What are Somatoform Disorders?
Somatoform disorders are a group of psychogenic diseases in the clinical picture of which mental disorders are hidden behind somatovegetative symptoms resembling a somatic disease, but no organic manifestations can be attributed to a disease known in medicine, although there are often non-specific functional disorders. The main symptom of somatoform disorders is the recurring occurrence of physical symptoms along with the constant demands of medical examinations, contrary to the negative results confirmed and the doctors assured us that there is no physical basis for the symptoms. If physical disorders are present, then they do not explain the nature and severity of the symptoms or distress and concern of the patient. Even when the onset and preservation of symptoms is closely related to unpleasant life events, difficulties or conflicts, the patient resists attempts to discuss the possibility of its psychological conditioning; this can occur even if there are distinct depressive and disturbing symptoms. The achievable degree of understanding of the causes of symptoms is often frustrating and frustrating for both the patient and the doctor.
With these disorders, there is often a certain degree of hysterical behavior aimed at attracting attention, especially in patients who are indignant due to the inability to convince doctors of the predominantly physical nature of their disease and the need to continue further examinations and examinations. Some patients are able to convince doctors of the presence of a specific pathology, being convinced of this themselves (Munchausen syndrome). Some researchers are convinced that somatoform symptoms are actually manifestations of latent depression, and on this basis they are treated with antidepressants, others believe that they are special conversion, that is, dissociative disorders, and therefore should be treated with psychotherapeutic methods. However, it should be remembered that these disorders can be pre-symptoms of true somatic diseases, and this implies close attention to the somatic examination of these patients.
The prevalence of this type of disease ranges from 0.1-0.5% of the population and averages about 280 cases per 1000. Currently, patients with somatoform disorders, according to WHO, make up 25% of patients with somatic practice. Most often, somatoform disorders are observed in women . Somatoform disorders are specific for adults, but can occur starting from primary school age.
The structure of various somatoform disorders includes a number of syndromes, among which conversion syndromes, asthenic conditions, depressive syndromes, anorexia nervosa syndrome, dysmorphophobia syndrome (dysmorphomania) can be especially distinguished.
- Conversion syndromes. It is characterized by a change or loss of any body function (anesthesia and paresthesia of the extremities, deafness, blindness, anosmia, pseudoceisis, paresis, choreiform tics, ataxia, etc.) as a result of psychological conflict or need, while patients do not realize what psychological the cause of the disorder, therefore, can not control it arbitrarily. Conversion – the transformation of emotional disorders into motor, sensory and autonomic equivalents; these symptoms in domestic psychiatry are usually considered as part of a hysterical neurosis.
- Asthenic conditions are among the most common in the practice of a general practitioner. Fast exhaustion acts in these cases against the background of increased neuropsychological excitability. The somatic complaints the patient is dealing with include, first of all, variable and varied headaches, sometimes of the type of “neurasthenic helmet,” but also tingling in the forehead and neck, the feeling of a “stale head. The pain intensifies with mental stress and usually becomes more severe in the afternoon. Asthenic conditions can mimic the symptoms inherent in one or another somatic disease. These are, as a rule, palpitations, lability of blood pressure, frequent urination, dysmenorrhea, decreased libido, potency, etc.
- Depressive syndromes are also quite common (in about half of cases, the state of somatoform patients qualifies as depressive). Of particular interest is the so-called somatized (masked) depression.
- Anorexia nervosa syndrome is a progressive self-restriction in food while maintaining an appetite for weight loss due to the belief in overweight or for fear of being overweight. This condition occurs mainly in females in adolescence. The triad is considered characteristic of the syndrome, expressed in its entirety: refusal to eat, significant weight loss (about 25% of premorbid mass), amenorrhea.
- Syndrome of dysmorphophobia (dysmorphomania). This is a type of hypochondriac syndromes, mainly found in adolescence (up to 80%). With dysmorphophobia, there is a pathological conviction either in the presence of any physical deficiency, or in the distribution of unpleasant odors to patients. At the same time, patients fear that others notice these shortcomings, discuss them and laugh at them. For a pronounced dysmorphophobic syndrome, a triad of symptoms is typical: ideas of physical disability, ideas of attitude, depressed mood. Patients with dysmorphophobia are characterized by a tendency to dissimulate their condition. In this regard, it is important to note the presence of two characteristic symptoms that can be identified by questioning patients and their relatives: these are symptoms of a “mirror” (looking closely at yourself in a mirror to make sure there is a physical defect and try to look for an expression on the face that conceals this “defect” “) and” photographs “(the latter is considered as documentary evidence of the deficiency of his appearance, in connection with which photographing is avoided).
Today somatoform disorders include:
- Somatic disorder
- Undifferentiated somatoform disorder
- Hypochondria disorder
- Somatoform vegetative dysfunction
- Chronic somatoform pain disorder
Causes of Somatoform Disorders
In etiology, the main role is played by 3 groups of factors.
Hereditary-constitutional factors. In this group of factors, the most significant role is played by the constitutional-typological features of the central nervous system and personality-accentuation features in the form of characterological features of the asthenoid circle with excessive sensitivity, timidity, increased exhaustion; One of the most common options is the “hypochondriac type”. The essential role is played by affective-dysthymic traits – “born pessimists” and hysteroid traits. The neurophysiological features of the central nervous system are characterized by the weakness of nonspecific activating systems, primarily the reticular formation.
Psycho-emotional, or psychogenic factors. These are factors of external influence, mediated through the mental sphere, having both cognitive and emotional significance, and therefore play the role of psychogeny.
By the nature of the impact in the group, the following variants of psychogenic factors can be distinguished:
- Massive (catastrophic), sudden, sharp, unexpected, amazing; one-sided: a) over-relevant to the individual; b) irrelevant to the person. Probably, the degree of relevance – significance – for the personality of these events can fluctuate over a wide range;
- Situational acute (subacute), unexpected, multifaceted personality involving (associated with the loss of social prestige, with damage to self-affirmation);
- Prolonged situational ones, leading to the realization of the need for persistent mental overstrain (exhausting): a) caused by the content and demand of the situation, or, b) caused by an excessive level of personality claims in the absence of objective opportunities to achieve the goal in the usual rhythm of activity;
- Prolonged situational, transforming conditions of many years of life (a situation of deprivation, a situation of abundance – the “idol of the family”). Inside them there can be psychological traumas: a) conscious and overcome, b) unconscious and insurmountable.
According to the scale of the impact, external factors are divided into:
- microsocial – there are families in which they consider external manifestations of emotions not worthy of attention, not accepted, a person from childhood learns that attention, love, support from parents can only be obtained using the “patient behavior”; he applies the same skill in adulthood in response to emotionally significant stressful situations;
- cultural and ethnic – in different cultures there are different traditions of the manifestation of emotions; the Chinese language, for example, has a relatively small set of terms to denote various psycho-emotional states; this corresponds to the fact that depressive states in China are represented to a greater extent by somatovegetative manifestations; rigid education in the strict framework of any religious and ideological fundamentalism, where emotions are not so poorly verbalized as their expression is condemned, can contribute to this.
Organic factors. This is a different kind of premorbid organic (traumatic, infectious, toxic, hypoxic, etc.) compromised integrative cerebral systems of a suprasegmental level, primarily the limbic-reticular complex. An important role in the group is played by prenatal and postnatal injuries, chronic sluggish infections, hypoxic-hypoxemic conditions, especially in the vertebrobasilar basin, etc.
Pathogenesis during Somatoform Disorders
Today, as a pathogenetic theory of the formation of somatoform disorders, it is customary to consider the neuropsychological concept, which is based on the assumption that people with a “somatic language” have a low threshold for tolerance of physical discomfort. What one feels as tension is perceived as pain in somatoform disorders. This assessment becomes a conditioned reflex reinforcement of the emerging vicious circle, imaginatively confirming the patient’s gloomy hypochondria premonitions. Personally significant stressful situations should be considered as a trigger mechanism. At the same time, it is more often not obvious, such as death or severe illness of loved ones, trouble at work, divorce, etc., but minor troubles, chronic stressful situations at home and at work, to which people pay little attention.
Symptoms of Somatoform Disorders
In the clinical picture of the disease, pathological bodily sensations predominate, which present significant difficulties for differential diagnosis. Manifestations of somatoform disorders are diverse, patients turn, as a rule, primarily to therapists, then, being dissatisfied with the lack of treatment results, they use expensive specialists to narrow specialists. sometimes invasive, diagnostic methods. Somatic is framed by emotional instability, anxiety, and low mood. Patients constantly complain about something, complaints are made very dramatically. Despite excessive detail, they are vague, inaccurate and inconsistent in time. Patients can neither be reassured nor convinced that the painful manifestations are associated with mental factors. The doctor has a natural, sometimes difficult to hide irritation – and as a result, the patient continues to go to doctors in search of a “good doctor”, the patient is often hospitalized in somatic hospitals and undergoes inconclusive surgical interventions. However, behind all these complaints are mental disorders that can be detected with careful questioning: a lowered mood that does not reach the level of depression, a decline in physical and mental strength, in addition, irritability, a feeling of internal tension and dissatisfaction are often present. Exacerbation of the disease is provoked not by physical exertion or by changes in weather conditions, but by emotionally significant stressful situations.
Diagnosis of Somatoform Disorders
To make a diagnosis, it is first necessary to exclude somatic causes that can cause these complaints, and only then raise the question of the presence of somatoform disorder. If the patient presents a lot of fuzzy complaints that do not find instrumental and laboratory confirmation, the history of numerous examinations and consultations, the results of which he remains unsatisfied, we can assume that he suffers from somatoform disorder. Such patients undergo complex diagnostic procedures, often doctors tend to surgical treatment, here there are frequent cases of dependence on analgesics. Often, temporary relief comes from unconventional methods of therapy or as a result of invasive interventions (surgical treatment). The peculiarity of reactions to diagnostic interventions and symptomatic therapy also testifies in favor of somatoform disorder:
- paradoxical relief from diagnostic manipulations;
- a tendency to change the leading somatic syndrome (from exacerbation to exacerbation, and sometimes within the same phase);
- instability of the obtained therapeutic effect;
- tendency to idiosyncratic reactions.
Differential diagnosis. Differentiation of somatoform disorders is carried out with a whole group of diseases in which patients present somatic complaints, first of all, these are somatic symptoms of depression and primarily symptoms of true somatic diseases. Differential diagnosis is difficult due to the fact that dysfunctions can really be combined with these disorders. Differentiation from hypochondriacal delirium is usually based on careful consideration of the case. Although the patient’s ideas persist for a long time and seem contrary to common sense, the degree of conviction usually decreases to some extent and for a short time under the influence of argumentation, reassurance, and new examinations. In addition, the presence of unpleasant and frightening physical sensations can be considered as a culturally acceptable explanation for the development and preservation of a belief in a physical illness.
Treatment of Somatoform Disorders
Today, the treatment of somatoform disorders includes a wide range of therapeutic and prophylactic measures, however, the combination of psychotherapy and pharmacotherapy is the main focus.
Patients are almost never able to accept the thought of the psychic nature of painful somatic sensations. Therefore, the treatment program should be strictly individualized with the optimal combination of pharmacotherapy, psychotherapy, behavioral methods, social support and should be carried out mainly on an outpatient basis. Only with prolonged non-remission course of the disease, resistance to standard therapeutic regimens, treatment in a specialized department is possible.
- short-term dynamic;
- relaxation methods;
- biological feedback;
- identification of possible psychological causes and sources of symptoms, removal of the patient from a traumatic situation or its deactivation;
- psycho-educational work with the patient and his family (demonstration of the connection of symptoms with psychological problems);
- methods of personal growth;
- social and communication skills training;
- identification and expansion of interpersonal relationships significant for the patient;
- employment therapy.
Pharmacotherapy of somatoform disorders involves the use of a wide range of psychotropic drugs:
- tranquilizers – short-term (up to 1.5 weeks) or intermittent course of treatment;
- tricyclic antidepressants – small and medium doses in combination with tranquilizers and / or beta-blockers;
- selective serotonin reuptake inhibitors (small and medium doses) in combination with tranquilizers, citalopram is preferred, fluvoxamine can also be used. Of the other antidepressants, mianserin. These drugs are indicated for somatoform disorders with anxiety and sleep disturbances;
- antipsychotics – thioridazine, chlorprotixen, sulpiride, including parenteral. These drugs are prescribed for severe anxiety with agitation or for the ineffectiveness of tranquilizers;
- carbamazepine in small doses (50-200 mg / day), especially with violations of autonomic regulation, with relapsing and chronic course.
In addition, the therapy of somatoform disorders must be supplemented with vasoactive, nootropic drugs and vegetative stabilizers in medium therapeutic doses. The use of psychotropic drugs reveals the benefits of antidepressants and tranquilizers, apparently because they help to improve sleep, appetite, alleviate suicidal tendencies, which are often found in patients with persistent somatoform pain.
The use of psychotropic drugs in the clinic of somatoform disorders has its own characteristics. The choice of drugs in each case is determined by the characteristics of the symptoms and associated manifestations. When prescribing psychotropic drugs, it is advisable to limit yourself to monotherapy using convenient medications. Given the possibility of increased sensitivity, as well as the possibility of side effects, psychotropic drugs are prescribed in small doses. The requirements also include a minimal effect on somatic functions, body weight, minimal behavioral toxicity and teratogenic effect, the possibility of use during lactation, and a low probability of interaction with somatotropic drugs.
In addition to the main methods of therapy, physiotherapy and acupuncture are used.
Treatment should last at least 4-6 weeks, as the symptoms of somatoform disorders tend to recur with the rapid withdrawal of drugs; maintenance therapy is recommended for up to three months (on average, 1-1.5 months) with a gradual dose reduction every three days.