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Fact or fiction: Somatoform disorders explored

Sometimes a child complains continually of a pain or physical disability for which a physician cannot find a physical cause or the cause found does not account for the level of impairment experienced by the child. The pain or disability, however, is very real to the child.

When pain or physical complaints have no apparent medical basis, they may be due to a somatoform disorder—a group of disorders characterized by the presence of one or more physical complaints that appear to be medical in origin, but can't be explained in terms of a physical disease.

According to David DeMaso, MD, psychiatrist-in-chief at Children's Hospital Boston, unexplained somatic complaints represent a significant and complex challenge to pediatricians.

The Diagnostic and Statistical Manual of Mental Disorders lists five types of somatoform disorders: body dysmorphic disorder, conversion disorder, hypochondriasis, pain disorder and somatization disorder. Of these, conversion and pain disorders are the most common types seen in children and adolescents, and they frequently occur together.

Conversion disorders involve unexplained symptoms affecting voluntary motor or sensory function. The symptoms resemble neurological conditions and physical ailments, such as blindness, deafness, paralysis of a limb, pseudoseizures, and episodes of fainting. An example would be a girl who develops an inability to walk that is unexplained by a medical condition, but is temporally related to family conflicts. She is "converting" a psychological stress into a physical symptom.

Pain disorders involve symptoms that cause significant distress or impairment in a child's ability to function. The symptoms are commonly persistent and recurrent, including headaches, stomach aches and limb pain. An example would be a boy with recurrent stomach aches that correlate with stressful academic or social situations.

The symptoms are not intentionally produced or feigned in either disorder. Rather, they may be the result of psychological factors, such as anxiety about school (see "Bullying"), nervousness in social situations, developmental crises, learning difficulties, family conflicts or any other stressful situation. The presence of co-occurring anxiety and depressive disorders is also common.

According to Dr. DeMaso, it's crucial that pediatricians become proficient in identifying and managing these problems. Due to the frequent dual physical and emotional factors of the two disorders, he recommends an integrated medical and psychiatric treatment approach. "The pediatrician should begin the assessment with a thorough physical workup to exclude physical and neurological conditions," says Dr. DeMaso. "This should be followed by a complete psychiatric assessment, although some families may be resistant to a referral to a mental health clinician."

As some families go to their pediatrician certain that there is a medical cause for their child's symptoms, Dr. DeMaso recommends that the pediatrician tell the family that he is requesting a psychiatry consultation as part of a comprehensive developmental biopsychosocial evaluation that includes all aspects of the child's life. The pediatrician should also communicate to the family that he will integrate the findings of this consult into a comprehensive understanding of the child's symptoms.

When the medical and psychiatric assessments are complete, it's crucial for the pediatrician to present the findings to the patient and his or her family. "Families believe that the symptoms are due solely to a medical condition," says Dr. DeMaso. "So having the pediatrician communicate the findings can be reassuring."

An informing conference is the best means to convey findings to a family. The meeting generally begins with a review of medical findings. If a conversion or pain disorder has been diagnosed, the family should be told that many important things were discovered, such as, "We have good news. We've ruled out a number of serious illnesses." Statements, such as, "We couldn't find anything" or "The symptoms aren't real," should be avoided. While the mental health consultant may attend this family meeting, Dr. DeMaso believes it's important for the family to hear directly from their doctor that the symptoms are not solely due to a physical or medical condition.

After delivering the diagnosis, the pediatrician and psychiatrist should form an integrated medical and psychiatric treatment team. Pediatric treatment generally involves setting up ongoing follow-up appointments to monitor for symptom recurrence. Psychiatric treatment should be directed toward further understanding the child and family dynamics and the underlying psychological problems. Medication may play a role in treating pain symptoms and/or accompanying symptoms of clinical anxiety or depression.

The use of physical therapy is helpful for many patients as well. Not only does this give the patient a more proactive role in his or her treatment, but it also allows them a "face-saving" means for explaining improvement in their symptoms. Also, physical therapy may be needed in some cases to treat actual physical effects resulting from the disorder, such as muscle atrophy or decreased mobility.

For more information, visit: www.childrenshospital.org/psych.

To order the textbook, Clinical Manual of Pediatric Psychosomatic Medicine:
Mental Health Consultation With Physically Ill Children and Adolescents by
Drs. Richard Shaw and David DeMaso, click here.

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