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PSYCHOSOMATIC PROBLEMS AND STRESS IN ADOLESCENCE
0031-3955/97 $0.00
ADOLESCENT MEDICINE
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PSYCHOSOMATIC PROBLEMS AND STRESS IN ADOLESCENCE John W. Greene, MD, a n d Lynn S. Walker, PhD
Stress is universal in the lives of today's adolescents and may impact their health and well-being.18-20,36 High levels of stress may be associated with distress and somatic symptoms, leading the adolescent to seek health care.40,41,47 Pediatricians and other professionals who provide health care for adolescents will frequently encounter patients whose symptoms cannot be adequately explained by an identifiable organic cause.', 32, 48 Evaluation and management of these adolescents is challenging and requires an awareness of the role of stress and other psychosocial factors in the development and maintenance of the patient's symptoms. The purposes of this discussion are to provide the clinician with an understanding of the association between stress and somatic symptoms in adolescents and to outline a method for the evaluation and management of these symptoms in adolescents who are without other major medical or psychiatric conditions. PSYCHOSOMATIC DISORDERS
Psychosomatic disorders are typically defined as those in which psychological factors are thought to contribute significantly to the development, exacerbation, or maintenance of the illness.31A related term, somutizution, refers to the tendency to report physical symptoms that have no pathophysiologic basis or greatly exceed what one would expect on the grounds of objective medical findings.3O Psychosomatic symptoms and somatization are distinct from malingering in that the patient is truthfully reporting his or her bodily sensations and not consciously using these symptoms to manipulate or control others or the situation.l0The adolescent and his or her family usually attribute the symptoms to organic disease and, therefore, seek medical attention. The symptoms may
From the Division of College Health and Young Adult Medicine (JWG), and the Division of Adolescent Medicine (LSW), Vanderbilt University, Nashville, Tennessee
PEDIATRIC CLINICS OF NORTH AMERICA VOLUME 44 NUMBER 6 * DECEMBER 1997
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vary in severity and duration, may be acute or chronic, and concurrent organic illness may or may not be present. Because the symptoms are caused primarily by psychosocial factors, interventions that address these factors are essential for symptom improvement. It should be noted that the term psychosomatic is increasingly being replaced with terms such as psychophysiologicaI, biobehavioral, and biopsychosocial-terms intended to reflect the increasing awareness that psychosocial and biologic factors are inseparable and interdependent aspects of all illness.13,66 In this article the term psychosomatic is used to refer to symptoms in which psychosocial factors play a major role. We focus particularly on symptoms in which organic findings are absent or minor. Nonetheless, it is important to recognize that life stress and other psychosocial factors may exacerbate conditions, such as diabetes mellitus, that are associated with known organic disease9 and that adolescents with organic disease may experience added life stress resulting from these The presence of an identifiable organic disorder does not exclude the possibility that an adolescent may be experiencing high levels of stress and that this stress may influence the course of the illness. STRESS
Stress can be defined as a demand for adaptation and coping, usually in response to life changes.’O When the demands of change exceed capacities and 35 resources, negative effects of stress, such as somatic symptoms, can emerge.12, Today’s youth experience both the normative stressors associated with adolescent development (e.g., physical changes) as well as unforeseen stressful life events (e.g., break-up of a relationship) that require adaptation and coping5,l9 Both types of stressors must be considered in evaluation and management.2I
THE RELATION OF STRESS TO SOMATIC SYMPTOMS Components of Stress in Health and Illness Life Stress
A number of empiric investigations have found a significant association between stressful life events and somatic symptoms in adolescents. For example, among patients presenting to an adolescent clinic, more stressful life events were reported by adolescents with functional somatic symptoms ( e g , headaches or recurrent abdominal pain) than by those with identifiable organic disease.I8 Similarly, in another study adolescent patients with higher levels of stress scored significantly higher on a measure of psychophysiologic symptoms than did those with lower levels of stress.52Other studies have found that higher stress predicted symptom maintenance in adolescent patients with recurrent abdominal pain.53,56 Life stress has also been linked to psychosomatic symptoms among adolescents in a school setting.‘ Thus, there is substantial evidence linking stress to somatic symptoms in adolescents. Affect or Emotional State
Life stress may be associated not only with somatic symptoms but also with emotional distress. For example, anxiety and depression frequently coexist with
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psychosomatic ~ymptorns.'~, 25 Adolescents with recurrent pain that appears to be out of proportion to medical findings are characterized by levels of anxiety 55; however, the level of and depression that exceed those of control emotional distress in adolescents with recurrent pain appears to be significantly lower than that in adolescents presenting for evaluation at a psychiatric ~linic~~-suggestingthat an intervention within the physician's office setting might be appropriate for many patients with recurrent pain. Individual Differences and Competencies
Not every adolescent who is exposed to stress experiences an increase in somatic symptoms. It is important to consider the context in which stress is experienced, as illustrated in Figure 1. Several factors moderate the impact of stress on the adolescent's health and well-being. These moderators include individual and social resources. For example, social competence is an individual resource that appears to moderate the effect of stressors on adolescents. Among adolescent patients with chronic abdominal pain and high levels of stress, those with greater social competence were less likely to maintain their symptoms 1 year after the clinic visit than were those with less social ~ o m p e t e n c e . ~ ~
Figure 1. A conceptual model of the role of stress in health and illness.
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Coping Style as a Mediator of the Relation Between Stress and Illness
Evidence in the adult literature suggests that, under high levels of stress, personal resources affect future well-being indirectly through more adaptive coping strategies." Similarly, coping processes may mediate the relation between negative life events and psychosomatic problems in adolescents. Adolescents with lower levels of personal resources may have less effective strategies for coping both with life stress and with pain and other somatic symptoms. Thus, ineffective coping may be a mechanism that links stress and somatic symptoms. Particular patterns of coping with pain have been associated with psychosomatic symptoms in children and adolescents. In a study of patients evaluated for persistent abdominal pain at a pediatric gastroenterology clinic, higher levels of somatization symptoms 2 weeks following the clinic visit were predicted by a pattern of pain coping that included behavioral disengagement (i.e., discontinuing one's activities), self-isolation, failure to engage in problem-solving efforts, and lack of emotional expression.61Similarly, adolescents and young adults who had failed to recover from recurrent abdominal pain 5 years after a medical evaluation reported that the strategies they used to cope with pain included behavioral disengagement, self-isolation, and catastrophizing (i.e., assuming the worst)." Peer Support
Peer support also appears to buffer the effect of stressors on adolescents. Despite high levels of stress, adolescent boys with high peer support reported fewer psychophysiologic symptoms at an outpatient clinic than did boys with high stress and low peer Given the importance of peer relationships in adolescence, peer acceptance and support may be a critical resource in helping adolescents cope successfully with stressors. Adolescents who feel socially isolated or who have difficult peer relations appear to be more vulnerable to stressrelated psychosomatic pr0blems.3~ Family Support
Family support may also moderate the impact of stress on adolescent health. It is important to examine not only the amount but also the nature of support provided to the adolescent by his or her family. In families of children and adolescents with exaggerated somatic symptoms, it is common to observe that parents respond to their children's symptoms with attention and special privileges that may serve to reinforce symptoms and disability.%, 64, 67 In these families the nature of support provided to the adolescent may reinforce dependency associated with the sick role, thereby undermining the development of competencies necessary for coping successfully with stress." Another important aspect of the family environment involves the salience of illness and disability. Families of children with recurrent pain syndromes are characterized by high levels of illness in other family members.33,55, 61 Indeed, higher levels of somatization symptoms in parents have been associated with significantly higher somatization symptoms in children with recurrent pain.57In these families, parents may model illness behavior, increasing the likelihood that children will adopt such behavior, particularly at times of stress when symptoms may provide an excuse for avoiding a challenging situation, such as an examination or athletic competition.
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Cognitive Appraisal
One way in which individual and social resources may moderate the impact of stress is through their influence on the individual’s interpretation, or appraisal, of the stressor (Fig. 1). Appraisal involves an assessment of the importance and severity of the stressor as well as one’s perceived ability to When demands associated with the stressor are perceived to exceed available resources, negative emotions and physiologic reactions may be triggered, resulting in somatic complaints and health service utilization. Thus, adolescents with low levels of competence and social support may appraise stressors as more threatening and their coping potential as lower than adolescents who are more competent and have greater access to social support.
Common Psychosomatic Symptoms
As illustrated in Figure 1, the adolescent who appraises a situation as threatening may experience a variety of bodily reactions in response to the stressful situation. These bodily reactions may be perceived or reported as discomfort or pain. Various body systems may produce sensations and symptoms including dizziness, fatigue, shortness of breath, and syncope.38Individuals may have a particular organ system in which their discomfort is most likely to manifest itself, such as the gastrointestinal tract or musculoskeletal system. For example, adolescents who report abdominal pain may have increased gastrointestinal sensitivity. Laboratory studies demonstrate that acute psychological stressors can alter gastric, small bowel, and colonic motility in some individualsa; however, it is unclear whether stress triggers an alteration in motility or whether stress affects an individual’s tolerance for somatic sensations that would be considered normal and ignored by others.63 Recurrent Abdominal Pain
Recurrent abdominal pain is the most common recurrent somatic complaint among children and adolescent^.^, Is, 48 Patients with common functional gastrointestinal disorders, including irritable bowel syndrome (IBS) and dyspepsia, report experiencing high levels of stressful life events and multiple somatic complaints for which they frequently seek health care.=,47, a Recent data suggest that children and adolescents with recurrent abdominal pain later may be diagnosed as having IBS.60 Adolescents and young adults with a childhood history of recurrent abdominal pain may continue to exhibit higher levels of illness behavior, including abdominal pain, other somatic complaints, and functional disability, than control Headaches
Headaches are a common complaint in children and adolescents and are often observed in association with abdominal painz6Muscle tension headaches, either episodic or chronic, are the variety most commonly experienced. Carlsson found that children and adolescents with recurrent headaches reported more psychological distress than headache-free controls. Subjects with chronic recurrent headaches or migraine coexisting with tension headaches reported the highest levels of psychological d i ~ t r e s sStressors .~ such as parent marital prob-
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lems and family separation or divorce have been associated with recurrent headaches in adolescents.28 Chest Pain
Chest pain in adolescents often elicits concerns about underlying cardiac disease; however, chest pain in adolescents is rarely associated with heart disease and is most commonly attributed to idiopathic causes.I4,42 Costochondritis and musculoskeletal pain are the most common identifiable causes for chest pain in adolescent^.^^ Anxiety and hyperventilation can be associated with chest pain and other somatic Stressful life events can be identified in many adolescents with chest pain regardless of the cause?, 34 Musculoskeletal Pain
Musculoskeletal pain occurs in up to 20% of children and adolescents.*6 Sherry and colleagues" reported that stressors related to school, family, and personal expectations were common among 100 patients (median age of 13 years) referred to a rheumatology center for evaluation of chronic musculoskeletal pain. Most patients responded to a combination of physical and occupational therapy, together with interventions addressing underlying psychosocial issues. Chronic Fatigue
Chronic fatigue can accompany a variety of conditions, including psychosomatic problems, depression, and chronic fatigue syndrome. Chronic fatigue syndrome is a symptom complex consisting of profound, debilitating fatigue associated with a variety of nonspecific and constitutional complaints. While the cause of chronic fatigue syndrome in children and adolescents is likely to be multifactorial, stress and psychosomatic factors appear to play a role in some patientsw Carter and co-workers8found that subjects with chronic fatigue scored higher than healthy controls on the Child Behavior Checklist measures of internalizing behavior, withdrawal, and somatization symptoms. Nonspecific Symptoms
Other nonspecific symptoms, including dizziness, syncope, or tiredness, are often found to be associated with family problems, stress, school problems, and depression in high school students visiting the school nurse.4" Similarly, hyperventilation and functional stridor are respiratory conditions in which there is a nonorganic component, and psychological stressors often contribute to these
problem^.^, 6,27 SYMPTOM PRESENTATION AND EVALUATION
Adolescents and their families often seek medical attention for physical symptoms that ultimately are found to have no identifiable organic cause.I8,19,39 The decision to seek medical care may reflect the severity of the symptom, the duration of discomfort, the perceived significance of the symptom, or the presence of other personal or family concerns. In many cases, physical symptoms are associated with life stressors that have exceeded the adolescent's coping ability, resulting in feelings of helple~sness.3~
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Most visits for psychosomatic symptoms represent a response to psychosocia1 distress rather than an attempt to manipulate the health care provider, that is, malingering. Malingering is considered to be under the voluntary control of the patient and is a deliberate presentation of false or exaggerated physical or psychological symptoms.11The intent of malingering may be to avoid school or to obtain unnecessary medications. In the authors’ experience, most adolescents do not intentionally use their symptoms in this manner. Nonetheless, they may indeed receive some secondary gain for their symptoms. For example, parents are less likely to hold children and teenagers responsible for poor grades and misbehavior if they have concurrent somatic complaints than if they are well.58 Thus, parents may unintentionally reinforce symptoms and disability by excusing their teens from normal expectations.% Scheduling
Health care providers may encounter patients with psychosomatic problems at the initial presentation of the symptom or after the symptom has become chronic or recurrent. When it is the initial presentation, providers with busy office practices may be pressed for time and unable to adequately attend to psychosocial issues. In this situation, an evaluation process can be initiated and subsequent visits planned at relatively short intervals to continue the process. In referral settings, the provider is more likely to be aware of the chronic nature of the symptom, and a longer initial appointment can be scheduled. Initial Interview
A parent usually accompanies the adolescent patient with chronic somatic symptoms to the clinic. The initial interview should be conducted with the parent(s) and adolescent together. Limits of confidentiality can be defined and discussed at this time. A combined session allows the clinician to observe parent-adolescent interactions and to assess the quality of their relationship. During the initial interview, it may be helpful to ask the parent about specific concerns. For example, a parent might be asked whether he or she is concerned that a symptom is indicative of the presence of a particular disorder. This information allows the provider to focus on the area of concern and possibly allay the parent’s previously unexpressed fears regarding a serious or lifethreatening condition. Once the parent(s) have voiced their concerns, it is important to interview the adolescent alone; however, a final feedback or “wrap-up” session with the parents and adolescent together is desirable in order to ensure a shared understanding of the diagnosis and recommendations. History and Review of Symptoms
A complete history should be taken from the adolescent, including a comprehensive review of systems. The adolescent’s perception of the historical facts as previously given by parents may be useful. Any discrepancy between the parent’s and adolescent’s perceptions of the problem may suggest family conflict or poor communication and should be investigated. A description of the onset of the symptom and any associated events or situations may provide important
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clues regarding precipitating stressors. The adolescent’s level of emotional distress can be observed and assessed during the discussion. Psychosocial issues should be reviewed with a particular focus on the possibility of recent life events that may have been stressful.’, 36 A life-events checklist may be useful in gathering this information and clearly defining stressful life events to the adolescent and his or her Checklists may also suggest areas to target for interventions aimed at reducing stress.l*,39 Although an association between life stressors and psychosomatic symptoms may be obvious to an objective observer, many adolescents may not recognize the stressful nature of their circumstances. This situation is somewhat like the old Chinese proverb that says, ”It is not wise to ask a fish, how is the water?” The adolescent, like the fish, may have adapted to his or her circumstances and fail to recognize them as stressful. For example, an adolescent with chronic tension headaches may report that his or her noncustodial parent neither maintains contact nor provides financial support. It is common for patients in such circumstances to report that they have ”gotten used to it,” and that it “doesn’t bother them.” While a teenager might accept being neglected by a biologic parent, such parental behavior usually causes psychological distress, whether conscious or subconscious. Suppressed feelings regarding stressors may play a role in somatic complaints and should be explored. It is important that the clinician’s history explore the daily life of the adolescent, including areas of potential stress. By using nonthreatening and open-ended questions, information can be gained without encountering defensive or reactive responses. For example, the possibility that a particular symptom is triggered or exacerbated by school stressors can be explored in a conversational manner. The initial inquiry about an association between the symptom and school might include the following questions: Does the pain ever occur while you are at school or in the morning before school? Does the pain ever keep you from going to school? Subsequent conversation might aim to assess the extent to which school is a source of stress for the teen and how the teen deals with that stress: By the way, where do you go to school? What grade are you in this year? Do you like it better or worse than last year? Why? And how did you do on your last report card? Which subjects are most difficult for you? What is your favorite subject? How many days of school have you missed this year? How do you spend the day when you miss school? Answers to these questions can reveal relevant difficulties involving grades, teachers, school absence, and the possibility of secondary gain from somatic symptoms. Family History
When adolescents present with medically unexplained symptoms, a history of similar symptoms in relatives or family members should be investigated. Prior family illness associated with an undiagnosed or severe disease may cause excessive parental concern over a minor complaint.33,57 The clinician should be alert to parental anxiety reflected in comments such as, ”Aunt Dotty had the
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very same pain, and they told her it was in her head. They couldn‘t find a thing wrong with her, and she died of cancer three months later. I’m not going to let that happen to my child.” In these cases, parents may need additional reassurance that a particular diagnosis has been considered and ruled out. Physical Examination
A thorough physical examination is an essential part of the evaluation process. Parents must be assured that areas of concern have been thoroughly examined to exclude physical evidence of organic disease. At times, it may be helpful to allow the overly concerned parent to observe the clinician as he or she performs an examination. The physical examination is generally normal in adolescents with psychosomatic complaints, and whenever possible the clinician should give the patient this feedback during the examination. For example, it can be reassuring to tell a teenager who is concerned about possible cardiac causes for chest pain that his or her heart sounds fine. Laboratory Evaluation and Other Testing
When adolescents present for a medical evaluation, they and their parents are usually seeking an organic explanation for any somatic complaints. Many assume that laboratory tests are needed to rule out organic illness. Each somatic complaint should be assessed in a systematic fashion in order to minimize excessive and costly testing procedure^.^, 46, 49 Recommendations for laboratory and other specialized testing vary with the presenting symptoms. Some families may have difficulty accepting that every reasonable or indicated test has been performed, and some may insist upon a specific test that they feel is necessary. An open and frank discussion about the reasons for ordering or excluding testing is helpful. Patient and family anxiety may be reduced by providing a detailed explanation of all test results and their significance in ruling out specific disorders. MANAGEMENT Establishing Trust
The management of psychosomatic problems begins with the initial interview. The physician should establish a trusting relationship by conveying to the patient and family that he or she understands that the symptom is real and that it has caused concern, discomfort, and inconvenience. Physicians should also express concern for the patient’s general well-being, including his or her academic and social functioning. Development of trust requires allowing adequate time for the adolescent and the parents to express their perspectives in the initial and subsequent visits. Once the physician has conveyed genuine concern, he or she should make a firm statement of the nonorganic nature of the psychosomatic symptom and provide clear recommendations for action. For families who are reluctant to accept the absence of organic findings, it is sometimes helpful to explain that although no organic cause can be found at this time, the current symptoms may
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be the residual of an earlier condition that is now in the process of healing. The repair process places extra demands on the body. In order to facilitate this repair process it is helpful to reduce any external stressors (e.g., excessive academic pressure) and to begin a gradual return to normal activities to help the body build up its strength. We find that this explanation allows some adolescents to save face and helps the parent to accept the role of stress in illness and health. Graphic illustrations similar to the model presented in Figure 1 may be useful in discussing this with the patient and parent. A treatment plan should be outlined and agreed upon. Even after apparent agreement, some parents and adolescents raise the question of “what if” a certain new symptom arises or the current symptom does not improve. They should be assured that any new symptom or clue that suggests an organic disease will be thoroughly investigated. In addition, any diagnostic test that is clinically indicated will be performed. Symptom Relief Medication
Symptom relief or reduction is likely to be of foremost importance in adolescents with chronic or recurrent pain. Many patients will have tried overthe-counter analgesics prior to seeking medical attention. Analgesics should be used for temporary relief and viewed as only one part of the treatment process. Non-narcotic analgesics are preferable to those with addiction potential. Antispasmodics and dietary changes, such as increasing fiber intake, may benefit some patients with recurrent abdominal pain and IBS. Patients with dyspeptic symptoms may be given a therapeutic trial of E-I, blockers. Antidepressants may be useful in some patients with psychosomatic problems, including recurrent pain and depressive symptoms, even when they do not meet all of the criteria for major depression. Tricyclic agents or selective serotonin reuptake inhibitor (SSRI) medications, such as fluoxetine and paroxetine, may be helpful in some adolescents. Stress Reduction
Many adolescents and their families are able to accept the possibility of stress contributing to or perpetuating the symptoms. Therefore, interventions to modify the stressor and enhance the adolescent’s coping ability should be planned. When possible, resolution of specific stressors is desirable. For example, removal from an abusive living situation protects the adolescent from the source of severe distress. Older adolescents may be negatively affected by excessive adult responsibilities, such as after-school employment, child-care for younger siblings, and household chores. Decreasing or reassigning some of these adolescents‘ responsibilities can be helpful in reducing stress and thereby may help resolve somatic complaints. Many parents place a great deal of both direct and indirect pressure on their teenagers to compete athletically and academically. In some cases, an adolescent’s symptoms may be a message to parents to “back off.” A teenage athlete who has competed since early childhood may tire of the competition but may be unable to express this to his or her overzealous parents. The adolescent may be fearful that the parents will be disappointed. Decreased academic pressure, such as a reduced number of honors classes, may be a welcome relief for some overachieving teenage scholars.
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Competence Promotion
Adolescents who perceive themselves as inadequate in social, academic, or athletic arenas may be more likely to maintain their symptoms over time.56For those with this perception, normal activities may threaten self-esteem and be regarded as stressful. Interventions to support and enhance the adolescent’s competence in various activities have two potential benefits: (1) increased competence may improve the adolescent’s ability to deal with potentially stressful activities, and (2) involvement in activities may distract the adolescent’s attention away from symptoms. The physician can be helpful in identifying areas of actual or potential competence and encouraging parental promotion of the adolescent’s special interests and abilities in these areas. For example, the parent might encourage involvement in a hobby or activity, praise the teenagers efforts, and facilitate the pursuit of new opportunities. Such attention is a positive alternative to attention for symptoms and di~ability.5~ Return to School and Activities
School absence is a common occurrence in adolescents with psychosomatic complaints. Failure to return to school can lead to an increased sense of helplessness and perpetuation of the sick When an adolescent has missed school, a return to the classroom and other activities should be planned as soon as feasible; however, adolescents and their parents may resist a return to school for a variety of reasons. The adolescent may fear returning because he or she may be behind academically. Some are also concerned about re-entry into peer groups and are unsure of how to explain their absence to friends. A graduated return to school may be helpful. Attending school for a part of the day is a good start, allowing the adolescent to gradually become reacquainted with the academic, physical, and social pressures of a school setting. Academic difficulties, including learning disabilities, should be assessed in patients who have experienced long-term problems with poor grades. Psychoeducational testing by a clinical psychologist can assist in differentiating between failing grades caused by school absences versus those related to learning disabilities. It is not uncommon for an adolescent with a somatic complaint to request a written excuse for physical education classes, or ”gym.” While it may be beneficial for some to reduce their physical activity for a time, attendance at physical education class should be encouraged with the goal of returning to full activity. The school should be contacted to coordinate efforts for a return to the classroom and to discuss the possibility of homebound instruction. Many adolescents seen in the authors’ referral clinic for chronic somatic complaints have been granted homebound instruction by the referring physician. Not uncommonly, continuation is a primary reason for visiting the clinic. When homebound instruction is granted, it is best to set a specific time limit. The authors find it useful to include individual and family counseling as a requirement for continuing homebound classes. The Role of Primary Care Physician
Primary care providers might choose to manage some cases completely and others as part of a treatment team. Depending on the skills and interests of the
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physician, brief, targeted, psychologically based treatment in a primary care setting can be effective.I5Office counseling should be primarily supportive and focus on the current situation and positive ways of coping.59 Whether the physician provides total care or functions as part of a team, adolescent patients can benefit from having an accessible, trusted, and objective confidant outside his or her family. Professionals filling this role can contribute positively to the adolescent’s social support system.*O Inquiry about possible life stressors sends the message that the adolescent’s life situation is important. Supportive listening can enhance the patient‘s ability to think through situations and devise effective coping strategies. Symptom improvement may be observed when the adolescent is able to gain new insights and learn new ways of dealing with his or her stress or^.^^ Referral for Stress Management and Counseling
Referral to a mental health professional for stress management and counseling may be indicated in some cases. The referring physician should make it clear that he or she will remain an integral part of the treatment team. Therefore, follow-up visits with the clinician should be scheduled to assess progress, demonstrate ongoing commitment, and ensure follow through with any referrals. Although many parents acknowledge that stress may play a role in psychosomatic complaints, few accept counseling as potentially benefi~ial.5~ This reluctance to accept counseling may be due to the misperception that counseling is only for those with serious psychological problems.= In the authors’ experience, many families accept referral to a psychologist or other behavioral health professional if the purpose is defined as helping the adolescent cope with his or her physical symptoms. An empathetic comment from the physician, such as ”The amount of discomfort that you are experiencing must be difficult to cope with,” can provide an entrance into a discussion about and the acceptance of a referral. In cases in which the symptoms are longstanding and complex, both individual and family counseling may be helpful. Some therapists choose to see both the adolescent and the family. Others find it more helpful for one counselor to see the adolescent and another the family. Other Interventions
Anxiety and depression are frequently associated with psychosomatic symptoms. Primary care physicians who are familiar with commonly used psychotropic medications may choose to prescribe them for adolescents who are seeing a psychologist or social worker for psychotherapy. Others who are less familiar with anxiolytics and antidepressants may choose to refer their patients to a psychiatrist for medication. Physical or occupational therapy may be beneficial for adolescents with musculoskeletal pain and at times for those with lethargy, chronic fatigue syndrome, or generalized weakness.44We have found that adolescents with chronic musculoskeletal pain respond to a combination of rehabilitation and counseling. This approach allows adolescents to gracefully and gradually ”rehabilitate” the musculoskeletal system while addressing psychosocial issues through concurrent counseling. Biofeedback can be helpful for some patients, especially those who are
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likely to respond to concrete, demonstrable evidence of stress reduction. Biofeedback may be an acceptable adjunct for families who are reluctant to accept counseling but who are willing to invest in a method aimed at reducing the adolescent’s symptom^.'^, 46 Relaxation exercises and guided imagery can also be useful techniques of symptom reduction for practitioners skilled in these methods. Using these techniques, teenagers may be able to identify the signs of tension produced by stress and gain control over their Referral to a pain control clinic or center may be useful in patients with complex symptoms who are unresponsive to other interventions. Prevention of Psychosomatic Problems
Prevention of psychosomatic problems is a desirable goal. The concept that stress is an inevitable part of everyone’s life should be introduced in early adolescence (or before) as a part of anticipatory guidance. Discussion of how everyday stressors, especially those that involve change, can affect an individual’s overall sense of well-being can be incorporated into health maintenance visits for children and Clinicians can also observe adolescents’ efforts to cope with physical symptoms and can address exaggerated reactions to minor symptoms or illness. Discussion of strategies to enhance competence and coping skills can be useful. For example, teens may be taught that a particular symptom, such as headache or abdominal pain, may be a warning signal of stress and not necessarily indicative of an organic illness. Once this association is clear and a symptom recurs, stress reduction strategies can be initiated. A basic strategy is to talk with a trusted confidant about the stressor and symptom. Primary care physicians and other health care providers with an interest, skills, and adequate time to develop 32 relationships with adolescents can fill this important SUMMARY
Psychosomatic problems are common in adolescents, and stress frequently plays a role in their development and maintenance. Armed with an understanding of the stressors experienced by adolescents, the individual’s vulnerabilities and competencies and their level of social support, the physician can systematically assess each of these factors. Once the assessment is complete, a management plan can be formulated to address the particular psychosomatic problem. Symptom relief, stress reduction, and promotion of competence are important interventions that can be initiated by the primary care physician. When referrals are made for counseling and other stress management techniques, the primary care physician should maintain contact with the patient and family and remain an integral part of the management team. Incorporating brief discussions about the potential role of stress in health and illness into anticipatory guidance sessions may also help prevent the development of psychosomatic problems in adolescents. References 1. Aro H: Life stress and psychosomatic symptoms in adolescents. Psycho1 Med 17191. 1987
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2. Asnes R, Santulli R, Bemporad J: Psychogenic chest pain in children. Clin Pediatr 20788, 1981 3. Barskv A, Borus 1: Somatization and medicalization in the era of managed care. IAMA 2741+31,1995 4. Bass C: Unexdained chest uain and breathlessness. Med Clin North Am 751157.1991 5. Brown R: Psichosomatic iroblems in adolescents. Adolesc Med: State Art Rev 3237, 1992 6. Burton C: Hyperventilation in patients with recurrent functional symptoms. Br J Gen Pract 43:422, 1993 7. Carlsson J, Larsson 8, Mark A: Psychosocial functioning in schoolchildren with recurrent headaches. Headache 3677,1995 8. Carter B, Edwards J, Kronenberger W, et a1 Case control study of chronic fatigue in pediatric patients. Pediatrics 95:179, 1995 9. Chase H, Jackson G: Stress and sugar control in children with insulin-dependent diabetes mellitus. J Pediatr 98:1011, 1981 10. Chrousos G, Gold P: The Concepts of Stress and Stress System Disorders. JAMA 2671244,1992 11. Craig T, Drake H, Boardman A: The South London somatization study. I1 Influence of stressful life events and secondary gain. Br J Psychiatry 165:248, 1994 12. Dantzer R Stress and Disease: A psychobiological perspective. Ann Behav Med 13205,1991 13. Dorian BJ, Taylor C B Psychosomatic medicine. In Morrison RL, Bellack AS (eds): Medical Factors and Psychological Disorders. New York Plenum, 1987, p 267 14. Driscoll D, Glicklich L, Gallen W Chest pain in children: A prospective study. Pediatrics 57648, 1976 15. Finney J, Lemanek K, Cataldo M, et al: Pediatric psychology in primary care: Brief targeted therapy for recurrent abdominal pain. Behav Res Ther 20284, 1989 16. Friedman SB: Concepts in psychosomatic illness. In Hockleman RA (ed): Primary Pediatric Care. St Louis: CV Mosby, 1987, p 708 17. Gluckman RM: Physical symptoms as a mask for emotional disorder in adolescents. Adolesc Psychiatry 1984, 1993 18. Greene J, Walker L, Hickson G, et al: Stressful life events and somatic complaints in adolescents. Pediatrics 75:19, 1985 19. Greene J, Wemer M, Walker L Stress and the modem adolescent. Adolesc Med: State Art Rev 3:13, 1992 20. Haggerty RJ: Life stress, illness and social supports. Dev Med Child Neurol 33:391, 1980 21. Hemdon RL: Stress in adolescence. In Arnold LE (ed): Childhood Stress. New York John Wiley and Sons, 1990, p 247 22. Holahan C, Moos R Life stressors, personal and social resources, and depression: A four year structural model. J Abnorm Psychol 10031, 1991 23. Hyams JS, Burke G, Davis PM: Abdominal pain and irritable bowel syndrome in adolescents: A community-based study. J Pediatr 129:220, 1996 24. Johnson J: Life events as stressors in childhood and adolescence. In Lahey BB, Kazdin AE (eds): Adolescent Clinical Child Psychology, vol. 5. New York: Plenum Press, 1982 25. Jolly J, Wherry J, Wiesner D, et al: The mediating role of anxiety in self-reported somatic complaints of depressed adolescents. J Abnorm Child Psychol 22691,1994 26. King N, Sharpley C: Headache activity in children and adolescents. J Pediatr Child Health 2650, 1990 27. Kuppersmith B, Rosen D, Wiatrak 8: Functional stridor in adolescents. J Adolesc Health Care 14166, 1993 28. Larsson B: The role of psychological, health-behavioral and medical factors in adolescent headache. Dev Med Child Neurol 30616,1988 29. Lazarus R, Folkman S Stress, appraisal, and coping. New York Springer, 1984 30. Lipowski ZJ: Somatization: the concept and its clinical application. Am J Psychiatry 1451358, 1988 31. Nemzer E D Psychosomatic illness in children and adolescents. In Garfinkel BD, Y
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Carlson GA, Weller EB (eds): Psychiatric disorders in children and adolescents. Philadelphia: WB Saunders, 1990, pp 135-146 32. Orr D Adolescence, stress and psychosomatic issues. J Adolesc Health Care 7(suppl):97, 1986 33. Osbome RB, Hatcher J, Richtsmeier A The role of social modeling in unexplained pediatric pain. J Pediatr Psychol 1443-61,1989 34. Pantel R, Goodman B Adolescent chest pain: A prospective study. Pediatrics 71:881, 1983 35. Pennebaker JW: The psychology of physical symptoms. New York Springer-Verlag, 1982 36. Poikolainen K, Kanerva R, Lonnqvist J: Life events and other risk factors for somatic symptoms in adolescence. Pediatrics 96:59, 1995 37. Rauste-von Wright M, von Wright J: Habitual somatic discomfort in a representative sample of adolescents. J Psychosom Res 36383, 1992 38. Rickert V, Jay S: Psychosomatic disorders: The approach. Pediatr Rev 15:448, 1994 39. Robinson DP, Greene J, Walker L: Functional somatic complaints in adolescents: Relationship to negative life events, self-concept, and family characteristics. J Pediatr 113:58&593, 1988 40. Schneider M, Fiedman S, Fisher M Stated and unstated reasons for visiting a high school nurse’s office. J Adolesc Health Care 1635, 1995 41. Schor E: Use of health care services by children and diagnoses received during presumably stressful life transitions. Pediatrics 77834, 1986 42. Selbst S: Chest pain in children. Pediatrics 75:1068, 1985 43. Selbst S, Ruddf R, Clark B, et a 1 Pediatric chest pain: A prospective study. Pediatrics 82319,1988 44. Sherry D, McGuire T, Mellins E, et al: Psychosomatic musculoskeletal pain in childhood: Clinical and psychological analysis of 100 children. Pediatrics 88:1093, 1991 45. Smith MS: Psychosomatic symptoms in adolescents. Med Clin North Am 741121, 1990 46. Smith MS, Womack W: Stress management techniques in childhood and adolescence. Relaxation training, meditation, hypnosis and biofeedback Appropriate clinical applications. Clin Pediatr 26581, 1987 47. Smith RC, Greenbaum J, Vancouver R, et al: Psychosocial factors are associated with health care seeking rather than diagnosis of irritable bowel syndrome. Gastroenterology 98:293, 1990 48. Starfield B, Gross E, Wood M, et al: Psychosocial diagnoses in primary care of children. Pediatrics 66159, 1980 49. Strasburger V, Reeve A: The adolescent with chronic pains: Basic principles of psychosomatic medicine. Adolesc Med: State Art Rev 2677, 1991 50. Walford G, Nelson W, McCluskey D: Fatigue, depression and social adjustment in chronic fatigue syndrome. Arch Dis Child 68:384, 1993 51. Walker L, Greene J: Children with recurrent abdominal pain and their parents: More somatic complaints, anxiety and depression than other patient families? J Pediatr Psychol 14:231, 1989 52. Waiker L, Greene J: Negative Iife events, psychosocial resources and psychological symptoms in adolescents. J Clin Child Psychol 1629, 1987 53. Walker L, Greene J: Negative life events and symptom resolution in pediatric abdominal pain patients. J Pediatr Psychol 16:341, 1991 54. Walker L, Zeman J: Parental responses to child illness behavior. J Pediatr Psychol 1749, 1992 55. Walker L, Garber J, Greene J: Psychosocial correlates of recurrent childhood pain: A comparison of pediatric patients with recurrent abdominal pain, organic illness, and psychiatric disorders. J Abnorm Psychol 102248, 1993 56. Walker L, Garber J, Greene J: Somatic complaints in pediatric patients: A prospective study of the role of negative life events, child social support and academic competence and parental somatic symptoms. J Consult Clin Psychol 621213, 1994 57. Walker L, Garber J, Greene J: Somatization symptoms in pediatric abdominal pain patients: Relation to chronicity of abdominal pain and parent somatization. J Abnorm Child Psychol 19:379, 1991
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58. Walker L, Garber J, Van Slyke D Do parents excuse the misbehavior of children with physical and emotional symptoms? & investigation of the pediatric sick role. J Pediatr Psvchol20:329,1995 59. Wilker L, Greene J, Garber J, et a1 Psychosocial factors in pediatric abdominal pain: Implications for assessment and treatment. The Clinical Psychologist 26:206, 1993 60. Walker L, Guite J, Duke A, et a1 Recurrent abdominal pain: A precursor of irritable bowel syndrome in adolescents and young adults? (Submitted for publication) 61. Walker L, Smith CA, Garber J, et al: Development and validation of the Pain Response Inventory. Psycho1 Assessment (accepted for publication) 62. Walker L, VanSlyke D, Newbrough J R Family resources and stress: A comparison of families of children with cystic fibrosis, diabetes, and mental retardation. J Pediatr Psycho1 17327-343, 1992 63. Whitehead W. Psychosocial aspect of functional gastrointestinal disorders. Gastroenterol Clin North Am 25:21, 1996 64. Whitehead W, Crowell M, Heller B, et al: Modeling and reinforcement of sick role during childhood predicts adult illness behavior. Psychosom Med 56541, 1994 65. Williams C, Uchiyama C: Assessment of life events during adolescence. Adolescence 93:95, 1989 66. Wood BL: Beyond the psychosomatic family: A biobehavioral family model of pediatric illness. Fam Process 32:3, 1993 67. Wooley SC, Blackwell B, Winget C: The learning theory model of chronic illness behavior: Theory, treatment, and research. Psychosom Med 40:379-401, 1978
Address reprint requests to John W. Greene, MD Division of College Health/Young Adult Medicine Vanderbilt University Zerfoss Student Health Center Room SS-3407 Station 17 Nashville, TN 37232
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PSYCHOSOMATIC PROBLEMS AND STRESS IN ADOLESCENCE John W. Greene, MD, a n d Lynn S. Walker, PhD
Stress is universal in the lives of today's adolescents and may impact their health and well-being.18-20,36 High levels of stress may be associated with distress and somatic symptoms, leading the adolescent to seek health care.40,41,47 Pediatricians and other professionals who provide health care for adolescents will frequently encounter patients whose symptoms cannot be adequately explained by an identifiable organic cause.', 32, 48 Evaluation and management of these adolescents is challenging and requires an awareness of the role of stress and other psychosocial factors in the development and maintenance of the patient's symptoms. The purposes of this discussion are to provide the clinician with an understanding of the association between stress and somatic symptoms in adolescents and to outline a method for the evaluation and management of these symptoms in adolescents who are without other major medical or psychiatric conditions. PSYCHOSOMATIC DISORDERS
Psychosomatic disorders are typically defined as those in which psychological factors are thought to contribute significantly to the development, exacerbation, or maintenance of the illness.31A related term, somutizution, refers to the tendency to report physical symptoms that have no pathophysiologic basis or greatly exceed what one would expect on the grounds of objective medical findings.3O Psychosomatic symptoms and somatization are distinct from malingering in that the patient is truthfully reporting his or her bodily sensations and not consciously using these symptoms to manipulate or control others or the situation.l0The adolescent and his or her family usually attribute the symptoms to organic disease and, therefore, seek medical attention. The symptoms may
From the Division of College Health and Young Adult Medicine (JWG), and the Division of Adolescent Medicine (LSW), Vanderbilt University, Nashville, Tennessee
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vary in severity and duration, may be acute or chronic, and concurrent organic illness may or may not be present. Because the symptoms are caused primarily by psychosocial factors, interventions that address these factors are essential for symptom improvement. It should be noted that the term psychosomatic is increasingly being replaced with terms such as psychophysiologicaI, biobehavioral, and biopsychosocial-terms intended to reflect the increasing awareness that psychosocial and biologic factors are inseparable and interdependent aspects of all illness.13,66 In this article the term psychosomatic is used to refer to symptoms in which psychosocial factors play a major role. We focus particularly on symptoms in which organic findings are absent or minor. Nonetheless, it is important to recognize that life stress and other psychosocial factors may exacerbate conditions, such as diabetes mellitus, that are associated with known organic disease9 and that adolescents with organic disease may experience added life stress resulting from these The presence of an identifiable organic disorder does not exclude the possibility that an adolescent may be experiencing high levels of stress and that this stress may influence the course of the illness. STRESS
Stress can be defined as a demand for adaptation and coping, usually in response to life changes.’O When the demands of change exceed capacities and 35 resources, negative effects of stress, such as somatic symptoms, can emerge.12, Today’s youth experience both the normative stressors associated with adolescent development (e.g., physical changes) as well as unforeseen stressful life events (e.g., break-up of a relationship) that require adaptation and coping5,l9 Both types of stressors must be considered in evaluation and management.2I
THE RELATION OF STRESS TO SOMATIC SYMPTOMS Components of Stress in Health and Illness Life Stress
A number of empiric investigations have found a significant association between stressful life events and somatic symptoms in adolescents. For example, among patients presenting to an adolescent clinic, more stressful life events were reported by adolescents with functional somatic symptoms ( e g , headaches or recurrent abdominal pain) than by those with identifiable organic disease.I8 Similarly, in another study adolescent patients with higher levels of stress scored significantly higher on a measure of psychophysiologic symptoms than did those with lower levels of stress.52Other studies have found that higher stress predicted symptom maintenance in adolescent patients with recurrent abdominal pain.53,56 Life stress has also been linked to psychosomatic symptoms among adolescents in a school setting.‘ Thus, there is substantial evidence linking stress to somatic symptoms in adolescents. Affect or Emotional State
Life stress may be associated not only with somatic symptoms but also with emotional distress. For example, anxiety and depression frequently coexist with
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psychosomatic ~ymptorns.'~, 25 Adolescents with recurrent pain that appears to be out of proportion to medical findings are characterized by levels of anxiety 55; however, the level of and depression that exceed those of control emotional distress in adolescents with recurrent pain appears to be significantly lower than that in adolescents presenting for evaluation at a psychiatric ~linic~~-suggestingthat an intervention within the physician's office setting might be appropriate for many patients with recurrent pain. Individual Differences and Competencies
Not every adolescent who is exposed to stress experiences an increase in somatic symptoms. It is important to consider the context in which stress is experienced, as illustrated in Figure 1. Several factors moderate the impact of stress on the adolescent's health and well-being. These moderators include individual and social resources. For example, social competence is an individual resource that appears to moderate the effect of stressors on adolescents. Among adolescent patients with chronic abdominal pain and high levels of stress, those with greater social competence were less likely to maintain their symptoms 1 year after the clinic visit than were those with less social ~ o m p e t e n c e . ~ ~
Figure 1. A conceptual model of the role of stress in health and illness.
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Coping Style as a Mediator of the Relation Between Stress and Illness
Evidence in the adult literature suggests that, under high levels of stress, personal resources affect future well-being indirectly through more adaptive coping strategies." Similarly, coping processes may mediate the relation between negative life events and psychosomatic problems in adolescents. Adolescents with lower levels of personal resources may have less effective strategies for coping both with life stress and with pain and other somatic symptoms. Thus, ineffective coping may be a mechanism that links stress and somatic symptoms. Particular patterns of coping with pain have been associated with psychosomatic symptoms in children and adolescents. In a study of patients evaluated for persistent abdominal pain at a pediatric gastroenterology clinic, higher levels of somatization symptoms 2 weeks following the clinic visit were predicted by a pattern of pain coping that included behavioral disengagement (i.e., discontinuing one's activities), self-isolation, failure to engage in problem-solving efforts, and lack of emotional expression.61Similarly, adolescents and young adults who had failed to recover from recurrent abdominal pain 5 years after a medical evaluation reported that the strategies they used to cope with pain included behavioral disengagement, self-isolation, and catastrophizing (i.e., assuming the worst)." Peer Support
Peer support also appears to buffer the effect of stressors on adolescents. Despite high levels of stress, adolescent boys with high peer support reported fewer psychophysiologic symptoms at an outpatient clinic than did boys with high stress and low peer Given the importance of peer relationships in adolescence, peer acceptance and support may be a critical resource in helping adolescents cope successfully with stressors. Adolescents who feel socially isolated or who have difficult peer relations appear to be more vulnerable to stressrelated psychosomatic pr0blems.3~ Family Support
Family support may also moderate the impact of stress on adolescent health. It is important to examine not only the amount but also the nature of support provided to the adolescent by his or her family. In families of children and adolescents with exaggerated somatic symptoms, it is common to observe that parents respond to their children's symptoms with attention and special privileges that may serve to reinforce symptoms and disability.%, 64, 67 In these families the nature of support provided to the adolescent may reinforce dependency associated with the sick role, thereby undermining the development of competencies necessary for coping successfully with stress." Another important aspect of the family environment involves the salience of illness and disability. Families of children with recurrent pain syndromes are characterized by high levels of illness in other family members.33,55, 61 Indeed, higher levels of somatization symptoms in parents have been associated with significantly higher somatization symptoms in children with recurrent pain.57In these families, parents may model illness behavior, increasing the likelihood that children will adopt such behavior, particularly at times of stress when symptoms may provide an excuse for avoiding a challenging situation, such as an examination or athletic competition.
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Cognitive Appraisal
One way in which individual and social resources may moderate the impact of stress is through their influence on the individual’s interpretation, or appraisal, of the stressor (Fig. 1). Appraisal involves an assessment of the importance and severity of the stressor as well as one’s perceived ability to When demands associated with the stressor are perceived to exceed available resources, negative emotions and physiologic reactions may be triggered, resulting in somatic complaints and health service utilization. Thus, adolescents with low levels of competence and social support may appraise stressors as more threatening and their coping potential as lower than adolescents who are more competent and have greater access to social support.
Common Psychosomatic Symptoms
As illustrated in Figure 1, the adolescent who appraises a situation as threatening may experience a variety of bodily reactions in response to the stressful situation. These bodily reactions may be perceived or reported as discomfort or pain. Various body systems may produce sensations and symptoms including dizziness, fatigue, shortness of breath, and syncope.38Individuals may have a particular organ system in which their discomfort is most likely to manifest itself, such as the gastrointestinal tract or musculoskeletal system. For example, adolescents who report abdominal pain may have increased gastrointestinal sensitivity. Laboratory studies demonstrate that acute psychological stressors can alter gastric, small bowel, and colonic motility in some individualsa; however, it is unclear whether stress triggers an alteration in motility or whether stress affects an individual’s tolerance for somatic sensations that would be considered normal and ignored by others.63 Recurrent Abdominal Pain
Recurrent abdominal pain is the most common recurrent somatic complaint among children and adolescent^.^, Is, 48 Patients with common functional gastrointestinal disorders, including irritable bowel syndrome (IBS) and dyspepsia, report experiencing high levels of stressful life events and multiple somatic complaints for which they frequently seek health care.=,47, a Recent data suggest that children and adolescents with recurrent abdominal pain later may be diagnosed as having IBS.60 Adolescents and young adults with a childhood history of recurrent abdominal pain may continue to exhibit higher levels of illness behavior, including abdominal pain, other somatic complaints, and functional disability, than control Headaches
Headaches are a common complaint in children and adolescents and are often observed in association with abdominal painz6Muscle tension headaches, either episodic or chronic, are the variety most commonly experienced. Carlsson found that children and adolescents with recurrent headaches reported more psychological distress than headache-free controls. Subjects with chronic recurrent headaches or migraine coexisting with tension headaches reported the highest levels of psychological d i ~ t r e s sStressors .~ such as parent marital prob-
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lems and family separation or divorce have been associated with recurrent headaches in adolescents.28 Chest Pain
Chest pain in adolescents often elicits concerns about underlying cardiac disease; however, chest pain in adolescents is rarely associated with heart disease and is most commonly attributed to idiopathic causes.I4,42 Costochondritis and musculoskeletal pain are the most common identifiable causes for chest pain in adolescent^.^^ Anxiety and hyperventilation can be associated with chest pain and other somatic Stressful life events can be identified in many adolescents with chest pain regardless of the cause?, 34 Musculoskeletal Pain
Musculoskeletal pain occurs in up to 20% of children and adolescents.*6 Sherry and colleagues" reported that stressors related to school, family, and personal expectations were common among 100 patients (median age of 13 years) referred to a rheumatology center for evaluation of chronic musculoskeletal pain. Most patients responded to a combination of physical and occupational therapy, together with interventions addressing underlying psychosocial issues. Chronic Fatigue
Chronic fatigue can accompany a variety of conditions, including psychosomatic problems, depression, and chronic fatigue syndrome. Chronic fatigue syndrome is a symptom complex consisting of profound, debilitating fatigue associated with a variety of nonspecific and constitutional complaints. While the cause of chronic fatigue syndrome in children and adolescents is likely to be multifactorial, stress and psychosomatic factors appear to play a role in some patientsw Carter and co-workers8found that subjects with chronic fatigue scored higher than healthy controls on the Child Behavior Checklist measures of internalizing behavior, withdrawal, and somatization symptoms. Nonspecific Symptoms
Other nonspecific symptoms, including dizziness, syncope, or tiredness, are often found to be associated with family problems, stress, school problems, and depression in high school students visiting the school nurse.4" Similarly, hyperventilation and functional stridor are respiratory conditions in which there is a nonorganic component, and psychological stressors often contribute to these
problem^.^, 6,27 SYMPTOM PRESENTATION AND EVALUATION
Adolescents and their families often seek medical attention for physical symptoms that ultimately are found to have no identifiable organic cause.I8,19,39 The decision to seek medical care may reflect the severity of the symptom, the duration of discomfort, the perceived significance of the symptom, or the presence of other personal or family concerns. In many cases, physical symptoms are associated with life stressors that have exceeded the adolescent's coping ability, resulting in feelings of helple~sness.3~
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Most visits for psychosomatic symptoms represent a response to psychosocia1 distress rather than an attempt to manipulate the health care provider, that is, malingering. Malingering is considered to be under the voluntary control of the patient and is a deliberate presentation of false or exaggerated physical or psychological symptoms.11The intent of malingering may be to avoid school or to obtain unnecessary medications. In the authors’ experience, most adolescents do not intentionally use their symptoms in this manner. Nonetheless, they may indeed receive some secondary gain for their symptoms. For example, parents are less likely to hold children and teenagers responsible for poor grades and misbehavior if they have concurrent somatic complaints than if they are well.58 Thus, parents may unintentionally reinforce symptoms and disability by excusing their teens from normal expectations.% Scheduling
Health care providers may encounter patients with psychosomatic problems at the initial presentation of the symptom or after the symptom has become chronic or recurrent. When it is the initial presentation, providers with busy office practices may be pressed for time and unable to adequately attend to psychosocial issues. In this situation, an evaluation process can be initiated and subsequent visits planned at relatively short intervals to continue the process. In referral settings, the provider is more likely to be aware of the chronic nature of the symptom, and a longer initial appointment can be scheduled. Initial Interview
A parent usually accompanies the adolescent patient with chronic somatic symptoms to the clinic. The initial interview should be conducted with the parent(s) and adolescent together. Limits of confidentiality can be defined and discussed at this time. A combined session allows the clinician to observe parent-adolescent interactions and to assess the quality of their relationship. During the initial interview, it may be helpful to ask the parent about specific concerns. For example, a parent might be asked whether he or she is concerned that a symptom is indicative of the presence of a particular disorder. This information allows the provider to focus on the area of concern and possibly allay the parent’s previously unexpressed fears regarding a serious or lifethreatening condition. Once the parent(s) have voiced their concerns, it is important to interview the adolescent alone; however, a final feedback or “wrap-up” session with the parents and adolescent together is desirable in order to ensure a shared understanding of the diagnosis and recommendations. History and Review of Symptoms
A complete history should be taken from the adolescent, including a comprehensive review of systems. The adolescent’s perception of the historical facts as previously given by parents may be useful. Any discrepancy between the parent’s and adolescent’s perceptions of the problem may suggest family conflict or poor communication and should be investigated. A description of the onset of the symptom and any associated events or situations may provide important
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clues regarding precipitating stressors. The adolescent’s level of emotional distress can be observed and assessed during the discussion. Psychosocial issues should be reviewed with a particular focus on the possibility of recent life events that may have been stressful.’, 36 A life-events checklist may be useful in gathering this information and clearly defining stressful life events to the adolescent and his or her Checklists may also suggest areas to target for interventions aimed at reducing stress.l*,39 Although an association between life stressors and psychosomatic symptoms may be obvious to an objective observer, many adolescents may not recognize the stressful nature of their circumstances. This situation is somewhat like the old Chinese proverb that says, ”It is not wise to ask a fish, how is the water?” The adolescent, like the fish, may have adapted to his or her circumstances and fail to recognize them as stressful. For example, an adolescent with chronic tension headaches may report that his or her noncustodial parent neither maintains contact nor provides financial support. It is common for patients in such circumstances to report that they have ”gotten used to it,” and that it “doesn’t bother them.” While a teenager might accept being neglected by a biologic parent, such parental behavior usually causes psychological distress, whether conscious or subconscious. Suppressed feelings regarding stressors may play a role in somatic complaints and should be explored. It is important that the clinician’s history explore the daily life of the adolescent, including areas of potential stress. By using nonthreatening and open-ended questions, information can be gained without encountering defensive or reactive responses. For example, the possibility that a particular symptom is triggered or exacerbated by school stressors can be explored in a conversational manner. The initial inquiry about an association between the symptom and school might include the following questions: Does the pain ever occur while you are at school or in the morning before school? Does the pain ever keep you from going to school? Subsequent conversation might aim to assess the extent to which school is a source of stress for the teen and how the teen deals with that stress: By the way, where do you go to school? What grade are you in this year? Do you like it better or worse than last year? Why? And how did you do on your last report card? Which subjects are most difficult for you? What is your favorite subject? How many days of school have you missed this year? How do you spend the day when you miss school? Answers to these questions can reveal relevant difficulties involving grades, teachers, school absence, and the possibility of secondary gain from somatic symptoms. Family History
When adolescents present with medically unexplained symptoms, a history of similar symptoms in relatives or family members should be investigated. Prior family illness associated with an undiagnosed or severe disease may cause excessive parental concern over a minor complaint.33,57 The clinician should be alert to parental anxiety reflected in comments such as, ”Aunt Dotty had the
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very same pain, and they told her it was in her head. They couldn‘t find a thing wrong with her, and she died of cancer three months later. I’m not going to let that happen to my child.” In these cases, parents may need additional reassurance that a particular diagnosis has been considered and ruled out. Physical Examination
A thorough physical examination is an essential part of the evaluation process. Parents must be assured that areas of concern have been thoroughly examined to exclude physical evidence of organic disease. At times, it may be helpful to allow the overly concerned parent to observe the clinician as he or she performs an examination. The physical examination is generally normal in adolescents with psychosomatic complaints, and whenever possible the clinician should give the patient this feedback during the examination. For example, it can be reassuring to tell a teenager who is concerned about possible cardiac causes for chest pain that his or her heart sounds fine. Laboratory Evaluation and Other Testing
When adolescents present for a medical evaluation, they and their parents are usually seeking an organic explanation for any somatic complaints. Many assume that laboratory tests are needed to rule out organic illness. Each somatic complaint should be assessed in a systematic fashion in order to minimize excessive and costly testing procedure^.^, 46, 49 Recommendations for laboratory and other specialized testing vary with the presenting symptoms. Some families may have difficulty accepting that every reasonable or indicated test has been performed, and some may insist upon a specific test that they feel is necessary. An open and frank discussion about the reasons for ordering or excluding testing is helpful. Patient and family anxiety may be reduced by providing a detailed explanation of all test results and their significance in ruling out specific disorders. MANAGEMENT Establishing Trust
The management of psychosomatic problems begins with the initial interview. The physician should establish a trusting relationship by conveying to the patient and family that he or she understands that the symptom is real and that it has caused concern, discomfort, and inconvenience. Physicians should also express concern for the patient’s general well-being, including his or her academic and social functioning. Development of trust requires allowing adequate time for the adolescent and the parents to express their perspectives in the initial and subsequent visits. Once the physician has conveyed genuine concern, he or she should make a firm statement of the nonorganic nature of the psychosomatic symptom and provide clear recommendations for action. For families who are reluctant to accept the absence of organic findings, it is sometimes helpful to explain that although no organic cause can be found at this time, the current symptoms may
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be the residual of an earlier condition that is now in the process of healing. The repair process places extra demands on the body. In order to facilitate this repair process it is helpful to reduce any external stressors (e.g., excessive academic pressure) and to begin a gradual return to normal activities to help the body build up its strength. We find that this explanation allows some adolescents to save face and helps the parent to accept the role of stress in illness and health. Graphic illustrations similar to the model presented in Figure 1 may be useful in discussing this with the patient and parent. A treatment plan should be outlined and agreed upon. Even after apparent agreement, some parents and adolescents raise the question of “what if” a certain new symptom arises or the current symptom does not improve. They should be assured that any new symptom or clue that suggests an organic disease will be thoroughly investigated. In addition, any diagnostic test that is clinically indicated will be performed. Symptom Relief Medication
Symptom relief or reduction is likely to be of foremost importance in adolescents with chronic or recurrent pain. Many patients will have tried overthe-counter analgesics prior to seeking medical attention. Analgesics should be used for temporary relief and viewed as only one part of the treatment process. Non-narcotic analgesics are preferable to those with addiction potential. Antispasmodics and dietary changes, such as increasing fiber intake, may benefit some patients with recurrent abdominal pain and IBS. Patients with dyspeptic symptoms may be given a therapeutic trial of E-I, blockers. Antidepressants may be useful in some patients with psychosomatic problems, including recurrent pain and depressive symptoms, even when they do not meet all of the criteria for major depression. Tricyclic agents or selective serotonin reuptake inhibitor (SSRI) medications, such as fluoxetine and paroxetine, may be helpful in some adolescents. Stress Reduction
Many adolescents and their families are able to accept the possibility of stress contributing to or perpetuating the symptoms. Therefore, interventions to modify the stressor and enhance the adolescent’s coping ability should be planned. When possible, resolution of specific stressors is desirable. For example, removal from an abusive living situation protects the adolescent from the source of severe distress. Older adolescents may be negatively affected by excessive adult responsibilities, such as after-school employment, child-care for younger siblings, and household chores. Decreasing or reassigning some of these adolescents‘ responsibilities can be helpful in reducing stress and thereby may help resolve somatic complaints. Many parents place a great deal of both direct and indirect pressure on their teenagers to compete athletically and academically. In some cases, an adolescent’s symptoms may be a message to parents to “back off.” A teenage athlete who has competed since early childhood may tire of the competition but may be unable to express this to his or her overzealous parents. The adolescent may be fearful that the parents will be disappointed. Decreased academic pressure, such as a reduced number of honors classes, may be a welcome relief for some overachieving teenage scholars.
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Competence Promotion
Adolescents who perceive themselves as inadequate in social, academic, or athletic arenas may be more likely to maintain their symptoms over time.56For those with this perception, normal activities may threaten self-esteem and be regarded as stressful. Interventions to support and enhance the adolescent’s competence in various activities have two potential benefits: (1) increased competence may improve the adolescent’s ability to deal with potentially stressful activities, and (2) involvement in activities may distract the adolescent’s attention away from symptoms. The physician can be helpful in identifying areas of actual or potential competence and encouraging parental promotion of the adolescent’s special interests and abilities in these areas. For example, the parent might encourage involvement in a hobby or activity, praise the teenagers efforts, and facilitate the pursuit of new opportunities. Such attention is a positive alternative to attention for symptoms and di~ability.5~ Return to School and Activities
School absence is a common occurrence in adolescents with psychosomatic complaints. Failure to return to school can lead to an increased sense of helplessness and perpetuation of the sick When an adolescent has missed school, a return to the classroom and other activities should be planned as soon as feasible; however, adolescents and their parents may resist a return to school for a variety of reasons. The adolescent may fear returning because he or she may be behind academically. Some are also concerned about re-entry into peer groups and are unsure of how to explain their absence to friends. A graduated return to school may be helpful. Attending school for a part of the day is a good start, allowing the adolescent to gradually become reacquainted with the academic, physical, and social pressures of a school setting. Academic difficulties, including learning disabilities, should be assessed in patients who have experienced long-term problems with poor grades. Psychoeducational testing by a clinical psychologist can assist in differentiating between failing grades caused by school absences versus those related to learning disabilities. It is not uncommon for an adolescent with a somatic complaint to request a written excuse for physical education classes, or ”gym.” While it may be beneficial for some to reduce their physical activity for a time, attendance at physical education class should be encouraged with the goal of returning to full activity. The school should be contacted to coordinate efforts for a return to the classroom and to discuss the possibility of homebound instruction. Many adolescents seen in the authors’ referral clinic for chronic somatic complaints have been granted homebound instruction by the referring physician. Not uncommonly, continuation is a primary reason for visiting the clinic. When homebound instruction is granted, it is best to set a specific time limit. The authors find it useful to include individual and family counseling as a requirement for continuing homebound classes. The Role of Primary Care Physician
Primary care providers might choose to manage some cases completely and others as part of a treatment team. Depending on the skills and interests of the
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physician, brief, targeted, psychologically based treatment in a primary care setting can be effective.I5Office counseling should be primarily supportive and focus on the current situation and positive ways of coping.59 Whether the physician provides total care or functions as part of a team, adolescent patients can benefit from having an accessible, trusted, and objective confidant outside his or her family. Professionals filling this role can contribute positively to the adolescent’s social support system.*O Inquiry about possible life stressors sends the message that the adolescent’s life situation is important. Supportive listening can enhance the patient‘s ability to think through situations and devise effective coping strategies. Symptom improvement may be observed when the adolescent is able to gain new insights and learn new ways of dealing with his or her stress or^.^^ Referral for Stress Management and Counseling
Referral to a mental health professional for stress management and counseling may be indicated in some cases. The referring physician should make it clear that he or she will remain an integral part of the treatment team. Therefore, follow-up visits with the clinician should be scheduled to assess progress, demonstrate ongoing commitment, and ensure follow through with any referrals. Although many parents acknowledge that stress may play a role in psychosomatic complaints, few accept counseling as potentially benefi~ial.5~ This reluctance to accept counseling may be due to the misperception that counseling is only for those with serious psychological problems.= In the authors’ experience, many families accept referral to a psychologist or other behavioral health professional if the purpose is defined as helping the adolescent cope with his or her physical symptoms. An empathetic comment from the physician, such as ”The amount of discomfort that you are experiencing must be difficult to cope with,” can provide an entrance into a discussion about and the acceptance of a referral. In cases in which the symptoms are longstanding and complex, both individual and family counseling may be helpful. Some therapists choose to see both the adolescent and the family. Others find it more helpful for one counselor to see the adolescent and another the family. Other Interventions
Anxiety and depression are frequently associated with psychosomatic symptoms. Primary care physicians who are familiar with commonly used psychotropic medications may choose to prescribe them for adolescents who are seeing a psychologist or social worker for psychotherapy. Others who are less familiar with anxiolytics and antidepressants may choose to refer their patients to a psychiatrist for medication. Physical or occupational therapy may be beneficial for adolescents with musculoskeletal pain and at times for those with lethargy, chronic fatigue syndrome, or generalized weakness.44We have found that adolescents with chronic musculoskeletal pain respond to a combination of rehabilitation and counseling. This approach allows adolescents to gracefully and gradually ”rehabilitate” the musculoskeletal system while addressing psychosocial issues through concurrent counseling. Biofeedback can be helpful for some patients, especially those who are
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likely to respond to concrete, demonstrable evidence of stress reduction. Biofeedback may be an acceptable adjunct for families who are reluctant to accept counseling but who are willing to invest in a method aimed at reducing the adolescent’s symptom^.'^, 46 Relaxation exercises and guided imagery can also be useful techniques of symptom reduction for practitioners skilled in these methods. Using these techniques, teenagers may be able to identify the signs of tension produced by stress and gain control over their Referral to a pain control clinic or center may be useful in patients with complex symptoms who are unresponsive to other interventions. Prevention of Psychosomatic Problems
Prevention of psychosomatic problems is a desirable goal. The concept that stress is an inevitable part of everyone’s life should be introduced in early adolescence (or before) as a part of anticipatory guidance. Discussion of how everyday stressors, especially those that involve change, can affect an individual’s overall sense of well-being can be incorporated into health maintenance visits for children and Clinicians can also observe adolescents’ efforts to cope with physical symptoms and can address exaggerated reactions to minor symptoms or illness. Discussion of strategies to enhance competence and coping skills can be useful. For example, teens may be taught that a particular symptom, such as headache or abdominal pain, may be a warning signal of stress and not necessarily indicative of an organic illness. Once this association is clear and a symptom recurs, stress reduction strategies can be initiated. A basic strategy is to talk with a trusted confidant about the stressor and symptom. Primary care physicians and other health care providers with an interest, skills, and adequate time to develop 32 relationships with adolescents can fill this important SUMMARY
Psychosomatic problems are common in adolescents, and stress frequently plays a role in their development and maintenance. Armed with an understanding of the stressors experienced by adolescents, the individual’s vulnerabilities and competencies and their level of social support, the physician can systematically assess each of these factors. Once the assessment is complete, a management plan can be formulated to address the particular psychosomatic problem. Symptom relief, stress reduction, and promotion of competence are important interventions that can be initiated by the primary care physician. When referrals are made for counseling and other stress management techniques, the primary care physician should maintain contact with the patient and family and remain an integral part of the management team. Incorporating brief discussions about the potential role of stress in health and illness into anticipatory guidance sessions may also help prevent the development of psychosomatic problems in adolescents. References 1. Aro H: Life stress and psychosomatic symptoms in adolescents. Psycho1 Med 17191. 1987
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2. Asnes R, Santulli R, Bemporad J: Psychogenic chest pain in children. Clin Pediatr 20788, 1981 3. Barskv A, Borus 1: Somatization and medicalization in the era of managed care. IAMA 2741+31,1995 4. Bass C: Unexdained chest uain and breathlessness. Med Clin North Am 751157.1991 5. Brown R: Psichosomatic iroblems in adolescents. Adolesc Med: State Art Rev 3237, 1992 6. Burton C: Hyperventilation in patients with recurrent functional symptoms. Br J Gen Pract 43:422, 1993 7. Carlsson J, Larsson 8, Mark A: Psychosocial functioning in schoolchildren with recurrent headaches. Headache 3677,1995 8. Carter B, Edwards J, Kronenberger W, et a1 Case control study of chronic fatigue in pediatric patients. Pediatrics 95:179, 1995 9. Chase H, Jackson G: Stress and sugar control in children with insulin-dependent diabetes mellitus. J Pediatr 98:1011, 1981 10. Chrousos G, Gold P: The Concepts of Stress and Stress System Disorders. JAMA 2671244,1992 11. Craig T, Drake H, Boardman A: The South London somatization study. I1 Influence of stressful life events and secondary gain. Br J Psychiatry 165:248, 1994 12. Dantzer R Stress and Disease: A psychobiological perspective. Ann Behav Med 13205,1991 13. Dorian BJ, Taylor C B Psychosomatic medicine. In Morrison RL, Bellack AS (eds): Medical Factors and Psychological Disorders. New York Plenum, 1987, p 267 14. Driscoll D, Glicklich L, Gallen W Chest pain in children: A prospective study. Pediatrics 57648, 1976 15. Finney J, Lemanek K, Cataldo M, et al: Pediatric psychology in primary care: Brief targeted therapy for recurrent abdominal pain. Behav Res Ther 20284, 1989 16. Friedman SB: Concepts in psychosomatic illness. In Hockleman RA (ed): Primary Pediatric Care. St Louis: CV Mosby, 1987, p 708 17. Gluckman RM: Physical symptoms as a mask for emotional disorder in adolescents. Adolesc Psychiatry 1984, 1993 18. Greene J, Walker L, Hickson G, et al: Stressful life events and somatic complaints in adolescents. Pediatrics 75:19, 1985 19. Greene J, Wemer M, Walker L Stress and the modem adolescent. Adolesc Med: State Art Rev 3:13, 1992 20. Haggerty RJ: Life stress, illness and social supports. Dev Med Child Neurol 33:391, 1980 21. Hemdon RL: Stress in adolescence. In Arnold LE (ed): Childhood Stress. New York John Wiley and Sons, 1990, p 247 22. Holahan C, Moos R Life stressors, personal and social resources, and depression: A four year structural model. J Abnorm Psychol 10031, 1991 23. Hyams JS, Burke G, Davis PM: Abdominal pain and irritable bowel syndrome in adolescents: A community-based study. J Pediatr 129:220, 1996 24. Johnson J: Life events as stressors in childhood and adolescence. In Lahey BB, Kazdin AE (eds): Adolescent Clinical Child Psychology, vol. 5. New York: Plenum Press, 1982 25. Jolly J, Wherry J, Wiesner D, et al: The mediating role of anxiety in self-reported somatic complaints of depressed adolescents. J Abnorm Child Psychol 22691,1994 26. King N, Sharpley C: Headache activity in children and adolescents. J Pediatr Child Health 2650, 1990 27. Kuppersmith B, Rosen D, Wiatrak 8: Functional stridor in adolescents. J Adolesc Health Care 14166, 1993 28. Larsson B: The role of psychological, health-behavioral and medical factors in adolescent headache. Dev Med Child Neurol 30616,1988 29. Lazarus R, Folkman S Stress, appraisal, and coping. New York Springer, 1984 30. Lipowski ZJ: Somatization: the concept and its clinical application. Am J Psychiatry 1451358, 1988 31. Nemzer E D Psychosomatic illness in children and adolescents. In Garfinkel BD, Y
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Carlson GA, Weller EB (eds): Psychiatric disorders in children and adolescents. Philadelphia: WB Saunders, 1990, pp 135-146 32. Orr D Adolescence, stress and psychosomatic issues. J Adolesc Health Care 7(suppl):97, 1986 33. Osbome RB, Hatcher J, Richtsmeier A The role of social modeling in unexplained pediatric pain. J Pediatr Psychol 1443-61,1989 34. Pantel R, Goodman B Adolescent chest pain: A prospective study. Pediatrics 71:881, 1983 35. Pennebaker JW: The psychology of physical symptoms. New York Springer-Verlag, 1982 36. Poikolainen K, Kanerva R, Lonnqvist J: Life events and other risk factors for somatic symptoms in adolescence. Pediatrics 96:59, 1995 37. Rauste-von Wright M, von Wright J: Habitual somatic discomfort in a representative sample of adolescents. J Psychosom Res 36383, 1992 38. Rickert V, Jay S: Psychosomatic disorders: The approach. Pediatr Rev 15:448, 1994 39. Robinson DP, Greene J, Walker L: Functional somatic complaints in adolescents: Relationship to negative life events, self-concept, and family characteristics. J Pediatr 113:58&593, 1988 40. Schneider M, Fiedman S, Fisher M Stated and unstated reasons for visiting a high school nurse’s office. J Adolesc Health Care 1635, 1995 41. Schor E: Use of health care services by children and diagnoses received during presumably stressful life transitions. Pediatrics 77834, 1986 42. Selbst S: Chest pain in children. Pediatrics 75:1068, 1985 43. Selbst S, Ruddf R, Clark B, et a 1 Pediatric chest pain: A prospective study. Pediatrics 82319,1988 44. Sherry D, McGuire T, Mellins E, et al: Psychosomatic musculoskeletal pain in childhood: Clinical and psychological analysis of 100 children. Pediatrics 88:1093, 1991 45. Smith MS: Psychosomatic symptoms in adolescents. Med Clin North Am 741121, 1990 46. Smith MS, Womack W: Stress management techniques in childhood and adolescence. Relaxation training, meditation, hypnosis and biofeedback Appropriate clinical applications. Clin Pediatr 26581, 1987 47. Smith RC, Greenbaum J, Vancouver R, et al: Psychosocial factors are associated with health care seeking rather than diagnosis of irritable bowel syndrome. Gastroenterology 98:293, 1990 48. Starfield B, Gross E, Wood M, et al: Psychosocial diagnoses in primary care of children. Pediatrics 66159, 1980 49. Strasburger V, Reeve A: The adolescent with chronic pains: Basic principles of psychosomatic medicine. Adolesc Med: State Art Rev 2677, 1991 50. Walford G, Nelson W, McCluskey D: Fatigue, depression and social adjustment in chronic fatigue syndrome. Arch Dis Child 68:384, 1993 51. Walker L, Greene J: Children with recurrent abdominal pain and their parents: More somatic complaints, anxiety and depression than other patient families? J Pediatr Psychol 14:231, 1989 52. Waiker L, Greene J: Negative Iife events, psychosocial resources and psychological symptoms in adolescents. J Clin Child Psychol 1629, 1987 53. Walker L, Greene J: Negative life events and symptom resolution in pediatric abdominal pain patients. J Pediatr Psychol 16:341, 1991 54. Walker L, Zeman J: Parental responses to child illness behavior. J Pediatr Psychol 1749, 1992 55. Walker L, Garber J, Greene J: Psychosocial correlates of recurrent childhood pain: A comparison of pediatric patients with recurrent abdominal pain, organic illness, and psychiatric disorders. J Abnorm Psychol 102248, 1993 56. Walker L, Garber J, Greene J: Somatic complaints in pediatric patients: A prospective study of the role of negative life events, child social support and academic competence and parental somatic symptoms. J Consult Clin Psychol 621213, 1994 57. Walker L, Garber J, Greene J: Somatization symptoms in pediatric abdominal pain patients: Relation to chronicity of abdominal pain and parent somatization. J Abnorm Child Psychol 19:379, 1991
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58. Walker L, Garber J, Van Slyke D Do parents excuse the misbehavior of children with physical and emotional symptoms? & investigation of the pediatric sick role. J Pediatr Psvchol20:329,1995 59. Wilker L, Greene J, Garber J, et a1 Psychosocial factors in pediatric abdominal pain: Implications for assessment and treatment. The Clinical Psychologist 26:206, 1993 60. Walker L, Guite J, Duke A, et a1 Recurrent abdominal pain: A precursor of irritable bowel syndrome in adolescents and young adults? (Submitted for publication) 61. Walker L, Smith CA, Garber J, et al: Development and validation of the Pain Response Inventory. Psycho1 Assessment (accepted for publication) 62. Walker L, VanSlyke D, Newbrough J R Family resources and stress: A comparison of families of children with cystic fibrosis, diabetes, and mental retardation. J Pediatr Psycho1 17327-343, 1992 63. Whitehead W. Psychosocial aspect of functional gastrointestinal disorders. Gastroenterol Clin North Am 25:21, 1996 64. Whitehead W, Crowell M, Heller B, et al: Modeling and reinforcement of sick role during childhood predicts adult illness behavior. Psychosom Med 56541, 1994 65. Williams C, Uchiyama C: Assessment of life events during adolescence. Adolescence 93:95, 1989 66. Wood BL: Beyond the psychosomatic family: A biobehavioral family model of pediatric illness. Fam Process 32:3, 1993 67. Wooley SC, Blackwell B, Winget C: The learning theory model of chronic illness behavior: Theory, treatment, and research. Psychosom Med 40:379-401, 1978
Address reprint requests to John W. Greene, MD Division of College Health/Young Adult Medicine Vanderbilt University Zerfoss Student Health Center Room SS-3407 Station 17 Nashville, TN 37232