- Email: [email protected]
Somatoform disorders in childhood and adolescence
International Congress Series 1241 (2002) 185 – 188
Somatoform disorders in childhood and adolescence Nico H. Bouman* De Jutter Centre for Child and Adolescent Psychiatry, PO Box 84193, 2508 AD The Hague, The Netherlands
Abstract Somatoform disorders (SFD) are complex disorders and form a major challenge for the consultation and liaison child and adolescent psychiatrist. In this paper, it is argued that the different SFD have more aspects in common than differences and that they are more usefully treated as one disorder. The etiology of SFD is placed within a bio-psycho-social framework and an etiological model is presented. Key aspects of treatment are presented with an emphasis on cooperation between somatic medical specialists and those in the psychiatric disciplines. D 2002 Elsevier Science B.V. All rights reserved. Keywords: Somatoform disorders; Classification; Etiology; Treatment
1. Introduction Somatoform disorders (SFD) may be as old as medicine, but they still puzzle clinicians as well as researchers. As a consultation and liaison child and adolescent psychiatrist, the author saw many children with SFD. Based on this experience, this paper will elaborate on some aspects of SFD. First, the discrimination between the different SFD will be discussed. Then, based on a review of the literature, an etiological model for SFD will be presented. Finally, treatment strategies will be discussed.
2. Are there different somatoform disorders? The DSM-IV [1] discriminates between several SFD, but this discrimination appears not to be based on evidence concerning differences in etiology, treatment, or prognosis. In
*
Tel.: +31-70-3386060. E-mail address: [email protected] (N.H. Bouman).
0531-5131/02 D 2002 Elsevier Science B.V. All rights reserved. PII: S 0 5 3 1 - 5 1 3 1 ( 0 2 ) 0 0 6 9 2 - 1
186
N.H. Bouman / International Congress Series 1241 (2002) 185–188
clinical practice, we saw children with pain disorder, conversion disorder or somatization disorder, whose clinical pictures had more similarities than differences:
the children and their parents were convinced that their complaints were somatic; many of the children and their parents presented themselves as ‘supernormal’; hardly any of the children showed externalizing behavioral problems; many children, despite different disorders, responded to virtually the same treatment strategy. Wessely et al. [2] argued that almost every medical specialty has its own functional syndrome and that these syndromes have more similarities than differences. What SFD and somatic functional syndromes essentially have in common is somatization, defined by Lipowsky [3] as ‘a tendency to experience and communicate somatic distress and symptoms unaccounted for by pathological findings, to attribute them to physical illness, and to seek medical help for them’. In this definition, he left out the aspect of expressing psychological distress in the form of physical symptoms because those who opposed this notion argued that somatizers do not experience psychological distress. However, particularly this aspect of SPD seems to be crucial to understand their etiology.
Fig. 1. Etiological model for SFD.
N.H. Bouman / International Congress Series 1241 (2002) 185–188
187
3. Etiology of SFD The history of psychiatry could well be written in terms of the proposed causes for SFD. Disorder of the animal spirits, repressed sexual conflicts, alexithymia, reinforcement of illness behavior, and family dysfunctioning are among the many proposed etiologies for SFD. It is recognized by most authors that the etiology for SFD is multifactorial and should be understood within a bio-psycho-social framework. Based on several reviews [3– 6], an etiological model is proposed below (Fig. 1). This model shows that there are several possible pathways leading to somatic complaints. The psychological distress behind the somatic complaint is often hidden. This may be caused by ‘alexithymia’ but also by shame about the nature of the stress or by anxiety about revealing the true nature of the problems, for example, in the case of severe family problems, the act of incest. The somatic complaints are given a meaning that leads to illness behavior. This is one way out of the somatic loop, and it is sometimes done because of the recognition, by parents for example, of the true nature of the problem. Illness behavior is invariably reinforced. There may be a primary gain, of avoiding the original conflict or the stress, or there may be secondary gain through the often-enormous amount of attention given by parents to ill children. Reinforcement will enhance illness behavior, which in turn will cause increased reinforcements, etc. Family functioning may influence several aspects of the disorder and enhance illness behavior. Space is lacking to elaborate further on this model.
4. Treatment of SFD In the treatment of SFD, there are many roads that lead to Rome. However, there are some key aspects of treatments that are shared by many authors:
accept the somatic complaints as real although not caused by a somatic disease reduce stress reinforce wellness behavior
In our clinical practice we used a ‘two tracks policy’. In cooperation between a pediatrician or child neurologist and a child and adolescent psychiatrist, a thorough somatic as well as a psychiatric and psychological investigation is proposed to the child and its parents. This is accepted in most cases, and through the process we gain two things, first is the possibility to gain an insight into the possible etiological factors of the case, and, second is the time. Time is essential to help parents and children begin to accept that there is no somatic disease and that there might be other factors involved. A good connection with the somatic medical specialist is essential to prevent ongoing somatic examinations while at the same time assuring the patients and the parents that good somatic care is being provided. It may be very difficult to reduce stress, especially when it is hidden. We saw many children for whom school was a major source of stress. Being high achievers, coming from high-achieving families, these children were often at a school level that in fact was too
188
N.H. Bouman / International Congress Series 1241 (2002) 185–188
high for them. Advice to return to a lower school level, often difficult to accept at the onset, opened the way back to school. It is very important to reduce the reinforcement of illness behavior. A direct statement that too much attention is given to the symptoms often has a negative effect. A stepwise building up of normal physical activities while praising the child for its effort is more effective. If symptoms are too serious for such an approach, illness behavior can be ‘punished’, for example, by prescribing strict bed rest, with the possibility of reducing bed rest as the symptoms improve. Further treatment must be tailored to findings from the psychiatric and psychological examination. However, in practice you often must be satisfied that symptoms are reduced and that functioning is restored although a child might still have several problems for which treatment is warranted.
5. Conclusion SFD are a challenge for the clinician. Patients with SFD often ask much of your tact and patience. You will have to accept failure and sometimes bide your time. In these cases, the patients have created the Cartesian split. It is up to us to bring mind and body together again.
References [1] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th edn., The American Psychiatric Association, Washington, DC, 1994. [2] S. Wessely, C. Nimnuan, M. Sharpe, Functional somatic syndromes: one or many? Lancet 354 (9182) (1999 Sep. 11) 936 – 939. [3] Z.J. Lipowsky, Somatization: the concept and its clinical application, Am. J. Psychiatry 145 (11) (1988) 1358 – 1368. [4] R. Mayou, C. Bass, M. Sharpe, Treatment of Functional Somatic Symptoms, Oxford Univ. Press, Oxford, 1995. [5] E. Garralda, Somatisation in children, J. Child Psychol. Psychiatry 37 (1) (1996) 13 – 33. [6] N.H. Bouman, J.B. Jacobs, Somatoforme stoornissen [Somatoform disorders], in: F.C. Verhulst, F. Verheij (Eds.), Adolescentenpsychiatrie [Adolescent psychiatry], Van Gorcum, Assen, The Netherlands, 2000, pp. 255 – 271.
Somatoform disorders in childhood and adolescence Nico H. Bouman* De Jutter Centre for Child and Adolescent Psychiatry, PO Box 84193, 2508 AD The Hague, The Netherlands
Abstract Somatoform disorders (SFD) are complex disorders and form a major challenge for the consultation and liaison child and adolescent psychiatrist. In this paper, it is argued that the different SFD have more aspects in common than differences and that they are more usefully treated as one disorder. The etiology of SFD is placed within a bio-psycho-social framework and an etiological model is presented. Key aspects of treatment are presented with an emphasis on cooperation between somatic medical specialists and those in the psychiatric disciplines. D 2002 Elsevier Science B.V. All rights reserved. Keywords: Somatoform disorders; Classification; Etiology; Treatment
1. Introduction Somatoform disorders (SFD) may be as old as medicine, but they still puzzle clinicians as well as researchers. As a consultation and liaison child and adolescent psychiatrist, the author saw many children with SFD. Based on this experience, this paper will elaborate on some aspects of SFD. First, the discrimination between the different SFD will be discussed. Then, based on a review of the literature, an etiological model for SFD will be presented. Finally, treatment strategies will be discussed.
2. Are there different somatoform disorders? The DSM-IV [1] discriminates between several SFD, but this discrimination appears not to be based on evidence concerning differences in etiology, treatment, or prognosis. In
*
Tel.: +31-70-3386060. E-mail address: [email protected] (N.H. Bouman).
0531-5131/02 D 2002 Elsevier Science B.V. All rights reserved. PII: S 0 5 3 1 - 5 1 3 1 ( 0 2 ) 0 0 6 9 2 - 1
186
N.H. Bouman / International Congress Series 1241 (2002) 185–188
clinical practice, we saw children with pain disorder, conversion disorder or somatization disorder, whose clinical pictures had more similarities than differences:
the children and their parents were convinced that their complaints were somatic; many of the children and their parents presented themselves as ‘supernormal’; hardly any of the children showed externalizing behavioral problems; many children, despite different disorders, responded to virtually the same treatment strategy. Wessely et al. [2] argued that almost every medical specialty has its own functional syndrome and that these syndromes have more similarities than differences. What SFD and somatic functional syndromes essentially have in common is somatization, defined by Lipowsky [3] as ‘a tendency to experience and communicate somatic distress and symptoms unaccounted for by pathological findings, to attribute them to physical illness, and to seek medical help for them’. In this definition, he left out the aspect of expressing psychological distress in the form of physical symptoms because those who opposed this notion argued that somatizers do not experience psychological distress. However, particularly this aspect of SPD seems to be crucial to understand their etiology.
Fig. 1. Etiological model for SFD.
N.H. Bouman / International Congress Series 1241 (2002) 185–188
187
3. Etiology of SFD The history of psychiatry could well be written in terms of the proposed causes for SFD. Disorder of the animal spirits, repressed sexual conflicts, alexithymia, reinforcement of illness behavior, and family dysfunctioning are among the many proposed etiologies for SFD. It is recognized by most authors that the etiology for SFD is multifactorial and should be understood within a bio-psycho-social framework. Based on several reviews [3– 6], an etiological model is proposed below (Fig. 1). This model shows that there are several possible pathways leading to somatic complaints. The psychological distress behind the somatic complaint is often hidden. This may be caused by ‘alexithymia’ but also by shame about the nature of the stress or by anxiety about revealing the true nature of the problems, for example, in the case of severe family problems, the act of incest. The somatic complaints are given a meaning that leads to illness behavior. This is one way out of the somatic loop, and it is sometimes done because of the recognition, by parents for example, of the true nature of the problem. Illness behavior is invariably reinforced. There may be a primary gain, of avoiding the original conflict or the stress, or there may be secondary gain through the often-enormous amount of attention given by parents to ill children. Reinforcement will enhance illness behavior, which in turn will cause increased reinforcements, etc. Family functioning may influence several aspects of the disorder and enhance illness behavior. Space is lacking to elaborate further on this model.
4. Treatment of SFD In the treatment of SFD, there are many roads that lead to Rome. However, there are some key aspects of treatments that are shared by many authors:
accept the somatic complaints as real although not caused by a somatic disease reduce stress reinforce wellness behavior
In our clinical practice we used a ‘two tracks policy’. In cooperation between a pediatrician or child neurologist and a child and adolescent psychiatrist, a thorough somatic as well as a psychiatric and psychological investigation is proposed to the child and its parents. This is accepted in most cases, and through the process we gain two things, first is the possibility to gain an insight into the possible etiological factors of the case, and, second is the time. Time is essential to help parents and children begin to accept that there is no somatic disease and that there might be other factors involved. A good connection with the somatic medical specialist is essential to prevent ongoing somatic examinations while at the same time assuring the patients and the parents that good somatic care is being provided. It may be very difficult to reduce stress, especially when it is hidden. We saw many children for whom school was a major source of stress. Being high achievers, coming from high-achieving families, these children were often at a school level that in fact was too
188
N.H. Bouman / International Congress Series 1241 (2002) 185–188
high for them. Advice to return to a lower school level, often difficult to accept at the onset, opened the way back to school. It is very important to reduce the reinforcement of illness behavior. A direct statement that too much attention is given to the symptoms often has a negative effect. A stepwise building up of normal physical activities while praising the child for its effort is more effective. If symptoms are too serious for such an approach, illness behavior can be ‘punished’, for example, by prescribing strict bed rest, with the possibility of reducing bed rest as the symptoms improve. Further treatment must be tailored to findings from the psychiatric and psychological examination. However, in practice you often must be satisfied that symptoms are reduced and that functioning is restored although a child might still have several problems for which treatment is warranted.
5. Conclusion SFD are a challenge for the clinician. Patients with SFD often ask much of your tact and patience. You will have to accept failure and sometimes bide your time. In these cases, the patients have created the Cartesian split. It is up to us to bring mind and body together again.
References [1] American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th edn., The American Psychiatric Association, Washington, DC, 1994. [2] S. Wessely, C. Nimnuan, M. Sharpe, Functional somatic syndromes: one or many? Lancet 354 (9182) (1999 Sep. 11) 936 – 939. [3] Z.J. Lipowsky, Somatization: the concept and its clinical application, Am. J. Psychiatry 145 (11) (1988) 1358 – 1368. [4] R. Mayou, C. Bass, M. Sharpe, Treatment of Functional Somatic Symptoms, Oxford Univ. Press, Oxford, 1995. [5] E. Garralda, Somatisation in children, J. Child Psychol. Psychiatry 37 (1) (1996) 13 – 33. [6] N.H. Bouman, J.B. Jacobs, Somatoforme stoornissen [Somatoform disorders], in: F.C. Verhulst, F. Verheij (Eds.), Adolescentenpsychiatrie [Adolescent psychiatry], Van Gorcum, Assen, The Netherlands, 2000, pp. 255 – 271.