Beena Johnson, MBBS, DCH, MD,
PhD
Baby Memorial Hospital, Kozhikode, Kerala, India. PIN: 673004
Address for Correspondence: Dr.
Beena Johnson, MBBS, DCH, MD, PhD, Senior Consultant,
Learning Disability Clinic, Department of Child Guidance,
Baby Memorial Hospital, Kozhikode, Kerala, India. Email:
jiacam@gmail.com
Abstract
Physical symptoms without any identifiable structural or
biochemical abnormalities on detailed clinical examination and
investigations, are common in children. Some children may have
persistent physical discomfort which can lead to debilitating
impact on their academic and social functioning. These
children seek repeated medical consultations and are usually
subjected to unnecessary invasive diagnostic procedures. It is
extremely important to understand that emotional factors can
contribute to the development as well as maintenance of
impairing physical symptoms. There is scientific evidence for
the association of anxiety and functional somatic symptoms in
children. The diagnostic category which was previously
called somatoform disorders is now included in
somatic symptom disorders.
The main feature of the somatic symptom disorders is the
excessive concern with somatic symptoms. Detailed clinical
examination and investigations will not reveal any
abnormalities to explain the symptoms. The somatic symptom
disorders are common in childhood. Cognitive behavioural
therapy by experts in child guidance, will relieve the somatic
symptoms related to anxiety and stress. If not intervened at
the earliest, the persistent physical symptoms associated with
emotional stress will cause significant functional disability
in childhood. Unnecessary invasive medical interventions cause
more agony to the child. These children also have high risk
for developing anxiety disorders and depressive disorders in
young adulthood. Hence, early intervention using cognitive
behavioural techniques should be provided to all children with
somatic symptom disorders, which will definitely improve their
quality of life.
Keywords: Somatic symptom disorder, cognitive
behavioural therapy, children
Introduction
Medically unexplained somatic symptoms in
children are indeed a major clinical problem [1]. Physical
symptoms related to stress are very common among
children. Emotional stress can lead to somatic symptoms.
These somatic complaints occur unintentionally. Somatization
is diagnosed when emotional distress is manifested in the form
of physical symptoms that cannot be explained medically. The
patient actually experiences the physical symptoms. But
there will not be any definite physical pathology
[2,3].
Even after detailed clinical examination and investigations,
no structural or biochemical abnormalities can be found to
explain the somatic symptoms [4]. Some of these physical
symptoms will become persistent and can lead to significant
adverse impact in the academic and social functioning of
children [5]. These children are subjected to unnecessary
repeated medical consultations [6]. Invasive and costly
diagnostic procedures are also done repeatedly in these cases.
Hence it is very important to understand the emotional factors
that contribute to the development and maintenance of the
functional somatic symptoms and provide proper management at
the earliest.
Somatic Symptom Disorders
Persistent physical symptoms associated with disproportionate
feelings and behaviours is included in the new diagnosis of
Somatic Symptom Disorder (SSD) in Diagnostic and Statistical
Manual, 5th edition (DSM-5) [7]. The diagnostic category which
was previously called somatoform disorders is now
known as somatic symptom disorders [8]. DSM-5 criteria for
somatic symptom disorder are more restrictive compared to
DSM-4 criteria for somatoform disorders and are associated
with higher symptom severity and lower level of physical
functioning [9]. The children with somatic symptom disorders
will have persistent complaints of somatic distress, which
cannot be explained by a medical diagnosis.
Prevalence
The prevalence of somatic symptom disorder is estimated to be
5% to 7% in the general population. Patients with somatic
symptom disorders belong to one of the most common categories
of patients in the primary care setting. The female-to-male
ratio of somatic symptom disorder is 10:1 [8]. Somatoform
disorders are very common in primary care. Medically
unexplained symptoms were reported by two-thirds of women as
well as adolescents and children in primary care practices and
the 12-months prevalence of somatoform disorders was 22.9%, in
the study conducted in Germany [10]. In a population-based
sample of Danish 5-7-year-old children, it was found that
functional somatic symptoms are common in this age group. The
1-year prevalence was found to be 23.2% [1].
Clinical features
Somatization is very common among children and adolescents.
The main feature of these disorders is the concern with
physical symptoms resulting in excessive feelings related to
those symptoms. The thoughts about the physical symptoms will
be distressing and can result in disruption of daily
activities. These children usually have high level of anxiety.
The somatic symptoms must be persistent and can be associated
with predominant pain. Academic, family related, personal and
peer group related stressors as well as parental
overprotection are common predisposing factors for somatic
symptom disorders. There is strong association between
emotional factors and physical complaints in children [11]. In
the study involving 1323 children, recruited from the
Copenhagen Child Cohort, health anxiety symptoms were found in
17.6% [12].
Children with somatoform disorders can present with varying
physical symptoms. Children under stress may present with
complaints of nausea, vomiting, diarrhoea, palpitation,
headache, abdominal pain, limb pain, pain over multiple sites,
difficulty in breathing, hyperventilation, aphonia, giddiness,
fatigue, weakness, non-epileptic seizures, tremors,
abnormalities of gait and problems related to micturition.
Somatic symptoms are common responses to stress in children.
Clinical examination will be normal. Even after detailed
investigations, there will not be any structural or
biochemical abnormalities to account for the physical symptoms
[4].
Common Somatoform Disorders in Children
Pain disorders and conversion disorders are the most common
somatoform disorders seen in children.
Pain Disorders
Pain complaints especially limb pain, abdominal pain and
headache, are the most prevalent symptoms seen in pain
disorders in children [1, 13,14, 15]. Higher prevalence of
recurrent abdominal pain is seen in girls compared to boys.
The highest prevalence of these symptoms is seen in the age
group between 4 and 6 years and also during early adolescence
[16]. Psychological stress play a major role in functional
gastrointestinal disorders [17,18]. Children with peer
problems usually experience functional abdominal pain [19].
Several school-aged children report recurrent
functional abdominal pain which can be severe enough to
interfere with daily activities.
Conversion Disorders
Conversion disorders presenting as movement disorders are
indeed challenging for the treating doctors. There can be
involuntary movements and gait abnormalities. Usually the
onset is acute and the movement patterns are not consistent
with organic movement disorders [20,21]. Dissociative motor
disorder presenting as limping is common among children. There
will be an underlying conflict which should be identified and
managed by cognitive behavioural therapy.
Paroxysmal non epileptic events are very
common in children and adolescents [22].
Non-epileptic seizure is the most common conversion disorder
which is misdiagnosed as epilepsy. It will significantly
affect the quality of life of the patients [23]. The
presentation of paediatric patients with paroxysmal
non-epileptic events differ according to age. They usually
have age-specific patterns [24]. Psychogenic non-epileptic
seizures (PNES) are somatic manifestations of emotional
distress [25]. Several psychological stressors have been
identified as precipitating factors in the development of PNES
[26]. Paroxysmal non-epileptic seizures are difficult to
manage conversion disorders with high medical morbidity. The
children with high anxiety sensitivity, inadequate stress
coping skills and more lifetime adversities are more prone to
develop PNES [27].
Management - Cognitive Behavioural Therapy (CBT)
Management of patients with somatoform disorders is very
complex and challenging [28]. Researchers have found the
beneficial effects of CBT in the management of somatoform
disorders [29]. Cognitive-Behavioural Therapy is the proven
treatment for somatic symptom disorders [8].
The basic premise of cognitive-behavioural therapy holds that
maladaptive cognitions contribute to emotional distress which
in turn can cause stress related physical symptoms.
Therapeutic strategies to alter these maladaptive cognitions
lead of relief from emotional distress and associated somatic
symptoms. In a comprehensive survey of meta-analyses conducted
by Hofmann SG et al, it was found that cognitive behaviour
therapy is effective in the management of children with
somatoform disorders [30].
Cognitive-behavioural interventions reduce anxiety and somatic
symptoms in children [31]. Study by Warner CM et al
proved that cognitive-behavioural interventions are effective
in the management of co-occurring physical symptoms and
anxiety in children and adolescents [32]. Cognitive
behavioural interventions are effective in children with
nonspecific recurrent abdominal pain [33].
The Cochrane database systematic review by Abbott RA et al
included 18 randomised controlled trials involving 928
children and adolescents with recurrent abdominal pain in the
age group between 6 and 18 years carried out in the USA,
Australia, Canada, Netherlands, Germany and Brazil. In this
systematic review the authors concluded that there is evidence
for beneficial effects of cognitive behavioural therapy in
reducing the recurrent abdominal pain in children and
adolescents [34].
Cognitive behavioural therapy is effective in the
management of nonepileptic seizures [35]. Excessive anxiety is
seen in children with non-epileptic seizures and cognitive
behaviour therapy provides high rates of full remission of
symptoms in these children [36].
CBT is proved to be most effective treatment for somatoform
disorders in children and adolescents [14]. After reviewing 34
randomised controlled trials involving 3922 patients, Kroenke
K concluded that cognitive behavioural therapy is the best
established treatment for somatoform disorders [37].
Prognosis
Somatic symptom disorders can become chronic, if early
interventions are not provided. Patients intervened
scientifically usually recover completely. Studies have shown
that about 50% to 75% of patients with medically
unexplained symptoms show improvement [38]. Fewer physical
symptoms and better functioning at baseline are good
prognostic indicators [39].
In the observational cohort study, conducted on
1327 children of 5-7 years from Copenhagen, it was
found that 250 children (18.9%) had functional somatic
symptoms with healthcare use and 58 children (4.4%) had
impairing functional somatic symptoms with healthcare use. The
impairing functional somatic symptom in children aged 5-7
years is a predictor of the future primary healthcare use of
the child [40].
Children with persistent somatic complaints have increased
risk for developing generalized anxiety disorder and
depressive disorder during young adulthood. Only early
interventions for somatic complaints in childhood can
alleviate this problem [41].
Early Intervention
Awareness about the interaction between psychosocial stressors
and somatic symptoms is necessary for improving functional
status of patients with multiple somatic symptoms. If not
intervened at the earliest, unnecessary testing and
ineffective treatment may be provided, which in turn
aggravates the morbidity of the patient [42]. Hence
appropriate understanding and early diagnosis of somatic
symptom disorders is essential. Cognitive behavioural
interventions should be provided by experts in child guidance,
for all children with functional physical symptoms. There
should be strong positive relationship between the child
guidance expert and the patient. Supportive visits are
essential even after the somatic symptoms subside. When there
are no definite indications, the temptation for medications
and unnecessary diagnostic procedures should be avoided. Early
treatments will significantly improve the quality of life of
children with somatoform disorders [43].
Conclusion
Persistent physical symptoms associated with emotional stress
can cause significant functional disability in childhood. The
impairing somatic symptoms adversely affect the academic and
social functioning of children. Unnecessary invasive medical
interventions usually increase the agony of the child. More
over children with recurrent somatic symptoms have high risk
for developing anxiety disorders and depressive disorders in
young adulthood.
After ruling out organic causes, anxiety and other emotional
factors underlying persistent somatic symptoms in children
should be identified and managed at the earliest with the help
of experts in child guidance. Several scientific studies have
proved the beneficial effects of cognitive behavioural therapy
in the management of somatic symptom disorders. CBT gives
relief to the child from emotional distress and the associated
physical symptoms. Thus the emotional and physical well-being
of these children can be definitely improved.
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