Somatoform Disorders in Children and Adolescents Texas Children s Hospital Toi Blakley Harris, M.D. Quentin Collard, M.D

1. Somatoform Disorders in Children and AdolescentsTexas Children’s HospitalToi Blakley Harris, M.D.Quentin Collard, M.D.January 27, 2009

2. Speakers Quentin Collard, M.D. Bootin-Savrick Pediatrics Toi Harris, M.D. TCH Psychiatry-Psychology Consultation Liaison

3. Goals of Presentation Highlight Common Features of Somatoform Disorders Review Conceptual Framework/Theories Describing Somatoform Disorders Identify Challenges Associated with Diagnosis and Treatment Process in the primary care setting

5. How Common Is This??? Physical symptoms without medical explanation Historical Names Functional Psychogenic Non-organic Hysterical Medically unexplained symptoms (MUPS) Question #1Question #1

6. Epidemiology/Prevalence Psychological disorders in pediatric chronically ill patients 2-4 times general population

7. Epidemiology/Prevalence Ontario Child Health Study (recurrent distressing somatic complaints 12-16 year-olds) 11% females 4% males 50% preschool-school age children reported at least 1 somatic complaint in 2 weeks 15% reported 4 symptoms in 2 weeks

8. Epidemiology/Prevalence 3 month prevalence chronic pain 25% prevalence 50% took medications to treat pain 40% sought medical attention for pain

9. Pediatric Somatic Complaints Headaches: most common across children and adolescents 10-30% once per week 1-2% ambulatory visits Functional abdominal pain: most common in younger children 7-25% school age 2-4% ambulatory visits Polysymptomatic symptoms: adolescents Other stats?Other stats?

10. Long-term 1/3-1/2 children with FAP have symptoms in adulthood 4 year olds with stomach pain 3 times more likely to c/o 10 years v. peers

11. Somatic Conditions Functional Abdominal Pain (FAP) Irritable Bowel Syndrome: FAP with at least 2 Relief with defecation, change in bowel frequency or character Fibromyalgia 2 months of multiple musculoskeletal pains and pain to palpitation on PE in at least 11/18 tender point sites Complex Regional Pain Syndrome I. Reflex sympathetic dystrophy After immobilization or trauma Pain in excess Edema, change in blood flow or temperature

12. Continued Chronic Fatigue Syndrome Severe fatigue > 6 months Impaired Concentration, Memory, Sleep, and Musculoskeletal pains Vocal Cord Dysfunction Vocal cord spasm mimics asthma Adduction of vocal cords on laryngoscope Localized wheezing throat and upper chest Normal blood gases with symptoms

13. Continuum Somatic symptoms---Somatoform Disorder

14. Somatoform Disorders in DSM IV-TR (2000) Somatization Disorder Conversion Disorder Hypochondriasis Body Dysmorphic Disorder* Pain Disorder* Undifferentiated Somatoform Disorder* Somatoform Disorder, NOS*

15. Somatoform Disorders Common features Presence of physical symptoms suggesting an underlying medical condition, but the medical condition either is not found or does not fully account for the level of functional impairment Represent the severe end of a continuum which includes unexplained ‘functional symptoms in the middle and transient, every day aches and pains at the other end Diagnostic criteria were established for adults; there is no child-specific research base or developmentally appropriate diagnostic classification Symptoms are not intentionally produced, as are those of malingering and factitious disorder (Munchausen’s and MBP/Medical Child abuse).

16. Common Clinical Questions Is she/he “faking it?” When to discharge?: I can’t take them home like this! When to treat? When to refer?

17. K.H. 19 year-old 15 year old presented in 2007 with 2 year history of abdominal pain and weight loss H/O extensive GI work up

18. Somatization Disorder: 4-2-1-1 DSM-IV criteria require at least 4 pain symptoms, 2 GI symptoms, 1 sexual symptom, and 1 pseudoneurological symptom Diagnosis is rare in childhood and adolescence Revised criteria for these age groups are needed Associated with Anxiety, Depressive Disorders; Conduct Disorder and Substance abuse Differential: Physical disease, Depression and Anxiety Prognosis: Poor to fair

19. Body Dysmorphic Disorder Preoccupation with an imagined or slight defect in physical appearance causing significant distress or impairment in functioning Patients often experience significant shame and will not volunteer their concerns 10% of a recent case series <18y May need to be a consideration for plastic surgeons Anorexia Nervosa, OCD, Avoidant /Compulsive personality traits Differential: Delusional psychosis, Depression, Somatization, normal adolescence Prognosis: Fair to good Mirror checking; efforts to camouflage; Mirror checking; efforts to camouflage;

20. Hypochondriasis Persistent, preoccupying fear that one has a serious disease, based on misinterpretation of one or multiple physical symptoms Fear persists despite appropriate medical work-up and reassurance Associated with dissatisfaction with care, “doctor shopping,” deteriorating interpersonal relationships and the risk of iatrogenic complications from repeated diagnostic or treatment procedures Rarely reported in youth; ? because must involve parents in seeking help for medical concerns Equal male to female ratio Duration is at least 6 months. Depression, Panic disorder and OCD associated Differential: Physical disease, Depression, Delusional disorder Prognosis is fair to good (intermittent)

21. Conversion Disorder Term conversion derived from the theory that the somatic symptom represented a symbolic resolution of an unconscious conflict, reducing anxiety and serving to keep the conflict out of awareness (“primary gain”) “Secondary gain” is the external benefits that are obtained or the noxious duties or responsibilities that are avoided by virtue of the symptom Diagnostic criteria currently require that psychological factors be associated with the onset or exacerbation of symptoms—this etiologic relationship may be very difficult to establish Determination that a symptom is not intentionally produced may be very difficult to establish Symptoms include voluntary motor or sensory functions Subtypes: Motor, Sensory, Seizures/Convulsions, Mixed presentation

22. Conversion Disorder, Continued Drug/alcohol dependence, Somatization disorder, Histrionic personality traits associated Differential: Depression, Neurological disease Prognosis: Excellent (unless chronic)

23. Pain Disorder New to DSM-IV Essential characteristics Significantly disabling pain in one or more sites Psychological factors are judged to play a major role in pain’s onset, severity or maintenance Pain is not feigned, nor part of a mood, anxiety, or psychotic disorder A general medical condition may or may not interact with psychological factors central to the pain disorder Includes RAP and RSD Pain disorder associated with psychological factors Pain disorder associated with both psychological factors and GMC Pain disorder associated with a GMC Acute (< 6 months); Chronic (> 6 months) Prognosis is guarded; variable

24. Pain Disorder, Continued Depression, Anxiety, Substance use, Dependent/Histrionic personality associated Differential: Depression, Psychophysiological, Physical disease and Malingering

25. Undifferentiated Somatoform Disorder One or more physical complaints that are not fully accounted for by a medical condition or the effects of a substance Either (1) or (2): After investigation, symptoms cannot be explained due to GMC When there is a related GMC, the physical complaints or resulting social/occupational impairment is in excess Duration of disturbance is at least six months Doesn’t meet criteria for Somatization disorder by virtue of duration and number and distribution of symptoms

26. Somatoform Disorder, NOS Doesn’t meet criteria for any other specific somatoform disorder The most frequently diagnosed somatoform disorder by C/L services in this practice model (tertiary care hospital) A disorder involving nonpsychotic hypochondriacal symptoms or unexplained physical symptoms of less than 6 months’ duration

27. J.C. 20 year-old Paroxysmal dystonia (1991); tegretol Congenital Heart Disease (21 months, Tetralogy of Fallot; Stents 1995) Hospitalized fatigue, syncope multiple times ADHD (1996)-Adderall Frontal Lobe Epileptic Events Documented (2000) Back pain, leg pain and enuresis (day and night)

28. J.C. Continued (2001) Pneumonia, hospitalized; developed pneumonia (xopenex, singulair, claritin) (2002) J.C. and siblings-Lyme disease; amoxicillin (2003) Multiple syncopal and seizure episodes at school

29. Theories, Concepts, Research Related to Somatization One model does not fit all patients/families Fully describing working model to families may be counterproductive initially

30. Biopsychosocialcultural Model Biological Gender (female>male) Genetic Polymorphism genes Promoter region Serotonin transporter (neuroticism, anxiety) Catecholamine-O-Methyl transferase (pain sensitivity) Tryptophan hydroxylase (somatic anxiety) Temperament: Behavioral inhibition, harm avoidance History of illness Genetic predisposition (Wender and Klein, 1981; Torgensen 1986; Guze 1993; Kender et al. 1995): concordant in twins, clusters in families with ADHD and Alcohol Dependence and Antisocial Personality Disorder Genetic predisposition (Wender and Klein, 1981; Torgensen 1986; Guze 1993; Kender et al. 1995): concordant in twins, clusters in families with ADHD and Alcohol Dependence and Antisocial Personality Disorder Genetic predisposition (Wender and Klein, 1981; Torgensen 1986; Guze 1993; Kender et al. 1995): concordant in twins, clusters in families with ADHD and Alcohol Dependence and Antisocial Personality Disorder Genetic predisposition (Wender and Klein, 1981; Torgensen 1986; Guze 1993; Kender et al. 1995): concordant in twins, clusters in families with ADHD and Alcohol Dependence and Antisocial Personality Disorder

31. Biopsychosocialcultural Model Psychological Previous Trauma Sexual abuse Physically threatening events Personality Poor coping—castastrophize, passive coping, dwell on or avoid symptoms Alexithymia Psychopathology Anxious Depressed Substance use disorder Alexithymia: normal process:Immature cognitive verbal skills and limited vocabulary for emotional expression in children may lead to somatization, the expression of distress through somatic symptoms.This normative phenomena becomes a problem if it is exaggerated and it leads to dysfunction and recurrent medical help-seeking. People who are called alexithymia continue to have not words for emotional distress and therefore may express it somatically. 33-50% with psych diagnosisAlexithymia: normal process:Immature cognitive verbal skills and limited vocabulary for emotional expression in children may lead to somatization, the expression of distress through somatic symptoms.This normative phenomena becomes a problem if it is exaggerated and it leads to dysfunction and recurrent medical help-seeking. People who are called alexithymia continue to have not words for emotional distress and therefore may express it somatically. 33-50% with psych diagnosis

32. Biopsychosocialcultural Model Social/Environmental Parent behavior Medical system School Role of Culture Across all racial-ethnic groups and cultures Lower SES and lower parent education Expression of pain/distress influenced by culture Stigma mental health (somatic c/o more socially acceptable and assistance given) Parents can model and reinforce illness behavior. RAP study Medical system-- The process of dx and tx gives families ideas about the condition. Families tend to interpret number of tests DONE as sign of seriousness, even if they are all normal. School—May react to cause more stress, or may inadvertently reinforce the illness behavior and sick role.Parents can model and reinforce illness behavior. RAP study Medical system-- The process of dx and tx gives families ideas about the condition. Families tend to interpret number of tests DONE as sign of seriousness, even if they are all normal. School—May react to cause more stress, or may inadvertently reinforce the illness behavior and sick role.

33. Learning Theory Classical Conditioning Pain associated with a behavior (eg walking) continues after the organic pathology is resolved. Operant Conditioning Illness behavior reinforced by attention from parents and avoidance of unpleasant tasks Social Learning Theory Parents model illness behavior for children Not one theory of somatization, but various learning theory concepts help explain the development and maintenance of somatoform behaviors. Parental reinforcement of symptoms and discouragement of coping is likely to play a part in onset and maintenance of symptoms (in line with social learning theory) Walker, et al. (1993): well children vs. physically ill children vs. somatizers---parents of somatizers more frequently responded to their children’s complaints with increased attention and special privileges Osborne (19XX): somatizing children reported more positive consequences for their pain behavior than children with sickle cell anemia Dunn-Geier: mothers of somatizers discouraged coping behavior with pain during an experimental task; related to greater symptom-related handicap in the child Not one theory of somatization, but various learning theory concepts help explain the development and maintenance of somatoform behaviors. Parental reinforcement of symptoms and discouragement of coping is likely to play a part in onset and maintenance of symptoms (in line with social learning theory) Walker, et al. (1993): well children vs. physically ill children vs. somatizers---parents of somatizers more frequently responded to their children’s complaints with increased attention and special privileges Osborne (19XX): somatizing children reported more positive consequences for their pain behavior than children with sickle cell anemia Dunn-Geier: mothers of somatizers discouraged coping behavior with pain during an experimental task; related to greater symptom-related handicap in the child

34. Family Systems Theory Child’s symptoms serve a purpose in family keep parents together distract from other conflicts/stressors draw in absent family member Families of somatizers often have a very high level of agreement between patient and family regarding duration, location, severity and characteristics of pain and other complaints, which supports the notion of enmeshment; this dynamic is associated with more management problems and poor outcome Families of somatizers often have a very high level of agreement between patient and family regarding duration, location, severity and characteristics of pain and other complaints, which supports the notion of enmeshment; this dynamic is associated with more management problems and poor outcome Families of somatizers often have a very high level of agreement between patient and family regarding duration, location, severity and characteristics of pain and other complaints, which supports the notion of enmeshment; this dynamic is associated with more management problems and poor outcome Families of somatizers often have a very high level of agreement between patient and family regarding duration, location, severity and characteristics of pain and other complaints, which supports the notion of enmeshment; this dynamic is associated with more management problems and poor outcome

35. Family Systems-Characteristics of Psychosomatic Families Enmeshment: excessive closeness, lack of privacy, blurring of interpersonal boundaries Overprotection: worry excessively about each others’ health and safety Rigidity: strong aversion to change and trouble with normal transition points Lack of conflict resolution: much effort devoted to avoiding points of disagreement Families of somatizers often have a very high level of agreement between patient and family regarding duration, location, severity and characteristics of pain and other complaints, which supports the notion of enmeshment; this dynamic is associated with more management problems and poor outcome Families of somatizers often have a very high level of agreement between patient and family regarding duration, location, severity and characteristics of pain and other complaints, which supports the notion of enmeshment; this dynamic is associated with more management problems and poor outcome Families of somatizers often have a very high level of agreement between patient and family regarding duration, location, severity and characteristics of pain and other complaints, which supports the notion of enmeshment; this dynamic is associated with more management problems and poor outcome Families of somatizers often have a very high level of agreement between patient and family regarding duration, location, severity and characteristics of pain and other complaints, which supports the notion of enmeshment; this dynamic is associated with more management problems and poor outcome

36. Psychodynamic explanations Resolution of unconscious intrapsychic conflict, wish or need Choice of symptom determined by: Physical manifestation of an unacceptable wish and the defense against it The revival of a memory trace of a previous physical sensation Identification with an important figure who suffered from a similar symptom Punishment for an unacceptable wish or impulse directed against a loved one

37. Somatization and Sexual Abuse Study of adult patients with somatization disorder of five years or greater duration, showed an increase in self-reported childhood sexual abuse, as well as parental neglect or lack of attention, when compared to a control group Adolescents with histories of sexual abuse scored higher on somatization scales than adolescents without histories of sexual abuse Although practitioners should always be diligent in seeking out possible sexual abuse, unexplained somatic symptoms do not equal sexual abuse

38. Diagnosis/Assessment PCP sets the tone for the evaluation: avoid dichotomizing symptoms as organic versus non-organic Discuss the symptoms from a multi-factorial, complex or biopsychosocial perspective (mind-body)

39. What is the role of the Mental Health Professional? Assessment is geared toward: identification of psychiatric symptoms, behavioral reinforces, psychosocial stressors, and level of disability/functionality Treat co-morbid conditions Work with team during assessment and treatment process including planning feedback that is optimal for family

40. Psychiatric Assessment Medical findings (absent or inconsistent; relationship to stressor) Family beliefs regarding symptoms Single undiagnosed primary medical cause Belief in the role of environmental triggers Beliefs regarding symptom management History of childhood trauma

41. Psychiatric Assessment, Cont’d Family medical history FH of unexplained somatic symptoms Pattern of reinforcement of illness behavior Impact of somatoform symptoms Emotional Family Social and peer relationships Academic

42. Psychiatric Assessment Reinforcement of somatoform symptoms Reinforcement by parents Increased attention from family/friends Increased attention from medical providers Avoidance of school, social or athletic stressor

43. Management of Somatoform Disorders PCP needs to remain actively involved in the case despite the lack of physiological support for the symptoms Consolidate care and all referrals through the PCP?stop “doctor shopping” and search for alternative explanations Discuss and reinforce strategies to return to function Close communication between the PCP and the mental health professional (psychologist and psychiatrist)

44. Role of Mental Health Provider Identify Psychiatric Comorbidity Communication with PCP and school Self-management strategies Self-monitoring Training in coping and relaxation Hypnosis Biofeedback

45. Role of Mental Health Provider Improving Coping Skills Active Coping: problem focused with emotional expression and regulation; problem solving Accommodative Coping: accept and adjust to pain with distraction, self-encouragement, cognitive restructuring Treat or refer for treatment of co-morbid psychiatric symptoms

46. Treatment Modalities Psycho-education Psychotherapy Cognitive Behavioral Therapy Interpersonal Therapy Family Therapy Pharmacotherapy Antidepressants (SSRIs) BDD, Somatoform pain, IBS, Fibromyalgia, Functional Headaches Open trial Citalopram pediatric FAP 84% (+)

47. Management of Somatoform Disorders (cont’d.) Interventions must allow for “saving face” Focus on return to function, not etiology Prescribed exercise and rehabilitation program based on sound behavioral principles (PT/OT and nursing staff must be on board)

48. Good Prognostic Indicators Early identification Less expansive work-up Short duration of symptoms Monosymptomatic manifestation Good pre-morbid personality functioning 85-97 % of cases end in full recovery (Leary, 2003)

49. Poor Prognostic Indicators Co-morbid conduct disorder History of sexual abuse Co-morbid anxiety or depressive disorder Long duration of symptoms Multi-system symptoms Strong family history of somatization

50. Barriers to successful treatment Tertiary care treatment setting Lack of communication between PCP in community Disconnect between community providers, in-patient providers and mental health professionals trained and willing to work with this population Lack of support for this type of care---multiple providers, not diagnosis- and treatment-driven; lack of financial reimbursement for the appropriate treatment modality Multiple barriers for research into development of meaningful diagnostic entities and accumulation of evidence regarding outcome, treatment, etc.

51. Strategies to Improve Treatment Outcomes: Practice Tips Conceptualize and present problem in a way that is tolerable. Find an ally in the family. Do not focus on “cure” focus on increased function. Improve insurance company’s support of treatment. Continued communication between PCP and TCH.

52. Somatoform Action Plan:Future Directions  Improved diagnostic anchors to assess childhood/adolescent Somatoform disorders. Research to identify prevalence and associated co-morbidity of these disorders. Improved reimbursement for specialized services to treat these illnesses. Continued collaborative efforts between PCP and mental health providers while providing care.

53. References Levenson, J. Textbook of Psychosomatic Medicine (2005); 271-291; 768-769. Lewis, M. Child and Adolescent Psychiatry (2002); 847-858. Martin, A., Volkmar, F.R. Lewis’ Child and Adolescent Psychiatry: A Comprehensive Textbook, 4th edition (2007). Silber, T, Pao, M. Pediatrics in Review (2003);24:255-264.