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 physician explanations fail to dispel their doubts. Even if some kind of somatic disorder is sometimes present, it does not explain the nature or extent of the symptoms complained of, or their distress and predominant perceptions. It is often accompanied by anxiety or depression. 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. If the patient cannot convince the physician to accept this, he or she becomes indignant and is more likely to be accompanied by attention-seeking behavior at this time. The disorder is present in both men and women and has a chronic fluctuating course.
Etiology
The exact etiology is unknown. Psychodynamic theory suggests that patients with the disorder tend to be inept at exploring their own internal psychology and therefore often insist on a somatic cause. It is believed that the disorder is primarily caused by psychological factors.
Clinical manifestations
1. Somatization disorder
Somatization disorders are characterized by a wide variety of frequently changing somatic symptoms that can involve any system or organ of the body. The most important feature is stress-induced unpleasant moods that appear as somatic symptoms.
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 spots, sexual and menstrual complaints are also common, and significant depression and anxiety are often present. Multiple symptoms may co-exist. Patients have undergone many tests for this purpose, with no positive findings, and even surgical exploration has yielded nothing. The course is often chronic and fluctuating, with severe and long-standing social, interpersonal and family behavioral disturbances that rarely resolve completely. It is much more common in women than in men, and most often develops in early adulthood. The earliest symptoms in women may be related to sexual difficulties or marital or romantic problems. Some patients are treated frequently, which can lead to drug dependence or abuse (mostly sedatives and painkillers).
2. Undifferentiated 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. Hypochondriasis
Hypochondriasis is a persistent predominant notion that the patient fears or believes to have a serious physical illness (hypochondriacal notion). Patients therefore repeatedly go to the doctor, and all kinds of negative medical tests and doctors’ explanations cannot dispel their doubts. Even though patients sometimes have some kind of somatic disorder, they cannot explain the nature and extent of the symptoms complained of, or the patient’s distress and dominant perception, 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) It often develops under the effect of somatic diseases or mental stimulation triggers, showing excessive worry about physical health or disease, and its severity is very disproportionate to the actual health status. Patients are distressed by the illness they think 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 suspicious interpretation of certain physiological phenomena and abnormal sensations that occur on a daily basis (e.g., heartbeat, abdominal distension, etc.).
(3) The patient’s suspicion is solid 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 conceptual hypochondriasis is called conceptual hypochondriasis if the concept of suspicion is obvious, but the somatic discomfort and the change of state of mind are not obvious. Body deformation hypochondriasis is 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 have a clear emotional overtone, 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 notions.
(5) Despite repeated medical consultations or medical examinations, negative results and reasonable explanations from doctors cannot dispel their doubts.
(6) The onset of the disease is mostly slow, with a persistent course and mild to severe symptoms, often leading to social deficits. A better prognosis is often associated with the following factors: acute onset; concomitant 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 neurosis-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 excitation (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 at indeterminate locations, which on examination do not prove 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 in indeterminate locations, 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 eructation, gastrointestinal distention, and 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 contribute to the onset of pain, and no corresponding somatic lesion is found on examination. The course of the disease is prolonged, often lasting more than 6 months, and impairs social functioning.
Diagnosis
Somatization disorder is primarily characterized by a wide variety of recurrent and frequently changing somatic symptoms. These symptoms, when carefully explored, are likely to be transformed by stress-induced unpleasant moods. Symptoms are often present for several years prior to psychiatric consultation. Most patients have had a complex experience of prolonged contact with primary and specialized health care providers, during which many tests with no positive findings or procedures with no results were performed. The diagnosis should be made on the basis of the presence of a wide range of variable somatic symptoms for at least 2 years, the absence of any appropriate somatic explanation, and the constant rejection of advice and assurances from multiple physicians that there is no somatic explanation for their symptoms. The symptoms and the resulting behavior cause some degree of impairment in social and family functioning.
Treatment
1. Basic principles
The treatment of patients with somatoform disorders is difficult and should be comprehensive.
(1) Psychotherapy Patients often refuse to accept that the root of their symptoms actually lies in psychological possibilities. Therefore, psychotherapy aimed at improving introspection can help patients explore and resolve the internal conflicts that cause symptoms. Once the inner conflict is resolved, the symptoms often disappear automatically. Of course, some patients are resistant to this treatment.
(2) Symptomatic treatment For those with obvious symptoms of anxiety and depression, they should be treated with appropriate anxiolytics and antidepressants; for certain somatic symptoms, they can be treated with corresponding internal medicine.
(3) Other biofeedback and other whole-body relaxation treatment techniques can help patients to relax the whole body and control anxiety and pain, etc.
2. Treatment of somatoform disorders
(1) Psychotherapy ①Supportive psychotherapy gives patients explanation, guidance, and facilitation to make them understand the knowledge related to disease symptoms, which is effective in relieving emotional symptoms and enhancing treatment confidence. (2) Psychodynamic psychotherapy helps patients to explore and understand the inner psychological conflict behind the symptoms, which is effective for the complete relief of symptoms. ③Cognitive therapy is effective in the long term for patients with obvious suspicion and a suspicious personality to be treated with cognitive correction. ④Morita therapy enables patients to understand that the substance of symptoms is not serious, adopt an attitude of accepting and tolerating symptoms, and continue to work, study and live naturally, which is effective for relieving disease symptoms and improving the quality of life.
(2) Medication Patients with high health requirements and sensitivity to somatic reactions are advised to use drugs with low adverse reactions, and small doses of treatment are appropriate. Anxiety and depressive symptoms can be given in appropriate amounts of anti-anxiety drugs or antidepressants, often treated with an anti-anxiety drug (alprazolam, lorazepam, clonazepam, etc.) in small doses is effective. In addition, symptomatic treatment can be given for the manifestation of somatic symptoms, such as moderate doses of propranolol and metoclopramide, which should be given in short courses.
(3) Other such as spectrum therapy, massage therapy, extracorporeal counterpulsation therapy, etc., have certain auxiliary therapeutic effects.