A Suspected Case of Somatoform Disorder Successfully Treated with an Herbal Medicine

Introduction

A diagnosis of undifferentiated somatoform disorder can be made when there are insufficient objective findings to explain the physical symptoms that have existed over 6 months by currently available examinations. However, subjective physical symptoms, irrespective of whether they are psychosomatic or not, do not always show obvious or reasonable signs in examinations. In fact, at least one third of physical symptoms in medical care are medically unexplained. ¹ Furthermore, patients do not always realize possible psychogenic factors or life events causing somatization, which often makes the differential diagnosis between somatoform disorders and actual physical disease difficult for psychiatrists. ² In addition, psychiatrists engaging in consultation-liaison psychiatry have few clues as to how to treat these diverse “medically unexplained” or even “psychiatrically and medically unexplained” symptoms. ³ This difficulty has highlighted the need for alternative treatments for somatoform disorders.

This report presents a high school baseball player with coxalgia, psychiatrically diagnosed with undifferentiated somatoform disorder for whom conventional therapies such as psychotherapy, selective serotonin reuptake inhibitors, and conventional painkillers were ineffective, but who responded well to a Japanese traditional herbal (Kampo) medicine supposed to have a pain-relieving effect.

Subject

A 16-year-old high school baseball player was the most powerful hitter on his junior high school baseball team without any health problems. However, he lost confidence during his first high school baseball team camp in the face of superior power of the other hitters. He realized “the world is totally different from my junior high school team,” which led him to almost give up on winning a starting position. There was an intense onset of right coxalgia and movement disorder of his right leg by the end of the camp accompanied by mild muscle weakness of the entire right leg, and he was subsequently unable to walk without crutches.

Conventional painkillers were ineffective, and the orthopedist found no remarkable signs in blood tests, x-rays, computed tomography of the brain, or neurological examinations. Two (2) months later, while his right leg scored a 100% in a manual muscle test without any medication, he could not maintain that level of activity after a short time due to coxalgia that could not be reasonably explained. The orthopedist therefore referred him to a psychiatrist. Three (3) months later, he was diagnosed with undifferentiated somatoform disorder not otherwise specified, based on the DSM-IV criteria, and was prescribed 100 mg/day of fluvoxamine. Five (5) months later, he began psychotherapy and discussed his emotional conflicts. He had grown up in a “baseball family,” and was under pressure to become a good player. However, although he himself seemed to realize that his physical symptoms might be psychosomatic originating from his mental state, his leg showed no improvement. Six (6) months later, fluvoxamine treatment was discontinued and his therapeutic strategy was re-evaluated from the perspective of another medicine, Kampo medicine.

Kampo medicine, which originated in China, was introduced to Japan in the middle of the 6th century and has been uniquely modified in Japan over a thousand years. Thereafter, it had been the main medical treatment in Japan until Western medicine was introduced from Europe several hundred years ago. The Japanese Ministry of Health, Labor, and Welfare has approved more than 210 Kampo formulae for clinical use in the same way as conventional medicine.

Results

The patient frequently exhibited other symptoms before and after the first episode of coxalgia, including a cold, diarrhea, and rather dry skin for his age. Based on Kampo diagnosis, this tendency indicated that some physical or mental stressor had disturbed his biophylaxis and homeostasis, resulting in coxalgia as well as other symptoms. Therefore, keishikajutsubuto, a Kampo formula, was prescribed after consulting a physician of Kampo medicine, and this medicine had a remarkable effect. His leg function improved within 2 weeks, and his pain and need for crutches disappeared in 6 weeks. Administration of this medicine was terminated after 6 months without any recurrence. In addition, there was decreased incidence of colds or diarrhea after administering the keishikajutsubuto medication.

Discussion

Although his symptoms fully met the criteria for undifferentiated somatoform disorder, the patient's diagnosis is problematic because keishikajutsubuto, which is supposed to be effective for actual arthralgia, exerted remarkable efficacy where all conventional painkillers failed. In addition to this case, accumulating reports have shown that Kampo medicine often provides a valid alternative to conventional medicine. ^4,5,6,7 The reason for the surprising efficacy of this medicine is its unique diagnostic conceptualization: Mental and physical conditions may be interconnected and affect each other in more complex ways than we realize, and a serious imbalance between the two can cause both mental and physical symptoms that are resistant to conventional medicine. ⁸ Kampo medicine can provide an alternative approach for treating medically unexplained symptoms comprehensively without strictly distinguishing between physically existing illness and psychologically caused somatoform disorders. Kampo medicine has recently received increasing attention because of its immunomodulatory activities, ⁹ and its usefulness in unexplained physical symptoms, ⁵ especially in somatoform disorders, ^6,7 has been reported in recent years. Keishikajutsubuto, one of the Kampo prescriptions, is composed of seven herbs (Table 1) and has a characteristic function of warming up the body with a mild relaxing effect, which results in strengthening the immune system, lubricating skin and joints, and improving blood circulation in joints, thus have a pain-relieving effect. ⁸

Conclusions

Although details regarding the therapeutic mechanisms of each Kampo prescription remain unclear and further studies are needed to increase its usefulness in clinical practice, Kampo medicine should be considered as an alternative treatment for somatoform disorders, especially when physically existing illnesses and psychologically caused somatoform disorders are difficult to distinguish.