David M. Siegel
The patient who presents with physical and/or physiological symptoms for which an identifiable biomedical etiology cannot be found is a diagnostic and therapeutic challenge known to all experienced clinicians. It is therefore important to have an organized and consistent approach to such situations, with goals of carrying out a judicious, yet complete diagnostic evaluation as well as formulating a management plan that ameliorates symptoms and maintains (or restores) function and quality of life. Pitfalls of excessive, invasive, and inconclusive testing, possible worsening of symptoms, and provider frustration and resentment toward the patient and family are familiar and prudent concerns. However, an effective strategy for handling these cases can and should be developed by those caring for adolescents. In this chapter, a categorization for psychosomatic illness is described, including a framework for understanding how these conditions fit into a person's life. In addition, a plan for management is outlined.
Adolescent adjustment reaction: It is important to remember that adolescence is a time of change and transition. The physical changes of puberty, the cognitive developmental progression from concrete to formal operational thinking, and the changing demands and expectations in the family, and social, academic, and vocational realms, make the journey to young adulthood varied and challenging. Because of these demands, some teens will experience periods of significant struggle as they try to adapt. The resulting emotional upheaval, if sufficiently disruptive, can be characterized as an adjustment disorder and can sometimes be expressed in somatic terms. Milder and more time-limited psychological disequilibrium can also precipitate bodily discomfort. This can lead to physical complaints such as lightheadedness, nausea, headache, palpitations, and so on. All of these are commonly associated with emotional distress and may serve in the patient's mind as “legitimate” reasons to see the doctor or nurse practitioner; more acceptable to the patient and family than overtly expressed psychological problems.
As stipulated in the Diagnostic and Statistical Manual—Text Revision (DSM-IV-TR, 2000) (American Psychiatric Association, 2000) there are three broad categories of psychosomatic disorders:
In psychophysiological disorders, physical symptoms are observable and often fall into biological processes that are understood by the clinician. In addition, the disease course is clearly influenced by psychological function. For example, the patient with asthma experiences increased bronchospasm when under stress, leading to coughing, wheezing, and shortness of breath. Although, managing and optimally preventing these exacerbations is not necessarily easy or rapidly accomplished, the connection between the psychological and the physical, once shared with and understood by the patient and family, is not typically rejected or denied. The “medical legitimacy” of the primary physiological disorder (i.e., asthma) represents a common ground of acceptance between clinician and patient/family and also provides the clinician with a familiar and well-understood template for medical treatment. Beyond the strictly medical treatment, however, the clinician must attempt to facilitate the adolescent and parent(s) successfully identifying sources of stress and anxiety that contribute to inadequate control of the primary disease and its symptoms. This exploration may very well be enigmatic and may require open-ended questions, thoughtful probing, and multiple visits. Sometimes, referral to a health psychologist or medical family therapist is productive. In any case, the nature of the doctor–patient interaction in psychophysiological disorders is not typically one characterized by conflict or frustration.
Somatoform and factitious disorders are the more difficult of the psychosomatic illnesses. The discussion in the subsequent text focuses primarily on somatoform disorder
as it is more likely to be encountered by the adolescent health care provider. However, it is important to remember that factitious disorders especially those that are chronic, such as Munchausen syndrome and particularly Munchausen syndrome by proxy (Von Hahn et al., 2001), are serious and in some instances difficult to distinguish from somatoform conditions. Conscious falsification of symptoms and signs is a different behavior from the unconscious process of somatoform disorders. The intentional creation of the sick role is thought to be motivated by the unconscious need to be cared for. By contrast, symptoms in somatoform disorders are seen as associated with, or reflective of, unconscious conflict.
Somatoform disorders include:
In working with adolescents, it is much more common to encounter patients with undifferentiated somatoform disorder (Table 34.1) as opposed to those who meet the restrictive criteria for full-fledged somatization disorder (Table 34.2).
warranted. Less severe mood or anxiety disorder uncovered during the evaluation of somatization may be managed by the adolescent care provider as outlined elsewhere in this chapter.
Other aspects of a teen's present or past experience might also bear on somatization and provide insights for the provider into the possible meaning for the behavior. For example, a patient whose early life experience did not include consistent parental support and caretaking might develop physical symptoms as a means to meet dependency needs. When these patients become increasingly demanding about diagnostic evaluations, and angry and hostile with the clinician about the lack of a physical diagnosis or the inadequacy of treatment, these emotions may actually be expressions of deeper and unconscious feelings about early caretakers that are now displaced onto the clinician.
In summary, important areas to help the practitioner understand somatization include:
Approach to the Patient
Most teens and parent(s) are unaware of the connection between their physical symptoms and underlying distress
and conflict, and hence it is the somatic complaint that brings the adolescent to the health care provider. The clinician's initial history taking not only considers a differential diagnosis of physiological causes but also includes sensitivity for psychosomatic etiology. Screening questions about affect and recent life change or stress (both for the individual and family) are included in the history as the clinician considers a possible association between the physical complaints and the psychological inventory. As the physical examination proceeds, a lack of positive physical findings may elevate the likelihood of emotional distress as a major contributor to the symptoms, and also helps guide the clinician's diagnostic testing. At the conclusion of the initial visit, it is important that the clinician describe her/his formulation and plan with regard to the adolescent's physical complaint. Even if questioning directed toward emotional upset has proved positive, the clinician should avoid statements that suggest that this is the exclusive cause of the physical problem. For many patients, such an attribution, especially at the first encounter, will not only be unacceptable but may also threaten the clinician's credibility and thereby compromise effectiveness of future intervention. When an adolescent comes to see the doctor for a specific and disruptive symptom (for example, 3 months of persistent and severe headache), it is important that the problem be addressed in the terms expressed by the patient, and any diagnostic or therapeutic recommendations be presented in that context. When a psychological element is suspected as contributory, this can be constructively introduced to the patient and family without discrediting or trivializing the identified symptoms.
The clinician might say the following:
It is very clear to me that you have been experiencing some pretty bad headaches for quite some time and I'm glad you came to see me about this. My goal is to identify which illnesses or diagnoses can cause your headaches and then figure out which ones we should pursue and which ones we can cross off the list. You've had severe pain for a good while and we both know that making all of that pain go away in a short period of time, isn't very likely to happen. We need to put together an initial plan that decreases your headaches enough such that they don't interfere so much with your life, like with all the school you've missed due to the pain.
The other thing we both know is that anyone trying to deal with several months of all this discomfort can't help but get at least a little down, depressed, and discouraged about it. When we talked earlier about your mood, you did a good job of giving me a real sense of how depressing these headaches are. Who wouldn't start feeling down with all the pain and missed school you've had to cope with! So, at the same time that we're putting together a strategy for what is and is not the cause of your pain, and how to get these headaches under better control so they stop influencing your life so much, you can count on me not to ignore how this physical problem is also affecting your mood and emotions. We need to take a comprehensive approach to helping you feel and function better.
With this kind of dialogue and framing of the problem, the adolescent and family are assured that the clinician takes the symptoms seriously, intends to pursue a methodical approach for ruling in or out various diagnoses, and is not discounting their concerns by saying that it is “all in your head.” The critical groundwork has been laid, however, for incorporating a psychological health aspect to the problem. In our adolescent practice setting, we have clinical psychologists available onsite for consultation and I will often let patients and families know about this if I think mental health referral is likely at a subsequent visit.
For example I might say the following:
The emotional stress of all these headaches can get to be pretty tough, so I want you to know we have psychologists right here in our office who know about the psychological part of being sick and can work with us to help you and your family cope with the problem. These psychologists are experts at helping patients, just like you, figure out the best ways to get through those tough times while we continue to work on getting on top of the headaches. After all, for some people stress itself can turn out to be a cause of a headache.
Of course, if depression or anxiety screening have revealed serious risk and dysfunction, then mental health consultation should be made more urgently.
As discussed earlier, some theories of psychosomatic illness hypothesize that physical symptoms can result from psychological conflict and distress. In any complex biopsychosocial problem, such as a psychosomatic or somatizing illness, the initial cause of a symptom can be difficult to discern. The clinician statements quoted in the examples above focus on the emotional distress of patients and parents that is an understandable consequence of trying to cope with the symptom(s). Although this may be only part of the emotional story, it is an acceptable place to start. The aim is to let the patient know that the clinician is well aware of the teen's emotional distress, and to foster acceptance by the adolescent and parent(s) of a psychological dimension that will be integrated into the treatment. As strategies for symptom management and restoration of function develop, and further history gathering and counseling elaborate on significant emotional concerns, the patient/family may or may not come to endorse the psychological process as primary and the physical symptoms as secondary. This insight by the patient may be valuable but is not essential to successful symptom management. Identifying sources of stress, depression, and emotional distress and how to cope with them through an appropriate mix of individual and family counseling, cognitive behavioral therapy, and medication may be seen by the adolescent and parent(s) as a parallel (rather then integrated) process to improvement in the symptom. Both the somatic and psychological realms have, nonetheless, been addressed. In these resistant patients, the emotional/psychological/physical connection is framed in terms that fit the parents' and/or patient's insight, defensive structure, and level of sophistication. It also facilitates overall improvement in a manner that is experienced as supportive or acceptable (rather than provocative or confrontational) for the adolescent and parent(s).
The vast majority of somatizing adolescents can be successfully managed as outpatients, making full use of appropriate consultation. The team includes not only mental health expertise but other inputs as well. For example, if a patient whose somatic complaint is back pain
states that she/he is having great difficulty with weight bearing and walking, physical therapy should be instituted early. Therefore, while any psychological issues require explicit delineation and intervention, the physically compromised patient also requires effective treatment such as a physical modality to restore range of motion, strength, and endurance. These physical treatments often have psychological benefit (just as the reverse is true). Even in the case of conversion disorder, wherein the loss of a normal body function (often neurological) occurs in the face of clear evidence of a psychological conflict, the specific medical disability must be addressed through appropriate rehabilitation techniques, along side psychiatric consultation and care. Simultaneous collaborative and integrated medical and psychological attention is key in achieving both patient and family acceptance, as well as a positive treatment outcome.
Inpatient admission should be reserved for the small minority of patients who fail a multidisciplinary outpatient program and/or for those whose deterioration places them at significant risk for chronicity. Factitious disorder, particularly Munchausen syndrome by proxy, may be an indication for hospitalization and/or out-of-home placement depending on severity. The strategy of hospitalizing a somatizing patient with the goal of expediting the diagnostic evaluation and convincing the patient and family that the problem is psychological rather than physical carries the risk of setting up a confrontation with the clinician that is unlikely to facilitate either short-term improvement or a successful long-term outcome. If the clinician feels that all reasonable biomedical causes for a symptom have not been eliminated, and pursuit of necessary testing and referral will be prolonged in the ambulatory setting, then a well planned, highly structured, and organized inpatient admission might be advantageous. However, in many institutions, such well-intentioned strategies often encounter delays and inefficiencies, not to mention the iatrogenic risks posed by an inpatient stay. Furthermore, although the admitting physician may be reassured by the many negative test results and consultations garnered in-hospital, patients and families paradoxically view the decision to admit the adolescent as a statement of physiological severity and therefore have increased resistance to any subsequent psychological explanation and intervention. Therefore, for some patients being hospitalized can be associated with worsening of symptoms.
Psychosomatic illness in the adolescent is commonly encountered, and can be fascinating, yet challenging.
Its understanding, diagnosis, and treatment represent the clinical enactment of Engels' biopsychosocial approach. Those caring for teens should remain alert for the occurrence of psychosomatic illness, take a methodical and pragmatic approach to its identification, and develop a steadily practiced and multidisciplinary structure for its management. Although patience and persistence on the part of clinicians and patients/families are often called for as treatment progresses, eventual improvement is a realistic expectation in most instances.
References and Additional Readings
American Psychiatric Association. Somatoform disorders. In: Diagnostic and statistical manual—text revision (DSM-IVTR, 2000), 4th ed. Washington, DC: American Psychiatric Association, 2000.
Brown LK, Bruning K, Fritz GK, et al. Somatoform disorders. In: Wiener JM, Dulcan MK, eds. Textbook of child and adolescent psychiatry, 3rd ed. Washington, DC: American Psychiatry Publishing, 2004:751.
Engel GL. The clinical application of the biopsychosocial model. Am J Psychiatry 1980;137:5.
Kreipe RE. The biopsychosocial approach to adolescents with somatoform disorders. Adolesc Med Clin 2006;17:1.
Mayou R, Kirmayer LJ, Simon G, et al. Somatoform disorders: time for a new approach in DSM-V. Am J Psychiatry 2005;162:847.
McDaniel SH, Campbell TL, Hepworth J. Integrating the mindbody split: a biopsychosocial approach to somatic fixation. In: McDaniel SH, Campbell TL, Hepworth J, et al. eds.Family oriented primary care, 2nd ed. New York: Springer-Verlag, 2005:326.
Roca RP. Somatization. In: Barker LR, Burton JR, Zieve PD, eds. Principles of ambulatory medicine. Philadelphia: Lippincott Williams & Wilkins, 2003:252.
Servan-Schreiber D, Kolb NR, Tabas G. Somatizing patients: part I. Practical diagnosis. Am Fam Physician 2000;61:1073.
Servan-Schreiber D, Kolb NR, Tabas G. Somatizing patients: part II. Practical management. Am Fam Physician 2000;61:1423.
Silber TJ, Pao M. Somatization disorders in children and adolescents. Pediatr Rev 2003;24:255.
Von Hahn L, Harper G, McDaniel SH, et al. A case of factitious disorder by proxy: the role of the health-care system, diagnostic dilemmas and family dynamics. Harv Rev Psychiatry 2001;9:124.