Somatoform disorder

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Classification according to ICD-10
F45.0 Somatization disorder
F45.1 Undifferentiated somatization disorder
F45.2 Hypochondriac disorder
F45.3 Somatoform autonomic dysfunction
F45.4 Persistent somatoform pain disorder
F45.8 Other somatoform disorders
F45.9 Somatoform disorder, unspecified
ICD-10 online (WHO version 2019)

Somatoform disorders are physical complaints that cannot be traced back to an organic disease (in the classic medical sense of the ICD-10 ). It is characterized by an intense fixation on certain physical ( somatic ) symptoms that lead to considerable suffering and impair everyday life ( DSM-5 ).

In addition to general symptoms (such as tiredness and exhaustion), pain symptoms come first, followed by cardiovascular complaints, gastrointestinal complaints, sexual and (pseudo) neurological symptoms. Somatoform symptoms occur at least temporarily in around 80 percent of the population, usually pass by themselves and are hardly noticed. In some people (the information on the frequency fluctuates between 4 and 20 percent), however, these complaints can become chronic and play a central role in life.

Somatoform disorders are one of the most common complaints among general practitioners and general hospitals: at least 20 percent of all those who see a family doctor suffer from it. A frequency of 10 to 40 percent has been reported from inpatient departments. Patients with somatoform disorders are often perceived as difficult by the general practitioner; those affected themselves, in turn, are often disappointed with their practitioners, which on the one hand can lead to doctor hopping , on the other hand it has also been referred to as the “syndrome of thick nudes”. The disease is often recognized late and it often takes years before the patient is referred to a psychotherapist or is ready to deal with anything other than a purely physical cause.

The cost of treating this group of people is immense and higher than the average per capita treatment expenditure.

Origin of the diagnosis

The term "somatoform disorders" was introduced into the official classification systems in 1980. In the International Classification of Diseases ( ICD-10 ) they are included in category F45. The theoretical basis of the disease concept are the processes of somatization . Traditional names for similar diseases and syndromes are: psychogenic disorders, functional disorders , vegetative dystonia , general psychosomatic syndrome, conversion hysteria , Briquet hysteria and psychological superimposition.

causes

The causes of somatoform disorders have not yet been clarified; there are a number of explanatory models, none of which has been empirically proven. Somatoform disorders are therefore not clearly attributable to a single cause. Rather, an interplay of various biological, psychological and social factors is assumed to be the trigger. Genetic factors (for example an increased willingness of the autonomic nervous system to react) are also discussed. However, it is likely that psychosocial factors in particular are important for the development and course of somatoform disorders:

  • Long-lasting stress leads to tension or malfunctions in internal organs
  • a vicious circle of physical reactions, fear, and increased awareness of physical symptoms (so-called somatosensory amplification)
  • From a psychodynamic point of view, physical complaints are understood as the result of emotional conflicts: unconscious mental processes (e.g. fear, anger, anger, dissatisfaction with one's own appearance) can be expressed in body symptoms (compare psychosomatics ). (Early childhood) sexual trauma, physical abuse and, for example, war experiences can play a special role in the genesis of somatoform disorders.

Symptom picture

Somatoform disorders can manifest themselves in a variety of signs ( symptoms ):

  • in the area of ​​breathing (for example, as a feeling of being unable to breathe, lump in the throat , tight throat , shortness of breath)
  • in the area of ​​the cardiovascular system (e.g. feeling of pressure, stitches, tightness in the chest, stumbling of the heart)
  • In the gastrointestinal tract ( irritable stomach and irritable bowel ): nausea, bloating, abdominal pain, irregular stool
  • in gynecology: (chronic) pelvic pain radiating to the groin and sacrum , pelvipathy syndrome (pain that persists or recurs for more than six months, regardless of sexual intercourse and cycle)
  • In urology ( irritable bladder , urethral syndrome, prostatodynia): frequent or painful urination (feeling difficult to urinate ), pain in the lower abdomen or intestines.
  • as somatoform pain disorder : persistent pain without adequate explanatory physical findings.

Often these are symptoms that can be accompanied by strong excitation of the autonomic nervous system . But malfunctions that are mediated via the non-autonomous nervous system, such as tremors and muscular tension or hormonal abnormalities, can also be observed.

In addition, other psychological disorders , particularly depression and anxiety disorders, are often found in patients with somatoform disorders.

diagnosis

The diagnosis of a somatoform disorder has so far been based initially on the sufficiently reliable, temporally shortened and not constantly repeated exclusion of the sole organic cause of the complained physical complaints. In addition, however, a psychological diagnosis must be made that takes into account the current emotional and emotional life , psychological conflicts, aspects of the psychological structure, biographical stresses and social and cultural factors.

Various structured clinical interviews and questionnaires are available to aid diagnosis, since a professional diagnosis is never the sole result of the score of a self-disclosure questionnaire. In Germany (in addition to the general symptom checklist SCL-90 ) the screening for somatoform disorders ( SOMS ) is the most common questionnaire that is used to support the diagnosis. Another tool is the freely available health questionnaire for patients (PHQ-D) .

According to ICD-10

The ICD-10 distinguishes between:

  • somatization disorder (F45.0) and undifferentiated somatization disorder (F45.1)
  • hypochondriac disorder (F45.2)
  • somatoform autonomic dysfunction (F45.3x)
  • persistent somatoform pain disorder (F45.40)

According to DSM

In DSM-5 , the concept of "negative diagnostics" is abandoned together with the term "somatoform disorder". Rather, it is referred to as a "somatic stress disorder" and it is sufficient if one or more stressful or impairing physical symptoms are present.

In principle, this addresses every disease that is associated with a clinically conspicuous and painful psychosocial dysfunction, internal involvement of the person concerned (e.g. loss of job after frequent time off, separation of couples or family conflicts after prolonged and one-sided focus of communication on diseases, complaints, (finally) seriousness -Getting accepted and mutual disappointment spirals).

Subtypes according to ICD-10

Somatization disorder

In the case of a somatization disorder (F45.0), according to ICD-10, persistent complaints of various and changing physical symptoms (at least six) must be present over a period of at least two years. It is important that these are not predominantly vegetative (otherwise it is a somatoform autonomic dysfunction ). The symptoms must not be sufficiently explained by a physical cause, but this is not accepted by the person affected (or at most for a short time). Frequent visits to the doctor (at least three), self-medication or seeking lay helpers or complementary medicine procedures are characteristic . Typical symptoms are:

  • gastrointestinal symptoms (for example abdominal pain, nausea, bad taste in the mouth or thickly coated tongue, vomiting or gagging, diarrhea)
  • cardiovascular symptoms (for example, breathlessness without exertion, chest pain)
  • urogenital symptoms (for example, dysuria, uncomfortable sensations in or around the genital area, complaints of unusual or increased vaginal discharge)
  • Skin or pain symptoms (for example, complaints of blotchiness or changes in the color of the skin, pain in the limbs, uncomfortable numbness or tingling sensation).

An undifferentiated somatoform disorder (F45.1) may already be beyond a period of six months to be diagnosed. The number of symptoms or the behavior to seek help is less pronounced than in the case of somatization disorder.

While somatization disorder is thought of as a prototypical somatoform disorder in both diagnostic systems, practice has shown that undifferentiated somatoform disorder is the most commonly diagnosed. This state of affairs has been criticized for a long time. Therefore there are considerations in future versions of the two classification systems to redefine the criteria.

Hypochondriac disorder

In the case of a hypochondriacal disorder (F45.2), the focus is not on the current physical symptoms, but on the conviction that persists for at least six months (despite findings to the contrary) that you are suffering from one (or at most two) specific severe physical illness (s) (F45. 20). Alternatively, the person concerned may be firmly convinced that they have a physical disfigurement or deformity ( dysmorphophobia , F45.21). Here, too, there are frequent visits to the doctor or the search for complementary medical help, mostly through lay helpers.

Somatoform autonomic dysfunction

In the case of a somatoform autonomic dysfunction (F45.3), the focus is on symptoms of vegetative arousal (see autonomic or vegetative nervous system ) that can be assigned to one or more of the following systems or organs:

  • Heart and cardiovascular system (for example chest pain or feeling of pressure in the heart area)
  • Upper gastrointestinal tract (discomfort in the esophagus or stomach; for example, feeling of overinflation, bloating, aerophagia , singultus or burning sensation in the chest or upper abdomen)
  • lower gastrointestinal tract (bowel problems such as frequent bowel movements)
  • respiratory system (breathing difficulties such as dyspnoea or hyperventilation )
  • Genitourinary system (for example, increased urination frequency or dysuria )

For the diagnosis, there must be at least one symptom in one of these areas and / or exceptional fatigue with light exertion.

You must also have two or more of the following symptoms:

  • Palpitations
  • Sweats (hot or cold)
  • Dry mouth
  • Hot flashes or flushing
  • A feeling of pressure, tingling or agitation in the epigastric region

Persistent somatoform pain disorder

Persistent somatoform pain disorder (F45.4) must be diagnosed with persistent severe and distressing pain in any part of the body that cannot be adequately explained by physical evidence for at least six months (most days). Since 2009 this diagnosis has been coded in accordance with the German Modification 2009 within the ICD-10 under F45.40 or supplemented by the diagnosis of chronic pain disorder with somatic and psychological factors (F45.41). This diagnosis is made when pain has existed for at least six months in one or more anatomical regions that have their origin in a physiological process or a physical disorder. Mental factors are considered to play an important role in the severity, exacerbation or maintenance of pain, but not the causal role in causing it to begin. The pain causes suffering and impairment in a clinically significant manner in social, professional, or other important functional areas. The pain is not intentionally created or simulated (as in the simulated disorder or simulation). Pain disorders in particular in connection with an affective, anxiety, somatization or psychotic disorder should not be considered here.

The formerly so-called " larvae depression" with accompanying somatic symptoms is assigned to the depressive disorders .

Special features of the doctor-patient relationship

The interaction between doctors and patients with somatoform disorders is often difficult; It is not uncommon for the relationship to be broken off and doctor-hopping to be frequent . The reason is usually considered to be the discrepancy in the respective beliefs about the cause: if there is no evidence of organic explanations, the doctor usually suspects psychogenic causes or simulation . No, incorrect, or fashion diagnoses may be made. The patient experiences this situation with great concern and disappointment and usually continues to assume exclusively or primarily organic causes, because only these subjectively legitimize his complaints for him and feels that the doctor does not take him seriously. Often this leads to tension and anger on both sides.

In this situation, the course of somatoform disorders is largely determined by the behavior of the doctors: Repeated, complaint-controlled organic diagnostics and unnecessary (longer) sick leave, but also retirement, contribute, for example, to chronification (iatrogenic fixation).

treatment

The therapy consists first of all in creating a stable relationship of trust beyond an "either - or" (body or psyche), but towards an "both - and". For this purpose, information must first be given in a suitable form about somatoform symptoms or disorders and about the interplay between physical and mental processes. In 80% of cases, patients can be contacted by a trusted family doctor, e. B. General practitioner, are well looked after as part of basic psychosomatic care, in severe cases, patients are to be motivated to undergo further psychosomatic treatment, which is available on an outpatient and inpatient basis.

Therapy studies and therapy manuals are now available for the disorder-oriented treatment of this group of patients. In-patient acute treatment is paid for by the statutory health insurances in Germany if indicated, rehabilitative treatment by the pension insurance funds.

literature

Guidelines

Technical articles

  • E. Brähler, J. Schumacher: Finding and being: Psychological aspects of physical complaints. In: E. Brähler, B. Strauss (Ed.): Fields of action of psychosocial medicine . Hogrefe, Göttingen 2002, ISBN 3-8017-1498-5 .
  • U. Hagenah, B. Herpertz-Dahlmann: Somatization disorders in children and adolescents. In: Deutsches Ärzteblatt. 102 (27), 2005, pp. A-1953-A-1959. (PDF)
  • Winfried Rief , W. Hiller: Somatization Disorder. 2nd updated edition, Hogrefe Verlag, Göttingen 2011, ISBN 978-3-8017-2126-8 .
  • W. Hausotter: Assessment of somatoform and functional disorders. Urban & Fischer, Munich / Jena 2002, ISBN 3-437-22046-2 .
  • Hans Morschitzky : Somatoform disorders: diagnostics, concepts and therapy for body symptoms without organ findings . Vienna / New York Springer 2007, ISBN 978-3-211-48637-5 .
  • A. Martin, W. Rief: Somatoform disorders . In HU Wittchen, J. Hoyer (Ed.): Clinical Psychology & Psychotherapy . Springer Medizin Verlag, Heidelberg 2006, ISBN 3-540-28468-0 .
  • N. Sauer, W. Eich: Somatoform disorders and functional disorders. In: Deutsches Ärzteblatt. 104 (1-2), 2007, pp. A45-A53. (PDF)

Individual evidence

  1. ^ NC van Dessel, JC van der Wouden, J. Dekker, HE van der Horst: Clinical value of DSM IV and DSM 5 criteria for diagnosing the most prevalent somatoform disorders in patients with medically unexplained physical symptoms (MUPS). In: Journal of psychosomatic research. 82, 2016, pp. 4–10.
  2. ↑ T. Rosic, S. Kalra, Z. Samaan: Somatic symptom disorder, a new DSM-5 diagnosis of an old clinical challenge. In: BMJ Case Reports. 2016.
  3. ↑ R. Mayou: Is the DSM-5 chapter on somatic symptom disorder any better than DSM-IV somatoform disorder? In: The British journal of psychiatry: the journal of mental science. 204 (6), 2014, pp. 418-419.
  4. ↑ C. Hausteiner-Wiehle, H. Sattel, P. Henningsen: Ill or not ill? Towards a better management of patients with "medically unexplained symptoms". In: German Medical Weekly . 140 (17), 2015, pp. 1320-1323.
  5. ↑ H. Sattel, R. Schaefert, W. Hauser, M. Herrmann, J. Ronel, P. Henningsen and others: Treatment of non-specific, functional and somatoform bodily complaints. In: German Medical Weekly . 139 (12), 2014, pp. 602-607.
  6. ↑ C. Lahmann, P. Henningsen, M. Noll-Hussong, A. Dinkel: Somatoform disorders. In: Psychother Psychosom Med Psychol. 60, 2010, pp. 227-236. doi: 10.1055 / s-0030-1248479
  7. ↑ Kleinstäuber, M., Thomas, P., Witthöft, M., & Hiller, W. (2012). Cognitive behavior therapy for medically unexplained physical complaints and somatoform disorders. Springer publishing house.
  8. ↑ M. Noll-Hussong, H. Gundel: Etiopathogenetic aspects of somatoform disorders. In: Neurologist. 83 (9), Sep 2012, pp. 1106-1114.
  9. ↑ V. Duddu, MK Isaac, SK Chaturvedi: Somatization, amplification somatosensory, attribution styles and illness behavior: a review. In: Int Rev Psychiatry. 18, 2006, pp. 25-33. doi: 10.1080 / 09540260500466790
  10. ↑ ML Paras, MH Murad, LP Chen, EN Goranson, AL Sattler, KM Colbenson, MB Elamin, RJ Seime, LJ Prokop, A. Zirakzadeh: Sexual abuse and lifetime diagnosis of somatic disorders: a systematic review and meta-analysis. In: JAMA. 302, 2009, pp. 550-561. doi: 10.1001 / jama.2009.1091
  11. ↑ M. Noll-Hussong, H. Glaesmer, S. Herberger, K. Bernardy, C. Schonfeldt-Lecuona, A. Lukas and others: The grapes of war. Somatoform pain disorder and history of early war traumatization in older people. In: Z Gerontol Geriatr. 45 (5), Jul 2012, pp. 404-410.
  12. ↑ N. Sauer, W. Eich: Somatoform disorders and functional disorders. In: Dtsch Arztebl International. 1 (1), 2009, pp. -18-.
  13. ^ AM Murray, A. Toussaint, A. Althaus, B. Lowe: The challenge of diagnosing non-specific, functional, and somatoform disorders: A systematic review of barriers to diagnosis in primary care. In: Journal of psychosomatic research. 80, 2016, pp. 1–10.
  14. ↑ W. Rief, A. Martin: How to use the new DSM-5 somatic symptom disorder diagnosis in research and practice: a critical evaluation and a proposal for modifications. In: Annual review of clinical psychology. 10, 2014, pp. 339-367.
  15. ↑ Anna M. Ehret (2013): DSM-IV and DSM-5: What has actually changed? (Review) . In: behavior therapy . tape 23 , no. 4 , p. 258–266 , doi : 10.1159 / 000356537 ( karger.com [PDF] somatization disorders see p. 262).
  16. ↑ ICD-10-GM Version 2016: Mental and behavioral disorders. ( Memento of the original from February 14, 2016 in the Internet Archive ) Info: The archive link was inserted automatically and has not yet been checked. Please check the original and archive link according to the instructions and then remove this notice. on: dimdi.de @1@ 2Template: Webachiv / IABot / www.dimdi.de
  17. ^ P. Nilges, W. Rief: F45.41 - Chronic pain disorder with somatic and psychological factors. A coding aid. In: The pain. 24 (3), 2010, pp. 209-212. doi: 10.1007 / s00482-010-0908-0
  18. ↑ C. Lahmann, P. Henningsen, M. Noll-Hussong: Somatoform pain - an overview. In: Psychiatr Danub. 22, 9, 2010, pp. 453-458.
  19. ^ T. Bschor: Masked depression: the rise and fall of a diagnosis. In: Psychiatric Practice. 29, 2002, pp. 207-210.
  20. ↑ P. Henningsen, S. Zipfel, W. Herzog: Management of functional somatic syndromes. In: Lancet. (London). 369 (9565), 2007, pp. 946-955.
  21. ^ S. Weiss, M. Sack, P. Henningsen, O. Pollatos: On the interaction of self-regulation, interoception and pain perception. In: Psychopathology. 47 (6), 2014, pp. 377-382.
  22. ↑ C. Hausteiner-Wiehle, R. Schafert, H. Sattel, J. Ronel, M. Herrmann, W. Hauser et al.: New guidelines on functional and somatoform disorders. In: Psychotherapy, Psychosomatics, Medical Psychology. 63 (1), 2013, pp. 26–31.
  23. ↑ D. Olbrich, B. Cicholas, H. Klenke-Bossek: Psychosomatic-psychotherapeutic rehabilitation of social medicine problem patients - an exploratory study of findings, follow-up and treatment outcome. In: The rehabilitation. 37 (1), 1998, pp. 7-13.
  24. ^ R. Schaefert, C. Hausteiner-Wiehle, W. Hauser, J. Ronel, M. Herrmann, P. Henningsen: Non-specific, functional and somatoform physical complaints. In: Dtsch Arztebl International. 109 (47), 2012, pp. 803-813.
  25. ↑ C. Lahmann, P. Henningsen, A. Dinkel: Somatoform disorders and functional somatic syndromes. In: The neurologist. 81 (11), 2010, pp. 1383-1394.
  26. ↑ H. Sattel, C. Lahmann, H. Gündel, E. Guthrie, J. Kruse, M. Noll-Hussong, C. Ohmann, J. Ronel, M. Sack, N. Sauer, G. Schneider, P. Henningsen : Brief psychodynamic interpersonal psychotherapy for patients with multisomatoform disorder: randomized controlled trial. In: Br J Psychiatry. 200, 2012, pp. 60-67. doi: 10.1192 / bjp.bp.111.093526
  27. ↑ S3 guideline for dealing with patients with non-specific, functional and somatoform physical complaints of the German Society for Psychosomatic Medicine and Medical Psychotherapy (DGPM) and the German College for Psychosomatic Medicine (DKPM). In: AWMF online (as of 2012)
  28. ↑ A. Schneider, E. Horlein, E. Wartner, I. Schumann, P. Henningsen, K. Linde: Unlimited access to health care - impact of psychosomatic co-morbidity on utilization in German general practices. In: BMC family practice. 12, 2011, p. 51.