I. INTRODUCTION

Somatic symptom disorder is a disease in which mental conflict is expressed as somatic symptom. In the DSM-5, a somatic symptom disorder has one or more somatic symptoms that are distressing or result in significant disruption of daily life. Also, one or more of disproportionate and persistent thoughts about the seriousness of one’s symptoms, persistently high level of anxiety about health or symptoms, and excessive time and energy devoted to these symptoms or health concerns appear. It is characterized in that the state with these symptoms persist for more than 6 months¹⁾.

Patients with somatic symptom disorder can complain of various somatic symptoms across all organs, and it is difficult to find an organic cause for the symptoms. Symptoms can be inconsistent, dramatically exaggerated, and expressed in a variety of ways²⁾. Anxiety and concern about somatic symptoms can be overwhelming. In addition, depression or anxiety disorders can be associated with somatic symptom disorders^1,3).

Somatic symptom disorder is a disorder first defined in DSM-5, and encompasses all of DSM-IV-TR’s somatization disorder, undifferentiated somatoform disorder, pain disorder, and hypochondriac symptoms accompanied by somatic symptoms of hypochondriasis. Among these disorders, the basis of somatic symptom disorder is somatization disorder. Somatic symptom disorder in DSM-5 differs from somatization disorder in DSM-IV-TR in that it does not require age, number of somatic symptoms, and symptoms that are not medically explained, and focuses attention on stress caused by somatic symptoms and the resulting non-adaptive disease behavior³⁾.

In Korean medicine, there are no symptoms that clearly correspond to somatic symptom disorders, but when considering the pathogenesis factors and diversity of symptoms, several corresponding symptoms can be considered. When humans are under stress, mental and somatic reactions appear. According to epistemology of ‘body and mind as one (心身一如)’ in Korean medicine, stress phenomena such as seven kinds of pathogenic qi (七氣), nine kinds of pathogenic qi (九氣), qi depression (氣鬱), and qi counterflow (氣逆) occur due to changes in seven emotions (七情), a specific phenomenon of mental function, and it is considered that pathological symptoms occur by acting on various body organs⁴⁾.

Meanwhile, as the number of traffic accident patients and medical expenses continue to increase due to the recent increase in the use of automobiles in Korea, the scale of medical treatment at Korean medical institutions is also increasing⁵⁾. In addition to surgical pain, many traffic accident patients complain of systemic symptoms such as systemic weakness, dizziness, and neuropsychiatric pain such as anxiety and depressive disorder⁶⁾. Therefore, neuropsychiatric approach is necessary for traffic accident patients in Korean medical institutions.

In Korea, there are various case reports published by Seo⁷⁾, Kim⁸⁾, and others about somatic symptom disorder or somatization disorder. However, no cases of Korean medical treatment have been reported for patient whose symptoms of a somatic symptom disorder were worsened after traffic accident.

We report that patient with somatic symptom disorders worsened after traffic accident received improved results by performing Korean medical treatment during hospitalization.

This study was granted review exemption in accordance with the review exemption criteria of the Institutional Review Board of Dongguk University Oriental Hospital (DUBOH 2020-0008).

II. CASE

14. Treatment

1) Herbal medicine (Table 1)

Table 1.

The Change of Herbal Medication

(1) Bohyeolansin-tang (補血安神湯) tid: From July 30 to August 4.

(2) Yugul-tang-gagam (六鬱湯加減) bid: From August 4 to August 12.

(3) Bunsimgieum-gami (分心氣飮加味) bid: From August 12 to August 17.

(4) Yugul-tang-gagam (六鬱湯加減) bid: From August 17 to August 18.

(5) Yugul-tang-gagam (六鬱湯加減) qd (at morning): From August 19 to August 25.

(6) Dangguisoosan-gami (當歸鬚散加味) qd (at evening): F rom August 19 to September 2.

2) Acupuncture

Acupuncture (0.30×30 mm disposable acupuncture needle; Dong Bang Acupuncture Factory) treatment was applied once a day. Left heart tonifying acupuncture (心正格; Toniyfing HT9 (少衝) and LR1 (大敦), sedating HT3 (少海) and KI10 (陰谷)), GV20 (百會), GB20 (風池), CV22 (天突), PC6 (內關), LU7 (列缺), HT7 (神門), ST36 (足三里) used as basic acupoints. According to the patient’s pain level, left liver tonifying acupuncture (肝正格; Tonifying LR8 (陰谷) and KI10 (曲泉), sedating LR4 (中封) and LU8 (經渠)), the right rib region, finger joint, neck, shoulder, and lower back were used as additional acupoints. Also, electroacupuncture was applied to the acupoints at the region of pain. Needle retention time was set at 15 minutes.

3) pharmacopuncture

Jungsongouhyul (中性瘀血) pharmacopuncture was injected into the area complaining of pain in the both arms, both legs, etc. twice a week.

4) Moxa

Indirect moxa (間接灸; Dong Bang Moxa Factory) was applied on a CV12 (中脘) and CV04 (關元) for 30 minutes once a day.

5) Cupping

Dry cupping treatment was applied on bilateral baesu-point (背兪穴) for 5 minutes once a day.

6) Psychotherapy

Jieon-goron therapy (至言高論療法) was performed according to patient’s symptoms and condition, and was performed within 20 minutes per session.

7) Physical therapy

In consultation with the department of rehab ilitation medicine, TENS (Transcutaneous Electrical Nerve Stimulation), superficial heat therapy, and deep heat therapy were performed on the painful areas of both upper extremities for 30 minutes, 6 times a week.

15. Instruments of evaluation

1) MMPI-2 (Fig. 1)

Fig. 1.

MMPI-2 profile of the patient.

At the time of hospitalization, MMPI-2 was conducted once.

2) Heart Rate Variability (HRV) (Table 2)

Table 2.

Changes of Heart Rate Variability (HRV)

Heart rate variability was measured in a quiet room in a supine position for 5 minutes once a week.

3) BDI (Beck Depression Inventory)-II, BAI (Beck Anxiety Inventory) (Table 3)

Table 3.

Changes of BAI & BDI

BDI-II consists of 21 questions and is composed of a likert scale of 0 to 3 points per question. It has a score range of 0 to 63 points, 14 to 19 points indicates ‘mild depression’, 20 to 28 points indicates ‘moderate depression’, and 29 to 63 indicates ‘severe depression’⁹⁾.

BAI consists of 21 questions and is composed of a likert scale of 0 to 3 points per question. It has a score range of 0 to 63 points, 22 to 26 points indicates ‘anxiety state (requiring observation and intervention)’, 27 to 31 points indicates ‘severe anxiety state’, and 32 to 63 indicates ‘extremely anxiety state’¹⁰⁾.

We assessed BDI-II and BAI on the first, 15, 29, and 36 days of hospitalization.

4) Global assessment (G/A) (Table 4)

Table 4.

Change of Somatic Symptoms Global Assessment (G/A)

Assuming that the level of symptoms the patient felt at the time of hospitalization was ‘10’ and when there was no pain as ‘0’, the degree of symptoms the patient-perceived after treatment was expressed in numb ers compared to those a t the time o f hospitalization.

5) Numerical rating scale (NRS) (Table 5)

Table 5.

Changes of Numerical Rating Scale (NRS)

The degree of pain the patient felt was expressed as a number between ‘0’ and ‘10’. The degree of pain was measured in the neck, right index finger, both upper extremities, and both lower extremities.

III. DISCUSSION

The number of traffic accident patients in Korean medicine has increased by 167% from 480,000 in 2014 to 127 million in 2019¹¹⁾. However, the psychosomatic symptoms of the injured tend to be neglected compared to the physical symptoms. Somatic symptoms often are accompanied by psychological symptoms such as initial ‘shock’, a ‘dazed’ feeling, anxiety, anger, depression, difficulty concentrating, insomnia, lassitude, loss of libido, altered appetite and weight, and in some cases, feelings of helplessness, horror, despair and reliving experiences¹²⁾. It is also affected by trauma characteristics, individual predisposition, and characteristics of the recovery environment¹³⁾. This has the potential to be solved through the Korean medicine theory of ‘body and mind as one (心身一如)’.

Patients with somatic symptom disorder tend to show hypersensitivity to somatic sensations and have a low threshold for pain²⁾. As a psychological factor, suppressed stress is converted into anxiety, frustration, or painful emotions or memories by using defense mechanisms such as repression, introjection, and somatization¹⁴⁾. According to the social learning model, the use of the disease state as a reason to avoid social pressures, obligations, and unwanted situations is explained as learning through observation or indirect experience, and this is called a ‘sick role’³⁾. Among patients with somatic symptom disorder, people with a neuroticism personality are common²⁾.

For the treatment of patient with somatic symptom disorder, it is necessary to focus on managing stress and dealing with the process of adapting to chronic diseases. It is great to have a single doctor responsible for consistent treatment. Cognitive behavioral therapy, psychological therapy such as psychoanalysis, and behavioral therapy such as biofeedback can be helpful. Depending on the target symptoms, medication may be considered. In western medicine, anxiolytics such as benzodiazepine, antidepressants such as selective serotonin reuptake inhibitor may be used^2,3,14).

According to epistemology of ‘body and mind as one (心身一如)’, excessive emotional changes are considered to cause diseases in the human body, and treatment according to the cause and pattern differentiation is performed¹⁵⁾.

The patient in this case received acute treatment for 18 days at western medical institutions after the traffic accident, and then was hospitalized in our hospital to receive neuropsychiatric treatment for the somatic symptoms she complained of after the traffic accident.

MMPI-2 was performed at the time of hospitalization to evaluate the patient’s psychological state, it was found that the Hy and Hs scales of the clinical scales was out of the normal range. As such, patients showing a 3-1 (Hy-Hs) upward scale pair are often diagnosed with somatic symptom disorder or pain disorder, and may report symptoms of anxiety and depression. They use denial, projection, rationalization defense mechanisms well, are unstable, and may have a desire to receive sympathy from others. In the validity scales, only the FBS scale was found to be out of the normal range. The FBS scale is a scale that detects the tendency to make false emotional pain (faking illness), but it also measures overall maladjustment and complaints of somatic discomfort. In the restructured clinical scales, RC1 was found to be out of the normal range. An increase of the score on the RC1 scale is associated with obsession with somatic health, somatic discomfort, depression and anxiety symptoms¹⁶⁾.

The patient in this case was sensitive and under constant stress and complained of various somatic symptoms such as throat discomfort, chest discomfort, and whole body tension intermittently even before the traffic accident, and she had problems with her daily life because of these somatic symptoms. In addition, anxiety and fear about somatic symptoms affected her job activities, and even if the somatic symptoms did not persist, the state of being symptomatic was persisted for a long time. Referring to the DSM-5 diagnostic criteria, MMPI-2 results, and social history, we diagnosed her with a somatic symptom disorder.

At the time of hospitalization, the patient complained of anxiety, insomnia, headache, and dizziness, along with somatic symptoms. We diagnosed her symptoms as blood deficiency (血虛), insufficiency of heart and gallbladder (心膽虛怯). Bohyeolansin-tang (補血安神湯) was administered. Bohyeolansin-tang (補血安神湯) is a prescription based on samultang (四物湯) to have the effects of nourishing the blood (補血), calming nerve (安神), clearing heat (淸熱), relieving pain⁴⁾. After administration of bohyeolansin-tang (補血安神湯), overall somatic symptoms and pain tended to be slightly relieved. But from the 4th day of hospitalization, somatic symptoms tended to worsen again, and symptoms of dyspepsia such as abdominal pain and nausea were intensified. We diagnosed her symptoms as qi movement stagnation(氣鬱) additionally and changed the prescription to yugul-tang-gagam (六鬱湯加減). To express the burden of the patient taking the herbal medicine 3 times a day, the number of administrations was changed to 2 times a day. Yugul-tang-gagam (六鬱湯加減) is used for talyoung (脫營), anxiety, and dyspepsia¹⁴⁾. Nausea, body tension, and chest discomfort symptoms were greatly relieved while taking yugul-tang-gagam (六鬱湯加減) for about a week. However, even after taking yugul-tang-gagam (六鬱湯加減), the patient felt a lot of chest discomfort, so it was changed to bunsimgieum-gami (分心氣飮加味). Bunsimgieum-gami (分心氣飮加味) is used for nervous breakdowns, anorexia, eructation (曖氣), acid regurgitation (呑酸), nausea and other symptoms⁴⁾. By administering bunsimgieum-gami (分心氣飮加味), we tried to improve the symptoms of dyspepsia, anxiety, throat discomfort, and chest discomfort that patient complained of. After the administration of bunsimgieum-gami (分心氣飮加味), the feeling of blockage in the throat began to gradually relieve, and the feeling of dullness in the head was also slightly relieved. However, while taking bunsimgieum-gami (分心氣飮加味), insomnia occurred intermittently and the patient seems to have a worsening of dyspepsia symptoms, so we rechanged the prescription as yugul-tang-gagam (六鬱湯加減). Afterwards, the prescription was changed again to take yugul-tang-gagam (六鬱湯加減) only in the morning and in the evening to take dangguisoosan-gami (當歸鬚散加味) for the improvement of upper limb pain that the patient complained of at night. Dangguisoosan-gami (當歸鬚散加味) is a prescription that is widely used for static blood (瘀血) due to trauma¹⁷⁾. After the administration of dangguisoosan-gami (當歸鬚散加味), the pain in the neck, right index finger, as well as upper extremity, which mainly complained at night, gradually decreased. Insomnia was also improved. In addition, as the degree of pain decreased, the anxiety and somatic symptoms complained of by the patient tended to improve together, and dangguisoosan-gami (當歸鬚散加味) was prescribed continuously until discharge.

The acupuncture combination used in this study, heart tonifying acupuncture (心正格; Tonifying HT9 (少衝) and LR1 (大敦), sedating HT3 (少海) and KI10 (陰谷)), has the effect of treating heart deficiency (心虛) and mental disorders¹⁸⁾. Acupoints such as GV20 (百會), CV22 (天突), PC6 (內關), HT7 (神門), and ST36 (足三里) were used to relieve psychological anxiety and somatic symptoms such as throat discomfort and chest discomfort. Meanwhile, liver tonifying acupuncture (肝正格; Tonifying LR8 (陰谷) and KI10 (曲泉), sedating LR4 (中封) and LU8 (經渠)) has the effect of relieving liver stagnation (肝鬱). In addition, there have been a number of studies reported on the control of pain such as cervical pain, lumbar pain, and neuralgia of the liver tonifying acupuncture¹⁹⁾. Jungsongouhyul (中性瘀血) pharmacopuncture was administered twice a week. Jungsongouhyul pharmacopuncture is used for pain or paralysis disease caused by qi stagnation and blood stasis (氣滯血瘀)¹⁷⁾. The above acupuncture treatment is thought to have led to the effect of improving the somatic symptoms and pain that patient complained of.

The patient complained of various somatic symptoms intermittently before the accident. After the accident, the somatic symptoms became worsen, and she complained of pain in various parts of the body. During hospitalization, the Global Assessment (G/A) was used to determine the degree of improvement in somatic symptoms, and the Numerical Rating Scale (NRS) was used to determine the degree of pain improvement. Comparing the G/A and NRS for each symptom on the first and last days of hospitalization, it was found that the degree of symptoms decreased in most of the symptoms, leading to improvement in symptoms.

At the time of hospitalization, the patient was in a mild depressive state with 17 points on the BDI-II, and an anxiety state with 23 points on the BAI. BDI-II and BAI were performed at intervals of 2 weeks, and the scores showed a tendency to gradually decrease with each application. On the discharge date, BDI-II score was 5 and BAI score was 8, which were all in the normal category. This improvement in BDI-II and BAI scores indicates that the patient’s depression and anxiety have been resolved after hospitalization treatment, and it can be predicted that the prognosis of her somatic symptoms after the traffic accident will be positive.

Since somatic symptoms in somatic symptom disorder are related to stress and autonomic nervous system dysfunction²¹⁾, the heart rate variability was performed at 1 week intervals to evaluate the level of stress felt by the patient and the balance of autonomic nervous system. Among the results of heart rate variability, changes in SDNN, TP, and LF/HF ratio values were observed. SDNN (standard deviation of all normal R-R intervals) indicates the complexity of the heart rate variability. Healthy people have high SDNN due to large heart rate variability. But in disease or stress situations, SDNN is low due to small heart rate variability. TP (Total power) refers to the activity of the entire frequency domain and reflects the overall activity and flexibility of the autonomic nervous system. LF (Low Frequency Power) is related to both sympathetic and parasympathetic nerves, and HF (High Frequency Power) represents parasympathetic activity. The LF/HF ratio means the control and balance of the heart’s parasympathetic and sympathetic nerves. The ideal value is 1.5∼2.0²²⁾. In the HRV test performed at the time of hospitalization, SDNN was 15.55, TP was 5.39, and LF/HF was 1.00. The SDNN at the time of discharge was 21.17, which was higher than the SDNN at the time of hospitalization of 15.55. However, until the 3rd week of hospitalization, the SDNN tended to increase gradually, but from the 4th week of admission, the SDNN tended to decrease. TP rose and fell repeatedly. LF/HF was 1.30 at the time of discharge, which was relatively close to the ideal value of 1.5 to 2.0. As a result, it can be seen that the balance ratio of the patient’s autonomic nerve is close to the normal range at the time of discharge, but the degree of stress felt by the patient is somewhat high. Significant improvement in somatic symptoms and pain was shown, and HRV results did not significantly improve at discharge even though BDI-II and BAI scores were lowered. As the discharge date approaches, it is thought that it is because of the fear of returning to work after discharge.

In this case, a patient with a somatic symptom disorder who was hospitalized to a Korean medicine hospital after traffic accident was treated with Korean medicine treatment such as herbal medicine, acupuncture treatment, and psychotherapy for 36 days. It is thought to be meaningful in that it had a significant effect on improving anxiety, somatic symptoms, and pain level. The limitations of this study are that there was only one patient case, that western medicine therapy was combined, and that the progress was evaluated mainly by subjective evaluation of patient such as NRS and G/A. Somatic symptom disorder is difficult to treat and often shows a chronic course, so it is thought that more attention and research on somatic symptomatic disorder is needed. We look forward to the publication of case reports and control studies on more diverse somatic symptom disorders in the future.

IV. CONCLUSION

In this case, we performed Korean medical treatment for patient with somatic symptom disorder who are hospitalized in after traffic accident and got improvement in terms of reducing somatic symptoms and pain.