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(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