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Psychosomatics 42:467-476, December 2001
© 2001 The Academy of Psychosomatic Medicine

A Management Model for Pediatric Somatization

John V. Campo, M.D., and Gregory Fritz, M.D.

Received February 15, 2001; revised June 14, 2001; accepted June 18, 2001. From University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, Pittsburgh, PA, and Brown Medical School and Hasbro Children's Hospital, Providence, RI. Address correspondence and reprint requests to Dr. Campo, University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, 3811 O'Hara Street, Pittsburgh, PA 15213. E-mail: campojv{at}msx.upmc.edu


  ABSTRACT

 
TOP
 ABSTRACT
INTRODUCTION
 PRINCIPLES OF ASSESSMENT
 DIAGNOSIS
 TREATMENT
 CONCLUSION
 REFERENCES
 
Medically unexplained physical symptoms are common in pediatric settings, though little systematic research is available to guide the development of treatment efforts for pediatric somatization and somatoform disorders. This paper presents a management model for pediatric somatization based on principles distilled from the available pediatric and adult literature. Careful assessment, frank presentation of the diagnosis, and a cognitive-behavioral and rehabilitative approach are emphasized, along with aggressive psychiatric treatment of comorbid psychopathology. Well-designed empirical studies of intervention are needed that should examine efficacy as well as the relationship between symptomatic improvement, functional improvement, and comorbid anxiety and depressive symptoms.

Key Words: Other Childhood Disorders • Somatoform Disorders • Somatic Therapies

  INTRODUCTION

 
TOP
 ABSTRACT
 INTRODUCTION
PRINCIPLES OF ASSESSMENT
 DIAGNOSIS
 TREATMENT
 CONCLUSION
 REFERENCES
 
Used descriptively, the term "somatization" refers to the subjective report of physical symptoms in the absence of clear physical pathology as well as to circumstances in which the reported physical symptoms and associated disability exceed what would be expected based on medical evaluation.1,2 This paper will adhere to this descriptive use given the goal of proposing core principles of management for youth with a variety of medically explained physical symptoms where serious physical disease is unlikely. It is worth acknowledging the potential for confusion given other uses of the term (e.g., as a presumed mechanism of symptom production or the defining label of a specific polysymptomatic somatoform disorder). Physical symptoms considered to be representative of somatization have also been labeled "functional" somatic symptoms. Current nosology defines a "somatoform disorder" by the presence of physical symptoms that suggest a physical disorder but that are not fully explained by the presence of a general medical condition, the direct effects of a substance, or another mental disorder.3 The reported symptoms must cause distress or functional impairment and should not appear to be intentionally produced. Somatization as a concept is rooted in the biomedical paradigm, where illness, the patient's subjective distress and impairment, is presumed to be accountable to objective disease and thus reducible to a pathophysiological process understandable in biophysical or chemical terms.4

Although there is little information available regarding the incidence and prevalence of specific somatoform disorders in children and adolescents, medically unexplained physical symptoms are common,5,6 particularly recurrent complaints of pain.7–9 Somatization in pediatric primary care has been associated with a significantly greater risk for psychopathology, family conflict, parent-perceived ill health, school problems and absenteeism, and excess use of health and mental health services.10 Medically unexplained pain in childhood may predict emotional disorder and functional impairment in adulthood11,12 as well as persistent physical symptoms and suffering.13 Complaints of pain are common in children, but pain and nociception are not identical. Pain can be defined as an unpleasant sensory and emotional experience that is associated with tissue damage or perceived as representative of such damage.14 It is essentially subjective and must be assessed by self-report. Although it is clear that prior tissue damage can sensitize nociceptors, with resultant hyperalgesia at the site of tissue damage or in surrounding, presumably undamaged areas, pain can also arise spontaneously in the absence of nociceptor activity. Conversely, pain can be minimal or absent in the presence of great nociceptor activation, suggesting that peripheral nociception can be modified by central nervous system mechanisms.

The diagnosis of somatoform disorder is often based on the subjective interpretation of the examiner, who must determine whether a particular physical symptom is consequent to a physical disease or disorder, and who must also make an inference regarding the patient's motivation and experience of the symptom. Pediatric somatoform disorders are distinguished from factitious disorders and malingering, disorders in which physical symptoms are judged to be voluntarily fabricated, feigned, or intentionally produced.3 Similarly, psychological factors affecting medical condition is applied diagnostically when psychological factors are believed to adversely affect a known general medical condition or pathophysiologic process.3 The diagnostic process is further confounded by physical symptoms being included among the criteria used to diagnose specific anxiety and depressive disorders. It can also be difficult to decide when a particular symptom constellation should be recognized as a bona fide disease or physical disorder, such as might be the case with disorders such as irritable bowel syndrome, fibromyalgia, and chronic fatigue. The diagnostic label may also be influenced by the context of the presentation and the training and discipline of the diagnostician.15 For the purposes of this paper, the term somatization will be used descriptively to refer to situations in which medically unexplained physical symptoms play a prominent role in the presentation and are understood by the patient and family as being responsible for associated impairment and distress, as would be expected in pediatric somatoform disorders, as well as anxiety and depressive disorders in which somatic symptoms are prominent.

There have been few systematic studies of intervention in pediatric somatization, though practical approaches to assessment and intervention have been offered.16–19 Although it is likely that there may be considerable heterogeneity even within groups of children with a single type of symptom, such as medically unexplained recurrent abdominal pain,20 functional somatic syndromes appear to share high rates of comorbidity with one another and with anxiety and depressive disorders, leading some to suggest a common pathophysiology.15 The aim of this paper is to present a management model for pediatric somatization that is based on a few core principles distilled from the available pediatric and adult literature that may be operationalized and tested in future studies.


  PRINCIPLES OF ASSESSMENT

 
TOP
 ABSTRACT
 INTRODUCTION
 PRINCIPLES OF ASSESSMENT
DIAGNOSIS
 TREATMENT
 CONCLUSION
 REFERENCES
 
Assessment lays the foundation for all subsequent intervention and is of critical importance in the context of suspected somatization.21 The differential diagnosis of medically unexplained physical symptoms includes: 1) unrecognized physical disease; 2) somatoform disorder; 3) anxiety, depressive, or other psychiatric disorder; 4) factitious disorder; 5) factitious disorder by proxy; 6) malingering; and 7) psychological factors affecting medical condition.

While a comprehensive listing of all components of a competent assessment is beyond the scope of this paper, several key principles are offered.

Acknowledge Patient Suffering and Family Concerns
Acknowledging patient suffering and family concerns is essential to establishing a working partnership. Many patients express concerns that their symptoms are considered by others to be imaginary, feigned, or "all in my head." What may be experienced subjectively as embarrassment can be expressed interpersonally as anger and a sense of entitlement. Professionals should acknowledge the reality of the patient's suffering and any concerns of the patient and family early in the process of assessment. Except in the unusual circumstance of true factitious illness or malingering, it is both unproductive and presumptuous to challenge the subjective reality of the patient's complaint. Use of standardized inventories can help objectify the assessment. The Children's Somatization Inventory22 is a potentially useful 35-item self-report instrument with both child and parent versions that can provide a quick and helpful overview of somatic symptoms experienced by children and adolescents in the previous 2 weeks. Similarly, the Functional Disability Inventory23 is a 15-item questionnaire with child and parent report versions addressing the child's functional disability caused by physical health status in the previous 2 weeks that correlates with school absenteeism and somatic symptom reporting.22

Explore Prior Assessment and Treatment Experiences
It is easy for patients and families to feel "dismissed" by professionals and concerned that they are not being taken seriously. Negative experiences with professionals are common, and even the most caring physician can be perceived as guilty of an empathic failure when the patient and family believe they are being told that "nothing is wrong" after weeks or months of symptomatic distress and several hours in a waiting room. Similarly, mental health professionals can be perceived as dismissive of the patient's physical suffering by virtue of labeling it a consequence of anxiety or depression. Families with affected children also commonly report past experiences with health care and physicians that have generated considerable mistrust. For example, many families cite stories about a friend or relative who was reassured by a trusted physician only to learn later that a serious physical disease had been missed. Such experiences can make it extremely difficult to reassure a concerned child or parent, and are important to recognize and acknowledge.

>Investigate Patient and Family Fears Provoked by the Symptoms
Anxiety experienced by the patient, the family, and the involved professionals can exacerbate the presenting symptoms, confound judgment, and interfere with both assessment and intervention. Separation fears and parental "overprotection" are common in the context of medically unexplained symptoms,24–27 and affected children may be considered "vulnerable" by family members.28 There is considerable variability in the concerns experienced by individual children and their parents; some children are terribly frightened, if not convinced, that a serious physical disease has been missed, while others express little or no concern about serious disease but are searching for symptomatic relief and a return to prior function.

>Remain Alert to the Possibility of Unrecognized Physical Disease and Communicate an Unwillingness to Prejudge the Etiology of the Symptom
It is essential to remember that there are circumstances in which medically unexplained symptoms are simply unexplained and not representative of a functional somatic syndrome or psychiatric disorder. The assessment should be conducted with an open mind, and the examiner should avoid prejudging the etiology of the patient's symptoms. Previous records should be carefully reviewed. There should be no reluctance to initiate additional medical evaluation if the assessment generates new concerns about physical disease or if the clinical picture should change over time. Many reports document the discovery of previously undiagnosed physical disease in children with presumably unexplained symptoms.29,30 It is nevertheless reassuring to note that most recent case series suggest that the likelihood of finding undiagnosed physical disease sufficient to explain the original symptoms is 10% or less in presumed pediatric somatization.22,31–34

Avoid Excess and Unnecessary Tests and Procedures
There is no simple answer to the question as to when the medical work-up should be considered complete, as it may be impossible to absolutely and definitively rule out unrecognized disease. There is a need to achieve a balance among the importance of minimizing professional anxiety about unrecognized disease, family anxiety, risk of medical tests and procedures, and cost. In general, unless the professional is reasonably comfortable that a serious physical disease has not been missed and is able to communicate this conviction to the patient and family, it is difficult to then discuss the diagnostic impression of a somatoform disorder or psychosomatic syndrome and thus lay the foundation for intervention. Unnecessary medical tests and treatments carry the risk of iatrogenic disease and have the potential to communicate physician uncertainty, thus potentially maintaining or exacerbating somatization.25,35

Avoid Diagnosis by Exclusion
Somatoform disorder should not be diagnosed solely by excluding physical disease; rather, an effort should be made to identify positive findings or "clues" to the diagnosis, as the conclusive elimination of physical disease as a diagnostic possibility beyond a shadow of a doubt is unusual.16,32,35–37 It is also both inaccurate and undesirable to consider a particular symptom as being purely "psychogenic" in nature. Some clues to the diagnosis of a somatoform disorder16,17,35,37 include 1) temporal relationship of symptoms with psychosocial stressors; 2) presence of comorbid anxiety, depression, or other psychiatric disorder; 3) prior personal or family history of somatization; 4) evidence of social or familial reinforcement of the symptom; 5) a model for the symptom in the family or social milieu; 6) symptom violation of known anatomic or physiologic patterns; and 7) response to psychological treatment, suggestion, or placebo. No single clue is definitive, as virtually all have been observed in patients with documented physical disease. A constellation of clues taken together is most persuasive.16,37 For example, while "la belle indifference" (an apparent lack of concern in relation to the symptom) has often been considered to be suggestive of conversion disorder,32,34,38 its significance is both questionable and difficult to operationalize.33,36,39 Stressful life events, particularly life events perceived to be negative, such as the loss or death of a family member, parental marital conflict, and family disruption, are commonly associated with pediatric somatization. This highlights the importance of family and environmental assessments, as well as careful assessment for any history of psychological trauma such as physical or sexual maltreatment.5 It should also be remembered that even events perceived as positive in the life of the family might be experienced as stressful.

Explore Symptom Timing, Context, and Characteristics
It is particularly important to examine the social reinforcements and other potential benefits associated with the sick role, the so-called secondary gain associated with the symptoms. Multiple sources of information can be helpful, with parents, other professionals, and school personnel (particularly the teacher and school nurse) serving as important resources. The presence of school difficulties can be especially important clinically, since the presence of a learning disorder can reinforce absenteeism.40 Somatization may play a role in an individual child's "self-handicapping" by providing a ready "explanation" as to why he or she may not be performing up to expectations.41 Although potentially confusing, it is also important to note that the risk of somatization may be increased in the context of chronic medical illness or the early history of such illness,42–44 following an acute physical illness or accident,36,38,45 or with exposure to physically ill or disabled family members.43,46 Experiencing or observing the potential benefits associated with the sick role, including the avoidance of unpleasant responsibilities or special indulgences, may increase risk for some predisposed children.47 Parents may inadvertently encourage sick role behaviors by responding to complaints of pain with attention, rewards, or opportunities to avoid unpleasant activities or school.48


  DIAGNOSIS

 
TOP
 ABSTRACT
 INTRODUCTION
 PRINCIPLES OF ASSESSMENT
 DIAGNOSIS
TREATMENT
 CONCLUSION
 REFERENCES
 
>State the Diagnostic Impression Clearly, Frankly, and Directly16,17
Negative findings in the absence of an explanatory model for the symptoms generally provide little reassurance to the patient and family.15 A review of the clinician's understanding of the number and types of physical, emotional, and behavioral symptoms presented, time course, and context with the patient and family is useful immediately prior to discussing the diagnosis. This allows for clarification of details from the history and examination and usually helps establish some consensus regarding the patient's symptomatic profile. In cases where the diagnosis cannot be made definitively or is presumptive, a truthful acknowledgment of diagnostic uncertainty is far superior to feigned certainty and glib pronouncements. Once the diagnosis has been made and discussed with the patient and family, additional diagnostic evaluation should be avoided in the absence of new clinical information, a change in the clinical picture, or persuasive evidence that intervention will not be possible until the patient and family can be reassured by an additional, relatively low-risk investigation.

Build a Foundation for Intervention
Building a foundation for intervention is first accomplished by educating the patient and family, which serves to challenge stigma and can instill hope and positive expectations. Well-designed longitudinal studies addressing the prognosis of medically unexplained physical symptoms in children and adolescents are lacking, but some remission in the presenting symptoms can be expected in the majority of those affected, and the risk of subsequent serious physical disease appears to be small. Multiple somatic symptoms, greater chronicity, and the presence of symptoms of conversion disorder may predict poorer outcomes.5,17 Given the pervasive nature of stigma, it is especially important to avoid communicating any sense of embarrassment regarding the diagnosis of somatoform disorder or other psychiatric disorder because this can contribute to treatment resistance and a patient's wish to perpetuate the search for traditional disease. Avoid mind-body dualism by discussing the relationship between mind and body and the false dichotomies presented by our current health care system. Patients and families can be educated about how physical symptoms of distress in the absence of serious disease have been suffered by individuals since antiquity and have been recognized and managed by physicians for nearly as long. Although there is still much to learn, understanding that such problems are both common and "real" is often helpful to patients and families, as is the notion that these sufferings may ultimately be understood from the biomedical perspective. In the meantime, patients and families can be reassured that much practical help is available, even in the absence of a clear understanding of etiology. Explaining the physical symptoms as simple reactions to psychosocial adversity or "stress" may prove unproductive because psychosocial adversity may not be present or recognized by the patient or family, and preoccupation with "stress" may inadvertently encourage the misguided belief that avoidance of uncomfortable situations will solve the problem.


  TREATMENT

 
TOP
 ABSTRACT
 INTRODUCTION
 PRINCIPLES OF ASSESSMENT
 DIAGNOSIS
 TREATMENT
CONCLUSION
 REFERENCES
 
Be Honest and Direct
Be honest and direct; emphasize the collaborative nature of the treatment process. The importance of a therapeutic partnership or alliance as the foundation for therapeutic success should be discussed directly. Patient, family, and professional roles and responsibilities should be delineated, with an emphasis on solid communication and the importance of "working together." Determining shared functional goals for the patient, the family, and the treating professionals is an important task because a focus on functional improvement rather than an unequivocal "cure" is generally most productive.1 Avoid deception. Using placebo or sham interventions is discouraged for both ethical and practical reasons. Such efforts may inadvertently contribute to patient and family convictions that the symptom is caused by physical disease. In addition, if suggestion or placebo proves unsuccessful, the clinician is forced to perpetuate new deceptions or must backtrack and attempt to convince the patient that serious physical disease is absent and that symptom removal is not really necessary for functional improvement.

Reassurance
Reassurance that a life-threatening or serious physical disease is not present is a necessary but rarely sufficient step in the treatment process.1,25,32,49–51 It is often essential that the patient and family view the presenting symptoms as less threatening because it may be impossible to proceed with intervention until their anxiety has decreased.26,32,42,50,52 Parents must be helped to understand that the patient's quite real subjective distress does not appear to be associated with actual tissue damage. Excessive reassurance may nevertheless prove counterproductive in cases where obsessional illness worry and hypochondriacal fears are prominent.53 In such cases, the illness worry should be addressed directly and framed as a problem to be solved together rather than continuing to perpetuate the notion that such worry can be overcome via external reassurance alone.

Cognitive-Behavioral Interventions
Available research suggests that cognitive factors are important in somatization; symptom perception and amplification appear to be augmented by patient and family expectations and beliefs that the symptoms are threatening harbingers of tissue damage and incapacitation.15 Cognitive-behavioral approaches have been core features of multimodal interventions demonstrated to be successful in the treatment of functional pediatric recurrent abdominal pain.54–56 Sanders et al.55 employed cognitive coping skills training in association with differential reinforcement of healthy behavior and self-monitoring techniques. Although the sample size was small, the positive results of their study were encouraging, with the treated group of patients doing significantly better than control subjects. Extending this research, a cognitive-behavioral family intervention was compared to standard pediatric care for children with functional abdominal pain and resulted in higher levels of parental satisfaction with treatment, greater functional improvement, greater pain resolution, and lower levels of relapse at 6- and 12-month follow-ups.56 Finney et al.54 completed a small controlled trial of treatment for children with functional abdominal pain in a primary care setting with reductions in complaints of pain, school absenteeism, and health care utilization in the experimental treatment group as compared to an untreated control group. Treatment emphasized a rehabilitative approach and participation in routine activities, and was combined with self-monitoring of the symptoms, limiting parental reinforcement of illness behavior, relaxation training, and administration of a dietary fiber. It is unclear which components of the multimodal interventions described above were responsible for the positive results, but such trials are important in that they are likely to approximate clinical practice and demonstrate that effective treatment is possible.

Rehabilitative Approach
Many authors have discussed the advantages of an approach that may be described as "rehabilitative" in nature, encouraging the patient to return to usual activities and responsibilities prior to definitive symptomatic relief and discouraging illness-related behaviors.32,36,38,50 The rehabilitative approach helps reframe the problem confronting the patient and family from finding a "cure" to finding a way to cope with and overcome a distressing physical problem. This helps shift the burden of responsibility for therapeutic success from the clinician and parents to the patient, albeit within the context of a supportive and encouraging network of family and helping professionals. It also serves to dissuade the notion that the patient can safely return to normal developmental functioning only after the symptoms have resolved. The patient is treated as an active agent empowered to overcome a difficult but manageable problem. Improvement is understood as a personal success based on individual courage and hard work and an accomplishment of which the patient can be proud. Active, problem-focused approaches to coping appear to be superior to passive acceptance, which is associated with greater symptom burden and functional impairment.57 In keeping with a rehabilitative model, the use of physical therapy has sometimes been advocated, particularly in conversion disorder.32,36,38,51 The importance of the patient's education should be emphasized, with attendance and performance serving as critical indicators of successful functioning. Professionals should respect the importance of school by scheduling follow-up visits outside of regular school hours whenever possible. Homebound instruction must be avoided or challenged. Success with a rehabilitative approach is contingent on the clinician's ability to manage patient and family anxiety in relation to the symptom and to challenge any perceptions that the patient is especially "vulnerable" and thus unable to cope. Most important, parents and caretakers must understand that expecting the patient to function in spite of physical distress is not cruel in the circumstance of somatization, but actually therapeutic. Many parents benefit from a discussion of how kindness demands a firm approach, which communicates the conviction that the patient is indeed strong enough and competent enough to overcome his or her very real distress. The rehabilitative approach challenges the misperceived vulnerability of the child and serves as the linchpin of a cognitive-behavioral strategy emphasizing the child's fundamental health, strength, and adaptability.

Behavioral and Operant Interventions
Operant approaches are particularly relevant in helping to leverage functional improvements. Controlled trials of behavioral interventions for pediatric somatoform disorders are lacking, but several case reports highlight potential benefits.5,18 Most have emphasized positive reinforcement for healthy behavior as well as extinction or withdrawal of reinforcement for somatic symptoms where the sick role is being rewarded.26,36,58,59–61 The latter process can prove difficult for parents to implement unless their fears and concerns that such actions might be "punitive" have been addressed. Although the use of punishment per se is not advisable, the successful application of a time-out procedure in the management of recurrent pain has been reported.62 Negative reinforcement, which produces an increase in the frequency of a desired response by removing an aversive event immediately after the desired response,63 has been employed in the management of somatization, generally by lifting restrictions theoretically imposed by illness contingent upon functional improvement.38,58,64,65 For example, discharge from the hospital might be allowed only if the patient shows sufficient physical improvement,38 or persistent bed rest might be imposed with removal contingent on the patient returning to premorbid function and responsibilities.64 Similarly, the threat of inpatient psychiatric hospitalization can be removed contingent on the patient maintaining at least minimally acceptable function (e.g., returning to school).

Self-Management and Other Individual Strategies
Encouraging results with circumscribed self-management strategies have been reported,66 with specific techniques such as self-monitoring, training in coping and relaxation,67,68 hypnosis,69–71 and the use of biofeedback59,60 being described as helpful. Such strategies are likely helpful in providing some degree of symptomatic relief and also encouraging active coping, which may contribute to efforts to improve functioning. Interpersonal and expressive psychotherapies have not been systematically studied in pediatric somatization, but they may be useful, particularly in the presence of psychological trauma.72

Family and Group Interventions
The use of family therapy has also been advocated,39,73,74 but aside from the study by Sanders et al.,56 specific family interventions have not been studied. Because patients presenting with medically unexplained physical symptoms are more likely as a group to be viewed as health impaired10 and to be encouraged to adopt the sick role by parents,48 it is important to respectfully challenge the perceived physical vulnerability of the patient and any familial encouragement of illness behavior.75 There are no reports regarding the use of group psychotherapy in the treatment of pediatric somatization.5

Communicate
Establish and facilitate communication between involved professionals, including teachers and the school nurse when appropriate. A close working relationship with the primary care physician or referring specialist is essential. Poor communication is the most frequent complaint made by pediatricians about child and adolescent psychiatrists.76 Improved communication decreases the risk of treatment efforts being repeated, diluted, or misinterpreted. Work with adults has shown that a simple consultation letter from a consulting psychiatrist to the primary care physician outlining a management approach was effective in improving patient satisfaction and functioning, as well as reducing health care expenditures.77 School absenteeism or school refusal is commonly associated with pediatric somatization.10 School officials may benefit from a better understanding of the patient's difficulties and may be a source of useful information and suggestions regarding practical interventions. The clinician can serve as a bridge to help bring together the school and the patient's family because tensions frequently develop regarding absences and requests for special treatment of the patient.

Consolidate Care
Attempt to consolidate coordination of medical care with a single physician. Regularly scheduled medical visits can reassure the patient and family that their concerns have not been dismissed. The primary physician may serve as a powerful attachment figure for families in whom rejection sensitivity and fears of abandonment are prominent. Regularly scheduled visits allow the patient and family to see the physician without the requirement that the patient be sick.1 It is often useful to help define what constitutes a legitimate, medically excused school absence for both the family and the school and to clarify who will be the physician responsible for legitimizing medical excuses, thereby helping to prevent "doctor shopping." The patient and parents need to understand that absence from school without the approval of the collaborative treatment team and an appropriate medical excuse will be viewed as truancy and that the school will take appropriate action. With such a treatment plan, the cooperation of the school can benefit the treatment effort.

Aggressive Treatment of Comorbid Psychiatric Problems
Pediatric somatization is commonly associated with comorbid psychopathology, particularly internalizing symptoms and disorders5,10,18 (for review). Evidence from studies of adults suggests that active intervention for comorbid anxiety and depression can ameliorate associated somatic symptoms.1,78

Consider Psychopharmacologic Interventions
There have been no systematic studies of psychoactive medications in pediatric somatization.16 Psychopharmacologic interventions are nevertheless worthy of consideration in the treatment of persistent medically unexplained pain, gastrointestinal symptoms, or fatigue, particularly in the presence of psychiatric comorbidity or when psychotherapeutic interventions have not been entirely successful. Antidepressant medications appear to be of significantly greater benefit than placebo in the treatment of adult somatoform pain disorders.79 Preliminary evidence suggests that selective serotonin reuptake inhibitors (SSRIs) may ameliorate hypochondriacal distress in adults80 and have a role in the treatment of body dysmorphic disorder,81 but comparable research in children and adolescents is lacking. Clinical experience suggests that some patients who experience physical symptoms associated with emotional arousal and anxiety may benefit from a short course of a benzodiazepine, such as clonazepam or lorazepam; benzodiazepines can provide relatively rapid symptomatic relief, thus helping to reassure the patient and family and provide a powerful example of how emotional activation and physical distress may be associated.16

A recent meta-analysis of available studies in the adult literature found antidepressant medications to be helpful for specific medically unexplained physical symptoms as well as symptom complexes such as fibromyalgia, functional gastrointestinal disorders, and headache syndromes.82 Another recent critique of treatments for irritable bowel syndrome (IBS) suggested that antidepressants are of benefit but cautioned that available studies are of limited quality and characterized by small sample sizes.83 Most prior studies of antidepressant treatment for functional gastrointestinal disorders such as IBS have used tricyclic antidepressants, but more recent case reports and case series suggest that SSRIs such as paroxetine84 and fluvoxamine85 may also be helpful. Migraine is a disorder of special interest given powerful associations with anxiety and depression,86 as well as possible associations with other medically unexplained somatic symptoms in children and adolescents.11 A variety of psychopharmacologic agents have been noted to be of potential benefit in the prevention of migraine headaches, with antidepressants, anticonvulsants, and beta-adrenergic blockers playing prominent roles.87 Serotonergic transmission is considered to be important, with reports suggesting that pizotifen88 and cyproheptadine89 are useful prophylactic agents. Additional agents reported to be helpful in children include trazodone90 and propranolol.89 Despite understandable concerns about inducing a possible serotonin syndrome, available evidence suggests that combining antidepressants with antimigraine drugs such as sumatriptan is relatively safe.91 SSRIs also appear to be useful in treating the physical and emotional symptoms associated with premenstrual syndrome and premenstrual dysphoric disroder.92,93

Monitor Outcome
Though symptomatic relief is certainly desirable, the recommended management approach emphasizes the primacy of functional improvement. Domains include school attendance and performance; family, peer and social functioning; and health service use.

Particularly in situations of persistent diagnostic uncertainty, a successful response to treatment may help reassure the family and any concerned professionals that the diagnostic impression of somatization was indeed correct. This can then allow additional treatment to proceed, with an increasing focus on comorbid emotional and behavioral difficulties.


  CONCLUSION

 
TOP
 ABSTRACT
 INTRODUCTION
 PRINCIPLES OF ASSESSMENT
 DIAGNOSIS
 TREATMENT
 CONCLUSION
REFERENCES
 
Well-designed and well-executed empirical studies of intervention are needed to help guide the work of clinicians in addressing the common but difficult-to-manage problem of pediatric somatization. Future studies should examine not only the efficacy of tested interventions, but also whether symptomatic and functional improvements are independent of changes in comorbid anxiety and depressive symptoms. This is an area where efforts to bridge the gap between efficacy and effectiveness research and to develop relatively potent, tiered interventions are likely to prove exceptionally important, particularly given the prevalence of presentations with medically unexplained symptoms in primary care and other medical settings.


  ACKNOWLEDGMENTS

 
Dr. Campo was supported in part by National Institute of Mental Health (NIMH) grant K23 MH 01780 and in part by grant MH 55123, Child and Adolescent Developmental Psychopathology Research Center (CADPRC) for Early Onset Affective and Anxiety Disorders.


  REFERENCES

 
TOP
 ABSTRACT
 INTRODUCTION
 PRINCIPLES OF ASSESSMENT
 DIAGNOSIS
 TREATMENT
 CONCLUSION
 REFERENCES
 

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