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C H A P T E R 72 Somatoform and related disorders M. Elena Garralda1 and Charlotte Ulrikka Rask2 1 Academic Unit of Child and Adolescent Psychiatry, Imperial College London, UK 2 The Research Clinic for Functional Disorders and Psychosomatics, Regional Centre for Child and Adolescent Psychiatr...

C H A P T E R 72 Somatoform and related disorders M. Elena Garralda1 and Charlotte Ulrikka Rask2 1 Academic Unit of Child and Adolescent Psychiatry, Imperial College London, UK 2 The Research Clinic for Functional Disorders and Psychosomatics, Regional Centre for Child and Adolescent Psychiatry, Aarhus University Hospital, Aarhus, Denmark Characteristics of the disorders recently published DSM-5 classificatory systems, as well as the and classification uses of a dimensional approach. We will address clinical presen- tations, developmental issues, assessment and diagnosis, aetiol- The essential feature of somatoform disorders as described in the ogy, risk factors and treatment. World Health Organization (WHO, 1992) and the Diagnostic Throughout the chapter, key abbreviations are FSS for func- and Statistical Manual of Mental Disorders (DSM) classificatory tional somatic symptoms RAP for recurrent abdominal pains, systems (WHO, 1992; American Psychiatric Association, 1994, CFS for chronic fatigue syndrome and CBT for cognitive behav- 2013) is the presence of physical symptoms that cause concern ioral therapy. and are not explained by a general medical condition or psychi- atric disorder. Symptoms must lead to noticeable and significant The experience of somatic symptoms in children and young people distress or impairment in social (family and friends) and occu- Somatic symptoms are part of everyday life experience in chil- pational spheres of functioning, which in children means school dren and young people (Offord et al., 1987; Garber et al., 1991; and academic difficulties. The symptoms are not feigned and Eminson et al., 1996; Domenech-Llaberia et al., 2004; Rask et al., usually occur in association with emotional conflict or psycho- 2009b). These symptoms are mostly “functional” rather than “or- social stress. In rare cases, the associated impairment may be ganic” (i.e. the expression of a medical disorder) and reflect com- extreme and result in states of severe or pervasive withdrawal mon non-pathological or physiological bodily changes. In con- when children stop communicating, walking, and looking after trast with somatoform disorders, most functional somatic symp- their basic needs. toms (FSS) in healthy children are neither persistent nor impair- Conversion/dissociative disorders share the main features ing, they tend to be ascribed to non-medical everyday biological of the somatoform disorders, but differ from them in that the or psychological stress and do not lead to medical help seeking main presentation is symptoms specifically affecting the motor (Huang et al., 2000; Rask et al., 2013a). and sensory systems. Nevertheless, because of their closeness to somatoform disorders, they and other related problems such as The concept of somatization chronic fatigue syndrome (CFS) and juvenile fibromyalgia will The concept of somatization is central to understanding the psy- be outlined in this chapter. chological ramifications of FSS and of somatoform and related Somatoform disorders present predominantly in older chil- disorders. The term has gained currency to describe a constel- dren and adolescents, but early manifestations can be identified lation of clinical and behavioural features involving: first, a ten- in younger preschool children. The diagnosis often relies on dual dency to experience and communicate distress through somatic pediatric medical and psychiatric assessments and can therefore symptoms unaccounted for by pathological findings; secondly be more complex than that of other purely psychiatric or medical these symptoms are attributed to physical illness and thirdly they disorders. lead to seeking medical help (Lipowski, 1988). In this review, we We will describe how to differentiate somatoform disorders will describe FSS and somatoform and related disorders likely from physical complaints in healthy children, outline the con- to be an expression of psychological distress and of somatiza- cept of somatization, the classification of somatoform disorders tion, even if these symptoms and disorders can also reflect bodily in International Classification of Diseases (ICD-10) and in the vulnerabilities. Rutter’s Child and Adolescent Psychiatry, Sixth Edition. Edited by Anita Thapar and Daniel S. Pine, James F. Leckman, Stephen Scott, Margaret J. Snowling, Eric Taylor. © 2015 John Wiley & Sons, Ltd. Published 2015 by John Wiley & Sons, Ltd. 1035 1036 Chapter 72 The current classification of somatoform anxiety disorder” unless the health anxiety is explained by a and related disorders primary anxiety disorder, such as generalized anxiety disorder. Current ICD and DSM classification systems diagnose dis- There is lack of clarity about the extent to which the essence of orders categorically. In ICD-10, somatoform disorders are somatoform disorders lies in the functional or medically unex- a sub-category (coded F45) of the broader “Neurotic, stress plained nature of the symptoms or in the distress/impairment disorders and somatoform disorders”. Among its various caused (Dimsdale & Creed, 2009; Fink & Schroder, 2010). In sub-divisions, persistent somatoform pain disorder is most DSM-5 (and probably also in the forthcoming ICD-11), the commonly observed in children and young people, while the disorders are defined on the basis of positive symptoms, namely diagnostic criteria for somatization disorder and hypochondri- distressing somatic symptoms together with abnormal thoughts, asis are seldom fully met in this age group. feelings and behaviours in response to these symptoms. This Closely related clinical problems, also with somatization at might help improve the present situation where the same FSS their core, are classified in ICD-10 under the same broad group- are classified in medical and pediatric clinics as functional (non ing but as a separate dissociative (conversion) sub-category organic) disorders, but as somatoform disorders in psychiatric (code F44), the main complaint being medically unexplained clinics. Table 72.1 provides examples of overlapping diagnostic neurological sensory or motor symptoms, such as paralysis, labels in different specialties. Nevertheless in DSM-5 medically abnormal gait, loss of sensation, or pseudo-seizures. Pre- unexplained symptoms remain a key feature of conversion dis- sentations with fatigue as a main symptom are diagnosed order, because it is possible to demonstrate definitively in such as neurasthenia (F48). This term is now out of favour, but disorders that the symptoms are not consistent with medical is descriptively close to clinical problems referred to in the pathophysiology. research literature as CFS and CFS-like disorders, which also share the key features of the somatoform disorders. The dimensional perspective Comparatively short-lived episodes with key somatoform fea- A categorical conceptualization is appropriate for somatoform tures may be diagnosed as “adjustment disorders” if they follow disorders at the severe end of the spectrum (Figure 72.1). How- closely on the experience of a marked and universally stress- ever, the dimensional perspective is useful in clarifying the sig- ful event. nificance of somatic symptoms in general populations or those In DSM-5, somatoform disorders are referred to as “so- attending primary health care and other medical clinics. In addi- matic symptom and related disorders”, and the number of tion, while the categorical framework is appropriate for school sub-categories has been substantially reduced (somatization children and adolescents, it is rare for young preschool children disorder, hypochondriasis, pain disorder and unspecified to have complaints that are severe and impairing enough to somatoform disorder are no longer included). The category reach the diagnostic threshold for somatoform disorders: a does include “psychological factors affecting other medical con- dimensional perspective is more appropriate in this age group. ditions” and “factitious disorder” as well as conversion disorder, now referred to as “conversion disorder (functional neurological Developmental aspects symptom disorder)”. Individuals with high health anxiety levels Key components of the somatoform disorders are not readily without somatic symptoms will receive a diagnosis of “illness expressed by young preschool children as they do not have the Table 72.1 Different terms and diagnostic labels used for somatoform and related disorders according to medical specialty. Specialty Somatoform and related disorders Child and adolescent psychiatry Adjustment disorder, somatoform disorder, conversion/dissociative disorder, neurasthenia, pervasive refusal (withdrawal) Pediatric rheumatology Juvenile fibromyalgia, chronic benign pain syndrome, growing pains Pediatric cardiology Non cardiac chest pain Pediatric gastroenterology Functional abdominal pain conditions (Rome III criteria): childhood functional abdominal pain, childhood functional abdominal pain syndrome, abdominal migraine, irritable bowel, functional dyspepsia, cyclic vomiting syndrome Pediatric infectious medicine Chronic fatigue syndrome, myalgic encephalomyelitis Pediatric respiratory medicine Hyperventilation syndrome Pediatric neurology Tension headache, pseudo-epileptic seizure Ophthalmology Non organic visual loss, amblyopic school girl syndrome  Somatoform and related disorders 1037 Contact with the health care system Adjustment Somatoform disorder disorders Conversion disorder Chronic fatigue syndrome Juvenile fibromyalgia Functional gastrointestinal disorders Pervasive withdrawal/refusal Mild self-limiting Recurrent symptoms/ normal Chronic symptoms symptoms Physiological reaction Disability/distress Number and severity of symptoms Figure 72.1 The spectrum of functional somatic symptoms and somatoform and related disorders. necessary experience and knowledge to articulate illness beliefs, the day, less prominent at nights or in school holidays. It may be and medical help seeking is a parental activity well into adoles- accompanied by vomiting, headache and lethargy and the child cence. However, parental-reported symptoms suggestive of som- may look pale and unwell, which can reinforce family beliefs atization have been reported in children as young as 5–7 years of an organic pathology. Headaches are more likely than not (Rask et al., 2009b, 2012). to be characterized as tension headaches (frequent, bilateral, Somatization-related disorders in young children although typically frontal, “like a band”), but they do sometimes coexist based on complaints by the children themselves are primarily with migraine attacks (a periodic, severe, unilateral pain with manifested through parental concerns, beliefs and behaviours. an accompanying aura, nausea and a similar family history). Excessive unreasonable parental concern about children’s Commonly, there are additional complaints of other less promi- FSS, when linked to illness conviction and repeated medi- nent physical symptoms—multi-symptomatic presentations cal help-seeking, can lead to unnecessary assessments and being habitual in clinical settings—as well as mood changes and treatments, some of which may be potentially damaging and marked impairment with reduction in social contact with peers compromise the child’s physical and mental health. This may and school absence. be conceptualized as parental somatization and raises the ques- Attempts have been made by gastroenterologists to subdi- tion whether the diagnosis in some cases should be a parental vide the group of children with unexplained gastrointestinal psychiatric one within the spectrum of factitious illness or symptoms into specific symptom patterns such as vomiting, Munchausen by Proxy (Eminson & Postlethwaite, 1992). defecation and pain in accordance with the Rome Criteria (Rasquin-Weber et al., 1999). However, the validity and reliabil- ity of these sub-groupings are not well established (Chogle et al., Clinical presentations, assessment 2010) and only a subset of children reporting abdominal pain and diagnosis fulfil the Rome criteria for “abdominal-pain related functional Clinical presentations gastrointestinal disorders” (or FGIDs) (Saps et al., 2012). Typical presentations in children are (i) pain, most commonly Juvenile fibromyalgia is a functional medical disorder descrip- with recurrent episodes of severe abdominal pain, headaches, or tively close to the somatoform pain disorders. It is defined as other pains which occur at least monthly and often weekly or a chronic pain condition of unknown aetiology, primarily dis- daily; (ii) fatigue/exhaustion—severe and incapacitating lasting tinguished by wide spread musculoskeletal pain, sleep difficulty, at least 3 months and often over 6 months and (iii) loss of the depression and fatigue (Anthony & Schanberg, 2001). There are ability to carry out usual bodily movement, loss of sensory per- no objective signs of arthritis and normal laboratory tests. ceptions and/or pseudo-seizures. The key features of CFS include severe disabling physical and Characteristically, functional abdominal pain (FAP) presents mental fatigue and exhaustion after minor effort, not relieved as intense, recurrent, diffuse, or peri-umbilical, often worse in by rest, of at least 6 months duration (although 3 months is 1038 Chapter 72 regarded as more appropriate for children), accompanied by 2010) and they can delay addressing the potential underlying marked functional impairment and often headaches and sleep psychosocial aspects. disruption, muscle or other pains and mood changes. It com- A psychiatric opinion is important for differential diagnosis, monly starts with an acute flu-like illness or glandular fever, but to confirm or exclude the presence of a somatoform or related the onset may also be gradual and fluctuating. Many children disorder and of co-morbid psychiatric disorders amenable to complain of sore throats, which may be accompanied by lymph psychiatric intervention. It should also be helpful in identifying node tenderness, anorexia, nausea and dizziness (Garralda & biopsychosocial factors likely to play a part in symptom main- Chalder, 2005). tenance and to put into place a programme of psychiatrically Conversion/dissociative disorders involve partial or complete informed psychosocial rehabilitation. loss of bodily sensations or movements. In children, loss or The mental health assessment will require specific skills in disturbance of motor function and pseudo-seizures are most medical/psychiatric differential diagnoses, liaison with pedi- common, but other presentations are loss of sight, hearing, atric services, prioritizing family engagement in assessment and sensation, consciousness, fugue or mutism. Symptoms are often treatment and helping families move from a purely physical to brought on by a traumatic trigger and remit after a few weeks or a biopsychosocial framework, crucially at a pace that is appro- months (Ani et al., 2013). priate and acceptable to them. These skills are usually available Hypochondriasis, or health/illness anxiety involves persistent to pediatric liaison teams see Chapters 32 and 42. preoccupation with fears of having a serious illness, based on the misinterpretation of bodily sensations believed to be indica- tive of serious disease and persistent seeking of medical reassur- Diagnosis, differential diagnosis, and psychiatric ance. It has been suggested that hypochondriasis has primarily comorbidity an onset in adulthood, but evidence is now emerging that cogni- In accordance with criteria for other psychiatric disorders, tive and behavioural features similar to those described in adults diagnosis is determined by the severity, distress and impair- are also present in children and adolescents (Wright & Asmund- ment caused by the symptoms, and more specifically by illness son, 2003; Rask et al., 2012). behaviours, concerns or beliefs in the absence of an identifiable medical disorder and despite a reasonable medical explana- Associated impairment tion. A diagnosis of a somatoform or related disorder should Symptom-related impairment is a key feature of the somatoform be considered when there is a time relationship between a disorders and multi-symptomatic complaints and is observed psychosocial stressor and the somatic symptoms (i.e. when in community samples of children as young as 5–7 years as stressors are closely related in time to or precede the onset of well as in adolescents (Rask et al., 2009b; Vila et al., 2009). physical symptoms) and when the nature and severity of the Impairment can involve prolonged periods of withdrawal from symptom(s) and related impairment are out of keeping with the social relationships and school absence, lasting for months or pathophysiology. years, potentially restricting opportunities for the development The nature of the somatic symptoms is an important guide for of social skills and academic advancement (Rangel et al., 2000b; diagnosis and for the decision to investigate medically. In recur- Smith et al., 2003; Garralda & Rangel, 2004). Uncommonly rent abdominal pains and in the absence of organic indicators, children become wheelchair- or bed-bound, unable to com- some authors recommend a coeliac disease screen as the only municate and look after their basic needs (Garralda, 1992a; investigation worth carrying out (Wright et al., 2013). Thompson & Nunn, 1997; McNicholas et al., 2013). Somatoform and conversion disorders may sometimes develop in the context of an organic medical problem. A child Pathways and engagement in mental health with inflammatory bowel disease may display symptoms, dis- referral tress and impairment that do not correspond to or far exceed Most children with recurrent somatic complaints will be known what may be expected from other children and young people to their general practitioners or family doctors and be referred with comparable illness levels (Garralda, 1992b); or a young by them in the first instance to their local pediatric clinic. For person with epilepsy may have “pseudo-seizures” outside the many children, a pediatric assessment will be sufficient to clarify range of epileptic phenomena, alongside medically recognizable the nature of the problem and lead to a resolution. epileptic ones (Patel et al., 2011). It is, of course, important and indeed essential that the appro- FSS and somatoform disorders should be differentiated priate physical examinations are conducted to exclude a treatable from malingering or the intentional production by the medical disorder. However, there is also a danger—especially child of false or grossly exaggerated symptoms in order to in the more severe cases—of over-investigating medically. In achieve privileges. Childhood illness can have clearly desirable the absence of organic indicators, these over-investigations consequences—including increased parental attention and are thought likely to be unproductive, potentially harmful as care and legitimate withdrawal from difficult situations—and well as non-cost-effective (Lindley et al., 2005; Dhroove et al., the child is in a strong position to modulate and control  Somatoform and related disorders 1039 the consequences. Not surprisingly, therefore, a spectrum of Thus, prevalence estimates vary considerably due to different intentionality is to be expected and should be duly evaluated in case definitions, assessment instruments and study populations. somatoform disorders. It is, however, not helpful for this inten- Table 72.2 outlines results of population-based studies which tionality to be exposed, unless it is gross and the predominant have assessed a variety of somatic complaints/FSSs. feature of the presentation. On balance, prevalence rates based on studies attempting to Somatic symptoms are commonly reported as part of anxiety cover the whole spectrum of FSS, symptom-related impairment and depressive disorders, but unlike in somatoform disorders, as well as medical information about actual physical health, sug- they are not the main focus of concern. However, psychiatric gest that 4–10% of children and adolescents in the general pop- disorders—usually anxiety and depressive disorders—are a ulation are substantially affected and likely to be in need of a common comorbidity. In a study of children with recurrent clinical intervention, the higher rates being found among older abdominal pains attending pediatric clinics, three quarters children and adolescents. In general, symptoms are also more were found to have a comorbid anxiety disorder (Campo et al., prevalent in girls. Complaints lead to medical consultation in 2004a) and psychiatric disorders had been present in the 12 approximately a third of cases—possibly depending on symp- months before the assessment in three quarters of young people tom severity and impairment and on familiar health care seeking with CFS attending specialist clinics (Garralda et al., 1999). patterns (Huang et al., 2000; Perquin et al., 2000; Rask et al., Comorbid psychopathology is reported in a quarter to half of 2013a). the children with conversion disorders seen in specialist services Functional or recurrent abdominal pain is the most investi- (Pehlivanturk & Unal, 2000; Ani et al., 2013). gated single somatic symptom. It affects 7–25% of school age The high levels of comorbid anxiety and to a lesser extent children and accounts for more than 50% of consultations in depressive disorders in childhood FSS and somatoform disor- pediatric gastroenterology (2–4% of all general pediatric office ders, the fact that comorbid anxiety and depression are linked visits) often incurring high medical costs (Dhroove et al., 2010). with the number of somatic symptoms, the strong and recipro- Cross-sectional studies in Nordic countries suggest that the cal associations between somatic and mood symptoms across prevalence of self-reported somatic symptoms such as frequent the life span have led some authors to question the separate headache and abdominal pain in children has increased during classification of these disorders and to call for research to clarify the past decades (Berntsson & Kohler, 2001; Santalahti et al., the nature of these interactions (Campo, 2012). 2005), but whether this has led to a higher use of health care sources has not been documented. Epidemiology Prevalence rates of somatoform and related disorders Knowledge of the epidemiology of somatoform and related Very few large-scale studies have been conducted in younger disorders and symptoms is critical to develop an appreciation populations to examine the prevalence of somatoform disorders of their public health implications and to optimize health following DSM or ICD diagnostic criteria. Two large German care planning. However, there are two major barriers in the population-based adolescent surveys assessed the prevalence epidemiological field of these disorders. The first is case defi- of somatoform syndromes and disorders through the use of nition. This is a special problem in younger children as even highly structured interviews incorporating DSM-IV diagnostic though clustering of different types of somatic symptoms has algorithms; they reported lifetime prevalence rates of 12–13% been shown in preschool and early primary school children (Essau et al., 1999; Lieb et al., 2000). However, in the study (Domenech-Llaberia et al., 2004; Rask et al., 2009b) develop- of 14–24-year-olds by Lieb et al., this was mainly accounted mental immaturity prevents their full syndromic manifestation. for by undifferentiated somatoform/dissociative syndromes. Furthermore, the current fragmented clinical approach with the Specific disorders were considerably less common, the lifetime use of various diagnostic labels as illustrated in Table 72.1 can prevalence of specific pain somatoform disorders being 1.7% be an obstacle to research in clinical populations. (12-month prevalence of 0.9%). The second barrier is case ascertainment. The requirement of With regard to functional unexplained gastrointestinal symp- a physical examination to establish the lack of an explanatory toms defined according to Rome criteria, a cross-sectional medical diagnosis and of links with stressors poses method- community study reported rates of irritable bowel syndrome ological problems in large community studies, the majority (IBS) in 14% of high school and 6% middle school students of which have simply used self- or parent-report somatic (Hyams et al., 1996). CFS-like problems have been identified symptom questionnaires. In most children and adolescents, in some 2–4% of 5–17-year-olds or adolescents in the United FSS will be short-lived with no negative long-term impact States and United Kingdom (Garralda & Chalder, 2005; Viner on daily functioning or developmental course and inclusion et al., 2008; Crawley et al., 2012), but only 0.2% of adolescents of symptom-related impairment criteria, therefore, decreases in the general population meet criteria for full CFS (Chalder prevalence estimates substantially. et al., 2003). Prevalence rates of juvenile fibromyalgia of 6% have 1040 Chapter 72 Table 72.2 Selected population-based studies that have assessed different types of somatic complaints/functional somatic symptoms (FSS). Reference/country Symptoms N/age Prevalence/time frame Offord et al. (1987) Combination of possible N = 2674 Somatizationa/past 6 months Canada unexplained symptoms, loss of 4–16 yrs 4–11 yrs: not measurable function and health concerns 12–16 yrs: ♀: 10.7%, ♂: 4.5% Garber et al. (1991) 35 symptoms N = 540 Symptoms/past 2 weeks United States “school-aged” ≥4 symptoms: 15.2%, ≥13 symptoms: 1.1% ♀ > ♂ in high school students. No gender difference in younger age groups Perquin et al. (2000) Pain (locations: head, abdomen, N = 5423 Chronic pain/past 3 months Holland limb, ear, throat, back or 0–18 yrs Total: 25.0%, ♀ > ♂ elsewhere) 0–3 yrs: 11.8%, ♀ < ♂ 4–7 yrs: 19.3%, ♀ > ♂ 8–11 yrs: 23.7%, ♀ > ♂ 12–15 yrs: 35.7%, ♀ > ♂ 16–18 yrs: 31.2%, ♀ > ♂ Multiple chronic pain: 12.9% Berntsson & Kohler Stomach complaints, headache, N = 3812 Any symptom: 25.0%/not stated, ♀ > ♂ (2001) sleeplessness, dizziness, backache, 7–12 yrs Mild: 16.7% Nordic countries loss of appetite Moderate: 7.5% Severe: 0.8% Domenech-Llaberia Abdominal pain, leg pain, N = 807 ≥Four times complaints/past 2 weeks: 20.4% et al. (2004) headaches, tiredness, dizziness 3–5 yrs Frequent complaints associated with more pediatric consultations Spain and absence from preschool. No gender difference Vila et al. (2009) 35 symptoms N = 1173 Symptoms/past 2 weeks United Kingdom 11–16 yrs ≥1 symptom: 37%, ≥4 symptoms: 12% ≥7 symptoms: 4%, ≥13 symptoms: 0.8% ♀>♂ At least 10% associated impairment (reduced ability to concentrate, enjoy activities, go to school, see friends) Rask et al. (2009) 20 symptoms N = 1327 One-year prevalence of FSSb Denmark 5–7 yrs FSS overall: 23.2%, ♀ > ♂ Impairing (distress, interference with social life, high use of health services and/or absence from school/day care) FSS: 4.4%, no gender difference Multiple FSS: 9.3% FSS: functional somatic symptoms. a Case definition: distressing recurrent somatic symptoms with no known organic cause and perception of oneself as sickly. b Assessment by layman administered parent interview (SAI) with subsequent clinical rating of information. been reported in a population-based sample of 9–15-year-olds children below 7 years, the incidence increasing with age and (Buskila et al., 1993). with a female preponderance. The prevalence of hypochondriasis or health anxiety in child- hood is unknown. This may be related to the lack until recently Cultural aspects of relevant screening tools (Wright & Asmundson, 2003). The literature suggests variations in the types of somatoform clinical presentations in different cultural areas. The incidence Prevalence rates of dissociative/conversion of conversion disorders appears high in children attending disorders Indian outpatient and child guidance clinics, where they have The incidence of dissociative or conversion disorders has been been found to account for 14% and 9% of attenders (Srinath studied through surveillance studies of new cases reported et al., 1993; Chaudhuri et al., 2007), rates being even higher by pediatricians and child psychiatrists in Australia and the among inpatients (30% in Srinath et al. (1993)). Conversion United Kingdom, yielding low yearly incidence rates of 1.30 disorders constituted 2–8% of children observed by a Turk- and between 2.3 and 4.2 per 100,000, respectively (Ani et al. ish clinical child psychiatric service (Pehlivanturk & Una, 2013; Kozlowska et al., 2007). Conversion is rarely identified in 2008).  Somatoform and related disorders 1041 These comparatively high rates have been thought to be disability when compared with patients with adaptive pain related to Asian cultures being more reserved in expressing profiles (Walker et al., 2012). feelings and distress and by requests for medical attention for A 3-year follow-up of adolescents with fibromyalgia revealed bodily symptoms being more imperative than purely psycho- persistent symptoms in close to two-thirds as well as signif- logical ones. However, the rates have been derived from clinical icantly more symptoms of anxiety and depression compared samples and we are not aware of systematic studies that examine with healthy controls (Kashikar-Zuck et al., 2010). the influence of culture and ethnicity on the aetiopathogenesis of various somatoform and related disorders in children. Chronic fatigue syndrome Although about two-thirds of children with CFS attending specialist services may be expected to recover, this can be Longitudinal outcome and long-term protracted, a 3-year follow-up documenting a mean time to adjustment recovery of 38 months (Rangel et al., 2000b). Moreover, even after recovery, half of the young people remained prone to Short-term surveys of, for the most part, clinical samples of chil- fatigue, and nearly two-thirds developed a psychiatric disorder dren with somatoform disorders show that the majority recover mainly consisting of anxiety disorders (Garralda et al., 1999). In in the short run, although some continue to experience symp- a longer term follow-up of young people with CFS-like illness, toms of lesser severity and/or develop psychiatric disorders. For a third of the patients considered themselves recovered, the rest example in highly “somatizing” adolescents, a 4-year follow-up documented an enhanced risk for major depression and panic being either not fully recovered or chronically ill (18%) (Bell attacks (Zwaigenbaum et al., 1999). et al., 2001). The majority of long-term prospective outcome studies have Conversion disorder addressed general population samples or young people with Follow-up studies of children and young people with conversion abdominal pains attending specialist services. These data are disorders note clinical improvement in 56% to 100% (Pehli- consistent in showing that somatic symptoms predict in adult- vanturk & Unal, 2002; Ani et al., 2013). Many cases appear to hood somatic symptoms, but also psychiatric comorbidities recover within 3 months and some symptoms remit sponta- including depression and anxiety (Hotopf et al., 1998; Hotopf neously or with minimal intervention after a few days or weeks. et al., 1999; Dhossche et al., 2001; Fearon & Hotopf, 2001; In a Turkish 4-year follow-up study (Pehlivanturk & Unal, Steinhausen & Winkler, 2007; Shelby et al., 2013). 2002), complete recovery was reported in 85% and favourable The existing literature indicates that childhood FSS, conver- outcome was predicted by early diagnosis and good premorbid sion disorder and CFS will rarely be the forerunners of medical disorders, but whether this is the case in clinical practice may adjustment. However, 35% developed a new psychiatric disorder depend on the thoroughness of the medical assessments, and it during follow-up, especially anxiety and depressive disorders. is worth noting that some studies have excluded from follow-up children with subsequent medical problems (Shelby et al., 2013). The following sections describe outcome in clinical popula- Risk factors tions with different somatoform and related disorders. Although the aetiology of FSS and somatoform disorders Abdominal pains and other pain syndromes remains incompletely understood, most investigators agree on It is rare for children with recurrent abdominal pains seen in multifactorial influences whereby an interplay of genetic and specialist clinics to develop an explanatory organic disorder environmental factors shapes the development and perpetuation at follow-up (1 out of 31 former patients in Walker (1995)). of symptoms. A biopsychosocial model is the preferred current Nevertheless, symptom persistence is observed in a substan- operational framework for FSS and somatoform disorders, as it tial minority. Longer term follow-up studies have reported recognizes the interaction between physiological and psycho- persistence of abdominal pain into adulthood in up to one logical processes with social and environmental influences. half of affected children (Apley & Hale, 1973; Christensen In clinical practice, a complex explanatory model for the & Mortensen, 1975) and links with both adult psychological development and maintenance of FSS and somatoform and comorbidity—mainly depression and anxiety (Shelby et al., related disorders can be used, which takes into account the var- 2013)—and somatic complaints, including other chronic pain ious risk factors and typically subdivides them into vulnerability conditions and headache (Walker, 1995, 2010). Impairment (the person’s susceptibility to develop the disease), precipitants and coping mechanisms are relevant to outcome. In a 9–year or triggers (factors that directly cause the onset of the disease) follow-up of children with RAP, the risk of persistence of and maintaining, which maintain or aggravate the pathological chronic pain and of psychiatric disorders was doubled in the processes (Figure 72.2). quarter of children with a “dysfunctional high pain profile” Various aetiological and pathophysiological factors may be rel- characterized by low perceived pain coping and efficacy, high evant at different times in this process and it rarely makes sense levels of negative affect, pain catastrophizing and functional to talk about “the cause”. 1042 Chapter 72 Vulnerability Precipitants Maintainig factors Acquired Parental distress and psychiatric disorders Acute stressors a Parental somatization and health anxiety Infection/other physical disease, Iatrogenic factors: Adverse life events and physical injury or trauma b Repetitive diagnostic testing Long-trem psychosocial stressors psychosocial stressors Misdiagnosis and mistreatment Repetitive medical investigations Lack of unity among professionals Different symptom explanations Inherited Developmental Family factors: Genetic influences process Parental emotional overinvolvement Biological reactivity Funtional somatic Somatoform or related disorder Familiar somatic attribution Emotional liability symptoms and/or disease conviction Stress reactivity Family conflict/strain Child factors: Withdrawal and deconditioningc Maladaptive coping strategies Depression/anxiety Other contextual factors: Continuous psychosocial stressors a over-concern about illness and bodily function b (e.g. bullying, separation/loss, family conflict) c adverse physical effects of inactivity Figure 72.2 Explanatory model. Explanatory model for the development and maintenance of functional somatic symptoms and somatoform and related disorders. Although vulnerability and maintaining factors have a cen- genetic heritability appears to be stronger for short than for long tral aetiological role, the triggers determine which symptoms duration of fatigue (Farmer et al., 1999; Crawley & Smith, 2007). develop and as a result, the child and family may consider them A joint action of genes and environment is assumed, but there to be the “cause”. These are often somatic in nature, for example, is still insufficient clarity on the actual genes and environmental an infectious illness commonly precipitates pediatric CFS (Gar- factors involved. Studies in adult patients have identified genetic ralda & Rangel, 2002). In conversion disorder, a problem in influences interacting with environmental hazards in IBS, con- walking may be triggered by a broken leg and pseudo-seizures cordance being higher in monozygotic than in dizygotic twins coexist with epilepsy, but antecedent stressors are also reported (22% compared with 9%) heritability in females being estimated for 80%, most commonly bullying in school, separation and at 48% (Bengtson et al., 2006). loss or family conflict or violence (Kozlowska et al., 2007; Ani There are indications that biological susceptibilities can influ- et al., 2013). ence the expression of somatoform syndromes. Children and While vulnerability factors will influence the development of young people with RAP report significantly greater symptom a syndrome, treatment most usefully addresses maintaining fac- increase to a water load symptom provocation test than controls, tors susceptible to change. Nevertheless, the same factors may be suggesting gastrointestinal sensitivity (Walker et al., 2006a). To both predisposing and maintaining, and as the existing empir- explain the high levels of comorbidity between abdominal pains ical evidence tends to be based on cross-sectional studies and and mood disorders, and given that serotonin is an impor- cannot differentiate cause and effect, in the following sections we tant neurotransmitter in the gastrointestinal tract and enteric will consider joint vulnerability and maintaining factors, divided nervous system, Campo et al. (2003) have put forward the according to their biological or psychosocial nature. possibility of dysregulation of serotonergic neurotransmission as being implicated in both, although this is an issue requiring Biological factors empirical validation. Familial clustering is well established in the literature on As pain somatoform disorders when severe usually involve somatoform disorders and functional somatic syndromes such pain in different bodily sites, it is possible that central pain as IBS and CFS (Wright & Beverley, 1998; Garralda, 2000; sensitization is a contributing factor, as a result of elevated Craig et al., 2002; Levy et al., 2004; Crawley & Smith, 2007; responsiveness to nocioceptive stimuli resulting from increased Schulte & Petermann, 2011) and this is thought to reflect in spinal cord neuron excitability, but this again needs more part genetic influences. Twin studies have confirmed a genetic empirical confirmation (Al-Chaer et al., 2000; Mayer & Collins, contribution to fatigue symptoms and CFS syndromes, although 2002; Walker et al., 2012).  Somatoform and related disorders 1043 The increased stress reactivity and emotional lability associ- Their precursors may manifest in infancy through hyper- ated with child somatoform disorders discussed in the following sensitivity to sensory and tactile stimulation and difficulty in sections point to a possible role of the hypothalamic–pituitary– self-regulation, as two studies have now found this to predict the adrenal system. Significant associations between cortisol levels development of recurrent somatic and impairing symptoms in and clusters of FSS have been identified: an overtiredness and later childhood (Ramchandani et al., 2006; Rask et al., 2013b). musculoskeletal pain cluster being associated with low cortisol after awakening, and a gastrointestinal and headache symp- Stress reactivity and coping mechanisms tom cluster being associated with low cortisol levels during Temperamental and personality features may underlie enhanced psychosocial stress (Janssens et al., 2012). stress reactivity in children with impairing somatic symptoms. There have been reports of autonomic dysregulation—with Those with recurrent abdominal pains report more daily hassles high blood pressure and heart rate at rest and orthostatic and stressors both at home and in school than normal children anomalies—in pediatric CFS (Wyller et al., 2007, 2008), but it is and a stronger association between daily stressors and somatic difficult to know the extent to which this is primary or secondary symptoms (Walker, 2001). They also appear to be less confident to the sometimes profound “physical deconditioning” resulting in their ability to change or adapt to stress and less likely to from prolonged inactivity. Children with functional abdomi- use accommodative coping strategies (Walker et al., 2007). nal pains fail to report the expected higher pain threshold in Empirical evidence from studies in children with headache the presence of elevated blood pressure when compared with and abdominal pain further supports the notion that children healthy controls, which may possibly reflect autonomic dysreg- with high levels of somatic symptoms tend to use poor cop- ulation or its interplay with overlapping systems modulating ing strategies characterized by negative affect and avoidance pain (Bruehl et al., 2010). (Walker et al., 2012). Young people with CFS report higher levels of distress about their condition than controls with other Psychosocial risk factors pediatric chronic conditions and less use of active problem Psychosocial risk factors can be subdivided into child psy- solving techniques when dealing with illness and impairment chological features, factors in the family, and in the school or (Garralda & Rangel, 2004). wider environment, including adverse life events, all of these The adult literature has addressed the possible role of other acting as both vulnerability and maintaining the symptoms and psychological mechanisms for the development of FSS, such impairment. as alexithymia (i.e. difficulties identifying feelings and differ- entiating them from bodily arousal), dissociation (or failure to Child factors integrate different elements of consciousness), introspection, Psychological features in the child known to be associated the somatosensory amplification of physical sensations and with the development and maintenance of FSS or somatoform anomalous illness attributions. Results, however, have not been symptoms include early reactivity, vulnerable personalities and conclusive (Duddu et al., 2006) and these mechanisms have ineffective coping styles. A consistent finding is the very high been comparatively little explored in children. co-morbidity with anxiety and mood disorders, suggestive of shared underlying risks. Family factors Parental and family influences are highly relevant. Mothers Personality and temperament of children with recurrent abdominal pain have an excess of There have long been pediatric observations of children with histories of anxiety and depression (Campo et al., 2007), and RAP having characteristic personalities, such as conformism parental anxiety and psychiatric disorder during the child’s first and obvious attempts to please adults and obtain approval, year of life predict FSS in children 6 years later (Ramchandani sensitivity to distress and insecurity, anticipation of dangers et al., 2006; Rask et al., 2013b). Children of parents with current and failures for themselves and their families (Garralda, 1992b). somatization display an excess of somatic symptoms and school Davison et al. (1986) described an excess of irregular temper- absence (Craig et al., 2002). amental styles and a tendency to withdraw in new situations Of more immediate relevance, a particularly high parental in young primary school children with abdominal pains when focus and involvement with the child’s somatic symptoms are contrasted with healthy controls, and work on young people associated with the development of FSS in young people. Work with CFS has identified high rates of personality disorder and with children with recurrent abdominal pains has shown that difficulty characterized by conscientiousness, vulnerability, parental behaviours that entail giving attention to the symptom worthlessness and emotional lability when compared with result in doubling of complaints, especially in girls, whereas healthy controls or with children with other chronic pedi- distraction reduces the symptoms by half. Interestingly, while atric disorders such as juvenile arthritis (Rangel et al., 2000a). children in these experiments report that distraction makes the These traits are comparable to personality features of young symptoms better, parents rate distraction to be more likely than people with anxiety and mood disorders (Rangel et al., 2003), attention to have a negative impact on their children’s symptoms suggesting shared vulnerabilities. (Walker et al., 2006b). These findings may reflect high levels 1044 Chapter 72 of “accommodation” of the family to the child’s symptoms, Pathological risk processes similar to that described in children with emotional disorders (Lebowitz et al., 2013). The biological and psychosocial factors described earlier may Work on young people with CFS has demonstrated high in combination be expected to influence the development and levels of parental emotional over-involvement with the maintenance of somatoform and related disorders. In explain- children’s illness, when compared with parents of children ing the processes through which they exert their influence, it is with other chronic pediatric disorders (Rangel et al., 2005). useful to consider the role of impairment. Over-involvement is manifested at interview by parental com- Functional impairment involves withdrawal from everyday ments that include overprotectiveness and self-sacrificing responsibilities and stresses. As outlined under risk factors, behaviours as well as preoccupation with the child, which are children with somatoform disorders are described as stress sen- over and above what may be expected from the child’s age and sitive; they therefore find themselves comparatively frequently developmental level, melodramatic speech, intense affect and in situations that are unsettling and upsetting, which they find preoccupation with the past. In addition to parental “disease difficult to manage. In this context, illness—despite being an conviction” or over emphasis on possible medical causes for the unpleasant and distressing physical experience—represents a symptoms despite negative medical investigations, such parental welcome escape from stress. It provides the child with a source attitudes may impede adolescents in developing active coping of control over the rate at which ordinary life and its attendant mechanisms. Conversely, parental acceptance of a multifactorial stresses will be confronted and managed. This could explain illness model can be associated with a better prognosis (Crushell why some children appear to “hold on” to the illness and oppose et al., 2003). or resist rehabilitation attempts and expectations from others. Childhood somatization has been further articulated in terms Social factors of superficially compliant children who tend to avoid overt Epidemiological work on children with somatic symptoms has expressions of vulnerability or distress, but who find themselves found associations with broad psychosocial stressors such as in intolerable “predicaments” they cannot escape or communi- broken families—although the latter is not necessarily associ- cate, without threatening their feeling of safety. Physical illness ated with symptom-related impairment—and with preceding or would serve to elicit parental care and protection and safeguard contemporary negative life stresses or events (Aro, 1987; Boey the child from parental expectations and anger, displeasure or & Goh, 2001; Vila et al., 2012). Stressful events are reported as rejection in the face of failure to perform (Kozlowska, 2001). illness precipitants in the majority of clinical studies of chil- dren with conversion disorder (Ani et al., 2013). Examples of Assessment. Treatment and treatment emotional and social stressors may be the loss of a close family setting member, parents’ divorce, but school events such as pressure on the child to perform in school or being bullied are especially Assessment using a biopsychosocial framework reported. Studies in adults with somatoform disorders have The assessment of young children relies primarily on parental documented an excess of sexual abuse and disruptive early information and child/parent interactions, while in older chil- life experiences but the evidence on sexual abuse is somewhat dren more emphasis will be put on interviews with children. inconclusive (Chen et al., 2010) and these factors have not Dual assessments are important given the limited concor- emerged as of general significance in the child literature. dance in symptom reporting in parents and children (Garber In addition to familial and school factors, the health system et al., 1998). itself can become iatrogenic. Physicians tend to pursue organic Core assessment includes in the first place a detailed medical explanations and repeated medical investigations, which can and psychiatric history and examination, together with a thor- lead to amplification of the children and family’s illness worry ough review of previous medical records; secondly, the assess- and behaviour. In a study of young people with CFS observed ment of physical and psychiatric comorbidity; and thirdly, the in specialist clinics, a mean of seven medical professionals had use of a biopsychosocial perspective that takes into account bio- already been consulted (Rangel et al., 2000b) and repeated logical, psychological and social risk and maintaining factors, medical assessments are also a feature in non-transient con- which will be central to the rehabilitation process. version disorders (Ani et al., 2013). This has to be tempered The assessment needs to take into account the medical against the danger of under-investigating and missing a pri- disorders that are being investigated alongside the mental mary medical disorder and clearly any organically suspicious health referral and maintain a physical/medical or a psychi- symptom should promote a reassessment of possible medical atric/psychosocial perspective, which may include liaison and causes. However, it is important to note that the diagnosis of discussion with pediatricians or other medical teams. Contact a somatoform disorder should be made positively on the basis with schools and especially clarification of school absence and of the characteristic psychological features and that a somato- of other potential educational and social problems is important. form disorder may indeed coexist with a medical problem Standardized questionnaires and interviews that may be helpful (Garralda, 1992b). in the assessment are summarized in Table 72.3. Table 72.3 Selected measures for assessment of functional somatic symptoms and somatoform and related disorders. Rating scales Measure (Ages) Domaine Time frame/scale Versions Comments Children’s Somatization Inventory (CSI) Somatization Past 2 weeks Child, parent version Subscales of pseudoneurological, [8–18 yrs] 5-point scale: Original version (35 items) cardiovascular, gastrointestinal and (Garber et al., 1991; Walker, 2009) bothered not at all to a whole Short version (18 items) pain/weakness symptoms akin to somatization lot Revised version (24 items) disorder symptom categories (score 0–140) In the revised version, CSI-24, statistically weak items have been removed, making it more appropriate for children and adolescents Childhood Illness Attitude Scales Health anxiety Not stated Self report (35 items) Covers fears, beliefs and attitudes associated (CIAS) 3-point scale: with hypocondriasis and abnormal illness [8–15 yrs] Applies: none, some or a lot behaviour and parents’/guardians’ role in (Wright and Asmundson, 2003) (score 33–99) facilitating medical attention or treatment Questions regarding recent medical treatment less reliable and probably need revision. Chalder Fatigue Scale (CFS) Fatigue Not stated Self report (11 items) Measures physical and mental fatigue in CFS [10 yrs+] 4-point scale (0, 0, 1, 1): Score 0–11 patients (Chalder et al., 1993) Applies: less, no more, more, much more than usual (score 0–11) Functional Disability Inventory (FDI) Impairment/physical Past 2 weeks Child, parent version (15 items) Has primarily been used to assess physical [8–18 yrs] functioning 5-point scale: disability in a variety of pediatric chronic pain (Walker et al., 1991) No problems to conditions such as abdominal pain, (score 0–60) fibromyalgia, headaches, back pain and other non-disease specific musculoskeletal pain syndromes Interview modules Interview [Ages] Diagnoses Time frame/interview type Versions Comments Munich-Composite International Somatoform and dissociative Life time Self report Includes 46 symptoms according to Diagnostic Interview (M-CIDI) disorders including subtypes Highly structured interview No parent version DSM-IV/ICD-10 [Adult interview applied in children Probably not applicable to younger children and adolescents with age as low as 12 yrs] (Wittchen et al., 1998) Schedules for Clinical Assessment in Somatoform and dissociative Current /previous/life time Self report Includes 78 symptoms according to Neuropsychiatry (SCAN) disorders including subtypes Semi-structured interview No parent version DSM-IV/ICD-10 [Adult interview applied in Probably not applicable to younger children adolescents] Somatoform and related disorders (Brugha et al., 2001) 1045 (continued)  1046 Chapter 72 Table 72.3 (continued) Interview modules Interview [Ages] Diagnoses Time frame/interview type Versions Comments The Child and Adolescent Psychiatric Symptom diagnosis based on Past 3 months CAPA: child/parent version Includes only three symptoms: headache, Assessment (CAPA) information on onset date, Interviewer-and glossary-based PAPA: parent version stomach ache and musculoskeletal pain [9–17 yrs] duration, frequency and interview & impact The Preschool Age Psychiatric Assessment (PAPA) [3–6 yrs] (Angold et al., 1995 and Egger & Angold, 2004) The Soma Assessment Interview (SAI) Functional somatic symptoms, Past year Parent version Consists of 5 sections covering items on the [5–10 yrs] −/+impairment Mixture of highly structured No child version child’s: (i) physical health, (ii) physical (Rask et al., 2009a) and open-ended questions. complaints, (iii) duration and impact of Final assessment by a clinical possible unexplained somatic symptoms, and rater number of doctor’s visit’s during the past year due to these symptoms and (iv) health anxiety symptoms Probably not applicable to older children and adolescents  Somatoform and related disorders 1047 Treatment setting More specific advice may involve (i) pain management The management should ideally follow a stepped care mode with the use—as appropriate—of relaxation (especially for according to the level of specialization required by each patient headaches) and distraction techniques, combined with negoti- (Figure 72.3). ated reduction of avoidance and inactivity and graded return Most children with FSS are seen by primary health care to school if applicable; (ii) addressing contributory factors practitioners and pediatricians and improve with medical such as stresses in school or from peer interactions, helping examination, explanation and advice built on psycho-educative parents decrease their concerned attention to symptoms, while principles. In pediatric settings, parents of children with FSS, increasing attention and encouragement of non-pain behaviour especially mothers with high anxiety levels, provide more pos- and shared enjoyable activities. itive feedback to biopsychosocial than to purely biomedical For children with more protracted problems, the referral pediatric consultations (Williams et al., 2009). This accords with from pediatrics to child mental health services requires a sen- the fact that many mothers of children consulting for abdominal sitive appreciation by all concerned of the “somatic focus” and pains, and indeed with conversion disorder, acknowledge a con- reluctance to accept a mental health approach by a number of tribution of psychosocial factors to their children’s symptoms children and families. Details on how this may be achieved are (Claar & Walker, 1999; Ani et al., 2013). given in Table 72.4. The cornerstone of treatment is for pediatric clinicians to Comorbid mood disorders will require specific and coor- be interested in the child and its background, to carry out the dinated treatment as will comorbid medical disorders. Severe necessary investigations, to discuss with parents tactfully that cases and pervasive withdrawal may call for inpatient treatment, organic disease has been excluded and any harmful aspects a multidisciplinary and often multiagency approach with school in the child’s environment (such as excessive academic and involvement. emotional demands, often self-imposed by the child) and to help modify them. Sharing information about the population Specialized mental health treatment frequency of FSS, existing knowledge about risk factors as To become involved with psychological treatments, children and well as guidance about management strategies can be helpful parents need to perceive that the somatic symptoms and their in “normalizing” the problem and “empowering” families in predicament are taken seriously by clinicians, that their concerns management. are not dismissed as being “all in the mind” or “all in the family” 4 Persistent FSS/Severe somatoform disorders Management at specialized unit. Rehabilitation (multi-disciplinary) and family CBT. Consider pharmacological treatment (e.g. SSRI if comorbid anxiety/depression). 3 Moderate FSS/somatoform disorders, comorbidity Management in pediatric setting if appropriate, in collaboration with mental health specialist (who is in charge of assessment, treatment plan and supervision) 2 Moderate, uncomplicated FSS Management in primary care or pediatric setting. Follow-up consultations. 1 Mild or transient FSS Management in primary care. Key principles: Normalisation, explanation, advice Follow-up of at-risk patients. FSS: functional somatic symptoms Figure 72.3 Stepped care model for the management of functional somatic symptoms and somatoform and related disorders. Source: Inspired by model presented in Schroder and Fink (2011). 1048 Chapter 72 Table 72.4 General principles for helping engagement in assessment and Table 72.5 General principles for the treatment of somatoform and related treatment (Goldberg et al., 1989). disorders. Stage 1 Feeling understood Goal setting: establish realistic goals with a good chance of success in the light of the child’s illness and the framework of the therapy Take a full history of the child’s symptoms Engagement and motivation: provide the rationale for a treatment pro- Explore emotional cues gramme emphasizing the focus on reducing impairment Explore social and family factors Psycho education: including (i) the body’s reaction to stress and how stress Explore the families health beliefs/illness perception may be expressed in somatic symptoms, (ii) possible biological and physio- Brief focused physical examination if indicated logical basis for the symptoms, and (iii) sleep hygiene and dietary advice Links between symptoms and stress: use diaries for documentation of Stage 2 Broadening the agenda variations in symptom intensity in relation to stressors in everyday life, which Feedback the results of the examination may provide a focus for intervention Acknowledge the reality of the symptoms and related impairment Behaviour: address dysfunctional avoidance behaviour, e.g. increasing Reframe the complaints in a biopsychosocial model: link physical, psy- school absence chological and social factors Coping: help the child and family learn new techniques to cope with spe- cific symptoms and impairments e.g. distraction, muscular relaxation for Stage 3 Making the link headaches, graded physical exercise for muscular problems and fatigue, Give a simple explanation practical management of pseudo-seizures ° How stress, tension and anxiety cause or aggravate physical Family and social network: address any factors in the family or school that symptoms may be contributing to the symptoms or interfering with symptom resolution ° How depression lowers the pain threshold Address help-seeking behaviour: gradually shift the burden of responsi- Demonstrate bility from clinician to parent/patient ° Practical (e.g. how pain results from tense muscles) Treatment of comorbid psychiatric problems ° Link to life events (e.g. how pain can be made worse by stressors) Consider psychopharmacologic interventions: especially for comorbid ° “Here and now” (e.g. rate the pain and link to feelings) internalizing disorders such as anxiety and depression Broaden the scope (ask if anyone else in the family or among friends Establish joint professional meetings and integrated investigations and has suffered from similar symptoms) management plans between different medical and other professionals involved Source: Adapted from Elsevier. and that the rehabilitation approach will be collaborative and while confirming that the child is not feigning the symptom. proceed at a pace that the child and family can manage and is Key principles of treatment are provided in Table 72.5. acceptable to them. The following sections describe in more detail treatment In line with the guidelines described earlier, psychological options for different somatoform and related disorders. treatment approaches will best involve psycho education and exploration of concerns and illness beliefs and be followed by Treatment of recurrent abdominal pains symptomatic treatment, with an emphasis on rehabilitation There is now evidence supported by randomized controlled and learning to cope with symptoms, alongside the exploration trials (RCTs) that family CBT programmes can be efficacious and management of contributory stressors (often involving for RAP. An early RCT by Sanders and colleagues (Sanders problems in school and in peer relationships) and/or psychiatric et al., 1994) showed this to be superior to treatment as usual and disorders. Because of the importance of parental influences, was replicated by Robins and colleagues (Robins et al., 2005). family work is of the essence. The main ingredients of Sanders et al.’s active CBT intervention The best evidence of efficacy comes from randomized con- were: (i) discussion of investigations and of the rationale for trolled treatments (RCTs) using relaxation for circumscribed pain management; (ii) reinforcement of well behaviour by problems such as headaches and family-based cognitive promotion of distracting activities, ignoring non verbal pain behavioural therapy (CBT). Additional treatments showing behaviours, avoiding modelling the sick-role and discriminating promise are hypnotherapy and new cognitive behavioural ther- the seriousness of symptoms; (iii) promoting coping skills such apies such as Acceptance Commitment Therapy (ACT) and as relaxation, positive self-talk and distraction; (iv) problem mindfulness techniques. solving for future pain involving positive imagery skills. In this Specific cognitive-behavioural techniques involve self- study, over 50% of children were pain free on children’s diaries monitoring of the main symptoms through diaries, teach- at the end of active treatment compared with approximately ing children to observe symptom fluctuation with changes 20% who had standard pediatric treatment (70% compared in intensity and severity, limiting the attention given to the with about 30% according to parental reports) and the gains symptom by others, relaxation if appropriate and encouraging were largely maintained at 6- and 12-month follow-up. Levy participation in routine activities through gradual exposure, et al. with a much larger sample of 200 children compared three  Somatoform and related disorders 1049 sessions of CBT (aimed at altering parental responses to pain as weekly sessions to be significantly superior to usual treatment well as children’s coping responses to it) with three educational including Amitryptiline, in terms of functional disability, pain sessions. CBT was associated with significantly greater decrease intensity and discomfort (Wicksell et al., 2009). in pain and gastrointestinal symptom severity and in parental solicitous responses to pain, and the effects were maintained at Treatment of chronic fatigue syndrome 12-month follow-up (Levy et al., 2010). A rehabilitation treatment framework offers most chances of A meta-analysis has confirmed the effectiveness of psycho- success. Understanding the maintaining power of inactivity for logical therapies, principally CBT (in person and on line) and fatigue and the related behavioural vicious circles that follow relaxation in the treatment of children with chronic abdominal from this can be helpful, fatigue leading to inactivity which in pain (Sprenger et al., 2011). Hypnotherapy can also help reduce turns generates more fatigue. A behavioural family approach abdominal pain intensity, although the existing evidence makes will address this through a graded activity program while it difficult to quantify the exact benefits (Vlieger et al., 2007; acknowledging fear that activity may make the condition worse, Rutten et al., 2013). There is little evidence of efficacy of bio- a belief often based on unsuccessful previous attempts to fight logical/medical or dietary treatments (Huertas-Ceballos et al., the symptoms (Garralda & Rangel, 2005). 2002; Horvath et al., 2012; Wright et al., 2013). This approach is broadly supported by the existing research evidence. A pilot RCT found active rehabilitation to be superior Treatment of headaches to patients “pacing” themselves by acting according to their National Institute for Health and Care Excellence (NICE) subjective tiredness and energy levels (Wright et al., 2005) and guidelines (2012) advise the use of paracetamol or NSAIDs in an open study of young people with CFS, those taking part (non-steroid anti-inflammatory drugs) during the acute phase in an active treatment programme performed better than those of tension-type headaches in young people and adults, but declining involvement (Viner et al., 2004). RCTs have shown preparations containing aspirin are contraindicated under 16 CBT to be superior to waiting list controls (Stulemeijer et al., years because of the association with Reye’s syndrome (Carville 2005; Knoop et al., 2008), although its superiority over psycho et al., 2012). However, ongoing use of painkillers is not rec- education is less clear-cut (Chalder et al., 2010). CBT can be ommended and alarm has been caused by reports of a marked successfully delivered through Internet-based interventions and increase in the use of paracetamol over recent decades by chil- this has been found to be more efficacious than standard care dren and adolescents, alongside an increase in the number of (Nijhof et al., 2012). NICE guidelines emphasize the importance children reporting stomach aches (Holstein et al., 2009). of family engagement and of establishing a supportive and A variety of drug treatments are recommended for the collaborative relationship with the child and family (Baker & treatment and prophylaxis of pediatric migraine (Lewis et al., Shaw, 2007). Good communication is regarded as essential, 2002). Nevertheless, it is also recognized that behavioural supported by evidence-based information to allow families to treatments such as relaxation training, biofeedback, CBT and reach informed decisions about the child’s care. Generally, it is stress-management training can be superior to placebo in the recommended that CBT and/or graded exercise therapy should treatment of both tension and migrainous headaches (Rains be offered because currently these are the interventions for et al., 2013). which there is the clearest research evidence of benefit. Treatment of juvenile fibromyalgia and other pain syndromes Treatment of conversion disorder CBT strategies have also been found effective for the treat- Probably because of its rarity, there are no trial-based evidence ment of fibromyalgia. An RCT reported this to significantly treatments for childhood conversion disorder. Descriptions of improve function compared with controls assigned to only useful treatments include graded physiotherapy programmes self-monitoring (Kashikar-Zuck et al., 2005). (Brazier & Venning, 1997) and these are to be recommended Acceptance and Commitment Therapy (ACT), an extension alongside the general principles for the treatment of other of traditional CBT with a focus on improving functioning and somatoform-like disorders. quality of life, has recently been developed for the treatment of children with pain syndromes. This promotes acceptance of Medication negative reactions (thoughts, emotions and bodily sensations) Selective serotonin reuptake inhibitors (SSRIs) such as Citapro- of pain and other symptoms that cannot be directly changed, lam have been piloted successfully for the treatment of RAP and the promotion instead of activities that are meaningful to but there is not as yet direct evidence of efficacy (Campo et al., the patient, even if painful or fear-provoking, as a means of 2004b). In adults, antidepressants have been found to have a helping patients distance themselves from the pain or distress. A moderate to good effect in the treatment of different types of recent small RCT of children with longstanding pain showed ten functional somatic syndromes (Henningsen et al., 2007). 1050 Chapter 72 Treatment of psychiatric comorbidity References The most common psychiatric comorbidities and their treat- ment will follow the guidance provided in the relevant chapters Al-Chaer, E.D. et al. (2000) A new model of chronic visceral hyper- in this book. sensitivity in adult rats induced by colon irritation during postnatal development. Gastroenterology 119, 1276–1285. Angold, A. et al. (1995) The Child and Adolescent Psychiatric Assess- Treatment of severe withdrawal cases ment (CAPA). Psychological Medicine 25, 739–753. For the treatment of severe cases of pervasive withdrawal, a coor- Ani, C. et al. (2013) Incidence and 12-month outcome of non-transient dinated multidisciplinary rehabilitation package is required that childhood conversion disorder in the UK and Ireland. British Journal ensures consistency and collaboration between different profes- of Psychiatry 202, 413–418. sionals and families. This will commonly involve attending to Anthony, K.K. & Schanberg, L.E. (2001) Juvenile primary fibromyalgia basic needs with assisted feeding and elimination, exposure to a syndrome. Current Rheumatology Reports 3, 165–171. selected group of carers, gentle encouragement to communicate American Psychiatric Association (1994) DSM-IV: Diagnostic and Sta- verbally, active treatment of any comorbid anxiety or depressive tistical Manual of Mental Disorders, 4th edn. American Psychiatric disorders and family work. Any parental misgivings about treat- Association, Washington, DC. ment need to be addressed and progress must be expected to be American Psychiatric Association (2013) DSM-V: Diagnostic and Sta- slow at early stages until the child’s mood and trust in therapy tistical Manual of Mental Disorders, 5th edn. American Psychiatric improve to the extent of allowing them to start “letting go” of Association, Washington, DC. their withdrawal (Nunn et al., 1998). Apley, J. & Hale, B. (1973) Children with recurrent abdominal pain: how do they grow up? British Medical Journal 3, 7–9. Aro, H. (1987) Life stress and psychosomatic symptoms among