Somatization Disorders in Children & Adolescents

1. Somatization Disorders in Children & Adolescents Prepared by: Maa’n I. Mesmeh, M.D. Moderated by: Dr.Yousef K. Abu-Osba.

2. 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.

3. 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.

4. 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.

5. 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.

6. 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.

7. Pathogenesis: • Role of genetics: • Recent studies showed twins concordance. • Cluster in families with attention deficit disorder & alcoholism above what would be expected by chance.

8. 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.

9. 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.

10. 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.

11. 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.

12. 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.

13. 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.

14. 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.

15. 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.

16. 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.

17. 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.

18. 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.

19. 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.

20. 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.

21. 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.

22. 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”.

23. 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.

24. 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.

25. 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.

26. 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.

27. 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.

28. 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.

29. Quiz

30. 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.

31. 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.

32. 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.

33. 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.

34. 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.

35. 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.

36. 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.

37. 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.

38. Thank You