(As easy as ABC?)

Ruth Brand FluLocum Consultant developmental Child and adolescent Psychiatrist

Formulating distress to disorderAnd the psychosomatic conundrumIn child and adolescent psychiatry

Introduction

• Interactive• Problem based learning• Evidence based? And own examples • I want you to be critical

Distress/ disorderFormulationSomatoform disorders

Questions and answers

Distress/disorderDistressWithin normal limits:• Duration• Intensity• Quality• Within cultural boundaries• Developmentally appropriate• Frequency• QualityConsidering context and situation

Distress/ disorderDisorder: physical or mental anguish or suffering A derangement or abnormality of function, a

morbid physical or mental state. Impairment not always included in the definition

Abnormal in :• Duration• Intensity• Quality• Within cultural boundaries• Developmentally appropriate• Frequency• QualityOut of context and beyond explanations of situational factors

Normal/disorder examples

A four year old who drowned her baby brother in the bath

A cough

A 16 year old who sucks his thumb

A 6 month old baby who sleeps three hours per day

Distress/disorder examplesA child whose mood can swing in a split

secondA child complaining of tummy acheA child who tells you that an alien is living in

his tummyA child who cries at the sound of thunderA child who scratches his face open at the

sound of thunderA baby who bangs his head

Formulation

Components:Bio psycho socialDevelopmentalPredisposing,

precipitating, perpetuating

Strength, weaknessPrognosisProtective factors ,

internal (strength) or External

ImpairmentRisks, Continuity in

adulthood

Formulation continued

SIRSE• Symptom• Impact• Risks• Strength• Explanatory

• (State , trait, pattern)

Formulation continuedAetiological Nurture /natureGenetic or trans-generationalDevelopmental: physically, emotionally, neuro-

cognitively and sociallyEnvironment at home/school and extra-curricular

activities

Formulation: exampleAdrian is a 12 year child who was adopted from birth. , His birthmother

overdosed on cocaine and mescaline during pregnancy. He was born prematurely and due to cardiac complications spent 9 months of his first year in hospital. He has mild global delay, his coordination is way below par and he displays a significant degree of attentional and impulsivity features and explosive outburst in school, but never in the home environment. Despite that he has got a large circle of friends from early primary school and except for maths he is consistently performing low average in school. He was referred for marked anxiety features nightmares, clinginess and bedwetting following a burglary at home, which he witnessed. He was initially quite anxious at the assessment, but with some reassurance and structure he calmed down quickly with good rapport. He displayed some PTSD features when the burglary was discussed

Considering his impressive insight into his problems, with minimal counselling, progress in school and his warm an boundaried adoptive family his prognosis short term and long term is considered good. Risks of harm to others and self-harm short and long terms are minimal

(A multimodal summarised narrative of the patient

Somatoform disorders (F45)Unexplained physical symptoms (UPS)

Abnormal illness behaviourGeneral differences DSMIV/ICD10Co-morbidity• Somatisation disorder (genuine symptoms)• Hypochondriacal disorder (interpretation and

fear to conviction of having an illness)• Somatoform autonomic dysfunction (the

sense of.. .Being flushed)• Persistent somatoform pain disorder

•

• Undifferentiated somatoform disorderA mixture and incomplete

• Other somatoform disorder (isolated i.e. Globus hystericus)

• Somatoform disorder unspecified

Somatisation disorder• At least 2 years duration• Persistence refusal to accept reassurance by

physician, (in younger kids) not making a psychological link

• Some degree of impairment of social and family life... How do you separate between primary and secondary problems

DD Physical/affective/anxiety disorder, but often co-existence

0.1% year and life time prevalence – true value?

More about somatisation disorderSubculture in familyInternalisation tendencies of too much stressNervous dispositionMore in girlsMore frequent and complex in adolescents• In small children just headaches, tummy ache

and fatigue 25% neurological• 23% with low energy: 21% with sore muscles

17% with abdominal discomfort•

Aetiology

Internal: alexithymia, learning disabilities, low self esteem, personality: perfectionistic, worried, previous abuse, genetic component in somatisation tendencies? Co-existing physical illness: Pseudo-epilepsy

External: Pressure from environment: too much stress: marital problems, bullying in school, academic achievement

Somatisation still continued

‘Primary illness gain’: Internal gain, i.e. Distraction from the original psychological pain or awareness of what is going on in the person’s life

Secondary gain: reaction of the environment: Less responsibilities, more nurturedSustaining factors: internal and environmental,

reaction by environment

External factors• • Family factors;• Family history of

anxiety and depression

• A family experience of illness

• High expectations of the child

• Systematic family dysfunction

• • Social factors:• Lower socio economic

status• Predisposition may

vary culturally• diff

Psychiatric disorder? Impact

• Psychiatric disorder? Depends • Impact?

• Defense mechanism?

State to trait

Hypochondriacal disorder F45.2

• More about the appraisal of bodily feelings than the sensations

• Can be delusional, • More persistent in continuation into

adulthood?• Media overload?• Otherwise similar in aetiology, illness gain

Somatoform autonomic dysfunction F45.3

A certain system or organ fully under that autonomous control such as the heart, gastrointestinal:

F45.30 Heart and cardiovascular Cardiac neurosis, Da Costa syndrome, neuro-circulatory neurasthenia

F45.31 Upper gastro-intestinal: psychogenic aerophagia, hiccough, pyloro spasm

Somatoform autonomic dysfunction continued

• F45.32 Lower gastro-intestinal tract: psychogenic flatulence, IBS, diarrhoea gas syndrome

• F45.33 respiratory Psychogenic forms of cough and hyperventilation

• F45.34 Genito-uterine Micturition and dysuria

Treatment

• Treatment of the environment• Removing abusive situations, tackling bullying,

academic adjustments• Solution focussed• Behaviour therapy• CBT• Family therapy, narrative therapy• Psychotherapy• Play therapy?

BIBLIOGRAPHYAll major child and adolescent Psychiatry textbooks, i.e.

Royal college, also paediatric textbooksCoghill D. 2008 Oxford Child and adolescent psychiatry

Oxford, Oxford University pressScott, S. 2002 Classification of psychiatric disorders in

childhood and adolescence: building castles in the sand? Adv. Psychiatr. Treat., May 2002; 8: 205 - 213.

Tsuang: M. Texbook in psychiatric epuidemiology Wiley New York Eminson D. 2001advances in psychiatric treatment somatising in children and adolescents 7 266- 274