Somatization and somatoform disorders

Disorders presenting with functional physical symptoms and somatization

'Functional' somatic symptoms with no obvious organic explanation are frequent in childhood. Children have a limited vocabulary for expressing their emotions and often communicate their worries by means of physical symptoms. In a number of cases functional symptoms may be an expression of somatization, namely the somatic presentation of psychological distress leading to a degree of impairment resulting in help-seeking behaviour. (38) The definitions of somatization disorder (one of the somatoform disorders) used in ICD-10 and DSM-IV are too stringent for children (in that they require multiple symptoms for a diagnosis to be made), but other disorders (namely somatoform pain disorder, dissociative/conversion disorder, and neurasthenia) are seen in children and adolescents. The risk factors for somatization in this population are shown in T§ble...,5.

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Table 5 Risk factors for somatization in children and adolescents

Aches and pains and somatoform pain disorder

Aches and pains (often abdominal pains and headaches) are a common manifestation in young children. Between 2 and 10 per cent of children in the general population have problems in this area. Mothers make an assessment of the child's symptomatology with specific regard to whether the child is 'pretending', 'upset', or 'ill'(39) and in the main respond appropriately. They recognize that children may experience symptoms as a result of stress or use them to avoid something they find difficult.

Abdominal pain commonly leads to a general practitioner consultation and accounts for 10 per cent of new appointments with paediatricians. In only a few of these cases is serious organic pathology found. A lack of identifiable organic pathology does not imply a psychogenic aetiology. This is likely if there is evidence that psychological events influence the symptoms.

Children who somatize tend to have a family history of physical ill-health and parental illness, and in some cases there are also psychosocial difficulties in the family. There is an association with stressful life events. Although these children have an excess of internalizing (namely depression and anxiety) over externalizing disorders (i.e. conduct disorder), the majority do not have psychiatric comorbidity.

In adolescence, headaches become a more prominent symptom, peaking in prevalence at 12 years of age. As with abdominal pain in younger children, they are frequently preceded by physical or psychological precipitants. The latter may include academic or social stresses in school or difficulties at home. Headaches lead to absence from school but are not associated with underachievement. A family history of migraine is often reported.

As defined in ICD-10, in persistent somatoform pain disorder or psychalgia severe distressing pain occurs in association with emotional conflict or psychosocial problems that are sufficient to allow the conclusion to be drawn that they are the main causative influences. The result is usually a marked increase in support and attention, either personal or medical.

In trying to best manage severely affected children, close collaborative work between paediatricians and child psychiatrists is of the upmost importance. In some hospitals, the two specialists run joint clinics. The lack of demonstrable organic pathology should be clearly communicated and professionals should help the family to make the link between physical symptoms and psychological precipitants with the help of a written diary if necessary. It is important to reduce the attention given to the physical symptoms, with the aim of decreasing the resulting functional handicap. An early return to school together with the resumption of normal activities, should be encouraged. The short-term prognosis for presentations to medical services is good, with 75 per cent of children recovering within several months. (40) However, half the adults with a childhood history of abdominal pains have been found to have recurrent symptoms in adult life despite a pain-free period in adolescence. (41)

Dissociative/sconversion disorder

Children and adolescents with this condition present as if having a physical disorder affecting voluntary motor or sensory functioning, although none can be found that will explain the symptoms. The symptoms correspond to the patient's idea of physical disorder, which may not coincide with physiological or anatomical principles. Aetiologically, the disorder is believed to arise largely unconsciously and to represent an escape from an unbearable personal conflict.

It usually manifests in adolescence and is more common in girls than boys. The most common presentation is neurological with disturbance of motor function such as weakness of legs, paralysis of a limb, or bizarre gait. Multiple symptoms often occur.

Premorbid psychopathology in the child and family are often strikingly absent, although perfectionistic and conscientious traits in the child with concerns about academic performance and a child and family focus on high achievement have been noted. Overconcern with physical health and illness often characterize these families and frequently there is a family history of physical health problems. Families often present as being close, but communication, particularly regarding emotions, may be limited.(38)

It is assumed that children develop conversion disorders as an unconscious means of escaping a situation with which they cannot cope. This includes intolerably high academic expectations (often the child's own), unresolved family conflict, and, in a minority of cases, sexual abuse. The disorder is often precipitated by a minor physical illness and may also occur in children who already have an identified organic pathology, for instance the development of pseudoseizures in an individual with epilepsy.

The majority of these patients are managed by paediatricians. After investigations have excluded organic pathology and a psychogenic contribution is suspected, this needs to be conveyed to the family. The shift from physical to psychological factors may be difficult for the family to accept and information may need to be conveyed slowly 'at a pace the family can cope with'. The importance of a collaborative approach between paediatricians and child psychiatrists cannot be overemphasized. Since a persistent focus on a physical aetiology may be unhelpful, it may be more useful to focus on the handicap caused by specific symptoms and to introduce a programme of rehabilitation and physiotherapy directed at these features. Psychotherapeutic work, both individually and with the family, may be useful in helping the family to understand the factors maintaining the child's symptoms and to explore any identified stressors or conflicts. In addition, time can be spent helping families to consider alternative strategies they may use to cope with future conflicts.

In most reported cases, recovery is usually complete by 3 months, but little is known about the long-term outcome.(42) Chronic fatigue syndrome (neurasthenia in ICD-10)

This syndrome is operationally defined as characterized by disabling physical fatigue of over 6 months' duration, unexplained by primary physical or psychiatric causes. There are often other unexplained somatic symptoms and a strong belief by the patient and his or her family that the aetiology is physical. (43) It might be considered as one of the somatoform disorders, as they share similarities with regard to aetiology and management.

There is no firm evidence that chronic fatigue syndrome results from a specific viral infection. However, a physical illness is often the precipitating factor for many children. There is frequently a family history of physical illness and a preoccupation with physical symptoms. Parents invariably attribute the symptoms to an organic aetiology. Children are frequently described as high achieving and perfectionistic and the onset of symptoms is often temporally related to transitions at school, for example transfer to secondary school. Depressive mood changes are common in this group of patients, but depressive disorder is only found in one-third of cases. (43)

Chronic fatigue syndrome can be extremely disabling. A self-perpetuating cycle is set up whereby fatigue and the resultant inactivity lead to a loss of muscle bulk and a deterioration in physical fitness. Activity then becomes increasingly difficult and the child avoids it, leading to a further deterioration in physical ability. An essential focus of treatment is to disrupt this cycle.

Treatment of these children often involves a multidisciplinary team including paediatricians, physiotherapists, school teachers, and child psychiatrists. Physical and psychological treatments are often intimately connected and the relevant professionals need to work collaboratively. A clear explanation of the results of physical investigations and the fact that no serious organic pathology has been found is important. Focusing on improving symptoms, as opposed to debating aetiology, with the family is most helpful. Helping the family to shift from a purely physical model to one that includes psychological factors in maintaining symptoms may be difficult and it is important to negotiate this slowly. In particular, enabling them to see the disorder as an interaction between physical, social, and emotional factors is useful.

Treatment ingredients usually include a graded exercise programme which may be supervised by a physiotherapist, a progressive return to school, and work with the family to facilitate engagement and to address factors that may be impeding recovery. Antidepressants may be useful if there is associated depressive disorder.

Treatment of functional symptoms and somatoform disorders in children and adolescents: research evidence

There are few satisfactory controlled studies on the effects of treatment for childhood somatization. Most of the work on children with somatoform disorders has been based on small groups of children with severe problems, and the management advice outlined above is derived from the conclusions of experienced clinicians and open-treatment case reports. However, there is some evidence from controlled studies indicating the superior efficacy of a cognitive-behavioural family intervention compared with standard paediatric care for recurrent abdominal pains in 7- to 14-year-olds (44> and the superiority of relaxation training over placebo in reducing migraine attacks.*45' Studies in adult patients have also demonstrated the value of cognitive-behavioural techniques in the treatment of patients with somatization disorder.(4 ,46)

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