Somatoform disorder of the nervous system: debunking the myth of malingering

Everyone in their circle of friends has a person who constantly complains about their health: they have a stabbing pain, they are sick, or they simply don’t feel well. But no matter how many times he goes to doctors, no one finds a specific reason for this condition. He’s pretending, we think. But don't rush to conclusions. These symptoms may be a sign of a somatoform nervous system disorder. It does not have an organic background, but leads to a mental imbalance of the individual.

Why does the disorder develop?

Somatoform disorder is a disease of a psychological nature in which the symptoms of damage to internal organs are functional, not organic.

Such dysfunction is detected in 0.5% of the world's population, and it affects mainly women. The reason lies, first of all, in the psychological state of a person.

The first group of factors influencing the occurrence of the syndrome is heredity and character traits. For example, people with asthenoneurotic and hysterical types of character are more likely to develop it. They are characterized by hypersensitivity, timid or demonstrative behavior. Such people are characterized by rapid nervous exhaustion; as a rule, they are pessimistic.

The second group is psychogenic traumatic external influences. These include acute stress factors, when a powerful psychological blow at once leads to a disorder of nervous activity. This could be the loss of a loved one, a decrease in social status, or a situation of severe fear.

Chronic stress occurs as a result of systematic mental and physical overstrain, lack of positive emotions, unmet needs and excessive demands on oneself.

It is worth noting that somatoform disorder very often develops in people who are emotionally stingy, hide their feelings, and do not know how to express them. And since emotions need a way out in any case, they find it in this unique way. A similar state can accompany members of religious families, where an atmosphere of strict morality reigns.

Other factors that provoke the disorder include complicated pregnancy, trauma, infections, and some somatic diseases.

Signs of illness

Symptoms of somatoform disorder are quite varied and manifest themselves in malfunctions of almost all body systems.

As a rule, several symptoms associated with different systems occur simultaneously.

There are the following types of this disorder:

• hypochondriacal;
• somatized;
• somatoform dysfunction of the autonomic nervous system (SDVNS);
• chronic somatoform pain disorder;
• undifferentiated somatoform disorder.

Patients with somatoform dysfunction are distinguished by several features. This includes a peculiar, emotional or overly specific narrative about one’s condition. For example, a man comes to a cardiologist with pain and discomfort in his heart. But at the same time, he speaks not only about their character, but also about the fact that they cause him a lot of inconvenience. Such attacks occur at work, at the moment when he is supposed to make a report on his achievements. As a result, he cannot concentrate, paying all attention to his heart.

The reason here is this aspect: perhaps the man is psychologically not ready to talk about his work (for example, due to his failures), and the heart is assigned to the extreme. And it is precisely this that reacts to this stressor in order to divert attention from it.

Other distinguishing features are:

• exaggeration of pathological sensations;
• denial of the role of psychological factors in their development;
• increased irritability towards others.

Somatoform disorder in the practice of a gastroenterologist

A number of functional disorders in the functioning of the digestive organs should be considered from the perspective of somatoform disorder. The article presents the classification and pathogenesis of this disease, analyzes the personality characteristics of this category of patients, as well as functional gastroenterological symptoms from the perspective of disorders in the somatosensory system.

Somatoform disorder is a pathological condition manifested by symptoms of dysfunction of various organs and systems in the absence of organic changes in them that could cause such symptoms [1].

According to the results of epidemiological studies conducted at the end of the last century, somatoform disorder is detected in 10–26% of patients in the general somatic network [2]. More recent clinical observations (in particular, those conducted by employees of the clinical psychology laboratory of the Moscow Clinical Research and Practical Center named after A.S. Loginov) indicate a steady increase in the frequency of symptoms caused by somatoform disorder and the pathomorphism of the clinical manifestations of the disease.

Speaking about the essence of the disease, it should be borne in mind that somatoform disorder is a disorder in the somatosensory system, which is responsible for the perception of impulses coming from the body. Disturbances can occur both in its peripheral (at the receptor level) and central parts, mutually reinforcing each other. Primary dystrophic changes in receptors in the periphery are caused by various reasons (for example, changes in receptors of the esophagus as a result of exposure to pathologically acidic refluxate from the stomach). In this case, inadequate (erroneous) signals about pain activate the central mechanisms of pain maintenance. Their hyperactivity causes a retrograde increase in excitation of peripheral receptors and the development of sensitization to pain. It is also possible that the central regulatory mechanisms may initially be strained against the background of stress or mental conflict, which is accompanied by a decrease in the threshold for the perception of physical discomfort (similar to the threshold for pain sensitivity) with the subsequent transfer of pathological arousal to the peripheral receptors of the somatosensory system.

External manifestations are distinguished by the diversity and variability of somatic symptoms. Therefore, patients seek help from doctors of various specialties, including gastroenterologists. A constant feeling of trouble also affects the emotional state. General practitioners often interpret various reactions of the anxiety spectrum as “inventing” symptoms, “obsessing” over the disease. This is an erroneous interpretation: patients with somatoform disorder do not invent, but actually experience unusual sensations.

At the initial stage of the disease, new bodily sensations differ from the manifestations of normal functioning of the body only by a slight increase in intensity (increased rumbling in the stomach or a feeling of bloating, discomfort in the right hypochondrium, occasional minor difficulty swallowing, an unusual burning sensation in any part of the body, etc.) . The physiological basis of such sensations may be transient autonomic dysfunction due to excessive food loads, chronic emotional fatigue, and acute stress. Close attention to any part of the body can also be triggered by anxious thoughts after the death of a loved one. This is especially true in the case of cancer, when the diagnosis is made too late. First recorded episodes of physical discomfort may be repeated, which over time causes an alarming reaction to unusual sensations in the body.

The further development of events depends on the characteristics of the individual: the more pronounced the tendency to long-term experiences, the more likely it is that all subsequent sensations are “colored” by anxiety and are perceived more acutely. A long-term anxiety state is always accompanied by autonomic disorders. It is no coincidence that they are called autonomic correlates of anxiety. Having achieved stability, autonomic imbalance is expressed in functional disorders in the work of various organs and systems. Unlike the initial symptoms of the disease, disorders at this stage can be confirmed by instrumental examination methods.

Malfunctions in the digestive tract are associated with impaired motor function and interoceptive sensitivity. Disorders of the motor function of the digestive tract are more often confirmed [3]. In this case, the role of x-ray examination is great, making it possible to establish dyskinesia of the esophagus, functional bending of the stomach, hypertonicity or hypokinesia of different parts of the intestine. A good example of more accurate methods for diagnosing motor disorders is esophageal manometry [4, 5].

Things are more complicated with instrumental confirmation of disturbances in interoceptive sensitivity, manifested by increased or distorted perception of impulses coming from internal organs [6]. When analyzing the clinical picture and comparing it with the results of instrumental studies, it is often possible to only assume the presence of such disorders. An example of hyperesthesia (a pathological increase in the reaction of receptors to stimulation of normal strength) is hypersensitivity of the esophagus. Experts make this conclusion when the clinical picture (intense, painful heartburn) does not correspond to the 24-hour pH-metry data, indicating the presence of gastroesophageal reflux within physiological values. In such a situation, there is no effect of acid-lowering drugs. This suggests that the mechanism of development of symptoms is not associated with the aggressiveness of gastric reflux, but with damage to the receptors of the somatosensory system [7, 8].

Disturbances in the somatosensory system are confirmed by the presence of so-called sensory phenomena (sensopathy), that is, a qualitative change in the perception of impulses. The most common type of sensopathy is paresthesia - unusual sensations of burning, burning, drilling, tingling, etc. With paresthesia, patients clearly indicate the organ that is bothering them, for example, “burning in the stomach.” It is characterized by an emotional coloring with a description of the sensation as “fire”, “boiling water”, “conflagration”. In cases where the sensation is characterized by the patient as pain, the term “senestalgia” is appropriate. Senestalgia of various localizations is designated by the corresponding terms: stomalgia (burning of the oral mucosa), glossalgia (burning of the tongue), etc. If an unusual, often painful, difficult-to-describe sensation is not associated with any organ, it is designated by the term “senesthopathy”.

Sensopathies are possible not only in the area of ​​pain perception, but also in other areas, in particular the gustatory sensory system. Pathological excitation of taste buds (bulbs) is manifested by a taste disorder - dysgeusia. The most characteristic disorder is parageusia (the appearance of taste sensations in the absence of corresponding stimuli). In gastroenterology, parageusia is especially relevant in the form of a debilitating sensation of acid in the mouth, which in some cases is mistakenly attributed to extraesophageal manifestations of gastroesophageal reflux disease. Other variants of taste sensitivity disorders in gastroenterological patients are less common. A relatively rare symptom is a change in the sense of smell, or dysosmia.

Visceral perception disorders can occur in any part of the digestive tract and manifest as abdominal pain disorders (epigastric pain syndrome, biliary pain, proctalgia) or other functional disorders (functional dyspepsia, functional defecation disorder).

Numerous disorders are also observed in other systems and organs that are completely innervated and controlled by the autonomic nervous system (cardiovascular, respiratory, urogenital). The following complaints are considered typical:

• a feeling of pressure, compression, burning, tingling in the heart area;
• heart rhythm disturbances in the form of a feeling of rapid heartbeat or “fading” in the work of the heart;
• a feeling of lack of air with the inability to compensate by taking a deep breath, difficulty or increased breathing;
• pain in the lower abdomen, difficulty or pain when urinating, sexual dysfunction, etc.

As you can see, the symptoms are in many ways reminiscent of signs of organic lesions of these organs and systems. A characteristic difference is their diversity, changeability and vagueness.

Patients with somatoform disorder often present with nonspecific complaints - fleeting pain throughout the body, hot flashes or chills, a feeling of heaviness, fatigue, lethargy, chronic headache, dizziness, a feeling of internal trembling, trembling of the arms and legs.

In general, the complaints are so diverse that it is not possible to present a complete list of them. It is believed that to diagnose a somatoform disorder, the presence of at least four somatic complaints in men and six in women is necessary.

Somatic complaints at this stage of the disease are combined with pronounced anxious (less often depressive) reactions, the nature of which patients clearly explain as a reaction to long-term and untreatable symptoms of the disease. Therefore, they extremely rarely complain about mood disorders, trying to direct the conversation with the doctor towards a detailed description and discussion of somatic symptoms. As a rule, patients refuse psychopharmacological treatment, but even if they start taking psychopharmacological drugs prescribed by a doctor, they soon cancel them on their own, fearing side effects.

Due to the described circumstances, patients with somatoform disorder are considered difficult patients requiring special attention and an individual approach. First of all, this applies to those who are completely “immersed in illness.” This condition is invariably accompanied by disruption of interpersonal relationships and social connections.

According to the International Classification of Diseases, 10th revision, the disease is named in the section of mental disorders and has code F45 [9]. In this case, several variants of somatoform disorder are distinguished depending on the clinical manifestations [10]:

• F45.0 – somatization disorder;
• F45.1 – undifferentiated somatoform disorder;
• F45.2 – hypochondriacal disorder;
• F45.3 – somatoform dysfunction of the autonomic nervous system;
• F45.4 – somatoform pain disorder.

The first three options have similar symptoms. It is based on numerous and varied complaints, often changing depending on the manifestations and location. Autonomic symptoms are hardly noticeable because they are minimal and unstable.

In the presence of severe somatic symptoms for two or more years, accompanied by persistent changes in the emotional background and social maladjustment, the diagnosis of “somatization disorder” (F45.0) is eligible. With a shorter (but not less than six months) history and a rather vague, atypical clinical picture, an undifferentiated somatoform disorder (F45.1) is diagnosed. In the case when the disease reminds itself constantly and for a long period of time (at least six months), persistent anxiety about somatic complaints, formulated as a severe, progressive illness, dominates, a diagnosis of hypochondriacal disorder is made (F45.2).

Of particular interest to gastroenterologists is somatoform dysfunction of the autonomic nervous system (F45.3). In addition to disturbances in gastrointestinal functioning (complaints are related to a specific organ - distension in the intestines, burning in the esophagus, heaviness in the stomach, etc.), patients have the above-described pronounced vegetative symptoms of a general nature and functional disorders in other organs and systems. During an objective examination, symptoms are determined based on objective signs of autonomic irritation: sweating, redness of the skin, dermographism, rapid heartbeat, non-verbal signs of anxiety - pronounced fear and anxiety on the face, tremor of the limbs.

Somatoform pain disorder (F45.4) is diagnosed if the central element of the clinical picture is severe and excruciating pain in different parts of the body, not associated with dysfunction of the organ on which the patient's attention is focused. When making a diagnosis, it is necessary to take into account the time factor: pain must be present on most days for at least a six-month period.

Despite their differences, somatoform disorders have much in common:

• a variety of complaints in the absence of signs of organic diseases according to laboratory and instrumental studies;
• repeated visits to doctors of different specialties and repeated laboratory and instrumental examinations;
• lack of effect from traditional gastroenterological treatment;
• negative attitude towards psychopharmacological treatment.

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So, in gastroenterological practice, it is advisable to consider the manifestations of somatoform disorder primarily from the standpoint of the pathology of the somatosensory system. It is necessary to take into account that this disease develops in people of a certain type who are prone to anxious reactions and prolonged experiences.

Patients with somatoform disorder require complex treatment, including the use of gastroenterological medications taking into account the identified functional disorders and psychopharmacological medications with the selection of an individual dose and duration of course treatment based on the characteristics of the mental status and the severity of autonomic disorders.

Hypochondriacal dysfunction

Hypochondriacal disorder is characterized by a person's extreme concern about his or her health. He is sure that he is developing a severe, sometimes fatal disease. But their types may vary from case to case. One time the patient thinks that he has cancer, another time it is a severe heart pathology, etc.

The degree of sensation also changes. Either it seems to the individual that he is on the verge of death, then the manifestations become quite bearable.

It has been established that about 14% of patients visiting doctors of various specialties suffer from hypochondria. Most often it occurs in childhood and adolescence, as well as in mature people.

Basically, the patient is accompanied by the following symptoms:

• from the cardiovascular system - pain in the heart, disruptions in its functioning. The patient's conclusion is heart defects, heart attack;
• from the digestive system - abdominal pain, diarrhea, constipation. Conclusion – stomach and intestinal cancer;
• on the part of the excretory system – fear of uncontrolled urination, and therefore patients even limit leaving the house. Pain in the lower abdomen.

Important criteria for recognizing pathology are the presence of senestopathies and mood disorders.

Senestopathies are manifested by unusual and painful tactile sensations. This may be itching and burning, a feeling of cold, compression and constriction, pulsation of blood in the vessels, twisting, displacement and other similar phenomena.

Mood disorders manifest themselves in increased anxiety, sadness, melancholy, and a feeling of hopelessness. Patients focus only on themselves, and do not hear others at all. At the same time, they believe that no one needs them, everyone has abandoned them.

Such people systematically seek help from doctors. And if a specific disease is not found, they insist on re-examination.

The following nuances will help determine pathology:

• constant belief that a person has a serious illness, often with other concomitant illnesses. And even numerous normal examination results cannot convince them;
• lack of trust in doctors, despite their regular visits;
• the activity of such a patient is not aimed at alleviating the condition, but at confirming the presence of a progressive pathology;
• constant concentration on your illness;
• independent diagnosis.

As hypochondria worsens, it can develop into a paranoid state or hypochondriacal depression.
The diagnosis of hypochondriacal disorder is made when schizophrenia and schizotypal disorders, bipolar affective disorder are excluded.

Hypochondriacs are often found among famous people. Actor and director Woody Allen is one of them. One day, his illness saved him from food poisoning. The entire crew ate pizza, which only he refused due to concerns about his health. As a result, everyone except him developed an eating disorder.

Somatoform disorders of the gastrointestinal tract in children

Somatoform disorders are a group of disorders characterized by constant patient complaints about a disturbance in their condition, reminiscent of a somatic disease; however, no pathological process is detected that explains their occurrence. The disorder is not caused by another mental illness or substance abuse disorder. If the patient has a physical illness, data from the medical history, physical examination and laboratory tests cannot explain the cause and severity of the complaints. Symptoms are not intentionally invented, unlike artificially demonstrated disorders and malingering. Despite the fact that the onset and persistence of symptoms are often closely related to unpleasant events, difficulties or conflicts, patients usually resist attempts to discuss the possibility of its psychological cause; this may occur even in the presence of distinct depressive and anxiety symptoms. The attainable degree of understanding the cause of the disorder is often disappointing, annoying, and alarming for both the patient and the doctor [1]. A figurative idea of ​​somatoform disorders was formulated back in 1954 by academician physiologist K. M. Bykov: “Sadness that is not cried out in tears makes the internal organs cry” [2].

Attempts to treat a patient suffering from a somatoform disorder will always be unsuccessful if the attending physician does not find out the cause of the disease. Currently, clinicians, especially pediatricians, must master the basics of psychosomatics, a branch of medicine and psychology that studies the influence of psychological (psychogenic) factors on the occurrence and course of somatic diseases.

It is known that emotional disorders are the main suffering in a third of all patients receiving medical care, and 25% of patients with somatic diseases suffer from neuroses [3]. The incidence of somatoform disorders in Russia in adult patients is 40–68%, in children seeking help at a clinic - 25–90% [4, 5].

Employees of the laboratory of psychosomatic pathology of the Research Institute of Pediatrics of the Russian Academy of Medical Sciences (Scientific Center for Children's Health) studied the frequency of somatoform disorders in children in schools in Moscow and Orel. Prolonged low-grade fever (thermoneurosis) was detected in 20.6% and 19.8%, tension cephalgia in 39% and 30%, recurrent abdominal pain in 30% and 15% of children, respectively [5]. The incidence of disorders turned out to be comparable in a metropolis with a stormy and nervous life and a regional center, which traditionally contrasts its calm and measured existence. These results indicate that what is important for a child is not the place of residence itself, but emotional comfort and well-being.

When a doctor realizes that he is dealing with a psychosomatic pathology, his main efforts should be aimed at finding out its cause. There are several options for the development of psychosomatic diseases: situational option (primary psychogenic etiological factor); personal variant (changed type of psychological response with the formation of chronic emotional stress); psychopathological variant (with genotypic characteristics of the central apparatus of emotions); cerebral variant (with organic, residual-organic brain disease); somatic variant (with defective regulatory and executive mechanisms of visceral systems of various origins) [6].

In clinical practice, a combination of the above options is usually found, which significantly complicates the treatment of the patient (both children and adults).

In isolation, a “situational variant” can occur, which results in the formation of post-traumatic stress disorder - a delayed and protracted reaction to a stressful event or situation of an exceptionally threatening or catastrophic nature, which, in principle, can cause general distress in almost every person (ICD-10). Collecting anamnesis from a child with psychosomatic pathology and finding out the possible causes of its development is not the idle curiosity of the doctor, but his professionalism.

Post-traumatic stress disorder develops in 31.3% of children who experienced the death of relatives and friends; 23.8% of children faced school problems (conflicts with teachers, classmates, poor performance); in 18.3% of children who experienced the death and disappearance of their favorite animals and birds. Quarrels in the family, drunkenness of fathers, divorce of parents were the cause of post-traumatic stress disorder in 15.4% of children, and worry about their illnesses and injuries led to the formation of pathology in 11.2% of children [7].

Currently, psychosocial risk factors play a major role in the formation and progression of somatoform disorders in children. Among this group of children, 16.6% live in a single-parent family, 21% experience psycho-emotional stress, 25% associate the onset of clinical symptoms with visiting child care institutions, 37.5% with the birth of sisters and brothers. The most significant risk factors are considered to be pathology of upbringing and disruption of the mother-child system, which occur in 60% of children with somatoform disorders [8].

According to the classic psychological study by E. Harutyunyants (1988), there are three types of family: traditional (patriarchal), child-centric and marital (democratic).

In a traditional family, respect for the authority of elders is brought up, pedagogical influence is carried out from the top down. The main requirement is submission. Children from these families easily learn traditional norms, but have difficulty forming their own families. They are uninitiative, inflexible in communication, and act based on the idea of ​​what should be done.

In a child-centric family, the main task of parents is to ensure the “happiness of the child.” The family exists only for the child. The influence is carried out, as a rule, from the bottom up (from the child to the parents). As a result, the child develops high self-esteem and a sense of self-worth, but the likelihood of conflict with the social environment outside the family increases. Therefore, a child from such a family may evaluate the world as hostile. There is a very high risk of a child’s social maladjustment upon entering preschool and school.

The conjugal (democratic) family aims at mutual trust, acceptance and autonomy of its members. The educational impact is “horizontal”, a dialogue between equals: parents and child. In family life, mutual interests are always taken into account, and the older the child, the more his interests are taken into account. The result of upbringing in such a family is the child’s assimilation of democratic values, harmonization of his ideas about rights and responsibilities, freedom and responsibility, development of activity, independence, goodwill, self-confidence and emotional stability [9].

To improve the effectiveness of treatment and preventive measures for somatoform disorders, the attending physician in each specific case must evaluate the existing type of family upbringing of the child. A.E. Lichko and E.G. Eidemiller identify six types of family education that provoke or enhance certain character accentuations.

1. Hypoprotection (hypoprotection) - lack of necessary care for the child and lack of control. The child is left to his own devices, experiencing his abandonment. Failure to satisfy the need for parental love and lack of inclusion in family life can lead to antisocial behavior.
2. Dominant hyperprotection (hyperprotection) - obsessive care, excessive care, petty control, prohibitions. The child’s sense of responsibility is suppressed, lack of initiative develops, and the inability to stand up for himself; or there is a pronounced desire for emancipation.
3. Indulging hyperprotection is the desire to satisfy all the desires and needs of the child, in excessive admiration for his minimal successes. The child is assigned the role of a family idol, his selfishness is cultivated. As a result, the child develops an inadequate, inflated level of aspirations that does not correspond to his capabilities, which contributes to the development of hysterical accentuation.
4. Emotional rejection - non-acceptance of the child in all its manifestations, his needs are completely ignored. There are obvious and hidden emotional rejection. This parenting style has the most detrimental effect on a child’s development.
5. Cruel relationships - open in the form of violence, beatings; hidden in the form of emotional hostility and coldness.
6. Increased moral responsibility - the child is required to demonstrate high moral qualities: decency, a sense of duty not in accordance with the child’s age, they are assigned responsibility for the well-being of relatives and care for them. With this style of education, hyperthymic and epileptoid traits develop into leadership and the desire to dominate [10].

Chronic traumatic experiences, emotional deprivation (loss, deprivation), incorrect, overly strict education with the use of physical punishment cause emotional stress, constant dissatisfaction, the child experiences conflicting feelings towards loved ones. In these situations, pathological habitual actions reduce and temporarily suppress negative emotional experiences, which, along with the feeling of pleasure that accompanies some of these actions, contributes to their fixation [11].

Pathological habitual actions that combine body and head rocking (yactation), nail biting (onychophagia), hair pulling (trichotillomania), finger and tongue sucking, pre-pubertal masturbation, as well as a number of more elementary behavioral stereotypies constitute a group of specific disorders typical for children and adolescents. They are rudimentary non-pathological prototypes of various forms of stereotypical motor behavior: eating, research, play, comfort, cleansing (grooming) behavior. They provide calming, falling asleep, stimulation and stabilization of the basal emotional background, psychophysical tone, and expression of innate social instincts. The prevalence of individual phenomena belonging to this group, or their combinations, is quite high. According to various authors, from 6% to 83% of children have these habits at one age or another [8].

According to our own observations (unpublished data), among children aged 7–17 years with irritable bowel syndrome, pathological habitual actions (onychophagia, trichotillomania, thumb sucking) were observed in 52% of patients (M. I. Dubrovskaya, O. A. Varakina, 2015 ).

One of the most striking pathological habitual actions is nail biting, which occurs in a third of children aged 3 to 10 years. Typical onychophagia is biting fingernails, less often toenails; the habit of chewing pencils, pens and other objects, biting the tongue, the mucous membrane of the cheeks, grinding teeth. There is also a non-phagic version of the phenomenon - the habit of breaking, twitching and picking nails, twisting and fingering fingers.

In the clinical picture, the common features of pathological habitual actions are their voluntary conscious nature, the ability to stop them temporarily by force of will, an increased sense of internal tension when they are suppressed, and the child’s understanding of them (starting from the end of preschool age) as negative and even bad habits in the absence of in most cases desire to overcome them and even actively resist adults’ attempts to eliminate habitual actions [11].

Over time, repeated stereotypes, supplemented by conditioned reflex connections, acquire functional autonomy and are preserved due to the lack of sufficient incentives for alternative behavior and the acquisition of the quality of a stable pathological state (according to N.P. Bekhtereva). Based on the presence of the symptoms described above, one can judge the degree of neuroticism of a child suffering from somatoform disorders.

An additional key to understanding the development of the psychosomatic process is the model of two-phase repression by A. Mitscherlich (1953, 1954), presented in the form of the following sequence:

1. Psychosocial level at which a person (child) copes with conflict using exclusively mental means:
   conflict resolution using ordinary means of social interaction with a sufficiently mature personality (discussion of relevant problems and emotional experience) or through mature defense mechanisms (repression, sublimation);
2. connection of neurotic (pathological) defense mechanisms (neurotic depression, obsessive thoughts and actions, fears, phobias, etc.) in cases where the use of normal (healthy) defense mechanisms is not enough, which determines neurotic personality development or character neurosis.
3. Psychosomatic level - somatization:
   if for some reason it is not possible to cope with a conflict that threatens one’s own existence by purely mental means, the second echelon defense is activated - at the psychosomatic level, somatization, which over time can lead to structural changes in one or another organ.

Modern psychoanalysts (O. Kernberg, 2000) also identify a third level of defense - psychotic symptom formation [5].

Thus, the main points necessary to understand the essence of somatoform disorders were discussed above.

Somatoform disorders of the digestive system include:

• appetite disturbances - decrease, increase (in adults 39%);
• aerophagia (aerophagic tics - hiccups not associated with food intake);
• nausea;
• vomit;
• irritable bowel syndrome (IBS);
• psychogenic hyperalgesia (diffuse hyperesthesia with iatrogenic fixation of the patient);
• flatulence (gas pain, gas colic, abdominal paroxysms - psychogenic tympanitis or hysterical pseudoileus);
• vegetative pelviopathy (complaints of unbearable pain in the lower abdomen requiring urgent surgery) [12].

Nausea is an unpleasant, painful subjective sensation that precedes or accompanies vomiting. Nausea as a symptom of damage to the digestive system indicates an increase in intraduodenal pressure that occurs when the motor-evacuation function of the stomach, duodenum and small intestine is impaired; characteristic of diseases of the duodenum (duodenitis, gastroduodenitis, peptic ulcer).

Psychogenic nausea and vomiting is a fairly common occurrence. In emotionally unstable individuals, these physiological reactions develop quite easily. This unique way of expressing an emotional state can subsequently become fixed as a pathological reflex [13].

Nausea as a somatoform disorder is not associated with dietary errors, increases with the deterioration of the physical and mental condition of patients, and is regarded as a consequence of an extreme degree of rejection and fear. When carefully questioned, many schoolchildren and students report a feeling of nausea during exams and tests. Psychogenic nausea in the clinic of anxious depression is primarily fear [13].

Vomiting is a reflex act of expelling the contents of the stomach through the mouth, controlled by two functionally different centers in the medulla oblongata: the vomiting center and the chemoreceptor trigger zone. Excitation of the vomiting center causes an increase in intracranial pressure (tumors, abscesses near the fourth ventricle); exposure to impulses from the membranous labyrinth of the inner ear; exposure to chemicals (drugs, poisons, toxins) - chemoreceptor trigger zone; irritation of receptors in various parts of the body (reflex); various mental stimuli.

Emotive vomiting occurs in children aged 2–5 years, mainly in the morning during or immediately after eating, sometimes immediately after the first sips, and does not depend on the quantity and quality of food eaten. The frequency of vomiting episodes varies from once a month to several times a year, and the duration ranges from several hours to days. Attacks of vomiting have little effect on the child’s general well-being and may be accompanied by an increase in body temperature, blood pressure, tachycardia, abdominal pain, headaches, and frequent bowel movements. This symptom is not amenable to diet therapy, is tolerated almost painlessly, does not affect the concentration of urine, and does not bring relief to the child. Vomiting is often preceded by forced aggressive feeding, attempts to force the child to eat all the food offered. It should be noted that children easily induce vomiting in order to stop feeding, manipulate relatives, when they do not want to follow the instructions of adults, when they do not want to go to kindergarten or school, or in conflicts with parents. The origins of psychogenic vomiting lie in a fairly pronounced depressive reaction. In this case, the cause of nausea and vomiting can be not only a feeling of pain, fear, sadness or melancholy, but also a positive emotion if it manifests itself quite intensely, for example, during or after children's parties (birthdays, New Year trees).

Another pathology of the upper digestive tract is rumination - repeated reflux of food (undigested or partially digested) into the lumen of the esophagus and oral cavity without nausea or vomiting, occurs almost immediately after eating and continues for 1-2 hours. In early childhood, it is a clear reflection of the disruption of the mother-child bond [14]. Rumination is most often observed in orphans raised in social institutions and in conflict families. A study of clinical symptoms and dynamics of the disease in 147 children and adolescents suffering from rumination, aged from 5 to 20 years (average age 15.0 ± 0.3 years), among whom 68% were girls, for the period 1975–2000. showed the following results. Gastroesophageal reflux was detected in 54%, impaired evacuation-motor function of the stomach in 46%, rumination waves (according to the results of gastroduodenal manometry) in 40%, the number of postprandial regurgitations after each meal was 2.7 ± 0.1. 38% of children suffered from abdominalgia, 21% from constipation; nausea bothered 17% of children. Symptoms were corrected in 30% of children; in 56% of cases, therapy was ineffective. In the study group of children, mental disorders were diagnosed in 16% of cases, eating disorders (anorexia or bulimia) in 3.4% of children [15].

The most common recurring somatic complaint among children and adolescents is recurrent abdominal pain. Adolescents and young adults who experience recurrent abdominal pain during childhood continue to exhibit higher levels of pain behaviors, including pain, other somatic complaints, and functional impairment [16].

Currently, irritable bowel syndrome is interpreted as a biopsychosocial disorder, the development of which is based on the interaction of two main pathological mechanisms: psychosocial effects and sensory-motor dysfunction. The third factor is neuroimmune damage resulting from infectious bowel diseases (a possible cause of sensorimotor dysfunction). The causes of pain in IBS are extremely diverse: impaired tone and peristalsis of smooth muscles, impaired motor skills, excessive gas formation, decreased sensitivity to nociceptive affects, the influence of endogenous opiates, the negative effect of inflammatory mediators (IL-1) on nerve receptors, increased serotonin concentrations, psychoemotional stress.

These causes can occur in very young children, which leads to a wide range of clinical symptoms: colic, regurgitation, constipation and painful passing of gas, all types of restless behavior under the breast - up to complete refusal of the breast. If other pathology and irrefutable evidence for the presence of stress in the child are excluded, these clinical symptoms can be regarded as psychosomatic disorders of early childhood [17, 18].

However, a number of reasons leading to pain in functional disorders of the gastrointestinal tract in children, such as impaired peristalsis and smooth muscle tone, impaired motor skills, excessive gas formation, can be eliminated with a diet limited in cow's milk protein, gluten, soy, eggs, nuts, honey, seafood - the so-called obligate allergens, as well as restrictions on sugars and coarse dietary fiber.

O. Olén et al. Over the course of 12 years, we studied the likelihood of recurrent abdominal pain (RA) in 2682 Swedish children who had it at an early age. Questionnaires were filled out at 1 and 2 years by parents (at 1 year the presence of RA was noted in the last 6 months, at 2 years - over the last 12 months) and at 12 years by the children themselves. Among all children surveyed, the frequency of RA was 15% (n = 390), at two or more ages it was 2% (n = 44). If abdominal pain was noted at the age of 6–24 months, then at 12 years of age it was 2 times more common than in children who did not suffer from RA in the first 2 years of life [19].

According to our own observations (unpublished data) among children aged 7–17 years with IBS, recurrent abdominalgia in the first year of life was observed in 76% of children, while the diagnosis was established in only 33%; intestinal infections as a cause of abdominalgia were excluded. Attending kindergarten caused abdominal pain in 33% of children in the study group (M. I. Dubrovskaya, O. A. Varakina, 2015).

In a study of psychologists and clinicians conducted among 17-18 year old students with abdominalgia, it was found that in these patients the incidence of abdominalgia at primary school age was 38%, at middle school age - 44%, at senior school age - 18%. According to clinical interviews, most of the subjects were traumatized in primary school or early adolescence by a conflictual family situation (quarrels between parents, cruel or manipulative treatment of them by parents and older brothers), the loss of one of the parents (death, divorce), as well as multiple changes in place of residence (for example, in a military family). Children with abdominalgia are characterized by a high level of personal anxiety and depression. They have low self-esteem compared to healthy children, and pain sensations are distorted: what healthy children perceive as tension, subjects with psychosomatic disorders perceive as pain [16]. In a study by D. Jacob et al. it was shown that in children suffering from anxiety and depressive disorders, abdominalgia occurred in 51.5% vs. 8.8% in the control group (p = 0.0002) [20].

It has been proven that the development of functional abdominalgia is closely related to anxiety and depression in the mother. The somatic and emotional status of two groups of mothers, whose children suffered from functional abdominal pain (n = 59) and whose children were healthy (n = 76), was studied using a case-control type. The age of the children was 8–15 years. A questionnaire and blind interviewing were used to assess the presence of anxiety, depression, and somatic disorders. Among mothers whose children suffered from functional abdominalgia, migraine was 2.4 times more common, IBS 3.9 times more common, anxiety 4.8 times more common, depression 4.9 times more common, and somatoform disorders 16.1 times more common. than in mothers whose children were healthy (Fig.). If a mother suffers from anxiety and depression, then the likelihood of her child having functional abdominalgia increases by 6.1 times [21].

In conclusion, it is necessary to dwell on a significant amendment in our knowledge about the state of development of the modern child. In July 2013, at a meeting of the Board of the Russian Book Union, Vice-President of the Russian Academy of Education D.I. Feldshtein presented a report “The nature and degree of changes in modern childhood and the problems of organizing education at a historically new level of development of society.” The analysis carried out by scientists of the Russian Academy of Education shows quite serious, diverse, multi-character, multi-level changes:

• 25% of children of primary school age are not socially competent enough, helpless in relationships with peers, and unable to resolve simple conflicts.
• The energy of children and their desire to be active have decreased. At the same time, emotional discomfort increased.
• There is an impoverishment and limitation of live, tactile communication of children, including adolescents, with peers, an increase in the phenomena of loneliness, rejection, and a low level of communicative competence.
• Anxiety in 12–15 year olds ranks second in severity of manifestation.
• There are more and more children with emotional problems who are in a state of affective tension due to a constant feeling of insecurity, lack of support in their close environment and therefore helplessness [22].

Kids today (Generation Z) prioritize video games in their lives, with 66% of children ages 6-11 and 51% of teens citing games as their primary source of entertainment. 85% of teenagers have looked for information on the Internet at least once in their lives. 52% of teenagers use YouTube and social media to complete school assignments. Teens aged 13–17 are more likely to use their phones than watch TV (76% vs. 72%), while 8–12 year olds are more likely to do the opposite (39% vs. 72%). As a result, adolescents’ speed of information perception increases, but difficulty arises in maintaining attention on one subject for more than eight seconds, which affects the ability to learn and assimilate information [23].

This knowledge is necessary for a pediatrician to have a professional approach to the treatment of children with somatoform disorders of the digestive tract. And yet, despite the apparent obviousness of the problem, the diagnosis of any somatoform disorder is a diagnosis of exclusion. Patients should be examined according to an expanded protocol, including examination of the central nervous system in order to exclude a tumor process, the gastrointestinal tract in order to exclude all possible organic causes, examination of the endocrine system, cardiovascular system, etc.

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22. https://www.myshared.ru/slide/470783/.
23. https://www.lookatme.ru/mag/live/interweb/205189-generation-z.

M. I. Dubrovskaya*, 1, Doctor of Medical Sciences, Professor O. A. Varakina

* GBOU VPO RNIMU im. N. I. Pirogova Ministry of Health of the Russian Federation, Moscow ** SPC MP DPRCL and VZNS, Moscow

1 Contact information

Somatization and chronic somatoform pain disorder

Somatized dysfunction, in addition to organ manifestations, causes a decrease in the functioning of analyzers: vision, hearing, touch, smell. Coordination of movements is impaired: patients become clumsy and have an unsteady gait. Movement disorders manifest themselves in the form of paresis and paralysis.

They describe failures in the functioning of internal organs colorfully and with charm. For example, my head hurts, as if a hoop was put on it and was gradually being squeezed. Or your stomach is swollen like a balloon.

Unlike a hypochondriac, who expresses anxiety about his health, such a patient responds more rudely and persistently. He is convinced that he is sick. And if the doctor tries to hint at the psychogenic nature of the disorder, he screams and is indignant, rejecting what was said, and demands additional examination. This patient is constantly dissatisfied and complains.

The course of the disease is chronic, with wide variability of symptoms that persist for 2 years or more.

Often, a person, due to his anxiety and aggressiveness, experiences social maladjustment and family conflicts.

A pain disorder is distinguished by the presence of severe, debilitating pain that occurs for no reason. Usually it has a clear localization - the stomach, the heart. The pain characteristics do not change, there are no other symptoms.

During somatoform dysfunction, an undifferentiated disorder is also distinguished. With it, a person suffers all the typical symptoms of the disease, but it is not possible to classify them into any known group.

Somatoform dysfunction of the autonomic nervous system

The syndrome develops when there is a malfunction of the autonomic nervous system, which controls the functioning of internal organs, blood vessels, and is responsible for the course of physiological processes and the mobilization of the body as a whole.

The ANS consists of 2 sections: parasympathetic and sympathetic.

The sympathetic nervous system increases the heart rate, constricts blood vessels and increases blood pressure. Increases sweating and slows down intestinal motility. It relaxes the bladder, dilates the bronchi and pupil. Sympathy speeds up metabolism and activates the body as a whole.

The parasympathetic system has the opposite effect. But, despite the opposition of departments, normal well-being of a person is ensured by their coordinated work. Any malfunctions in the functioning of both systems cause various pathological sensations and syndromes, in particular, somatoform dysfunction.

There are 3 types of disorders:

• with a predominance of sympathy;
• with a predominance of parasympathetics;
• mixed.

According to the flow, stable and paroxysmal, with vascular and other types of crisis are distinguished.

Pathology can be primary, that is, it develops on its own, or secondary, after previous illnesses. Its symptoms manifest themselves under the influence of a psychotraumatic factor.

Such patients are characterized, first of all, by the appearance of vegetative signs: severe sweating, tremors of the limbs, paleness and redness of the skin.

Another group of signs expresses the dysfunction of internal organs under the control of the ANS:

• cough, shortness of breath, laryngeal spasm;
• tachycardia, arrhythmia, blood pressure changes. Heart pain does not have a clear localization and can be of various types. It happens that they are accompanied by a feeling of anxiety or fear. They are worse at rest, but go away during physical activity. Lasts from a few minutes to several days. Heart symptoms are so believable that they sometimes confuse even specialists;
• abdominal pain, bloating, difficulty swallowing; “bear disease” - diarrhea under the influence of stress;
• difficulty urinating, urinary incontinence;
• headaches, fatigue, poor sleep.

The complaints are numerous, but lack specifics. They signal a disruption in the functioning of several organs at once.

Patients are concerned about their condition, but still not to the same extent as hypochondriacs. They strive to find a way out of the situation and receive adequate treatment.

Autonomic dysfunction syndrome

What it is? This is a complex of symptoms that arise due to a violation of the neuro-humoral regulation of the functioning of organs and systems. Normally, the sympathetic and parasympathetic nervous systems work together harmoniously and smoothly. Sympathetic system

prevails if a person needs to act quickly, actively: run, hide, be afraid.
Parasympathetic
, on the contrary, is when a person is resting, relaxed, sleeping.

When these two systems malfunction, autonomic dysfunction syndrome

.

This disorder can be of central or peripheral origin. In the first case, the problem is localized in the structures of the brain. In the second, a malfunction occurs in the structures of the sympathetic and parasympathetic nervous systems.

Primary disorders occur rarely - only in the case of organic damage to brain structures. More often there are secondary disorders in the presence of somatic, mental or neurological diseases.

The course of autonomic dysfunction syndrome can be permanent (constant) or paroxysmal.

People with excess sympathetic innervation have a certain character - they are active, very efficient, energetic people.

who think quickly, make decisions quickly, and are creative. But at the same time, they often find it difficult to fall asleep, and there is anxiety to a greater or lesser extent.

As a rule, they get used to their personality type, but at certain moments in life, when they take on too much without calculating their strength, or circumstances develop in such a way that they do not have time to recover, their sympathetic system becomes too tense, and then the following arise: complaints:

• sleep is disturbed
• blood pressure increases
• pulse quickens
• there is a feeling of lack of air
• Panic attacks may occur with fear of death or fear of going crazy.

People with a predominance of the parasympathetic nervous system in their constitution are often thoughtful, slow, indecisive, dreamy

, prone to depression. In difficult life situations or when there is excessive load, their parasympathetic nervous system becomes even more active:

• blood pressure decreases, even to the point of fainting
• sweating occurs
• hands and feet are cold
• it becomes difficult to rejoice, apathy develops
• migraines occur.

Individuals with autonomic dysfunction syndrome are usually pleasant, sensitive, and responsive. Among such people there are many poets, writers, artists, journalists, teachers or simply creative people.

The neurologist's task

– help a patient with autonomic dysfunction syndrome, explain, reassure, examine and prescribe treatment.

First of all, it is necessary to establish the patient’s sleep and wakefulness patterns. It is also necessary to provide him with proper nutrition, to compensate for the lack of vitamins and microelements. It is very important to drink enough water. The TV and computer should be removed from the bedroom, and the sleeping room should be darkened as much as possible. If possible, avoid communication with unpleasant people, maintain information hygiene, that is, reduce the number of irritating factors.

The neurologist must examine the patient to exclude primary damage to the nervous system, prescribe a series of examinations and develop a treatment regimen. In such cases, there is no single template; each patient requires an individual approach and selection of therapy. The treatment uses antioxidants, nootropics, antidepressants, tranquilizers, vitamins, vascular agents, and symptomatic therapy.

SDVNS in children

Often, somatoform autonomic disorder appears in children at puberty, that is, during the period of maturation. This is due to a hormonal surge and intensive growth of the body.

The following factors can provoke the process:

• heredity;
• stress;
• mental, physical stress;
• infections;
• bad habits;
• surgical interventions;
• large body weight;
• sedentary lifestyle;
• staying at the computer for a long time.

The appearance of teenagers is typical. If sympathy predominates, then the skin of such children is moist and oily, with acne. She alternately turns red and pale. A bluish tint appears. Cold, with a marbled pattern called a vascular necklace. When pressed with a finger, the skin turns pale and red dermographism is observed.

When parasympathetics dominate, the skin is dry, with pink or white dermographism. These children have an increased appetite, but they do not gain weight.

The disorder is accompanied by a sudden rise in temperature under the influence of stress. A typical occurrence is fainting.

All characteristic changes in internal organs are present.

The psycho-emotional sphere is also undergoing changes. Such a child becomes distracted and nervous. He quickly gets tired, drowsiness and apathy appear, and his memory deteriorates.

In most cases, the course of the disease is stable. But periodically panic attacks and crises occur:

• sympatho-adrenal - accompanied by tachycardia, elevated blood pressure, headaches, thirst, chills and hyperthermia. Anxiety and feelings of fear develop;
• vagoinsular – migraine-like attacks, nausea, vomiting, pain in the abdominal area. Hyperhidrosis, decreased blood pressure and fainting, slow heart rate, increased urine output, breathing disorders;
• mixed.

The attack can last up to several hours.

Symptoms of autonomic dysfunction (almost all occurring sharply and acutely):

• changes in heart rhythm (tachycardia or bradycardia);
• feeling of lack of air, shortness of breath;
• pallor of the skin or, on the contrary, redness as a result of a rush of blood;
• increase or decrease in blood pressure;
• heartache;
• feeling of fear, anxiety;
• headache;
• dizziness, weakness, near fainting, tingling and goose bumps, noise in the head;
• chills;
• sweating;
• sore throat.

One of the most common options is a panic attack. This is a sudden onset anxiety disorder, initiated by a sharp release of the stress hormone - adrenaline. The pulse and breathing quicken, despite this the person feels short of air, experiences increasing anxiety, dizziness, weakness in the legs. Symptoms appear in attacks, with the attack passing in 10-40 minutes, leaving behind a feeling of weakness and a feeling of fear of a new attack. Over time, the situation only gets worse - the person becomes a slave to his fear of a new attack. A particular danger of VSD is an increased tendency to commit suicide. However, it is possible to help people suffering from autonomic dysfunction. The initial stages of VSD are treated with several visits to a psychotherapist. More advanced cases require complex treatment from a neurologist, but they are also not hopeless. Breaking the vicious circle of fear and pain is the main goal of treatment.