▪ Somatoform Disorders



▪ Somatoform Disorders





The somatoform disorders present important challenges in relation to medical and psychiatric systems of care. The child or adolescent may present with dramatic or painful somatic symptoms even when no pathological process is demonstrable. These symptoms challenge the model of medicine practiced in the United States and other developed countries, where distinctions between physical and mental illnesses tend to be drawn rather sharply and where differences in conceptualization (i.e., of mental and physical illness) may make for major differences in both treatment and reimbursement of care. Child and adolescents with what appear to be “functional” problems tend to be viewed with suspicion and distrust. The original concept of neurosis, as developed by Freud and others, particularly Freud’s conceptualization of hysteria, underscored the attempt to understand physical symptoms in the apparent absence of medical disease. Developmental issues are important, as anyone who has dealt with young children is very much aware, given the potential anxiety related to bodily experiences in this age group.


DEFINITION AND CLINICAL FEATURES

The Diagnostic and Statistical Manual of Mental Disorder (DSM-IV-TR) recognizes several conditions in which symptoms suggest a physical disorder but are not adequately explained by the presence of an associated general medical condition. These include somatization disorder, undifferentiated somatoform disorder, conversion disorder, pain disorder, hypochondriasis, body dysmorphic disorder (BDD), and somatoform disorder not otherwise specified (NOS). These diagnoses require clinical judgment about the extent to which a particularly symptom does or does not arise from a general medical condition and whether that disorder, if present, is sufficient to account for the patient’s difficulties. By definition, these disorders do not represent conscious falsification or malingering. They are also distinguished from psychological factors affecting medical conditions. Given the potential of children to experience somatic symptoms with a range of problems, notably anxiety disorders, a clinical judgment must be made about whether the somatic symptoms are most appropriately (“better”) explained by a different condition. As a result of all these factors, these diagnoses may be among the least reliable ones made in child psychiatry. It is particularly important for the clinician to be supportive and not to rush to premature judgment because sometimes the true nature of difficulties will only become apparent over time. On the other hand, if findings are negative and the child or adolescent’s functioning is significantly impacted, it is important that plans for treatment and
intervention move forward. Various alternatives to the current approach have been considered and it is likely that changes will be made in these categories and their definitions in the future (Campo & Fritz, 2005). Table 17.1 provides an overview of these disorders.








TABLE 17.1 THE SOMATOFORM DISORDERS: AN OVERVIEW





































Condition


Diagnostic Features


Other Information


Somatoform disorder


Multiple symptoms, including pain (multiple sites); GI (at least two symptoms); and some sexual, reproductive, or other (nonpain) symptoms


Diagnosis is unusual in children (partly because of the definition); concept has its origins in Briquet’s description (he noted that symptoms typically began before adulthood)


Undifferentiated somatoform disorder


Multiple somatic complaints, various body systems or locations, lasting at least 6 months


Children are more likely to qualify for this diagnosis


Conversion disorder


One or more symptoms in voluntary motor or sensory system suggesting neurological or other medical condition, but symptoms appear to have a psychological basis (e.g., might arise after stress, family model of illness) and often the child is not particularly disturbed by the symptom (la belle indifference)


In children and adolescents, apparent seizures, paralysis, sensory symptom(s), or gait problems are most common; various subtypes proposed based on symptom nature (motor, sensory, seizures, mixed motor and sensory)


Pain disorder


Pain in one (or more) sites causing clinical attention and distress or impairment


Subtypes include association with psychological factors, medical condition, or both


Hypochondriasis


Persistent fear or belief that a child or adolescent has a physical disease; must last at least 6 months


Issues of overlap with anxiety disorders, and OCD in particular has been noted


Body dysmorphic disorder


Either a slight or imagined body defect becomes preoccupation, causing distress or impairment


Limited information in children and adolescents is available, but the condition clearly starts during this time in some cases; skin concerns are most common; possible relationship to OCD


Somatoform disorder not otherwise specified


A residual category used when an individual does not meet specific criteria for one of the somatoform disorders but symptoms are present


This category would be used, for example, in cases not yet meeting time or duration criteria


GI, gastrointestinal; OCD, obsessive-compulsive disorder.


In somatization disorder, various, multiple somatic complaints are present in association with requests for medical treatment or some significant impairment. These complaints must have their onset before age 30 years. The DSM-IV-TR required multiple (at least four) pain
symptoms in various part of the body or /bodily functions, at least two gastrointestinal (GI), one sexual, and one apparently neurological symptoms. By definition, these difficulties have not been explained after reasonably medical assessment or, if a medical condition is present, the degree of impairment or complaint is excessive. By definition, the disorder cannot be one that is consciously produced (in such a situation malingering or “factitious” disorder) would be diagnosed. In undifferentiated somatoform disorder, the patient has ether one or more physical complaints, which again, do not appear to be explained adequately by a medical condition or use of a drug or medication or, if such a condition were present, the impairment or complaint is greater than would be expected.

The notion of somatoform disorder has its roots in the notions of hysteria or, as it is sometimes termed, Briquet’s syndrome. Briquet noted that the onset was often in childhood or adolescence and that early onset seemed to prefigure worse outcome. The DSM-IV-TR criteria are somewhat detailed and arbitrary and require some sexual symptoms, which makes the diagnosis somewhat more difficult (but not impossible to make) in children. Children and adolescents with complaints in various locations who do not meet criteria for somatization disorder often do meet criteria for undifferentiated somatoform disorder, although this requires a minimum duration of 6 months. This term roughly corresponds to an old term, neurasthenia, which is no longer recognized in the DSM-IV.

The diagnosis of conversion disorder is made when there is a disturbance in voluntary motor or sensory functions suggesting a specific medical or neurological disorder but when psychological factors appear to play a major role (e.g., stress, conflict, or bereavement). Frequent presenting symptoms include the onset of paralysis, a movement problem, or other muscular or sensory disturbance after some stress. Typically, the child or adolescent is much less concerned about the symptom than either parents or physicians; the term la belle indifference has been used to refer to this phenomenon. Symptoms may also take the form of sensory symptoms or apparent seizures, gait disturbance, or paralysis. Although usually self-limited, these symptoms can occasionally result in long-term disability. The DSM-IV-TR makes various distinctions between subtypes based on the nature of the symptoms present (e.g., motor, sensory, seizures, mixed). The condition is unusual in that psychological factors are thought to be clearly associated with the symptom or disturbance, which must be a source of distress or impairment. The diagnosis is not made if the condition is factious or if the problem is limited to pain or sexual dysfunction.

In pain disorder, pain is present in one or multiple sites and is sufficient to warrant attention and cause distress or impairment. The subtypes of this disorder reflect the degree to which the difficulties are associated with a medical condition, a psychological factor, or some combination of the two. A further distinction is made based on chronicity (shorter vs. longer than 6 months’ duration).

In hypochondrias, the child or adolescent fears or indeed believes that he or she has a significant medical condition, and this fear persists for at least 6 months even when medical reassurance is provided. The term somatosensory amplification refers to the misinterpretation or experience of excessive concern related to one or more physical sensations. The condition must be differentiated from delusional disorder; in the latter, the concern is of delusional proportion. The condition is not diagnosed if the preoccupation or belief is related to some perceived body defect; in such cases, BDD (described subsequently) is the more appropriate diagnosis. Differentiation from other conditions (e.g., obsessive-compulsive disorder [OCD]) can be a challenge at times, and in some ways, hypochondria might just as appropriately be viewed as an anxiety disorder.

In BDD, there is preoccupation with either a real, although slight, or imagined defect in physical appearance. This must be the source of significant distress or impairment. Although the literature on this topic in children is very limited, it does appear that in perhaps 10% of cases the onset is in childhood or adolescence. Any body area or part can be the focus of the preoccupation, although skin concerns (scars, facial acne, other blemishes) are most common. BDD is one of the easier diagnoses to miss because it often the focus of much shame, and attempts are made to conceal it. Furthermore, the condition may present more in dermatologic or surgical settings, where an awareness of real lesions (even if self-inflicted) may lead to the
impression of a significant medical problem and to treatment. Efforts to conceal the presumed defect may be considerable. In many ways, this condition is closely related to OCD.

A final category, somatoform disorder NOS, is made when symptoms consistent with a diagnosis in this group of disorders are present but the individual fails to meet specific guidelines for one of the other, better defined, disorders.


EPIDEMIOLOGY AND DEMOGRAPHICS

As any pediatrician or primary care provider can attest, it is very common for children (and or their parents) to present with physical symptoms without an apparent medical etiology. Available research on the topic is complicated by many factors (e.g., changes in definition, problems in case finding and sample selection, overreliance on a single informant, or a selective focus on some symptoms to the exclusion of others). A major problem arises relative to the issue of a symptom’s being medically “unexplained.” Sometimes early in the course of an illness, the child or adolescent may present with vague symptoms without having, as yet, developed characteristic physical findings, and it is important that the clinician keep this in mind before “writing off” patients with unexplained pain or physical complaints. A failure to include careful medical examination at the time and at follow-up is another limitation of much of the available case report literature.

About 50% of preschool- and school-age children will report at least one functional somatic symptom. Often, more than one complaint is present. One study (Offord et al, 1987) found recurrent, but distressing, symptoms in 4% of boys and 11% of girls (ages 12 to 16 years of age). It is common for multiple complaints and symptoms to cluster together. Similarly, chronic pain is a relatively frequent complaint in children and adolescents with a prevalence of perhaps 25%. Medications for pain are frequently given, and medical evaluations are common. Headache is the most frequently reported pain symptom in children and adolescents and probably accounts for 1 to 2% of all outpatient pediatric visits. Other frequent complaints include functional abdominal pain frequently associated with other GI symptoms. Complaints of chest pain are also relatively frequent. Other functional difficulties may include chronic fatigue, musculoskeletal aches and pains, and fatigue. The latter is more frequent in adolescents, and GI complaints are more common in preschool children (Abu-Arafeh & Russell, 1995).

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Aug 1, 2016 | Posted by in PSYCHIATRY | Comments Off on ▪ Somatoform Disorders

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