Paediatrics: Somatoform disorders and typical consultation–liaison presentations

Somatoform disorders and typical consultation–liaison presentations

This is a poorly defined area with a whole host of overlapping terms, and confusions between descriptive terms and implied aetiology. Some of the terms in common usage are:

·  Psychosomatic: a very general and rather unhelpful term that can include both illnesses brought on by stress, e.g. tension headache and physical symptoms secondary to psychiatric illness, e.g. hypothermia secondary to malnutrition in anorexia nervosa.

·  Somatoform disorders: physical symptoms with no organic basis. These are subdivided into:

·  conversion disorders;

·  chronic fatigue syndrome;

·  pain syndromes, hypochondriasis;

·  somatization disorder.

Whilst many of these terms are entrenched, and so unlikely to disappear, the concept of somatoform disorders has been much criticized on the following grounds:

·  It implies a cause that is not demonstrable and often intuitively does not appear to be correct.

·  It is often unacceptable to patients and parents and is therefore an obstacle to forming a collaborative relationship.

·  Its use may result in missing psychiatric or physical diagnoses.

·  There seems little relationship between this term and other diagnoses commonly applied to the same patients in non-mental health settings, e.g. irritable bowel, chronic fatigue.

Conversion disorder

Conversion disorder is characterized by the presence of physical symptoms (e.g. paralysis, seizures, and sensory deficits) or men-tal symptoms (e.g. amnesia), but without any evidence of physical cause. Previously called hysteria. Proposed underlying mechanism is transforma-tion of emotional conflict into mental or physical symptoms. The postu-lated splitting off of mental processes from each other is referred to as dis-sociation. There may be secondary gain, e.g. when the child who is being bullied at school develops paralysis, which keeps him at home. Conversion disorders are rare in childhood, particularly before the age of 8yrs.

Treatment

Principles of treatment include attempts to resolve any apparent emotion-al difficulties, avoidance of unnecessary physical investigation, removal of secondary gain, and help in returning to normal life.

Prognosis 

Generally favourable.

Chronic fatigue syndrome

Recurrent non-organic abdominal pain

The child’s complaints of recurrent abdominal pain are not found to have a physical basis.

·Common, affecting 710–15% of children at some point, usually between 5 and 12yrs (no apparent gender or social class bias).

·There may be associated symptoms of other pains, nausea, or even vomiting.

·Pains are usually episodic and relapsing though may be more persistent.

·An uncommon variant is the periodic syndrome where episodes of pain are associated with vomiting, headache, and low grade pyrexia. This is thought by some to be a form of migraine.

Differentiation from organic pathology may be difficult. Features that may help include the diffuseness of the pain, the tendency not to be woken by it, pains elsewhere in the body, anxiety, and depression in child and parent, and the lack of positive findings on physical examination.

Treatment

Generally a combination of reassurance, education about the links between stress and the body, psychological treatment where appropriate and avoidance of unnecessary physical investigation and treatment.

Prognosis

Short-term outcome is usually favourable though it is not known whether this is due to or in spite of treatment. In the longer term further episodes of non-organic pain are found in a large minority of cases.

Selective eating

This is a condition of younger children that in most, though not all, resolves in the teenage years. These children eat only a limited range of foods. In severe cases the restriction may be to only 3 or 4 foods. It is surprising that most children seem to ingest all the required nutrients in their very limited diet. To treat, a mixture of reassurance and encourage-ment seems to be the best approach. More active intervention is indicated when the child is malnourished and usually entails a gradual hierarchical desensitization programme.