1. (As easy as ABC?) Formulating distress to disorder
And the psychosomatic conundrum
In child and adolescent psychiatry
(As easy as ABC?)
Ruth Brand Flu
Locum Consultant developmental Child and adolescent Psychiatrist

2. Introduction Interactive Problem based learning
Evidence based? And own examples
I want you to be critical
Distress/ disorder
Formulation
Somatoform disorders
Questions and answers

3. Distress/disorder Distress Within normal limits: Duration Intensity
Quality
Within cultural boundaries
Developmentally appropriate
Frequency
Considering context and situation

4. Distress/ disorder Disorder:
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
Out of context and beyond explanations of situational factors

5. 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

6. Distress/disorder examples
A child whose mood can swing in a split second
A child complaining of tummy ache
A child who tells you that an alien is living in his tummy
A child who cries at the sound of thunder
A child who scratches his face open at the sound of thunder
A baby who bangs his head

7. Formulation
Components: Bio psycho social Developmental Predisposing, precipitating, perpetuating Strength, weakness Prognosis Protective factors , internal (strength) or External Impairment Risks, Continuity in adulthood

8. Formulation continued
SIRSE
Symptom
Impact
Risks
Strength
Explanatory
(State , trait, pattern)

9. Formulation continued
Aetiological Nurture /nature Genetic or trans-generational Developmental: physically, emotionally, neuro-cognitively and socially Environment at home/school and extra-curricular activities

10. Formulation: example
Adrian 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

11. Somatoform disorders (F45) Unexplained physical symptoms (UPS) Abnormal illness behaviour
General differences DSMIV/ICD10
Co-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

12. Undifferentiated somatoform disorder
A mixture and incomplete
Other somatoform disorder (isolated i.e. Globus hystericus)
Somatoform disorder unspecified

13. 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?

14. More about somatisation disorder
Subculture in family
Internalisation tendencies of too much stress
Nervous disposition
More in girls
More 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

15. 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

16. 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 nurtured Sustaining factors: internal and environmental, reaction by environment

17. External factors Systematic family dysfunction Family factors;
Systematic family dysfunction
Family factors;
Family history of anxiety and depression
Social factors:
Lower socio economic status
A family experience of illness
Predisposition may vary culturally
High expectations of the child
diff

18. Psychiatric disorder? Impact
Psychiatric disorder? Depends
Impact?
Defense mechanism?
State to trait

19. 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

20. 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

21. 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

22. Treatment Treatment of the environment
Removing abusive situations, tackling bullying, academic adjustments
Solution focussed
Behaviour therapy
CBT
Family therapy, narrative therapy
Psychotherapy
Play therapy?

23. BIBLIOGRAPHY
All major child and adolescent Psychiatry textbooks, i.e. Royal college, also paediatric textbooks Coghill D Oxford Child and adolescent psychiatry Oxford, Oxford University press Scott, S Classification of psychiatric disorders in childhood and adolescence: building castles in the sand? Adv. Psychiatr. Treat., May 2002; 8: Tsuang: M. Texbook in psychiatric epuidemiology Wiley New York Eminson D. 2001advances in psychiatric treatment somatising in children and adolescents