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Somatization Disorders in Children & Adolescents. Prepared by: Maa ’ n I. Mesmeh, M.D. Moderated by: Dr.Yousef K. Abu-Osba . Introduction:. Diagnosis & treatment of somatization disorders in children & adolescents constitute a challenge to the pediatricians: Missing something vs. false step.

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Somatization Disorders in Children & Adolescents

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Somatization disorders in children adolescents l.jpg

Somatization Disorders in Children & Adolescents

Prepared by: Maa’n I. Mesmeh, M.D.

Moderated by: Dr.Yousef K. Abu-Osba.


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Introduction:

Diagnosis & treatment of somatization disorders in children & adolescents constitute a challenge to the pediatricians:

  • Missing something vs. false step.

  • Frustration by never-ending recurrent complaints & annoyed by caring of not really sick patient.

  • Scanty researched field.

  • Psychiatrist seldom see these patients.


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Definition:

  • Somatization defined as the occurrence of one or more physical complaints for which appropriate medical evaluation reveals no explanatory physical pathology or pathophysioloic mechanism.

  • Somatization can coincide with a physical illness when complaints are in excess of what expected from the illness.


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Classification:

  • The diagnostic criteria for somatoform disorders were established for adults & are applied to children.

  • Currently, progress made a recent classification of child & adolescent mental diagnosis in primary care.

  • Factitious disorders not involved because signs & symptoms staged deliberately by the patient.


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Current classification of somatization disorders in children & adolescents:

  • Somatic complaint variation.

  • Somatic complaint problem.

  • Somatization disorder.

  • Somatoform disorder, undifferentiated.

  • Somatoform disorder, not otherwise specified.

  • Pain disorder.

  • Conversion disorder.


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Epidemiology:

  • The prevalence of somatic symptoms is high in the pediatric population.

  • Recurrent abdominal pain account for 5% of office visits.

  • Headaches affect 20 – 55% of all children.

  • Frequent headaches, chest pain, nausea & fatigue affect 10% of teenagers.

  • 11% girls & 4% boys.

  • Higher rates among lower socioeconomic groups.


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Pathogenesis:

  • Role of genetics:

  • Recent studies showed twins concordance.

  • Cluster in families with attention deficit disorder & alcoholism above what would be expected by chance.


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Pathogenesis:

  • Family factors:

  • Learned behavior when children’s somatic complaints are more acceptable in a household than is the expression of strong feelings. This reinforce the “psychosomatic pathway”.

  • If a family member has a chronic physical illness, there are more somatic symptoms among the children of this family.

  • Children often somatize with similar physical complaint of suffering family member.


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Pathogenesis:

  • The effect of family therapy.

  • Symptoms displayed by the child as a way of protecting the parents by distracting them from their own concerns.

  • Stress that implicated as triggering factor often bound to parental anxiety; the most common form of stress is the pressure on the child to perform.

  • Adolescents with sexual or physical abuse often present with somatic complaints.


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Clinical aspects:

  • Somatic complaints often result from a disease such as tonsillitis, gastroenteritis or urinary tract infection.

  • Similar complaints in the absence of physical disease must be approached as possible somatization.

  • Somatization diagnosis ranges from everyday aches to disabling “functional symptoms”.

  • Symptoms should be spontaneous & not explained by another mental illness such as depression or anxiety.


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Clinical aspects:

  • Somatic complaint variation:

  • This involves discomforts & complaints that do not interfere with everyday functioning.

  • Infancy: gastrointestinal distress.

  • Childhood: recurrent abdominal pain & headaches.

  • Adolescence: menstrual discomfort & other transient aches.


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Clinical aspects:

  • Somatic complaint problem:

  • This consist of one or more physical complaint that do cause sufficient distress & impairment (physical, social or school) to be considered a problem.

  • Infancy: GI symptoms that seriously interfere with feeding & sleep.

  • Childhood: symptoms that entails refusing to undertake expected activities.


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Clinical aspects:

  • Somatic complaint problem:

  • Adolescence: somatic complaints associated with more emotional distress, social withdrawal & academic difficulties. Sever complaints result in aggressive behavior & recurrent pain syndromes.


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Clinical aspects:

  • Somatization disorder:

  • Usually is an adult condition.

  • Undifferentiated somatoform disorder:

  • Multiple severe symptoms of at least 6 months’ duration which emerges during adolescence causing significant impairment.

  • Include pain syndromes, gastrointestinal or urogenital complaints, fatigue, loss of appetite & pseudoneurologic symptoms.


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Clinical aspects:

  • Somatoform disorder, not otherwise specified:

  • This involves conditions in which adolescents complaints do not meet the criteria for any specific somatoform disorder.

  • Unexplained physical complaints of fewer than 6 months’ duration.

  • Pseudocyesis.


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Clinical aspects:

  • Pain disorder:

  • Pain associated with psychological factors.

  • Pain associated with both psychological factors & general medical condition.

  • Pain associated with general medical condition.

  • Onset related to stress or avoidance.

  • Begins as mild pain syndrome.

  • Secondary gain.


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Clinical aspects:

  • Conversion disorder:

  • In this condition one or more symptoms affect a sensory or motor function suggesting a medical condition, yet the findings are not consistent with any known pathophysiologic explanation.

  • The symptoms appear to relieve conflict (primary gain) & they often increase attention for the patient (secondary gain).

  • Symptoms are self-limiting resolved in 3 months.


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Clinical aspects:

  • Conversion disorder:

  • May be associated with chronic sequelae.

  • Over time up to 1/3 of conversional patients develop a neurologic disorder.

  • Additional disorders:

  • Hypochondriasis.

  • Body dysmorphic disorder.

    These are seen primarily in young adulthood.


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Psychiatric disorders & somatic complaints:

  • 14 – 20% of American children have one or more moderate – severe psychiatric disorders.

  • Psychiatric disorders present initially with poor concentration, fatigue, weight loss, headaches, stomachaches & chest pain.

  • These must considered as primary or comorbid conditions.


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Evaluation:

Diagnosis:

  • Ruling out the organic diseases.

  • Identify psychosocial dysfunction.

  • Alleviating stressors; bioosychosocial assessment by itself is therapeutic.

    Differential diagnosis:

  • Physical disease, psychological disease, factitious disorder & psychologically modified medical condition.


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Evaluation:

  • Considering psychosomatic etiology initially for unclear symptoms makes disclosure later on easier.

  • Findings that are suggestive of somatization:

  • Multiple somatic complaints.

  • Doctor shopping.

  • Family member with chronic & recurrent symptoms.

  • Dysfunction in school, peers & family areas.


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Evaluation:

  • “Red flag” that determine the extent of laboratory & radiographic evaluation is the detecting of findings suggest organic pathology (syncope on exercise, asymmetric pain, anemia & weight loss).

  • When findings suggest somatization the following laboratory investigations are sufficient: CBC, ESR or CRP, blood chemistry, stool for occult blood & urinalysis.

  • Extensive investigations reserved for “red flags”.


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Evaluation:

  • Preceding disclosure the pediatrician must convey a sense of specialness to the family & the patient.

  • Always in evaluating children with recurrent somatic complaints consider anxiety disorder, depression, attention – deficit/hyperactivity disorder, substance abuse & conduct disorder.


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Management/Disclosure:

  • Correct identification of these disorders may not be sufficient to provide help to the patient & his family.

  • Patients willing to listen to the pediatrician only of he first listens to them.

  • “You think it is all in my head, but I know I hurt & that there is something wrong”.

  • Psychosomatic is not craziness.


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Management/Disclosure:

  • Reminding the family of connection between emotion & bodily processes could be of help (fear: cold sweat, anger: stiffening muscles & clenching teeth & makes me vomit).

  • Some other principles of treatment:

  • Be direct & avoid deception.

  • Offer reassurance.

  • Positive & negative reinforcement.


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Management/Disclosure:

  • Some other principles of treatment:

  • Teach self – monitoring techniques.

  • Family & group therapy.

  • Communicate with the school.

  • Aggressively treat comorbid psychiatric disorder.

  • Psychiatrist consultation & psychopharmacologic intervention: prolonged impairment >3 months.

  • Monitor outcome.


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Management/Disclosure:

  • Some other principles of treatment:

  • Avoid unnecessary treatment which may reinforce the search for the “magic pill”.

  • Informing patients & family of the nature of the disease is ethical duty except in patients who have conversion disorder & can not benefit from the information.


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Prognosis:

  • Very good with appropriate intervention.

  • Untreated children will continue somatization as adults.

  • Undifferentiated somatoform is the most severe form, related closely to personality disorders, is of long duration & has persistent course continuing into adulthood.


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Quiz


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  • You are evaluating a 10 – year old girl for abdominal pain. She complains of generalized vague abdominal pain that has occurred almost daily for 6 weeks. There is no associated vomiting, diarrhea or weight loss. She has missed a total of 2 weeks of school because of her pain, but overall she is a good student. Findings on her physical examination are normal. Of the following , the most likely diagnosis is:

  • Conversion disorder.

  • Factitious disorder.

  • Somatic complaint problem.

  • Somatic complaint variation.

  • Undifferentiated somatoform disorder.


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  • You are evaluating a 10 – year old girl for abdominal pain. She complains of generalized vague abdominal pain that has occurred almost daily for 6 weeks. There is no associated vomiting, diarrhea or weight loss. She has missed a total of 2 weeks of school because of her pain, but overall she is a good student. Findings on her physical examination are normal. Of the following , the most likely diagnosis is:

  • Conversion disorder.

  • Factitious disorder.

  • Somatic complaint problem.

  • Somatic complaint variation.

  • Undifferentiated somatoform disorder.


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  • A 12 – year old girl comes to your office with the complaint of an inability to walk for 2 days. Her father carries her into the examination room. Except for refusal to walk, findings on the neurologic examination are completely normal. Further history reveals that she is a good student & that her parents are insistent that she makes all A’s in school so she can get a scholarship to college. When you ask the girl how she feels about her inability to walk, she appearsindifferent. Of the following, the most likely diagnosis is:

  • Conversion disorder.

  • Depression.

  • Factitious disorder.

  • Pain disorder.

  • Somatoform disorder, not otherwise specified.


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  • A 12 – year old girl comes to your office with the complaint of an inability to walk for 2 days. Her father carries her into the examination room. Except for refusal to walk, findings on the neurologic examination are completely normal. Further history reveals that she is a good student & that her parents are insistent that she makes all A’s in school so she can get a scholarship to college. When you ask the girl how she feels about her inability to walk, she appears indifferent. Of the following, the most likelydiagnosis is:

  • Conversion disorder.

  • Depression.

  • Factitious disorder.

  • Pain disorder.

  • Somatoform disorder, not otherwise specified.


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  • Which of the following statements about somatoform disorders in children is true ?

  • Adolescent who have somatization disorders feign pain for secondary gain.

  • An extensive laboratory evaluation is required before making the diagnosis.

  • It is rare for coexistent psychiatric disorders to be present.

  • Parents often complain of symptoms similar to the child’s complaint.

  • The rate of somatoform disorders is higher in boys than in girls.


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  • Which of the following statements about somatoform disorders in children is true ?

  • Adolescent who have somatization disorders feign pain for secondary gain.

  • An extensive laboratory evaluation is required before making the diagnosis.

  • It is rare for coexistent psychiatric disorders to be present.

  • Parents often complain of symptoms similar to the child’s complaint.

  • The rate of somatoform disorders is higher in boys than in girls.


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  • Which of the following statements regarding the evaluation of & treatment of somatoform disorders is true ?

  • Biofeedback & hypnosis are often effective treatments.

  • Medication rarely is indicated because it perpetuates the patient’s feelings that there is a true medical problem.

  • Screening for coexistent psychiatric disorders is recommended only if there is a family history of psychiatric illness.

  • Telling a family initially that the problem may be due to stress usually angers the family & jeopardizes the doctor – patient relationship.

  • The most effective method of treating the patient's complaint is to ignore it & explain that there is no medical explanation for the problem.


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  • Which of the following statements regarding the evaluation of & treatment of somatoform disorders is true ?

  • Biofeedback & hypnosis are often effective treatments.

  • Medication rarely is indicated because it perpetuates the patient’s feelings that there is a true medical problem.

  • Screening for coexistent psychiatric disorders is recommended only if there is a family history of psychiatric illness.

  • Telling a family initially that the problem may be due to stress usually angers the family & jeopardizes the doctor – patient relationship.

  • The most effective method of treating the patient's complaint is to ignore it & explain that there is no medical explanation for the problem.


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Thank You


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