Somatoform disorders are a group of diseases of a psychogenic nature, the peculiarity of which is the presence of somatic complaints in the absence of pathological changes in internal organs that could explain the cause of the complaints. People often visit various doctors, undergo examinations for the presence of physical diseases and undergo treatment. Somatoform disorders (F45) according to ICD-10 belong to the group of neurotic, stress-related and somatoform disorders (F40-48).
With somatoform disorder, a person cannot recognize the psychosomatic onset of the disease, even if there are symptoms of anxiety and depression. Disorders affect a person’s ability to work and quality of life. A specific manifestation of the disease should be considered the patient’s conviction that he has somatic diseases, which decreases after research and health assessment by a specialist.
There are five types of somatoform disorders: hypochondriacal, somatization, chronic somatoform pain disorder, undifferentiated somatoform disorder and somatoform dysfunction of the autonomic nervous system.
The main reasons for the development of the disorder are stress, indifference of loved ones, the presence of other mental illnesses and personality traits.
In patients, the results of medical examinations will be within normal limits or with minor deviations, but will not explain the symptoms that occur. Symptoms of the disorder cause a person to experience excessive worry and anxiety, which interferes with everyday life, and the person constantly seeks medical help.
In the presence of a somatoform disorder, the clinical picture may include any symptoms, most often pain of various types, vegetative and somatic manifestations. The presence of symptoms is not associated with a physical illness. Normal sensations are perceived by the patient as abnormal. A person focuses all his attention on internal sensations, as a result of which somatoform disorders are often accompanied by anxiety and symptoms of depression.
There are five types of somatoform disorders:
Hypochondriacal disorder. The patient has numerous concerns about the presence of a serious incurable disease, which, in his opinion, may cause death. Fears are accompanied by affective disorders - anxiety, hopelessness, despondency. There is instability in ideas about the presence of a specific disease and its severity; the “diagnosis” depends on somatic manifestations and can change; the level of fear for one’s health also changes. Hypochondriacal depression often develops against the background of affective disorders.
Somatization disorder. With this form of the disorder, the patient's internal mental conflicts are expressed in the form of somatic symptoms. The person is convinced that the symptoms are caused by a physical illness. Complaints are varied, constant, atypical for a somatic disease. Examination is carried out for timely diagnosis of the disease and prompt treatment. He does not express concern about the severity and curability of his “illness,” unlike people with hypochondriacal disorder. They deny that they have a psychological problem as the cause of their symptoms. Somatization disorder is accompanied by a persistent low mood, and the development of depressive and anxiety disorders is possible.
Somatoform dysfunction of the autonomic nervous system. Accompanied by vegetative symptoms. The reason lies in the disruption of the functional state of organs controlled by the autonomic nervous system. Complaints are nonspecific, changeable, symptoms can be observed in various conditions and diseases (sweating, shortness of breath, tachycardia, slight increase in body temperature, change in blood pressure). The patient is convinced of the presence of a somatic illness, does not recognize the psychological nature of the disorder, but conflict is not clearly expressed. With this form of the disorder, da Costa syndrome, irritable bowel syndrome, etc. can be observed. Symptoms may be similar to the clinical picture of damage to a specific organ controlled by the autonomic nervous system.
Chronic somatoform pain disorder. The patient suffers from constant pain. The pain is localized in the same place, is debilitating, painful, and the nature and location do not change over time. There are no neurological or autonomic disorders.
Undifferentiated somatoform disorder. There are numerous complaints characteristic of the group of somatoform disorders, but they cannot be assigned to a specific form of the disorder. Complaints are numerous and variable, vegetative symptoms are subtle.
A person with somatoform disorder experiences emotional and physical torment, which only treatment from a specialist can cope with.
Painful and undifferentiated disorders often initiate in childhood and early adolescence. Pain disorder in girls manifests itself between 11 and 19 years of age, and in boys up to 13 years of age. Abdominal symptoms (nausea, abdominal pain, etc.) are more common in adolescence, as are headaches. Somatoform disorders are more common among girls than boys.
At the beginning of the disease, bodily sensations differ from normal ones only by a slight increase in the intensity of the manifestation. Close attention to “new” sensations in the body develops gradually as they are repeated. Over time, the sensations begin to cause an alarming reaction.
The further course of the disorder depends on the personality-neurotic characteristics (the greater the tendency to long-term experiences, the more likely it is to increase anxiety and a more acute reaction to symptoms). A long-term state of anxiety is always accompanied by autonomic disorders, which manifest themselves as functional disturbances in the functioning of various organs. Unlike the initial symptoms of the disease, disorders at a later stage can be confirmed by instrumental examination methods.
Features of the pathology
Experts classify somatoform disorders as a group of psychogenic diseases manifested by somatovegetative symptoms that are not due to organic causes. A person suffering from this form of mental illness periodically experiences physical manifestations of any illness, and also constantly requires doctors to conduct medical examinations. But clinical tests and instrumental techniques do not confirm the presence of the pathologies that the patient complains about. At the same time, the patient categorically rejects the idea that his physical condition can be caused by mental problems.
People with somatoform disorders are prone to hysterics, because such behavior allows them to attract the attention of doctors and others. But such patients cannot be called malingerers - they really have serious health problems, and they need qualified medical care.
According to statistics, approximately a quarter of all patients seeking help from general somatic doctors today suffer from somatoform disorders. Such diseases occur after a person finds himself in a stressful situation.
People most susceptible to developing somatoform disorder are those who do not allow themselves to express emotions, suppress them, or keep them to themselves. This behavior may be imposed by family or social traditions. If a child is raised in an environment where the expression of emotions is something shameful, and he receives care and support only during illness, then severe stress can lead to the development of somatic symptoms. In this way, a person unconsciously tries to attract attention to himself.
Somatoform disorders are especially common in older people living separately from their adult children. Their constant complaints and visits to doctors often turn out to be a way to remind their too busy relatives about themselves.
Causes of somatoform disorder
Somatoform disorder is a disorder in the somatosensory system, which is responsible for the perception of impulses coming from the body. Disturbances can occur in peripheral receptors and central sections, mutually reinforcing each other. Primary dystrophic changes in receptors occur for various reasons. Altered erroneous pain signals activate central pain maintenance mechanisms. Their hyperactivity increases the excitation of peripheral receptors, which leads to sensitization to pain.
Against the background of stress, a primary tension of the central regulatory mechanisms occurs, the threshold for the perception of physical discomfort decreases, which leads to the subsequent transmission of pathological excitation to the peripheral receptors of the somatosensory system. Normal tension or discomfort is perceived by the patient as pain and other symptoms of his “disease.” Over time, this perception of discomfort is reinforced by internal beliefs, so any unpleasant sensations begin to be regarded as pain. Somatic symptoms are very common among children and adolescents, who often have difficulty expressing their feelings and emotions through language.
There are three groups of factors that can provoke the development of somatoform disorders.
Heredity and personality traits. People with character traits such as asthenia, hysteria, dysphoria, and impressionability are at increased risk of developing somatoform disorders. Persons with a history of anxiety and emotional lability, genetically determined by the level of reactivity of the nervous system. Patients with somatoform disorders are often sensitive, pessimistic, demonstrative, and quickly become mentally exhausted.
Psycho-emotional factors. The presence of traumatic events, the characteristics of upbringing, the family situation, the nature of professional stress - all this can become a provoking factor in the development of the disorder. Psychogenic factors shape behavior patterns and ideas about the world around us.
The reason for the occurrence of somatoform disorders can be situations of loss of social status, unsuccessful attempts to realize themselves professionally. Chronic psychological trauma appears as a result of constant emotional and physical overstrain, demandingness, mismatch between needs and external conditions, situations of deprivation in childhood or, conversely, being the center of attention in the family circle.
The child’s symptoms may be a mirror manifestation of the illness of one of his loved ones. If a family member has physical health problems, somatic disorders, behavior with excessive concern about one's health or frequent visits to medical institutions, this can model similar behavior in the child.
Organic factors. These include previous injuries and illnesses, usually severe or with a long course, they can leave behind exhaustion of the body or psychological trauma.
Why does somatoform disorder occur?
The main reason for this manifestation is external factors. For example, stress at work or problems in the family, lack of attention from loved ones, burdened financial situation. In some cases, complaints about disorders in the body are a reason to draw attention to yourself. It is noteworthy that people with such a deviation themselves actually feel the symptoms. They are real to them. But they are not caused by physical illnesses, but by the reaction of the nervous system to environmental aggression (stress, problems, emotional stress or exhaustion). At a subconscious level, pain receptors in one or another area of the body are activated. Unfortunately, many people find it difficult to prove that everything is fine with them if the results of tests and examinations are 100% positive.
Diagnosis of somatoform disorder
The disease may remain undiagnosed for a long time due to the variety of symptoms, especially with somatization and undifferentiated somatoform disorders. The basis for the diagnosis of somatoform disorders is the collection of anamnesis and analysis of behavioral reactions. The presence of a disorder may be indicated by an improvement in condition after diagnostic examinations, ineffectiveness of treatment for a suspected somatic disease, uncertainty of complaints, or their dramatic change over time. The disorder may be accompanied by somatic illnesses, anxiety and depressive disorders.
It is important to pay attention to the presence of these clinical manifestations:
- Specific emotionally charged complaints about somatic malaise, autonomic dysfunctions, functional disorders (pain, cramps, muscle tremors, sleep disorders, appetite disorders, etc.) A person is fixated on any confirmation of his “diagnosis” and requires the appointment of examinations.
- The presence of manifestations of a mental disorder of the neurotic range (anxiety, fussiness, mood swings, irritability, short temper, apathy, fatigue, etc.)
- The presence of disorders of the somatosensory system. Sensopathy often manifests itself in the form of paresthesia (sensations of burning, burning, drilling, tingling, etc.). With paresthesia, the patient clearly points to the organ that is bothering him, describes the sensations clearly and emotionally. If discomfort is interpreted by the patient as pain, this is senestalgia. Senestalgia is distinguished by the location of pain and has its own name. With senestopathy, it is difficult for a person to describe what he feels; as a rule, the discomfort does not have a clear localization.
In the presence of pronounced somatic symptoms for two or more years, with social maladjustment and a persistent change in the emotional background, a diagnosis of somatization disorder is possible. If the disease lasts for at least six months and the clinical picture is atypical, an undifferentiated somatoform disorder is diagnosed. If a person experiences persistent anxiety about his health and fear of the “incurability of the disease,” a diagnosis of hypochondriacal disorder is made.
Differential diagnosis is carried out with the initial stages of somatic diseases, depression, hypochondriacal delirium and other mental disorders.
Conversion and somatoform disorders in general medical practice
G.M. DUKOVA
, Doctor of Medical Sciences, Professor,
FPPOV MMA named after. THEM. Sechenov Hysterical neurological and somatic symptoms are often observed in clinical practice.
Until now, patients with these symptoms are classified as “difficult patients.” The article presents the modern classification of hysterical disorders in accordance with ICD-10. Neurological manifestations typical of hysteria are described: seizures, paresis, walking disorders and hyperkinesis. The characteristic features of hysterical symptoms observed in therapeutic practice are highlighted. Diagnostic criteria for psychogenic pain, features of hysterical gastrointestinal and respiratory disorders, psychogenic fever and hemorrhagic syndromes are presented. The possibilities of pharmaco- and psychotherapeutic approaches in the treatment of hysterical syndromes are discussed. Conversion (hysterical) disorders in the practice of both a neurologist and a therapist are one of the pressing problems, since they often lead to erroneous diagnosis and, accordingly, the use of expensive and complex diagnostic and treatment procedures. According to the latest statistics, a neurologist's diagnosis of hysterical (conversion) disorders is in 6th place among the 20 most common diagnoses [1]. In neurological hospitals, the number of patients with hysterical neurological disorders reaches 9% [2]. Data on the frequency of hysteria in general somatic practice are scarce, but it can be assumed that its occurrence is no less frequent, and perhaps even more frequent, than in neurology.
Nosological rubrifications
Currently, the term “hysteria” is practically excluded from all classifications and nosological headings. In the International Classification of Diseases, 10th Revision [3], hysterical disorders are in the class of disorders designated as “Neurotic, stress-related and somatoform disorders” (F4). Within it, hysteria is grouped into 2 headings: 1) dissociative (conversion) disorders (F44), which mainly includes functional neurological syndromes (FNS), such as seizures, paralysis, hyperkinesis, etc., as well as psychogenic disorders of consciousness (stupor, amnesia , trances, etc.) and 2) somatoform disorders (F-45), i.e. hysterical disorders in the somatic sphere: a) somatization disorder (Briequet's disease) (F-45.0); b) hypochondriacal disorder (F-45.2); c) somatoform autonomic dysfunction (F-45.3): heart and cardiovascular system (F-45.30), upper gastrointestinal tract (F-45.31), lower gastrointestinal tract (F-45.32), respiratory system ( F-45.33), urogenital system (F-45.34); d) chronic somatoform pain disorder (F-45.4).
Clinical manifestations
In the vast majority of cases, the doctor deals with polysymptomatic hysteria - in 93% of patients a combination of 2-3 or more hysterical symptoms is found, i.e. diagnosing hysteria in the presence of a monosymptom requires great care and responsibility of the doctor. The key to diagnosing hysteria are functional neurological symptoms (FNS): paroxysmal states (hysterical seizures), hysterical paralysis and gait disturbances, disturbances in vision and movement of the eyeballs, speech and voice, hyperkinesis, etc., which makes these syndromes especially significant in diagnosis hysteria. Since only in half of the cases they dominate the clinical picture, the targeted and active identification of these syndromes (including in the anamnesis) significantly increases the reliability of the diagnosis of hysteria.
Diagnosis of hysteria includes two stages. The first stage is the exclusion of the organic origin of the symptom at both the clinical and paraclinical levels. The second stage is to establish the hysterical nature of the symptom based on its characteristic features, a combination of several typical symptoms, and conducting the necessary tests. This stage is designated as a positive diagnosis of hysteria.
Knowing the typical manifestations of hysteria can help the therapist suspect or diagnose hysteria. Let's start with a brief description of typical hysterical symptoms observed by a neurologist.
Neurological manifestations of hysteria
Paroxysmal conditions
Paroxysms that occur in patients with hysteria can be divided into psychogenic (hysterical) seizures and panic attacks. The structure of the former is determined mainly by hysterical neurological symptoms, among which motor phenomena are the most obvious. In the extremities these are tonic spasms with the formation of various pathological postures in the hands and feet; flexion and extension movements in the limbs; large-amplitude tremor and irregular twitching; chaotic erratic movements with throwing arms and legs. In this case, half-turns of the body to the right and left sides, arching of the body (“hysterical arc”), and jerking movements of the pelvis are often observed. During a seizure, the head is often thrown back, turned from side to side, eyes rolled upward, spasms of the muscles of the eyes, lips and tongue, chewing muscles (trismus) or the entire half of the face (pseudogemispasm). Moans, mooing, less often crying and laughter are observed; speech is often disturbed by the type of mutism, slowness, prolongation or pseudo-stuttering. The severity of the motor manifestations of a seizure can vary from a motor storm to a feeling of tension in the limbs, convulsive movements of the arms and legs, and the need to “bend the body.” However, seizures with motor phenomena are relatively rare in the therapist's practice. More often, the doctor deals with the so-called “loss of consciousness”, or “psychogenic unresponsiveness”, which can be accompanied by a fall of the patient. Psychogenic seizures are differentiated primarily from epileptic seizures. In these cases, the characteristic pattern of motor phenomena, the significant duration of the seizure and, above all, “loss of consciousness” (more than 5–15 minutes), the patient’s active resistance to the doctor’s attempts to open his eyes, as well as the emotionally expressive phenomena of the seizure (screams, moans, tears). However, a reliable diagnosis of an epileptic seizure can only be made by a neurologist using modern research methods (electroencephalography at the time of a seizure, video recording of a seizure, reaction to antiepileptic drugs).
In addition to epilepsy, it is necessary to remember about non-epileptic paroxysms, among which the most common are fainting and vegetative crises (panic attacks). Fainting, unlike psychogenic seizures, is short-term and occurs in certain situations (stuffiness, vertical position, emotions). Panic attacks are often observed during hysteria. Their peculiarity is the absence of fear in paroxysm and a significant frequency of FNS (convulsions, sensation of a lump in the throat, “loss of consciousness,” mutism, etc.).
Paresis is one of the most common hysterical neurological phenomena. As a rule, hysterical movement disorders are accompanied by a decrease in muscle tone, the absence of asymmetry of reflexes, and the absence of muscle atrophy. Sometimes local muscle tension is observed in combination with intense pain and limitation of movements in the upper or lower limb. Positive diagnosis is greatly facilitated by the use by a neurologist of specific diagnostic samples and tests that differentiate psychogenic and organic paresis [4].
Gait disturbances. Typical variants of walking disorders are distinguished: 1) pseudo-atactic gait with crossed legs (“braid braiding”); 2) gait with dragging feet; 3) gait with constant or periodic bending of the knees. The clinical diagnosis in all cases is made by a neurologist and requires the modeling of non-standard situations (walking with eyes closed, on heels and toes, tandem, running), in which the motor pattern becomes even more pretentious, and the demonstrative nature of motor skills acquires the necessary evidence.
Hysterical hyperkinesis. Trembling is the most common form of hyperkinesis in hysteria. It can have any localization and be observed either in isolation or in combination with other types of psychogenic hyperkinesis. The characteristic features of hysterical tremor are identified: signs of rest tremor, postural tremor and action tremor are simultaneously detected; a discrepancy is revealed between the severity of tremor and the preservation of limb functions, for example writing; characterized by a sudden emotional onset, non-progressive course, spontaneous remissions, resistance to drug treatment with a positive effect of psychotherapy and placebo.
In the structure of psychogenic visual and oculomotor disorders, the following are typical: concentric narrowing of the visual fields, detected by perimetry by an ophthalmologist, narrowing of the palpebral fissure (blepharospasm), double vision, which persists when looking with one eye, etc.
Undoubtedly, the diagnosis of neurological manifestations of hysteria should be carried out by a neurologist, however, detection by a therapist at the time of examination or identification of the above symptoms in the anamnesis will suggest the hysterical origin of somatic symptoms, which will be discussed below.
Somatoform disorders
It is known that the symptoms of hysteria are diverse and can manifest themselves in various areas. Typically, patients with hysteria come to see a therapist with complaints of pain in different parts of the body, difficulty breathing, fever, nausea, vomiting, a feeling of a lump in the throat, etc.
Pain syndromes
Pain syndromes occupy the main place among the hysterical symptoms encountered in the practice of a therapist. Most patients with hysteria, as a rule, as a first complaint report pain in the head, neck, spine, interscapular region, arms, legs, etc. However, there are no signs yet that allow us to speak unambiguously about the psychogenic nature of local pain. The criteria for psychogenic pain are: multiple localization of pain; high pain intensity according to VAS; dissociation of pain intensity and the degree of discomfort that the patient experiences; connection of pain with psychogenic neurological symptoms in time and location; the presence of pain behavior in the form of: groans, painful grimaces and gestures, the use of additional devices (wearing a “hat”, collar, corset, using a stick or crutch); characteristic features of the personal structure: depression and social dependence, passive-aggressive traits, demonstrativeness, predominance of people associated with the medical profession; signs of social disability: frequent visits to the doctor and ambulance calls, frequent hospitalizations, disability group, frequent connection of the onset of pain with physical trauma.
Hysterical respiratory disorders are represented primarily by hyperventilation syndrome (HVS), in which there are 4 variants of respiratory disorders [5]: 1) empty breathing syndrome, when patients feel dissatisfaction with inhalation or lack of air, “air hunger”, “lack of oxygen” in the environment . In this case, breathing occurs freely, since there is no obstacle to the passage of air, however, patients constantly open the windows, take care of fresh air, any emotional factors and physical activity increase the feeling of lack of air; 2) a feeling of inadequate functioning of the respiratory organs, when patients are fixed on the regularity of the breathing rhythm, afraid of stopping it, losing the automaticity of breathing; 3) difficulty breathing syndrome - patients feel difficulty breathing due to an internal “obstruction” to the flow of air, complain of a “lump in the throat,” “tightening, compression of the throat,” “stiffness, constriction of the chest,” and the inability to take a deep breath. Patients look tense, restless, have an anxious look, with a call for help; 4) hyperventilation equivalents are a feeling of dryness in the throat, soreness, often with periodic coughing, dry cough, sniffling or sniffing, repeated deep sighs, “oohs” and “ahs,” repeated uncontrollable yawning and, finally, atypical bronchial asthma.
The most striking and dramatic are hyperventilation crises. A characteristic symptom at the beginning of a crisis is difficulty breathing, which patients describe as follows: “the air stopped flowing,” “the neck or chest was compressed,” “the throat suddenly tightened,” “a lump appeared in the throat, making it difficult to breathe,” etc. Feeling of suffocation at the beginning of the attack leads to restlessness, anxiety and fear of death due to “difficulties” in breathing. Particularly “threatening” and “frightening” for patients are sensations from the nervous system - this is, firstly, dizziness, a feeling of lightness in the head, the unreality of the surrounding world, a presyncope, fainting, and secondly, the appearance of paresthesia in the perioral region, tongue , arms and legs and a feeling of squeezing, squeezing and convulsive information in the limbs. The structure of the attack often includes chill-like trembling and gastrointestinal symptoms: bloating, aerophagia, abdominal pain. At the end of the attack, as a rule, polyuria occurs, and there may be loose stools. Emotional manifestations naturally accompany a hyperventilation crisis. In addition to the fear of suffocation, the severity of which is usually maximum and comparable in intensity to panic, patients feel anxiety and worry about the possibility of “loss of consciousness”, fear of “going crazy”, “losing control”, a feeling that “something will explode in the body ", sometimes there may be bursts of crying and laughter.
In patients with HVS, mixed hysterical-anxiety disorders are often observed, and then in an attack, against the background of panic fear, hysterical symptoms may appear - “hysterical arc”, convulsions in the limbs, “loss of consciousness”, etc.
Objectively, with HVS, a constant disturbance in the pattern of the respiratory cycle is detected: unlike healthy people, in whom the duration of inhalation is related to the duration of exhalation as 1:2, in patients with HVS, inhalation is 2 times longer than exhalation.
In addition to HVS, psychogenic stridor (motor disturbances of the vocal cords) is described as the most dramatic hysterical syndrome in the respiratory sphere [6]. Such patients usually make up the contingent of pulmonary pathology, emergency care or intensive care departments. The reason for the admission of such patients may be an atypical clinical picture of the disease, resistance to traditional therapy, or the urgent nature of respiratory disorders. Psychogenic stridor is a hysterical syndrome manifested by acute obstruction (stenosis) of the upper respiratory tract. Patients experience wheezing, labored, constricted breathing. Usually inspiratory stridor. Diagnostic studies (examination of the larynx and laryngoscopy) reveal pathological closure (adduction) of the true and false vocal cords at the moment of inspiration and their normal excursion during exhalation with a normal anatomical structure of the respiratory tract. Oxygen saturation never drops to pathological levels.
The picture of acute respiratory failure directs the doctor to unjustified urgent procedures - tracheal intubation, tracheotomy and tracheostomy. Often such patients are on long-term corticosteroid therapy. The anamnestic usually reveals stressful situations preceding the onset of respiratory disorders, repeated episodes of aphonia, dysphonia, dyspnea and apnea, or loss of consciousness. Adequate psychotherapy can successfully stop this syndrome. It is necessary to differentiate from stridor of organic etiology associated with a foreign body or laryngeal edema. Hysterical dysfunction of the gastrointestinal tract
Lump in the throat. The feeling of a “lump in the throat” is traditionally considered the prerogative of hysteria; it is no coincidence that it is called Globus hystericus. In healthy people, the feeling of a “lump in the throat” often accompanies increased emotionality. According to statistics, in the population, episodes of “coma in the throat” occur in 6% of women; When visiting a general practitioner, up to 8% of patients complain of similar sensations. According to our data, 60% of patients with hysteria periodically experienced the feeling of a “lump in the throat” throughout their lives [7]. Usually this symptom occurs as a stigma long before the onset of the disease, but patients themselves, as a rule, do not associate it with emotional stress.
Patients usually complain of “a feeling of a foreign object (lump, stake) in the throat”, “a feeling of discomfort in the throat”, “a constant desire to swallow something”, etc. The feeling of a “lump in the throat” can be isolated (in 20% of patients) or accompanied by other symptoms (80%), in particular neurasthenic (weakness, headaches, irritability, sleep disturbance) or FNS.
In some patients, the feeling of a “lump in the throat” may be accompanied by breathing and swallowing problems. Modern research, including the study of the anatomical and functional features of the upper respiratory and esophageal systems, has identified a wide range of changes that can cause a “lump in the throat” sensation. Most often, motor disorders are found in the pharynx, pharyngolaryngeal sphincter and esophagus. For this purpose, primarily use: 1) radiography with barium; 2) video cinematography; 3) endoscopic methods (laryngo-, esophagoscopy and gastroscopy): 4) 24-pH monitoring; 5) manometry of the pharynx and esophagus. Along with physical causes, the role of psychological factors is discussed, and depressive and anxiety disorders are identified. In patients with hysteria, a “lump in the throat” is one of the symptoms of polysyndromic hysteria. Active identification of other FNS, the connection between the onset and exacerbations of the disease with psychogenic factors, the effectiveness of psychotherapy and psychopharmacotherapy confirm the psychogenic genesis of the “lump in the throat” sensation.
In terms of differential diagnosis, organic diseases leading to the occurrence of this syndrome are excluded. The range of such diseases is quite wide and includes somatic (esophagitis, gastroesophageal reflux, hiatal hernia, antral gastritis, etc.), neurological (osteochondrosis of the cervical spine, neurogenic tetany, damage to the superior laryngeal nerve, neuromuscular diseases, muscular dystonia, etc. etc.), endocrine (pathology of the thyroid gland), otorhinolaryngological (diseases of the pharyngeal tonsils, larynx), oncological (benign and malignant tumors of the larynx and pharynx), purely mechanical causes (compression of the calcified cryolaryngeal ligament, foreign body, congenital strictures of the esophagus).
Vomiting, nausea, belching
From the point of view of psychoanalysis, nausea and vomiting are classic symptoms of rejection, rejection of any situation. In childhood, a child often reacts by vomiting to an unpleasant or unwanted situation. In patients with hysteria, vomiting is not typical as an independent symptom; much more often, a feeling of nausea and episodic vomiting are observed in the structure of polysyndromic hysteria. Often in these cases, nausea and vomiting accompany “severe” headaches. If, at the urgent request of the doctor, the patient “tries to overcome” his defect (for example, to stand up with weakness in the legs or walk a few steps if he has astasia-abasia), then at this moment nausea and sometimes vomiting may suddenly appear. Repeated, sometimes cascading, belching can be included in the structure of a hysterical attack.
Pseudogravidal syndrome (Alvarez syndrome), or functional strain syndrome of the abdominal muscles, leading to enlargement and protrusion of the abdomen forward. In these cases, within a few minutes the abdomen enlarges to the size of a 6–8 month pregnancy. The course can be intermittent or chronic. Under our observation was a 46-year-old patient, whose abdomen increased to the size of a 6-month pregnancy within 15 minutes at the time of a hysterical attack and spontaneously subsided after the end of the attack. The essence of the syndrome is a change in tension in the abdominal muscles in combination with hyperlordosis, which causes protrusion of the abdomen. Aerophagia can also contribute to an increase in the abdomen, and at the end of the attack a cascading belch may occur. Hysterical hemorrhagic syndromes
Probably the most dramatic manifestations of hysteria are the hemorrhagic syndromes. Even in the Middle Ages, skin hemorrhages were described in the form of ecchymoses, or hemorrhagic blisters, in the so-called. "stigmatized" In the literature there are descriptions of hemoptysis, “bloody sweat”, when blood appeared in drops on the surface of the skin of the palms and soles, in the area of the heart and forehead, and the syndrome of bloody tears is described.
Hemorrhagic syndrome during hysteria can manifest itself: 1) painful or painless spontaneous bruises (often on one side of the body or in the area of hysterical paralysis, bruises may appear immediately after a hysterical attack); 2) episodes of hemoptysis (with a detailed study in such cases, fresh red blood cells are found in the clot, which allows us to speak about the mechanism of hemorrhage per diapedesin) [8]; 3) bleeding from various organs (nose, ears, eyes, uterine, etc.). In some cases, it is difficult to exclude the artificial nature of the syndrome. In modern literature, about 50 observations of hysterical hemorrhagic disorders are described under the general term “psychogenic purpura” or “autoerythrocytic sensitization syndrome” [9]. Detailed studies usually reveal normal coagulation mechanisms. A positive reaction (the appearance of typical hematomas) is characteristic of intradermal injection of one's own erythrocyte stroma. Auto-aggression is considered as psychological mechanisms. Psychotherapeutic influences can block both the appearance of hemorrhagic syndrome and the reaction to the introduction of red blood cells. Violation of thermoregulation
Psychogenic thermoregulation disorders are a well-known fact in clinical practice. Good tolerability even of febrile fever, discrepancy between temperature and pulse rate, as well as the absence of changes in paraclinical studies are emphasized.
Among psychogenic fevers, the following variants are distinguished [10]: • hyperthermia of emotional stress; • hyperthermia in neuroses; • hysterical hyperthermia; • simulative hyperthermia.
Patients with hysteria experience both permanent long periods of low-grade fever and short-term rises to febrile levels. Among the 50 patients with hysteria we examined, 22 patients (44%) reported episodes of low-grade fever [7]. According to A.D. Solovyova, an increase in temperature (up to 40–42 °C) is often observed during hysterical seizures [11].
False or artificially induced fever may be associated with feigning, i.e. deliberately causing a symptom for a clearly understood purpose (for example, to avoid conscription, prosecution, etc.), or with factitious disorder (so-called Munchausen syndrome ), when the main manifestation of pathology is assigning oneself the “role of the patient.” The first situation is usually considered within the framework of medico-legal norms, the second - within the framework of mental illness. In both cases, a false temperature can be caused by manipulations with the thermometer (pushing mercury in the thermometer, heating it on a heating pad, battery, manipulation with a temperature sheet, etc.), iodine intake (in sugar or applied to the skin or mucous membranes), administration under the skin or into the urinary tract of pyrogenic substances. Among such patients, there is a high percentage of people who are in one way or another connected with the medical profession (nurses, orderlies, medical students, doctors). To clarify the artificial nature of the fever, it is recommended:
1) pay attention to the discrepancy between body temperature and pulse rate, as well as to the satisfactory condition of the patient; 2) examine the skin in order to detect traces of injections, infiltrates from the administration of drugs; 3) interview neighbors in the ward about how the patient measures the temperature: does he take any additional medications, does he leave the room shortly before measuring the temperature; 4) measure the temperature in the presence of personnel in both armpits, do it suddenly, not at the allotted time, simultaneously measure oral and rectal temperatures, or use your thermometer to measure the temperature in a fresh portion of urine.
In all cases of psychogenic hyperthermia, infectious, tumor, immunological diseases, systemic connective tissue diseases, demyelinating processes, intoxications, etc. must first be excluded.
Autonomic disorders associated with hysterical defect. The possibilities of using “body language” in patients with hysteria are unique. In patients with severe and persistent psychogenic defects (pseudoparalysis, hibernation), a persistent increase in blood pressure, low-grade or febrile temperature, and stable tachycardia are often found, which spontaneously resolve with the resolution of the functional neurological defect. On the side of pseudoparesis, pronounced vegetative-trophic changes are sometimes observed - cold skin, cyanosis, marbling of the pattern. A psychogenic variant of complex regional pain syndrome (CRPS) with vegetative-trophic disorders (edema and osteoporosis) has been described [12, 13].
Treatment of patients with hysteria
The treatment of patients with hysteria remains one of the most difficult problems, largely due to the "conditional desirability" and "secondary benefit" of the symptom. That is why in the management of such patients the tactic of “saving face” is used, i.e. the psychogenic aspect of his illness is not discussed with the patient. Therapeutic tactics include psychotherapeutic influences and psychopharmacological therapy.
Drug therapy for somatoform disorders includes two groups of drugs: antidepressants and antipsychotics. Antidepressants
In 1998, Fishbain et al. conducted a meta-analysis of randomized placebo-controlled trials of the effectiveness of antidepressants in psychogenic pain syndromes. From 155 publications, 11 studies were selected that met the criteria for analysis. The results of the analysis showed that in this category of patients, antidepressants reduce pain intensity significantly more than placebo [14].
Another study (Heinemann AC, 2003) showed a significantly greater effectiveness of antidepressants in the treatment of patients with somatoform pain, in whom pain was the leading syndrome (89 patients), in contrast to patients where the leading syndrome was FNS (185 patients), and pain was a concomitant disorder. It should be noted that in the first group, depressive disorders, both manifest and manifest, or hidden, were significantly more likely to be present [15].
A wide range of antidepressants today allows you to choose a drug depending on the range of its side effects, additional effects (stimulating or sedative effects), and influence on abnormal behavioral patterns. Tricyclic antidepressants (amitriptyline), drugs from the group of selective serotonin reuptake inhibitors (SSRIs) - fluoxetine, paroxetine, sertraline, fluvoxamine, escitalopram, as well as selective serotonin and norepinephrine reuptake inhibitors (SNRIs) - duloxetine, venlafaxine, milnacipran remain relevant. Neuroleptics
General practitioners are well aware of the effectiveness of minor antipsychotics in treating a wide variety of symptoms. The effectiveness of antipsychotics is associated with their effect on various biochemical structures of the central and peripheral nervous system, resulting in multiple effects: dopamine-blocking, serotonin-stimulating, adrenergic and anticholinergic and antihistamine. Such a diverse spectrum of activity of antipsychotics determines their widespread use in a wide variety of areas of medical practice. They are widely used in gastroenterology for the treatment of functional gastrointestinal disorders, including as antiemetic drugs, in dermatology for the treatment of “pruritic dermatoses”, and are used as antiallergic, vestibulolytic, vegetostabilizing and hypnotic agents [16].
For more than 50 years, minor neuroleptics have been used in psychiatry and neurology for the treatment of the so-called. non-psychotic anxiety or neurotic level disorders [17, 18]. The basis of the psychotropic effect of neuroleptics is their dopamine-blocking effect in the mesolimbic and mesocortical dopaminergic systems. However, they do not cause severe side effects in the form of iatrogenic hyperprolactinemia and extrapyramidal insufficiency, observed when prescribing large antipsychotics.
Antipsychotics are the treatment of choice in the treatment of behavioral disorders in borderline personality disorders and, in particular, in histrionic personality disorders. In this context, the functional neurological and somatic symptoms observed in hysteria, combined with affective tension, irritability, irascibility, mood instability, impulsivity and motor restlessness, are more responsive to the use of antipsychotics than tranquilizers. In addition, minor antipsychotics in combination with antidepressants are successfully used in the relief of anxiety and depressive disorders. The most effective is the combined use of antidepressants and antipsychotics, especially in the case of a combination of functional neurological symptoms with pain, senestopathic, hypochondriacal and anxiety-depressive syndromes. It should be noted that often patients with hysteria do not tolerate tranquilizers well, therefore, if a sedative effect is necessary, it is possible to use antipsychotics with a sedative, and in case of sleep disorders, with a hypnotic effect.
One of the world's widely known minor antipsychotics is alimemazine (Teraligen - pharmaceutical). The drug was synthesized in 1958 and became widespread in different countries. So, in Germany it is known as Repeltin, in the USA - as Temaril, in France and Italy - as Teralen. The French drug Teralen was sold in Russia for a long time as a drug for the treatment of diseases in “minor psychiatry” and was well known to Russian clinicians. However, since 2000, the drug Teralen has not been supplied to Russia, and only in 2007 did Valenta resume production of the drug under the brand name Teraligen. The drug has an anxiolytic effect, has a hypnotic, sedative and vegetostabilizing effect, and is also effective as an antipruritic and antiallergic agent. In small doses (15 mg/day), the drug has proven itself in the treatment of somatoform disorders. Research data from E.S. Akarachkova (2010) assessed the effectiveness of Teraligen (at a dose of 15 mg/day, divided into three doses, for 8 weeks of therapy), which included 1053 outpatient neurological patients with somatoform autonomic dysfunction, demonstrated its significant therapeutic effect on functional cardiovascular, respiratory, gastrointestinal cephalgic symptoms. Against this background, there was an increase in performance and an improvement in the quality of night sleep [19].
Thus, hysterical (somatoform) disorders are not uncommon in general medical practice today. Their timely diagnosis and adequate comprehensive psychopharmacotherapy, especially in the early stages of the disease, can provide a significant therapeutic effect.
Literature
1. Perkin G. An analysis of 7836 successful new outpatient referrals // J. Neurol Neurosurg Psychiatry. 1989. No. 52. P. 447–448. 2. Lempert T., Dieterich M., Huppert D., Brandt T. Psychogenic disorders in neurology: frequency and clinical spectrum // Acta Neurol Scand. 1990. V. 82. P. 335–340. 3. ICD-10/ICD-10 International Classification of Diseases (10th revision). Classification of mental and behavioral disorders. Clinical descriptions and diagnostic guidelines. World Health Organization, Russia. St. Petersburg: Overlayd, 1994. P. 303. 4. Dyukova G.M. Basic principles of diagnosing hysteria in neurology. Selected lectures. Eidos-Media, 2006. pp. 316–337. 5. Vein A.M., Moldovanu I.V. Neurogenic hyperventilation. Chisinau, Shtiintsa, 1988. P. 182. 6. Lacy TJ, McManis SE Psychogenic stridor. Review // Gen. Hosp. Psychiatry. 1994, May. No. 16(3). P. 213–223. 7. Dyukova G.M. Clinical and experimental study of the autonomic nervous system in neuroses. Diss. ... Ph.D. M., 1977. 158 p. 8. Rodshtat I.V., Andreev V.L., Vodolagin V.D., Varrick L.D. On the issue of hemorrhagic and some visceral manifestations in neurotic syndromes // Soviet Medicine. 1974. No. 8. pp. 65–68. 9. Ratnoff OD The psychogenic purpura: a review of autoerythrocyte sensitization, autosensitization to DNA, “hysterical” and factitial bleeding, and the religious stigmata // Semin Hematol. 1980, Jul. 17. No. 3. P. 192–213. 10. Vorobyov P.A. Fever without diagnosis. M.: Newdiamed, 2008. 80 p. 11. Solovyova A.D. Violation of thermoregulation // Autonomic disorders. Clinic, diagnosis, treatment / ed. A.M. Veina. MIA., 1998. pp. 291–299. 12. Rodriguez-Moreno J., Ruiz-Martin J.M., Mateo-Soria L., at al. Munchausen`s syndrome simulating reflex sympathetic dystrophy // Ann. Reum. Dis. 1990. No. 49. P. 1010–1012. 13. Dyukova G.M., Alekseev V.V. Psychogenic dystrophy, occurring as complex regional pain syndrome type 1 // Pain. 2006. No. 2. P. 19–24. 14. Fishbain DA, Cutler RB, Rosomoff HL, Rosomoff RS Do antidepressants have an analgesic effect in psychogenic pain and somatoform pain disorder? A meta-analysis // Psychosom-Med. 1998, Jul.-Aug. No. 60(4). P. 503–509. 15. Heinemann AC Klinicher und diagnostischer Stellenwert von Schmerzsymptomen bei 274 Patienten einer neurologischen Universitätsklinik mit psychogenen Symptomen. 2003. 16. Ibragimov D.F. Alimemazine in medical practice // Journal. neurol. and psychiatrist. 2008. No. 108(9). pp. 76–78. 17. Nemchin T.A., Tupitsyn Yu.Ya. Experience of therapeutic use of Teralen in the clinic of neuroses // Questions of psychiatry and neuropathology. 1965. No. 11. pp. 218–230. 18. El-Khaya R., Baldwin D. Antipsychotic drugs for non-psychotic patients: assessment of the benefit/risk ratio in generalized anxiety disorder // Journal of Psychopharmacology. 1998. Vol. 12. No. 4. P. 323–329. 19. Akarachkova E.S. On the issue of diagnosis and treatment of psychovegetative disorders in general somatic practice // Attending physician. 2010. No. 10. pp. 2–7.
Treatment of somatoform disorder
Treatment of somatoform disorder is long-term and carried out comprehensively, combining drug treatment and psychotherapy. Psychotherapy helps the patient reconsider his beliefs and physical sensations, and learn to cope with stress and anxiety. Pharmacotherapy eliminates anxiety and corrects mood. Drugs are selected according to the clinical picture.
At the Alter Mental Health Center, the method of psychotherapy is selected taking into account the form and severity of the somatoform disorder. Often used in treatment are cognitive-behavioral and dynamic therapy, training in relaxation skills, and group classes to improve communication and social skills.
Lack of timely treatment can lead to loss of performance, problems in social relationships, and the risk of developing concomitant mental disorders increases.
If you notice signs of somatoform disorder in yourself or your family, we will provide you with qualified assistance, of high quality and at an affordable price. Our clinic is located in the center of Moscow, on Vsevolozhsky Lane, next to the Kropotkinskaya metro station. The specialists at the Alter Mental Health Center are interested in your speedy recovery.
Treatment
Treatment of somatoform disorders requires an integrated approach. It includes a large number of different therapeutic measures, but the leading role is played by psychotherapy in combination with medication.
Since patients almost never accept the idea that the cause of their illness is hidden in mental problems, the treatment regimen is drawn up strictly individually in each specific case. Placing the patient in a hospital is usually not required; such measures are resorted to only if improvement does not occur for a long time, and standard therapeutic regimens are ineffective.
The most effective psychotherapeutic methods are:
- cognitive behavioral therapy;
- short-term dynamic psychotherapy;
- relaxation techniques;
- elimination of a traumatic situation after identifying the causes of the disorder. If this is not possible, then the psychotherapist must take measures to deactualize it;
- explaining to the patient and his family members the relationship between somatic symptoms and psychological problems;
- various methods of personal growth and auto-training.
In order to prevent somatoform disorders, it is necessary to identify interpersonal connections that are significant for the patient and expand them. In addition, it is necessary to help the person find an activity that would bring pleasure (occupational therapy).
Pharmacological therapy involves the use of psychotropic drugs. Patients with somatoform disorders may be recommended to take tranquilizers, antidepressants, antipsychotics, etc. This group of drugs can be supplemented with nootropic and vegetative-stabilizing agents. As a result of this treatment, it is possible to improve the patients' sleep and appetite, as well as prevent the development of suicidal thoughts, which often occur in patients with severe somatoform pain.
In each specific case, the doctor selects medications based on the patient’s condition, symptoms and additional manifestations of the disorder. If psychotropic drugs were nevertheless prescribed, then preference is given to monotherapy, and drugs that are convenient to take are selected.
Additional methods may also be used during treatment. Physiotherapy and acupuncture demonstrate good results in healing from somatoform disorders.
If you have discovered signs of somatoform disorder in yourself or your loved ones, then you should make an appointment with a specialist. You can contact a therapist, neurologist or psychotherapist.
3. Treatment of the disease
Patients suffering from somatoform disorders always think that their physical symptoms are caused by a very real illness. They also often don't believe that mental factors can also play an important role in physical health.
A friendly, trusting relationship between doctor and patient is the key to understanding the treatment of somatoform disorders. In addition, meeting with one such doctor will help save a lot of time, nerves and money on unnecessary tests to look for non-existent diseases.
Unlike many other diseases, treatment for somatoform disorders does not focus on symptoms, but on increasing daily activity. Reducing stress also helps treat somatoform disorders.
Cognitive therapy can help relieve symptoms of somatoform disorders. With the help of therapy the following is corrected:
- Altered vision of reality;
- Unrealistic expectations;
- Behavioral factors.
About our clinic Chistye Prudy metro station Medintercom page!
