Academic journal article Indian Journal of Psychiatry

Clinical Practice Guidelines for the Management of Somatoform Disorders in Children and Adolescents

Academic journal article Indian Journal of Psychiatry

Clinical Practice Guidelines for the Management of Somatoform Disorders in Children and Adolescents

Article excerpt

Byline: Vivek. Agarwal, Chhitij. Srivastava, Prabhat. Sitholey

Introduction

Somatoform disorders are characterized by the repeated subjective experience of physical symptoms (hereafter somatoform symptoms) which are not explained by any physical disease. The types of somatoform disorders in International Classification of Diseases-10 (ICD-10) are listed in [Table 1]. All the disorder subtypes share one common feature, that is, predominance and persistence of somatic symptoms associated with significant distress and impairment. There are repeated requests by the child or adolescent (hereafter child unless specified) or family for medical investigations inspite of consistent negative findings and reassurances from medical professionals. Even if a physical disorder is present, it does not explain the nature and extent of the somatoform symptoms. These affected children often have a degree of attention-seeking behavior. They are usually diagnosed by excluding organic causes for the somatoform symptoms. Despite the absence of any physiological abnormality, these children show considerable distress and impairment.{Table 1}

These guidelines are an update of the previous IPS guidelines on the management of pediatric somatoform disorders (2008). These guidelines are broad and are expected to help in the systematic assessment and management of a child with somatoform disorders.

Assessment

Difficulties in assessment [Table 2] {Table 2}

The assessment of these disorders is not straightforward, partly because of the nature of these disorders and partly because of the nature of medical training of physicians [Table 2]. Mind-body dualism has traditionally existed in the way doctors understand medical problems. Therefore, when presented with disorders that are not properly understood because they do not conform to this dualism, physicians feel that it must be something to do with the mind (functional/psychogenic) and hence refer the patient to a psychiatrist. The message often perceived by the family is that their child is making up the symptoms. Poor liaison between the treating physician and the psychiatrist results in the family seeking multiple medical opinions. Even when the family sees a psychiatrist, they do not feel confident enough as the treating physician is not seen as competent in assessing the physical symptoms.

Initial assessment [Table 3] {Table 3}

Once somatoform disorders are suspected, the assessment requires a comprehensive, multidisciplinary approach with close monitoring of symptom evolution [Table 3]. The assessment should include thorough history taking, physical examination, and diagnostic tests to rule out both serious and benign medical factors that may be contributing to the child's symptoms. Relevant investigations should be done wherever indicated. The possibility of a somatoform disorder superimposed on neurological or medical disorders, or other psychiatric disorders should always be considered.

Somatoform disorders should not be primarily diagnosed by the exclusion of an organic cause. It is much more effective to pursue a positive diagnosis of somatoform disorder when the child presents with typical features of somatoform disorders. Multiple symptoms, often occurring in different organ systems, symptoms that are vague or that exceed in number or intensity or do not conform to the objective findings are suggestive of somatoform disorders. A chronic course, prior history of unexplained physical symptoms, the presence of a psychiatric disorder, history of extensive diagnostic testing, rejection of previous physicians, and responsiveness of the symptoms to placebo or suggestion are some important pointers to the diagnosis of somatoform disorders. The treating psychiatrist should always consider seeking appropriate consultations if there are new symptoms or there is a possibility of a somatoform disorder superimposed on neurological or medical disorders. …

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