Psychiatric Aspects of Somatic Disorder in Child and
Psychiatric Aspects of Somatic Disorder in Child and
Psychiatric Aspects of Somatic Disorder in Child and
Somatic Disorder in
Child and Adolescent
DR. SAIFUN NAHAR
Associate Professor, Psychiatry, NIMH
Introduction..
In both, DSM-5 and ICD-11, the somatizing disorders most commonly seen in
children and adolescents are:
Pain.
Feeling tired or having a low energy level.
Stomach ache, nausea or vomiting.
Shortness of breath or trouble breathing.
Rapid heartbeat.
Dizziness.
Fainting.
Bowel problems (diarrhea, constipation, bloating, gas).
Movement challenges like weakness, paralysis, seizure-like episodes.
Memory problems.
Symptoms..
Biological and psychosocial factors, which are learned ways of thinking in the
context of a person’s environment, contribute to the cause of somatic symptom
disorder.
These factors may include:
Continuing, unresolved symptoms after an illness or an injury.
Stress or challenges that a child hasn’t been able to communicate verbally.
Excessive attention to bodily functions.
Possible signs of an illness.
Low pain threshold.
Increased anxiety about good health
Psychological Theories of FSS
A second school of thought, attachment theory, frames FSS as a way for the
child to maintain close proximity to the attachment figure (Bowlby, 1973).
The child's expression of physical discomfort and distress acts as a care-
eliciting function from the attachment figure (Campo & Fritsch, 1994).
Neither psychodynamic nor attachment theory, however, has received much
empirical attention with respect to FSS in children and adolescents.
Psychological Theories of FSS..
Third, the family systems approach posits that children's FSS serve a
communicative function for family members to maintain their daily routine
functioning as well as a way to avoid conflict and has been supported by
empirical studies (Aro, 1987, 1989; Terre & Ghiselli, 1997; Zuckerman et
al., 1987).
According to Minuchin's family systems theory, children's FSS are
conceptualized as a homeostatic mechanism for avoiding conflict in
enmeshed, over-protective, and rigid families (Minuchin et al., 1975).
FSS also have been viewed as having a communicative function, or being a
“plea for help,” for children (Campo & Fritsch, 1994), especially in families
characterized by poor parent–child relationships (Aro, 1989; Aro et al., 1987;
Raust-von Wright & von-Wright, 1981).
Psychological Theories of FSS..
Sixth, coping and stress response theories delineate that children's cognitive and
behavioral responses to chronic pain influences their level of pain and psychological
adjustment (Thomsen et al., 2002; Walker et al., 2007).
Coping has been defined as a child's voluntary efforts to regulate their emotions,
thoughts, behavior, physiology, and environment in response to stressful events (Compas,
Conner-Smith, Saltzman, Thomsen, & Wadsworth, 2001).
The manner in which children cope with such stressors has a great impact on FSS, pain
intensity, and internalizing symptomatology.
For example, in studies of children with recurrent abdominal pain, those children who
used more accommodating coping strategies (e.g., acceptance or distraction) in
response to pain demonstrated fewer FSS and symptoms of anxiety and depression.
In contrast, passive coping responses, such as disengagement, were found to be strongly
associated with increased levels of pain, FSS, and depressive symptoms (Thomsen et
al., 2002; Walker et al., 1997).
Psychological Theories of FSS..
Lastly, due to the high comorbidity of symptoms and diagnoses, FSS have been
hypothesized as a consequence of a psychiatric disorder, such as anxiety or
depressive disorders (Campo & Reich, 1999).
In the 1970s, FSS were viewed as “masked depression,” a condition where
children expressed their emotions through physical symptoms (Bschor, 2002;
Carlson & Cantwell, 1980).
Many studies have investigated the positive relation between internalizing
and/or externalizing behaviors and FSS, but few explicate possible
mechanisms for this association.
Some theories may be more important in earlier childhood (e.g., attachment
theory), while others may be more salient during adolescence (e.g., family
systems theory).
Figure 1. A working model for the study of functional
somatic symptoms across childhood and adolescence
Risk factors for somatization in children
and adolescents*
Individual Personal experience of physical illness • Enhanced focus on
physical sensations • Conscientious, vulnerable, sensitive,
anxious personalities • Particular concerns about peer
relationships • High achievement orientation
Family Physical health problems • Mental health problems • Parental
somatization • Emotional over-involvement • Limitations in the
ability to communicate about emotional issues
Environment • Life stresses e.g. school, teasing or bullying, • Academic
pressure.
Adapted from Gledhill & Garralda (2009)
Mechanism of developing FSS
In response to this perceived threat, the child may exhibit more signs of
physiological reactivity than other children, due in part to a heightened
awareness of bodily sensations (cognitive psychobiological and modeling
theories).
The quality of the parent–child relationship may shape the way a sensitive,
anxious, or emotionally reactive child copes with stress, which in turn, may
affect the course of FSS (pathway/progression).
On the other hand, a sensitive and/or anxious child may feel rejected by the
parent or may be more prone to get upset and emotionally overaroused in a
parent–child relationship ridden by hostility and conflict.
In such an acrimonious climate, or where emotional repression as opposed to
emotional expression is accepted, the child may begin to internalize feelings
and express FSS more frequently, as it is the only outlet for an anxious child's
feelings (psychodynamic theory).
Mechanism of developing FSS..
If a child lacks social competence (risk/protective factor), and has a high level of
anxiety (risk factor), the child may eventually feel helpless and hopeless, which
increases the risk for a later mood disorder and continued FSS
(pathway/progression).
With the onset of puberty, girls may be at greater risk for comorbid internalizing
and continued FSS than boys, perhaps due to hormones, interpersonal relationship
stressors, or socialization practices.
Boys with FSS may follow a much different trajectory than girls, where early
concentration difficulties and behavior problems prevent boys from learning
appropriate coping styles.
Social and academic failure and low self-esteem may lead to anger and acting out.
If taken to an extreme, these boys may evidence an externalizing disorder, and to
a lesser extent, FSS in later childhood and adolescence.
Impact
Consider somatic symptom and related disorders when the following are
present:
There is a time relationship between psychosocial stressor and physical
symptoms
The nature and severity or handicap from the symptom are out of keeping
with the pathophysiology
There is a concurrent psychiatric disorder
Differential Diagnosis
Specific treatments may involve individual psychological work, family work, liaison with
school and with social services.
Coordination of all therapists and professionals involved is vital to ensure everyone is working
towards similar goals.
Treatment should aim to develop partnerships with the child, family and all professionals
involved, including teachers, especially where school attendance is an issue.
Specific strategies will vary depending on the exact nature of the somatoform disorder.
The management of factitious disorders is similar to that for somatic symptom and related
disorders.
Emphasis on engaging the parents is crucial to reduce the risk of becoming punitive or
disengaging when the factitious nature of the presentation becomes known.
Young people with severe factitious symptoms often live in a family with interpersonal
problems, communication difficulties, and substance misuse, which make family work
challenging (Fiertag & Eminson, 2014).
Psychological Interventions
Close liaison with school to reduce school related stress and to address
conflicting expectations between the child, family and teachers is important.
Tailoring a school program and setting up strategies to help the child cope
with symptoms within the school (e.g., a reduced timetable) is an important
part of treatment.
If psychogenic non-epileptic seizures are a symptom, a clear management
plan that includes ways of reducing their dramatic impact within the school,
needs to be instituted.
In severe cases where children have been absent from school, a gradual
reintegration should be arranged, with consideration of admission to a
pediatric or psychiatric unit with educational facilities if available.
Elements of Cognitive Behavioral Family
Intervention
Discuss investigations and rationale for pain management
Encourage self-monitoring of pain
Reinforce well behavior
Develop healthy coping skills: relaxation, positive self-talk, distraction,
positive imagery
Teach problem solving skills
Encourage participation in everyday activities
Reduce attention from parents in relation to physical symptoms
Increase attention when symptom free by instituting pleasant joint activities
Hospitalization
Always consider child abuse and safety issues—the safety of the child must be
the uppermost consideration.
In rare instances the somatoform disorder will be the expression of severe
family dysfunction or child abuse.
Close cooperation and communication between all the professionals involved
are essential to avoid differing opinions being relayed to the patient and
family.
If families are unwilling to engage in any type of treatment for the child,
clinicians should consider whether it would be in the best interests of the
child to be treated away from the family.
This is a difficult issue to assess and would require close collaboration
between clinicians and child protection personnel.
Prognosis
Childhood somatic symptom disorders are associated with a history of somatic symptoms in the family
and with school non-attendance in the child.
A tendency to somatize can be observed in children as young as preschoolers and throughout childhood,
adolescence and adulthood.
Therefore, identifying families with high levels of somatic symptoms in the parents as well as the
children, and identifying those with frequent school absences, may provide an opportunity for early
intervention.
This could be done via
(i) primary care practitioners identifying parents who regularly attend with somatic complaints and
providing guidance regarding strategies for coping with their own and their children’s somatic
symptoms (e.g., distraction techniques) and
(ii) teachers and medical professionals identifying children who miss a lot of school because of physical
symptoms and supporting them in developing coping strategies and feel in control of situations they
find difficult.
In children with established symptoms, addressing personality vulnerabilities and excessive academic
and behavioral expectations may help prevent relapse
Cultural perspectives
The best evidence of efficacy comes from the use of family CBT.
However, helping families communicate about, and manage stressors for the
child is often clinically efficacious.
Engaging families during every step of assessment and treatment is important
and will aid recovery.
The lack of pediatric mental health facilities may impede this work in
developing countries with low levels of investment in child mental
healthcare, but psychoeducation by primary healthcare workers and
educators may still be an effective means of preventing and managing these
disorders across different countries and cultures.
Saira
Saira was a 12 year old girl of Pakistani background who had been diagnosed as suffering from epilepsy
at the age of five. She had been treated with anti-epileptic medication and had been seizure free for
four years. Saira presented to the local outpatient clinic with a recurrence of her fits. Her earlier
convulsions had been grand-mal seizures, mostly occurring during the night, accompanied by
incontinence. Her current episodes were not consistent with epilepsy, were occurring during the day
and were prolonged, lasting half an hour at a time. A stressor was identified; the family had decided
that as Saira had completed her primary school education there was no need for her to continue with
her schooling, she would stay at home to look after her youngest sibling so that her mother could return
to attend to the family’s livestock. A poor harvest meant that the family was under financial stress.
Treatment consisted of psychoeducation for Saira and her family, highlighting the close relationship of
the body and the mind, and the co-occurrence of physical symptoms with psychological stresses. In
individual meetings and later in family meetings, Saira was able to talk about her distress at the
proposed plan, which would result in the loss of her friendships at school as well as the positive
relationships she had with her teachers. Although financial considerations meant that no immediate
change could be made to the planned arrangements, the family agreed amongst themselves to try and
support her in continuing her education once the financial pressures had eased. They were happy to
support her in continuing to meet with her friends. Saira’s seizures subsided soon after.
Parents’ Perspective of a Child Presenting With Co-Existing Somatising and Physical Illness Sarah had a sudden and complete
loss of movement in her arms and legs and headaches. She was diagnosed with conversion disorder despite the presence of
an operable brain tumor. All her symptoms resolved following a joint medical and mental health intervention prior to surgery
– the surgeons were not prepared to operate until all symptoms had resolved, which fortunately they did, and fully. Below is
a quote from her parents: “Our daughter was approaching her 15th birthday and seemed to be enjoying life. She had plenty
of friends, was doing well at school and displayed a wide-ranging and vivid enthusiasm for learning and playing. After a
family holiday in a foreign country came complaints of severe back pain. This developed into intermittent headaches and an
inability to move her arms and legs. Upon admission to hospital it was clear that some of her symptoms did not have a
physical origin. This did not mean that the problem was less real, only more problematic. We were at a loss as to what may
have triggered this behavior. There were none of the obvious causes; a grandparent had died but some years previously and
of reasonably old age, and there was no evidence of abuse or trauma. All we were left with were the concerns that are
peculiar to puberty and adolescence, which are not part of the open discourse between parents and children. So, we were
standing on the edge of a half forgotten sea, half remembered from our own adolescence but unknown with this individual
and at a loss as to how it could relate to these symptoms. It ought to be stressed that there was huge support from the
medical team. Our daughter had physiotherapy, frequent reviews from the pediatric team and numerous interviews with the
child psychiatrist. Her life was explored from a psychological, family and social perspective. Eventually a physical event was
found: a brain tumor. This diagnosis led to a rapid mitigation of symptoms. It is possible − or probable − that the diagnosis of
a physical illness gave her a face-saving way to retreat from her symptoms. What is sure is that her symptoms served a
purpose. Certainly, we started the process with symptoms and no physical cause and we ended with a physical cause but no
symptoms; a strange sequence.” This example illustrates the complexities of many of these disorders and the fact that a
diagnosis such as conversion disorder can coexist with a physical illness, where the physical illness is not congruent with the
symptoms, and psychosocial contributory factors are identified on the psychiatric assessment.
Saira Saira was a 12 year old girl of Pakistani background who had been diagnosed as suffering from
epilepsy at the age of five. She had been treated with anti-epileptic medication and had been
seizure free for four years. Saira presented to the local outpatient clinic with a recurrence of her
fits. Her earlier convulsions had been grand-mal seizures, mostly occurring during the night,
accompanied by incontinence. Her current episodes were not consistent with epilepsy, were
occurring during the day and were prolonged, lasting half an hour at a time. A stressor was
identified; the family had decided that as Saira had completed her primary school education there
was no need for her to continue with her schooling, she would stay at home to look after her
youngest sibling so that her mother could return to attend to the family’s livestock. A poor harvest
meant that the family was under financial stress. Treatment consisted of psychoeducation for Saira
and her family, highlighting the close relationship of the body and the mind, and the co-occurrence
of physical symptoms with psychological stresses. In individual meetings and later in family meetings,
Saira was able to talk about her distress at the proposed plan, which would result in the loss of her
friendships at school as well as the positive relationships she had with her teachers. Although
financial considerations meant that no immediate change could be made to the planned
arrangements, the family agreed amongst themselves to try and support her in continuing her
education once the financial pressures had eased. They were happy to support her in continuing to
meet with her friends. Saira’s seizures subsided soon after.
Janine, a 10 year old girl, was referred because of a oneyear history of weekly presentations to casualty for multiple pains in all joints. Despite
extensive investigations, including X-rays and MRI scans, no organic pathology had been identified. Janine had been in a plaster cast and wheel
chair bound on five occasions despite no fractures being identified; as a result she had missed a lot of school. At the initial psychiatric
appointment Janine was extremely distressed by: − Severe aches and pains throughout her body (giving the pain a score of nine out of 10) − One
year history of bullying (mentioned for the first time at the assessment) − Weight gain − Deep sadness at the death of grandfather three years
earlier (“It is as if it has happened yesterday”). As a result of her aches and pains Janine had missed a lot of school. Her mother’s believed that
Janine had a physical illness yet to be identified and was unhappy about being “sent” to see a psychiatrist. Both Janine and her mother
described not communicating much as “talking makes things worse”. Hence, Janine had remained silent about the bullying and about her
feelings about her grandfather’s death. Her mother dealt with stress by “burying her head in the sand” and used alcohol on occasions (following
the example of some of her relatives). The child psychiatrist knew that many people contributed to Janine’s care, and all needed to be kept in
mind. In addition to the family doctor who had referred her, school staff, emergency room staff and the physiotherapist, all needed to work
together with Janine and her family. In spite of the family believing that Janine was suffering from a yet to be discovered physical illness, the
child psychiatrist and the others involved in Janine’s care, worked with Janine and her family in a model that incorporated the psychological,
biological, family and social factors. Janine was offered individual therapy sessions using cognitive behavioral techniques, as well as facilitating
emotional expression (including writing a letter to her deceased grandfather), positive self-talk, exploring alternative explanations for her pain,
anger management, problem solving skills, relaxation exercise, and distraction when in pain. Alongside this, family sessions were arranged to
encourage Janine’s mother to reinforce well-behavior, to spend time helping Janine cope with stress, to problem solve with Janine, to have non-
pain based talk with Janine, and to learn how to assess the seriousness of symptoms. Soon after the first session, the previous weekly attendance
to the emergency department stopped. Therefore, unnecessary use of medicines and procedures ended. When Janine was asked what had
changed since starting treatment, she described that she had acquired an emotional language. She felt safe to speak to people about her fears
about bullying and said she knew that talking was helpful as her aches and pains had got “half better”. Writing a letter to her late grandfather as
if he were still alive, about how much he had meant to her, helped her grief. She said that her aches and pains got better because “I had done
activities more often”. She was able to keep going “despite the pain” and she started to enjoy physical activities again, helped by using the
distraction and relaxation techniques she had learnt. She said she was accepting “a bit of pain”, which went away after a day following exercise.
Janine’s mother added that exercise had kept her joints working even though it hurt her. She spoke about how they had turned the TV off,
started talking and playing together. J
Kofi
Kofi is an 8 year old boy from a Nigerian family who presented with abnormal movements
affecting all his limbs. At the same time he would suddenly stop responding to questions from
others, make scary noises, sometimes stare at his family in a frightening way and he even
attacked his family occasionally. The abnormal movements and associated behaviors lasted
about 20 minutes at a time. His maternal grandmother suffered from generalized tonic-clonic
seizures. The family were concerned that he may be suffering from epilepsy but were equally
concerned that Kofi’s disturbed behavior resulted from being possessed by evil spirits. The
family described Kofi as being cursed after an elderly man in their community had looked at
him with an evil eye. They were keen to consult with a priest to perform an exorcism.
Psycho-social stressors included financial difficulties, housing problems, parental separation,
peer relationship difficulties at school, poor school attendance and Kofi experiencing
symptoms of anxiety. Kofi’s difficulties resolved with interventions involving the family,
medical consultation to exclude seizures (including EEG), help with housing and financial
support, liaison with the priest to ensure religious rituals did not harm the child and, finally,
meetings with the school to support Kofi’s attendance and reintegration with peers.