Somatoform Disorders Symptoms, Ayurveda Treatment

By Dr Raghuram Y.S. MD (Ay) & Dr Manasa, B.A.M.S
Somatoform Disorder or Somatization Disorder is a kind of mental illness that causes symptoms related to the body which also includes pain. In the present day it is known by the name ‘Somatic Symptom Disorder – SSD’.

SSD is characterized by the patient extremely focusing on physical symptoms like pain or fatigue which eventually causes major emotional distress and problems in daily functioning. In these conditions many times the physical causes including general medical conditions, substance abuse or other mental illnesses will not be traced. Sometimes the causes may be traced. Immaterial of the causes being traced or not, these disorders cause excessive and disproportionate levels of distress to the person.

The patient may –

• Think in a worst possible way about their symptoms
• Frequently seek medical care and attention
• Continue to search for an explanation in spite of all serious conditions that they have imagined have been excluded
• Get too concerned about their health
• Find difficult to function normally in life
• Might suffer from disabilities

The symptoms involve and belong to one or more organs and body systems and include –

• Pain
• Neurological issues
• Complaints pertaining to gastrointestinal system
• Symptoms related to sexual dysfunctions

Most people with SSD are also victims of anxiety disorder. Those having SSD might experience significant emotional and physical distress. Treatment when given promptly might help in easing the symptoms, help you to cope up and improve your quality of life.
Read – Anxiety Tips, Ayurvedic Treatment, Herbs, Home Remedies

Are people with SSD faking their symptoms?

It appears as if the symptoms narrated by the people with SSD are fake. It appears as if they are cooking symptoms but it is not the reality. Pain and other problems that these people are suffering and the related distress they are experiencing are real immaterial of whether a physical cause which explains those symptoms are available or not. The distress that these people experience from their symptoms affects their daily functioning to significant levels.

Other possible causes for these symptoms should necessarily be ruled out before diagnosing a given condition as SSD. This will be done by your doctor by subjecting you to a series of necessary tests and investigations.
Read – Depression Causes, Ayurvedic Treatment, Tips And Remedies

Symptoms

The symptoms are actually vague and might differ from person to person.
Weakness, fatigue
Pain
Shortness of breath
Heart or breathing disorder, cancer etc

Pain, among all the symptoms, is the most common one presented by the patient. The patient will have excessive thoughts, feelings or behaviors related to the symptoms immaterial of the symptoms the patient is suffering from. These thoughts would bring about more problems and add to the misery of the patient and caretakers. They will also meddle with daily easy functioning and sometimes can also be disabling.
Read – Should You Suppress Your Emotions? Do They Grow on You?

The patient would experience the below mentioned thoughts, feelings and behaviors –

• Always worrying about potential and impending illness
• Considering the normal sensations that they experience as signs of severe physical illness
• Always fearing that the symptoms they have are of very serious nature even when there is no evidence for their fears
• Always thinking that their physical sensations are harmful / threatening
• Always feeling that the medical evaluation made on them and the treatment that they have received are not adequate
• Always fearing that any physical activity may cause damage to their body
• Regular and repeated checking of their bodies fearing and being assured of finding some abnormalities
• Frequently taking healthcare visits which either make their concerns worse or do not relieve them
• Not showing response to medical treatment
• Being unusually sensitive to side effects of medication
• Having more severe impairment in comparison to what is usually expected from a medical condition
• From the perspective of the patients of SSD – the way they interpret and react to the symptoms and the way in which they impact their daily life activities is more important than the specific symptoms they experience.

Causes of SSD

The exact causes of SSD are not clearly known. The below mentioned factors may play a role in the causation of the disease –
Genetic and biological factors – example, increased sensitivity to the pain
Familial – genetic, environmental or both
Personality traits – some persons carry traits of negative thinking; this will impact on how these people identify and perceive illness and bodily symptoms
Decreased awareness of processing the emotions or problems in processing emotions – this would bring physical symptoms to focus for the patients rather than the emotional issues Learned behavior – one would show the ‘pain behaviors’ in response to the symptoms, example – avoiding in excess of those activities which tend to increase one’s level of disability
Read – Dosha Prakriti Theory And Modern Genetics

Risk Factors

Anxiety
Depression
Suffering from a medical condition
Recovering from a medical condition / disease
Having risk of developing a disease or medical condition (example – having a family history of a disease)
Stressful events – suffering from effects of trauma or violence
Past traumatic experiences like childhood sexual abuse etc
Lower educational level
Lower socio-economic status
Read – 24 Stress Management Tips: Pranayama, Meditation, Lifestyle Changes

Complications

Poor quality of health
Physical disability and other problems functioning in daily life
Facing problems with relationships
Facing problems at workplace
Unemployment
Anxiety, depression, personality disorders and other mental health disorders
Increased suicide risk
Financial problems because of regular and excessive healthcare visits and consultation with experts
Read – Ways To Handle Anxiety Depression Symptoms With Ease

Diagnosis

The doctor will diagnose SSD after thorough examination of your body and mind and after recommending the needed diagnostic tests. If necessary they may refer you to an expert mental health care professional. They may help you in the below mentioned ways –

Conduct psychological evaluation – the doctor would openly talk to you about your symptoms, fears, concerns, situations which bring about stress in you, your relationship problems, situations you tend to avoid on regular basis, family history etc which would give a clarity of disease and condition and help in proper diagnosis which in turn help in planning and charting out comprehensive treatment measures

Make you fill out a psychological self-assessment or questionnaire to extract all relevant information about your problem

May gather information about your addiction to alcohol or drug if any or about any other substance use / abuse which are triggers of SSD
Read – Disease Analysis At Physical and Mental Planes

Criteria for Diagnosis

The below mentioned are the criteria for diagnosis of SSD according to DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) published by American Psychiatric Association –

Presence of one or more somatic symptoms which cause distress or problems in dealing with daily life – example, pain, fatigue etc

Presence of excessive and persistent thoughts – will be experienced about the seriousness of symptoms. You will have high anxiety persistently. The anxiety is about your health or symptoms. You would spend a lot of time and energy focusing on your symptoms or health concerns.

Symptoms continue for more than 6 months – you will continue to have the symptoms that cause deep and persistent concern in you. The symptoms may vary but you will have them for more than 6 months.
Read – Shoola Types, Symptoms, Treatment, Medicines, Remedies

Impact of diagnosis of SSD

Once SSD has been diagnosed and announced, the patients undergo immense stress and frustration. This is also due to dissatisfaction since there is no evident physical explanation for their symptoms. This is also because the doctor would have told them that their level of distress about a physical illness is excessive and beyond what it needs to be. This stress often leads them to become excessively worried about their health. All these events create a vicious cycle that can persist for years.

Disorders related to SSD

Illness Anxiety Disorder – People with this condition are always preoccupied with the thoughts and are concerned that they have a serious disease. Even small problems are of greater concern. They think that the minor complaints are signs of very serious diseases. Example – they believe that a headache is a sign of brain tumor. This condition was previously called hypochondriasis.

Conversion Disorder – The people suffering from this condition have neurological symptoms for which no medical cause may be traced. The patients will have symptoms such as weakness, paralysis, tremor, unsteady gait or seizures. The symptoms might also include blindness or hearing loss, or loss of sensation. This condition is also called as ‘Functional Neurological Symptom Disorder’. The symptoms of this condition are worsened by stress.
Read – Relationship Between Doshas And Nervous System

Other Specific Somatic Symptom and Related Disorders
There are some situations in which the somatic symptoms occur for less than 6 months.

Pseudocyesis – is a related condition which occurs in women. The women suffering from this condition have a false belief that they are pregnant along with signs of pregnancy like expansion of abdomen, occurrence of labor pains, nausea, feeling the movements of fetus, changes in the breast and stoppage of menstrual period.

Preventive measures

There are no known proved preventive measures for SSD. But the below mentioned measures may help –

• Seeking medical / professional help for anxiety or depression as soon as possible or once the symptoms are identified
• Learn about what causes stress and how they affect body
• Practice stress management and relaxation techniques on regular basis
• Get early treatment for SSD if you happen to recognize its symptoms, this will prevent worsening of the symptoms and also from the symptoms impairing life quality
• To prevent relapses of symptoms or their worsening strictly follow the treatment plan recommended by your physician and stick to the plan
  Read – Stress Causes, Types, Tips On How To Handle Stress

Lifestyle, Home Remedies

The below mentioned lifestyle recommendations and home remedies can help in lessening the symptoms but are not sure or proven remedies for SSD.

• Team up with your healthcare / mental healthcare professionals – Work with your doctor in the best possible way. The equation and chemistry between patient and doctor is essential in dealing with SSD in an effective way.
• This teaming will help you in determining and charting out a working regular schedule. This will also include appointments and visits to discuss your concerns and build a trusting relationship. This will also limit the need of tests, evaluations and specialist referrals as you build up a good relationship and trust in doctor.
• Avoid meeting or calling multiple doctors, visiting emergency rooms and stop taking too many opinions. This will only increase your concerns and make your care difficult to coordinate and might also subject you to duplicate testing.
• Stress management and relaxation techniques – You have to practice stress management and relaxation techniques on a regular basis. Example – progressive muscle relaxation might help you in improving symptoms. Yoga, meditation etc will also help.
• Regular physical activities – Be physically active. Your mood can be calmed and physical symptoms might improve. Keep yourself indulged and involved in your work and also in social and family activities. You need not wait for your symptoms to get resolved to do this.
• Avoid alcohol and recreational drugs – Substance use / abuse is very harmful and might work as a trigger in SSD and worsen symptoms. If you are planning to quit addictions, speak to your doctor or take expert help.
  Read – Alcoholism: Ayurvedic Treatment, Medicines, Remedies

Treatment

Goal of the treatment will be to improve symptoms and at the same time improve your ability to function easily in daily life. Psychotherapy (talk therapy) is useful. Medications can be added especially when associated with depression.

It is difficult to handle patients with somatic symptom disorders due to 3 reasons –

• They stubbornly believe that their symptoms have a definitive underlying physical cause in spite of absence / lack of evidence which could give a physical explanation
• If at all there is a medical condition causing symptoms in them they will not be in a position to recognize that the quantity of distress that they are experiencing or displaying is excessive and blow out of proportions than what it actually is
• They will also disagree and dismiss that their physical symptoms have developed on the backdrop of psychiatric factors

The physician should look into these factors before dealing with the patients suffering from this disease.

Treatment principles

Strong relationship of trust between patient and doctor – For the treatment to become successful a strong relationship / bond of trust should be first developed between the doctor and the patient. The relationship and trust should be biphasic. If the patient will find an experienced doctor / healthcare provider having expertise in managing somatoform disorders and adhere with the same doctor for many months (without frequently changing the doctor), the patient might help themselves in managing the disorder in a comprehensive way. This will also help in cutting down on unnecessary tests and treatments.

Improving daily functioning – The prime focus of treatment of somatoform disorders will be towards improving the daily functioning of the patient and not on managing the symptoms of the disease.

Stress management – Stress management and reduction play a major role in these disorders and will help the patient in getting better.

Counselling – This is the best and mandatory part of the treatment. There is no doubt that patient counselling should be done. Along with that counselling sessions should also involve the family and friends of the patient. This will help them in understanding the nature of the disease and also manage the patient and his symptoms effectively.
Read – Counselling – Types, Benefits, Myths And Facts

Cognitive Behavioral Therapy (CBT) – This will help in relieving the symptoms associated with SSD. This therapy is of utmost help and will focus on correcting –
Distorted thoughts
Unrealistic beliefs
All behaviors which will tend to increase, nurture or trigger anxiety

It shall also help you in –

• Examining your expectations and beliefs about your symptoms and wellbeing and also to adapt them in a good way
• Cope up with physical symptoms
• To reduce stress levels
• Avoidance of situations and activities brought about by uncomfortable physical sensations
• Reducing preoccupation with symptoms
• Addressing and taking control over your depression and other mental health disorders
• Improving daily functioning at home, work place, in social situations and relationships

Family Therapy – Done by effectively examining the family relationships and improving family support and functioning.

Medications
Generally one kind of medication will not help. It might take many days to several weeks to notice any positive improvements after the use of medications.
Antidepressants – help in reducing symptoms associated with depression and pain
One should regularly talk to his or her doctor regularly and know about medicine options, their utility, possible side effects and risks.
Read – Effective Ayurvedic Treatment Protocol For Depression

Researches

A study conducted in Europe on the prevalence and correlates of somatoform disorders in elderly showed that these disorders are prevalent, highly impairing conditions in older adults, which are often associated with other mental disorders and should receive more research and clinical attention. (A)

Another study which was conducted as a part of a community survey in Florence about Epidemiology of Somatoform Disorders showed that the prevalence rates of somatoform disorders were generally found to be slightly lower than expected. Since the exclusion of somatic causes is necessary for somatoform disorders to be diagnosed there is little information on the prevalence of such disorders in the community. Although the sample which was investigated was small, this study may be seen as one of the first one in the area wherein knowledge about this is still scanty. (B)

Another study on psychobiological perspectives on SSD – Existing models for the development and maintenance of common physical symptoms encountered in the medical practice emphasize a vicious circle with cognitive-perceptual, behavioral and psychobiological components. This study showed examples of psychobiological factors which might contribute to somatoform disorders. It was emphasized that somatoform symptoms are not strictly mental events but are associated with a diversity of biological processes. The possible role of the endocrine and immune system, amino acids and neurotransmitters, but also physiological activation and cerebral activity is exemplified. (C)

SOMS-7 – is a new approach to the assessment of the treatment effects of somatoform disorders. It is a new 53-item instrument for the evaluation of treatment effects in somatoform disorders, the ‘Screening for Somatoform Symptoms – 7’ i.e. SOMS-7 covers all the somatic symptoms mentioned as occurring in somatization disorder according to DSM-IV & ICD-10. A group of 325 patients was assessed at the beginning and end of treatment to compute scores of reliabilities and validity. SOMS-7 seems to be a comprehensive, reliable, and valid instrument for the evaluation of treatment effects in patients with somatoform disorders. (D)

Another study showed that somatoform disorders are disorders of affect regulation. This paper considered the role of disturbances in affecting regulation in the development and course of somatoform disorders. (E)

Ayurveda Concept

As such we do not find a direct reference of any condition explained in Ayurveda which matches with the explanation of somatic disorders or somatoform disorders.

Study of Avara Sattva people in relation to SSD – Master Charaka while describing the sattva pariksha i.e. examination of the mind of the patient as a part of ‘tenfold examination of the patient – dashavidha pariksha’ has described the characteristic features of people having three kinds of mental attributes or mental makeup. These variants will also describe the mental strength and endurance of the patient and also will point out towards the possible mental / mind related disorders they may face in future or the proneness of developing mental disorders in each person belonging to each category of persons.

The 3 kinds of mental frames are –
Pravara sattva – strong minded people
Madhyama sattva – people with moderately strong mind
Avara / hina sattva – people with weak mind strength
Read – Manasika Doshas – Satva, Rajas, Tamas As Per Ayurveda

Among these people of moderate and weak mind strength display the characteristics of somatoform disorders. The classification of sattva by Master Charaka is for describing the mind-states of these people but not to explain the pathological aspects of mind. But the later 2 categories of people have the tendency to develop somatoform disorders to a greater extent. Even among the moderate and weak mind strength categories, people with weak mind strength are prone to get this disorder.
When we read through the characteristic features of people with weak minds, we do not find the symptoms matching with those of somatoform disorders but these people may present their problems in a way that somatoform disorder patients display.

We have seen that SSD patients explain physical symptoms in blown out proportions and those symptoms will lack evidence of any causal disorders in the backdrop. They focus more on physical symptoms which cause major emotional distress and problems in daily functioning in spite of absence of diagnosed medical conditions associated with these symptoms or which can define these symptoms.

These disorders cause excessive and disproportionate levels of distress. The reaction of the patient to these symptoms will not be normal. These people will frequently seek medical attention and imagine disorders, are concerned too much about their health and do not function normally in life.

Coming to weak minded people, these people are hard to convince and cannot take care of themselves. They get scared when facing hardships. This makes them susceptible to situations which increase fear in them which in turn hinder their life activities. Master Charaka says that they cannot be influenced even by strong people. However, the physician who represents a strong person here tries to counsel and influence the patient it would be difficult for him to do so. Therefore, the treatment and effect of the same on somatoform disorders will take a long time.

No one can convince the weak-minded people that their problems or health issues including pain etc which they are presenting in a magnifying way are not a part and parcel of a physical disorder. They cannot be convinced that the problems and diseases are short lived and there is cure for them. Filling courage in them is an uphill task. This is because these patients have preoccupied ideas and are not open for suggestions, advice and counselling. Master Charaka further says that since these people get easily disturbed by situations, they suffer from one or more of depression, syncope, loss of consciousness, giddiness, insanity or falling off. This might not actually fit into the description of SSD but can be considered in closer study.
Read – Sattva Pariksha Examination Of The Mind, Tolerance

Patients with SSD also magnify their physical symptoms because they think they have those symptoms in spite of lack of evidence. This is possible only when people have in built misconceptions, false beliefs and strong fears due to their weak mind. A strong-minded person on the other hand can be easily managed and so also the moderately strong-minded people with little effort.

Guru Vyadhita – People having weaker minds define and explain their small health problems and diseases as greater and incurable diseases. They unnecessarily magnify their problems. This will mislead the physician in thinking that these people have bigger health problems and implement stronger medicines and drastic interventions which are unnecessary. This might in turn damage the health of these persons because the medicines are more and stronger than what is needed for the given health condition. These people might be suffering from somatoform disorders.
Read – Classification of Vyadhi (diseases) according to Ayurveda

Ayurveda treatment of somatoform disorders

Sattvavajaya Chikitsa – is one of the most important treatment formats and a bigger section of therapy in Ayurveda and covers the entire concept of psychiatric and psychological interventions including psychotherapy and CBT. Sattvavajaya means ‘to conquer the mind’. In other words, ‘all treatments, medicines and therapies which bring about balance of mind and cure the mind disorders’ are called sattvavajaya chikitsa.

Manasika Roga Chikitsa – General line of treatment of mind disorders should be adopted in treating SSD. They include –
Dhee – training the person towards proper and skillful use of his or her intellect and trimming the thought process
Dhairya – seeding of courage in one’s mind
Atmadi vijnanam – to make the persons to understand and realize the importance of self and self-worth

All these can be compared to the modern-day interventions of psychotherapy, counseling and cognitive behavior which are all useful in the treatment of SSD.
Read – Best Natural Medicine For Mental Problems: Courage

Other treatment strategies

Manovaha sroto dushtijanya Vikara – The channels rendering the functions of the mind are seated in the heart /brain and the 10 dhamanis connected to or taking origin from the heart / brain (blood vessels / nerves). These channels are invariably contaminated in the mind related disorders. Diseases like SSD should be treated on the lines of treating the contaminated mind carrying channels.
Read – Manovaha Srotas Description, Vitiation Symptoms, Treatment

Medhya Dravyas – are the group of brain tonics explained in Ayurveda. They not only improve the intellect and memory of the person but will also help in keeping the mind in a state of balance. If the mind is imbalanced, they will also help in bringing the mind and mind functions to balance. Medhya medicines should be used in the treatment of somatoform disorders.

Chittodvega Chikitsa – Chittodvega implies and refers to the set of anxiety disorders. Many people with SSD also suffer from anxiety disorders.

Unmada / Apasmara Chikitsa – Unmada is a term which is generally used for all mental illnesses. It is often equated to insanity but it is more than that. Similarly the term apasmara is often equated with epilepsy, but the term and the definition also includes disorders of memory process. The diseases of the central nervous system can be included in both these diseases. The pathogenesis of both these diseases may lead to conditions like SSD.

Masked intelligence or diversion of intellect, deviation of mind, lack of courage and irrelevant speech are some of the symptoms of unmada explained in Ayurveda. All these can lead to manifestation of symptoms similar to those of SSD.
Read – Unmada Chikitsa – Charaka 9th Chapter

Atatvabhinivesha Chikitsa – Atatvabhinivesha means ‘lack of judgment and loss of discrimination between what is good and what is bad, what is true and what is false’. Patients of SSD too do not differentiate between what is real and false. Even if they know they would have fixed ideology and perception and they would not accept things. This leads them to explain physical symptoms in spite of lack of evidence. It is just because they believe that they have serious disease and related symptoms. Therefore, SSD can be treated on the lines of atatvabhinivesha treatment principles.
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