Somatisation in children and adolescents.
Somatisation in black Africans
Somatisation in black Africans has variously been described as paraethesias, (3) masked depression, (4) brain fag syndrome, (5) adaptation to trauma and stress (6) and largely a phenomenon of psychoneurosis. (7) Other symptoms include heat sensation from inside the head or body, peppery feeling and crawling sensations in various parts of the body, baffling muscular fasciculation, feelings of heaviness, soreness, numbness, poorly localised aches and pains, etc.
Somatisation in children and adolescents
Children do express bodily complaints and worries about their health that seem to have no physical basis (8) and up to 50% of adolescents report at least one common physical symptom or express a concern that their health should be better. (9) The majority of somatising children are not limited in their daily functioning, nor do they suffer from any emotional disorders. Cross-sectional studies of somatising children have indicated that symptoms peak in early adolescence. Although there are no significant gender differences in childhood, female symptom reporting becomes predominant by adolescence. (1) Lower socio-economic status (10) and family dysfunction (11) have been associated with high levels of somatisation in children. Extreme levels of somatisation symptoms are also associated with medical illness in childhood, concurrent psychiatric disorder, history of physical and sexual abuse in children and adolescents (12) and increased risk of major depression 4 years later. (13) Somatisation in adolescents is said to be an alternative expression of emotional disorder. (14)
The developmental transition from adolescence to early adulthood represents a high-risk period for the onset of somatisation. (15) Traditional perspectives on somatisation in adolescents and very young adults conceptualise physical symptom complaints as a developmental coping mechanism or defence that masks negative affect.
Another perspective from psychoanalysis is that 'hysterics suffer mainly from reminiscences' and therefore, when faced with emotionally traumatic memories, hysterics subjugate them from conscious appreciation in order to prevent the unbearable emotional pain and suffering that they cause. Therefore, rather than being driven out of the mind, these memories are instead driven into an area of the mind that is unconscious and inaccessible. Here the memories may be redirected from the emotional system into the somatic or bodily system and appear as apparently unexplained physical symptoms.
Somatisation is also seen as an information processing problem in which negatively biased, internal monitoring leads to the 'amplification' or misinterpretation of common body sensations. Certain family characteristics such as parental concern with a child's health and parental abusiveness are particularly relevant to the development of negatively biased introspectiveness and the inclination to monitor inner body sensations. (16)
What doctors should know
* Explanations for this disorder should be sought in doctor-patient interaction rather than in patients' psychopathology.
* Physical interventions should be proposed by patients rather than by doctors.
* Somatisation ranges from mild stress-related symptoms to severe debilitation. Patients with mild symptoms often respond to simple reassurance but patients who are more impaired require interventions. (17)
* Also important is a physician's clinical experience and existing diagnostic criteria.
Investigation of patients with vague somatic complaints should follow a standard process:
* Step 1: Evaluate for organic medical conditions.
* Step 2: Evaluate for psychiatric conditions associated with somatic complaints (depression, anxiety disorders, substance abuse/dependence, etc.).
* Step 3: Pursue a positive diagnosis of somatisation based on the principle of understanding patients' suffering from a concerned attitude. Failure to acknowledge this suffering and disability/complaints may be interpreted by patients as trivialising and may impair the doctor/patient relationship.
* Step 4: Pursue an understanding of cultural meaning and association with somatic complaints.
For successful treatment, physicians and GPs should give an acceptable explanation of the symptoms to the patient. This should be done within the framework of medical, psychological and cultural understanding. If a doctor is unsure of what to do, the patient should immediately be referred to a clinical psychologist.
For effective management of children and adolescents who somatise, the following techniques have been suggested: (17,18)
The BATHE technique
Background: 'What is going on in your life?'
Affect: 'What do you feel about it?'
Trouble: 'What troubles you the most about that situation?'
Handle: 'What helps you handle that?'
Empathy: 'This is a tough situation to be in. Anybody would feel (down, depressed, stressed, etc.). Your reaction makes sense to me (even if it doesn't).....'
* use one designated physician
* schedule frequent, brief, regular visits not contingent on new complaints
* allow 'sick role' focus on function rather than symptoms
* explore psychosocial (and cultural) issues
* prescribe benign treatments and enjoyment time.
* suggest 'It's all in your head'
* pursue invasive diagnostic tests, medications or surgical interventions without good indications.
(1.) Walker LS, Greene JW. Negative life events and symptom resolution in paediatric abdominal pain patients. J Pediatr Psychol 1991; 16: 341-360.
(2.) Gureje O, Simon GE, Ustun TB, Goldberg DP. Somatisation in the cross-cultural perspective: A World Health Organisation study in primary care, Am J Psychiatry 1997; 154: 989-995.
(3.) Ayorinde A. Heat in the head or body--A semantic confusion? African Journal of Psychiatry 1977; 1 (2) 59-63.
(4.) Jegede RO. Depression in Africans revisited: a critical review of the literature, Afr J Med Sci 1979; 8: 125-132.
(5.) Ebigbo PO, Ihezue UH. Psychodynamic observations on heat in the head. African Journal of Psychiatry 1981; 7: 25-30.
(6.) Idemudia ES, Jegede SA, Madu SN, Ibe B. Somatisation symptom report in a sample of Nigerian prisoners. Journal of Social Sciences 2001; 5: 101-107.
(7.) Ohaeri JU, Adeyemi JD. The pattern of somatisation symptoms at the Ibadan teaching hospital psychiatric clinic. West Afr J Med 1990; 9: 26-34.
(8.) Garralda ME. Somatisation in children. J Child Psychol Psychiatry 1996; 37:13-33.
(9.) Taylor DC, Szatmari P, Boyle MH, Offord DR. Somatisation and the vocabulary of everyday bodily experiences and concern: a community study of adolescents. J Am Acad Child Adolesc Psychiatry 1996; 35: 491-499.
(10.) Steinhausen HC, Aster MV, Pfeiffer E, Godel D. Comparative studies of conversion disorders in childhood and adolescence. J Child Psychol Psychiatry 1989; 30: 615-621.
(11.) Walker LS, McLaughlin FJ, Greene JW. Functional illness and family functioning: a comparison of healthy and somatising adolescents. Fam Process 1988; 27: 317-325.
(12.) Larson BS. Somatic complaints and their relationship to depressive symptoms in Swedish adolescents. J Child Psychol Psychiatry 1991; 32: 821-832.
(13.) Zwaigenbaum L, Szatmari P, Boyle H, Offord DR. Highly somatising young adolescents and the risk of depression. Paediatrics 1999; 103: 1203-1209.
(14.) Campo JV, Fritsch SL. Somatisation children and adolescents. J Am Acad Child Adolesc Psychiatry 1994; 33: 1223-1235.
(15.) Terre L, Ghiselli W. Do somatic complaints mask negative affect in youth? J Am Coll Health 1995; 44: 91-96.
(16.) Mechanic D. The experience and reporting of common physical complaints. J Health Soc Behav 1980; 21: 146-155.
(17.) Servan-Schreiber D. Somatisation patients: part I. Practical diagnosis. Am Fam Physician 2000; 61: 1073-1078.
(18.) Lieberman JA. BATHE: An approach to the interview process in the primary care setting. J Clin Psychiatry 1997; 58 (suppl 3): 3-8.
ERHABOR S IDEMUDIA, BSc (Hons) Psychology, MSc, PhD
Seminar and Research/PhD Co-ordinator, Department of Psychology, School of the Social Sciences, Faculty of Humanities, University of Limpopo, Sovenga
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|Title Annotation:||More about ... Adolescent psychiatry|
|Author:||Idemudia, Erhabor S.|
|Publication:||CME: Your SA Journal of CPD|
|Article Type:||Clinical report|
|Date:||May 1, 2007|
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