10 Myths about Psychosomatics

Introduction

Psychosomatics is seemingly clear to everyone (doctors and patients), but at the same time, it is a section of medicine covered with myths. Let us discuss some of them.

Myth 1. Psychosomatic disorders are the “holy seven”

The idea that somatic diseases may arise due to various mental disorders has a long history. For example, Cicero was convinced that many bodily sufferings develop as a result of psychogenic, emotional factors [1]. The term “psychosomatics” itself belongs to the German psychiatrist Johann Christian Heinroth (1818), who formulated the concept of psychogenesis of several somatic diseases.

The concept of “psychosomatic medicine” was formed about a hundred years later. Its origins are the works of the Viennese physician Felix Deutsch, one of the students of Freud. At that time, this concept comprised such diseases as coronary heart disease, arterial hypertension, bronchial asthma, peptic ulcer disease, atopic dermatitis, psoriasis, and rheumatoid arthritis (the so-called “holy seven”). The initial interpretation of the development of these seven diseases was psychoanalytical. It was believed that unfavorable mental influences played a significant (if not exclusive) role in their development.

Currently, this view of psychosomatics is revised, and the spectrum of psychosomatic diseases appears to be much broader. Thus, according to Smulevich (2011) [2], the following variants of psychosomatic disorders are distinguished (Table 1).

Congenital anomalies of the somatopsychic sphere (somatoperceptual constitution) – somatoperceptual psychopathy according to Lemke – include accentuations of the somatoperceptual circle. According to Smulevich (2011) [2], this accentuation is defined by neuroticism, pronounced emotional reactivity, innate lability of the autonomic nervous system, a strong tendency to self-observation of body reactions with fixation of the obtained experience, a tendency to evaluate normal visceral sensations as painful, and a tendency to hypochondria.

The main sign of somatoform disorders is the recurrent occurrence of physical symptoms in the absence of somatic distress; if present, it does not explain the severity of the symptoms or the patient’s concerns.

The term “organ neurosis” is conditional. There is no idea that a separate organ is “neurotized”; what is meant here is the disturbance of regulation. At the same time, it is significant that the emphasis in the clinical picture on this particular organ is due to the somatically unfavorable ground, the presence of locus minoris. According to the results of the examination of patients in a multidisciplinary hospital and a city polyclinic [3], the most frequent localization of organoneurotic disorders is the cardiovascular system (4.7%), less frequently, the respiratory system (2.1%), digestive system (2.8%), and even less frequently the genitourinary system (1.1%).

Somatopsychosis is an acute attack of mental illness manifested by marked anxiety about health with the perception of bodily sensations as a life-threatening somatic illness. There are marked coverage, complete absorption in pathological sensations, agitation, pronounced fear of death, and conviction in the presence of severe incurable somatic suffering [2].

Hypochondriacal delusion is an unshakeable (with fundamental immutability) conviction in the presence of somatic suffering, with a constant demand for new diagnostic and therapeutic procedures, attempts at self-medication (often grotesque), and often autodestructive behavior.

Artificial disorders include autoaggressive non-suicidal behavior in the form of self-harm. This behavior is caused by various mental disorders (psychogenic and endogenous disorders, organic CNS diseases, chemical dependence, oligophrenia, personality disorders). In this case, patients, concealing the known cause of symptoms, seek help from doctors.

According to Smulevich (2011) [2], all artifacts are subdivided into the following main subclasses depending on the topics of the simulated disorder:

1. Skin diseases (including ulcerative bullous form of simple contact dermatitis) – damage due to mechanical, chemical (application of concentrated acids), and thermal effects.

2. Internal diseases:

2.1 fever of unclear genesis (manipulation with a thermometer, injection of infectious material);

2.2 hematologic and hemostasiologic symptoms (heparin injections, inducing petechiae by compression of extremities, bloodletting);

2.3 metabolic disorders (due to self-administration of insulin and other medications);

2.4 cardiac symptoms (unprescribed use of cardiotropic medications, etc.);

2.5 pulmonologic symptoms (injection of blood into the respiratory tract, etc.);

2.6 individual somatic symptoms:

• diarrhea (laxatives);
• electrolyte imbalance (diuretics);
• anemia (bloodletting);

3. Gynecologic diseases (self-inflicted abscesses, mastitis, etc.).

4. Surgical diseases (impaired wound healing due to suture manipulation, mutilation, etc.).

5. Urologic diseases (self-injury and urinary tract injuries with instruments, injection of blood or fecal matter, etc.).

6. Ophthalmologic diseases (mechanical manipulations on the cornea, self-induced conjunctivitis).

7. Neurologic diseases include anisocoria due to the administration of anticholinergic eye drops.

Nosogenies are psychopathological reactions and personality development as a consequence of somatic suffering. They are formed with the participation of two main components: psychogenic (stress of diagnosis and treatment) and biological (pathogenesis of the somatic suffering itself). Nosogenies are primarily manifested as anxiety-phobic, dissociative, and hypochondriacal reactions.

Somatogenies are asthenic disorders caused by somatic suffering, somatogenic depression, and symptomatic psychoses.

Endoform disorders (psychopathological reactions of endogenous type (affective or schizophrenic) provoked by the development of a physical disease), as well as somatogenic provocation of the development of endogenous disease, take place in the presence of predisposition to endogenous mental disorders; somatic disease acts as a trigger providing the penetrance of the corresponding genes.

The description of the psychosomatic spectrum may lead to the idea that all human diseases are psychosomatic. However, like any other categorical thought, it is also a myth.

Myth 2. Psychosomatics underlie all human diseases in general

Psychosomatic medicine is a discipline formed at the intersection of psychiatry, psychology, and somatic medicine, which covers the whole range of combinations of mental and somatic pathology [4]. At the same time, the continuum of psychosomatic relationships, including possible variants of such interaction, is characterized by different degrees of involvement of psychiatric and somatic spheres in the pathological process in each patient [5]. Sidorov et al. (2006) [5] identified the following variants of psychosomatic correlations:

1. somatic disorders are associated with psychogenic mental disorders;
2. mental disorders develop based on somatic diseases;
3. somatic and mental disorders are formed because of a single pathological process;
4. mental disorders are manifested by functional somatic changes;
5. severe somatic complications are formed in the process of development of mental disorders;
6. psychological and psychic changes are formed as a reaction of personality to somatic disease.

Only scientifically proven causal links between psychiatric disorders and somatic suffering allow speaking of a psychosomatic disorder.

According to currently available statistical data, psychosomatic disorders are detected in 25–30% of patients in the general somatic network [6]. In the general population, the prevalence of psychosomatic disorders ranges from 15 to 60% [4].

Myth 3. Anyone can develop a psychosomatic illness

There are no invulnerable people. Yet, psychosomatic suffering requires a predisposition.

Predisposition to psychosomatic disorders (by Shamrei, Storozhakov, 2014)

Biological factors

Genetic factors, determining the somatic and psychic constitution, are significant factors of predisposition to psychosomatic disorders. Thus, the asthenic type of constitution is a predisposing factor to the development of vegetovascular dysfunctions, picnic type – to the formation of biliary dyskinesia and type 2 diabetes mellitus.

Damage to CNS structures as a result of infectious diseases, poisoning, trauma, and tumors leads to the weakening of corticovisceral regulation.

Sexual peculiarities, particularly those reflected in the characteristics of hormonal regulation, lead to significant differences in the spectrum of psychosomatic disorders in men and women.

Age, especially in periods of critical restructuring of the organism (puberty, menopause), is one of the factors of predisposition to the development of psychosomatic disorders.

Damage to the internal organ tissues by previous diseases makes them more vulnerable to the development of diseases with impaired nerve regulation.

Psychological factors.

The most significant proven factors include:

A) In early childhood:

• failure of psychological mother-child symbiosis (leads to the violation of body-psychic reactivity);
• psychological retardation (fixation on the bodily sphere);
• alexithymia (inability to express emotions and label bodily sensations, usually combined with distortion of body perception and predominance of bodily forms of response to stress).

B) In adults:

• intra- and interpersonal conflicts;
• rental attitudes;
• unconscious self-punishment (self-destruction);
• conversion (use of “symbolic organ language”);
• peculiarities of the patient’s personality, in particular, the predominance of psychasthenic, hypochondriacal, and hysterical radicals; personality rigidity.

Social factors.

In this section, one could do the traditional thing, saying that poverty, loneliness, war, and devastation increase the likelihood of psychosomatic suffering. However, this would be superficial and unproven (remember the works of Nietzsche and Viktor Frankl: “If you have a reason to live, you can bear any kind of suffering”). More important is a person's attitude to the surrounding reality. That is why to characterize the relationship between mental health and the social sphere of human life, Dmitrieva and Polozhij (1994) [7] proposed to use such a characteristic as “quality of life” – a concept reflecting “the degree of correspondence between the available needs, value orientations, and the level of their satisfaction in all major spheres of life”. It was established that there are several significant social factors influencing the probability of development of psychosomatic disorders:

• social and professional status;
• formation of socially important abilities;
• satisfaction with relationships with relatives, social status, economic status, health, and ability to work;
• educational level;
• leisure activities;
• general attitude toward life [7].

Myth 4. “One’s mind is a dark subject and cannot be examined”.

The phrase from the movie Formula of Love can be considered outdated. The pathogenesis of psychosomatic disorders is quite clear. The basis for modern understanding is very worthy. It consists of the theory of Sechenov’s nervism, Pavlov’s psychophysiological doctrine, Bykov and Kurtsin’s cortico-visceral concept, Orbeli’s theory of the regulating influence of the sympathetic nervous system on peripheral organs and the CNS, and Sellier’s theory of stress.

Shamrey and Storozhakova (2014) [4] believe that the pathogenesis of psychosomatic disorders fits into one of three variants.

A) Psychogenic variant.

As a result of stress reaction (in case of decompensation of anti-stress protection mechanisms), the process of somatization begins, the essence of which is the uneven distribution of corticovisceral load on various organs and systems. At that, first functional, and later – also organic disorders of internal organs develop. The process of somatization depends on the strength, duration, and individual significance of the stressor impact.

B) Dysontogenetic variant.

Dysontogenesis, disrupting the integration of body systems, significantly increases the likelihood of psychosomatic disorders. In this variant, they occur early (at the age of 5–7 years), often combined with infectious and allergic diseases.

C) Encephalopathic variant.

In this variant, in addition to the direct lesion of diencephalic structures by the pathological process, which leads to disorders of regulation (functional and trophic), psychopathology, inherent in encephalopathy emotional lability, weakness, dysphoria, and anxiety play a significant role.

It should be noted that it is rarely possible to clearly distinguish one of the above-described variants of pathogenesis; more often, there is a combination of several pathological processes or their transformation [4].

Myth 5. Psychiatrists deal with mental disorders

A clear refutation of this myth is the most common group of psychosomatic diseases – somatoform disorders. Let us repeat: their main characteristic is the dominance of somatic symptoms in the clinical picture in the absence of bodily suffering. Mental disorder is “masked” by somatic symptoms, which leads to the fact that patients have a long and difficult time achieving results in therapy with an internist (avoiding referral to a psychiatrist).

The following somatoform disorders are distinguished [4] (Table 2):

Myth 6. Neurosis does not concern the organs of the human body

Organ neuroses are a variant of combined psychosomatic disorders in which psychiatric disorders are manifested by persistent dysfunction of one or another organ and are associated with subclinical pathology/morphological abnormalities. Individual organ dysfunctions (belching, constipation, feeling of heart palpitations) can be noted in a wide range of borderline psychiatric disorders (anxiety, depressive). Organ neurosis is only considered when the symptoms persist for a long time in the area of one organ system.

It is believed that organ-neurotic symptoms can occur in any organ of the human body, but they are most often localized in four organ systems: respiratory, cardiovascular, digestive, and urinary. In accordance with this, the division of organ neuroses in ICD-10 is carried out (see Table 3). The information on organ neuroses, which are the most frequently encountered in clinical practice, is presented below [8].

The symptomatology of cardioneurosis is represented by three series of symptoms:

1. unpleasant sensations in the heart area (piercing pains, feeling of pressure, heaviness);
2. functional hemodynamic disorders (tachycardia, extrasystoles, lability of blood pressure);
3. anxiety with a predominant fear of death from cardiovascular accident (cardiophobia).

Cardioneurosis is clinically heterogeneous, which allows distinguishing at least two types: anxiety-phobic and dominated by pathologic bodily sensations (coenesthesiopathy).

In the anxiety-phobic type of cardioneurosis, the symptoms of cardiophobia come to the fore, supplemented at the height of anxiety by functional disorders of hemodynamics and cardiac conduction (sinus tachycardia, ventricular extrasystoles, transient increase in blood pressure). The course of this type is paroxysmal, with an intensification of symptoms similar to anxiety paroxysms, which cause patients to seek emergency medical care.

In the coenesthesiopathic type of cardioneurosis, anxiety symptomatology and functional disorders of hemodynamics are expressed to a lesser extent. The dominance of various sensations in the heart area (feeling of pressure, piercing, squeezing) is typical. The attack-like intensification of pathological sensations is less characteristic. In some patients, such symptoms can monotonously persist for a long time.

Clinical manifestations of functional dyspepsia are manifested by two series of symptoms: pathological sensations and disturbances of esophageal motility. The most typical bodily sensations in this type of organ neurosis are the feeling of a lump in the throat, painful spasms and the sensation of a foreign body behind the sternum, and heaviness in the projection of the stomach. Motility disorders are represented by periodic episodes of aerophagia and belching of just eaten food associated with stress or psychotraumatic events. It is considered that the most important differential-diagnostic sign is swallowing disorder, first of all, spreading on solid food, but not on liquid food, which is opposite to dysphagia in organic lesions of the esophagus. The described symptoms have little to do with dietary errors and show a clearer association with various psychologically traumatic events.

Within the irritable bowel syndrome (IBS), according to the possible modus operandi of lower digestive tract dysfunction, two types are distinguished – with predominance of constipation and diarrhea.

IBS with predominant constipation is determined by the transit disorders of intestinal contents for many months/years. In addition to impaired motility itself, there is also a wide range of associated symptoms: unpleasant taste in the mouth, persistent appetite disturbance, pain in the projection of the large intestine, a feeling of heaviness in the abdomen after eating, and rare episodes of diarrhea.

Most patients with such IBS have prolonged shallow depressive symptomatology of apathetic and adynamic circles.

Symptomatology of IBS with predominant diarrhea is defined by spontaneous spastic, cutting pain in the abdominal region, accompanied by sharp and intense urges to defecate, a feeling of bloating, “bubbling” in the intestine. Repeated liquid stools are noted.

This type of IBS is associated with anxiety-phobic disorders in the form of panic attacks. Their content reflects the fear of losing feces during diarrhea in public places or transport, and thus, embarrassing oneself (so-called scoptophobia, fear of being embarrassed in public). About one-third of patients have agoraphobia, in which the patient makes a plan of movement outside the home, taking into account the presence of toilets and secluded places where it is possible to perform physiological excretions.

Both types of IBS are among the least favorable types of organ neuroses, revealing a tendency to chronic course and a significant negative impact on the quality of life.

The most typical variant of organ neurosis realized in the respiratory system is hyperventilation syndrome (HVS).

The clinical picture of HVS is defined by the so-called “behavioral dyspnea” – a feeling of incomplete breathing, insufficiency of respiratory function. Respiratory disorders in HVS are diverse and can be represented by both rapid breathing and increased chest excursion with excessively deep breaths, yawning.

It was shown that HVS is formed in patients with constitutionally determined high sensitivity of the respiratory system. These are people with pronounced sensitivity to odors, stuffiness, temperature, and humidity variations with poor well-being both in high and low temperatures.

The symptomatology of HVS in such patients is formed by the type of temporary (from days to 1–2 months) exacerbation, associated with anxiety and developing under psychogenic or somatogenic (acute respiratory infection, surgical intervention in the nose or throat) provocation. The course of HVS is usually favorable without increasing the severity of symptoms.

Vocal cord dysfunction is characterized by paradoxical movements of the vocal muscles, which leads to the formation of short-term episodes of acute respiratory distress. It is characterized by a feeling of tightness in the throat, the presence of a septum there, and the fear of death from respiratory arrest. The attacks are characterized by a sudden onset, short duration, and spontaneous resolution.

Psychogenic (behavioral) cough is characterized by repeated painful bouts of dry coughing that do not provide relief. Usually, the cough is described as loud, sometimes barking or trumpeting. It is often associated with unpleasant sensations in the throat area – dryness, tickling, fever, and a sense of foreign body (hair, crumbs).

Organ neurosis localized in the genitourinary system, similar to IBS, is divided into two types: with increased bladder motility and fear of its involuntary emptying (psychogenic pollakiuria) and difficulties in emptying the bladder (paruresis). Similar to IBS, mixed variants of these disorders can also be observed.

Psychogenic pollakiuria is defined by attacks of fear of involuntary urination in a situation that excludes direct access to the toilet (subway car, elevator, lecture). It leads to various pathologic sensations in the bladder area, mainly of the type of overflow or burning. Many patients have multiple trips to the toilet before trips, important events, reaching in some situations the degree of compulsive repeated actions.

Paruresis is characterized by the inability to perform the act of urination voluntarily in the presence of others or in an uncomfortable or dirty place. This form of bladder neurosis is thought to be more characteristic of males. Paruresis reveals a close relationship with disorders of the sociophobic circle, which are noted in 2/3 of patients in this category. The severity of paruresis varies from subsyndromal manifestations, which are revealed only when the patient is questioned in detail, to a markedly maladaptive degree, when the whole life is subordinated to the search for accessible places of physiological needs, and it is difficult to perform work outside the home or receive education on a full-time basis.

Diagnosis of organ neuroses (Volel, 2021 [8]).

Diagnosis of organ neuroses is carried out in two directions: 1) exclusion of unfolded somatic pathology and 2) differentiation of organ neuroses from psychic disorders that can imitate organ neurotic symptomatology.

When making a differential diagnosis of organ neuroses and somatic pathology, one should keep in mind their possible coexistence. In particular, patients with two types of choking attacks (hyperventilatory and typical asthmatic) or cardiac pain (angina and cardioneurotic) were described.

The leading role, along with detailed clinical assessment in this case, is played by a qualified interpretation of the results of laboratory and instrumental examinations.

Among the psychiatric disorders that mimic the picture of organ neurosis, it makes sense to mention conversion hysteria. Separate organ-neurotic symptoms are detected in most patients with conversion hysteria, but unlike true organ neuroses, they have a “volatile” character: the change of the involved organ is characteristic both under the influence of psychologically traumatic circumstances and spontaneously. In turn, in true organ neuroses, the change of the organ involved is uncharacteristic; for many years, symptoms concerning one organ system persist.

Thus, a significant layer of work for the internist includes somatoform disorders, which are not associated with somatic disease, and organ neuroses, in which there is only a locus minoris of an organ or system of the body. However, it is not easier even when there is a real somatic disease (the patient came “to the right place”), but psychological mechanisms of reaction to the occurred health disorder are activated.

Myth 7. The diagnosis and modern conditions of treatment of a diagnosed disease are always for the benefit of the sufferer

The richness of the human psyche leads to a wide variety of its possible responses to the challenge posed both by the disease itself and by factors related to treatment (information about the diagnosis, methods of its clarification, hospital stay, undergoing therapeutic procedures).

There are several variants of personality reactions to somatic illness. Each of these reactions can be limited to the level of mild pre-disease disorders or reach deeper registers of mental disorders [9][10]:

1. Phobic reaction, when a wary attitude prevails, both towards the disease and towards diagnostic and therapeutic methods.
2. Sensitive reaction is a pronounced feeling of embarrassment and shame about the disease.
3. Melancholic reaction is a decrease in mood, often with pronounced pessimism and refusal of treatment.
4. Hypochondriacal reaction includes a total focus on the disease, studying it, a “medical odyssey” with changing specialists and scrutinizing them thoroughly.
5. Neurasthenic reaction is characterized by weakness, irritability, and tearfulness.
6. Hysterical reaction fully conforms to the “three E’s rule of hysteria”: egoism, egocentrism, and eccentricity.
7. Dysphoric reaction includes explosions of anger with decreased control over emotional response.
8. Euphoric reaction is characterized by elevated mood, which does not correspond to the objective situation; the disease is denied or clearly underestimated.
9. Paranoid reaction includes searching for enemies, which often turn out to be medical workers (reproaches for negligence, incompetence).
10. Suicidal reaction includes the patient’s antivital attitudes.
11. Apathetic reaction is expressed as a loss of will to resist the disease, striving for recovery, passivity.
12. A harmonious response is a conditional ideal, in which the patient calmly and attentively accepts information about the disease, clearly assesses the prospects, analyzes treatment alternatives, making informed decisions, strives for recovery, doing everything in his or her power.
13. Ergopathic reaction is dissimulation (concealment) of the disease.
14. Alienation reaction is perceiving the illness in an alienated way, as having happened to someone else.

Based on the reactions described above, nosogenias develop under the influence of stress associated with the manifestation of somatic disease and biological factors caused by somatic suffering itself. They primarily occur in the form of anxiety-phobic, dissociative, and hypochondriacal reactions.

Nosogenic depression, according to Volel (2021) [8], is the type of affective pathology most typical of the somatic network. This is a special type of depression, the genesis of which involves both psychogenic factors (stress associated with diagnosis and hospitalization) and biological factors (pain, choking attacks in asthma, itching in skin diseases, etc.).

Clinically nosogenic depression is characterized by mildly pronounced hypothymia. The patient’s consciousness is dominated by anxious hypochondriacal ideas, pessimistic perception of the disease, and aggravated self-observation. A large contribution to the picture of nosogenic depression is made by various manifestations of somatized anxiety, often intensifying the manifestations of the disease that caused the depression. Some patients also show signs of the so-called demoralization reaction (especially often in urgent pathology) with a temporary refusal of any activity and taking a passive position in relation to the disease.

Persistent anhedonia, longing, guilt ideas, and suicidal ideation are uncharacteristic. Depression is completely devoid of both a depressive circadian rhythm and a return rhythm. Instead, patients’ well-being fluctuates throughout the day according to external events (conversations with the doctor, results of examinations) and the severity of symptoms. The reversal of depression, even without treatment, occurs with the normalization of the somatic state and depends to a greater extent on the course of the disease.

The clinical picture of nosogenic anxiety-phobic disorders is determined by a combination of somatized anxiety, amplifying (multiplying) the manifestations of somatic disease, fears about the prognosis of the disease, as well as expressed hypochondriacal reflexion (aggravated self-observation, and desire to obtain maximum information about their disease).

The role of anxiety disorders in psychosomatic practice is great and can be conditionally divided into two large blocks. First, anxiety disorders can mimic/duplicate somatic pathology, complicating the diagnosis of somatic pathology and the selection of therapy and assessment of its effectiveness. For example, patients with paroxysms of anxiety are prone to frequent calls to the ambulance. Many patients with generalized anxiety often visit doctors on a routine basis for somatized manifestations of anxiety. In the presence of an actual somatic illness in these patients, the symptomatology may be augmented by somatized anxiety.

On the other hand, long-term existing pathology of the anxiety circle similarly to depression significantly worsens the prognosis of many somatic diseases, which is associated with both the direct biological impact of anxiety (activation of stressor systems of the body, increase in BP, blood glucose and triglycerides) and worse compliance in attitude.

Subsyndromal anxiety disorders and uncomplicated typical cases of panic disorder and generalized anxiety disorder are treatable in non-psychiatric outpatient settings. Nevertheless, it is useful for the clinician in any specialty to be aware of some orienting signs that indicate that a patient should be referred to a psychiatrist due to low curableness outside of a specialized psychiatric network. These include the following:

• severe restrictive behavior (refusal to go outdoors, inability to stay home alone due to anxiety, lowered social standards in the form of quitting work);
• hypochondriac behavior in the form of “medical odyssey” (multiple visits to doctors in the past, frequent change of specialists, lack of compliance with self-treatment);
• dependence on alcohol or psychoactive substances, including those used to reduce the severity of anxiety;
• psychotic level of anxiety with confusion or pronounced doubts preventing even simple decisions from being made;
• comorbid disorders (obsessions, depersonalization, perceptual deceptions).

As for nosogenic hypochondriacal reactions, they will be described in the following myth.

Myth 8. All hypochondriacs are the same, and coenesthesiopathy is a term no one understands

According to ICD-10, the main feature of hypochondriacal disorder is a constant preoccupation with the possibility of a severe and progressive somatic disorder. Patients constantly present somatic complaints, they are clearly and persistently concerned about their somatic condition. Normal sensations and phenomena are often interpreted as abnormal and unpleasant, with attention usually focused on one or two organs or body systems.

Hypochondria is based on excessive, unreasonable attention to one’s health (“bodily hypervigilance”, bodily hypervigilance, which is based on coenesthesiopathy – a feeling of uncertain total physical disadvantage), preoccupation with even an insignificant ailment or conviction in the presence of serious illness, bodily disorders or deformities [4]. In hypochondria, it is not just a question of anxiety as such but about the corresponding mental, intellectualized processing of those or other painful sensations from the somatic sphere. In this case, the concept of a particular disease is constructed and the struggle for its recognition and treatment begins. The psychopathological character of hypochondria is confirmed by the fact that when it is combined with a real somatic disease, the patient does not pay a fraction of the attention to the latter, which pays to imaginary disorder.

There are several types of non-blind hypochondria [8].

Neurotic hypochondria is defined by dominant fears about the possible presence of a serious somatic disease. In this syndrome, there is close attention to the functioning of one's own body with a desire to interpret any sensations in the body as a manifestation of a somatic catastrophe. There is frequent seeking of medical help (so-called “medical shopping”), regular calls for ambulance, and a tendency to excessive taking of tests. In some cases, manipulative behavior is formed with the adoption of the role of the seriously ill in an attempt to attract the attention of others, to cause them a sense of guilt. The constitutional basis for the formation of neurotic hypochondria is the so-called neuropathy – a tendency to somatic fragility, manifested by vegetative lability, frequent episodes of unexplained subfebrile, asthenic, and pseudoallergic reactions.

In contrast, the picture of super valuable hypochondria is determined mainly by the desire to cope with the manifestations of a real or imaginary illness. The dominant position in consciousness is not fear of the disease, but attempts to cope with it. Patients are inclined to create various, including fanciful systems to maintain their health by means of diets, physical exercises, and folk methods of treatment. In addition, there is an increased turn to doctors for medical help. Patients seek more radical measures to restore health, including surgical interventions, aggressive pharmacotherapy, multiple sessions of physical therapy and physiotherapy. Super valuable hypochondria is formed on the basis of somatotonia – a constitutional tendency to high physical activity, maintenance of a healthy lifestyle, “cult of the body”.

A special type of super valuable hypochondria is restricted (Lat. circumscripta) hypochondria, which is manifested by an obsession with pains (so-called idiopathic algias) with a desire to remove the area of the body in which they are observed.

Pseudoneurasthenia is characterized by the dominance in the patient's perception of atypical sensations alien to the usual bodily perception – a combination of diametrically opposite sensations (“cold fever”), manifestation of symptomatology in vegetatively silent organs (pericardium, soft palate), atypical spatial localization. Pseudoneurasthenia is formed in patients with schizotypal personality disorder and constitutionally determined paradoxical perception of one’s body – proprioceptive diathesis.

Finally, aberrant hypochondria is a polar type in relation to all of the above, essentially being “anti-hypochondria”. Such patients are characterized by complete disregard for somatic disadvantage, denial of the presence of somatic disease, and lack of emotional response to the manifestations and semantics of the diagnosis. This type of anti-hypochondria is formed in persons with segmental depersonalization, which is manifested by a lifelong neglect of the body’s needs and a reduced self-perception of bodily ill-being.

Myth 9. Psychosomatics is always a mild level of disorder

Let us remember once again that in the field of psychosomatics, there is hypochondriacal delirium and somatopsychosis, and it will become clear that psychosomatic disorders are not always of a relatively mild level (however, they are always “extremely severe” for the patient). It should be added that there are mental disorders that are extremely severe, accompanied by pronounced psychosomatic manifestations. Such conditions include febrile schizophrenia, toxic Gayet-Wernicke encephalopathy, and malignant neuroleptic syndrome [4].

Febrile schizophrenia is a hypertoxic form of this disease (lethal without adequate treatment). Severe disintegration of the body, disturbances of water-electrolyte balance, hypovolemia, rapid weight loss are accompanied by severe somatic disorders.

Gayet-Wernicke’s encephalopathy develops in stage III of alcoholic disease, and there is a pathogenic effect of a complex of factors – alcohol intoxication, metabolic, toxic, and alimentary disorders, resulting in severely disturbed central and peripheral regulation.

Malignant neuroleptic syndrome is a severe manifestation of drug-induced disease, manifested by impaired consciousness, extrapyramidal symptoms, fever, and severe metabolic disorders.

The severe level of psychosomatic disorders also includes disorders arising from food addiction (anorexia nervosa and bulimia nervosa).

Myth 10. There are no specialists to treat psychosomatic disorders

It is not really a myth. For many internists, psychosomatics is a pejorative term for “higher nervous activity” (even simpler, “hysteria”). These patients are also rarely seen by a psychiatrist (unwilling or unable to find a specialist). As a result, many are left without help.

Ideally, the treatment of psychosomatic disorders should include the correction of both components – mental and somatic, that is, it should be comprehensive [4]. As for psychopharmacotherapy, it should be as delicate as possible, according to the principle of “minimal sufficiency”.

Eliseev (2008) [11] formulated the key requirements for drugs used in psychopharmacotherapy of psychosomatic disorders:

1. effectiveness in relation to the main psychopathological syndromes;
2. sufficient therapeutic breadth to allow the use of low and even ultra-low dosages;
3. low toxicity;
4. possibility of simultaneous correction of both mental and somatovegetative disorders (good somatotropic effect);
5. low “behavioral toxicity”;
6. good compatibility with somatotropic drugs;
7. ease of use, i.e. the drug can be prescribed by general practitioners;
8. low teratogenicity, possibility of use in pregnant women.

Unfortunately, absolutely none of the currently used psychotropic drugs meets all of the above requirements.

According to Eliseev (2008) [11], at the present stage of psychopharmacology development, anxiolytics and thymoanaleptics are most often used (in 40–65% and 12–25% of patients, respectively), the so-called minor neuroleptics are rarely used (5%).

The most important methods of non-medication treatment include psychotherapy, physical therapy, and spa treatment.

Conclusion

Whatever myths we discuss, there is an understanding that only science can dispel them. That is science that is based on a comprehensive and evidence-based approach. In the field of psychosomatics, the chances for this are given by the concept of “counter-movement” developed by academician Smulevich, the essence of which is the urgent need for interdisciplinary interaction between psychiatrists and internists, increasing the chances of successful assistance in such a complex and myth-filled field as psychosomatics.