Psychosomatics 48:502-509, November-December
doi: 10.1176/appi.psy.48.6.502
© 2007 Academy of Psychosomatic Medicine
Course and Outcome of Somatoform Disorders in Non-Referred Adolescents
Cecilia A. Essau, Ph.D.
Received August 2, 2006; revised November 7, 2006; accepted November 28, 2006. From the School of Human and Life Sciences, Roehampton University, Whitelands College, Holybourne Ave., London SW15 4JD, UK. e-mail: C.Essau{at}roehampton.ac.uk
© 2007 The Academy of Psychosomatic Medicine
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ABSTRACT
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The author examined the course of somatoform disorders in non-referred adolescents. Somatoform disorders were coded from DSM–IV criteria, using the computerized Munich (Germany) version of the Composite International Diagnostic Interview. About 35.9% of the adolescents with somatoform disorders at the index investigation continued to have the same disorders at the follow-up investigation: 26.7% had anxiety, 17.1% had depression, 22% had substance-use disorders, and 53.7% had no psychiatric disorders. Factors related to the chronicity of somatoform disorders included gender, comorbid depressive disorders, parental psychiatric disorders, and negative life events. Somatoform disorders showed a heterogeneous pattern of course.
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INTRODUCTION
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Findings of studies in adults have given us much information about the course and outcome of somatoform disorders. According to these studies,1,2 most patients with somatoform disorders experienced their first symptoms before the age of 15 years. These disorders have been reported to have a chronic course, with an average duration of about 18 years,3 and they are associated with long-term psychosocial impairment. Although useful, these adult studies may be biased because of recall problems.
Information on somatoform disorders among non-referred children and adolescents is lacking, especially information on their course and outcome.4 This lack of attention may be because of the ill-defined nature of the disorders, at least before the introduction of DSM–III. That is, the problem in studying somatoform disorders has been due to the unresolved problems at the interface of psychiatry and medicine.5 Furthermore, there has been an absence of diagnostic criteria for somatoform disorders in childhood and adolescence, and it has often been argued that the application of adult criteria may be inappropriate for these age-groups.6
The few studies on the course and outcome of somatoform disorders in children and adolescents are limited to small sample sizes, or focus on specific types of somatoform disorders, or are limited to young patients in clinical settings. Several reports on the course of somatoform disorders were based on case studies of adolescents suffering from specific types of somatoform disorders (pain disorder, conversion disorder, somatization disorder, dysmorphic disorder, undifferentiated somatoform disorders, hypochondriasis). According to these few studies, body dysmorphic disorder (BDD) has been described as a chronic and handicapping condition, with a waxing and waning of intensity.3
With respect to conversion disorder, a study by Pehlvanturk and Unal7 has shown that 85% of the youngsters with this disorder had recovered completely at the 4-year follow-up investigation. About 5% of the patients showed some improvement; 10% showed no change; and 35% received a diagnosis of other psychiatric disorders (mostly anxiety and depressive disorders). Among three patients (7.5%) who recovered shortly after the initial visit, relapse was reported to have occurred 12 to 36 months later. Factors that predicted poor outcome in conversion disorder included polysymptomatic presentation, pseudoseizures, chronicity of the symptoms, comorbid psychiatric or medical disorders, poor capacity to gain insight, severe internal conflict, and serious family dysfunction.7 Adolescents with conversion disorder who were classified as polysymptomatic, versus monosymptomatic, had significantly poorer prognosis and had more past psychiatric histories and family problems.8
No information is available on the course of hypochondriasis and somatization disorder in adolescents. However, according to previous adult studies, between 80% and 90% of the adult patients diagnosed with somatization disorder retain the same diagnosis over several years.9 Among adults with hypochondriasis,10 two-thirds continued to meet the criteria for the disorder 1 year later. Although one-third of these patients no longer met the criteria, they had persisting hypochondriacal symptoms.
Given the lack of information on the course of somatoform disorders in non-referred adolescents, the main aims of this article were to examine the course and outcome of somatoform disorders and to examine factors related to their chronicity. The specific aims of the present study were to address the following questions: 1) How many adolescents who met the diagnosis of somatoform disorders at the index interview still met these disorders at the follow-up interview? 2) How many of the adolescents with somatoform disorders at T1 developed other disorders at T2? 3) What are the factors that predict the chronicity of somatoform disorders?
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METHOD
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Participants were adolescents, age 12 to 17 years, who were randomly selected from 36 high schools in the province of Bremen, Germany. Details about the study design, the sample, and its characteristic have been described elsewhere.11 Permission to conduct the study in the schools was granted by the Ministry of Education, the Ministry of "Confidentiality" (in German: "Landesbeaufragter für den Datenschutz"), and the ethics committees in each participating school. Schools were selected to ensure nationally representative estimates for each grade, and classes were selected from the target grade by use of simple random sampling. All students in a selected class were asked to participate and gave active parental and student written consent.
In all, 2,300 students were approached to participate in the study (Figure 1); the number of students approached in each individual school varied because of organization (e.g., tight schedule, lack of room to conduct the interview) and political issues (e.g., lack of interest or support from teachers) in some schools. A total of 1,444 adolescent respondents agreed to participate; however, data from 1,035 students were used in the present analysis. Data from 197 adolescents were excluded because they did not fulfill the age criterion (younger than 12 and older than 17 years; N=87), or had too many missing or problematic data-points (N=110). Also, 79 students wanted to participate but were unable to do so because they were sick, on holidays, or not allowed by their teachers to participate because of tight academic schedules in their class; another 133 were unable to obtain a signed consent form from their parent or guardian. Thus, the response rate for the present study was 62.8%.
Of the 1,035 adolescent respondents with a complete data-set, there were 421 boys and 614 girls. The average age was 14.3 years (standard deviation [SD]: 1.7). Almost all of the respondents were living at home with at least one of their parents. About 15 months after the first interview (T1), attempts were made to contact (via telephone and mail) all the 1,035 adolescents to participate in the follow-up investigation; of these, 760 could be reached; 240 adolescents could not be contacted either by telephone (up to 10 attempts) or by mail (e.g., unknown new address), and 35 adolescents were not in Bremen during the whole of the follow-up period: 6 were on an exchange program overseas, and 29 had moved to other German cities; 138 refused to take part mostly because of lack of time. Among those who agreed to participate (N=622) in the T2 interview, 566 were actually interviewed. No follow-up interview could be done for 61 subjects because of organizational problems such as their being sick or being on holiday. Data from 43 adolescents had to be excluded because of "problematic" or missing data (i.e., the participants checked two or three boxes, instead of one). Therefore, responses from 523 adolescents formed the database for the T2 interview. Of these, 195 were boys and 328 were girls, with a mean age of 15.2 years (SD: 1.7). The attrition and non-attrition groups did not differ significantly in composition by age or gender, or on parental-marital or socioeconomic status, presence of depressive disorders, or number of negative life events.
Measures
A set of measures was administered to all participants for assessing psychosocial factors known or hypothesized to be related to somatoform and other psychiatric disorders, as well as predictors for the maintenance of these disorders.11 The Columbia Impairment Scale and the SCL-90–R were used to measure general level of psychosocial impairment. Details about the instruments used and the theoretical background for their choice have been presented elsewhere.11 The same instruments were used at both T1 and T2.
We administered the computer-assisted personal interview (CAPI) of the Munich (Germany) version of the Composite International Diagnostic Interview (CIDI). The lifetime (assessed at T1) and current (assessed at T1 and T2) diagnosis of somatoform disorders (somatization disorder, undifferentiated somatoform disorder, conversion disorder, pain disorder, and hypochondriasis) and some selected psychiatric disorders (agoraphobia, simple phobia, specific phobia, panic disorder, generalized anxiety disorder, posttraumatic stress disorder, obsessive-compulsive disorder, alcohol abuse and dependence, drug abuse and dependence, major depressive disorder, dysthymic disorder) were coded on the basis of DSM–IV criteria, using the computerized Munich (Germany) version of the CIDI.12 The CIDI is a fully-structured diagnostic interview developed as a collaborative project between the World Health Organization (WHO) and the U.S. Alcohol, Drug Abuse, and Mental Health Administration (ADAMHA). The CIDI was designed for use in epidemiological studies of psychiatric disorders and may be administered by trained lay interviewers. Diagnostic findings reported here are based on the M–CIDI/DSM–IV algorithms, without applying DSM–IV hierarchy rules.12
Section P of the CAPI contains questions related to adolescent’s family environment. The questions are broadly divided into two areas: 1) living arrangements; that is, whether the adolescent has been brought up with both parents, parental conflict leading to divorce, whether parents are living together, or with a new partner; and 2) parental psychopathology; that is, the presence of a psychiatric syndrome in their parents.
Both the reliability and validity of the CIDI diagnoses have been examined in numerous studies in different centers throughout the world, as part of the WHO field trials of the CIDI. Findings of these field trials have shown the CIDI to have good cultural appropriateness, excellent interrater reliability, and good test–retest reliability.13
The Symptom-Checklist (SCL-90–R)14 is a 90-item, self-report questionnaire used to assess psychological distress. Each item is rated on a 5-point scale ("Not at all" to "Extremely") to indicate the severity of the symptom over the past week. The inventory assesses nine clusters or primary symptom-dimensions: somatization, obsessive-compulsive behavior, interpersonal sensitivity, depression, anxiety, hostility, phobic anxiety, paranoid ideation, and psychoticism. Although the SCL-90–R was originally developed for adults, it has been used in adolescent subjects and has proved to have good-to-excellent psychometric properties.15 Both the reliability and validity of the German version of the SCL-90–R, used in adolescents, have been reported in our earlier publication.16 The internal consistency scores for all the SCL-90–R subscales were all relatively high, with Cronbach alphas ( ) between 0.64 and 0.84. Furthermore, adolescents who met the diagnostic criteria for several psychiatric disorders (e.g., anxiety, depressive, somatoform, and substance-use disorders) had higher scores on the SCL-90–R than those without any of these psychiatric disorders.16
The Columbia Impairment Scale (CIS) has been designed for children age 9 to 17 years old, to measure functioning in interpersonal relations, psychopathology, at school or work, and use of leisure time.17 The CIS has been found to show excellent psychometric properties, with high internal consistency and test–retest reliability. As for its validity, the CIS correlated significantly with most indicators of psychological dysfunction and with the clinician’s rating based on the Children’s Global Assessment Scale.17
The Inventory of Parent and Peer Attachment was used to measure perceived attachment to parents and peers.18 It contains 24 items, 12 items for each of the parent and peer scales. Each item is rated on a 4-point Likert scale: "Almost never or never;" "Sometimes;" "Often;" and "Almost always or always." Coefficient was 0.82 for the Parent scale and 0.80 for the Peer scale.
The Perceived Control Scale was used to measure perceived control, defined as the belief that one is able to obtain a desired or avoid an undesired outcome.19 The questionnaire yields a score for Total perceived control and three subscales (each containing eight items) that reflect control over academic, social, and behavioral outcomes. The value for The Perceived Control Scale was 0.88.
The Self-Perception Profile for Adolescents was used to measure perceived competence in different domains and the adolescent’s global sense of self-worth.20 The specific domains are scholastic competence, social acceptance, athletic competence, physical appearance, job competence, romantic appeal, behavioral conduct, close friendship, and global self-worth. In each item, adolescents were given two contrasting descriptions and asked which was more true of them. Harter20 reported internal-consistency values for the various scales, based on four different samples, as ranging from 0.77 to 0.91 for the scholastic scale, 0.86 to 0.92 for the athletic scale, 0.77 to 0.90 for the acceptance domain, 0.79 to 0.85 for close friend, 0.75 to 0.85 for romantic appeal, 0.58 to 0.78 for behavioral conduct, and 0.80 to 0.89 for the self-worth scale.
The Bremen Event Checklist was used to assess the occurrence of 55 events occurring to self or significant others.21 These items are grouped under eight areas: school/education, parents/family, social/leisure-time activities, partner/marriage, death, accommodation, law, and health. A space is provided at the end of each section for the respondent to report events not included on the list. The respondent reads every item on the questionnaire-like list and decides whether or not the event has been present in the last 7 years. On the basis of our pilot study,21 the items were grouped as negative and positive.
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RESULTS
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Course and Outcome of Somatoform Disorders
A total of 64 adolescent respondents who met the diagnosis of somatoform disorders at T1 could be reinterviewed at an average of 15 months later (T2). Of these, 23 (35.9%) still met the diagnosis of somatoform disorders (Table 1). Forty-one (64.1%) who had somatoform disorders at T1 no longer met the same diagnosis at T2. Among those who no longer had somatoform disorders at T2 (N=41), their somatoform disorders were replaced by several other disorders. Specifically, 11 (26.8%) had anxiety disorders; 7 (17.1%) had depressive disorders; and 9 (22%) had substance-use disorders. Also, some adolescents had comorbid disorders: 1 participant had depressive and substance-use disorders; 2 had depressive and anxiety disorders; and 2 had anxiety, depressive, and substance-use disorders; 22 (53.7%) fulfilled no diagnostic criteria for any DSM–IV psychiatric disorder.
At the follow-up investigation (T2), there were 70 new cases with somatoform disorders; 10 of them (14.3%) were boys, and 60 were girls (85.7%). Similar gender distribution was found for those with chronic somatoform disorders (T1 and T2; boys: 17.4%, and girls: 82.6%). Within the somatoform disorders, undifferentiated somatoform disorder was the most common disorder at T1 and also at T2; 11 adolescents met the diagnosis of undifferentiated somatoform disorder at T1 and continued to have the same disorder at T2.
In this article, the term "transient cases" will be used to describe those who met the diagnosis of somatoform disorders only at T1, and "chronic cases" for those with these disorders at both the index and follow-up investigations.
Of interest was the impact of comorbidity in the development of new psychiatric disorders at T2. For this purpose, the adolescents who had any somatoform disorders at T1 were divided into those who had comorbid disorders (N=44) and those who did not (N=20). These two groups of adolescents were compared in a series of contingency tables examining the probability of having various diagnostic categories at T2. Adolescents with comorbid somatoform disorders were more likely than those with somatoform disorders-only to retain these disorders (47.7% with comorbidity versus 10% without;  2=8.50; p<0.01). No significant group differences were found for anxiety (31.8% with comorbidity versus 25% without; 2=0.31; NS), depressive (29.5% with comorbidity versus 10% without; 2=2.93; NS); and substance-use disorders (15.9% with comorbidity versus 15% without; 2=0.01; NS) at the follow-up investigation.
Factors Affecting the Course of Somatoform Disorders
A number of psychosocial variables were examined to determine whether they played a role in the chronicity of somatoform disorders. A logistic regression was used, with group (transient versus chronic somatoform disorders) as the dependent variable and the following constructs as independent variables: gender, age, parental psychopathology, life events, parent/peer attachment, presence of other psychiatric disorders (depressive disorders, somatoform disorders, substance-use disorders), and cognitive factors, measured at T1.
The factors that were significantly associated with the chronicity of somatoform disorders included gender (odds ratio [OR]: 4.10; 95% confidence interval [CI]: 1.19–14.19), presence of depressive disorders (OR: 4.03; 95% CI: 1.36–11.98), parental psychiatric disorders (OR: 1.30; 95% CI: 1.03–1.65), as well as number of negative life events (OR: 1.35; 95% CI: 1.05–1.73) at T1. None of the following factors, assessed at T1, were associated with the chronicity of somatoform disorders: age, presence of anxiety and substance-use disorders, cognitive factors (perceived competence and perceived control orientation), parent’s chronic physical illness, and perceived attachment to parent or peer.
The next step of our analysis was to examine which somatoform-disorder symptoms assessed at T1 might predict the stability of somatoform disorders as measured at T1. For symptoms that were related specifically to female functioning (e.g., menstruation), only female participants were included in the analysis. The only symptom present at T1 that was significantly associated with the chronicity of somatoform disorders was pain during menstruation (OR: 17.50; 95% CI: 1.99–153.8).
When the symptoms were summed according to the following groups: pain, gastrointestinal, pseudoneurological, dissociative, gynecological, and sexual, the symptom that differentiated adolescents with chronic from transient somatoform disorders was pain: F[1,63]=8.44; p<0.01. This finding indicated that a significantly higher number of pain symptoms were reported by adolescents with chronic (mean=1.61; SD: 1.2) than those with transient (mean=0.80; SD: 1.0) somatoform disorders.
Psychosocial Impairment
Next, we compared psychosocial impairment in three groups of adolescents, that is, those who never met criteria for any psychiatric disorders at either T1 or T2 (i.e., non-disordered group), those with somatoform disorders at T1 and T2 (i.e., chronic cases), and those who met the diagnosis of somatoform disorders only at T2 (i.e., new cases). For this purpose, these three groups were compared on how impaired they were at the T2 interview, as measured using the SCL-90–R and the Columbia Impairment Scale (CIS). One-way analysis of variance (ANOVA) was used, with the subscales of the SCL-90–R and CIS as dependent variables and group (new and chronic cases, and non-disordered group) as independent variable, controlling for the effects of gender and age. Significant group differences were further examined with a Duncan post-hoc test.
As shown in Table 2, the three groups differed significantly on seven of the nine SCL-90–R subscales: somatization (F[2, 377]=14.93; p<0.001); obsessive-compulsive behavior (F[2, 377]=3.89; p<0.05); interpersonal sensitivity (F[2, 377]=3.89; p<0.05); depression (F[2, 377]=9.49; p<0.001); anxiety (F[2, 377]=5.82; p<.01); hostility (F[2, 377]=7.38; p<0.01); and phobic anxiety (F[2, 377]=3.62; p<0.01). Closer examination of Table 2 shows that the adolescents with chronic somatoform disorders had the highest and the non-disordered group the lowest scores on almost all these SCL-90–R subscales.
Significant group differences were also found for the total CIS scores (F [ 2, 469]=8.05; p<0.000) and for the following subscales: interpersonal relationships (F[2, 469]=6.35; p<0.01), psychopathology (F[2, 469]=7.27; p<0.01), and leisure time (F[2, 469]=4.44; p<0.01). Duncan post-hoc tests showed the adolescents with somatoform disorders (chronic and new cases) to be significantly more impaired, as shown by its highest scores on the total CIS and on three of its four subscales (interpersonal relationships, psychopathology, and leisure-time activities).
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DISCUSSION
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The main aims of this article were to examine the course and outcome of somatoform disorders in non-referred adolescents and to examine factors associated with the chronicity of these disorders. Among the 64 adolescents with somatoform disorders at T1 who could be reinterviewed at T2, 23 (35.9%) had somatoform disorders at both the T1 and T2 assessments. Because the present study is among one of the first longitudinal studies of somatoform disorders in non-referred adolescents that used the diagnostic definitions and criteria of DSM–IV, it is not possible to compare our findings with those of other studies.
Factors related to the chronicity of somatoform disorders included the following: gender (female), comorbid depressive disorders, parental psychiatric disorders, as well as number of negative life events at T1. The finding that more girls than boys had chronic somatoform disorders seemed to be consistent with gender differences in the focus of somatic symptoms.22 As reported by Baker and Stewart,22 adult women tend to receive greater attention for their somatic complaints than men, and, according to DSM–IV, women more frequently experience medically unexplained physical complaints and worries about physical illness. There is no clear explanation for this gender difference; however, socialization practice and/or gender-specific learning experiences have been discussed as being a contributing factor.22
The presence of parental psychiatric disorders predicted the chronicity of somatoform disorders. Although the reason for this is unclear, it could be argued that it is not only the parental disorder (e.g., depression) that is important, but also the problems associated with that specific disorder (e.g., irritable mood, lack of interest) that could have a detrimental effect on the adolescent children. That is, mechanisms involved in the transmission of psychiatric disorders from parent to child are likely to be complex and include dysfunctional parent–child interactions, marital conflict, and emotional unavailability of parents, as well as genetic factors.23
The presence of a high number of stressful negative life events was also related to the chronicity of somatoform disorders. One could argue that somatoform disorders may have developed as a result of an interaction between personal vulnerability and negative life events, which in turn may have activated the underlying cognitive predisposition, as proposed by Hammen and Rudolph24 in their diathesis-stress model.
Unlike findings from previous studies,8 familial dysfunction in our sample did not significantly distinguish adolescents with chronic from those with transient somatoform disorders. This inconsistency could be attributed to the domain of "family dysfunction" measured in previous studies as compared with our study. For example, in the study by Murase and colleagues,8 family dysfunction included living with a single parent; having a physically abusive father; as well as having harsh, rejecting, and verbally abusive parents. In the present study, the Inventory of Parent and Peer Attachment was used to measure a specific family dysfunctional interaction, namely, lack of attachment.
In line with previous studies, adolescents with somatoform disorders are impaired across multiple domains, including severe impairment in social and occupational activities such as having poor grades,3 dropping out of sports and other activities,25 dropping out of high school,3 social withdrawal,25 being housebound,26 and having excessive school absences.27 Somatoform disorders have also been reported to result in psychiatric hospitalization, suicidal ideation, and suicide attempts.28 In the present study, those with chronic somatoform disorders had the highest scores on the SCL-90–R; the lowest scores were found among adolescents in the non-disordered group. This finding suggests the need for appropriate referral and treatment of somatoform disorders, to prevent or at least reduce their severity and associated morbidity.
Despite its major strength (e.g., non-referred samples, large sample size, use of DSM–IV criteria), the present study has several limitations. First, information on psychosocial impairment was based on adolescents’ self-report, since no permission could be obtained from the "Ministry of Confidentiality" to obtain teachers’ reports about the adolescents in school. Second, the interrater reliability of the CAPI was not tested in the present study because we used the computerized version of the CIDI. However, in our earlier study, using the paper-and-pencil version of the CIDI,13 the interrater reliability of most diagnostic categories has been found to be high, with percentage agreements over 90%. Third, the concordance rate between clinicians and the CIDI interview was relatively low for somatoform disorders, with a  of 0.50.30 Furthermore, between 22% and 100% of somatic symptoms were lost to recall at follow-up, which suggests a need to interpret the lifetime symptoms elicited by the CIDI with caution.31 Fourth, the response rate was relatively low compared with many similar studies in other countries,29 but is comparable with the response rate in similar studies conducted in Germany.30 Fifth, the drop-out rate was relatively high, with almost two-thirds of the original sample missing the T2 interview. Finally, the present study used the same criteria as those for adults, and it is questionable whether the application of adult criteria is appropriate for use among adolescents because they contain some symptoms that are not relevant to younger children (e.g., sexual symptoms).
To conclude, of the adolescents who had somatoform disorders, about one-third continued to have somatoform disorders. This finding shows that somatoform disorders in some adolescents are not benign conditions that will self-resolve. Furthermore, there are a number of adolescents with somatoform disorders at T1 who have developed other disorders by the follow-up investigation. Thus, the outcome of somatoform disorders in adolescents seemed to show a rather heterogeneous pattern. Environmental or social factors, alone or in combination with individual-specific risk factors, may contribute to the diverse diagnostic outcomes.
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ACKNOWLEDGMENTS
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This study was funded by the German Research Council (PE 271/5-3)
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REFERENCES
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- Wells JE, Bushnell JA, Hornblow AR, et al: Christchurch Epidemiology Study, part I: methodology and lifetime prevalence for specific psychiatric disorders. Aust N Z J Psychiatry 1989; 23:315–326[Medline]
- Wittchen H-U, Essau CA, von Zerssen D, et al: Lifetime and six-month prevalence of mental disorders in The Munich Follow-Up Study. Eur Arch Psychiatry Clin Neurosci 1992; 241:247–258[CrossRef][Medline]
- Phillips KA, McElroy SL, Keck PE, et al: Body dysmorphic disorder: 30 cases of imagined ugliness. Am J Psychiatry 1993; 150:302–308[Abstract/Free Full Text]
- Fritz GK, Fritsch S, Hagino O: Somatoform disorders in children and adolescents: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry 1997; 36:1329–1338[CrossRef][Medline]
- Lipowski ZJ: Somatization: the experience and communication of psychological distress as somatic symptoms. Psychother Psychosom 1987; 47:160–167[Medline]
- Taylor DC, Szatmari P, Boyle MH, et al: Somatization and the vocabulary of everyday bodily experiences and concern: a community study of adolescents. J Am Acad Child Adolesc Psychiatry 1996; 35:491–499[CrossRef][Medline]
- Pehlivantürk B, Unal F: Conversion disorder in children and adolescents: a four-year follow-up study. J Psychosom Res 2002; 52:187–191[CrossRef][Medline]
- Murase S, Sugiyama T, Ishii T, et al: Polysymptomatic conversion disorder in childhood and adolescence in Japan: early manifestation or incomplete form of somatization disorder? Psychother Psychosom 2000; 69:132–136[CrossRef][Medline]
- Cloninger CR: Somatoform and dissociative disorders, in The Medical Basis of Psychiatry. Edited by Winokur G, Clayton P. Philadelphia, PA, WB Saunders, 1986
- Noyes J Jr, Kathol RG, Fisher MM, et al: One-year follow-up of medical outpatients with hypochondriasis. Psychosomatics 1994; 35:533–545[Abstract/Free Full Text]
- Essau CA, Conradt J, Petermann F: Course and outcome of anxiety disorders in adolescents. J Anxiety Disord 2002; 16:67–81[CrossRef][Medline]
- Wittchen H-U, Pfister H: DIA-X-Manual: Instrumentsmanual zur Durchführung von DIA-X Interviews (DIA-X-Manual: Manual for the Administration of DIA-X Interviews). Frankfurt, Germany, Swets and Zeitlinger, 1997
- Wittchen HU, Robins LN, Cottler LB, et al: Cross-cultural feasibility, reliability, and sources of variance of the Composite International Diagnostic Interview (CIDI): results of the multicenter World Health Organization/ADAMHA field trials (Wave I). Br J Psychiatry 1991; 159:645–653[Abstract/Free Full Text]
- Derogatis LR: SCL-90-R: Administration, Scoring, and Procedures Manual for The Revised Version. Baltimore, MD, Johns Hopkins University School of Medicine, 1997
- McGough J, Curry JF: Utility of the SCL-90-R with depressed and conduct-disordered adolescent inpatients. J Pers Assess 1992; 59:552–563[CrossRef][Medline]
- Essau CA, Groen G, Conradt J, et al: Reliabilität und validität der SCL-90-R: ergebnisse der Bremer jugendstudie. Z Differentielle und Diagnostische Psychol 2001; 22:139–152[CrossRef]
- Bird HR, Gould MS: The use of diagnostic instruments and global measures of functioning in child psychiatry epidemiological studies, in The Epidemiology of Child and Adolescent Psychopathology. Edited by Verhulst FC, Koot HM. Oxford, UK, Oxford University Press, 1995
- Armsden GC, Greenberg MT: The Inventory of Parent and Peer Attachment: individual differences and their relationship to psychological well-being in adolescence. J Youth Adolesc 1987; 16:427–453[CrossRef]
- Weisz JR, Sweeny L, Proffitt V, et al: Control-related beliefs and self-reported depressive symptoms in late childhood. J Abnorm Psych 1993; 3:411–418
- Harter S: Self-Perception Profile for Adolescents. Denver, CO, University of Denver, 1988
- Essau CA, Petermann F, Conradt J: Depressive symptome und syndrome bei jugendlichen. Z Klinische Psychol Psychopathol Psychother 1996; 44:150–157
- Baker JM, Stewart SH: Gender differences in fear content: a re-analysis of Kirkpatrick and Berg’s (1982) Fear Survey data. Presented at the Annual Meeting of the Association for Advancement of Behavior Therapy, New York, 1996
- Cummings EM, Davies PT: Families, Conflict, and Conflict Resolution: The Children’s Perspective. New York, Guilford, 1994
- Hammen C, Rudolph K: Childhood depression, in Child Psychopathology. Edited by Mash EJ, Barkley RA. New York, Guilford, 1996
- El-Khatib HE, Dickey TO: Sertraline for body dysmorphic disorder. J Am Acad Child Adolesc Psychiatry 1995; 34:1404–1405[Medline]
- Cotterill JA: Body dysmorphic disorder. Psychodermatology 1996; 14:457–463
- Albertini R, Phillips KA, Guvremont D: Body dysmorphic disorder in a young child (letter). J Am Acad Child Adolesc Psychiatry 1996; 35:1425–1426[CrossRef][Medline]
- Albertini RS, Phillips KA: Thirty-three cases of body dysmorphic disorder in children and adolescents. J Am Acad Child Adolesc Psychiatry 1999; 38:453–459[CrossRef][Medline]
- Reed V, Gander F, Pfister H, et al: To what degree does the Composite International Diagnostic Interview (CIDI) correctly identify DSM-IV disorders? testing validity issues in a clinical sample. Int J Meth Psychiatr Res 1998; 7:142–155[CrossRef]
- Leiknes KA, Finset A, Moum T, et al: Methodological issues concerning lifetime medically unexplained and medically explained symptoms of the Composite International Diagnostic Interview: a prospective, 11-year follow-up study. J Psychosom Res 2006; 61:169–179[CrossRef][Medline]
- Lewinsohn PM, Hops H, Roberts RE, et al: Adolescent psychopathology, I: prevalence and incidence of depression and other DSM-III-R disorders in high school students. J Abnorm Psych 1993; 102:133–144[CrossRef]
- Wittchen H-U, Nelson CB, Lachner, G: Prevalence of mental disorders and psychosocial impairments in adolescents and young adults. Psychol Med 1998; 28:109–126[CrossRef][Medline]
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ABSTRACT
INTRODUCTION
