Psychosomatic Disorders in CAMHS Fernanda Garcia-Costas Child and Adolescent Consultant Psychiatrist

Psychosomatic Disorders Group of disorders characterized by physical symptoms that cannot be fully explained by a neurological or organic condition. It is common for children to report recurrent physical symptoms with no physical cause, and the actual diagnosis in children can be made.

Signs and symptoms Headaches. Abdominal distress. Anxiety and worry, fatigue, loss of appetite, aches and pain are frequent symptoms, more prevalent in girls than boys. Symptoms that mimic neurological disorders, such as double vision, poor balance and coordination, paralysis, seizures. Perceived physical deformities or defects. Back pain. Fatigue. Sore muscles. Often accompanied by academic problems, school refusal, social withdrawal, anxiety and behavioural problems.

Demography Prevalence: between 1.3 to 5 %. Less sophisticated or less educated populations and lower SES groups. Prepubertal Female=Male Post-puberty 2 Female=Male General population somatic complaints 11% girls and 4% boys.

Aetiology Children react differently to stress Role of personality, resilience and coping strategies. Ability to express emotions related to developmental stage, temperament and emotional climate of the family and cultural customs Most common triggers: Psychosocial stressors Trauma (physical or sexual abuse) Family conflict.

Causes Causes are unknown. Psychosocial theory: Symptoms as social communication to express emotions or to symbolize feelings. Psychoanalytic interpretation: Symptoms as repressed instinctual impulses. Biological studies : Individual may have a faulty perception and assessment of sensory inputs. Genetic data: Somatoform disorders tend to run in families with an occurrence of 10 - 20% in first degree female relatives. Anxiety and depression are more common in the families of somatizing children

Specific types DSM IV

Conversion Disorder Most common type diagnosed in children. Unexplained symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition. The symptoms resemble neurological conditions such as blindness, seizures, gait imbalance, paralysis, tunnel vision and numbness. Children may complain of weakness; trouble walking, talking, or hearing. Trauma and abuse increase the likelihood of Conversion Disorder, which is usually triggered by psychological factors.

Somatization Disorder At least 2 years of multiple and variable physical symptoms for which no physical explanation has been found. Persistent refusal to accept the advice of several doctors that there is no physical explanation. Some degree of impairment of social and family functioning attributable to the nature of the symptoms.

Body Dysmorphic Disorder The preoccupation with an imagined or exaggerated defect in physical appearance.

Hypochondriacal disorder Preoccupation with the fear of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms or bodily functions.

Undifferentiated Somatoform Disorder Unexplained physical complaints Lasting at least 6 months Below the threshold for a diagnosis of Somatization Disorder. When somatoform symptoms do not meet the criteria for any of the specific Somatoform Disorders, a diagnosis of Somatoform Disorder Not Otherwise Specified is utilized.

Treatment Educate the child regarding the interpretation of bodily sensations. Develop and reinforce coping behaviours that reduce the gain associated with the sick role through individual, family, group and cognitive behavioural therapies. Relaxation techniques useful. Identify and plan appropriate treatment for co-morbid diagnoses, i.e., anxiety, depression. When indicated, medication management with SSRIs, anxiolytics, and mood stabilizers is effective.

Ania (17) Born in the U.S. to eastern Arabic parents. Wanted to attend an out-of-town college. Parents disapproving as in accordance with their culture, wanted her to remain at home while attending college. The disagreement was not discussed openly; it was assumed that Ania would attend a local college. She developed seizures and was admitted to a hospital for observation. Neurological tests were negative and an organically-based seizure disorder was ruled out.

After psychiatric consultation: Seizures as related to a long-established pattern in which Ania did not deal directly with her anxiety. Unable to express negative and angry feelings, Ania reacted with her body. Her conflict in assertively expressing her feelings to her parents about leaving home resulted in the pseudo-seizures. Family was helped to consider the symptoms as a manifestation of cultural style they learned new ways to communicate their feelings, and the symptoms remitted.

Scott (10) Complained over a period of more than a year of severe stomach aches, often resulted in vomiting. His paediatrician conducted a series of diagnostic tests and found no physical basis for his complaints. School avoidance pattern was ruled out, since Scott willingly attended school. He was a good student, well-liked by his classmates and an outstanding football player. He spent many after-school hours at football practice and practiced at home, travelled with his team, took trombone lessons, and often stayed up until midnight completing his homework. Scott's parents began to think his complaints were imagined.

Psychiatric consultation Helped to understand that when stress builds up without relief the body may react. They were advised to make life-style changes such as limiting his football practice and trombone lessons to reduce the pressure that Scott was experiencing. The stomach aches and vomiting subsided within a few months.