You are in: eMedicine Specialties > Pediatrics: Developmental and Behavioral > MEDICAL TOPICS Somatoform Disorder: SomatizationArticle Last Updated: May 30, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 9
  Author: Eve G Spratt, MD, Associate Professor of Psychiatry and Pediatrics, Pediatric Consultation Liaison Psychiatry, Medical University of South Carolina; Director, Medical University of South Carolina Children's Hospital at Charleston Eve G Spratt is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry Coauthor(s): David R DeMaso, MD, Professor of Psychiatry (Pediatrics), Harvard Medical School; Psychiatrist-in-Chief and Chairman of Psychiatry, Children's Hospital Boston Editors: Chet Johnson, MD, Medical Director, Child Development Unit, Department of Pediatrics, Professor, University of Kansas Medical Center; Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine.com, Inc; Carrie Sylvester, MD, MPH, Director of Education in Child and Adolescent Psychiatry, Professor, Departments of Psychiatry and Pediatrics, Northwestern University Medical School; Caroly Pataki, MD, Professor of Clinical Psychiatry, Department of Psychiatry and Biobehavioral Sciences, Division Chair of Child and Adolescent Psychiatry, Director of Training, Child and Adolescent Psychiatry Residency Program, University of Southern California Keck School of Medicine Author and Editor Disclosure Synonyms and related keywords: somatization disorder, undifferentiated somatoform disorder, conversion disorder, pain disorder, body dysmorphic disorder, somatoform disorder not otherwise specified, NOS, hypochondriasis INTRODUCTIONSection 2 of 9
  The presence of physical symptoms or painful complaints of unknown etiology is a fairly common occurrence in pediatric populations (Campo, 1994; Garralda, 1996; Garralda, 1986). Many normal young children may express emotional distress in terms of physical pain, such as stomachaches or headaches, but these complaints are usually transient and do not affect the child's overall functioning. Somatization in children consists of the persistent experience and complaints of somatic distress that cannot be fully explained by a medical diagnosis. The somatic symptoms in children with somatization disorder become a main focus of their attention and often interfere with school, home life, and peer relationships. Somatization often occurs in response to psychosocial stress and generally persists even after the acute stressor has resolved, resulting in the child and family to believe that the correct medical diagnosis has not yet been found. Thus, patients and families may continue to seek repeated medical treatment after being informed that no acute medical illness has been found and that the symptoms can not be fully explained by a medical diagnosis. It is generally well accepted that stress and worry can take a physical toll on bodies. This can be the unseen source of headaches, backaches, chest pain, and stomachaches. Somatic complaints can be the presenting and/or comorbid symptoms of childhood depression and anxiety disorders (Livingston, 1988; Wilens, 1990; Sadeh, 1994; Hodgman, 1995). Conscious and unconscious worries can lead to somatic symptoms with a spectrum of degrees of severity in almost every organ system. The somatoform disorders are a group of psychological disorders in which a patient experiences physical symptoms despite the absence of an underlying medical condition that can fully explain their presence. Patients with these disorders typically present to general medical settings rather than mental health settings. These disorders can be represented by a wide spectrum of severity ranging from mild self-limited symptoms to chronic disabling symptoms. The physical symptoms can occur in the context of comorbid medical and psychiatric disorders requiring diagnostic and treatment interventions from both medical and mental health professionals. The somatoform disorders represent the severe end of a continuum of somatic symptoms. At the other end lie the mild and self-limited general aches and pains of unknown etiology. The physicians who manage these symptoms have varying degrees of interest, experience, and success depending where the symptoms are in the somatization spectrum. The recurrent complaints often present as puzzling diagnostic dilemmas. The primary care physician trying to make sense of these symptoms may feel poorly prepared and/or have little time to assess or treat the somatic concerns. The more disabling somatic complaints are more likely to be referred to a mental health professional. These psychological disorders are often difficult to approach and complex to understand. They present with unexplained physical symptoms that are not intentional or under voluntary control, but they are understood by the patient and family as having a medical cause. They can be confused with disorders that have situations in which patients are intentionally simulating or creating their problems. The term malingering is used when the patient has a specific goal in mind when creating the symptoms. Examples are the child's Monday morning "sore throat" before school or the shy girl's "sudden weakness" before the school prom. The other entity is factitious disorder within which the patient simulates a somatic complaint without a specific issue needing control but to create an ambiance within family or environment that fulfills a less specific need. The assessment and treatment of a patient with a somatoform disorder can be challenging to primary care physicians and mental health specialists. An integrated medical and psychiatric treatment approach is needed to successfully decrease the impairment caused by these disorders (DeMaso, 1998). Morbidity The morbidity associated with unexplained pediatric somatic complaints can be significant. These children and adolescents are more likely to be considered sickly or health-impaired by parents and caretakers, to be absent from school, and to perform poorly in academics. Patients with somatization disorders use more nonpsychiatric health care facilities than general medical patients (Belmaker, 1985; Fink, 1999; Campo, 1999). Somatoform disorders have been associated with impairment in functioning and suffering for the child and family as well as costly and dangerous medical investigations and treatments. Appropriate and timely diagnosis combined with collaborative psychological and medical interventions can decrease significant long-term morbidity and suffering. Clinical The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) classifies somatoform disorders in the following diagnoses: Somatization disorder, undifferentiated somatoform disorder, somatoform disorder not otherwise specified (NOS), conversion disorder, pain disorder, body dysmorphic disorder, and hypochondriasis. The Diagnostic and Statistical Manual for Primary Care (DSM-PC) child and adolescent version (Wohlraich, 1996) includes definitions for the codes of somatic complaint variation and somatic complaint problems. These disorders all involve clinically significant distress or impairment in daily functioning. The diagnostic criteria for these somatoform disorders were established for adults, and very few published case studies and research have focused on pediatric populations. This article reviews the DSM-IV criteria for each somatoform disorder and outlines available and pertinent pediatric literature. Grouping these disorders together does not indicate that they have a shared etiology or mechanism, but it is based on the need to exclude general medical conditions or substance-induced etiologies to explain the somatic symptoms. Clinical vignettes are included to illustrate each disorder, and the reader is referred to comprehensive articles in this journal for more extensive reading. The conclusion of the article includes suggested methods to approach assessment and treatment. SOMATIZATION DISORDERSection 3 of 9
Somatization disorder The essential feature of a somatization disorder is a pattern of many physical complaints in persons younger than 30 years that occurs over several years and results in unnecessary medical treatment, causes significant impairment in functioning, or both. This diagnosis was historically referred to as hysteria or Briquet syndrome. The somatic symptoms are neither intentionally produced nor feigned and appear to be unconscious to the patient. All the following historical criteria are required for a diagnosis:
After appropriate investigation, a known general medical condition or direct effects of a substance cannot explain the multiple symptoms. When a related medical condition is present, the physical complaints are in excess of what would be expected. This disorder is not generally diagnosed until adulthood, although adolescents can present to primary care facilities with these symptoms. The criteria for somatization disorder were designed for adults, and attempts have been made to apply criteria to pediatric populations. Nevertheless, this diagnosis is rarely made in the adolescent population, probably because of the time requirement of several years that is needed to meet the symptom criteria. Somatization disorder case example: Susan was a 15-year-old girl with a 2-year history of body aches, fatigue, fevers, headaches, diarrhea, nausea, joint pain, dysuria, and irregular menses. Her mother stated that she had chronic fatigue syndrome (CFS). During multiple medical clinic visits, Susan repeatedly had normal physical and extensive laboratory examinations. The patient repeatedly denied stressors, psychological trauma, and/or victimization despite assessments by an adolescent medical specialist and a psychiatrist. While being evaluated by neurology department personnel for her headaches, Susan became completely mute. Following a negative medical workup, she was admitted to a psychiatry inpatient unit where she began talking upon arrival. During this admission, she disclosed that her stepbrother had been sexually abusing her and her mother's boyfriend had physically abused her for several years. Gambling and domestic violence in the home were also identified. Susan was placed in foster care with some decrease in her somatic complaints. Susan subsequently recanted her previous allegations of physical and sexual abuse to child protective services. Despite family court involvement, she was allowed to return home and was lost to follow-up. Susan met criteria with 2 years of complaints of recurrent aches and pains, pain with urination, nausea, and constipation. Chronic fatigue syndrome was in the differential diagnosis. It was felt that her somatic complaints were a reflection of her distress from secretly living with incest, physical abuse, and domestic violence. It was necessary to build rapport and remove her from her family before she could begin to share her family secrets. Undifferentiated somatoform disorder and somatoform disorder NOS Children and adolescents are more likely to meet DSM-IV criteria for an undifferentiated somatoform disorder or somatoform disorder NOS than for a somatization disorder. The criteria for undifferentiated disorder require only one or more unexplained physical complaints, functional impairment, and duration of 6 months. Symptoms of less than 6 months are coded in DSM-IV for a NOS disorder. Again, the difference may lie in the developmental course of somatoform disorders and possible differences in illness severity and expression of sexual symptoms in childhood. No evidence exists to predict which patients will go on to develop the full symptom criteria for somatization disorder, although one might expect that comorbid psychopathology (ie, depressive and/or personality disorders) or chronic trauma (ie, physical and/or sexual abuse) might be important predictors. Undifferentiated somatoform disorder case example: Ben was a 13-year-old "worrier" with a history of 2 years of successful psychopharmacologic management for anxiety. At the start of school, his parents separated after an increase in parental conflict and possible domestic violence. In this context, Ben developed recurring headaches and stomachaches of unknown etiology that resulted in almost daily visits to the school nurse. He increasingly became more anxious about school, his somatic symptoms intensified, and his school performance declined. The complaints continued until he began to miss school. He responded well to supportive psychotherapy and cognitive-behavioral techniques to decrease anxiety that began 8 months after his somatic symptom development. Ben was able to recognize the association between his worry about his parents' separation and worsening stomachaches and headaches. This led to a significant reduction in somatic complaints and a subsequent improvement in his functioning. Ben did not meet full symptom criteria for a somatization disorder, but he did meet DSM-IV criteria for an undifferentiated somatoform disorder. If duration had been less than 6 months, a diagnosis of somatoform disorder NOS would be considered. Conversion disorder This DSM-IV disorder involves unexplained symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition. Psychological factors are judged to be temporally associated with the symptoms or deficits because conflicts or other stressors precede their initiation or exacerbation. Symptom models and comorbid individual/family psychopathology are also helpful in making the diagnosis (DeMaso, 1998). The symptom or deficit is not intentionally produced or feigned. Four different types of symptoms or deficits are described: (1) motor, (2) sensory, (3) seizures, and (4) mixed presentations. The major diagnostic concern is to exclude occult neurological or other general medical conditions or substance (including medication)-induced etiologies. An acute underlying physical illness may be present, but the conversion disorder inappropriately magnifies or imitates the real symptoms. Conversion disorders appear to be more common in adolescents than in adults or children (Gold, 1995). In adult studies, low education, personality disorders, and depression are commonly associated with conversion disorders (Bintzer, 1997). The differential diagnosis is critical and must be used to rule out neurological disease (Parobek, 1997; Bauer, 1996) and other medical conditions. The 2 groups of families that have been described to be associated with conversion disorder include anxious families preoccupied with disease and chaotic families (Grattan-Smith, 1988). Psychiatric comorbidity is poorly studied. High rates of dissociative and affective disorders are associated with conversion disorder (Saxe, 1994). Some evidence suggests that, when the diagnosis is presented early and made with certainty, the parental acceptance and recovery is easier and less expensive (Zeharia, 1999). A strong positive correlation exists between duration of conversion symptoms and the necessary treatment time to resolve them (Speed, 1996). Conversion disorder case example: Julia was a 15-year-old pregnant Hispanic girl who presented in the emergency room with her right elbow held in a flexion position and her left toe pointed downward in plantar extension. When asked about her symptoms, she stated with little affect that, "I'll get used to it." Her presentation could not be explained by any known medical condition and was subsequently diagnosed as a conversion disorder. She subsequently reported that her boyfriend, who was the father of the baby, recently had started seeing another girl. Julia noted that she was so angry with her ex-boyfriend that she wanted to hit and kick him, yet, with her current symptoms, she could not do so. Pain disorder A pain disorder is diagnosed instead of a conversion disorder if the symptoms are dominated by pain dysfunction. Pain is the predominant focus of clinical attention. The DSM-IV divides pain disorders into those associated with psychological factors, with both psychological and medical factors, and those in which the medical condition is the major factor in the pain symptom. Recurrent abdominal pain (RAP) is a particularly common and potentially disabling pediatric problem occurring in as many as 10-30% of children and adolescents (Garber, 1991). In pediatrics, RAP has been defined by intermittent pain with full recovery between episodes lasting more than 3 months (Apley, 1958). RAP is a common and potentially disabling pediatric problem occurring in as many as 10-30% of children and adolescents (Garber, 1991). Neuropsychobiologic mechanisms have been proposed as the etiology. Approximately, 90% of pediatric patients with normal physical examinations along with normal complete blood counts, urine analyses, and erythrocyte sedimentation rates do not have an organic illness to account for their abdominal pain (Rappaport, 1995). An estimated 10% of these patients have documented physical illness, with one third of these being urinary abnormalities. It is important to look for Helicobacter pylori as a source of misdiagnosed recurrent abdominal pain. One study found that 22% of children with RAP were infected with Helicobacter pylori (Ashorn, 1993). It is also important to rule out pain away from the umbilicus, fever, weight loss, blood in stools, bowel pattern changes, anemia, dysuria, and an elevated erythrocyte sedimentation rate (Rappaport, 1995). Reflex sympathetic dystrophy (RSD) is more common among adults than children, yet can quite problematic and disabling when it does occur in childhood. It has been referred to as a complex regional pain syndrome in which pain spreads beyond the area of injury along a dermatomal pattern to a regional one. RSD is characterized by pain, autonomic dysfunction, edema, movement problems, and atrophy, depending on severity. It typically presents with chronic painful swelling in a previously injured extremity along with decreased skin temperature, cyanosis, delayed capillary refill, and limitation in functioning (Fritz, 1997). In one study of 70 patients younger than 18 years, almost 6 times as many girls had RSD than boys, and the lower extremity was most often involved (Wilder, 1992). Anxiety and depression are frequent accompanying problems following the development of RSD. Pain disorder case example: Sheila was a 9-year-old girl evaluated for possible rheumatoid arthritis. She woke up with pain in one knee, which caused her to limp through her day at school. Findings from her medical workup were negative, and the pain shifted to her other leg. Social history revealed that her maternal grandfather, who had a limp caused by an old hip injury, had died 3 weeks before the onset of symptoms. Sheila was close to him and felt guilty for not playing checkers with him during their last visit. The pain waxed and waned but persisted for 10 days. The pain gradually decreased and resolved with supportive medical evaluation and family attention. Body dysmorphic disorder Body dysmorphic disorder (BDD) is the preoccupation with an imagined defect in appearance, or excessive concern over a slight physical anomaly. The distressing preoccupation may involve any part of the body; however, it most often involves imagined or slight flaws of the face or head such as acne, scars, thinning hair, facial asymmetry, or excessive facial hair (DeMaso, 1998). There has been little written about this disorder in the child and adolescent literature because most patients are secretive about their symptoms and are reluctant to seek psychiatric treatment. The onset often occurs during adolescence, with the male-to-female ratio being almost equal (DeMaso, 1998). Many of these patients have had consultations with surgeons and dermatologists. Patients with BDD often are referred for cosmetic surgery but are poor candidates because they are unlikely to be satisfied with the results (Brunell, 1998). Body dysmorphic disorder case example: Sylvia was an attractive college student who complained of her face being slightly asymmetrical. She felt this was the first thing noticed about her; yet, it was an almost imperceptible feature. She went to a craniofacial surgeon to try and have this corrected. In his opinion, she was not disfigured, so he sent her to a mental health specialist for evaluation. Hypochondriasis This DSM-IV disorder is defined as a preoccupation with fears of having or the idea that one has a serious disease based on misinterpretation of bodily symptoms. This preoccupation persists despite appropriate medical evaluation and reassurance. Hypochondriasis is distinguished by a set of beliefs and attitudes about illness. Patients with hypochondriasis have been found to have high correlations with depression, anxiety, and somatic symptoms (Barsky, 1990; Noyes, 1994; Noyes, 1999) and patients often have higher rates of personality disorders and amplified perceptual style. They are frequent users of medical services but often report dissatisfaction with the care they receive (Kirmayer, 1994; Noyes, 1993). Hypochondriasis case example: Jennifer was a mildly anxious and depressed 13-year-old adolescent girl who feared the possibility of having cancer. She became convinced she had cancer when her breast development was asymmetrical. She felt her hair was falling out, and, in her mind, this further confirmed her diagnosis. She was seen by her pediatrician who reassured her that her symptoms were normal and provided her with information about her normal physical examination findings. Antidepressants improved her symptoms of depression and anxiety, and somatic complaints decreased with a combination of reassurance and psychopharmacologic intervention. FACTITIOUS ILLNESSSection 4 of 9
The somatoform disorders can be confused with factitious disorders and malingering. In these latter disorders, symptoms are intentionally produced or feigned. False information is given intentionally, whereas, in somatoform disorders, intentional deception does not occur. In factitious disorders, the self-injurious behaviors or simulated somatic complaints are done consciously but for unconscious reasons (ie, assume a sick role to obtain the caring that comes with medical treatment). In contrast, malingering symptoms are produced in the context of readily apparent external incentives for the behavior (ie, avoidance of school or uncomfortable group situations, economic gain, avoidance of legal responsibility or improving sense of physical well-being). No specific targeted gain exists in factitious disorder. Malingerers, on the other hand, have a very specific goal in mind as an outcome of the feigned symptoms. In a review of 41 adults with factitious illness, most patients improved when confronted with their behavior, although less than one third acknowledged the factitious nature of their symptoms (Reich, 1983). Most of the patients in this study were immature, passive, and hypochondriacal. Factitious disorder has been associated with borderline personality traits and substance abuse disorders (Livingston, 1992). Factitious disorder case example: A 17-year-old teenage girl named Sarah complained to her doctor of chronic intermittent diarrhea. Her family confirmed her symptoms. A test for phenolphthalein (an ingredient that used to be common in laxatives) was positive, suggesting that Sarah was inducing her symptoms. During the course of therapy, Sarah subsequently acknowledged that she enjoyed the attention she received while in the sick role. Factitious illness by proxy This DSM-IV disorder is synonymous with Munchausen syndrome by proxy. It is a form of child abuse in which a parent (usually the mother) fabricates or produces illness in a child and/or creates physical signs that persistently result in unnecessary medical treatment (Sugar, 1990). The parent is diagnosed with factitious illness by proxy while the child can be diagnosed with Factitious Disorder, depending on their participation in presentation. Controversy continues to surround the exact criteria for this diagnosis. The DSM-IV lists this disorder among its section on criteria sets in need of further study. The pediatric condition falsification syndrome is an alternative approach to this problem (Ayoub, 1998). The following differential diagnoses are considered when one is dealing with this syndrome in which medical illness is falsified:
Some health care professionals are not aware of this possible diagnosis (Ostfeld, 1996); for others, it does not readily come to mind when treating relevant patients. It is a diagnosis most commonly identified in young children, but often after several months or years of unexplained and unseen illnesses and unnecessary procedures and tests. Negative medical consequences, including death, have been well documented (Alexander, 1990; Eminson, 1992). The horror of psychologic morbidity can include withdrawal and hyperactivity to hysterical disorders and personal adoption of factitious behavior in adolescence (McGuire, 1989). One victim's childhood experiences have been described (Bryk, 1997). Factitious illness by proxy case example: A 9-month-old infant named Samuel was admitted almost monthly to the children's hospital with complaints of bloody diarrhea. This was never witnessed until the mother brought the diaper to clinic that contained a bloody red streak with a small amount of guaiac-negative stool in the middle of it. Examination of the blood revealed that it was mother's type, and it was thought to be menstrual blood. The mother left the hospital against medical advice (AMA) stating that she needed a better medical opinion. It was discovered that the child was admitted to another hospital, and a report was made to child protective services. Malingering In malingering, the patient has intentional and obvious goals, such as financial compensation or avoidance of duty or school, evasion of criminal prosecution, or obtaining of drugs. Such goals may resemble secondary gain in conversion symptoms, but with the distinguishing feature being the conscious intent in the production of the symptoms. Malingering case example: Henry was a toddler evaluated for developmental delays. His mother brought him to clinic in a wheelchair, yet it did not appear necessary. She stated he had diarrhea that morning and slept all the time. He fell asleep in the clinic. An attempt was made to obtain collateral information from the father. The answering machine requested that people give money to the Henry Fund. Evaluation revealed no developmental concerns. A family meeting that included Henry's grandparents was held. Child Protective Services monitored the situation, and the child remained with the family. This mother exaggerated Henry's symptoms in hopes of gaining monetary compensation. A continuation of these issues could lead to detrimental consequences for Henry because he would not be allowed to meet his physical potential. Child-centered malingering begins with consideration of the symptom. For instance, the "sore throat" on Monday morning that improves by afternoon when the child is permitted (because of the symptom) to stay home from school may be the beginning of often-repeated symptoms related to unpleasant issues in the child's future life. IS IT MEDICAL OR PSYCHIATRIC?Section 5 of 9
Comorbid psychiatric conditions Somatic complaints appear to be twice as common in children and adolescents who meet DSM-IV criteria for depression than in control subjects (McCauley, 1991), with the somatic symptoms arising as long as 4 years after the onset of the depression (Zawaigenbaum, 1999). In a comparison of incarcerated adolescent girls with a normative sample, the lifetime prevalence of somatic symptoms was found to be twice as high for the incarcerated adolescent girls (Williams, 1998). The most common symptoms were dizziness, heart pounding, chest pains, and nausea. Self-reported symptoms of depression and illness were positively correlated. Anxiety disorders (eg, separation anxiety, posttraumatic stress disorders) can present with somatic complaints (eg, headaches, stomachaches, nausea, vomiting) (DeMaso, 1998). Thus, it is critical to consider comorbid psychiatric illnesses (eg, anxiety, depression) in any pediatric patient presenting with medically unexplained symptoms. Neurological and medical conditions The exclusion of neurological or medical conditions is the major diagnostic concern. Migraine syndromes, temporal lobe epilepsy, and central nervous system tumors have presented difficult diagnostic dilemmas (DeMaso, 1998). Seizures, syncope, and breath-holding spells can present as puzzling changes in the level of consciousness (Kosofsky, 1990). The dual existence of a medical condition and a somatoform disorder (eg, seizures and pseudoseizures) in the same patient is another consideration (Devinsky, 1998; Barry, 2001). The list of systemic medical disorders that could present with unexplained physical symptoms is large and may include multiple sclerosis, myasthenia gravis, periodic paralysis, endocrine disorders, chronic systemic infections, acute intermittent porphyria, polymyositis fibromyalgia, and other myopathies. Headaches, seizures, and behavior disorders frequently are encountered in primary care, neurology, and psychiatry settings. Headaches can reflect a symptom of stress and worry or may be a primary complaint. Seizures, syncope, and breath-holding spells can present as puzzling changes in the level of consciousness (Kosofsky, 1990). Somatoform disorders can be imitators of many neurologic conditions. The DSM-IV contains a nonmental disorder classification termed psychological factors affecting medical conditions. The essential feature is the presence of one or more specific psychological or behavioral factors that adversely affect a general medical condition. The following psychological factors that can impact a diagnosable general medical condition are noted as criteria: mental disorder, personality traits, coping style, maladaptive health behaviors, and/or stress-related physiological responses. This classification differs from the somatoform disorders, in which no medical conditions exist to completely account for the symptoms produced. Chronic fatigue syndrome (CFS) has been considered to be a possible somatoform disorder. The most recent criteria to diagnose CFS involve the occurrence of severe mental and physical exhaustion that cannot be attributed to exertion or diagnosed disease (Fukada, 1994). A viral etiology has been theorized, but, to date, no specific virus has been implicated. Presently, CFS is viewed as a legitimate physical illness, overlapping with many psychiatric and medical diagnoses (Greenberg, 1998). Neurologic condition case study: Cynthia was a 3-year-old girl who had a strong family history of schizophrenia and was admitted to children's hospital because she was complaining of seeing bugs and feeling as if bugs were crawling on her. The symptoms resolved, and it was thought that this might have been a somatic attention-seeking symptom reflective of the distress associated with being in a new home. The symptoms recurred, but they were associated with a distant stare to the right. An EEG revealed complex partial seizures, and she was treated with antiseizure medications with no recurrence of somatic or visual symptoms. Systemic medical disorder case study: Mary was a tall thin African American girl in the seventh grade. She had multiple somatic complaints and was seen in a pediatric walk-in clinic. She gave intense and almost fearful eye contact stating, "I'm hot," and then she hesitated stating, "I'm weak," and almost collapsed to the floor. She had just started at a new school; she gave a history of having few friends and wishing it was still summer vacation. Her history also included an upper respiratory infection (URI) 2 weeks before this visit. The chief resident told the medical student he thought she was a "crock" because she was unattractive and school had just started, but he thought that she probably should be admitted and observed. By the evening, Mary clearly had muscle weakness. Her CBC showed an elevated white blood cell count. She developed increasing respiratory distress overnight, requiring intubation. Her medical course was consistent with Guillain-Barré syndrome. EPIDEMIOLOGIC FACTORS CONTRIBUTING TO THE DEVELOPMENT OF SOMATOFORM DISORDERSSection 6 of 9
Medically unexplained physical symptoms account for as many as 50% of new medical outpatient visits (Van Hemert, 1993). In adults, it is thought that almost one half of new somatic complaints contain some element of somatization, with 10% representing pure somatization (Calabrese, 1998). Somatization is associated with more frequent use of medical and mental health services (Campo, 1999) and has been found to be associated with female sex, minority race, family dysfunction, poor school performance and attendance, and increasing age (Campo, 1999; Eminson, 1996; Garber, 1991; Oster, 1972; Taylor, 1993). Developmental considerations Many prepubertal children may experience psychological distress as somatization symptoms. Headache and recurrent abdominal pain are frequently reported painful somatic symptoms, with 10-30% of school-aged children and adolescents reporting symptoms as often as weekly (Garber, 1991; Larson, 1991; Tamminen, 1991). Complaints of limb pain, aching muscles, fatigue, and neurological symptoms appear to increase with age (Walker and Green, 1991). Personality characteristics Stuart and Noyes (1999) have hypothesized that somatizing behavior is best understood as a unique form of interpersonal behavior driven by an anxious and maladaptive attachment style. They believe that somatizing behavior is fostered by real or perceived rejecting responses from significant others. Patients who somatize attempt to elicit care by using persistent complaints of pain or physical illness. Unfortunately, the self-defeating nature of this behavior ultimately leads to rejection by others and further fuels the patient's somatic complaints. Bass and Murphy (1995) have proposed that somatization disorders are closely related to personality disorders because they have a persistent course, long duration, and early age of onset and because they occur more often as comorbid with personality disorders than with other DSM-IV disorders. Genetic contributions to the development of somatoform disorders Some evidence indicates that physical symptoms have an inheritable component (Kendler, 1995; Happel, 1999). In adults, researchers examined whether hypochondriasis was familial in a group of first-degree relatives of hypochondriacal and nonhypochondriacal probands who participated in a family study. Hypochondriasis was identified in 7.7% of relatives of hypochondriacal patients, and the relatives had high rates of comorbid anxiety, depression, and somatoform disorders. These relatives also reported more frequent use of health care but less satisfaction with that care; and the relatives showed many of the same characteristics found in earlier studies of hypochondriacal patients (Noyes and Happel, 1999). Family Environment Some research exists to indicate that possible antecedents of somatization may include living with a family member (parent) with physical illness, a history of family secrets, or child maltreatment. Patients with medically unexplained symptoms appear to come from families with a high rate of physical illness during the individual's childhood. The exact nature of the ill health reported in parents is unclear; however, in a study of subjects with somatoform disorder from birth to age 36 years, parental death was not associated with the outcome, nor was poor health of the father if he subsequently died (Hotopf, 1999). This suggests that severe fatal family illness is not associated with later unexplained symptoms. However, a strong relationship did exist between poor reported health of the parents when the subjects with somatoform disorder were aged 15 years and medically unexplained symptoms when the subjects with somatoform disorder were aged 36 years. This relationship was independent of current psychiatric disorders. In other studies, it was also found that somatization occurred in pediatric patients with a parent who had either non–life-threatening physical diseases or medically unexplained symptoms (Craig, 1993; Mechanic, 1980). Children of parents with a somatization disorder have been found to have significantly higher rates of psychiatric disorders and suicide attempts (Livingston, 1993). Transmission may occur through maternal modeling and reinforcement of illness behavior (Craig, 2002). Medically unexplained symptoms in adult patients have been associated with abdominal pain in childhood but not with defined childhood diseases (Hotopf, 1998). Some evidence suggests that medically unexplained symptoms are related to prior experience of illness in the family and previous unexplained symptoms in the individual. This may reflect a learned process whereby illness experiences leads to symptom monitoring. It has been hypothesized that adverse childhood experiences (eg, loss of parents) may contribute to more tender points in fibromyalgia (McBeth, 1999). Growing evidence of the association between medical use and childhood maltreatment exists (Kinzl, 1995; Bachman, 1988). Adolescents with histories of physical and sexual abuse score higher on measures of somatization than adolescents without histories of abuse (Atlas, 1995). Adults presenting with functional neurologic and abdominal symptoms frequently have a history of physical and sexual abuse. Although few pediatric studies have been performed, common somatic complaints of child sexual abuse victims include dysuria, vaginal discharge, and chronic abdominal pain (Locke, 1988; Drossman, 1990; Drossman, 1996). Emotional abuse may be the primary maltreatment that leads to somatization. High levels of rejection or hostility in fathers (not mothers) have been found to be more strongly associated with somatization than abuse (Lackner, 2004). Two adult groups of patients with physical symptoms in the absence of organic disease (nonepileptic attack disorder and irritable bowel syndrome) have been contrasted with groups of patients who have organic disease and comparable symptoms (epilepsy and Crohn disease, respectively). Despite their contrasting clinical presentations, patients who had irritable bowel syndrome and nonepileptic attack were similar in recalling more sexual and physical abuse as both children and adults than their comparison groups. They were also similar in being emotionally troubled, socially disturbed, and illness oriented (Reilly, 1999). Although some adult studies have looked at the assumption that gynecologic or gastrointestinal somatic symptoms are related to the organ symptoms that were targets of abuse (Levis, 1991), it is more likely that childhood abuse is followed by general tendencies to experience physical symptoms or engage in illness behavior (Reilly, 1999). Many families react to trauma by denying its impact and avoiding future discussion and follow-up care. This unconscious avoidance sets the stage from the conflict to be expressed as physical symptoms. Although associations between childhood trauma and somatic symptoms must be made with care, clinicians need to inquire about abuse experiences in patients with multiple medical and psychiatric symptoms (Walker, 1992). Screening A clinical interview is key to diagnosing any of these disorders. No pediatric screening instrument is available. An adult scale, which is called the Whiteley 7-Scale and Illness Convection Subscale, has had acceptable psychometric profiles and appears to be a promising screening tool for hypochondriasis and somatoform disorders in general (Fink, 1999). However, it has only been used in patients aged 18-65 years. There is some evidence of instability of recall of somatic symptoms (Simon, 1999) over time in adult patients. The Pediatric Symptom Checklist is a broadband screen that has been used in specialty clinics to determine psychosocial dysfunction (Spratt, 1997). Treatment The ideal strategy in the treatment of patients with multiple unexplained physical complaints is a long-term relationship with a primary care physician. The goals are to maintain or improve overall functioning, care for the patient, and rule out concurrent physical disorders. It may not be possible to "cure" the somatization symptoms. Mental health consultation can be helpful in addressing a somatization disorder in conjunction with the primary care physician. Little research has been done to determine how to treat pediatric patients who somatize. One adult study revealed adult patients with 6-12 unexplained physical symptoms reported improved physical functioning after the primary care physician was provided appropriate treatment recommendations via a psychiatric (Smith, 1995) consultation. In addition, one uncontrolled study in youth appeared to demonstrate decreased health care use with psychiatric intervention (Goodyer, 1991). Practitioners must recognize that many families (Garralda, 1999) with children who have somatoform disorder believe in the presence of a currently undiagnosed physical disorder. Physicians must be aware of their own reactions to patients with somatoform disorder. Appropriate limits must be set, and physicians must recognize that patients with somatoform disorders truly do suffer. Many patients may feel offended if the doctor infers that their physical symptoms are "just in their head." Some families may be resistant to considering a psychological etiology to their family member's symptoms. Patients and parents may be fearful of not being seriously believed. The physician needs to convey an attitude that demonstrates empathic understanding of their disabling distress. There is research with adult patients suggesting that empathic physician behavior can have a beneficial impact on a patient's use of services and perception of health (Smith, 1995). Given that somatic complaints frequently present within medical settings, the process of referral from a primary care to a mental health specialist must be handled carefully. Some children have such severe disabling functional impairment that these symptoms lead to excessive expenditure of health care dollars and services. For patients in the more severe group, consultation with psychiatrists, psychologists, or other experienced mental health experts is definitely indicated. Family treatments and cognitive behavioral techniques can help, and antidepressants should be considered when comorbid mood or anxiety disorders are present. Frequently, multiple causal attributions coexist and contribute to a presentation associated with comorbid depression and illness behavior (Rief, 2004). Many patients feel abandoned by their primary care doctor if planned follow-up care is only with a mental health professional. A collaborative follow-up plan with a focus on rehabilitation generally works best (Campo, 1994; Hodgman, 1995). Contingent reinforcement of coping behavior is helpful to reduce secondary gain associated with the sick role and to increase compliance with the prescribed regimen. Psychoeducation is always valuable, and psychotherapy is only useful if it appears to be relevant to patients with somatoform disorder and their families (Fritz, 1997). Sound empirical research on treatment of somatization disorders is relatively lacking, and the existing literature exhibits a number of methodological problems (Campo, 1994; Fritz, 1997, Garralda, 1996), including small sample size, lack of standardized measurement, and heterogeneous samples. Further research is needed regarding treatment for children with a somatoform disorder and their families. RECOMMENDATIONSSection 7 of 9
Recommendations for assessment and treatment of pediatric somatoform disorders in primary care settings The following recommendations are adapted from Calabrese (1998), Campo (2000), Campo and Fritz (2001), DeMaso and Beasley (1998), Demos (1998), Fritz (1997) Herzog (1990), and Hodgman (1995).
GUIDELINES FOR PARENTSSection 8 of 9
Dealing with pain The following guidelines for dealing with pain (eg, headaches, stomachaches) are adapted from tips by Rebecca Blakeman, PhD, and team at Children's Mercy Hospital in Kansas City. They were created for parents to help their children learn to participate in home and school activities despite any pain the children may be experiencing (eg, headaches, stomachaches). It is important to recognize that the pain experienced by a child with somatization is real and not just in their heads, while maintaining the goal of increasing the child's ability to cope with the pain and participate in school and social relationships. It is important to provide parents with the following points of advice:
For excellent patient education resources, visit eMedicine's Muscle Disorders Center. Also, see eMedicine's patient education articles Fibromyalgia, Chronic Fatigue Syndrome, and Chronic Pain. REFERENCESSection 9 of 9
|