CHILDREN'S HEALTH * SANTE ENFANTILE ET ADOLESCENTE
Practical
approach
psychosomatic
illness in
Practilcal approach to psychosomiatic illness in children can save
time and
heartache,
MD
says
Olga Lechky P sychosomatic illness is a common condition of childhood and adolescence, but still represents one of the most difficult diagnostic challenges clinicians face. A battery of diagnostic tests will invariably come up negative, straining both physician patience and the overburdened health care system. Dissatisfied parents won't accept the lack of a physical cause for their child's symptoms and prefer to question the physician's competence and the accuracy of the tests instead of entertaining the possibility that the child's feelings are causing the symptoms. Because there is often a "brick wall of family resistance" to a diagnosis of psychosomatic illness, the physician may have no choice but to order another round of tests and prescribe analgesics that usually don't help. The vicious cycle will continue, with anxious parents often going from doctor to doctor, hoping to pin down the elusive cause of their child's pain. But physicians and patients need not get trapped in this painful scenario, says Dr. Rose Geist, director of the psychiatric consultation liaison service to the departments of Pediatrics and SurOlga Lechky is a freelance writer living in North York, Ont. JUNE 1, 1992
gery at the Hospital for Sick Chil"That's less threatening than dren, Toronto. She was course if you first exclude organic patholcoordinator for a recent Universi- ogy and then suggest a psychologity of Toronto continuing medical cal etiology. Parents find that education program on the art of hard to accept because they beinterviewing children, held at the lieve you either haven't done the Mount Sinai Hospital. Geist, a right tests or the test results were child psychiatrist, presented a wrong. By enlisting the parents as practical approach that can save allies at the beginning, both of you will feel relatively comfortable both time and heartache. with the psychosomatic etiology of the symptoms, irrespective of the psychiatric diagnosis, and about not doing any more organic diagnostic procedures." Geist warns that overzealousThere is often a "brick ness in diagnosing psychosomatic illness should be avoided. Alwal of family it is most common in adothough resistance" to a lescents, followed by school-age diagnosis of children, the condition is rare in psychosomatic illness. young children. "If a child under age 5 is referred to me with a diagnosis of psychosomatic illness, I'm very careful and sceptical," says Geist. "There have been several studies showing that kids who are diagnosed with psychoso"One way of dealing with the matic problems under age 5 and inevitable resistance is to use a whose pain persists into older biopsychosocial model at the be- childhood are the ones with the ginning of the diagnostic inter- greatest percentage of organic view,"' she says. "If there's a good problems found down the line. chance that the child's problem is Although children under 5 can functional, then why not tell the have psychosomatic symptoms, parents right at the outset that it's uncommon and tends to be a you're going to look at organic dangerous diagnosis in that age and psychological factors together group."' and invite them to join you in Although theories about the that pursuit? cause of psychosomatic symptoms CAN MED ASSOC J 1992; 146 (1 1)
2071
have broken into the resistance." When the family is assembled for a diagnostic interview, the doctor should ask the child to describe the pain. This is done to "find a door through the resistance in order to get a clue to what the psychological conflict is." The language that children use to describe pain often holds the key to the meaning of their somatic experience. Children with psychosomatic illness tend to use visual images and metaphors to describe their pain; in contrast, children with organic pain usually describe the pain tersely, using words such as "sharp" or "tight." "When parents actually hear or activities. a symbolic description, it helps "The learning perspective is them to accept a psychological interesting because more often cause,"' says Geist. "When parents than not there's another family become aware of the child's feelmember who has a psychosomatic ings they often change their behaproblem, usually the mother," viour toward the child and that's says Geist. enough to resolve the pain." Geist provided several examDepression and anxiety in one or both parents is very com- ples of the symbols children use to mon. "Children with psychoso- describe psychosomatic illness. matic illness worry about their One 15-year-old girl, who had an parents, often the mother, and extremely restrictive relationship deflect their concern for the par- with her parents, described her ent onto themselves." As a result, abdominal pain as her stomach parents use their own or their telling her: "You can't breathe. I child's pain to avoid emotionally don't want you to do anything." A 9-year-old girl who was tercharged issues and to maintain family balance. That's why direct- rified by the bodily changes of ly asking the child or parents if puberty described the pain in her they are under stress or depressed periumbilical region this way: "[It will almost always meet with deni- was] as though there was a shortal. This is where other family age of courage. Everything is members, such as siblings, can blocked out in front of me." A 14-year-old boy whose parprovide help. "If there's collusion between ents had just asked an older siba mother and a child toward keep- ling to leave the house felt angry ing the pain going, often another at them but because he was very family member will help in identi- dependent on them, he couldn't fying what the issues are," Geist express his anger. He described explains. "For example, I saw a his pain as "a balloon expanding. 7-year-old boy with chronic ab- Something is trying to get out, dominal pain in whom there was about to explode." a tremendous amount of denial "From my experience, chilthat there were any psychological dren with chronic headaches tend issues. But his 4-year-old broth- to use images related to pressure er said that his older brother and anger," Geist says. "Those was worried all the time. With- with abdominal pain tend to use out that sibling, we couldn't images to do with anxiety."
abound, knowledge about all of them is not needed to make a correct diagnosis. It is enough to understand that psychosomatic pain, functional disorder or preoccupation with bodily function or appearance is basically a psychologic experience that gets translated into the body. The experience may stem from intrapsychic conflict but most often is a result of family dynamics that cause children psychologic and emotional problems. Children learn to experience that conflict in a somatic way either because they're reinforced by the family or because the pain allows them to avoid certain situations
The symptom itself can give a clue to the conflict. Geist illustrated this with the case of a 10-year-old girl who had been admitted to the neurology ward with a 4-month history of being unable to walk. Her parents were architects who travelled and moved house frequently. "It's very symbolic that she developed a movement disorder to stop her parents from moving," says Geist. "It was as simple as that." Asking the patient when the symptoms started can be revealing. Children with psychosomatic pain can usually state exactly when the pain started and the circumstances surrounding its onset. Exploring these circumstances often provides clues to the conflict. In contrast, children with organic pain are often vague about time of onset. Physicians unsure whether an illness is psychosomatic or organic should ask whether the pain is constant or intermittent. Somatic pain tends to be constant because "the pain is serving a function"; organic pain will come and go, depending on physiologic factors. Children with somatic pain often have difficulty falling asleep because of their pain, but unlike children with organic pain once asleep they are not wakened by the pain. Analgesics tend to alleviate pain related to organic disorders but are relatively ineffective in psychosomatic illness. Inquiring how much school the child misses because of pain also gives insight into its cause. Children with somatic pain tend not to go to school, in contrast with children experiencing organic pain. "Kids with organic pain want to keep up with peer relationships and stay in touch with their social world, whereas children with functional pain are troubled and prefer to avoid social situations," says Geist. The list of differential diagnoses associated with psychosomatic illness is long and sometimes re-
CAN MED ASSOC J 1992; 146 (1 1)
LE ler JUIN 1992
2072
"If there's a good chance that the child's problem is functional, then why not tell the parents right at the outset that you're going to look at organic and psychological factors together and invite them to join you in that pursuit?" -Dr. Rose Geist quires referral to a psychiatrist or consequential childish remark." Although talking directly to family therapist. It includes various anxiety disorders, mood dis- young patients seems self-evident, orders, major depression, adjust- Rosenbaum says many clinicians ment reactions, psychotic condi- don't do it because it is easier to tions, and physical or sexual talk to the parents. "Kids have a lot to say if we give them a abuse. "At the end of the diagnostic chance. The thing I worry about is interview, sit down with the fami- not giving them the chance." ly for a feedback session," Geist Sometimes when physicians suggests. "Ask them what they try to engage a child in conversathink is causing the child's symp- tion, a parent will try to answer. toms. Try to have them make the This is a valuable clue to the diagnosis. In cases of psychoso- family dynamic, but puts the onus matic illness, this approach works on the physician to politely tell better than the physician declar- the parent to let the child answer ing, 'I think feelings have a lot to for herself. Certain questions put to the child also shed light on the do with the pain.'" In another presentation, Dr. family dynamic. Rosenbaum ofPeter Rosenbaum, professor of pe- fered two of the most useful: diatrics at McMaster University Who's the boss in your family? Is in Hamilton, Ont., stressed the there anything your Mom or Dad importance of tailoring the pediat- told you not to say to me today? A useful way to get children ric interview to the child's developmental level. "At different ages, to open up is to talk to them kids are going to respond differ- about their interests. "Doctors ently," he says. "It's a matter of have to use these experiences as a becoming experienced at knowing key to getting into the child's how to interpret what kids tell you world. Simply talking about the and that comes from seeing and things that children are involved talking to them a lot. For those with will give you a lot of vital who are not pediatricians, that information about developmental may not be possible. So the key skills, social awareness and the thing to remember is to engage the family." While preschoolers are still child. But don't just try to engage the child in a situation in which quite egocentric, children aged 5 you think you should - do it all and 6 are "social butterflies and the time so it becomes automatic the most important things in their and you become aware of the lives are their friends and things significance of the types of things like birthday parties. One of the children might say to you. Then questions I always ask school-age if something's off-the-wall or wor- children is whether they've been rying, you'll recognize it and invited to a birthday party lately. not just put it down to some in- With 7- to 9-year-olds, I ask
whether they've had any sleepovers. Social relationships are very important to children and reveal a lot about the child's concept of self and relationship to the world. "Kids don't want to talk about the geography of India that they're learning in school. They want to talk about their friends and what goes on in school in terms of the social dimension." While friends remain important for adolescents and teenagers, this age group is also preoccupied with teams, extracurricular activities and hobbies. Doctors might begin a conversation like this: What do you do for fun? Who's your best friend? How old is your best friend? "Children who play with kids younger than themselves usually do so because they are immature," says Rosenbaum. "On the other hand, kids who have friends older than themselves are usually advanced in terms of ma-
JUNE 1, 1992
CAN MED ASSOC J 1992; 146 (1 1)
turity." While physicians should make an effort to always talk directly with their pediatric patients, they should not go to the other extreme and exclude the parents. "Parents are the greatest experts on their own child," Rosenbaum concluded. "Always listen for the word 'because.' Parents use it a lot and it's very revealing. It's an indirect way parents have of telling you what's going on, the signal that they're moving from observation to inference. Often parents are right about what's going on and we get a lot of good free information."2073
Practical
approach
psychosomatic
illness in
Practilcal approach to psychosomiatic illness in children can save
time and
heartache,
MD
says
Olga Lechky P sychosomatic illness is a common condition of childhood and adolescence, but still represents one of the most difficult diagnostic challenges clinicians face. A battery of diagnostic tests will invariably come up negative, straining both physician patience and the overburdened health care system. Dissatisfied parents won't accept the lack of a physical cause for their child's symptoms and prefer to question the physician's competence and the accuracy of the tests instead of entertaining the possibility that the child's feelings are causing the symptoms. Because there is often a "brick wall of family resistance" to a diagnosis of psychosomatic illness, the physician may have no choice but to order another round of tests and prescribe analgesics that usually don't help. The vicious cycle will continue, with anxious parents often going from doctor to doctor, hoping to pin down the elusive cause of their child's pain. But physicians and patients need not get trapped in this painful scenario, says Dr. Rose Geist, director of the psychiatric consultation liaison service to the departments of Pediatrics and SurOlga Lechky is a freelance writer living in North York, Ont. JUNE 1, 1992
gery at the Hospital for Sick Chil"That's less threatening than dren, Toronto. She was course if you first exclude organic patholcoordinator for a recent Universi- ogy and then suggest a psychologity of Toronto continuing medical cal etiology. Parents find that education program on the art of hard to accept because they beinterviewing children, held at the lieve you either haven't done the Mount Sinai Hospital. Geist, a right tests or the test results were child psychiatrist, presented a wrong. By enlisting the parents as practical approach that can save allies at the beginning, both of you will feel relatively comfortable both time and heartache. with the psychosomatic etiology of the symptoms, irrespective of the psychiatric diagnosis, and about not doing any more organic diagnostic procedures." Geist warns that overzealousThere is often a "brick ness in diagnosing psychosomatic illness should be avoided. Alwal of family it is most common in adothough resistance" to a lescents, followed by school-age diagnosis of children, the condition is rare in psychosomatic illness. young children. "If a child under age 5 is referred to me with a diagnosis of psychosomatic illness, I'm very careful and sceptical," says Geist. "There have been several studies showing that kids who are diagnosed with psychoso"One way of dealing with the matic problems under age 5 and inevitable resistance is to use a whose pain persists into older biopsychosocial model at the be- childhood are the ones with the ginning of the diagnostic inter- greatest percentage of organic view,"' she says. "If there's a good problems found down the line. chance that the child's problem is Although children under 5 can functional, then why not tell the have psychosomatic symptoms, parents right at the outset that it's uncommon and tends to be a you're going to look at organic dangerous diagnosis in that age and psychological factors together group."' and invite them to join you in Although theories about the that pursuit? cause of psychosomatic symptoms CAN MED ASSOC J 1992; 146 (1 1)
2071
have broken into the resistance." When the family is assembled for a diagnostic interview, the doctor should ask the child to describe the pain. This is done to "find a door through the resistance in order to get a clue to what the psychological conflict is." The language that children use to describe pain often holds the key to the meaning of their somatic experience. Children with psychosomatic illness tend to use visual images and metaphors to describe their pain; in contrast, children with organic pain usually describe the pain tersely, using words such as "sharp" or "tight." "When parents actually hear or activities. a symbolic description, it helps "The learning perspective is them to accept a psychological interesting because more often cause,"' says Geist. "When parents than not there's another family become aware of the child's feelmember who has a psychosomatic ings they often change their behaproblem, usually the mother," viour toward the child and that's says Geist. enough to resolve the pain." Geist provided several examDepression and anxiety in one or both parents is very com- ples of the symbols children use to mon. "Children with psychoso- describe psychosomatic illness. matic illness worry about their One 15-year-old girl, who had an parents, often the mother, and extremely restrictive relationship deflect their concern for the par- with her parents, described her ent onto themselves." As a result, abdominal pain as her stomach parents use their own or their telling her: "You can't breathe. I child's pain to avoid emotionally don't want you to do anything." A 9-year-old girl who was tercharged issues and to maintain family balance. That's why direct- rified by the bodily changes of ly asking the child or parents if puberty described the pain in her they are under stress or depressed periumbilical region this way: "[It will almost always meet with deni- was] as though there was a shortal. This is where other family age of courage. Everything is members, such as siblings, can blocked out in front of me." A 14-year-old boy whose parprovide help. "If there's collusion between ents had just asked an older siba mother and a child toward keep- ling to leave the house felt angry ing the pain going, often another at them but because he was very family member will help in identi- dependent on them, he couldn't fying what the issues are," Geist express his anger. He described explains. "For example, I saw a his pain as "a balloon expanding. 7-year-old boy with chronic ab- Something is trying to get out, dominal pain in whom there was about to explode." a tremendous amount of denial "From my experience, chilthat there were any psychological dren with chronic headaches tend issues. But his 4-year-old broth- to use images related to pressure er said that his older brother and anger," Geist says. "Those was worried all the time. With- with abdominal pain tend to use out that sibling, we couldn't images to do with anxiety."
abound, knowledge about all of them is not needed to make a correct diagnosis. It is enough to understand that psychosomatic pain, functional disorder or preoccupation with bodily function or appearance is basically a psychologic experience that gets translated into the body. The experience may stem from intrapsychic conflict but most often is a result of family dynamics that cause children psychologic and emotional problems. Children learn to experience that conflict in a somatic way either because they're reinforced by the family or because the pain allows them to avoid certain situations
The symptom itself can give a clue to the conflict. Geist illustrated this with the case of a 10-year-old girl who had been admitted to the neurology ward with a 4-month history of being unable to walk. Her parents were architects who travelled and moved house frequently. "It's very symbolic that she developed a movement disorder to stop her parents from moving," says Geist. "It was as simple as that." Asking the patient when the symptoms started can be revealing. Children with psychosomatic pain can usually state exactly when the pain started and the circumstances surrounding its onset. Exploring these circumstances often provides clues to the conflict. In contrast, children with organic pain are often vague about time of onset. Physicians unsure whether an illness is psychosomatic or organic should ask whether the pain is constant or intermittent. Somatic pain tends to be constant because "the pain is serving a function"; organic pain will come and go, depending on physiologic factors. Children with somatic pain often have difficulty falling asleep because of their pain, but unlike children with organic pain once asleep they are not wakened by the pain. Analgesics tend to alleviate pain related to organic disorders but are relatively ineffective in psychosomatic illness. Inquiring how much school the child misses because of pain also gives insight into its cause. Children with somatic pain tend not to go to school, in contrast with children experiencing organic pain. "Kids with organic pain want to keep up with peer relationships and stay in touch with their social world, whereas children with functional pain are troubled and prefer to avoid social situations," says Geist. The list of differential diagnoses associated with psychosomatic illness is long and sometimes re-
CAN MED ASSOC J 1992; 146 (1 1)
LE ler JUIN 1992
2072
"If there's a good chance that the child's problem is functional, then why not tell the parents right at the outset that you're going to look at organic and psychological factors together and invite them to join you in that pursuit?" -Dr. Rose Geist quires referral to a psychiatrist or consequential childish remark." Although talking directly to family therapist. It includes various anxiety disorders, mood dis- young patients seems self-evident, orders, major depression, adjust- Rosenbaum says many clinicians ment reactions, psychotic condi- don't do it because it is easier to tions, and physical or sexual talk to the parents. "Kids have a lot to say if we give them a abuse. "At the end of the diagnostic chance. The thing I worry about is interview, sit down with the fami- not giving them the chance." ly for a feedback session," Geist Sometimes when physicians suggests. "Ask them what they try to engage a child in conversathink is causing the child's symp- tion, a parent will try to answer. toms. Try to have them make the This is a valuable clue to the diagnosis. In cases of psychoso- family dynamic, but puts the onus matic illness, this approach works on the physician to politely tell better than the physician declar- the parent to let the child answer ing, 'I think feelings have a lot to for herself. Certain questions put to the child also shed light on the do with the pain.'" In another presentation, Dr. family dynamic. Rosenbaum ofPeter Rosenbaum, professor of pe- fered two of the most useful: diatrics at McMaster University Who's the boss in your family? Is in Hamilton, Ont., stressed the there anything your Mom or Dad importance of tailoring the pediat- told you not to say to me today? A useful way to get children ric interview to the child's developmental level. "At different ages, to open up is to talk to them kids are going to respond differ- about their interests. "Doctors ently," he says. "It's a matter of have to use these experiences as a becoming experienced at knowing key to getting into the child's how to interpret what kids tell you world. Simply talking about the and that comes from seeing and things that children are involved talking to them a lot. For those with will give you a lot of vital who are not pediatricians, that information about developmental may not be possible. So the key skills, social awareness and the thing to remember is to engage the family." While preschoolers are still child. But don't just try to engage the child in a situation in which quite egocentric, children aged 5 you think you should - do it all and 6 are "social butterflies and the time so it becomes automatic the most important things in their and you become aware of the lives are their friends and things significance of the types of things like birthday parties. One of the children might say to you. Then questions I always ask school-age if something's off-the-wall or wor- children is whether they've been rying, you'll recognize it and invited to a birthday party lately. not just put it down to some in- With 7- to 9-year-olds, I ask
whether they've had any sleepovers. Social relationships are very important to children and reveal a lot about the child's concept of self and relationship to the world. "Kids don't want to talk about the geography of India that they're learning in school. They want to talk about their friends and what goes on in school in terms of the social dimension." While friends remain important for adolescents and teenagers, this age group is also preoccupied with teams, extracurricular activities and hobbies. Doctors might begin a conversation like this: What do you do for fun? Who's your best friend? How old is your best friend? "Children who play with kids younger than themselves usually do so because they are immature," says Rosenbaum. "On the other hand, kids who have friends older than themselves are usually advanced in terms of ma-
JUNE 1, 1992
CAN MED ASSOC J 1992; 146 (1 1)
turity." While physicians should make an effort to always talk directly with their pediatric patients, they should not go to the other extreme and exclude the parents. "Parents are the greatest experts on their own child," Rosenbaum concluded. "Always listen for the word 'because.' Parents use it a lot and it's very revealing. It's an indirect way parents have of telling you what's going on, the signal that they're moving from observation to inference. Often parents are right about what's going on and we get a lot of good free information."2073
