Somatization disorder

Introduction Somatic disorders are the main complaints of various physical discomfort symptoms. Although many medical treatments have been confirmed by various medical examinations, there is no organic damage or a clear pathophysiological mechanism, but it still cannot eliminate the type of neurosis.

Cause

(1) Causes of the disease

The exact cause of the disorder in this group is unknown. Studies in recent years have suggested that such diseases are related to the following factors:

Genetic

Reports suggest that somatoform disorders are associated with genetic predisposition. A study of a group of chronic functional pain demonstrated a positive family history that was significantly higher than organic pain; multivariate analysis showed a positive correlation between family genetic history and pain.

2. Personality

The author's study found that both male and female patients have MMPI profiles of 1, 2, 3, and 7 types, and their two-point coding is basically consistent with the personality characteristics of neurosis. Patients with "nervous" personality focus more on their physical discomfort and related events, leading to a lower sensory threshold, increased sensitivity to body sensation, and a variety of physical discomfort and pain. Sterm's research found that patients with somatoform disorders often have certain personality disorders, and passive-dependent, performance-type, and sensitive attacks are more common.

3. Neurophysiological and neuropsychological research

It has been found that patients with somatoform disorders have changes in brainstem reticular attention and arousal function. Studies on brain function asymmetry link the feelings, attentions, and emotional changes of the transition disorder to the information processing process in the right hemisphere of the brain. Brain studies of somatoform disorders point to the second sensory zone (S11), which appears to be particularly well-suited to explain its neurophysiological and neuropsychological dynamics. Some people think that in the emotional conflict, neuroendocrine, autonomic nerve and blood biochemical changes in the body lead to changes in blood vessels, internal organs, muscle tension, etc. These physiological reactions are perceived by the patient as physical symptoms.

4. Psychosocial factors

(1) Subliminal benefit: The psychoanalytic school believes that such physical symptoms can provide patients with two benefits in the subconscious. One is to relieve emotional conflict through disguised venting; the other is to avoid the problem by presenting the sick character. Willing to take responsibility and get care and care. (2) Cognitive role: the patient's personality characteristics and bad mood can affect the cognitive process, leading to sensitivity and enlargement of perception, making the person's feelings about the body information stronger, selectively paying attention to the body sensation and interpreting it with physical diseases. This tendency enhances the association and memory associated with the disease and the negative evaluation of one's own health.

(3) Alexithymia: Some people think that low-cultural people are not good at expressing their deep feelings in words, the so-called alexithymia. Lesser believes that alexithymia is a long-standing personality trait. Patients are not good at expressing their inner conflicts. It is easier to describe the body than emotional expression, and even to achieve indistinguishable inner feelings or physical sensations. Some people think that patients have serious defects in the self-perception and verbal expression of emotional experience. Their emotional experience is not transmitted to the cerebral cortex and expressed through linguistic symbols, but is released through the formation of so-called "organ language" by the nerves.

(4) Life events: Dantzer emphasizes the connection between life events and the body. Bacon found that life events were directly proportional to body complaints. The authors' study also found that the stimuli of negative events were higher in the study group than in the control group, and life events were positively correlated with the amount of pain. The total social support score of the study group was significantly lower than that of the control group and negatively correlated with the amount of pain. Long-term stress is the main cause of life.

(5) Social and cultural factors: Some studies have found that physical form disorders are particularly common in middle-aged and older women with lower culture. Studies have also shown that chronic functional pain is also more common in women with lower levels of education. Some people think that the expression of emotions is influenced by specific social culture. Whether in the Western society before the 20th century or the grassroots society in today's developing countries or developed regions, negative emotions are often seen as an expression of incompetence and shame. The direct expression of this kind of emotion, and the complaint of physical discomfort is a "legal" way. In this cultural context, patients will consciously or unconsciously conceal, deny, and even not feel their emotional experience, but pay attention to their physical discomfort. Although the onset and persistence of symptoms are closely related to unpleasant life events, difficulties, psychological factors or internal conflicts, patients often deny the existence of psychological factors and refuse to explore the possibility of psychological causes.

(two) pathogenesis

There have been many studies on the psychosocial mechanisms of somatization disorders, but there have been few reports on the biological basis of their occurrence. The role of somatization can be understood as social and emotional communication, and can also be interpreted as the result of psychodynamics.

Social exchange

It mainly refers to the patient's use of physical symptoms to achieve the purpose of controlling others (such as a young woman showing persistent abdominal pain, thus preventing his parents from going out on weekends).

2. Emotional communication

Sometimes patients can't express their emotions verbally, so they may use physical symptoms or physical complaints to express them. Some patients may also use physical complaints to deal with stress. Physical symptoms may also be a way to alleviate psychological conflicts. Psychological testing studies reported that MMPI-R scores in patients with somatization were significantly higher than those in the control group.

3. Psychodynamic factors

Classical theory of psychodynamics suggests that somatization disorders refer to the replacement of suppressed non-instinctive impulses with physical symptoms. Such physical symptoms of the patient can provide two benefits to the patient in the subconscious. One is that the disguised venting can alleviate the emotional psychological conflict; the other is that through the role of the somatization disorder, the unwilling responsibility can be avoided, and the family, The care and care of colleagues.

The patient's bad personality characteristics and bad mood can lead to sensitivity and enlargement of perception, selectively gradually pay attention to the body's feelings, and explain this tendency with physical diseases, and enhance the negative evaluation of their own health. Some patients are not good at expressing inner conflicts, describing physical discomfort is easier than emotional expression, and even reaching the difficulty of distinguishing between inner feelings and physical discomfort. Some people think that patients have serious defects in self-perception and verbal expression of emotional experience, and their emotional experience is good. Released by the so-called "organ language."

4. Biological factors

Neuropsychiatric examination confirmed that patients with somatization disorders were associated with functional deficits in the bilateral frontal lobe of the cerebral hemisphere and hypofunction in the non-dominant hemisphere. However, some studies have shown that patients with predominantly left side symptoms may suggest that the right hemisphere of the brain is more severely affected than the left side. Basic research has also confirmed that patients with somatization disorders are often associated with cortical dysfunction, and this result is also confirmed by auditory evoked potential examination. Compared with the control group, patients with somatization had similar responses to related and unrelated stimuli, suggesting that the patient's selective attention was reduced. Studies in pathophysiology have shown that increased physical complaints are related to the following factors: living alone, receiving less environmental stimuli, depression and anxiety. In addition, the personality threshold, the neurological allergy and the introversion personality have lower body somatosensory thresholds, which are also related to the occurrence of somatization disorders.

an examination

Related inspection

CT examination

Somatic symptoms can involve various systems throughout the body, and multiple symptoms can occur simultaneously, manifesting as various discomforts or pains. The patient may have been seeking medical treatment for a long time, and no evidence of organic lesions was found, and even surgical exploration was found. However, the negative of various medical tests and the doctor's explanation can not dispel their doubts, often accompanied by obvious anxiety and depression, which can lead to social function defects. The main clinical types are as follows:

Somatization disorder

Somatization disorder is also known as Briquet syndrome. Somatization disorders are characterized by the presence of one or more, often repeated changes, that may involve physical symptoms of any system or organ in the body, many of which cannot be explained by medicine, and cannot be confirmed by any medical examination. Sufficient to explain the physical symptoms, often lead to repeated medical treatment and significant social dysfunction. Often onset before the age of 30, the course of disease lasts at least 2 years, most common clinical symptoms are multiple, recurring, often changing physical discomfort and pain, such as headache, abdominal discomfort, other parts of the pain, dizziness, palpitations, other Anxiety symptoms, constipation or diarrhea (intestinal irritation syndrome), depression or anxiety. The handling of these patients is much more difficult than specific, isolated somatic symptoms. In addition, there may be a physical (physical) complaint due to specific and repeated concerns about your health. Physical form disorders are shown in Table 1.

Patients with somatization disorders have multiple, repeated and frequently changing somatic symptoms for many years. In some cases patients are completely immersed in the experience of physical symptoms, and they are reluctant to link the disease to psychological factors. Therefore, the diagnosis of psychiatry is not helpful. The patient's treating physician will play a key role in dealing with this condition. The doctor can limit the patient's further examination and drug treatment, provide a time-limited and regular appointment, and deal with the new signs and symptoms.

The course and prognosis of somatization disorders are unknown. However, the link between physical symptoms and psychological pain cannot be recognized and handled improperly, and patients will repeatedly go to many doctors and experts for treatment, multiple drug treatments, and even invasive medical examinations and surgery. Therefore, the lack of awareness of this problem and the continued referral to experts have caused great waste to both individuals and the health care system. The most common symptoms of somatization disorders can be summarized into the following four categories:

(1) Pain: This is a group of frequently occurring symptoms. The parts are often very wide, such as the head, neck, abdomen, back, joints, limbs, chest, rectum and other pains of various natures, not fixed in one place, can occur during menstruation, sexual intercourse or urination.

(2) Gastrointestinal symptoms: such as hernia, acid reflux, nausea, vomiting, abdominal pain, bloating, diarrhea or certain foods cause special discomfort. Gastrointestinal examinations sometimes only see superficial gastritis or intestinal irritation syndrome, which is inconsistent with the patient's severe physical symptoms, and it is difficult to explain the serious symptoms often present in patients.

(3) genitourinary symptoms: such as urinary sleepy, urinary retention, or frequent urination, genital or surrounding discomfort, sexual dysfunction visibility cold, erection and ejaculation disorders, menstrual disorders, excessive menstrual blood, abnormal or a large number Vaginal secretions, etc.

(4) pseudo-neuropathic symptoms: common: ataxia, limb paralysis or weakness, difficulty swallowing or pharyngeal obstruction, aphonia, urinary retention, tactile or analgesia, diplopia, blindness, deafness, convulsions and ataxia Limb paralysis or weakness, difficulty swallowing or pharyngeal obstruction, loss of sound, touch or analgesia, diplopia, blindness, deafness, abnormal skin feeling such as itching, burning sensation, stinging and other symptoms. However, neurological examination can not find the corresponding evidence of neurological damage or positive signs.

(5) Symptoms of respiratory circulatory system such as shortness of breath and chest pain.

2. Undifferentiated Somatoform Disorder An undifferentiated somatoform disorder patient complains of one or more somatic symptoms, which is painful; however, medical examinations do not reveal evidence of physical illness and any organic lesions. The course of the disease is more than half a year, and there are significant social dysfunctions. Common symptoms such as fatigue, loss of appetite, and gastrointestinal or urinary system discomfort. This clinical type can be seen as an atypical somatization disorder. The symptoms are not as extensive as the somatization disorders, and are not so rich, and the course of the disease may not be as long as 2 years or more.

3. Suspected illness

Hypochondriasis is a type of somatoform disorder with suspected symptoms as the main clinical feature. The course of a suspected disorder is chronic and fluctuating. Preemptive concepts of the disease can cause pain, anxiety, and behaviors that seek assurance. Most patients have normal functions in other aspects. Some patients control or manipulate family and social relationships due to the presence of symptoms. It is a somatoform disorder characterized by a persistent superiority concept (suspected concept) that fears or believes in a serious physical illness. The patient is overly concerned about his or her own health or illness, fearing that he or she is suffering from a serious illness, or that he or she is already suffering from a serious illness; The severity of the annoyance is not commensurate with the actual health of the patient. These patients are particularly alert to changes in their body, and any minor changes in body function such as heartbeat, bloating, etc. can cause the patient's attention. These insignificant changes in the normal person's view make the patient pay special attention to it, unconsciously exaggerating or misinterpreting it, and become evidence of serious diseases. On the basis of an increase in the level of alertness, the general slight feeling can also cause the patient to be significantly uncomfortable or seriously uncomfortable and feel unbearable; thus making the patient convinced that he or she has a serious illness.

Although the results of various tests do not support the patient's speculation, the doctor patiently explained and repeatedly ensured that the patient did not have serious diseases. The patient was often skeptical about the reliability of the test results, disappointed with the doctor's explanation, and still insisted on his own concept of doubt. Continue to the hospitals repeatedly requesting examination or treatment. Because the patient's attention is mostly or mostly focused on health issues, learning, work, daily life, and interpersonal relationships are often significantly affected. Some patients control or manipulate family and social relationships by virtue of their symptoms. Among them, the concept of persistent dominance (suspicion of illness), which is worried or believed to be suffering from serious physical illness, is called "conceptual suspected disease"; it is very obvious that physical discomfort is accompanied by anxiety or depression. "Some"; some are expressed as a single suspected symptom, specifically and specifically called "single symptom suspected"; the patient's concept of doubt is very solid, afraid or think that he is suffering from a serious disease, excessive health or disease Worried about being overly concerned about your own health, being particularly alert and worried about your body's minor discomfort, feeling unbearable, unconsciously exaggerating or misinterpreting, and acting as evidence of serious illness, even for certain physiological physiology Phenomes often also make pathological explanations. However, it is not a delusion; the patient knows that his disease evidence is not sufficient, so he is eager to further confirm the diagnosis and treatment through repeated examinations. The patient repeatedly seeks medical treatment. Although various medical examinations are negative, the doctor's patient explanation and repeated guarantees cannot dispel his doubts. As for the reliability of the test results, I was disappointed and dissatisfied with the doctor's explanation. I still insisted on my own concept of illness and continued to repeatedly ask for examination or treatment in various hospitals. The patient pays close attention to the various readings related to the disease, and often reads the number after reading, which further strengthens the concept of doubt.

The chief complaint of a suspected disorder can lead to many manifestations:

1 Physiological alertness: increased alertness and anxiety, sleep disorders;

2 pay attention to the body; closely monitor the physical condition, pay attention to the information consistent with the disease that is worried, preoccupy the concept and repeatedly think about the main body complaint;

3 Avoid or check the behavior of physical illness: avoid (such as physical exertion or contact with disease), use stereotypes and behaviors to guide diet or lifestyle, repeat self-test, repeatedly go to the hospital for treatment and seek assurance, access to information (such as See the medical book).

4. Physical deformity disorder

Body dysmorphic disorders, also known as dysmorphophobia. Mainly seen in adolescents or early adulthood. The patient firmly believes that his body's appearance, such as the nose, lips, etc., has serious defects, or becomes ugly, requiring orthopedic surgery; but the actual situation is not the case, even if the appearance is slightly variable, it is far from the ugly thought of the patient. . Such concepts are not shaken by explanations, with obvious emotional color; in terms of the patient's cultural background, they are understandable, not ridiculous, and thus have the characteristics of a super-price concept. The patient has no other psychotic symptoms and does not meet the diagnostic criteria for mental illness. For such single-symptom cases, treatment is difficult and the prognosis is poor; some cases require long-term follow-up to finally rule out the diagnosis of schizophrenia or paranoid status.

5. Somatoform pain disorder

Somatoform pain disorder is also known as psychogenic pain. Sometimes chronic pains of unknown cause are collectively referred to as chronic pain syndrome. Mainly manifested as persistent pain in various parts, causing pain to the patient or affecting its social function, but medical examination can not find any organic lesions in the painful part, can not be reasonably explained by physiological processes or physical disorders, after medical treatment The examination revealed no persistent, severe pain symptoms of any organic disease. Pain can occur in any part of the body, but the typical pain areas are headache, atypical facial pain, low back pain and chronic pelvic pain; pain can be located on the body surface, deep tissue or internal organs; the nature can be blurred dull pain, swelling Pain, soreness or sharp pain. There is clinical evidence that psychological factors or emotional conflicts play an important role in the occurrence, aggravation, persistence and severity of such pain.

The peak age of onset is between 30 and 50 years old, and female patients are twice as many as men; most of them are physically laborers. There is a tendency to family gathering. Patients often use chronic pain as their prominent symptom and repeatedly seek medical treatment. They often use a variety of drug treatments, physical therapy, and even surgical treatments. They have not achieved definite results, often leading to sedative and analgesic drug dependence; Depression and insomnia. The course of the disease is prolonged and often lasts for more than 6 months.

6. Somatic Autonomic Disorders are neurosis-like syndromes caused by somatic disorders in organs or systems that are primarily innervated and controlled by the autonomic nervous system. The systems often involved are cardiovascular, gastrointestinal, respiratory, and genitourinary systems.

(1) Symptoms are dysfunction of the organ system that is predominantly or completely controlled and controlled by the autonomic nervous system.

(2) Symptoms often involve one or more organ systems, the most common being the cardiovascular, respiratory or gastrointestinal systems.

1 The chest system can be seen in the cardiovascular system or in the precordial area.

2 Gastrointestinal system can be seen in hernia, hiccups, burning sensation in the chest or upper abdomen, or upper abdominal discomfort, or stomach tumbling or stirring, as well as bowel, bloating, increased stool frequency.

3 respiratory system can be seen breathing difficulties or excessive ventilation.

4 genitourinary system can be seen frequent urination or difficulty urinating, genital or surrounding discomfort.

(3) Symptoms are usually characterized by two types. One is based on the objective signs of autonomic excitation, such as palpitations, sweating, dry mouth, blushing (or flushing), tremors, etc.; second, subjective symptoms, such as irregular pain, burning sensation, heavy feeling, tight bundle Feeling, swelling, etc.

A variety of physical symptoms as a common feature of these diseases, although different clinical types have their corresponding outstanding performance, but medical evidence can not find evidence of organic lesions, or although there are physical symptoms, but with the persistence of symptoms It is very disproportionate to the severity. Patients are deeply concerned and suffering from their physical illnesses, and social functions are often compromised. There is evidence that the occurrence, persistence and aggravation of physical symptoms are closely related to psychological factors. The corresponding diagnosis can be considered for a duration of more than half a year. The summary is as follows:

1. There are many physical symptoms that cannot be explained by medicine, or these discomfort experiences are much more serious than the pathological changes that exist (which must be determined by their own medical history and physical examination).

2. Excessive care for physical illnesses.

3. All kinds of medical examinations are negative, and there is no clinically positive evidence corresponding to the physical symptoms of the patient's pain.

4. Although there are no organic diseases in repeated examinations, there is still a frequent medical history.

5. Adhere to the doctor's instructions that there are no serious physical illnesses or abnormal advice. The patient still insists that there is a serious disease and shows symptoms. With these two conditions, suspected illness should be suspected.

Differential diagnosis

Physical illness

Early detection of such diseases may not lead to objective medical evidence. But in the end, objective medical evidence can be found. Therefore, the diagnosis of various somatoform disorders requires at least half a year of disease. When the onset age is over 40 years old, the physical symptoms are single, the site is relatively fixed, and the trend is persistently aggravated. First, it may be considered that there may be organic lesions, and close observation, it is not appropriate to make a diagnosis of somatoform disorders. Clinical practice shows that: according to the onset of mental causes, the initial examination did not find positive signs, patients are easy to accept the suggestion of these points, the diagnosis of lower body form disorders, may lead to misdiagnosis, not careless.

2. Depressive disorder and anxiety disorder

Different degrees of depression and anxiety often appear in somatoform disorders, but to a lesser extent. The physical discomfort associated with it is not much, mainly based on the core symptoms of depression and anxiety. Depression and anxiety are more common in physical form disorders. Depressive patients often present a "depression triad" with a small number of physical symptoms and are mainly concentrated in the gastrointestinal system. ICD-10 points out that after 40 years of age, especially the physical symptoms of men, it is likely to be an early manifestation of primary depressive disorder.

3. fraud

It occurs in prisons, courts, work injuries and traffic accidents. The parties consciously create or exaggerate various physical symptoms; the symptoms of somatoform disorders are unconscious and involuntary.

4. Suspected delusions

The patient's physical illness beliefs are absurd and out of touch, and delusional or depressed patients may have weird physical beliefs such as "an organ or part of the body is rot." It can't be shaken with debates, explanations, etc., and often other psychotic symptoms exist at the same time.

5. Identify the disease and identify the following diseases

(1) Patients with depressive disorder may have a preconceived notion that they have a serious disease. However, depression may also be secondary to a suspected disorder. It is important to know which one first appears.

(2) Unexplained physical complaints or somatization disorders are concerned with symptoms rather than the presence of a disease and consequences.

(3) Beliefs related to suspected disorders are not as fixed as depression or schizophrenia with physical delusions. Patients with long-term suspected complaints should be classified as personality disorders. Because when they feel that medical staff can't handle their problems, they often become dissatisfied and even hostile.

(4) Anyone may have short-term concerns about health issues.

(5) Many anxiety disorders also have the characteristics of suspected complaints.

(6) One of the concerns of generalized anxiety disorder (GAD) is the concern about physical illnesses of oneself or family members. However, GAD's disease anxiety is only one of many concerns, not the only one.

(7) During the panic attack period, the concept of avoidance and preemption of physical or mental illness is prominent (ie fear of death, madness or loss of control), however, patients with panic disorder tend to misinterpret their acute anxiety response (as the anxiety increases) . Symptoms of distorted symptoms are more misinterpreted than anxiety (such as lumps and small spots). Secondly, the misunderstanding of panic tends to be acute, and at the same time there are symptoms of anxiety (such as heart attack), and the fear of suspected disease is mostly long-term (such as cancer).

(8) OCD patients are worried that they or their families have serious diseases like AIDS or cancer, and they have forced thinking about infection. They will perform forced posture movements (washing or checking) to avoid infection.

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