Somatoform disorder (psychosomatic illness) - symptoms and treatment

Somatoform disorder (psychosomatic illness) - symptoms and treatment

Patients with this disorder do not see a connection between psychological experiences and clinical manifestations of the disease. They are fixated on physical (somatic) symptoms and are focused mainly on drug treatment from therapists.

Most often, people with somatoform disorder are bothered by various pains (algias), while painful manifestations are not always symptoms of organ pathology. Such painful sensations caused by mental disorders are encountered quite often. As a rule, they are not relieved even by strong analgesics. This is especially true for psychogenic headaches, which are more common than other headaches combined. The most common headaches are cephalgia (in the area from the eyebrows to the back of the head).

Gastrointestinal disorders, particularly constipation and diarrhea, often occur. From a psychoanalytic point of view, a tendency to constipation may indicate greed, a person’s reluctance to part with something. Diarrhea (we are not talking about a single diarrhea, but about a protracted or frequently recurring problem) can be a reaction to severe fear and severe anxiety. Diarrhea is an “escape” from a problem that cannot be comprehended.

The emotional manifestation of somatoform disorder includes depression. It is associated with self-directed aggression. Physical manifestations mainly include coronary heart disease, surges in blood pressure, and peptic ulcers of the stomach or duodenum. The latter is more often typical for people who do not know how to recognize aggressive emotions in themselves, such as irritation, anger, anger. Trying to prohibit oneself from experiencing them, not knowing how to express them in an “ecological” way, a person destroys himself from the inside.

Suppression of feelings of anxiety and fear, especially when their causes are unclear, cause a cascade of psychophysiological reactions (previously this was called a sympathoadrenal crisis).

In the primitive world, the source of the threat that caused fear was obvious - for example, an encounter with a bear. In this case, there were only two response options - hit or run. In modern society, the threat is not so obvious, and social norms and attitudes impose their own “prohibitions” on the manifestation of reactions. In this regard, panic and horror unfold inside a person, causing a cascade of vegetative reactions - cold sweat breaks out, the heartbeat quickens, blood pressure jumps against the background of the production of stress hormones, breathing becomes shallow and frequent. And here secondary anxiety arises, and with it the fear of loss of control, the onset of a heart attack, stroke and death. Often such patients call an ambulance, are repeatedly examined by therapists, cardiologists, neurologists and endocrinologists, undergo a series of diagnostic and laboratory tests and, not finding the cause of fear in diseases of the internal organs, are referred to a psychotherapist with a diagnosis of “Panic attack”.

Frequent throat diseases (sore throat or tonsillitis) may indicate a person’s fear of saying something or asking for something very important. Sometimes such people are afraid to raise their voice in their own defense and thereby “lose” it.

Bronchial asthma, like some other diseases associated with respiratory failure, occurs more often in people (mainly children) who are pathologically strongly attached to their mother. Their love is literally “suffocating.” Another option is parents’ strictness when raising a son or daughter. If a person is taught from a very early age that it is forbidden to cry, that laughing loudly is indecent, that jumping and running in the street is the height of bad form, then the child grows up afraid to express his true feelings and needs: they gradually begin to “strangle” him from the inside.

Neurodermatitis, psoriasis, atopic dermatitis, urticaria, like most diseases related to allergies, may indicate a rejection of something. The skin is the first protective psychological barrier, so its disease indicates a violation of a person’s psychological boundaries.

Features of development and diagnosis of somatoform anxiety disorders

In people who suffer from this disorder, medical tests are either normal or do not explain the symptoms. However, these complaints cause excessive concern, and the person constantly makes appointments with doctors and gets tested. Anxious thoughts take up all your time and energy and interfere with your work and life.

With somatoform disorders, symptoms include pain of any nature, heart failure, sensory disturbances, and loss of strength. The manifestations are not related to a somatic disease (there is no infection or tumor in the body), but normal examination results do not reassure.

Diagnosis of somatoform disorder is a consultation with a psychotherapist.

There are several types of somatoform disorder:

1. Somatization disorder - a person has many symptoms that change frequently and last for two years or more.
2. Somatoform ANS disorder - symptoms of autonomic disorders (tremor, sweating, palpitations, increased blood pressure, redness of the skin).
3. Persistent somatoform pain disorder is persistent and excruciating pain that cannot be explained by physiological abnormalities.
4. Hypochondriacal somatoform disorder - a person is firmly convinced that he is seriously, terminally ill. Analyzes do not confirm this. Normal sensations are interpreted as signs of illness, and depression is added.
5. Undifferentiated somatoform disorder - symptoms and complaints vary, the picture of the disease is not clear enough to talk about somatization disorder.

Why does somatoform disorder occur?

The main reason for this manifestation is external factors. For example, stress at work or problems in the family, lack of attention from loved ones, burdened financial situation. In some cases, complaints about disorders in the body are a reason to draw attention to yourself. It is noteworthy that people with such a deviation themselves actually feel the symptoms. They are real to them. But they are not caused by physical illnesses, but by the reaction of the nervous system to environmental aggression (stress, problems, emotional stress or exhaustion). At a subconscious level, pain receptors in one or another area of ​​the body are activated. Unfortunately, many people find it difficult to prove that everything is fine with them if the results of tests and examinations are 100% positive.

Introduction

Functional diseases of the gastrointestinal tract (FD GIT) are the most common gastroenterological diseases that have not only medical but also social significance, as they often manifest themselves at a young working age.
This pathology is based on both physiological and morphological disorders, which are often found in combination and include motility disorders, visceral hypersensitivity, alteration of the mucous membrane and disruption of local immune function, changes in the intestinal microbiota, disorders of perception and processing of signals entering the central nervous system (CNS), and other pathogenetic aspects [1, 2]. Although descriptions of GI symptoms have historically occurred for many centuries, the term has only emerged within the last few decades. This fact was due to the fact that only at the beginning of the 20th century. seminal studies have been conducted demonstrating the influence of central nervous system activity on the gastrointestinal tract.

One of the most famous is the work of academician Ivan Petrovich Pavlov, who demonstrated the presence of two phases of gastric juice secretion - neuroreflex and humoral-chemical - and led to an understanding of the role of the vagus nerve in the regulation of the neuroreflex phase of gastric juice secretion [1, 3].

The development of medical technologies after 1960 gave a new impetus to research into the gastrointestinal tract. Thus, research systems for assessing the motor and electrical activity of the gastrointestinal tract were developed, with the help of which the mechanisms of many movement disorders were determined. For example, it has been demonstrated that patients with irritable bowel syndrome (IBS) have an increased motor response to various environmental stimuli, such as psychological stress, ingestion of fatty foods, etc., compared to patients without this pathology [1].

In the 1980s A period of key changes has begun in the understanding of the psychosocial aspects of gastrointestinal diseases. In 1977, the work of George Engel (GL) was published, which inspired many researchers and clinicians to search for a more integrated, biopsychosocial model of disease (Fig. 1). Engel GL, a therapist and psychoanalyst, proposed that illness is the product of biological, psychological and social subsystems interacting at different levels, and it is the combination of these interacting subsystems that defines illness. Thus, a new model for understanding the psychosocial aspects of gastrointestinal diseases was based on a systems approach and the development of biology during the 20th century. [14].

At the end of the 1980s. Through the efforts of the world's leading gastroenterologists, the public organization “Rome Foundation” was created, the main goal of which was to study the federal laws of the gastrointestinal tract. The result of the organization’s work was the development of four versions of the so-called. Rome criteria for the diagnosis of gastrointestinal diseases (versions 1994, 1999–2000, 2006 and 2021). By the end of the 1990s. new clinical and diagnostic methods have improved the understanding of the interactions between the central nervous system and the intestine and this led to the formation of the concept of the “brain-gut” axis, which was reflected in the Rome Criteria II revision, which for the first time introduced a new scientific direction in gastroenterology, called “neurogastroenterology” . This scientific direction examines the interaction of the central nervous system and the enteric nervous system, which in turn consists of sensory neurons, motor neurons and interneurons, synaptically connected into neural networks that process information about the state of the intestine and control its functioning. Within this area, over the past decade, significant progress has been made in understanding how the functioning of the enteric nervous system changes under various pathophysiological conditions, what are the mechanisms of these changes and the influence of neuroplasticity on intestinal motility [5–7].

Major changes to the Rome Criteria IV Revision

According to the latest Rome IV revision criteria, published in 2016, gastrointestinal diseases are disorders of the interaction between the intestines and the brain. This is a group of disorders classified by gastrointestinal symptoms associated with any combination of the following: motility disorders, visceral hypersensitivity, mucosal alteration and impairment of local immune function, changes in the intestinal microbiota, impairment of the perception and processing of signals entering the central nervous system [1, 5 , 8]. Below is the classification of Federal Laws of the gastrointestinal tract, proposed by the Rome Consensus IV revision (2016), cited. according to [7] (see table).

It was in the latest revision of the Rome Criteria that it was first proposed to replace the term “functional” in relation to the gastrointestinal tract with a new definition of this group of diseases – “disorders of interaction between the brain and the gastrointestinal tract.” It is proposed to replace the term “functional abdominal pain syndrome” of the previous classification of gastrointestinal diseases with the term “abdominal pain syndrome of central origin” as a more correct reflection of the pathogenesis of the pathology in question. However, some clinical disorders (such as functional diarrhea, functional heartburn) have retained their terminology to ensure that they are distinguished from disorders that have similar symptoms but a clear organic etiology. The list of Federal Laws of the Gastrointestinal Tract included new nosological units with a known etiology: opioid-induced gastrointestinal hyperalgesia, opioid-induced constipation, cannabinoid-induced emetic syndrome. The inclusion of these nosologies in the updated classification was due to the fact that these diseases are based on a violation of the interaction between the brain and the gastrointestinal tract, which corresponds to the new definition of the gastrointestinal tract; in addition, these diseases are similar in clinical manifestations to the gastrointestinal tract. Also, the expert council of the Rome Consensus IV revision introduced a new nosological unit into the updated classification of gastrointestinal diseases - “nausea and vomiting syndrome”, which combines previously identified diseases - chronic idiopathic nausea and functional vomiting. The diagnostic criteria for sphincter of Oddi dysfunction (SDO) were also revised, since previous recommendations for papillosphincterotomy in type III SDO (dilation of the common bile duct, increased levels of transaminases and pancreatic enzymes) were not convincingly confirmed and were accompanied by an increased risk of pancreatitis, perforation and bleeding. That is why the former type III DSO (according to the Milwaukee classification) was removed from the new criteria and it was stated that patients without convincing evidence of bile duct obstruction should not undergo endoscopic retrograde cholangiopancreatography with manometry and sphincterotomy, but rather symptomatic treatment is recommended. When treating biliary-type DSO with moderate evidence of biliary obstruction, other diagnostic options should be considered before performing sphincterotomy [1, 7].

Differential diagnosis of functional heartburn and hypersensitive reflux syndrome

Some of the most widely encountered gastrointestinal diseases in routine practice are functional heartburn and hypersensitive reflux syndrome (HSRS).

GSRS was included by the Rome IV Consensus Expert Committee in the section “disorders of esophageal function,” previously considered a variant of non-erosive reflux disease (NERD). Diagnosis of this disease is based on the following criteria [9]:

1. Characteristic symptoms: heartburn or pain in the chest area (response to antisecretory therapy does not exclude this diagnosis).
2. The association of the occurrence of symptoms with physiological acidic or non-acidic gastroesophageal reflux (during pH-metry or pH-impedansometry of the upper gastrointestinal tract) against the background of normal indicators of acid exposure in the esophagus.
3. Detection of a normal endoscopic picture of the esophageal mucosa.
4. Absence of structural changes in the mucous membrane of the esophagus, characteristic of eosinophilic esophagitis (according to histological examination of biopsy specimens).
5. Absence of major diseases of the esophagus that occur with a violation of its motor function (achalasia cardia, diffuse esophagospasm, jackhammer-type motility disorders, hyperkinesia of the thoracic esophagus, hypokinesia, etc.).
6. Clinical symptoms should be observed at least 2 times a week over the past 3 months with a total duration of at least 6 months.

In contrast to HSRS, diagnostic criteria for functional heartburn include [9]:

1. A burning sensation, discomfort or pain in the chest area.
2. Symptoms persist despite optimal therapy with proton pump inhibitors (PPIs; double dose, regularly taken before meals).
3. It has been established that there is no connection between the occurrence of symptoms and pathological or physiological gastroesophageal reflux.
4. The absence of structural changes in the mucous membrane of the esophagus, characteristic of eosinophilic esophagitis, was confirmed (histological examination of biopsy specimens).
5. The absence of esophageal diseases associated with impaired motility and peristalsis of the esophagus (achalasia cardia, diffuse esophagospasm, jackhammer-type motility disorders, hyperkinesia of the thoracic esophagus, hypokinesia, etc.) has been proven.
6. Clinical symptoms should be observed at least 2 times a week over the past 3 months with a total duration of at least 6 months.

Due to the similarity of the symptoms of the above diseases, the need for a diagnostic search naturally arises in a patient complaining of heartburn. Thus, in the absence of changes in the mucous membrane of the esophagus according to the results of fibrogastroduodenoscopy and histological examination and if the patient does not have a previously established diagnosis of gastroesophageal reflux disease (GERD), it is recommended to conduct 24-hour intraesophageal pH impedance measurements while discontinuing PPIs or before their prescription. In patients with normal esophageal acid exposure and no relationship between the onset of symptoms and reflux episodes, a diagnosis of functional heartburn is established, while in the case of increased esophageal acid exposure based on the results of pH impedance measurements, NERD is diagnosed, and in patients with normal exposure indicators acid in the esophagus and the presence of a connection between the occurrence of symptoms and episodes of physiological reflux is diagnosed as HSRS (Fig. 2).

If the patient has previously been diagnosed with GERD, intraesophageal pH impedance testing is performed while taking a PPI. Those patients who, according to the results of pH-impedansometry, have normal indicators of acid exposure in the esophagus and there is no connection between symptoms and reflux, are diagnosed with GERD in combination with functional heartburn. If acid levels in the esophagus are normal, but there is a connection between symptoms and reflux, the patient is diagnosed with GERD overlap syndrome and esophageal hypersensitivity. If, according to the results of pH impedance testing, an increase in acid exposure in the esophagus is detected, then refractory GERD is diagnosed.

Symptoms of HSRS are associated with a combination of acid exposure and esophageal hypersensitivity (Figure 3), with the dividing curve reflecting a greater effect of acid exposure for NERD and a greater effect of esophageal hypersensitivity for HSRS, while symptoms of erosive esophagitis are due to abnormal acid exposure and symptoms functional heartburn – hypersensitivity [10].

Differential diagnosis of gastrointestinal tract disease and somatoform dysfunction of the autonomic nervous system

Of particular interest, especially in light of the new concept of gastrointestinal tract diseases as a violation of the interaction between the intestine and the central nervous system, is the question of identifying the relationship and, if necessary, differential diagnosis between gastrointestinal tract diseases and somatoform dysfunction of the autonomic nervous system (SDVNS).

Somatoform disorders

(F45) – a group of mental disorders of a neurotic nature, the distinctive feature of which is numerous signs of somatic diseases, not confirmed by objective clinical studies. In the International Classification of Diseases, 10th revision (ICD-10), the group of somatoform disorders includes SDVNS (“organ neuroses”; F45.3), which also includes SDVNS of the upper gastrointestinal tract (F45.31) and SDVNS of the lower gastrointestinal tract ( F45.32). It is believed that a particular manifestation of SDVNS of the lower part of the gastrointestinal tract can be IBS, and SDVNS of the upper gastrointestinal tract in its clinical manifestations corresponds to the FZ of the upper gastrointestinal tract [11].

Diagnostic criteria for SDVNS according to ICD-10:

• symptoms of autonomic arousal (palpitations, sweating, tremors, redness), which are chronic and distressing;
• the presence of additional subjective symptoms that relate to a specific organ or system;
• the patient’s concern about a possible serious, but, as a rule, uncertain disease of this organ or system, and repeated explanations and reassurances from doctors remain fruitless;
• there is no information about a significant structural or functional disorder of this organ or system.

It should be noted that to make this diagnosis, all criteria must be met. Thus, SDVNS has diagnostic criteria that differ from those of the gastrointestinal tract; in addition, such a diagnosis can only be made by a specialized specialist. It should be noted that in the American analogue of the classification of somatoform disorders “Diagnostic and Statistical Manual of mental disorders, fifth edition” there is no diagnosis of “somatoform dysfunction of the autonomic nervous system” [12 ].

At the same time, anxiety and depression are often found in patients with gastrointestinal tract diseases, and it is not entirely clear whether these conditions are the cause of gastrointestinal tract diseases, or whether they are secondary to them, but in general it is generally accepted that depression and anxiety, like somatization , affect the symptoms and frequency of exacerbations of the disease in such patients. For example, in patients with IBS, “somatization” occurs more often than in healthy people, but less often than in patients with somatoform disorders, and is associated with the severity of symptoms and deterioration in quality of life. A number of studies have demonstrated that those patients whose severity of heartburn weakly correlates with acid reflux symptoms on pH measurements demonstrate higher rates of anxiety and “somatization” than those whose symptoms are provoked by reflux [13–18].

In addition, “somatization” is associated with the frequency of seeking medical help and insufficient response to treatment, incl. due to discontinuation of medication due to patient-perceived side effects (Fig. 4). Therefore, assessing “somatization” and determining the number of somatic symptoms and their severity are clinically reasonable [19–24].

Rome criteria IV revision: unresolved issues

Although the Rome criteria are useful in clinical trials, they have limitations in clinical practice because many patients do not meet all the criteria or the quantitative time frame specified in the criteria to make a diagnosis. For example, patients with abdominal pain and bowel dysfunction for less than 6 months or with a frequency of less than 1 episode per week do not meet the Rome-IV criteria for a diagnosis of IBS, although these patients would probably receive similar empiric therapy. In addition, the diagnosis established on the basis of the Rome IV criteria does not always fully reflect the patient’s condition and select the optimal therapy for him. Thus, a patient with functional dyspepsia who has mild symptoms without a decrease in quality of life may not require special treatment. A similar patient with severe pain, depression and weight loss due to dietary restrictions requires appropriate treatment [5, 25, 26].

Conclusion

Thus, if previously the gastrointestinal tract diseases were determined by more or less specific symptoms and the absence of structural or biochemical disorders that cause these symptoms, now this concept is considered outdated, because with a thorough examination, pathomorphological changes can be detected in many patients that explain or cause symptoms. Consequently, the term “functional” in relation to gastrointestinal diseases does not reflect modern ideas about the pathogenesis of these diseases as a disruption of the “gut-brain” axis due to the influence of various factors. However, at present it is not possible to create a unified pathophysiological model for all gastrointestinal diseases, since even the most studied nosological units can be multifactorial in nature [27].

Another key feature of the gastrointestinal tract is the widespread prevalence of depression, anxiety and somatization among such patients, which requires the development of a systematic approach to the diagnosis and treatment of these conditions with the involvement of specialists not only in the gastroenterological profile.

Somatoform dysfunction of the autonomic nervous system

Characteristic signs of SDVNS are the abundance and vague nature of complaints. The patient may experience symptoms from several organs at the same time. The clinical picture consists of subjective sensations and disorders of the functioning of a particular organ caused by disruption of the autonomic nervous system. Symptoms and complaints resemble the clinical picture of any somatic disease, but differ from it by uncertainty, nonspecificity and high variability.

The cardiovascular system. Patients with somatoform dysfunction of the autonomic nervous system are often bothered by pain in the heart area. Such pain in its nature and time of occurrence differs from pain due to angina pectoris and other heart diseases. There is no clear irradiation. The pain can be stabbing, pressing, squeezing, aching, pulling, sharp, etc. Sometimes accompanied by excitement, feelings of anxiety and fear. They usually occur at rest and go away with exercise. Provoked by traumatic situations. They may disappear within a few minutes or persist for a day or more.

Along with pain, patients with somatoform dysfunction of the autonomic nervous system often complain of palpitations. Seizures occur both during movement and at rest, and are sometimes accompanied by arrhythmia. The resting heart rate can reach 100 or more beats per minute. Possible increase or decrease in blood pressure. Changes in blood pressure can be quite stable or detected in stressful situations. Sometimes pathological manifestations of the cardiovascular system are so pronounced that a therapist or cardiologist may suspect that the patient has hypertension or myocardial infarction.

Respiratory system. A characteristic symptom of somatoform dysfunction of the autonomic nervous system is shortness of breath, which increases with anxiety and stress. Such shortness of breath is usually not noticeable from the outside, but causes severe inconvenience to the patient. The patient may experience a feeling of shortness of breath, tightness in the chest, or difficulty breathing. Often, pathological manifestations of the respiratory system are observed for many hours in a row or disappear only during sleep. Patients constantly feel discomfort due to lack of air, ventilate the rooms all the time, and have a hard time tolerating the stuffiness. Sometimes coughing, choking and laryngospasm occur with SDVNS. Children with somatoform dysfunction of the autonomic nervous system more often suffer from respiratory infections, bronchitis and attacks of pseudoasthma are possible.

Digestive system. Swallowing disorders (dysphagia), aerophagia, pylorospasm, discomfort in the abdomen and pain in the stomach not associated with food intake may be observed. Sometimes patients with somatoform dysfunction of the autonomic nervous system are bothered by hiccups that occur in the presence of other people and are unusually loud. Another characteristic symptom of ADHD is “bear disease” - diarrhea during acute stress. Flatulence, irritable bowel syndrome and chronic stool disorders (tendency to constipation or diarrhea) are often detected.

Urinary system. Patients with somatoform dysfunction of the autonomic nervous system complain of various urinary disorders: an urgent need to urinate in the absence of a toilet, polyuria in psychologically traumatic situations, urinary retention in the presence of a stranger or in a public toilet, etc. Children may experience enuresis or increased frequency of urination in night time.

Other organs and systems. Somatoform dysfunction of the autonomic nervous system can manifest itself as mild, flying pain in large and medium-sized joints. The pain is not accompanied by restriction of movement, and is not associated with physical activity or changes in weather. Mild hyperthermia is often detected. Increased fatigue and decreased ability to work are possible. With the predominant activity of the parasympathetic nervous system, hypochondria and depressive disorders are often observed, while with the predominance of the sympathetic nervous system - insomnia, night awakenings, excitability and irritability.

What are the characteristic signs of the disorder?

Somatoform disorder belongs to the category of diseases of a psychosomatic nature. In people suffering from this disease, it is often impossible to identify obvious signs of a serious illness. Some believe that such patients are deceiving others about their poor health. In fact, such patients require the help of an experienced doctor.

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The list of main causes of this disorder includes such manifestations as:

• Unpleasant life situations;
• Stressful state;
• Frequent conflicts at work, in family, with friends;
• A state of loneliness.

Any emotionally significant situation can lead to the occurrence of such a disease.

Most often, the symptoms of somatoform disorder appear in hefty people who do not express their emotions openly, but hide all problems from strangers. Complex psychological problems can lead to the development of such an illness.

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COST OF TREATMENT

A family where there is an opinion that a child grows up independently in the absence of parental support may face problems in the health of their child. You cannot pay more attention to children only on holidays or when they are sick. Even teenagers should feel constant love and attention from adults.

Vegetative-vascular dystonia (VSD)

For somatoform dysfunction of the autonomic nervous system, the tactic of choice is non-drug treatment. However, a course of medications that improve metabolism and blood supply to the brain, as well as multivitamins up to 4 times a year, also helps to improve well-being.

Patients must strictly adhere to a daily routine with mandatory proper rest. The duration of sleep should not be less than 8-9 hours , but at the same time, prolonged sleep is not recommended. The room in which the patient rests must be well ventilated, and wet cleaning must be carried out regularly. The resting place should also be comfortable and convenient; if possible, you should give preference to an orthopedic mattress and pillow.

Periods of work and rest should be evenly distributed. It is necessary to alternate between mental and physical labor, reduce the time spent in front of the computer , and if this is not possible, take a break every 1-1.5 hours.

You should also spend enough time outdoors . Adequate physical activity is also important , which will be optimal for each individual patient, depending on the type and nature of the disease. A combination of outdoor exercise with swimming would be useful; in winter, you can give preference to skiing and skating. It is important to remember that physical activity should not overload the cardiovascular system.

If you are prone to anxiety and fear, as well as with a low background mood, consultations with a psychotherapist who will teach you proper breathing, as well as relaxation and calming techniques, can be useful. It is very useful to have a hobby that will also distract you from unwanted thoughts and experiences.

A significant aspect is to follow a diet that includes foods rich in potassium and magnesium. Such products include cereal porridges (buckwheat and oatmeal), legumes, potatoes, carrots, eggplants, nuts, dried fruits, and herbs. If you have a hypertensive type of ADHD, you should exclude salty and spicy foods, strong tea, and coffee from your diet. For the hypotonic type of the disease, foods that increase vascular tone, for example, green tea, natural coffee, should be added to the daily diet, without overusing the latter.

A course of physiotherapeutic procedures , which also include water procedures, has a positive effect. Patients with ADHD are advised to undergo contrast baths, showers, and swimming. For patients with sleep disorders and anxiety, massage and reflexology are recommended to promote relaxation.

Also useful for well-being is a change of environment ; for this, patients should periodically leave the city.

O.V. Bykova Doctor of Medical Sciences, Chief Researcher of the Scientific and Practical Center for Pediatric Psychoneurology of the Moscow Department of Health