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Somatic complaints common among adolescents

AAP 2011 National Conference

BOSTON — Differentiating between real physical symptoms of organic cause and symptoms of a psychosocial nature can be difficult, according to a presenter at the American Academy of Pediatrics 2011 National Conference and Exhibition.

According to Robert T. Brown, MD, of the Division of Adolescent Medicine at Cooper Regional Hospital for Children in Camden, N.J. and professor of Pediatrics at Cooper Medical School of Rowan University, typical psychosomatic problems involve complaints that are vague but dramatic and are fluctuating but chronic. Psychosomatic problems are more common in females than males, onset is generally in childhood or adolescence and the parents of the patients will visit several doctors looking for an answer.

These problems are characterized by presence of organic symptoms and evidence for psychosocial dysfunction. However, all potential causes of symptoms must be explored to ensure there is no serious underlying organic condition.

“The first thing you need to do is to be clear about what you’re dealing with and that there is no organic diagnosis,” said John Sargent, MD, a former pediatrician who is currently a child psychiatrist and family therapist at Tufts University in Boston.

“Alleviation of psychosomatic dysfunction will increase improvement of organic symptoms,” Brown said.

Brown explained the three basic patterns of somatization: 1) normal adolescent development concerns; 2) temporary adjustment reaction to new stress; and 3) dysfunctional coping with chronic stress.

Signs of stress

According to Brown, there are numerous typical adolescent stressors. Some of the more common ones that pediatricians should look for include:

• pubertal growth;
• Hormonal changes;
• Over-scheduling;
• Genetic vulnerability to illness;
• School changes;
• Peer pressure;
• Changed in family situation;
• Violence;
• Physical illness; and
• Sexual mistreatment.

Common psychosomatic symptoms include recurrent abdominal pain, headache, chest pain, fatigue and musculoskeletal pain. Abdominal pain is most common because blood leaves the abdominal area when the body is under stress, and “this relative ischemia results in pain,” Brown said. “So this may help understand why some patients have abdominal pain when they are under stress.”

Using the Minuchin criteria to determine if the family is psychosomatic, Brown recommends the clinician attempt to assess the family’s level of enmeshment, over-protectiveness, rigidity and their lack of conflict resolution.

Sargent said it is important that physicians tell both the parents and child that you intend to help them manage the problem and manage their life. Physicians also should let parents and children know that the evaluation of the child will end in treatment — whether it is mental or physical, according to Sargent.

“The goal is to get the child engaged back in their life, which may not mean they will be pain-free, but they will be able to function normally,” he said.

Management

Management of psychosomatic problems begins by validating the symptoms with the child and parents. Explain to them that both the organic and psychosocial causes will be explored simultaneously. Premature interpretation should be delayed, and the distanced parent in the family should attempt to become more involved.

“The first thing you need to do if you want to manage this patient is to agree that the symptoms are present and validate the symptoms,” Brown said.

Treating the symptoms, such as a heating pad for stomach or back pain, makes the patient and parent feel better and allows for better coping of symptoms. Frequent follow-up is also necessary, according to Brown.

“You buy into the symptoms and then you do something to help the symptoms improve. They will be happy with you and they will come back,” he said.

Sargent said that somatic symptoms affect development and should be resolved as quickly as possible. He also suggested pediatricians develop an algorithm for psychosomatic complaints similar to that of an algorithm for asthma to help with diagnosis.

When to refer

Issues that may lead the pediatrician to refer their patient to a mental health professional include marked psychosocial problems in a teenager; chronicity of symptoms and chronicity of poor function; marked family conflict or family adversity; family conflict about the patient’s symptoms; and severity of anxiety or depression symptoms, according to Sargent.

If the patient is referred, finding an experienced, trusted therapist is extremely important.

“I believe in my medicine as much as you believe in yours, and you need to trust that the therapist is effective and be sure to find one who is,” Sargent said. — by Cassandra A. Richards

Disclosure: Drs. Brown and Sargent report no relevant financial disclosures.

As an adolescent medicine specialist, one of the most valuable skills I have developed through the years is an approach to the patient with vague somatic complaints. When caring for these patients and their families, I find myself using every physician-patient communication tool in the book: validating their symptoms and experiences, reflecting back to demonstrate my understanding of what they are going through, and above all, listening. Perhaps the most challenging, but critical step in the process is discussing with the family that we are unlikely to come up with a specific and satisfying diagnosis, and it is time to stop doing tests and shift the focus to helping the patient cope with the symptom. This may include providing symptomatic relief through pharmacologic and nonpharmacologic means, by addressing dysfunctional personal thought habits and family dynamics, and providing ongoing support and follow up. Simply letting patients know that we are not "giving up on them" can go a long way. In this presentation, Dr. Brown and Dr. Sargent provided useful and insightful tips for dealing with every step of this challenging process!

Cynthia Holland-Hall, MD, MPH
Nationwide Children's Hospital

For more information:

• Brown R and Sargent J. #S2047. Somatic complaints in adolescents – Tell me where it hurts. Presented at: AAP 2011 National Conference and Exhibition. Oct. 15-18, 2011. Boston.