease is shorter than 2 years and the clinical manifestations are consistent with somatization disorder or atypical.
3.Suspicious disorder
Hypochondriasis refers to the patient’s predominantly persistent dominant notion of fear or belief of suffering from a serious somatic disease (hypochondriacal notion). The patient therefore repeatedly goes to the doctor, and various negative medical tests and doctors’ explanations fail to dispel his or her doubts. Even though the patient sometimes has some kind of somatic disorder, it does not explain the nature or extent of the symptoms complained of, or the patient’s distress and predominance perceptions, often accompanied by anxiety or depression. Doubts or predominant perceptions about physical deformities (although insufficiently based) are also part of the disorder. The disorder is present in both men and women, has no obvious family characteristics (unlike somatization disorders), and often has a chronic fluctuating course. Specific manifestations are as follows.
(1) The onset of the disorder is often triggered by physical illness or psychological stimuli, and is characterized by excessive worry about physical health or illness, the severity of which is very disproportionate to the actual health status. Patients are distressed by the illness they believe they are suffering from, rather than by the consequences of the illness or the secondary social effects.
(2) The patient often has a sensitive, suspicious, overly concerned, and demanding personality, with a hypochondriacal interpretation of certain physiological phenomena and abnormal sensations that occur on a daily basis (e.g., heartbeat, bloating, etc.).
(3) The patient’s suspicion is strong and lacks sufficient basis, but is not delusional, because the patient knows that there is insufficient evidence of his or her illness to urgently request examination and treatment.
(4) The patient’s manifestations described above are not identical. If the suspicious somatic discomfort is obvious, accompanied by anxiety or depression, it is called sensory hypochondria. The suspicious concept is obvious, but the somatic discomfort and the change of state of mind is not obvious is called conceptual hypochondriasis. Body deformation hypochondriacs are mainly seen in adolescents, who are convinced that their physical appearance, such as nose, lips, and other parts. The patient is convinced that his or her physical appearance, such as nose, lips, etc., is seriously flawed and requires orthopedic surgery, but this is far from the case. If such notions are not swayed by explanations and are clearly emotional, they are not absurd with respect to the patient’s cultural background and can be considered as a pathological hypercritical notion. Patients pay close attention to various readings about the disease, and after reading them, they tend to be right and reinforce their suspicious perceptions.
(5) Despite repeated visits to the doctor or medical examinations, negative results and reasonable explanations by the doctor cannot dispel their suspicions.
(6) The onset of the disease is mostly slow, the course of the disease persists, and the symptoms are sometimes mild and severe, often leading to social function deficits. A better prognosis is often associated with the following factors: acute onset; concomitant appearance with a somatic disease; duration of the disease within 3 years without severe personality deficits; absence of secondary benefit, etc.
4. Somatic form of autonomic dysfunction
This disorder is mainly manifested as a neurotic-like syndrome caused by somatic disorders in organ systems innervated by autonomic nerves (e.g., cardiovascular, gastrointestinal, respiratory systems). In addition to symptoms of autonomic arousal (e.g. palpitations, sweating, flushing, tremor), the patient develops non-specific, but more individual and subjective symptoms, such as pain, burning, heaviness, tightness, and swelling in variable locations, none of which on examination proves the occurrence of a somatic disorder in the organ or system in question. This disorder is therefore characterized by obvious autonomic involvement, nonspecific symptoms attached to subjective complaints, and insistence on attribution of symptoms to a specific organ or system. Specific clinical features are as follows.
(1) The symptoms are the result of dysfunction of an organ system that is primarily or exclusively under autonomic innervation and control.
(2) The most common and prominent ones involve the cardiovascular and other systems (“cardiac neurosis”), the respiratory system (cardiac hyperventilation and cough), and the gastrointestinal system (“gastric neurosis” and “neurogenic diarrhea “).
(3) Symptoms are usually of two types: the first type is characterized by objective signs based on autonomic excitation, such as palpitations, sweating, flushing, and tremor; the second type is characterized by more individual specificity and subjectivity, while the symptoms themselves are nonspecific, such as pain at indeterminate sites, burning, heaviness, tightness, and swelling.
(4) The patient attributes the symptoms to a specific organ or system (the same system as the autonomic symptoms). However, no evidence of the presence of organic lesions in the organ or system in question can be found for any of the types of symptoms.
(5) The characteristic clinical phase of the disease lies in a combination of the following three aspects: definite autonomic involvement, nonspecific subjective complaints, and the patient’s insistence on attributing it to a specific organ or system.
(6) The psychological stress or difficulties and problems present in many patients.
(7) Sometimes there can be mild disturbances of physiological function, such as ergitation, gastrointestinal distention, hyperventilation, but these do not in themselves affect the basic physiological function of the corresponding organ or system.
5.Persistent somatoform pain disorder
The main manifestation of this disorder is a persistent, severe pain that cannot be rationally explained by physiological processes or somatic disorders. Emotional conflicts or psychosocial problems directly lead to the onset of pain, and no corresponding somatic lesion is found after examination. The course of the disease is prolonged, often lasting for more than 6 months, and impairs social functioning.
III. Diagnostic criteria and differential diagnosis
If the patient has one or more symptoms of somatic discomfort as the main manifestation, but the medical examination cannot find evidence of corresponding organic lesion; or although there is the presence of somatic disease, but the severity or duration of its symptoms is very disproportionate, the possibility of somatoform disorder should be considered. The diagnosis is mainly based on clinical features, and in addition, pre-morbid personality characteristics should be 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) Meet the diagnostic criteria of neurosis.
(2) Predominantly somatic symptoms, with at least one of the following.
(1) Excessive concern for somatic symptoms (with severity clearly disproportionate to the actual situation), but not delusional.
(2) 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 neither the negative result of the examination nor the reasonable explanation of the doctor can dispel their concerns.
2.Serious criteria
Impaired social function
3.Course of illness criteria
Meet the criteria of symptoms for at least 3 months (somatoform disorder requires at least 2 years, undifferentiated somatoform disorder and somatoform pain disorder requires at least half a year.
4.Exclusion criteria
Exclude other neurotic disorders, depression, schizophrenia and paranoid psychotic disorders.
Differential diagnosis of somatoform disorders
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 somatoform disorders requires a disease duration of at least 3 months, and some even require more than 2 years, in order to naturally exclude the somatic disorders 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 easily make the diagnosis of somatoform disorder 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 one side; 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 rhythmic changes at night, 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 the somatoform disorder and the effect of medication is better, this disease can be distinguished.
3.Schizophrenia
Early symptoms of hypochondria may be present, but their content is more bizarre and irregular, with thought disorders and common hallucinations and delusions, and patients do not actively seek treatment, which can identify this disease.
4.Other neurological disorders
Various neurological disorders can have somatic discomfort or symptoms of hypochondriasis, but these symptoms are secondary and are not the main clinical phase.
IV. Treatment
The treatment of patients with somatoform disorders is difficult, and should be taken as a comprehensive treatment.
Treatment should pay attention to the following issues
1.Pay attention to the doctor-patient relationship
At the beginning of treatment, we should pay attention to the establishment of the doctor-patient relationship. To establish a good doctor-patient relationship, we should treat the patient’s pain and complaints with patience, sympathy and acceptance, and understand that he is indeed sick, not all “imaginary problems” or “pretend 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.
2. Emphasize early medical evaluation
For the management of such patients, a thorough medical evaluation and appropriate examination should be done at an early stage, and the doctor should give a clear report of the findings and give additional verbal explanations. A rash 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.
3. Introduce the topic of psychosocial factors contributing to the disorder as early as possible
Once a diagnosis of somatoform disorder is 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 one involving somatic, emotional and social aspects.
4.Give appropriate explanations and assurances
Giving explanations and reassurances based on medical findings has a certain therapeutic effect in itself. However, reassurance should be given at the right time, not easily before the examination and before the patient fails to properly describe their distress.
5. Appropriate control of patient requests and treatment measures
Physicians should avoid committing to scheduling too many tests that would reinforce the patient’s disease behavior. Doctors can make regular appointments to provide necessary tests but not too frequently, so that one analysis can avoid misdiagnosis and the other can reduce patients’ anxiety. It is important to educate the patient’s family members about the disease, as family members may also reinforce the patient’s disease behavior.
Psychotherapy
1.Supportive psychotherapy: giving patients explanations, guidance, and communication to make them understand the knowledge related to disease symptoms, which is effective in relieving emotional symptoms and enhancing treatment confidence.
2.Psychodynamic psychotherapy: Help patients to explore and understand the inner psychological conflict behind the symptoms, which is effective for the complete relief of symptoms.
3.Cognitive therapy: For patients with obvious suspicion and a suspicious personality, cognitive correction therapy is given, which has long-term efficacy.
4.Morita therapy: To make the patient understand that the symptoms are not serious, adopt the attitude of accepting and tolerating the symptoms, continue to work, study and live naturally, which is effective in relieving the disease symptoms and improving the quality of life.
Medication
Benzodiazepines, antidepressants and symptomatic analgesics and sedatives are available. The patient should be informed of the possible side effects and the time of onset of effect in order to increase the patient’s compliance with the treatment.
Others
Chinese medicine treatment, acupuncture, physiotherapy, qigong, etc. may be effective for some patients and can be tried.
V. Prevention
The cause of many mental illnesses is still unclear, but the occurrence of disease can be very different suggesting that individual characteristics have an important position in the occurrence of disease, so people advocate to improve the level of mental health of people to prevent the occurrence of this type of disease, so that they can resist the attack of external harmful factors. Firstly, the development of the whole body, including the brain function, should be fostered and constantly in a healthy state so that people are physically fit and mentally full; secondly, the healthy development of the personality should be fostered and the exercise should be strengthened so that it is compatible with the social environment.