Health Watch

Somatoform Disorders in children

Dr Ruwan M Jayatunge M.D.

Somatoform Disorders are common among the children due to various stress factors experienced by them in the contemporary society. Today the children face numerous kinds of stresses at home and school. Following the overwhelming stress and unresolved mental conflicts, Somatoform Disorders can be seen among the vulnerable groups. On most occasions, these ailments are not properly assessed or treated. Therefore, Somatoform Disorders can affect the child for a long period. sometimes until the adulthood.

The Somatoform Disorders are a group of mental problems characterized by physical complaints without any physical disease or condition. As a group, the somatoform disorders are difficult to recognize and treat because patients often have long histories of medical treatment with several different doctors.

In addition, the physical symptoms are not under the patient’s conscious control. Somatoform disorders are usually co-morbidity with other psychological disorders, particularly mood or anxiety disorders. Stress is believed to be one of the most common causes of somatoform disorders in children. Many stresses and anxieties affect children. For instance exam stress, sibling rivalry, parental separation etc can cause psychological degradation in children.

According to the DSM 4 Somatoform Disorders are classified as:

1) Somaization Disorder

2)Undifferentiated Somatoform Disorder

3) Conversion Disorder

4) Pain Disorder

5) Hypochondriasis

6) Body dysmorphic Disorder

7) Somatoform Disorder not otherwise specifiedSomaization Disorder

Children with Somaization Disorder chronically and persistently complain of varied physical symptoms that have no identifiable physical origin. One common general explanation of genesis of Somaization Disorder is that the internal psychological conflicts are unconsciously expressed as physical signs. Such symptoms cannot be related to any medical condition. The symptoms do not all have to be occurring at the same time, but may occur over the course of thedisorder.

Story of Miss G

Miss G- a young girl child who had special talents in music. She was praised by the parents and peers for her magnificent performances in music. Miss G anticipated good results in the music exam and wanted to further her education in music. Her talents and self-confidence faded gradually when the newly appointed music teacher of her school made sarcastic remarks over her performance. The teacher was highly critical of Miss G. As a result of the personal conflict Miss G did not like to attain the music classes and she was worried about the exam.

After a few weeks, Miss G experienced severe abdominal pain and loss of energy and tremors in both hands. She could not play the musical instruments anymore. Her parents took her to various physicians for the medical management and no specific diagnosis was established. Despite the analgesics, she experienced the pain for a log period. Eventually her mental worry was revealed and resolved via counselling. The teacher was advised to have a sympathetic attitude towards her. With the change of stressful environment, Miss G s condition improvedrapidly. She was able to pass her music exam with an excellent credit.Conversion disorder

Conversion disorder, once referred to as hysteria, is thought to be caused by mental factors, such as stress and conflict. Children with Conversion disorder experience as (convert into) physical symptoms. In conversion disorder, physical symptoms that resemble those of a neurological disorder develop.

The symptoms are triggered by mental factors such as conflicts or other stresses. An arm or leg may be paralyzed, or children may lose their sense of touch, sight, or hearing. Many physical examinations and tests are usually done to make sure symptoms do not result from a physical disorder. Often, symptoms begin after some distressing social or psychological event.

Master N was a 12 y old schoolboy who was troubled by the parental conflicts. His father who consumed alcohol heavily often assaulted the mother. When the father goes in to tantrums, Master N becomes uneasy and helpless. One day when the father tried to attack the motherMaster N intervened and he too was beaten by the father. Following the physical beatings Master N could not walk. Then he was rushed to the hospital. The doctors found no internal injury that could have caused the paralysis of the lower limbs.

Notwithstanding the treatment over 4 weeks, Master N s condition did not improve. Although the Neurological investigations showed no pathology, Master N still exhibited the symptoms of paralysis. After the psychological mode of management and family counseling he was assured that the family violence would not occur anymore. Following the father’s positive change, Master N regained his walking ability.Hypochondriasis in young children

Hypochondriasis is characterized by unexplained physical symptoms that can be directly related to fear that other person has contracting disease (disease conviction) or fear that he may acquire those identified disease (disease phobia).

Miss NB was a 16-year-old girl who looked after her aging grandmother. Her grandmother was diagnosed with throat cancer and Miss NB saw her prolonged suffering. While nursing her enfeeble grandmother, Miss NB had an unexplainable fear of contaminating the disease. After the Granny passed away, Miss NB had difficulty of swallowing food and experienced pain. Her parents immediately took her for medical treatment and further investigations. All the investigations concur that Miss NB had no apparent illness but her marked anxiety wasdetected.

She strongly believed that she too was getting the throat cancer like the grandmother. Her irrational fear was challenged under the friendly mediation and ultimately she was able to gain the insight. Today she is free of symptoms and continues her university education.Pain disorder

Pain disorder, it is termed when a patient complains severe focused pain that cannot be attributed or relate the pain to specific medical disorder and cannot be relieved by analgesic.

A large number of children are affected by pain disorder following school phobia and exam phobia. Children affected by pain disorder genuinely feel the painful sensations. Therefore punishing or threatening the child could aggravate the condition.

Body Dysmorphic Disorder

Body Dysmorphic Disorder is another form of somatoform disorder in which a patient think that he or she has a defect in his or her body well in fact there is none; this can further be associated to unsuccessful attempts to correct the patient’s image, through undergoing series of cosmetic surgery. Many teenagers feel that their body images are not attractive and have a low self-esteem and negative self-picture. In some children this negative thinking pattern becomesan over valued idea leading to overwhelming stressful reactions.

Master U a teenager troubled by severe sibling rivalry strongly believed that his nose was out of shape. He became furious if anyone made humorous comments on his facial appearance. Although there was no significant repulsive appearance, he was avoiding social situationsand preoccupied with correcting the nose via finger manipulation. He thought that his elder brother is more attractive then him.

On the contrary, there was no much of a difference between the anatomical shapes of the noses in two brothers.

Still Master U believed that he was ugly and wanted to go for a cosmetic surgery. Prier to the surgery he was referred for psychological support service and treated with psychotherapy to overcome the difficulty. After series of psychological interventions, Master U gave up the cosmetic surgery and realized that he had no anatomical defect.Specific interventions in somatoform disorders. Children with Somatoform Disorders have long history of stress and anxiety. They need counselling and psychotherapy to regain the life balance. Psychotherapy focuses on the unconscious and believes it influences human behaviour. Repressed conflicts from childhood lead to personality problems later in life. Anxiety is a direct result of the repression of conflicts Psychotherapist believes that the unconscious motives along with unresolved conflicts lead to maladapted behaviour.

Psycho education can also be useful tool to that explains a stress or any emotional distress can be factors for having physical symptoms. Sometimes drug treatments are needed to address the emotional disturbances and comorbid psychiatric symptoms.

Client Centered therapy can be used positively to treat children with somatoform disorders. Client Centered therapy gives more responsibility to the child in their own treatment and views his difficulty in a positive manner. The therapist will move the client towards self-awareness, helping the client to experience previously denied feelings.

They will teach the client to trust in himself or herself and to use this trust to find their direction in life. The person-centered therapist makes the client aware of their problems and then guilds them to a means of resolve them.

Relaxation, biofeedback and stress management is a great help in decreasing the

emotional and bodily arousal. Relaxation therapies drastically reduce anxiety attacks connected with somatoform disorders.

Behaviour therapy highlights that the abnormal behaviour is a direct result of defective learning. This may include assertion, behavioral rehearsal, coaching, cognitive restructuring, desensitization, modeling, reinforcement, relaxation methods, self-management, or new social skills to combat the ill effects of somatoform disorders.

Cognitive Behaviour Therapies are often used to treat children with somatoform disorders. The goal of treatment is to help the person learn to control the symptoms.

Hypnosis may help by enabling people to control how stress and other mental states affect their bodily functions. A certified clinician must conduct hypnotic therapy.

Rational-emotive therapy is a highly action-oriented and deals with the client’s cognitive and moral state. This therapy stresses the client’s ability of thinking on their own and in their ability to change. Rational-emotive therapy challenges the client’s irrational thinking that is connected with the somatoform features.

Newly introduced and internationally recognized therapeutic mode - EMDR or eye movement desensitization and reprocessing effective in treating children with somatoform disorders. Research suggests that EMDR is equally powerful as Cognitive Behaviour Therapy.Special Tips for Parents

1) Listen to the child when he/she complains of unusual symptoms

2) Do not punish or humiliate the child

3) Try to find the underline cause

4) Talk to the teachers and find out any school related problems troubling the child

5) Get medical opinion from a recognized medical practitioner

6) When seeking counselling and psychotherapy get advice from a Psychiatrist / Psychologist attached to a Government Hospital.

NIROGI Lanka - timely intervention

Fathima Razik

Not surprisingly, Diabetes, a non communicable disease, has been cause for concern amongst medical professionals over a period of time in view of the increasingly large number of patients who seem to be afflicted with this disease that has to be endured as there is no known permanent cure.

Thus the National Initiative To Reinforce And Organise General Diabetes Care In Sri Lanka (NIROGI LANKA) was launched under the aegis of the Ministry of Health in collaboration with all stakeholders in managing diabetes under the purview of the Diabetes Prevention Task Force (DPTF) of the Sri Lanka Medical Association (SLMA). The Ministry of Health has recognised the need to target chronic Non Communicable Diseases (NCD), in particular, the rapidly increasing number of diabetics from the lower socio-economic groups in the country.

With a grant from the World Diabetes Foundation (WDF) three specific areas of activity have been mapped out that would be implemented through the existing health care delivery systems underscored by the expertise and experience of the DPTF so as to ensure the smooth running of each activity, concurrently. DPTF has as its mandate and objectives, to stimulate and support the adoption of effective measures for the surveillance, prevention and control of Diabetes Mellitus in Sri Lanka combined with the prevention of Cardiovascular Diseases.

The three major components of NIROGI LANKA are:

(a) National program for capacity building in diabetes care by establishing a pioneer cohort of diabetes nurse educators initially for the state health sector, to be expanded later to selected private primary care services through the College of General Practitioners of Sri Lanka.

(b) Improving quality of diabetes care through the development of a health care model of tertiary-primary care partnership to be initiated in the city of Colombo - i.e. to provide quality care close to the homes of the affected persons

(c) Prevent Type 2 Diabetes by empowering the public through activities that encourage community and family participation in a defined area of the suburban areas of Colombo.

Since its launch in mid 2009, the team behind this worthy project has had a series of regular meetings with the main stakeholders - the Medical Officers of Health, the Education Officer (Colombo district) and the Head of the Department of Community Medicine to co-opt Health Promotion Facilitators (HPF) in the Kotte and Kolonnawa areas where the pilot project was conducted. Health Promotion Facilitators would be trained in all relevant areas of work they would engage in to create the necessary awareness to stem the spread of the disease and to assist those affected to seek treatment, adopt the correct lifestyle and take prevention measures so as to prevent a further deterioration of their health.

The initial workshop conducted for HPF was under the guidance of an expert team from the Department of Health Promotion, University of Rajarata, turned out to be a success with 100% participation of the identified HPF’s and the feed back received, thereafter. It included training in health promotion, recruiting target groups and establishing a Health Information System (HIS). Consequently, the meeting with the Department of Computing, University of Colombo, to set up a HIS was held which would facilitate health promotional activities within communities, schools and work places.

The project went on to target for screening the adult population in slum areas who are in real need of such services.

The laboratories of the Colombo Municipal Council (CMC) located in five localities within the city have the capacity to screen 1000 adults per month in addition to the approximately 2000 diabetics who are tested at its clinics every month.

The Ministry of Healthcare and Nutrition supplies the drugs and consumables for the project.

As the project progressed a major achievement was the developing of a national program for capacity building in diabetes care through which a pioneer cohort of Diabetes Nurse Educators was established and who through their acquired skills will practice in the state sector hospitals in the Western Province and Teaching Hospitals in Sri Lanka.

Medical professionals from various hospitals and institutions from many parts of the island along with the other partners in this venture have for the past nearly eight months worked very hard to implement this program that is aimed at stemming a disease that has turned out to be slow and silent killer, that once it sets in, will remain so within a person’s system, taking its time bring on much suffering as it gradually progresses.

Project Chairperson, Professor Chandrika Wijeyaratne, in response to a question on the status of the program expressed satisfaction at the manner in which targets and time lines are met, and added that this was possible due to the unstinted support and cooperation extended by all involved which also ensures that the first ever World Diabetes Foundation funded project is a success.

If so, the country would be one that has through its committed and devoted medical professionals, addressed an issue that otherwise would have been blown out of proportion, and too late to prevent an unfathomable number of diabetics in Sri Lanka.

Prevention is certainly better than cure. Only in this instance there is no cure. It is therefore up to each individual to keep a check on their own health and that of their near and dear ones. The well known proverb comes to mind - Health is better than wealth.