AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), somatoform disorders are characterized by "the occurrence of one or more physical complaints for which appropriate medical evaluation reveals no explanatory physical pathology or pathophysiologic mechanism, or, when pathology is present, the physical complaints or resulting impairment are grossly in excess of what would be expected from the physical findings." Pain disorder is 1 of the somatoform disorders.

The main clinical feature of this disorder is pain, which cannot be fully attributed to a known medical disorder, in at least 1 anatomic site. The pain causes clinically significant distress, impairment, or both in social, academic, occupational, or other areas of functioning. Psychological factors are judged to play an important role in the onset, severity, exacerbation, or maintenance of the pain. The pain is not produced intentionally and is not under the patient's voluntary control. A somatoform disorder cannot be better accounted for by a mood, anxiety, or psychotic disorder.

Pain disorder can be divided into 2 categories.

• Pain disorder associated with psychological factors and no identifiable general medical condition: Psychological factors play a major role in the onset, severity, exacerbation, or maintenance of the pain.
• Pain disorder associated with psychological factors and a general medical condition: Both the psychological factors and the general medical condition have important roles in the onset, severity, exacerbation, or maintenance of the pain.

Pathophysiology

Pain, as defined by the International Association for the Study of Pain, is an "unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage." Pain has a neurophysiologic sensory component, which signals that tissue insult is occurring, and a perceptual psychological component, which affects the subjective experience of pain.

The following factors may modify the experience and expression of pain:

• A heightened awareness of bodily sensations (ie, somatosensory amplification) characterizes a personality style.
• Affective states, such as anxiety and depression, may increase a subjective sense of suffering.
• A signal of severe tissue damage is how pain is interpreted.
• While pain threshold is similar in males and females, with increasing age, girls report pain and seek relief more readily.
• Pain catastrophizing by the child or parent increases pain intensity, disability, and school absenteeism.
• Cultural/ethnic groups differ in the acceptability of expressing discomfort and in the value placed on pain tolerance.
• Developmental stage plays a role because children experience pain no less intensely than adults, but children younger than 8 years express more overt distress.
• Family influences affect the degree of disability caused by pain, ie, dysfunction due to pain is more pronounced in some families as a result of modeling and positive reinforcement of the sick role.

Frequency

United States

Medically unexplained headache or abdominal pain occurs at least once a week in 10-30% of children and adolescents. Prevalence has increased over the past decade. The diagnosis of pain disorder rests not only on the physician's inability to fully explain the pain on an organic basis but also on the clinical implication of the role of psychological factors.

Mortality/Morbidity

Psychological stress may result in a number of physical effects:

• Stress affects immune responses through the hypothalamus-pituitary-adrenal axis and the sympathetic nervous system.Neuropeptides and neurotransmitters are released, triggering various gastrointestinal responses, such as gut dysmotility. In recurrent abdominal pain, nonspecific inflammatory changes can be found on biopsy specimens at all levels of the GI tract, suggesting that immunomodulation plays a role in the pathogenesis of the symptom.
• Emotional distress can cause muscular pains and headaches through increased muscular tension.
• Psychologically induced changes in behavior, such as compulsive activity or prolonged bed rest, lead to secondary physiologic changes and attendant symptoms.

Race

Ethnic groups may differ in the acceptability of expressing discomfort and in the value placed on pain tolerance.

Sex

Medically unexplained somatic symptoms are more frequent in girls than in boys, and the difference is more marked in adolescence. Differences in pain threshold have not been noted, but girls report pain and seek relief more readily.

Age

• Children experience pain no less intensely than adults; however, children younger than 8 years express more overt distress.
• Medically unexplained pains occur more frequently with increasing age.
• Prepubertal children with pain disorder are usually monosymptomatic; recurrent abdominal pain is the most frequent symptom, followed by headaches.
• Adolescents with pain disorder are often polysymptomatic, with increasing frequency of headaches, limb pain, and chest pain in the same individual.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

• Obtain a history of physical symptoms from the parent and child. When 1 pain symptom is reported, inquire about other symptoms as well.
• Obtain a psychosocial history, including separate interviews with the parent and child to facilitate disclosure. Psychosocial factors implicated in pain disorder include the following:
• • Family history of anxiety, depression, and psychiatric problems
  • Family history of somatization and preoccupation with illness
  • Chronic physical illness in a parent
  • History of negative life events
  • Disorganized chaotic family functioning
  • Academic difficulties experienced by the patient
  • Problems with peer relationships
  • Previous history of somatization, behavior problems, or psychiatric illness
• Positive evidence of the role of psychological factors includes the following:
• • Onset of pains after stressful event
  • Exacerbation linked with stressful events
  • Relief of symptoms following removal of stressor
  • Pain out of proportion to objective medical findings
  • Disability or handicap out of proportion to reported pain
  • Secondary gain

Physical

A thorough physical examination is imperative for purposes of diagnosing the symptoms and, when indicated, reassuring the family. Examination of the patient both with and without the parents present is advisable.

Causes

A number of theories regarding the causes of pain disorder have been proposed; they should not be considered mutually exclusive.

• Biologic factors: Adoption studies have found somatization disorders to be 5-10 times more common in first-degree relatives of probands with somatization than in the general population.
• Psychodynamic theory: An unconscious conflict, wish, or need is converted into a somatic symptom, thus protecting the individual from conscious awareness of it.
• Trauma and abuse: An association between physical abuse, psychological abuse, or both and somatization has been well documented.
• Learning theory: The child learns from role models for illness behavior within the family. The child learns about secondary gains from the modeled sick role.
• Emotions and communication: Limited vocabulary and concrete thinking may cause a child to express distress in terms of physical symptoms.
• Environmental and social influences: In families and cultures in which psychological problems are stigmatized, the individual may communicate distress through a somatic symptom.
• Family systems theory: The child's sick role is encouraged because it serves to perpetuate specific family dynamic patterns. According to the model developed by Minuchin, families of somatizing children use the following 4 distinct transactional patterns:
• • Enmeshment
  • Overprotection
  • Rigidity
  • Lack of conflict resolution

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Malingering or factitious disorder
Pain disorder associated with a general medical condition: A general medical condition has a major role in the onset, severity, exacerbation, or maintenance of the pain. If psychological factors are present, they are not judged to have a major role.
Pain secondary to undiagnosed medical condition

Associated disorders: anxiety, depression, ADHD, conduct disorder

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• The primary physician orders laboratory studies based on clinical suggestion of a specific medical condition.

Imaging Studies

• The primary physician orders imaging studies based on clinical suggestion of a specific medical condition.

Other Tests

• The following are prerequisite conditions for successful referral by a medical practitioner to a mental health professional:
• • Timely, thorough medical evaluation
  • Interview and observation of family for psychosocial problems
  • Early mention of possibility that symptoms are stress-related
  • Discussion of negative medical workup results
  • Rationale provided for mental health referral
  • Assurance of ongoing medical follow-up care and collaboration with mental health specialist
• Mental health evaluation involves the following:
• • Quantifying the pain
  • Observation scales used with preschool-aged children
  • Direct scaling techniques that ask that young children pick out from a graded series the drawings of faces that match the way they feel
  • Pain questionnaires for older children and adolescents
  • Screening instruments, such as the Child Behavior Checklist, to identify children with somatic symptoms and possible somatoform disorders
  • Comprehensive structured interviews, such as the Diagnostic Interview for Children and Adolescents (DICA), that contain questions on somatization
  • The Personality Inventory for Children (PIC), which has been used in the diagnosis of somatoform disorders in children
  • Projective tests that may help clarify underlying psychological issues and add to the evidence for a somatoform diagnosis, including the Thematic Apperception test (TAT), the Children's Apperception Test (CAT), the Rorschach, and sentence completion
• Psychoeducational evaluation is recommended for patients with academic difficulties and prolonged school absence.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

• Medical care for physical illness must be appropriate for the diagnosed medical problems and requires judicious use of analgesics.
• Effective mental health treatment for children is family-centered. Goals for therapy include the following:
• • Gaining understanding of pain as a product of the interaction of physical and psychological factors
  • Improved family functioning
  • Learning strategies that produce some control over symptoms or reaction to pain, although symptoms may not be eradicated totally
  • Dealing successfully with anxiety generated by pain
  • Decreasing disability caused by pain
  • Limiting medical testing that is not helpful or necessary
• Types of treatment include the following:
• • Counseling
  • Relaxation training (eg, progressive muscle relaxation, induced self-hypnosis)
  • Behavioral methods (eg, behavioral-cognitive therapy)
  • Biofeedback
  • Family therapy (eg, focus on communication and appropriate responses)
• Treat comorbid conditions (ie, anxiety, depression).

Consultations

• Subspecialist consultations based on suspicion of specific medical disorders include the following:
• • Neurologist (chronic headache pain)
  • Gastroenterologist (chronic abdominal pain)

Activity

Encourage early gradual return to normal activity.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical care for physical illness must be appropriate for diagnosed medical problems and requires judicious use of analgesics.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• Medical care for physical illness must be appropriate for diagnosed medical problems, and inpatient care should be limited to concerns about acute or chronic serious medical illness.

Further Outpatient Care

• Medical care for physical illness must be appropriate for diagnosed medical problems and requires judicious use of analgesics.
• Close communication should be maintained between the primary care physician and the mental health professional. A team approach helps assure that all aspects of the child's health are being addressed.

Prognosis

• Outcome measure (physical symptoms): In the spectrum of physical symptoms, recurrent abdominal pain has been studied.
• • Seventy percent of patients continue to experience abdominal pain into adulthood; the symptom does not impair activity as in childhood, but it is more significant than in control subjects.
  • Additional symptoms, such as headaches, develop in 30% of patients.
  • Multiple symptoms in childhood predict poorer adult outcome.
• Outcome measure (functional and psychiatric status): In adulthood, individuals with a childhood history of recurrent abdominal pain are more likely than control subjects to have an anxiety disorder, hypochondriacal beliefs, or poor social functioning, and they are more likely to be treated with psychoactive medication.

Patient Education

• Encourage the patient's acceptance of an alternative diagnosis of the pain other than severe illness.
• Help the patient understand the role of psychological factors.
• Help the patient discover strategies for coping with the symptoms.
• Seek ways to reduce stressors that maintain the symptoms.

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Failure to recognize the presence of serious physical disease in the patient (Systematic medical follow-up care minimizes this possibility.)
• Excessive unfounded testing for organic disease
• • Headache: With detailed history, physical examination, and neurologic examination, the correct diagnosis can be made on the first visit in 80-90% of patients. In retrospective studies of children with brain tumors, suspect symptoms and signs appeared within several months of the onset of headaches.
  • Abdominal pain: With detailed history, physical examination, and laboratory investigation based on clinical suspicion, follow-up care rarely reveals an occult physical problem.
• Regarding pain disorder as a diagnosis of exclusion without positive evidence for the role of psychological factors

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• APA. Diagnostic and Statistic Manual of Mental Disorders. 4th ed. Washington, DC:. American Psychiatric Press;1994.
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• Campo JV, Bridge J, Ehmann M, et al. Recurrent abdominal pain, anxiety, and depression in primary care. Pediatrics. Apr 2004;113(4):817-24. [Medline]. [Full Text].
• Drotar D, Wolraich ML, Felice ME. The Classification of Child and Adolescent Mental Diagnoses in Primary Care, Diagnostic and Statistical Manual for Primary Care (DSM-PC). Elk Grove, Ill:. American Academy of Pediatrics;1996.
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• Ramchandani PG, Hotopf M, Sandhu B, et al. The epidemiology of recurrent abdominal pain from 2 to 6 years of age: results of a large, population-based study. Pediatrics. Jul 2005;116(1):46-50. [Medline]. [Full Text].
• Ramchandani PG, Stein A, Hotopf M, et al. Early parental and child predictors of recurrent abdominal pain at school age: results of a large population-based study. J Am Acad Child Adolesc Psychiatry. Jun 2006;45(6):729-36. [Medline].
• Sanders D. Counseling for Psychosomatic Problems. London, England:. Sage Publications;1995.
• Santalahti P, Aromaa M, Sourander A, et al. Have there been changes in children's psychosomatic symptoms? A 10-year comparison from Finland. Pediatrics. Apr 2005;115(4):e434-42. [Medline]. [Full Text].
• Stein MT, Crow J, Abbott M, Tanner JL. Organic or psychosomatic? Facilitating inquiry with children and parents. J Dev Behav Pediatr. Oct 2004;25(5 Suppl):S97-101. [Medline].
• Vervoort T, Goubert L, Eccleston C, et al. Catastrophic Thinking About Pain is Independently Associated with Pain Severity, Disability, and Somatic Complaints in School Children and Children with Chronic Pain. J Pediatr Psychol. Aug 2006;31(7):674-83. [Medline].

Article Last Updated: Aug 23, 2006