|
|
Somatization
Additional information about child and adolescent somatization is
available from:
For information on treatments for somatization that are available
through CARE-NET, see
Studies. |
|
-
What is
Somatization?
- Assessment
(symptoms)
- Treatment
- More Information
What is
Somatization?
Somatization
(Somatoform disorder) is diagnosed when a patient suffers from
symptoms that suggest a physical disorder or disease, but the symptoms
don’t seem to be fully explained by the presence of a general medical
condition or exposure to a medication, substance of abuse, or toxin.
Medically unexplained physical symptoms are common in children and
adolescents, especially recurrent complaints of pain. These youth use
more health services and are at greater risk to also suffer from
psychiatric symptoms and disorders such as anxiety and/or depression,
and often experience school problems and frequent absences
back to top
Assessment (Symptoms)
Assessment is an important step in knowing how to move forward when
a child suffers from seemingly “unexplained” symptoms, and lays the
foundation for treatment. Multiple sources of information can be
helpful, with parents, teachers, and school nurses being good resources.
It is important for doctors to:
-
Acknowledge patient suffering and family concerns. This is
essential to establishing a working partnership. Many patients are
concerned that their symptoms are thought to be imaginary, “faked”,
or “all in my head”. The doctor should acknowledge that the
suffering is quite real. It is very unusual for children who present
with apparent somatization in the medical setting to be “faking it”
or lying about their symptoms.
-
Explore prior assessment and treatment experiences. It is
easy for patients and families to feel “dismissed” by professionals
and concerned that they are not being taken seriously. Previous
negative experiences with doctors are common. Even the most caring
physician can be perceived to be insensitive if the patient and
family believe they are being told that “nothing is wrong” after
weeks or months of symptomatic distress and several hours in a
waiting room. Similarly, mental health professionals can make a
mistake by insisting that the patient’s physical suffering is
“simply” a consequence of anxiety or depression. Families commonly
report past experiences with health care professionals that have
generated considerable mistrust, and many relate stories about a
friend or relative who was reassured by a trusted physician only to
learn later that a serious physical disease had been missed. Such
experiences can make it difficult for doctors reassure families that
a serious disease has not been missed.
-
Investigate patient and family fears. Patients and their
families are commonly anxious about the unexplained symptom(s). This
is understandable enough, but can make things worse and sometimes
interfere with both assessment and treatment. Separation fears are
common for affected children, and parents sometimes view the
children as especially “vulnerable” to physical problems. Some
families are terribly frightened, if not convinced that a serious
physical disease has been missed, while others express little or no
worries about disease but are searching only for symptomatic relief.
-
Remain alert to unrecognized physical disease. The examining
doctor should keep an open mind and avoid prejudging the cause of
the patient’s symptom(s). Sometimes medically unexplained symptoms
are just that – unexplained. In other words, it may not be wise to
claim that a child’s symptoms are caused by emotional distress
simply because an explanatory disease has not been identified.
Additional medical evaluation should be pursued if the assessment
generates concerns about unrecognized physical disease or if the
clinical picture changes over time. It is relatively unusual to find
undiagnosed disease in youth judged to be suffering from
somatization, with only about 10% or less being found to suffer from
explanatory disease later on.
-
Avoid unnecessary tests and procedures. There is no simple
answer to the question of when the medical work-up should be
considered “finished” or complete, since it may be impossible to
absolutely rule-out unrecognized disease. There is a need to balance
concerns about unrecognized disease, family anxiety, risk of medical
tests and procedures, and cost. It is important for the clinician
to be reasonably confident that serious physical disease has not
been missed in order to effectively communicate this conviction to
the patient and family. Unnecessary medical tests and treatments can
be dangerous, and also can communicate that the physician is
uncertain about the diagnosis, which can worsen anxiety and
somatization.
-
Avoid diagnosis by exclusion. Somatoform disorder should not
diagnosed just by excluding the possibility that a physical disease
might be causing the symptoms. An effort should be made to identify
positive findings or “clues” to the diagnosis. None of these clues
are definitive, but a constellation of clues taken together is most
persuasive. Clues to somatization include:
-
Observing that the symptom coincides with certain life stressors
(e.g., death of a family member or pet, maltreatment);
-
The
presence of a psychiatric disorder;
-
Association of the symptom with some reward or psychological
gain for the child;
-
Existence of a model for the symptom within the child’s
immediate environment;
-
The
symptom has a communicative or symbolic meaning within the
patient’s social world;
-
The
symptom is not compatible with what is known about anatomy or
physiology based on current scientific knowledge;
-
The symptom responds to placebo, suggestion, or psychological
treatment.
-
Explore symptom
timing, context, and characteristics. It is particularly
important to examine any benefits associated with the sick role.
Social benefits associated with the sick role are known as the
so-called secondary gain associated with the symptom(s). Some
children develop physical symptoms in response to seemingly
stressful situations, such as getting ready for school in the
morning or going to bed alone at night. Parents may inadvertently
encourage sick role behaviors by responding excessively to
complaints of pain with attention, rewards, or with opportunities to
avoid unpleasant activities or school.
-
Look for skill deficits. The presence of school difficulties can
be especially important clinically, since the presence of a learning
disorder can reinforce absenteeism. Somatization may also provide a
ready “explanation” as to why a particular child may not be
performing up to expectations. This is known as a “self-handicapping
strategy”. For example, a child might believe that they would get
excellent grades in school “if only I didn’t get headaches”.
back to top
Treatment
-
Treatment
should be a collaborative process between patients, families, and
professionals.
Patient,
family, and professional roles and responsibilities should be made
clear, and there should be some agreement about the goals of
treatment. The focus should be on functional improvement rather than
an unequivocal “cure”. The importance of good communication and of
“working together” should be emphasized. The use of placebo or sham
treatments should be discouraged for both ethical and practical
reasons.
-
Reassurance
that
a life threatening or serious physical disease is not present is a
necessary step in the treatment process. It is usually important
that the patient and family view the symptoms as less threatening
than at the time of original presentation. An explanation of how the
pain is quite real, yet not associated with tissue damage is
generally helpful.
-
Rehabilitative
approach.
Many authors have discussed the advantages of an approach that may
be described as “rehabilitative” in nature, encouraging the patient
to return to usual activities and responsibilities prior to
definitive symptomatic relief and discouraging illness related
behaviors. The rehabilitative approach helps reframe the
problem from one of finding a “cure” to instead finding a way to
cope with and overcome a distressing physical problem. The patient
is empowered to overcome a manageable problem. Improvement is
understood as a personal success based on individual courage and
hard work, and an accomplishment of which the patient can be proud.
Problem focused approaches to coping that direct the child to
accommodating to the symptom(s) appear to be superior to passive
coping or avoidance, which are associated with greater symptom
burden and impairment. In keeping with a rehabilitative model, the
use of physical therapy is sometimes helpful. The importance of the
child’s education should be emphasized, with attendance and
performance serving as critical indicators of successful
functioning. Professionals should respect the importance of school
by scheduling follow-up visits outside of regular school hours
whenever possible. Homebound instruction must be avoided or
challenged. Success with a rehabilitative approach is
contingent on the clinician’s ability to manage patient and family
anxiety in relation to the symptom and to challenge any perceptions
that the child is especially “vulnerable” and thus unable to cope.
Most importantly, parents and caretakers must understand that
expecting a child to function in spite of physical distress is not
cruel in the circumstance of somatization, but actually therapeutic.
The rehabilitative approach emphasizes the child’s fundamental
health, strength, and adaptability. Many parents benefit from a
discussion of how kindness demands a firm approach that communicates
the conviction that the child is indeed strong enough and competent
enough to overcome their very real distress.
-
Behavioral
treatment.
Most treatment
approaches emphasize positive reinforcement for
healthy behavior, meaning rewards and encouragement when the child
copes well with the symptom and keeps it from interfering with life.
Parents should avoid rewarding the child for unhealthy or sick role
behaviors.
-
Self-management
strategies.
Encouraging
results with self-management strategies have been
reported, with specific techniques being self-monitoring, training
in coping and relaxation, hypnosis, and the use of biofeedback. Such
strategies are likely helpful in providing some degree of symptom
relief and encourage healthy coping.
-
Family and
group interventions.
The use of family therapy has also been advocated, but is not
especially well studied. Since children presenting with medically
unexplained physical symptoms are more likely as a group to be
viewed as health impaired and to be encouraged to adopt the sick
role by parents, it is important for the doctor to respectfully
challenge the perceived physical vulnerability of the child and any
familial encouragement of illness behavior.
-
Communicate.
Encourage and improve communication between patient, family, and
involved professionals, including teachers and the school nurse when
appropriate. The clinician can serve as a bridge to help bring
together the school and the patient's family, as tensions frequently
develop regarding absences and requests for special treatment of the
child.
-
Consolidate
care.
Attempt to consolidate care with a single physician. Regularly
scheduled medical visits can be reassuring and allow the patient and
family to see the doctor without the requirement that the child be
sick. It is often useful for the doctor to define what constitutes
a legitimate, medically excused school absence. The child and
parents need to understand that absence from school without the
approval of the treatment team and an appropriate medical excuse
will be viewed as truancy and the school will take the appropriate
action. With such a treatment plan, cooperation of the school can
benefit treatment.
-
Aggressive
treatment of comorbid psychiatric problems.
Pediatric
somatization is commonly associated with anxiety and/or depression.
Evidence from studies of adults suggests that active intervention
for comorbid anxiety and depression can improve somatic symptoms.
-
Consider
medications.
There have been
few systematic studies of psychoactive medications in pediatric
somatization. Psychopharmacologic interventions are nevertheless
worthy of consideration in the treatment of persistent medically
unexplained pain, gastrointestinal symptoms, or fatigue,
particularly in the presence of psychiatric comorbidity or when
psychotherapeutic interventions have not been entirely successful.
Antidepressant medications appear to be of significantly greater
benefit than placebo in the treatment of adult somatoform pain
disorders. We have conducted an open trial of citalopram for
functional recurrent abdominal pain in youth that produced
encouraging findings, and are testing citalopram as a treatment in a
double blind placebo controlled trial. Preliminary evidence suggests
that SSRIs may ameliorate hypochondriacal distress in adults and
have a role in the treatment of body dysmorphic disorder, but
comparable research in children and adolescents is lacking. Clinical
experience also suggests that some patients who experience physical
symptoms associated with emotional arousal and anxiety may benefit
from a short course of a benzodiazepine such as clonazepam or
lorazepam; benzodiazepines can provide relatively rapid symptomatic
relief, thus helping to reassure the patient and family and provide
a powerful example of how emotional activation and physical distress
may be associated.
-
Monitor
outcome.
Though
symptomatic relief is certainly desirable, the recommended
management approach emphasizes the primacy of functional
improvement. Domains include school attendance and performance,
family, peer and social functioning, and health service use.
Particularly in situations of persistent diagnostic uncertainty, a
successful response to treatment may help reassure the family and
any concerned professionals that the diagnostic impression of
somatization was indeed correct. This can then allow additional
treatment to proceed, with an increasing focus on comorbid emotional
and behavioral difficulties.
back to top
|
