PCMC Behavioral Health Hyo Bae, PhD January 20, 2012

Significance
How common are somatic complaints? Half of all preschool/school-aged kids reported minimum 1 physical complaint in 2 wks before surveyed, 15% reported minimum 4 symptoms 2-20% children presenting to medical care providers reported symptoms without findings for physiological etiology Emotional distress and functional impairment Health care costs

Diagnostic Classifications
Somatization Disorder Undifferentiated Somatoform Disorder Conversion Disorder Pain Disorder Hypochondriasis Body Dysmorphic Disorder Somatoform Disorder NOS

Diagnostic Classifications
Shared Features Somatic symptoms cause clinically significant distress or functional impairment Psychological factors have important role in onset, exacerbation, severity, or maintenance of symptoms Symptoms not fully explained by known general med condition or substance use Symptoms not accounted for by another mental disorder Symptoms are not intentionally produced

Diagnostic Classifications
Somatization Disorder Undifferentiated Somatoform Disorder Conversion Disorder: symptoms affect sensory or voluntary

motor function, suggesting a medical/neurological condition but findings not consistent with any physiological explanation Pain Disorder: clinically significant pain in one of more anatomical sites Hypochondriasis Body Dysmorphic Disorder Somatoform Disorder NOS

Challenges and Pitfalls

False dichotomy: diseases considered either organic or

psychologically based Conceptualizing somatoform disorders as a diagnosis of exclusion Stressors arent always easily identified Communication between family and staff
What do we each bring to the table? Language, terminology

Management
Biopsychosocial model Identify risk factors and positive findings
Genetic factors Symptom modeling History of physical illness Developmental transitions School stressors Family factors Secondary gain Coping style Trauma Comorbid psychiatric

symptoms History of somatization

Introduce possible role of psychological factors early Mental health consultation alongside medical workup

Management
Validate feelings of anxiety, frustration/anger, confusion Reassure families no evidence of life-threatening illness Convey confidence that it is a somatoform disorder Educate re: biopsychosocial model, mind-body relationship, etc. Direct, honest communication Multidisciplinary team approach, use consistent language Focus on etiology treatment and functionality Instill hope! Educate re: prognosis, ongoing team collaboration after discharge Structured plan with goals identified by family and team

Management
Cognitive Behavioral Interventions Relaxation, biofeedback, hypnosis Pain management strategies Tx of anxiety/depression, develop coping skills, change beliefs about illness, increase self-efficacy Behavioral plan for making functional gains, enhance motivation Family therapy Pharmacological tx of comorbid anxiety or depression

Case Example: Conversion Disorder

17yo previously healthy male, 5 days of L sided weakness, ptosis,

sensory loss after wrestling incident Normal medical test findings Positive findings related to somatoform disorders
Inconsistencies in symptom patterns Benign initial injury

Witnessed physical abuse against brother, conflict with stepmother Breakup with girlfriend Academic difficulties Moves between parents Coping style Family models Secondary gain

Case Example: Conversion Disorder

Treatment Transferred to inpatient rehab Functional approach with multidisciplinary team Rehab team Behavioral health Education specialist Good progress during 5 day stay Moved from question about etiology and concern about wrestling injury to regaining functioning and emphasis on healthy behaviors Outpatient PT, psychotherapy, psychoeducational testing, follow-up with PCP

Key Points
Somatization is fairly common, can lead to significant emotional distress

& poor functioning Identify positive signs in addition to ruling out organic medical conditions Introduce psychological factors contributing to physical symptoms early on Biopsychosocial conceptualization and treatment, emphasis on mind-body relationship Multidisciplinary team approach Seek behavioral health consultation sooner rather than later Provide direct, consistent message to families Shift from focus on etiology to emphasis on coping, functionality/rehabilitation CBT for child and family Consider psychotropic medication for comorbid anxiety/depression Follow-ups with primary care physician after discharge

References
Dell, M.L., & Campo, J.V. (2011). Somatoform disorders in children and

adolescents. Psychiatric Clinics of North America, 34, 643-660. Campo, J.V., & Fritz, G. (2001). A management model for pediatric somatization. Psychosomatics, 42(6), 467-476. Ibeziako, P., & Bujoreanu, S. (2011). Approach to psychosomatic illness in adolescents. Current Opinion in Pediatrics, 23, 384-389. Shaw, R.J., Spratt, E.G., Bernard, R.S., & DeMaso, D.R. (2006). Somatoform disorders. Textbook of Pediatric Psychosomatic Medicine. Silber, J. (2011). Somatization disorders: Diagnosis, treatment, and prognosis. Pediatrics in Review, 32(2), 56-64. Silber, T.J., & Pao, M. (2003). Somatization disorders in children and adolescents. Pediatrics in Review, 24, 255-264.