Why do I feel unwell all over my body?

Author: Wu Heng, Deputy Chief Physician, Tongji Hospital Affiliated to Tongji University, Yin Jiaxin, Tongji Hospital Affiliated to Tongji University

Illustration: Yin Xiaowen Hangzhou Seventh People's Hospital

Reviewer: Lu Zheng, Chief Physician and Professor of Tongji Hospital Affiliated to Tongji University

Do you feel uncomfortable all over your body and have visited many hospitals and departments but still cannot get a diagnosis?

Even if you are not, I believe you have seen such patients around you. When they have some slight physical discomfort, they begin to suspect that they are sick and often complain of various physical discomforts, including gastrointestinal symptoms (such as abdominal pain, nausea), pseudo-neurological symptoms (such as difficulty swallowing, blurred vision), cardiopulmonary symptoms (such as shortness of breath, palpitations) and female reproductive system symptoms (such as irregular menstruation, excessive menstruation), etc. Then they go to various departments of a general hospital and undergo corresponding examinations, but the examination reports indicate that "everything is healthy". The doctors are very frustrated, the patients are even more frustrated, and their families also complain about the patients' repeated "doctor-hopping" routine.

Figure 1 Copyright image, no permission to reprint

When she was young, 68-year-old Grandma Wang was a smart and capable factory manager during the day and a mother raising her children alone after get off work. She thought she could finally start a happy old age with her husband after retirement, but her husband died of stomach cancer the following year. Not long after, living alone, Grandma Wang began to experience a variety of physical symptoms, from stomach pain, dizziness, chest tightness to insomnia.

In order to treat her illness, Grandma Wang went to the gastroenterology department, cardiovascular department, and neurology department for laboratory tests and physical examinations, but the doctors all gave the same answer: "You are not sick!"

Listening to the doctor's explanation and looking at the piles of examination reports, Grandma Wang was angry and helpless. Half a year passed, and the pain continued to intensify and spread. Grandma Wang was depressed every day and almost stopped doing housework.

Seeing that the situation was about to reach an impasse, a general practitioner referred Grandma Wang to the Department of Psychosomatic Medicine, who eventually diagnosed her with "Somatic Symptom Disorder."

1. What is somatic symptom disorder?

Somatic symptom disorder (SSD), also known as somatization disorder, psychogenic pain, and persistent pain disorder. As early as the 19th century, we called this disease "hysteria" and "hysteria". Since the 20th century, we have called this disease "medically unexplained physical symptoms" or "functional physical disorder". In 1980, the American Diagnostic and Statistical Manual of Mental Disorders (third edition) (DSM-Ⅲ) called this disease phenomenon "somatization disorder" or "somatoform disorder".

Are you a little confused by these similar terms? Don't worry, now you only need to remember the following. Finally, in the DSM-5 released in 2013, it was redefined as "somatic symptom disorder", which is defined as physical symptoms that cannot be explained by general laboratory tests and pathological physiological abnormalities, and can be combined with other physical diseases. It is described as follows:

1. The presence of one or more physical symptoms, mainly pain. The symptoms cause serious damage to the individual's life and body, manifested as at least one of the following:

(1) Persistent thoughts and behaviors that are disproportionate to the severity of the individual’s symptoms.

(2) Persistent high levels of anxiety about health or symptoms.

(3) Worrying about these symptoms or health issues takes up too much time and energy.

2. Physical symptoms may change continuously, but the duration of symptom distress lasts for more than 6 months.

2. Why do people suffer from somatic symptom disorder?

Although the pathogenesis and cause of SSD are still unclear, according to the modern bio-psycho-social medical model, pain acts as an "alarm signal" to remind us that something is wrong somewhere in the body. When these symptoms cannot be clearly explained by physiological reasons, we must begin to consider the role of psychological and social factors in the disease.

Studies have found that more than 50% of SSD patients have comorbid anxiety and depression disorders. When we are trapped in negative emotions or emotional stress, the brain's "perception" of pain becomes less accurate, such as increased sensitivity, intensity and frequency, which ultimately leads to the appearance and chronicity of physical symptoms, seriously affecting the patient's mental and physical health.

For some people, the risk of developing physical symptoms is twice as high or even higher than that of others, such as negative childhood experiences, early physical abuse, poor personality foundation (avoidant or anxious attachment pattern), abnormal regulation of emotion cognition, etc. We usually call these psychological factors.

Of course, most current studies point out that the common causes of SSD patients include biological factors caused by abnormal brain structure and function, and social factors induced by recent life event pressure and extensive psychosocial stress.

Figure 2 Copyright image, no permission to reprint

3. Are somatization symptoms fake? How to treat them?

Of course not. Although the prevalence rate in the general population is 0.1% to 0.7%, many factors such as the stigma and low awareness of the disease cannot be ignored. From the perspective of functional impairment and disease burden, patients may take sick leave due to physical discomfort, which may lead to serious occupational dysfunction and work disability, and even suicidal behavior. The annual medical resource consumption of somatoform disorder, the "predecessor" of somatic symptom disorder, accounts for more than 16% of the total medical expenses in the United States, which is more than twice that of patients with other mental illnesses.

So, their pain is real and seriously affects their lives.

We often say that the body is another way of expressing the mind. In treatment, doctors will first affirm the authenticity of physical symptoms, guide SSD patients to understand the psychological reasons behind physical symptoms, avoid excessive examinations, tap into the patient's social support and resources, and invite the patient's family members to participate in his care and treatment. Adopt personalized drug-psychological integration treatment according to the patient's personality characteristics. If there are significant anxiety and depression symptoms, anti-anxiety, anti-depression and other psychiatric drugs can be used for treatment.

Today, the answers to these three questions are here. I believe you already have a pair of "smart eyes" to identify patients with somatic symptom disorder and understand the meaning behind their symptoms. Please ask such patients to go to the Department of Psychosomatic Medicine as soon as possible and press the pause button for the endless "doctor shopping"!

References

[1] LÖWE B, SPITZER RL, WILLIAMS JB, et al. Depression, anxiety and somatization in primary care: syndrome overlap and functional impairment[J]. Gen Hosp Psychiatry, 2008, 30:191-199.

[2] HENNINGSEN P , ZIPFEL S , SATTEL H , et al. Management of functional somatic syndromes and bodily distress[J]. Psychotherapy and Psychosomatics, 2018, 87(1):12-31.

[3] WIBORG JF, GIESELER D, FABISCH AB, et al. Suicidality in primary care patients with somatoform disorders[J]. Psychosom Med, 2013, 75:800–806.

[4] BARSKY AJ, ORAV EJ, BATES D W.smatization increases medical utilization and costs independent of psychiatric and medical comorbidity [J]. Arch Gen Psychiatry, 2005, 62(8):903-9l0.