Patients who complain of autonomic dysregulation: A cross-sectional study of patients with somatic symptom disorder

Abstract

Background:

Somatic symptom disorder (SSD) is common in medical settings but has been underdiagnosed. Stigma related to psychiatric illness was one of the barriers to making the diagnosis. More and more SSD patients who visited psychiatric clinics with physical complaints identify themselves as having ‘autonomic dysregulation’ in Taiwan.

Aims:

This study aimed to investigate the characteristics of patients with a subjective diagnosis of ‘autonomic dysregulation’.

Method:

We assessed the sociodemographic profile, medical/psychiatric diagnoses, subjective psychiatric diagnoses, perceived psychiatric stigma, help-seeking attitude, and healthcare utilization of 122 participants with SSD. Participants who identified themselves as having ‘autonomic dysregulation’ (n = 84) were compared to those who did not (n=38).

Results:

Participants with a subjective diagnosis of ‘autonomic dysregulation’ were younger and had a higher education level than those who did not have such a subjective diagnosis. They also had higher scores on the Patient Health Questionnaire-15 (PHQ-15) and Health Anxiety Questionnaire (HAQ), whereas comorbid psychiatric diagnoses were similar in the two groups. Participants with and without a subjective diagnosis of ‘autonomic dysregulation’ did not have a significant difference in perceived psychiatric stigma and help-seeking attitude/behaviors. In a multiple logistic regression model, only age was associated with having a subjective diagnosis of ‘autonomic dysregulation’.

Conclusion:

Among SSD patients, those who identify themselves as having ‘autonomic dysregulation’ tend to have higher somatic distress and health anxiety than those who do not. ‘Autonomic dysregulation’ is not associated with perceived psychiatric stigma.

Keywords

Autonomic dysregulation health anxiety illness behavior somatic symptom disorder stigma

Introduction

Somatic symptom and related disorders, previously called somatoform disorders, often present with non-specific, functional, medically unexplained symptoms, and are common in primary care and other medical settings. One-third to two-thirds of patients are reported to have medically unexplained symptoms (Kroenke, 2003; Steinbrecher et al., 2011) and the prevalence of somatoform disorders in primary care, internal medicine, and neurology clinics is 20.2% to 34.9% (Fink et al., 2004, 2005; Steinbrecher et al., 2011). Costs in healthcare related to medically unexplained symptoms are comparable to mental health problems such as depression or anxiety disorder (Konnopka et al., 2012). Comorbidity with depressive and anxiety disorder in this population is considerable (de Waal et al., 2004; Kroenke, 2003; Steinbrecher et al., 2011) and exacerbates the functional limitation (de Waal et al., 2004).

Despite the prevalence and clinical significance, somatic symptom and related disorders have often been underdiagnosed (Murray et al., 2016). Problems with diagnostic frameworks is one of the explanations for underdiagnosis (Murray et al., 2016). The classification of DSM-IV (the Diagnostic and Statistical Manual of Mental Disorders, fourth edition) somatoform diagnoses had been frequently criticized and physicians rarely diagnosed somatoform disorder because of the vague nature of ‘medically unexplained’ (Dimsdale et al., 2013; Rief & Martin, 2014). A new diagnosis of somatic symptom disorder (SSD, the prototype diagnosis in the category ‘somatic symptom and related disorders’) in the DSM-5 removed the central premise of ‘medically unexplained’. This reconceptualization was to avoid the peril of reinforcing mind/body dualism and the implication that patients have inauthentic symptoms (Dimsdale et al., 2013). By not questioning the validity of somatic symptoms, SSD was expected to be less stigmatizing than the DSM-IV diagnosis of somatoform disorder. However, we are not sure whether this new classification approach improves patients’ acceptance of the diagnosis, especially in Asian countries, where mental illness is associated with a high level of stigma. Patients’ fear of being stigmatized is one of the barriers that physicians have encountered when diagnosing SSD (Murray et al., 2016). Patients might fear physicians diverting attention away from the physicality of their problem, be concerned about uncertain legitimacy when labeled as mental illness and worry about the social stigma of psychiatric disorder (Murray et al., 2016). In addition, the discomfort evoked by the psychological explanation of physical distress may lead patients to reject treatment or referral because of potential stigma (Kirmayer et al., 2004). Recognizing SSD and conveying the diagnosis effectively to the patients are challenging tasks. Using a term for the illness that patients are familiar with (e.g. neurasthenia) might increase the acceptability of SSD patients toward the illness.

In the past 20 years, the concept of ‘autonomic dysregulation’ (自律神經失調) has been gaining popularity in the general public in Taiwan (Chang, 2010; Lin, 2002). ‘Autonomic dysregulation’ literally implies disturbances of the autonomic nervous system, which regulates involuntary bodily functions, such as heart beats, respiration, and digestion. In Japan, physicians name medically unexplained symptoms ‘vegetative syndrome’ (Abe, 1979; Kawakami, 1989; Takii et al., 1994), which similarly implicates the involvement of autonomic nervous system. ‘Autonomic dysregulation’ has some resemblance to the diagnosis of bodily distress disorder in the 11th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-11) (World Health Organization). Both concepts are characterized by the presence of bodily symptoms that are distressing to the individuals. Meanwhile, ‘autonomic dysregulation’ is broader than bodily distress disorder in the cultural context of Taiwan. Although the symptom profile and diagnostic stability of ‘autonomic dysregulation’ have not been examined by empirical studies, it has been used by physicians not only as a substitute for medically unexplained symptoms but also for psychiatric diagnoses in Taiwan (Chen, 2021). Hence, we are interested in the psychological symptoms and psychiatric comorbidities of patients who have subjective ‘autonomic dysregulation’.

The popularity of ‘autonomic dysregulation’ was preceded by ‘neurasthenia’ in Chinese culture. Neurasthenia has been viewed as an equivalent of SSD in Chinese culture as far as the clinical presentation is concerned (Grover & Ghosh, 2014). The presumed etiology of neurasthenia was rather biological, namely exhaustion of the nervous system (Overholser & Beale, 2019). The increase in prevalence of neurasthenia in Asian countries since the 1930s was thought to be related to social stigma attached to mental illness (Lin, 1989). Both neurasthenia and ‘autonomic dysregulation’ have a connotation of nervous function impairment by nomenclature. However, they are distinct entities and no existing studies have investigated whether patients with a subjective diagnosis of ‘autonomic dysregulation’ perceive a higher social stigma of mental illness.

The aims of this study are: to compare the differences in sociodemographic profile, comorbid psychiatric and medical diagnoses, and psychopathology between patients who had a subjective diagnosis of ‘autonomic dysregulation’ and those who did not; and to examine whether having a subjective diagnosis of ‘autonomic dysregulation’ is associated with the perceived stigma related to psychiatric illness, help-seeking attitude, and healthcare use in patients with SSD. By comparing the two types of SSD patients, we hoped to find out the implication and possible function of a subjective diagnosis of ‘autonomic dysregulation’, which is becoming more prevalent in both general medicine and psychiatry clinics in Taiwan.

Material and methods

Participants and procedures

Participants were 122 patients diagnosed with SSD by board-certified psychiatrists (the authors of this manuscript: C-Y. T. and W-L. H.). The Institutional Review Board of the National Taiwan University Hospital approved this study (Approval no.: 201609081RINA). We have examined the association of SSD severity with psychiatric and medical comorbidity, psychological features and help-seeking attitude/behaviors using the same studied population, and the results have been reported in a previous paper (Tu et al., 2020). Eligibility criteria were age ⩾18 and ⩽70 years and fulfilling the SSD diagnostic criteria of the DSM-5 (American Psychiatric Association, 2013). Exclusion criteria included having psychotic disorder, neurocognitive disorder, or life-threatening medical diseases. Recruitment was performed at psychiatric and non-psychiatric (family medicine, ophthalmology, otolaryngology, and internal medicine) clinics of the National Taiwan University Hospital Yunlin Branch between January 2017 and February 2019. For patients who were referred from non-psychiatric clinics, only those who were willing to be approached by the psychiatrists were evaluated for eligibility. Participants provided informed consent prior to data collection.

Measures

Demographics and healthcare use

Participants provided information on their demographic data, height and weight (used to calculate body mass index, BMI), and habit of exercise. Information on healthcare use, including psychiatric outpatient, non-psychiatric outpatient, and emergency services, within 6 months prior to recruitment was collected by a self-report questionnaire retrospectively.

Subjective diagnoses

Participants were asked to select from a list of commonly-used psychiatric terms in Taiwan (including depressive disorder, anxiety disorder, panic disorder, obsessive-compulsive disorder, autonomic dysregulation, sleep disturbance, adjustment disorder) that brought him/her to the psychiatric clinic. Selecting more than one diagnosis was allowed based on the participant’s condition.

Psychiatric and medical comorbidities

Because major depressive disorder (MDD), generalized anxiety disorder (GAD), and panic disorder were found to be common comorbidities of SSD in a previous study (Huang & Liao, 2018) in Taiwan, psychiatrists routinely evaluated these three comorbidities using the diagnostic criteria of the DSM-5 in addition to SSD. Other comorbid psychiatric diagnoses were also recorded if identified in the interviews. Medical comorbidities that were not life-threatening, such as hypertension, hyperlipidemia, peptic ulcer, and reflux esophagitis, were recorded and categorized by organ system. The information was based on patients’ self-report and confirmed by reviewing the medical records. Most participants endorsed somatic symptoms that were not fully explained by the medical conditions they reported.

Patient health questionnaire-15 (PHQ-15)

This 15-item scale assesses the degree of distress from each of the symptoms during the past 4 weeks (Kroenke et al., 2002). Participants responded on a scale from 0 to 2. Prior research (Liao et al., 2016) showed that the Chinese version of the PHQ-15 used in our study had good reliability (0.803–0.930) and internal consistency (0.637–0.861).

Health anxiety questionnaire (HAQ)

The HAQ consists of 21 items measuring the levels of concern of individuals toward their health in the past week. Participants responded on a scale from 0 to 3. The HAQ has good internal consistency and test-retest reliability and appropriate discriminate validity (Lucock & Morley, 1996). Internal consistency (0.943) and test-retest reliability (0.958) of the Chinese version of the HAQ used in the present study have been examined in previous research (Chen et al., 2019).

Beck depression inventory-II (BDI-II)

The BDI-II is a self-administered scale for evaluating the severity of depression in the 2 weeks before assessment. It consists of 21 items. Participants responded on a scale from 0 to 3. The BDI-II has adequate validity and reliability and high internal consistency (Beck et al., 1996). The Chinese version of BDI-II has been shown to be internally consistent (0.94) (Lu et al., 2002).

Beck anxiety inventory (BAI)

The BAI is a self-administered scale widely used to evaluate the severity of anxiety (predominantly focusing on somatic symptoms) in the 2 weeks before assessment. It consists of 21 items. Participants responded on a scale from 0 to 3. The test-retest reliability and internal consistency are 0.75 and 0.92, respectively (Beck et al., 1988). Previous research has supported the reliability and internal consistency (0.95) of the Chinese version of the BAI used in our study (Che et al., 2006).

Perceived stigma related to psychiatric illness

The Perceived Psychiatric Stigma Scale–Short Form (PPSS-SF) is a 12-item self-report version of the PPSS. Participants responded on a scale from 1 to 4. Han and Chen developed the PPSS based on interviews with patients seeking help at psychiatric outpatient departments in Taiwan (Han & Chen, 2008). The correlation coefficient for the PPSS-SF and the PPSS was 0.97 (Han & Chen, 2008). The PPSS-SF consists of three subscales: fear of social ostracism (e.g. If I told others I’m seeing a psychiatrist, others would not accept me), concerns over marital preclusion (e.g. If I had a psychiatric illness, no one would marry me), and self-deprecation (e.g. If I had a psychiatric illness, I would regard myself as inferior). Participants responded to each item on a scale from 1 to 4, with higher scores indicating stronger perceived stigma. The PPSS-SF demonstrates good internal consistency (0.88) and 1-week test-retest reliability (0.92) (Han & Chen, 2008).

Attitude toward seeking psychological help

The Attitudes Toward Seeking Professional Psychological Help Scale (ATSPPHS) assesses attitudes toward seeking professional help for psychological disturbance (Fischer & Turner, 1970). It consists of 11 positively-worded items and 18 negatively-worded items. Participants responded on a scale from 0 to 3. As negatively-worded items are reversed when calculating the scores, higher scores indicate a more positive attitude toward seeking psychological help. The Chinese version of the ATSPPHS (Han & Chen, 2015) consists of four subscales: self-reliance (e.g. Emotional difficulties, like many things, tend to work out by themselves), agreeing to seek professional help (e.g. I would want to get psychological help if I were worried or upset for a long period of time), disclosure willingness (e.g. There are experiences in my life I would not discuss with anyone), and stigma tolerance (e.g. Having been a psychiatric patient is a blot on a person’s life). Previous research (Han & Chen, 2015) has supported the internal consistency (0.85) and test-retest reliability (0.86, 0.83, and 0.74 at intervals of 2, 4, and 6 weeks, respectively) of the Chinese version of the ATSPPHS used in this study.

Statistical analysis

Participants were categorized into two groups according to having a subjective diagnosis of ‘autonomic dysregulation’ or not. We first used chi-square tests and independent t-tests to compare the demographic profile. Chi-square tests were used to compare the between-group differences in psychiatric/medical comorbidity and help-seeking behavior. Independent t-tests were used to determine if there were significant differences in the PHQ-15, HAQ, BDI-II, BAI, PPSS-SF, and ATSPPHS scores between the two groups. We conducted a multiple logistic regression analysis using the enter method to examine associations between having a subjective diagnosis of ‘autonomic dysregulation’ and several independent variables (age, education level, and the PHQ-15, HAQ, PPSS-SF, and ATSPPHS scores). To evaluate the correspondence between the self-report diagnosis and the diagnosis made by psychiatrists, we calculated the kappa coefficients. Statistical analyses were performed using SPSS version 19.0 (IBM Corp, Armonk, NY). All tests were two-tailed and p < .05 was considered statistically significant.

Results

A total of 123 patients were eligible and included in this study. One patient was excluded from the analysis due to incomplete data. Among the 122 patients included in the analysis, 117 visited psychiatric clinics and 5 were referred by non-psychiatric physicians. Table 1 summarizes the characteristics of participants, showing that 69% (84/122) of participants with SSD reported having a subjective diagnosis of ‘autonomic dysregulation’. There were differences in age, education, and employment status between participants who reported a subjective diagnosis of ‘autonomic dysregulation’ and those who did not. Participants having a subjective diagnosis of ‘autonomic dysregulation’ were younger, had a higher education level and more of them were employed.

Table 1.

Demographic data by subjective diagnosis of autonomic dysregulation.

	Autonomic dysregulation (+)	Autonomic dysregulation (−)	Statistics
	(n = 84)	(n = 38)	Statistics
	mean/n (SD/%)	mean/n (SD/%)	t/χ²	p Value
Gender (male)	36 (42.9)	12 (31.6)	1.395	.24
Age (years old)	42.8 (±11.0)	50.7 (±13.2)	−3.450	.001**
Educational level (years)	13.5 (±3.2)	11.6 (±3.5)	2.909	.004**
Marital status (married)	54 (64.3)	27 (71.1)	0.537	.46
Employment (employed)	57 (67.9)	18 (47.4)	4.638	.031*
Exercise	27 (32.1)	17 (44.7)	1.800	.18
BMI (kg/m²)	23.0 (±3.88)	23.1 (±3.94)	−0.102	.92

Note. BMI = body mass index.

p < .05. **p < .01.

Table 2 shows the psychiatric and medical comorbidities of participants. Among participants having a subjective diagnosis of ‘autonomic dysregulation’, 71% and 57% had at least one psychiatric comorbidity and one medical comorbidity, respectively; these values were lower than for those without a subjective diagnosis of ‘autonomic dysregulation’. However, the between-group differences did not achieve statistical significance for any of the diagnoses.

Table 2.

Psychiatric and medical comorbidities by subjective diagnosis of autonomic dysregulation.

	Autonomic dysregulation (+)	Autonomic dysregulation (−)	Statistics
	(n = 84)	(n = 38)	Statistics
	n (%)	n (%)	χ ²	p Value
Psychiatric illness^†	60 (71.4)	31 (81.6)	1.422	.23
Major depressive disorder	21 (25.0)	10 (26.3)	0.024	.88
Panic disorder	24 (28.6)	14 (36.8)	0.835	.36
Generalized anxiety disorder	24 (28.6)	12 (31.6)	0.114	.74
Medical illness	48 (57.1)	24 (63.2)	0.391	.53
Cardiovascular	17 (20.2)	13 (34.2)	2.755	.10
Gastrointestinal	22 (26.2)	6 (15.8)	1.601	.21
Hepatic	8 (9.5)	1 (2.6)	1.819	.18
Neurological	3 (3.6)	2 (5.3)	0.191	.66
Pulmonary	1 (1.2)	3 (7.9)	3.708	.05
Urological	8 (9.5)	2 (5.3)	0.631	.43
Metabolic and endocrine	11 (13.1)	5 (13.2)	<0.001	.99
Immunological	1 (1.2)	3 (7.9)	3.708	.05
Hematological	2 (2.4)	1 (2.6)	0.007	.93
Oncological^‡	1 (1.2)	1 (2.6)	0.337	.56
Other	5 (6.0)	3 (7.9)	0.161	.69

†

Major depressive disorder, panic disorder, or generalized anxiety disorder.

‡

Having received operation and not requiring ongoing pharmacological treatment.

Comparisons of psychopathology, help-seeking attitude and help-seeking behavior are displayed in Table 3. Participants having a subjective diagnosis of ‘autonomic dysregulation’ scored higher on the PHQ-15 and HAQ, which means they had high somatic distress and health anxiety. The two groups had similar levels of perceived stigma to psychiatric illness and attitude to seeking psychological help. Medical use, including psychiatric outpatient, non-psychiatric outpatient, and emergency services, was not significantly different.

Table 3.

Psychopathology, help-seeking attitude, and help-seeking behavior by subjective diagnosis of autonomic dysregulation.

	Autonomic dysregulation (+)	Autonomic dysregulation (−)	Statistics
	(n = 84)	(n = 38)	Statistics
	mean/n (SD/%)	mean/n (SD/%)	t/χ²	p Value
Psychopathology
PHQ-15	14.3 (±5.7)	11.2 (±6.1)	2.757	.007**
HAQ	31.7 (±13.3)	26.0 (±14.2)	2.170	.032*
BDI-II	20.4 (±10.7)	18.0 (±11.9)	1.131	.26
BAI	23.6 (±11.8)	19.2 (±12.5)	1.882	.06
Help-seeking attitude
PPSS-SF	24.3 (±7.9)	23.1 (±7.2)	0.743	.46
ATSPPHS	57.9 (±8.9)	56.7 (±10.9)	0.648	.52
Help-seeking behavior
Psychiatric outpatient^†,‡	39 (47.0)	14 (37.8)	0.869	.35
Non-psychiatric outpatient^§	18 (21.4)	5 (13.2)	1.170	.28
Emergency service^§	6 (7.1)	2 (5.3)	0.151	.70

Note. PHQ-15 = patient health questionnaire; HAQ = health anxiety questionnaire; BDI-II = Beck depression inventory-II; BAI = Beck anxiety inventory; PPSS-SF = perceived psychiatric Stigma Scale, short form; ATSPPHS = attitudes toward seeking professional psychological help.

†

Before the encounter of recruitment.

‡

There was one missing value in each group.

In the previous 6 months.

p < .05. **p < .01.

Table 4 summarizes the results of multiple logistic regression analysis. Age was negatively associated with having a subjective diagnosis of ‘autonomic dysregulation’ (p = .021). Other variables were not significantly associated with having a subjective diagnosis of ‘autonomic dysregulation’. The R² value for the model was .161.

Table 4.

Multiple logistic regression models for subjective diagnosis of autonomic dysregulation.

Cox and Snell R²	Autonomic dysregulation
	0.161
	β	Odds ratio [95% CI]	p Value
Age	−0.052	0.950 [0.909–0.992]	.021*
Educational level	0.076	1.079 [0.941–1.239]	.28
PHQ-15	0.048	1.049 [0.967–1.137]	.25
HAQ	0.018	1.018 [0.983–1.054]	.31
PPSS-SF	0.046	1.047 [0.979–1.120]	.18
ATSPPHS	0.033	1.033 [0.981–1.088]	.22

p < .05.

We examined the correspondence between the participants’ self-report diagnosis and the diagnosis made by psychiatrists. The kappa coefficients for MDD, panic disorder, and GAD were 0.202, 0.389, and 0.100, respectively. The low kappa coefficients demonstrated a discrepancy between the self-report diagnosis and the diagnosis made by psychiatrists. The kappa coefficients for these diagnoses were lower in patients who had a subjective diagnosis of ‘autonomic dysregulation’ than patients who did not. The kappa coefficients for MDD, panic disorder, and GAD were 0.038, 0.267, 0.067, respectively in patients having a subjective diagnosis of ‘autonomic dysregulation’ and were 0.533, 0.586, 0.19, respectively in patients not having a subjective diagnosis of ‘autonomic dysregulation’.

Discussion

This study demonstrates that participants having a subjective diagnosis of ‘autonomic dysregulation’ tended to be younger, had a higher education level and scored higher on the PHQ-15 and HAQ than patients who did not identify themselves as having the diagnosis. A subjective diagnosis of ‘autonomic dysregulation’ was not related to a higher prevalence of psychiatric or medical comorbidity, perceived psychiatric stigma, or help-seeking behaviors. In the multiple logistic regression model, only age was associated with having a subjective diagnosis of ‘autonomic dysregulation’.

The results of this study indicated that age was associated with having a subjective diagnosis of ‘autonomic dysregulation’. Education level was higher in participants having a subjective diagnosis of ‘autonomic dysregulation’ but was not significant in the multiple regression model. It appears that the concept of ‘autonomic dysregulation’ is more widespread in the younger generation, who have access to information from diverse sources. We suppose that ‘autonomic dysregulation’ is a newly shaped concept rather than an immutable relic.

The finding that participants having a subjective diagnosis of ‘autonomic dysregulation’ had higher PHQ-15 and HAQ scores indicates that patients who reported having ‘autonomic dysregulation’ were more likely to be bothered by somatic distress and health anxiety. We performed additional analysis on the association between having subjective ‘autonomic dysregulation’ and the severity of DSM-5 SSD and found that compared with patients not having a subjective diagnosis of ‘autonomic dysregulation’, those having such diagnosis had higher risk of having severe DSM-5 SSD (odds ratio: 2.62, confidence interval: 1.77–5.88). In summary, patients who identify themselves with the diagnosis of ‘autonomic dysregulation’ suffered substantially from somatic discomfort. In Taiwan, a majority of patients who visited psychiatric clinics due to somatic complaints had sought help from primary care physicians or corresponding specialists earlier. However, physicians and patients often disagree on the etiology of non-specific somatic symptoms (Murray et al., 2016). A recent study interviewed sufferers of ‘autonomic dysregulation’ and physicians to investigate what is in the name of ‘autonomic imbalance’ (another translation for 自律神經失調) (Chen, 2021). In this study, sufferers of ‘autonomic dysregulation’ described it as an authentic disease that leads to bodily discomfort and occupational impairment, a chronic illness, and a disease of the brain, in which stress might play a role; however, ‘autonomic dysregulation’ is neither something ‘all in the mind’ nor a euphemism for psychiatric diagnoses. It seems that the concept of ‘autonomic dysregulation’ avoids mind-body dichotomy, hence, patients who suffer from medically explained symptoms are inclined to adopt the term to describe their illness.

Participants having a subjective diagnosis of ‘autonomic dysregulation’ did not have a higher prevalence of psychiatric comorbidity than participants who did not identify themselves as having the diagnosis. In addition, the two groups had similar levels of anxiety symptoms measured by the BAI. The findings suggested that subjective ‘autonomic dysregulation’ is a concept divergent from anxiety disorder. Besides, the association between autonomic activities and SSD has been investigated in several studies. A systemic review showed that patients with SSD were found to have significantly lower baseline total heart rate variability (HRV), lower parasympathetic specific indices, and lower HRV reactivity than healthy subjects (Cheng et al., 2020). Patients with SSD and anxiety disorders both revealed low parasympathetic activities (Cheng et al., 2020; Levine et al., 2016). Therefore, if not discussing sympathetic and parasympathetic activities separately, it is hard to connect over-activity or hypo-activity to the symptoms. Nevertheless, comorbidity of subjective ‘autonomic dysregulation’ with other psychiatric illness was common; more than 70% of participants having a subjective diagnosis of ‘autonomic dysregulation’ were diagnosed with MDD, panic disorder, or GAD. Hence, exploration of comorbid anxiety and depressive symptoms is important when encountering patients who report having ‘autonomic dysregulation’.

The term ‘autonomic dysregulation’ is reminiscent of neurasthenia due to the similarity in nomenclature and presentation. Neurasthenia was a popular diagnosis in North America from 1869 to 1930s (Overholser & Beale, 2019). The term was first used by the neurologist George Beard and was characterized by fatigue and irritability due to exhaustion of the nervous system (Overholser & Beale, 2019). Other symptoms included headaches, insomnia, vague pains, dyspepsia, palpitations, and flushing (Lin, 1989). The concept of neurasthenia was introduced to China in the 1920s to 1930s and acquired a semantic translation of Shen-jing-shuai-ruo, which means nervous weakness (Lee, 1994). The connotation of nervous weakness resonated with some concepts in traditional Chinese medicine (Lee & Kleinman, 2007). In addition, the putative physical disorder might have served the function of evading moral culpability and social stigma (Kleinman, 1982). From the 1950s to the early 1980s, 80% to 90% of medical and neurology outpatients in China received the diagnosis of neurasthenia (Lin, 1989). The concept of neurasthenia was also popular among traditional Chinese medicine practitioners and the general population in Taiwan in the 1940 and 1950s (Lin, 1989). In contrast, Western-trained psychiatrists in Taiwan rarely diagnosed neurasthenia (Lin, 1989). In our study, participants with a subjective diagnosis of ‘autonomic dysregulation’ had higher somatic distress but did not have higher perceived psychiatric stigma or more negative attitude toward seeking psychological help compared to those not having a subjective diagnosis of ‘autonomic dysregulation’. We assumed that ‘autonomic dysregulation’ was not so much associated with social stigma as with neurasthenia because abundant information related to ‘autonomic dysregulation’ could be accessed from the mass media, books/magazines (Lin, 2002), and health education materials (Chang, 2010). The majority of these information mentioned somatic symptoms rather than focusing on psychiatric illness. Hence, patients who suffer from medically unexplained symptoms are likely to find it a label which they can identify themselves. In addition, the Chinese translation of either somatoform disorder or SSD was barely used by either general public or non-psychiatrist physicians in daily practice. ‘Autonomic dysregulation’ might be a convenient term that have filled the ‘naming’ gap when neurasthenia was dropped from the DSM-III (Lin, 1989) but somatoform disorder or SSD did not fulfill the needs of doctor–patient communication.

Although patients’ report of having ‘autonomic dysregulation’ raises the possibility of SSD, the correspondence between subjective and psychiatrist-diagnosed MDD, panic disorder, and GAD was low to moderate, therefore it requires formal assessment to establish credible psychiatric diagnoses. It is interesting that patients who had subjective ‘autonomic dysregulation’ had lower correspondence between subjective and psychiatrist-diagnosed MDD, panic disorder, and GAD than patients who did not. The finding suggests that patients who identify themselves with ‘autonomic dysregulation’ might have concept for psychiatric illness which was more divergent from that of psychiatrists. We speculate that patients who identify themselves with ‘autonomic dysregulation’ are also more prone to regard themselves as having depressive and anxiety disorder because of higher suggestibility. However, it warrants further investigation to elucidate the difference.

This study should be interpreted within the context of its limitations. Firstly, all participants were diagnosed with SSD so we were not able to investigate the association of subjective ‘autonomic dysregulation’ and psychiatrist-diagnosed SSD. Secondly, most of the patients in this study were recruited from psychiatric clinics, therefore the finding might not be generalized to patients outside psychiatric settings. Thirdly, the question ‘What diagnoses brought you to the psychiatric clinic?’ was asked after evaluation by the psychiatrist and thus could be biased by the interview. Finally, this study provided a preliminary exploration of the characteristics of patients with ‘autonomic dysregulation’. Using an approach of explanatory model (Weiss, 1997) to investigate the patterns of distress, perceived causes, preferences for help-seeking, and general illness beliefs of patients with ‘autonomic dysregulation’ would be helpful to refine the concept of this diagnostic entity in the future.

This study highlights the association between a subjective diagnosis of ‘autonomic dysregulation’ and higher somatic distress/health anxiety among patients with SSD in Taiwan. Moreover, our findings have clinical implications by demonstrating ‘autonomic dysregulation’ as a diagnosis that was more widely used by young people and not associated with higher perceived psychiatric stigma. ‘Autonomic dysregulation’ might have become a diagnosis which sufferers can identify themselves when the Chinese translation of either somatoform disorder or SSD does not suffice the needs of doctor–patient communication. By further investigating the use of ‘autonomic dysregulation’ in more diverse populations and different settings, we will expand our understanding of patients having a subjective diagnosis of ‘autonomic dysregulation’.

Footnotes

Acknowledgements

The authors wish to acknowledge the help of Dr. Pei-Hsuan Lin, Dr. Chien-Hsieh Chiang, and Dr. Lu-Chun Wang in data collection. We also wish to thank Dr. Jia-Shin Chen from National Yang Ming Chiao Tung University for his insightful suggestions during the revision of the manuscript.

Author contributions

C-Y. T., W-S. L., Y-F. C., and W-L. H. conceived and designed the study. C-Y. T., Y-F. C., and W-L. H. contributed to the acquisition of the data. C-Y. T. and W-L H. participated in the analysis of the data and drafted the paper. All authors reviewed and approved the final manuscript.

Conflict of interest

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The conduction of this study was supported by the National Taiwan University Hospital Yunlin Branch (grant numbers NTUHYL106.N001, NTUHYL107.N001).

ORCID iD

Wei-Lieh Huang

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