Family and Environmental

Individual

Medical

The medical evaluation of suspected psychosomatic illness should include an assessment of biologic, psychologic, social, and developmental realms both separately and in relation to each other. A comprehensive medical work-up to rule out serious physical illness must be carefully balanced with efforts to avoid unnecessary and potentially harmful tests and procedures. Although the likelihood of finding physical illness in patients with somatoform disorders at initial diagnosis is less than 10%, certain physical illnesses should be considered, such as Lyme disease (Chapter 214), systemic lupus erythematosus (Chapter 152), multiple sclerosis (Chapter 593), infectious mononucleosis (Chapter 246), irritable bowel syndrome (Chapter 334), migraine (Chapter 588.1), and seizure disorders (Chapter 586).

The presence of a physical illness does not exclude the possibility of somatization having an important role in the child’s presentation. Somatic symptoms early in a disease course that can be directly attributed to a specific physical illness (e.g., acute respiratory illness) can evolve into psychologically based symptoms, particularly in situations in which the child experiences benefit from adopting the sick role. Somatic symptoms can also occur in excess of what would be expected of the symptoms experienced in true physical illness. Physical findings can occur secondary to the effects of a somatoform disorder (e.g., disuse atrophy).

Psychologic

Assessment of psychosomatic illness should consider inconsistent findings in the medical evaluation, the presence of psychosocial stressors, the presence of comorbid depressive or anxiety disorders, a past history of somatization in the child and/or family, a symptom model of illness behavior in the family, and the presence of secondary gain or reinforcement of physical illness. The presence of any one risk factor does not conclusively prove the presence of a somatoform disorder; psychiatric and social risk factors can increase the diagnostic likelihood.

If somatization is suspected, psychiatric consultation should be included early in the diagnostic workup. The reason for consultation should be carefully explained to the family to help avoid the parents’ perception that their child’s symptoms are not being taken seriously by the pediatric team (i.e., “it’s in her head”). It should be explained that the goal of the psychiatric consultation is to understand the origins of the child’s distress, why the child uses somatization as a way to express the distress, what perpetuates it, and which treatments are likely to be most effective.

Diagnosis and Differential Diagnosis

Conversion disorder denotes the loss or alteration of physical functioning without demonstrable organic pathology (see Table 20-3). It occurs in adolescence or adulthood, although numerous childhood cases have been reported. Conversion reactions usually start suddenly, can often be traced to a precipitating environmental event, and can end abruptly after a short duration. Voluntary musculature and organs of special sense are the most common target sites for expressions of conversion reactions. Such reactions can take the form of blindness, paralysis, diplopia, and postural or gait disturbances. Pseudoseizures are a common manifestation of a conversion disorder.

Physical examination often fails to reveal objective abnormalities. Histories might reveal a close relationship with someone who exhibited similar symptoms or had a recent episode of acute illness. Findings inconsistent with organic pathology are often seen. Deep tendon reflexes can be elicited in a paralyzed limb, or pupillary responses to light can be elicited in patients who report blindness. Video electroencephalography and postictal serum prolactin levels (elevated in true seizures) are useful in diagnosing pseudoseizures. Abasia-astasia is a conversion disorder manifest as an inability to stand or walk.

Vulnerability to conversion disorders is not clearly linked to any specific cause, although anxiety and family disturbance can be factors. Children with conversion disorders are highly suggestible, which often helps in treatment. Cultural background affects how illness and distress are expressed and should be considered before diagnosing conversion disorder. Follow-up studies indicate that about 30% of children with a diagnosis of conversion disorder are later found to have a medical disorder that can explain the original symptoms.

In somatoform pain disorder, pain is the primary physical symptom (see Table 20-4). These disorders are characterized by reoccurrence. Prevalence studies suggest that 11% of boys and 15% of girls have ongoing somatic symptoms. Recurrent abdominal pain accounts for 2-4% of all pediatric visits and headaches for an additional 1-2%. Most of these children do not have any positive clinical findings.

The primary differential diagnosis of psychosomatic illness is between that of somatoform disorder and a physical illness. Mood and anxiety disorders often include the presence of physical symptoms that tend to remit with treatment of the primary mood or anxiety symptoms and that appear distinct from physical complaints seen in somatoform disorders.

Additional diagnoses to consider include malingering and factitious disorders. Malingering, which is very rare in the pediatric setting, can be distinguished from somatoform disorders by looking at the motivation for the symptoms. Persons who are malingering will intentionally produce or exaggerate physical symptoms to receive some external reward. Persons with factitious disorder on the other hand are not motivated by external rewards but instead have an intrapsychic need to remain in the sick role (Table 20-5). Factitious disorders cause somatic and/or psychologic symptoms that are deliberately fabricated in the absence of any potential gain to the patient, other than the benefit of assuming the sick role (see Table 20-5). Munchausen syndrome is an example of a chronic factitious disorder typically seen in adults who persist in seeking medical treatments, including surgery, despite the lack of any real disease. Factitious disorder by proxy is a variant in which parents induce physical symptoms in their children in order to assume the sick role by proxy (Chapter 37.2). In such cases infants and young children can present with fractures, poisonings, persistent episodes of apnea, and other unusual ailments. It is considered a form of child abuse, which can be lethal, and must be reported to the appropriate authorities.

Education of the Patient and Family

With completion of the medical and psychologic assessments, it is crucial to present the findings to the patient and his or her family. The etiology of the child’s symptoms should be reframed in a broader biopsychosocial understanding through an “informing conference” where the findings are conveyed to the family. It is critical to give both a physical and emotional interpretation of the child’s symptoms in a supportive and nonjudgmental manner. It is important for the family to directly hear from the pediatric practitioner that the symptoms are not solely the result of a physical condition, thereby facilitating acceptance of the role of psychologic factors.

It is not unusual for parents to be doubtful or rejecting of the formulation and proposed treatment. In these instances it is helpful to gently explore the source of the parent’s resistance. Common reasons include previous errors on the part of health care providers leading to lack of trust, the family’s past experience of serious physical illness that can create a pattern of anxiety and hypervigilance, and concerns about the stigma of being labeled with a mental health illness. It is particularly important not to come across as dismissive of the family’s concerns or the child’s symptoms or suffering. It may be extremely beneficial to devote extra time to further discussion, clarification, education, and normalization of the child’s presentation.

Regular team meetings should be encouraged to maintain close communication between health care providers and minimize inconsistencies and miscommunications that have the potential to increase the patient’s and family’s mistrust and frustration.

Implementing a Rehabilitation Model

A rehabilitation model approach provides a useful framework for the treatment that shifts the focus away from finding a cure for symptoms and instead emphasizes a return to normal adaptive functioning. This includes increased activities of daily living, improved nutrition, enhanced mobility, return to school, and socialization with peers. It is generally counterproductive to adopt a confrontational approach or try to talk patients into giving up their symptoms. Unlike malingering and factitious disorders, somatoform symptoms are not consciously produced and they are experienced as “real suffering” by the patient. Any implication that the symptoms are not real can lead to increased frustration and escalation of symptoms.

Treatment approaches include the use of intensive physical and occupational therapies that emphasize the recovery of function. Behavioral modification approaches include increasing attention and reward for adaptive functioning as well as reducing environmental reinforcers and unnecessary medical interventions to minimize the sick role. Relaxation strategies, biofeedback, hypnosis, and/or integrative therapies (e.g., acupuncture and massage therapy) are also useful.

Cognitive-behavioral therapy, individual psychotherapy, and/or family therapy can help a child adjust to the stress of the illness and to learn new coping strategies. Individual psychotherapy can play an important role in helping change a child’s erroneous cognitions about his or her ability to resume functioning. Patients are encouraged to express their underlying emotions and to develop alternative ways to express their feelings of distress.

Psychotropic interventions may be beneficial if there is evidence of underlying or co-morbid depression or anxiety.

When the child is being managed as an outpatient, regularly scheduled visits to the pediatric practitioner can help alleviate anxiety and potentially reduce the frequency of unnecessary emergency department visits, diagnostic work-ups, and inpatient hospitalizations. It is also important to establish regular contact and liaison with key school personnel to provide guidance and education on how to address the child’s physical symptoms and complaints in the school setting. Collaborative models of health care that integrate mental health consultation within the primary care setting may be especially helpful for this group of patients and families.