F45.0 Somatisation disorder Somatoform dysfunction of the autonomic nervous system Somatoform autonomic disorder mkb 10
The first manifestations of the disorder occur at a young age. Symptoms of Briquet's syndrome can appear for a few minutes or a few days, or persist for many months. All symptoms of the syndrome can be divided into four groups: mental, autonomic, sensory and motor. Vegetative symptoms are very diverse, affecting various organs and systems. A characteristic feature is the colorful descriptions and the drama of clinical manifestations.
Most often, with Briquet syndrome, symptoms from the gastrointestinal tract are detected: nausea, vomiting, loss of taste, difficulty swallowing, anorexia, stomach pain, dyspepsia, constipation and diarrhea. A lump in the throat is a constant symptom. Less commonly, patients with Briquet's syndrome have heart pain, tachycardia, shortness of breath, imaginary pregnancy and vicarious bleeding. In the literature, there are references to urinary retention, polyuria, vaginismus, aerophagia, coughing, hiccups, yawning and sneezing.
Possible movement disorders in Briquet's syndrome include paresis, paralysis, contractures, hyperkinesis, seizures, various gait disturbances and astasia-abasia. Astasia-abasia is manifested by the inability to maintain balance and walk in the absence of pathological changes in the nervous system and musculoskeletal system. In severe cases, the patient can get up, but falls and cannot take a single step, in the lungs, he balances or sways when walking. Gait disturbances in Briquet's syndrome can manifest as a zig-zag gait, a dragging gait, a stilt gait (legs straightened), a sliding gait (reminiscent of a skater's movements), a jumping gait, and walking with constantly bent knees.
Movement disorders in Briquet's syndrome include writing spasm and other disorders that make it difficult to perform professional duties, as well as voice disorders in the form of hoarseness, whispering and aphonia. In some cases, patients with Briquet's syndrome have dumbness, stuttering, eyelid paralysis and blepharospasm. In recruits, especially during the period of hostilities, camptocormia can be detected - a strong flexion of the body in the absence of pathological changes on the X-ray of the spine.
Hyperkinesis in Briquet's syndrome is characterized by variability, instability, dependence on the emotional state and a combination with other autonomic or motor symptoms. Unlike epileptic seizures, seizures in Briquet's syndrome occur in traumatic circumstances, in the presence of other people. The alternation of clonic and tonic phases is disturbed, the duration of the seizure is increased, consciousness is preserved, there is no memory loss after the seizure.
Sensory disorders in Briquet's syndrome are pain, decrease, absence or increase in sensitivity. The patient may experience headaches, joint pains, abdominal or back pain. Skin sensitivity is impaired in the form of stockings or gloves, with a discrepancy between the areas of impaired sensitivity and the areas of innervation. Sometimes deafness or blindness occurs with Briquet syndrome.
The psychopathological polymorphism of psychosomatic disorders is reflected in their position in modern classifications of mental illness. In ICD-10, psychosomatic disorders can be classified in different sections: "Organic, including symptomatic, mental disorders" (headings F 04-F 07, corresponding to reactions of the exogenous type K. Bonhoffer), "Neurotic, stress-related and somatoform disorders" (headings F 44.4 - F 44.7, corresponding to psychogenias, and F 45 - somatoform disorders), as well as "Behavioral syndromes associated with physiological disorders and physical factors" (headings F 50 - F 53).
Despite such a variety of conditions under consideration, they are united by a common feature - a combination of mental and somatic disorders and related features of medical care for patients, which involves close interaction of psychiatrists and general practitioners, usually carried out either in general medical institutions or in specialized psychosomatic clinics.
Based on the structure of psychosomatic relationships, we consider it expedient to distinguish 4 groups of states:
Somatized mental (somatoform) reactions, formed with neurotic or constitutional disorders (neuroses, neuropathy).
Psychogenic reactions (nosogeny), arising in connection with a somatic illness (the latter acts as a traumatic event) and belonging to the group of reactive states.
Reactions by the type of symptomatic lability - psychogenically provoked manifestation or exacerbation of a somatic disease (psychosomatic diseases in their traditional sense).
Exogenous reactions (somatogeny), manifesting due to the impact of somatic harm on the mental sphere and belonging to the category symptomatic psychosis, that is, to the category of exogenous mental disorders.
In this chapter, for the reasons indicated above, we will restrict ourselves to considering the disease states of the first three types.
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CLASSIFICATION ICD-10
"Classic" psychosomatic diseases, according to the new classification criteria, are diagnosed primarily as organic diseases. If psychological processes are given significant importance in the occurrence and maintenance of these diseases, then the P54 code (psychological and behavioral factors associated with disorders or diseases classified in other headings) is used as an additional mental diagnosis in ICD-10.
05M-1 For this there is a code 316 (specific mental factors affecting somatic illness).
Most assessment forms in health care settings require a diagnosis based on ICD-10. It is the largest classification system for "mental and behavioral disorders" used in many | countries. Many psychologists and psychotherapists find I \\ ICD-10 limited for use in the analysis of I psychosomatic problems and planning
I psychotherapy. Nevertheless, the diagnosis disciplines | \\ thinking of a specialist, protects against mistakes in the appointment of methods of psychotherapy. |
The purpose of the classification is to streamline the variety of individual phenomena and subordinate them to categories of a higher level. In medicine, it is important to classify not only signs, but also individuals according to the type of diagnoses.
Since Cullen's isolation of neuroses, these disorders have been described in the framework of mental disorders occurring with autonomic stigmas. Later, a group of neuroses began to stand out, the terminological designation of which was different: vegetative, viscero-vegetative, systemic neuroses; neurocirculatory, vegetative-vascular dystonia. In the international classification of diseases (10th revision), adopted by WHO in 1992 and translated into Russian in 1994, these disorders are classified as "somatoform disorders".
In the discussion around the latest classification systems, there are several basic concepts that apply to ICD and 08M. Below are the variants of somatoform disorders of the two most leading classification systems in the world.
Somatoform disorders according to B8M-1U with ICD-10 codes
Somatisation disorder (P45.0)
Undifferentiated somatoform disorder (P45.1)
Conversion disorder (P44.xx)
Somatoform pain disorder (G45.4)
Dysmorphophobic disorder (P45.2)
Somatoform disorder, unspecified (P45.9)
The classification system ICD-10, in contrast to the American classification system 08M-1U, distinguishes between dissociative (conversion) (P44) and somatoform disorders. A sign of dissociative (conversion) disorder, just like in 08M-1U, is the presence of “pseudo-neurological symptoms”.
Let's dwell on their characteristics.
psychosomatic disorders
Psychosomatic diseases.
Psychosomatic diseases - dysfunctions of organs and systems of the body, in the emergence and development of which psychological reasons play a decisive role, rather than physical factors. The term "psychosomatics" was first used at the beginning of the 19th century. J.Heinroth (1818) A century later, the concept of "psychosomatic medicine" was introduced into the medical lexicon.
Initially, seven nosological units were classified as psychosomatic diseases: essential hypertension, thyrotoxicosis, neurodermatitis, bronchial asthma, some forms of rheumatoid arthritis, ulcerative colitis and peptic ulcer disease. At present, the list of psychosomatic disorders has significantly expanded due to the inclusion of diseases of the cardiovascular system, a large number of skin and urogenital diseases, migraines, etc. Among the typical psychosomatic diseases in North America and Europe, anorexia nervosa and bulimia are currently included. some forms of psychogenic obesity, diabetes mellitus, cardiospasm, nervous vomiting, irritable bowel syndrome, impotence, constipation, cancer, etc.
Classification:
A.B.Smulevich distinguishes four groups of psychosomatic disorders:
1. Psychosomatic diseases in their traditional understanding. This is a somatic pathology, the manifestation or exacerbation of which is associated with the lability of the body in relation to the impact of psycho-traumatic social stress factors. The manifestations of somatic pathology in psychosomatic diseases are not only psychogenically provoked, but intensified by disorders of the somatopsychic sphere - the phenomena of somatic anxiety with vital fear, algic, vegetative and conversion disorders. This concept unites ischemic heart disease, essential hypertension, peptic ulcer of the stomach and duodenum, psoriasis, some endocrine and allergic diseases.
2. Somatoform disorders and somatized mental reactions, formed with neurotic or constitutional pathologies (neuroses, neuropathy). Organ neuroses are psychogenic diseases, the structure of which is characterized by functional disorders of internal organs (systems) with the possible participation of borderline and subclinical somatic pathology. These include cardioneurosis (Da Costa's syndrome), hyperventilation syndrome, irritable bowel syndrome, etc.
3. Nosogeny - psychogenic reactions arising in connection with a somatic illness (the latter acts as a traumatic event) and related to the group of reactive states. These disorders are associated with subjectively severe manifestations of somatic suffering, patients' perceptions of the danger of diagnosis, and restrictions imposed by the disease on everyday and professional activities. Clinically, these psychogenic reactions can manifest themselves as neurotic, affective, pathocharacterological and even delusional disorders. The possibility of manifestation of nosogenies and their psychopathological features are largely determined by the clinical manifestations of somatic pathology (IHD, arterial hypertension, malignant tumors, surgical interventions, etc.).
4. Somatogeny (reactions of an exogenous type or symptomatic psychoses). These disorders belong to the category of exogenous mental disorders and arise as a result of the impact on the mental sphere of massive somatic harm (infections, intoxication, non-infectious somatic diseases, AIDS, etc.) or are complications of certain treatment methods (for example, depression and mnestic disorders after coronary artery bypass grafting, affective and asthenic states in patients receiving hemodialysis, etc.). Among their clinical manifestations is a wide range of syndromes - from asthenic and depressive states to hallucinatory-delusional and psychoorganic syndromes.
A reflection of the polymorphism of psychosomatic disorders is the fact that in the modern classification of mental diseases (ICD-10) there is no special section for these disorders. Thus, in the introduction to the ICD-10 it is indicated that SDP can be found in F45 ("somatoform disorders"), F50 ("eating disorders"), F52 ("sexual dysfunction") and F54 ("psychological and behavioral factors associated with disorders or diseases qualified in other sections "). The least studied group is somatoform disorders.
There are many theories explaining the mechanism of the onset and development of psychosomatic diseases. Generally speaking, the occurrence of psychosomatic disorders is associated with the suppression of their emotions and desires. In ancient times, people reacted to an external stimulus by action - they ran away from the enemy or attacked prey, which is facilitated by the production of adrenaline. And in a modern person in response to stress, adrenaline is also produced, but more often, due to social norms and generally accepted forms of relationships, it is not realized in physical activity. Negative emotions, irritation, aggression do not find a direct outlet to their cause, they are suppressed, driven inside. As a result, a person develops nervous tics, constant muscle tension, hand tremors, spasms, pain, and organ dysfunction. Of course, these changes do not occur quickly, so it is difficult for a person to grasp a clear relationship between their experiences and the disease. However, we all know that anxiety causes palpitations, difficulty breathing; anger, excitement contribute to a rise in blood pressure, etc. If these feelings become frequent, protracted, and the stereotype of a person's response to them does not change, this contributes to the consolidation of negative changes in the body. For example, a leader takes out anger at a subordinate, yells at him. He is forced to endure it, to be silent. As a result, suppressed anger and internal protest contribute to the development of hypertension in a fairly young person.
Since childhood, people are limited by family and social norms: “men don’t cry,” “you must not be rude to your elders,” “you must not be late for work,” “you have to do this and that,” etc. People with a pronounced individuality suffer to a greater extent. I think many will agree with me that changing your stereotype of responding to stressors is easier than pushing the boundaries of social norms. Of course, the importance of the psychological factor in the occurrence of diseases cannot be exaggerated: there are other reasons for the occurrence of a headache, and a violation of the heart rhythm often indicates an infectious lesion. But if, despite the examinations and treatment by different specialists for a long time, there is no relief of the symptoms of the disease, or they are insignificant, it is worth involving a psychotherapist in the treatment.
What is psychotherapeutic assistance for psychosomatic illnesses?
1. Learn to pay attention to your body. Realize that a symptom of a disease is an alarm that needs to be heeded. For example, by drowning pain with painkillers, a person allows the development and progression of diseases such as arthritis, peptic ulcer, coronary artery disease, etc.
2. Learn to cope with stress in a new way, expand the scope of your perception of the world around you and ways to respond.
3. Individual selection of drug therapy, if necessary (antidepressants, anxiolytics, hypnotics).
The psychosomatic approach allows you to treat a sick person, not his illness. Of course, one should not expect a miracle, instant healing from diseases that have been forming over the years or even decades. But an integrated approach to the treatment of psychosomatic diseases, including psychotherapy, helps to quickly achieve remission, prevent further development of the disease, and in some cases completely get rid of the disease.
Somatoform disorders (F45)
The main feature is the repeated presentation of somatic symptoms simultaneously with the insistent demands of medical examinations, despite their repeated negative results and the assurances of doctors that the symptoms are not of a somatic nature. If the patient has any somatic illness, they do not explain the nature and severity of the patient's symptoms or suffering or complaints.
The main features are numerous, recurrent, frequently changing physical symptoms that have occurred for at least two years. Most patients have a long and complex history of contacts with primary and specialized health care services, during which many ineffective examinations and sterile diagnostic procedures may have been performed. Symptoms can affect any part of the body or organ system. The course of the disorder is chronic and erratic and is often associated with impaired social, interpersonal, and family behavior. Short-lived (less than two years) and less prominent examples of symptoms should be classified as undifferentiated somatoform disorder (F45.1).
Multiple psychosomatic disorder
Excludes: simulation [conscious simulation] (Z76.5)
The diagnosis of undifferentiated somatoform disorder should be made when the patient's complaints are numerous, variable and persistent, but do not satisfy the full and typical clinical picture of the somatoform disorder.
Undifferentiated psychosomatic disorder
The most important feature is the patient's persistent concern about the possibility of having a serious, progressive disease or several diseases. The patient presents persistent somatic complaints or shows persistent anxiety about their occurrence. Normal, common sensations and signs are often perceived by the patient as abnormal, disturbing; he usually focuses his attention only on one or two organs or systems of the body. Severe depression and anxiety are often present, which may explain additional diagnoses.
Disorder of self-concern
Excluded:
- delusional body dysmorphic disorder (F22.8)
- delusions fixed on the functioning or appearance of one's own body (F22.-)
- aerophagia
- cough
- diarrhea
- dyspepsia
- dysuria
- flatulence
- hiccups
- deep and rapid breathing
- increased urination
- irritable bowel syndrome
- pylorospasm
- backache
- headache
- back pain NOS (M54.9)
- pain:
- NOS (R52.9)
- acute (R52.0)
- chronic (R52.2)
- fatal (R52.1)
- tension headache (G44.2)
- dysmenorrhea
- dysphagia, including "globus hystericus"
- torticollis
The symptomatology presented by the patient is similar to that which occurs when an organ or a system of organs is damaged, mainly or completely innervated and controlled by the autonomic nervous system, i.e. cardiovascular, gastrointestinal, respiratory and genitourinary systems. Symptoms are usually of two types, neither of which indicates a violation of a particular organ or system. The first type of symptoms are complaints based on objective signs of autonomic irritation, such as palpitations, sweating, redness, tremors and expressions of fear and concern about a possible health disorder. The second type of symptoms are subjective complaints of a nonspecific or variable nature, such as fleeting pains throughout the body, a feeling of heat, heaviness, fatigue, or bloating, which the patient associates with an organ or organ system.
Da Costa's Syndrome
Psychogenic forms:
Excludes: psychological and behavioral factors associated with disorders or diseases classified elsewhere (F54)
The main complaint is persistent, sharp, excruciating pain that cannot be fully explained by a physiological disorder or medical illness and which arises in connection with emotional conflict or psychosocial problems, which allows us to consider them as the main etiological cause. The result is usually a marked increase in personal or medical support and attention. Pain of a psychogenic nature that occurs in the process of depressive disorder or schizophrenia cannot be attributed to this rubric.
Psychogenic:
Somatoform pain disorder
Any other disorder of sensitivity, function, or behavior that is not due to somatic disorders. Disorders that are not mediated through the autonomic nervous system are limited to specific systems or areas of the body and have a close temporal relationship with traumatic events or problems.
Psychogenic:
Classification of psychosomatic disorders
An in-depth study of psychosomatic disorders, early prevention and diagnosis require their reasonable classification. One example of such classifications can be the idea of \u200b\u200bI. Jochmus, G. M. Schmitt (1986) about the grouping of somatic disorders closely associated with psychological difficulties.
The first group includes psychosomatic functional disorders, that is, those somatic syndromes in which organic lesions of organs and systems are not detected. These syndromes include: psychogenic disorders in infants and young children; sleep disorders; enuresis; encopresis; constipation; conversion neuroses.
The second group includes psychosomatic diseases: bronchial asthma, neurodermatitis, ulcerative colitis, Crohn's disease, stomach ulcer, anorexia nervosa, bulimia, obesity.
The third group unites those chronic patients who have serious experiences. It brings together patients with cystic fibrosis, diabetes mellitus, chronic renal failure, and malignant neoplasms.
Unfortunately, the classification is not based on a single approach, it includes a limited number of syndromes and diseases; a number of similar disorders remained outside its borders. Nevertheless, it can be used in clinical and prophylactic work, since it involves fundamentally different approaches to diagnosis, treatment and prevention. If functional disorders can be corrected by means of influencing the relationship between sick children and their environment, then patients with psychosomatic diseases need psychotherapy and influence on the affected organs and systems.
Another example is the classification of psychosomatic disorders in children, proposed by N. Zimprich (1984). Among these disorders, psychosomatic reactions, functional disorders, psychosomatic diseases with organic manifestation, specific psychosomatosis (colitis, stomach ulcer, etc.) are distinguished. According to N. Zimprich, these diseases, despite their differences, are united by a common therapeutic approach that combines drug treatment and psychotherapy.
T. Stark, R. Blum (1986), studying psychosomatic conditions, warn against simplifying the understanding of pain syndromes and malaise as purely psychogenic or organic in nature. In their opinion, there are a number of limitations for such a “dichotomous” division: the majority of physiological disorders have psychological consequences. The term "psychogenic" is mistakenly viewed as never having a serious meaning; “Dichotomy” erroneously implies homogeneity of psychogenic disorders. From the systematics of the types of psychosomatic disorders proposed by the authors, presented below, it becomes clear that the syndromes attributed to psychogenic are in fact different in development mechanisms.
Conversion disorders have traditionally been understood as a loss or impairment of physiological functions that lose voluntary control due to psychological problems. These conditions often resemble neurological symptoms, but they can affect any system or organ. In childhood, the combination of conversion and hysterical personality occurs in at least 50% of diagnosed disorders. Unlike other psychosomatic disorders, conversion disorders in children are equally prevalent in both sexes. The resulting pathological complex brings the individual primary and secondary benefits, which makes him keep the psychological conflict from awareness and thereby protect him from possible influences on him.
Pain syndrome. Its main feature is complaints of pain in the absence of physical disturbances or complaints of pain that is much stronger than it could be due to the physical condition. Often, the environmental stressor is found to precede pain. Similar to conversion reactions, complaints of pain can release the individual from certain responsibilities and entitle them to emotional support that cannot otherwise be acquired.
Somatization is often presented as multiple somatic complaints that cannot be explained by any physical cause. It is a way of coping with psychological stress, tends to appear during puberty and is often chronic, paroxysmal, with remissions throughout life.
Hypochondria has its own characteristics: conviction in the presence of a disease, focus on one's health, fear of illness, persistent abuse of medical care. Because of the rapid and dramatic physical changes during puberty, focusing on them is common in adolescents. Although a complex of somatic symptoms occurs at this age quite often, the occurrence of a hypochondriacal condition may be associated with skimping on their duties.
Simulation can be defined as pretending or using illness to avoid unwanted situations, work, or other responsibilities. There is a stereotypical view of the simulator — the adult — as an individual who invents a disease in order to evade responsibility. In the pediatric population, this label can be used with considerable caution. Typically, in children, the purpose of creating symptoms is easily discovered and easily understood when analyzing the circumstances of life. It is important to remember that for children, for example, school is work and thus school avoidance is a serious symptom that should be carefully examined.
An artificially produced health disorder is understood as a disease that causes deliberate actions of the patient, regardless of whether the disease is desired or not. Generally, there is no clear indication of secondary benefit to be derived from induced symptoms. More often, relatively unusual clinical syndromes such as hematuria and spontaneous hemorrhages are found.
Chronic artificial disorder (Munchausen syndrome) is characterized by repeated hospitalizations due to a feigned illness, often resulting in surgery. In its most pronounced form, this condition can be called "mania operativa": patients undergo up to 30 or more surgical operations. Although this disorder is extremely rare in pediatrics, there is evidence of artificially caused health problems in children by their mothers - Polle syndrome.
The above classification does not so much systematize various types of "psychosomatic disorders", but rather reflects the range of disorders that require differential diagnosis. This is exactly what, from our point of view, it can be useful for a pediatrician and psychiatrist.
In the international classification of diseases (10th revision), adopted by WHO in 1992 and translated into Russian in 1994, there are sections in which psychosomatic disorders are classified. Thus, in the section "Neurotic, stress-related and somatoform disorders" (F4), there is a subsection "Somatoform disorders" (F45), which includes the corresponding headings. In the introduction to this section, it is said that neurotic, stress-related and somatoform disorders are combined into one large group due to their historical connection with the concept of neurosis and the conditioning of the main (although not precisely established) part of these disorders by psychological causes. As noted in the general introduction to ICD-10, the concept of neurosis was retained not as a fundamental principle, but in order to facilitate the identification of those disorders that some specialists may still consider neurotic in their own understanding of the term. The definition of somatoform disorders is given as follows: “The main hallmark of somatoform disorders is the recurrent occurrence of physical symptoms along with constant demands for medical examinations, despite confirmed negative results and physicians' assurances that there is no physical basis for symptoms. If physical disorders are present, they do not explain the nature and severity of symptoms or distress and concern of the patient. "
Most doctors group psychosomatic disorders according to age.
In infancy, these disorders include colic in the third month of life, flatulence, chewing gum, regurgitation, functional megacolon, anorexia in infancy, developmental arrest, obesity, attacks of respiratory distress, neurodermatitis, yaktatsiya, spastic crying, sleep disorders, early bronchial asthma, sudden death baby.
At preschool age, psychosomatic disorders such as constipation, diarrhea, "irritable bowel", abdominal pain, cyclic vomiting, refusal to chew, anorexia and bulimia, encopresis, enuresis, obesity, sleep disturbances, fever, etc. are observed.
In schoolchildren and adolescents, psychosomatic disorders include migraines, “growth pains”, recurrent pains of varying localization, sleep disturbances, bouts of hyperventilation, fainting, vegetative vascular dystonia, bronchial asthma, anorexia nervosa, bulimia, obesity, gastric ulcer and duodenal ulcer, ulcerative colitis, enuresis, encopresis, neurodermatitis, menstrual disorders, etc.
Different authors give a different number of such symptoms and syndromes. The etiology of these disorders is not equally interpreted. However, it is obvious that, regardless of the more or less successful name, psychoemotional factors play a significant role in their pathogenesis. Some of the disorders listed in this taxonomy are given in other chapters in accordance with the affected system.
The reasons for the development have not been precisely established. Experts suggest that this pathology occurs under the influence of a number of psychological factors, while the individual meanings of pain play a decisive role in the formation of chronic somatoform pain disorder. In childhood, pain could be perceived as a way to receive love, atonement, or protection from future punishment. At an early age, a patient with chronic somatoform pain disorder may feel pain in the process of identifying with a parent suffering from mental or physical pain.
Pain could also become a kind of symbolic reflection of a strong affect (feelings of anger, powerlessness, hopelessness). Each person has his own "set" of meanings of pain that arose in the process of his individual development. Under unfavorable living conditions and certain characteristics of the personal organization, any of these meanings can provoke the development of chronic somatoform pain disorder.
Among the most common causes of this pathology, mental health experts call the need for care and attention, difficulties in interpersonal relationships, episodes of humiliation, violence and deprivation of important needs in the patient's personal history. Pain, as a way of getting attention, appears when the patient, for some reason, cannot openly declare his need for sympathy and support.
Interpersonal pain occurs when a patient with chronic somatoform pain disorder unknowingly tries to manipulate loved ones in order to gain an advantage, such as regaining lost intimacy or gaining loyalty from a partner. At the same time, the once experienced humiliation, violence or non-recognition of needs becomes the reason for an unconscious prohibition on the open manifestation of feelings and honest interactions in relationships.
It is important to distinguish chronic somatoform pain disorder from sham. In simulation, patients deliberately simulate the disease in order to achieve certain benefits. With CSPS, needs are realized through pain at the unconscious level, patients with chronic somatoform pain disorder really suffer from pain, do not understand what caused it and do not realize the connection between the symptom and their psychological problems. Attempts to clarify the psychological nature of painful sensations turn into a sincere resentment, a feeling of helplessness, disappointment in a specialist, and sometimes even aggression towards a doctor.
The leading complaint is persistent, severe and mentally depressing pain that cannot be fully explained by a physiological process or somatic disorder and which appears in conjunction with emotional conflict or psychosocial problems, which can be regarded as the main cause. The result is usually a distinct increase in support and attention from individuals or healthcare providers.
This does not include pain of presumably psychogenic origin that occurs during a depressive disorder or schizophrenia. Pains arising from known or implied psychophysiological mechanisms, such as muscle tension pain or migraine, but which are assumed to be of psychogenic origin, are coded with code F54 (psychological and behavioral factors associated with disorders or diseases classified elsewhere), plus - additional code from other ICD-10 headings (for example, migraine G43.-).
It should be noted:
In some cases, the state of persistent somatoform pain is accompanied by an overvalued desire to overcome pathological bodily sensations through the development of one's own methods of treatment, which are pretentious and brutal, and in severe cases it can cause varying degrees of autoaggression ("circumscripta hypochondria").
Differential diagnosis:
Most often it is necessary to differentiate this disorder with hysterical processing of organic pain. Patients with organic pain who do not yet have a definite physical diagnosis can easily become fearful or resentful, which in turn leads to the formation of attention-seeking behavior. Various pains are very common in somatized disorder, but they do not stand out in their strength and constancy from other complaints.
Includes:
Psychalgia;
Psychogenic back pain;
Psychogenic headache;
"Circumscripta hypochondria";
Somatoform pain disorder.
Excluded:
Back pain NOS (M54.9);
Pain NOS (R52.9);
Acute pain (R52.0);
Chronic pain (R52.2);
Intractable pain (R52.1);
Tension-type headache (G44.2).
2.7.5. F45.8 Other somatoform disorders
In these disorders, the complaints of patients are not mediated by the autonomic nervous system and are limited to individual systems or parts of the body; this contrasts with
the multiplicity and variability of interpretation of the origin of symptoms and emotional disorders found in somatized disorder (F45.0) and undifferentiated somatoform disorder (F45.1). There is no tissue damage.
This should also include any other sensory disorders that arise out of association with organic disorders that are closely related in time to stressful events and problems, or lead to significantly increased attention to the patient, either from individuals or doctors. Feelings of swelling, skin movement, and paresthesia (tingling and / or numbness) are common examples.
This should include the following types of disorders:
a) "hysterical lump" (sensation of a lump in the throat, causing dysphagia), and
other forms of dysphagia;
b) psychogenic torticollis and other disorders accompanied by spasmodic
movements (but excluding Gilles de la Tourette's syndrome);
c) psychogenic itching (but excluding specific skin disorders such as
alopecia, dermatitis, eczema or urticaria of psychogenic origin (F54));
d) psychogenic dysmenorrhea (but excluding dyspareunia (F52.6) and frigidity
(F52.0);
e) grinding of teeth.
Includes:
Psychogenic dysmenorrhea;
Psychogenic dysphagia, including globus hystericus;
Psychogenic itching;
Psychogenic torticollis;
Teeth grinding.
F45.9 Somatoform disorder, unspecified Includes:
Unspecified psychophysiological disorder;
Psychosomatic disorder NOS.
2.8. F48 Other neurotic disorders
2.8.1. F48.0 Neurasthenia
The pattern of this disorder is subject to significant cultural variation; there are two main types that have a lot in common.
In the first type, the main symptom is complaints of increased fatigue after mental work, often a decrease in professional productivity or efficiency in daily activities. Mental fatigue is commonly described as unpleasant interference with distracting associations or memories, inability to concentrate, and unproductive thinking. In the other type, the main one is physical weakness and exhaustion after minimal effort, accompanied by a feeling of pain in the muscles and the inability to relax. Other physical discomforts such as dizziness, tension headaches, and a feeling of general instability are common with both types. Concerns about mental and physical distress, irritability, anhedonia (loss of feelings of joy, pleasure), and mild depression and anxiety are also common. Often, the initial and intermediate phases of sleep are disturbed, but hypersomnia can also be pronounced.
Diagnostic instructions:
For a reliable diagnosis, the following signs are required:
a) persistent complaints of increased fatigue after mental work, or
complaints of weakness in the body and exhaustion after minimal effort;
b) at least two of the following symptoms:
Feeling of muscle pain
Dizziness,
Tension headache
Sleep disturbance,
Inability to relax
Irritability,
Dyspepsia;
c) any autonomic or depressive symptoms present are not so long and severe as to meet the criteria for more specific disorders described in this classification.
Differential diagnosis:
In many countries, the diagnosis of neurasthenia is rarely used. Many similar diagnoses made in the past would meet the criteria for depressive or anxiety disorder that exist today. However, there are cases that are more consistent with the description of neurasthenia than any other neurotic syndrome, and in some countries such cases are apparently more common, in others less often. If a patient is suspected of having neurasthenia, first of all, it is necessary to exclude a depressive illness or anxiety disorder. A distinctive feature of the syndrome is the patient's complaints of fatigue and weakness and his concern about the decrease in mental and physical performance (in contrast to somatoform disorders, where complaints of physical illness predominate in the clinical picture). If neurasthenic syndrome appears after a physical illness (especially influenza, viral hepatitis or infectious mononucleosis), the diagnosis preceding neurasthenia should also be noted.
It should be noted:
The selected subtypes in cases of predominance of complaints of mental fatigue and in the presence of objectively identifiable signs of decreased mental productivity should be differentiated with pseudo-neurasthenic states caused by affective disorder (asthenic depression), as well as with asthenic manifestations of "poor symptoms" of schizophrenia (F21.5).
Includes:
Fatigue syndrome.
Excluded:
Asthenia NOS (R53);
Emptiness (state of depletion of vitality) (Z73.0);
Post-viral fatigue syndrome (G93.3);
Malaise and fatigue (R53);
Psychasthenia (F48.8)
2.8.2. F48.1 Depersonalization-derealization syndrome
A disorder in which the patient complains that his mental activity, body and / or environment have qualitatively changed so much that they seem unreal, distant, or automatic. He may feel that he himself no longer thinks, does not imagine, does not remember; that his movements and behavior are not his; that his body appears lifeless, distant, or otherwise abnormal; the surroundings have become colorless and lifeless and seem artificial, or like a stage in which people play fictitious roles. In some cases, the patient may feel as if he is seeing himself from the outside or as if he is dead. The most common of these varied phenomena is the complaint of loss of emotion.
The number of patients in whom this disorder occurs in pure or isolated form is small. The most common phenomenon of depersonalization occurs within the framework of depressive disorder, phobic and obsessive-compulsive disorder.
Elements of this syndrome can also appear in mentally healthy individuals with fatigue,
sensory deprivation, hallucinogenic intoxication, or both
hypnagogic / hypnapompic phenomenon. The depersonalization-derealization syndrome is phenomenologically close to the so-called "near-death states" associated with moments of extreme danger to life.
Diagnostic criteria:
For a reliable diagnosis, signs must be present: a) or b) or both, plus c) and d):
a) symptoms of depersonalization, that is, the patient feels that his feelings and / or
actions are divorced from him, removed, not his own, lost, etc .;
b) symptoms of derealization, that is, objects, people and / or environment seem
unreal, distant, artificial, colorless, lifeless, etc .;
c) understanding that this is a subjective and spontaneous change, and not imposed
external forces or other people (that is, the presence of criticism),
d) clear consciousness and absence of toxic states of confusion or epilepsy.
Differential diagnosis:
It should be distinguished from other disorders in which "personality change" is felt or is present, such as schizophrenia (delusions of metamorphosis or sensation of impact), dissociative disorders (in which a change in state is not realized) and some cases of early dementia. As a secondary phenomenon, this syndrome may be present in the predictal aura of temporal lobe epilepsy or some postictal conditions.
If this syndrome occurs in the context of depressive, phobic, obsessive-compulsive disorders or schizophrenia, they should be considered the main diagnosis.
It should be noted:
The "involuntariness" of complaints, which is indicated in the introduction to the rubric, should be considered a figurative characteristic. Depersonalization disorder invariably proceeds without formal disturbances of consciousness. Even in cases of depressive depersonalization, the observed disorder may not be limited to manifestations of painful mental anesthesia. Disorders of self-awareness extend to all mental activity and, above all, to cognitive function. The diagnosis is established by belonging to affective disorders (F30 - F39) or schizotypal disorders (F21.-).
"Organic, including symptomatic, mental disorders" (headings F04-F07, corresponding to reactions of the exogenous type K. Bonhoffer)
"Neurotic, stress-related and somatoform disorders" (rubrics F44.4-F44.7, corresponding to psychogenias, and F45 - somatoform disorders)
"Behavioral syndromes associated with physiological disorders and physical factors" (headings F50-F53).
Most psychosomatic disorders are called somatoform and are considered under a separate heading, F45. Somatoform disorders are defined as the recurring occurrence of physical symptoms suggestive of a medical illness that is not supported by objective medical examination. If physical disorders are present, then they do not explain the nature and severity of the symptoms, as well as the suffering and concerns of the patient. Even when the onset and persistence of symptoms is closely related to unpleasant life events, difficulties or conflicts, the patient usually resists attempts to discuss the possibility of its psychological conditioning; this can be the case even with distinct depressive and anxiety symptoms. In these disorders, there is often some degree of demonstrative behavior aimed at attracting attention, as well as protest reactions associated with the patient's inability to convince doctors of the predominantly physical nature of his illness and the need to continue further examinations and examinations.
F45 Somatoform disorders
The main feature is the repeated presentation of somatic symptoms simultaneously with the insistent demands of medical examinations, despite their repeated negative results and the assurances of doctors that the symptoms are not of a somatic nature. If the patient has any somatic illness, they do not explain the nature and severity of the patient's symptoms or suffering or complaints.
Excludes: dissociative disorders (F44.-)
hair plucking (F98.4)
infant speech [babbling] (F80.0)
lisp (F80.8)
nail biting (F98.8)
psychological and behavioral factors associated
with disorders or diseases classified elsewhere (F54)
sexual dysfunction not attributable to organic disorder or disease (F52.-)
thumb sucking (F98.8)
tics in childhood and adolescence (F95.-)
de la Tourette syndrome (F95.2)
trichotillomania (F63.3)
F45.0 Somatisation disorder
The main features are numerous, recurring, frequently changing physical symptoms that have occurred for at least two years. Most patients have a long and complex history of contacts with primary and specialized care services, during which many ineffective examinations and sterile diagnostic procedures may have been performed. Symptoms can affect any part of the body or organ system. The course of the disorder is chronic and erratic and is often associated with impaired social, interpersonal, and family behavior. Short-lived (less than two years) and less pronounced examples of symptoms should be classified as undifferentiated somatoform disorder (F45.1).
Multiple psychosomatic disorder
Excludes: simulation [conscious simulation] (Z76.5)
F45.1 Undifferentiated somatoform disorder
The diagnosis of undifferentiated somatoform disorder should be made when the patient's complaints are numerous, variable, and persistent, but do not satisfy the full and typical clinical picture of the somatoform disorder.
Undifferentiated psychosomatic disorder
F45.2 Hypochondriacal disorder
The most important feature is the patient's persistent concern about the possibility of having a serious, progressive disease or several diseases. The patient has persistent somatic complaints or shows persistent
anxiety about their occurrence. Normal, common sensations and signs are often perceived by the patient as abnormal, disturbing; he usually focuses his attention only on one or two organs or systems of the body. Severe depression and anxiety are often present, which may explain additional diagnoses. Disorder of self-concern
Dysmorphophobia (non-delusional)
Hypochondriacal neurosis
Hypochondria
Nosophobia
Excludes: delusional dysmorphophobia (F22.8); delusions fixed on the functioning or appearance of one's own body (F22.-)
F45.3 Somatoform dysfunction of the autonomic nervous system
The symptomatology presented by the patient is similar to that which occurs when an organ or organ system is damaged, predominantly or completely innervated and controlled by the autonomic nervous system, i.e. cardiovascular, gastrointestinal, respiratory and genitourinary systems. Symptoms are usually of two types, neither of which indicates a violation of a particular organ or system. The first type of symptoms are complaints based on objective signs of autonomic irritation, such as palpitations, sweating, redness, tremors and expressions of fear and concern about a possible health disorder. The second type of symptoms are subjective complaints of a nonspecific or variable nature, such as fleeting pains throughout the body, a feeling of heat, heaviness, fatigue, or bloating, which the patient associates with an organ or organ system.
Cardiac neurosis
Da Costa's Syndrome
Gastroneurosis
Neurocirculatory asthenia
Psychogenic forms:
Aerophagia
Dyspepsia
Dysuria
Flatulence
Deep and rapid breathing
Frequent urination
Irritable bowel syndrome
Pylorospasm
Excludes: psychological and behavioral factors associated with disorders or diseases classified elsewhere (F54)
F45.30 Somatoform dysfunction of the autonomic nervous system of the heart and cardiovascular system
F45.31 Somatoform dysfunction of the autonomic nervous system of the upper gastrointestinal tract
F45.32 Somatoform dysfunction of the autonomic nervous system of the lower gastrointestinal tract
F45.33 Somatoform dysfunction of the autonomic nervous system of the respiratory system
F45.34 Somatoform dysfunction of the autonomic nervous system of the genitourinary organs
F45.38 Somatoform dysfunction of the autonomic nervous system of other organs
F45.4 Persistent somatoform pain disorder
The main complaint is persistent, sharp, excruciating pain that cannot be fully explained by a physiological disorder or medical illness and which arises in connection with emotional conflict or psychosocial problems, which allows us to consider them as the main etiological cause. The result is usually a marked increase in personal or medical support and attention. Pain of a psychogenic nature arising in the process of depressive disorder or schizophrenia cannot be attributed to this rubric.
Psychalgia
Psychogenic:
Backache
Headache
Somatoform pain disorder
Excludes: back pain NOS (M54.9)
NOS (R52.9)
Sharp (R52.0)
Chronic (R52.2)
Fatal (R52.1)
tension headache (G44.2)
F45.8 Other somatoform disorders
Any other disorder of sensitivity, function, or behavior not due to a somatic disorder. Disorders that are not mediated through the autonomic nervous system are limited to specific systems or areas of the body and have a close temporal relationship with traumatic events or problems.
Psychogenic:
Dysmenorrhea
Dysphagia, including "globus hystericus"
Torticollis
Teeth grinding
F45.9 Somatoform disorder, unspecified
Psychosomatic disorder NOS