IACAPAP 14 Associated Somatic Disorders

IACAPAP MOOC
Essentials of Child and Adolescent Psychiatry across the World
Associated somatic disorders

Pr. Oscar Snchez-Guerrero
Medico Especialista en Psiquitria Infantil y de la Adolescencia
Instito Nacional de Pediatria, Mexico
Introduction
IACAPAP MOOC: Somatic symptoms and related disorders
Somatic symptoms in psychiatry

In may 2013, the DSM-5 included a new category: the
somatic symptoms and related disorders
Diagnoses include
Somatic symptom disorders

Illness anxiety disorder
Conversion disorder
Psychological factors affecting medical conditions
Factitious disorder
Other somatic symptoms and related disorders
Unespecified somatic symptom disorder
Introduction

The common feature is the prominence of
somatic symptoms associated with significant
distress and impairment
These individuals are commonly encountered in
primary care, rarely in psychiatric settings
Introduction

Physical (somatic) symptoms are extremely
common in children and adolescents, who
often find it difficult to express their feelings
and emotions through language
Because of this, psychological distress may be
expressed as physical (somatic) symptoms
Introduction
Somatization
What is somatization?
Somatization describes clinical and behavioral features
indicating that a person is experiencing and
communicating psychological distress through physical
(somatic) symptoms not accounted for by pathological
findings; these symptoms are attributed to a physical
illness and this leads to seeking medical help.
Introduction
Somatization
In somatization, the production of

symptoms is usually not under conscious
control. However, in children and
adolescents it is particularly difficult to
establish the level of conscious control.
Introduction
Somatization
Parents are usually aware that their children may
sometimes experience somatic symptoms if they
are worried about something or trying to avoid
something
Most parents will naturally minimize the
importance of these symptoms and try and find
out the cause
This tactic aids children to learn to cope with
everyday stresses
Introduction
Somatization
However, sometimes symptoms persist : 2% - 10% of
children in the general population complain of aches
and pains that are likely to be medically unexplained
Medically unexplained symptoms refer to all
bothersome or recurrent bodily symptoms that do not
have a recognized medical illness explanation
These symptoms may cause little difficulty, or lead to
distress, impairment in functioning and healthcareseeking behavior
Introduction
Somatization
Even in very young children, those who present
with frequent somatic symptoms
Have associated behavioral and emotional problems
Miss nursery and attend clinics
These children are at increased risk of experiencing

further physical symptoms and psychological
difficulties later in childhood or adolescence
Introduction
Somatization
We can not separate the body from the mind

No illness is purely physical or psychological
There are many ways in which physical and

psychological symptoms interact, developing
psychological distress
Epidemiology
Contact with health care system

Somatic disorders tend to present repeatedly to
primary care practitioners and pediatricians
rather than psychiatrists because their
presenting symptoms are physical and families
tend to attribute the symptoms to organic, not
psychological, causes.
Epidemiology
Contact with health care system

The medical help-seeking behavior that usually
accompanies the symptoms often leads to numerous
(potentially painful) medical investigations and
treatments before their psychological nature is
identified
Families are often skeptical about the usefulness of a
psychiatric or mental health assessment and may
continue to pursue investigation of an organic
pathology
Epidemiology
Consequences
Over-investigation
Wastage of resources
Lost time for treatment
Epidemiology
Consequences
Children will miss school

Parents need to take time off work to care for
their child
Expertise is needed to avoid the huge
potential implications for patients, families,
services and wider society
Epidemiology
Epidemiology
Little is known about the exact incidence or

prevalence of the different somatic disorders
Epidemiology
Epidemiology
Contributing factors
Genetic and biological vulnerability

Early traumatic experiences
Learning
Cultural and social norms devaluating psychological suffering
Somatic presentations can be viewed as expressions of

personal suffering inserted in a cultural and social
context
Epidemiology
Risk factors for somatization

in children and adolescents
Personal experience of physical illness
Enhanced focus on physical sensations
Concientious, vulnerable, sensitive, anxious
personalities
Particular concerns about peer relationships
High achievement orientation
Gledhill J, Garralda ME (2009). The relationship between physical and mental

health in children and adolescents. In Gelder MG, Andreassen NC et al (eds),
New Oxford Textbook of Psychiatry 2nd Ed. Oxford Univ. Press, pp1740-1746.
INDIVIDUAL
Epidemiology

Physical health problems
Mental Health Problems
Parental somatization
Emotional over-involvement
Limitations in ability to
comunicate about emotional
issues
FAMILY
Epidemiology

Life stresses
School
teasing or bullying
ENVIRONMENT
Academic pressure

Diagnosis and treatment

Assessment
Consider somatic disorders if

There is a time relationship between psychosocial
stressors and physical symptoms
The nature, severity of the symptom or its resulting

handicap is out of keeping with the pathophysiology
There is a concurrent psychiatric disorder

Assessment
The family doctor is likely to be the first port of
call for most children
Evidence that there is no treatable medical

disorder will often relieve concerns for the child
to improve without the need for further
intervention

Assessment
If symptoms persist after assessment and
intervention (which includes targeting the
identified bio-psycho-social factors)
Or if symptoms are particularly severe
Or if there is diagnostic uncertainty
The child should be referred to a mental health
service

Assessment
Diagnosis is made on the basis of positive

symptoms and signs
Distressing somatic symptoms
Abnormal thoughts
Feelings and behaviors in response to these symptoms
Absence of a medical explanation for somatic symptoms

Assessment
Because of the predominant focus on lack

of medical explanation, individuals tend
to regard the diagnosis as pejorative and
demeaning, implying that their physical
symptoms are not real

Assessment
Other mental disorders may initially manifest with
primarily somatic symptoms
Depression
Anxiety
Panic disorder
Can be a cause of somatic complaints

Treatment
General management strategies
Engage the family
Understand
Beliefs about the illness

Level of conviction for physical causes
Satisfaction with investigations
Views about the mental health referral and treatment
Do not question the reality of the symptoms

Acknowledge that patients have a real illness disrupting
their life and impacting on the family
Fully discuss physical concerns preoccupying the family
and the results of the physical investigations

Treatment
Make families aware of the high prevalence of medically
unexplained symptoms (2%-10%) (this may reassure
parents about the absence of an organic cause)
Do not convey a sense of embarrassment when
communicating a diagnosis of somatic disorder
Emphasize that it may take time to recover but the majority
of young people do very well
Help the family and child develop ways of coping with the
symptoms and reduce functional impairment

Treatment
Specific treatments may involve
Individual psychological work
Family work
Liaison with school and with social services
Coordination of all therapists and professionals

involved
Teachers must be included, especially where school
attendance is an issue
Specific strategies will vary depending on the exact
nature of the somatic disorder

Psychological interventions
The specific psychological treatment and frequency of
contact will vary depending on the nature of the
disorder
Interventions by primary care clinicians, pediatricians,
psychiatrists or other mental health workers
Techniques dealing with specific symptoms and impairments
(e.g. distraction, muscular relaxation for headaches, graded
physical exercise for muscular problems and fatigue,)
Cognitive behavioral therapy for comorbid emotional
disorders

Medication
No medication specifically licensed for use in
somatoform disorders
Medication could be indicated to treat some
comorbid disorders
Selective serotonin reuptake inhibitors may be helpful if
there is associated depression or anxiety (very often)
Makes rehabilitation process easier to implement in
some children.

School liaison
Close school liaison
To reduce school related stress
To deal with conflicting expectations between the child, family
and teachers.
Tailoring a school program to help the child cope with

their symptoms within school (e.g. reduced timetable)
If the child has been absent from school, a gradual
reintegration should be arranged, in order to keep
formal education
Conclusion
Conclusion
Children, adolescents and even adults, have common recurrent,
unexplained physical symptoms that may be severe, impairing,
and result in frequent medical help seeking behavior
Modern psychiatric nosological classifications try to place them
as a group named somatic disorders, to better understand the
problem
Families tend to attribute the somatic symptoms to underlying
physical pathology despite the absence of medical evidence for
this
In some cultures families may explain the physical symptoms in
religious or culturally specific ways
Conclusion
Conclusion
Psychiatric comorbidity commonly occurs and
this, together with
Childs personality traits

Family health problems
Family response to the symptoms
Problems in communicating effectively on
emotionally laden issues
May contribute to the maintenance of the

disorder.
Conclusion
Conclusion
Core of a successful management
Medical examination and investigation
Recognition of parental and child attitudes to the symptoms
Management strategies to help reduce impairment
Psychiatric treatment of comorbidities and instituting

a child and family rehabilitation program are required
Treatment of the disorder may be with psychological
or sometimes psychopharmacological approaches
Conclusion
Conclusion
Engaging families during assessment and treatment is
important, helping them communicate about and
manage stressors is clinically efficacious
The lack of pediatric mental health facilities may impede
this work in developing countries
Psychoeducation by primary healthcare workers and
educators may still be an effective means of preventing
and managing these disorders across different countries
and cultures.
Conclusion

IACAPAP 14 Associated Somatic Disorders

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

IACAPAP 14 Associated Somatic Disorders

Uploaded by

Copyright:

Available Formats

IACAPAP MOOC

Essentials of Child and Adolescent Psychiatry across the World

Associated somatic disorders

Pr. Oscar Snchez-Guerrero

Somatic symptoms in psychiatry

Somatic symptom disorders

Somatic symptoms in psychiatry

Pr. Oscar Snchez-Guerrero

Somatic symptoms in psychiatry

Pr. Oscar Snchez-Guerrero

Pr. Oscar Snchez-Guerrero

In somatization, the production of

Pr. Oscar Snchez-Guerrero

Pr. Oscar Snchez-Guerrero

These children are at increased risk of experiencing

Pr. Oscar Snchez-Guerrero

We can not separate the body from the mind

There are many ways in which physical and

Pr. Oscar Snchez-Guerrero

Contact with health care system

Pr. Oscar Snchez-Guerrero

Contact with health care system

Pr. Oscar Snchez-Guerrero

Children will miss school

Little is known about the exact incidence or

Pr. Oscar Snchez-Guerrero

Genetic and biological vulnerability

Somatic presentations can be viewed as expressions of

Risk factors for somatization

Gledhill J, Garralda ME (2009). The relationship between physical and mental

Pr. Oscar Snchez-Guerrero

Risk factors for somatization

Pr. Oscar Snchez-Guerrero

Risk factors for somatization

Gledhill J, Garralda ME (2009). The relationship between physical and mental

Pr. Oscar Snchez-Guerrero

Diagnosis and treatment

Consider somatic disorders if

The nature, severity of the symptom or its resulting

Pr. Oscar Snchez-Guerrero

Diagnosis and treatment

Evidence that there is no treatable medical

Pr. Oscar Snchez-Guerrero

Diagnosis and treatment

Diagnosis and treatment

Diagnosis is made on the basis of positive

Absence of a medical explanation for somatic symptoms

Pr. Oscar Snchez-Guerrero

Diagnosis and treatment

Because of the predominant focus on lack

Pr. Oscar Snchez-Guerrero

Diagnosis and treatment

Pr. Oscar Snchez-Guerrero

Diagnosis and treatment

Beliefs about the illness

Do not question the reality of the symptoms

Diagnosis and treatment

Diagnosis and treatment

Coordination of all therapists and professionals

Diagnosis and treatment

Pr. Oscar Snchez-Guerrero

Diagnosis and treatment

Pr. Oscar Snchez-Guerrero

Diagnosis and treatment