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Introduction

Sometimes a child or adolescent continually complains of a discomfort or a pain for which a physician cannot find a cause. The pain or the discomfort, however, is very real to the child or adolescent. Physical complaints with no apparent medical basis may be a reflection of a stress, such as nervousness in a social situation, a demanding school setting, separation from parents, or other stressful situation. Stress, as it affects the body and the mind, has an effect on some illnesses and can influence how a child or adolescent perceives the symptoms of the illness, how he or she deals with the illness, and the rate of recovery.

Somatoform Disorders is the relatively new term used in the Diagnostic and Statistic Manual, Fourth Edition (DSM-IV) to describe a group of disorders characterized by physical symptoms that cannot be fully explained by a neurological or generalized medical ("organic") condition. Although it is common for children to report recurrent physical symptoms with no physical cause, the actual diagnosis in children can be made but is rare because the criteria for Somatoform Disorders were established for adults and certain symptoms are not yet experienced by children.

Real life stories

Ania, a 17-year-old girl, born in the U.S. to eastern Arabic parents, wanted to attend an out-of-town college. This plan evoked the sharp disapproval of her parents, who, in accordance with the custom of 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 and a number of sessions with both Ania and her parents, they came to view the 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. When the 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, aged 10, complained over a period of more than a year of severe stomachaches, which often resulted in vomiting. His pediatrician conducted a series of diagnostic tests and found no physical basis for his complaints. A school avoidance pattern was ruled out, since Scott willingly attended school; he was a good student, well-liked by his classmates and an outstanding soccer player. However, he spent many after-school hours at soccer practice, practiced compulsively 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. In consultation with a mental health professional they were 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 soccer practice and trombone lessons to reduce the pressure that Scott was experiencing. The stomachaches and vomiting subsided within a few months.

Ania and Scott were diagnosed as having Somatoform Disorder.

What are the symptoms?

In order to meet the diagnosis of Somatoform Disorder, the person must demonstrate a pattern of recurring, multiple, clinically significant physical complaints, the symptoms of which are NOT produced voluntarily.

The recurrent symptoms commonly reported by children and adolescents are:

• Headaches
• Abdominal distress
• With the hormonal changes of puberty, 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
• Imagined physical deformities or defects
• Back pain
• Fatigue
• Sore muscles

Academic problems, school refusal, social withdrawal, anxiety and behavioral problems often accompany Somatoform Disorders.

Somatoform Disorder must be distinguished from two other diagnoses: Malingering and Factitious Disorder, which are both characterized by consciously or purposely produced symptoms.

Types of Somatoform Disorders diagnosed in children (as specified in DSM IV)

Conversion Disorder is the most common type diagnosed in children (see the description of Ania above). Conversion Disorder involves unexplained symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition. The symptoms resemble neurological conditions and physical ailments with organic cause such as blindness, seizures, gait imbalance, paralysis, tunnel vision and numbness. Children may complain of weakness; they may have trouble walkiing, talking, or hearing. Trauma and abuse increase the likelihood of Conversion Disorder, which is usually triggered by psychological factors.

Somatization Disorder is a polysymptomatic disorder that begins before age 30 years, extends over a period of years, and is characterized by a combination of pain, gastrointestinal, sexual and pseudoneurological symptoms. This chronic, recurrent disorder with multiple complaints is often presented in a dramatic and exaggerated way. It is difficult to diagnose in children because of the criteria regarding sexual symptoms.

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

Hypochondriasis is the 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.

Pain Disorder has limited usefulness in children since there are few studies to distinguish it from Conversion Disorder. Pain Disorder is characterized by pain as the predominant focus of clinical attention.

In addition, psychological factors are judged to have an important role in onset, severity, exacerbation, or maintenance.

Undifferentiated Somatoform Disorder is characterized by unexplained physical complaints, lasting at least 6 months, that are 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.

Who is likely to have it?

Studies show conflicting evidence regarding the occurrence of Somatoform Disorders.

In a child psychiatric outpatient study, rates ranged from 1.3 to 5%. In a general population study, somatic complaints were found in 11% of girls, and 4% of boys. Adult studies show .2 - 2% in women and less than .2% in men. Somatoform disorders are believed to occur more often in less sophisticated or less educated populations and lower SES groups. In terms of gender differences there is a 5:1 female-male ratio.

Studies of prepubertal children report an equal ratio in boys and girls, but in post-puberty the female incidence increases.

Why does it happen?

Children react differently to stress, depending on individual personal characteristics, such as their appraisal of the event and their coping strategies. Certain childrn have more difficulty than others in expressing their emotions directly, due to their individual temperament, the emotional climate of the family, and cultural customs. The most common triggers of Somatoform Disorders are psychosocial stressors, trauma (physical or sexual abuse) or family conflict. Although there are a number of hypotheses regarding the genesis of Somatoform Disorders, the exact causes are as yet unknown.

1. Psychosocial theory views the symptoms as social communication to express emotions or to symbolize feelings.
2. A psychoanalytic interpretation views symptoms as repressed instinctual impulses.
3. Biological studies suggest the individual may have a faulty perception and assessment of sensory inputs.
4. Genetic data suggest that somatoform disorders tend to run in families with an occurrence of 10 - 20% in first degree female relatives. Other evidence shows that anxiety and depression are more common in the families of somatizing children. Parents of children with recurrent abdominal pain reported more psychiatric symptoms.

How is it treated?

A professional assessment is the first step in treating a child who may have a Somatoform Disorder. The professional conducting the assessment will generally perform the following procedures:

1. Perform a complete initial medical workup of the symptoms, including a physical exam.
2. Examine the child without the parent present and note if there are any changes in the child's behavior.
3. Obtain a psychosocial history, including information about possible stressors.
4. Inform the family of the importance of psychological factors which may contribute to the symptoms and the plan to manage them.
5. Introduce the concept of an in-depth psychiatric or psychological evaluation to assist in understanding the symptom picture and causes and management of the symptoms.

Intervention procedures include the following. A mental health professional will:

1. Communicate with the primary care physician to avoid duplication of services and tests and the transmission of contradictory information to the family.
2. Educate the child regarding the interpretation of bodily sensations.
3. Develop and reinforce coping behaviors that reduce the gain associated with the sick role through individual, family, group and cognitive behavior therapies. Relaxation and biofeedback techniques are useful.
4. Identify and plan appropriate treatment for co-morbid diagnoses, i.e., anxiety, depression.
5. When indicated, medication management with SSRIs, tricyclics, anxiolytics, stimulant and mood stabilizers is effective.

Questions & Answers

My 8-year-old daughter Lisa comes home from school most days crying and pointing to her legs. When we ask her if she's in pain she nods her head. When we ask her what happened at school she just shrugs her shoulders and won't answer. How can we tell if she really feels pains in her legs?
Lisa is expressing her pain as a younger child would, by crying and physical gestures. Encourage her to describe her pain in words. Reassure her that you know her pain is real and that ways can be found to help her. Try to ascertain if there are situations at home or at school that may be stressful for her.

My son is 16 and likes to eat a large dinner, including dessert. He gets up every night about 1 A.M. complaining of a stomachache or a headache and then can't get back to sleep. Is he just doing this to interfere with our sleep?
If, after a physical check-up, he still has abdominal complaints which are interfering with his daily personal and academic functioning, be aware that the symptoms are not produced intentionally, but may be emotionally based. Try to pinpoint potential causes. He may be experiencing academic pressure, family conflict, a change in school, a move, a reaction to the illness or death of a family member or friend, or possible physical or sexual abuse. Adolescents may attempt to self-medicate with alcohol or drugs.

Are there any practical ways to help an 8-year-old boy who says his throat always hurts him? His pediatrician finds no physical basis for this complaint.
Devise ways to give him a sense of control. For some children, keeping a log will help identify the times and specific situations which are associated with the pain. A particular cause of stress may then be apparent. Life changes, such as a change of school demands, adjustment in family relationships, modification of an overly crowded schedule of activities, may then bring relief.

My 12-year-old daughter has chronic sinusitis. She gets up late every morning and says she thinks she's getting an infection. Should I allow her to stay home from school even when I think she's really not sick?
Be careful not to inadvertently reinforce the behavior by becoming visibly alarmed and overly solicitous, or allowing her to stay home or to avoid social situations. Be sure that she is getting appropriate medical treatment for her sinusitis. If improvement does not occur, consultation with a mental health professional is warranted.

References

American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC: American Psychiatric Press.

Behrman, RE, Kliegman, R & Jenson, HB (Eds.) (2000) Nelson Textbook of Pediatrics (16th ed.). Philadelphia: W.B. Saunders & Co.

Lewis, M. (Ed.) (1991) Child and Adolescent Psychiatry: A Comprehensive Textbook. Baltimore: Williams and Wilkins.

Sadock, BJ & Sadock, VA (Eds.) (2000) Kaplan & Sadock's Comprehensive Textbook of Psychiatry (7th ed.). Baltimore: Lippincott, Williams & Wilkins Publishers.

Campo, JV & Fritsch, SL (1994) Somatization in children and adolescents. Journal of the American Academy of Child & Adolescent Psychiatry. 33, 1223-1235.

Leslie SA (1988) Diagnosis and treatment of hysterical conversion reactions. Archives of Disease in Childhood. 63, 506-511.