Somatoform Disorder
Somatoform disorder is a neurological disorder characterized by a persistent fear or belief in the predominance of various somatic symptoms. Patients repeatedly seek medical attention for these symptoms, and various negative medical tests and physicians’ explanations fail to dispel their doubts. Even though sometimes the patient does have some kind of somatic disorder, it does not explain the nature of the symptoms, their degree or the patient’s distress and predominant perception. These somatic symptoms are thought to be the result of psychological conflicts and personality tendencies, but for patients, they refuse to explore the possibility of a psychological etiology even if the symptoms are closely related to stressful life events or psychological conflicts. Patients are often accompanied by anxiety or depression.
Clinical manifestations.
(i) Somatization disorder is also known as Briquet syndrome. The clinical manifestations are multiple, recurrent, and frequently changing somatic discomfort symptoms dominated by neurosis. The symptoms can involve any part or organ of the body, and various medical examinations cannot confirm any organic lesion sufficient to explain its somatic symptoms, often leading to repeated visits to the doctor and significant social dysfunction, often accompanied by significant anxiety and depression. The disease mostly starts before the age of 30, is more common in women, and has a duration of at least 2 years. Common symptoms can be grouped into the following categories.
l. Pain
2. gastrointestinal symptoms
3.Genitourinary system
4.Respiratory and circulatory system
5, pseudo-neurological symptoms ;
(ii) Undifferentiated somatoform disorders;
(iii) Hypochondriasis;
(iv) somatoform pain disorder.
Disease description
It is a neurological disorder characterized by a persistent fear or belief in 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. Even though sometimes the patient does have some kind of somatic disorder, it does not explain the nature and extent of the symptoms and the patient’s notions of distress and predominance. These somatic symptoms are thought to be the result of psychological conflicts and personality tendencies, but for patients, they refuse to explore the possibility of a psychological etiology even if the symptoms are closely related to stressful life events or psychological conflicts. Patients often have semi-anxious or depressed moods.
Most of these patients are initially seen in various medical and surgical departments, and psychiatrists are often encountered with specific years of visits, extensive clinical examination data, and cases that have been treated with multiple medications or even surgical procedures with poor results. The current low recognition rate of such patients by physicians in the same department often leads to delays in the diagnosis and treatment of such diseases and consequently to a huge waste of medical resources. Therefore, it is of great practical importance to improve the recognition of somatoform disorders by contemporary physicians in various disciplines.
Somatoform disorders include somatization disorders, undifferentiated somatoform disorders, hypochondriac disorders, somatoform autonomic disorders, somatoform pain disorders, and many other forms. The disorder is more common in women, and the age of onset is mostly before 30 years. There is a lack of comparable epidemiological data due to differences in diagnostic criteria from country to country. Few systematic observations have been reported regarding the prognosis of somatoform disorders. It is generally accepted that the prognosis is good for those with an acute onset with obvious psychogenic triggers. If the onset is slow and the duration of the disease lasts more than 2 years, the prognosis is poor.
Symptoms and signs
(A) Somatization disorder
Somatization disorder is also known as Briquet’s syndrome. The clinical manifestations are multiple, recurrent, and frequently occurring somatic disorder-based neuroses. The symptoms may involve any part of the body and organs, and various medical examinations cannot confirm any organic lesion sufficient to explain its somatic symptoms, often leading to recurrent long-standing and significant social dysfunction, often accompanied by significant anxiety and depression. The disease mostly starts before the age of 30, is more common in women, and has a duration of at least 2 years. Common symptoms can be grouped into the following categories.
1.Pain
is a common symptom. Partly involved in a wide range, can be head, neck, chest, abdomen, limbs, etc., the site is not fixed, the nature of the pain is generally not very strong, related to the emotional condition, when the mood is good may not be painful or reduced. It can occur during menstruation, sexual intercourse and urination.
2.Gastrointestinal symptoms
It is a common symptom. Belching, acid reflux, nausea, vomiting, abdominal distension, abdominal pain, constipation, diarrhea and other symptoms can be manifested. Some patients may feel particularly uncomfortable with certain things.
3.Genitourinary system
The common ones are frequent urination, difficulty in urination; discomfort in or around the genitals; sexual frigidity, erection or ejaculation disorders; menstrual disorders, excessive menstrual blood; abnormal vaginal secretions, etc.
4.Respiratory and circulatory system
Such as shortness of breath, chest tightness, palpitations, etc.
5.Pseudo-neurological symptoms
Commonly, there are ataxia, limb paralysis or weakness, dysphagia or pharyngeal obstruction feeling, blindness, deafness, skin sensory loss, convulsions, etc.
(B) Undifferentiated somatoform disorder
Undifferentiated somatoform disorder often complains of one or more somatic symptoms, the symptoms are variable, and its clinical manifestations are similar to somatization disorder, but the typicality of constituting somatization disorder is not enough, and the parts involved in its symptoms are not as extensive and rich as somatization disorder. The duration of the disease is more than half a year, but less than 2 years.
(C) Hypochondriasis
Also known as hypochondriac disorder, the main clinical manifestation is the fear or belief that one is suffering from a serious somatic disease, and the degree of concern is very disproportionate to the actual health condition. Some patients do have certain physical illnesses, but cannot explain the nature and extent of the symptoms described by the patient or the patient’s perception of pain and dominance. Most patients have anxiety and depression. Suspicions of physical deformities (although not well founded or even unfounded) or predominant perceptions (also known as somatoform disorders) are also part of the disorder.
Symptoms vary from patient to patient, with some presenting mainly as suspicious discomfort, often with semi-obvious anxiety and depression; others with prominent suspicion of illness, but no significant somatic discomfort or mood changes. Some suspect a more vague or widespread disease, while others are more single or specific. In either case, the patient’s suspicion never reaches the level of absurdity or delusion. Patients mostly know that there is insufficient evidence of illness and thus want repeated tests to clarify the diagnosis and demand treatment.
(iv) Somatic forms of pain disorder
It is a persistent and severe pain that cannot be rationally 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 cannot reveal corresponding organic changes at the site of pain. The course of the disease is often prolonged and lasts for more than 6 months. The common sites of pain are headache, atypical facial pain, low back pain and chronic pelvic pain, which can be located on the body surface, deep tissues or visceral organs and can be dull, distending, aching or sharp in nature. The peak age of onset is 30-50 years old, and it is more common in women. Patients often complain of pain without repeated visits to the doctor, taking multiple medications, some even leading to sedative pain medication dependence, and accompanied by anxiety, depression and insomnia.
Disease etiology
1.Heredity
Some studies have suggested that somatoform disorders are related to genetic predisposition. 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 the current data, it is not possible to make a conclusion on the strength of the influence of genetic factors on such disorders.
2. Personality characteristics
Many studies have shown that these patients tend to have neurotic personality traits of sensitivity and suspicion, stubbornness, and excessive concern for health. They focus more on their own somatic discomfort and related events, resulting in lower sensory thresholds, 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. The individual is generally unable to perceive the normal activity 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 excitation 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, earlier production together 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 pattern 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.
Cultural factors may have several influences on somatization symptoms: firstly, linguistic influences, such as the absence of the word depression in the Yoruba language in Nigeria; secondly certain cultures go for less acceptance of overt expression of emotions, care and attention long 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 an individual’s fear of his or her internal or external environment, a disguised emotional outburst. parsons (1951) introduced the concept of the patient role, emphasizing the privileged, compensatory, and other reinforcing effects of the socially acquired patient role, i.e., the ability to avoid unwanted responsibilities and obtain care and attention through illness, also known as secondary benefits.
Cognitive effects: Because patients are sensitive, suspicious, and overly concerned with their own personality traits, many patients develop the perception that they are suffering from some undiagnosed illness. 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, where the patient can feel their heartbeat and gastrointestinal motions. This can lead to a vicious cycle in which increased selective perception leads patients to repeatedly seek medical attention, self-monitor blood pressure, pulse, urine and stool, etc. Any abnormalities trigger more anxiety, which in turn may lead to more somatic complaints.
Pathophysiology
1. Heredity
Some studies have suggested that somatoform disorders are associated with genetic predispositions. 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 the current data, it is not possible to make a conclusion on the strength of the influence of genetic factors on such disorders.
2. Personality characteristics
Many studies have shown that these patients tend to have neurotic personality traits of sensitivity and suspicion, stubbornness, and excessive concern for health. They focus more on their own somatic discomfort and related events, resulting in lower sensory thresholds, 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. The individual is generally unable to perceive the normal activity 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 excitation 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, earlier production together 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 pattern 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.
Cultural factors may have several influences on somatization symptoms: firstly, linguistic influences, such as the absence of the word depression in the Yoruba language in Nigeria; secondly certain cultures go for less acceptance of overt expression of emotions, care and attention long 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 an individual’s fear of his or her internal or external environment, a disguised emotional outburst. parsons (1951) introduced the concept of the patient role, emphasizing the privileged, compensatory, and other reinforcing effects of the socially acquired patient role, i.e., the ability to avoid unwanted responsibilities and obtain care and attention through illness, also known as secondary benefits.
Cognitive effects: Because patients are sensitive, suspicious, and overly concerned with their own personality traits, many patients develop the perception that they are suffering from some undiagnosed illness. 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, where the patient can feel their heartbeat and gastrointestinal motions. This can lead to a vicious cycle in which increased selective perception leads patients to repeatedly seek medical attention, self-monitor blood pressure, pulse, urine and stool, etc. Any abnormalities in turn trigger more anxiety, which in turn may lead to more somatic complaints.
Diagnostic tests
(I) Diagnosis
If a patient has one or more symptoms of somatic discomfort as the main manifestation, but medical examination cannot find evidence of corresponding organic pathology; or if there is a physical disease, but the severity or duration of its symptoms are not proportional, the possibility of somatoform disorder should be considered. The diagnosis is mainly based on clinical features, in addition, pre-morbid personality traits 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) Dominated by somatic symptoms with at least one of the following.
(1) excessive concern for somatic symptoms (the severity is clearly disproportionate to the actual situation), but not delusional ;
(2) Excessive concern for physical health, such as excessive concern for physiological phenomena and abnormal sensations that usually occur but are not delusional.
(3) Repeatedly seeking medical treatment or requesting medical examination, but neither the negative results 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 symptom criteria has been 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
Exclusion of other neurotic disorders, depression, schizophrenia and paranoid psychotic disorders, etc.
(II) 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 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 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 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. Differentiation on the one hand to consider the sequence of symptoms occurring; on the other hand, to analyze the characteristics of the symptoms. 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 somatoform disorders, and the effect of medication is better, etc. 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 be distinguished.
4.Other neurological disorders
Various neurological disorders may present with somatic discomfort or symptoms of hypochondriasis, but these symptoms are secondary and not the main clinical phase.
Treatment plan
(a) Treatment should pay attention to the following issues
1. Pay attention to the doctor-patient relationship
The establishment of doctor-patient relationship should be emphasized at the beginning of treatment. We should treat the patient’s pain and complaints with patience, sympathy and acceptance, and understand that he is indeed sick, not just “imagining 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.
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 the patient’s anxiety. It is important to educate the patient’s family members about the disease, because family members may also reinforce the patient’s disease behavior.
(II) Psychotherapy
Psychotherapy is the main form of treatment, which aims to let patients gradually understand the nature of the disease, change their misconceptions, contact or reduce the influence of mental factors, and make patients have a relatively correct assessment of their physical condition and health status. Currently, the commonly used psychotherapy includes psychoanalysis, behavior therapy and cognitive therapy chapters and related monographs.
(C) Drug treatment
Benzodiazepines, tricyclic antidepressants, SSRIs, and symptomatic analgesics and sedatives are available. The patient should be informed of the possible side effects and the time of onset of effect to increase the patient’s compliance with the treatment.