Somatisation in a child (functional abdominal pain)

Question 1

Define somatisation.

Answer 1

Somatisation – psychological difficulty or distress that is manifested through somatic symptoms. Patients have a tendency to experience and communicate somatic distress and symptoms, unaccounted for by pathological findings. There is tendency to attribute these to physical things and to seek medical help.

Question 2

What are the common somatic symptoms?

Answer 2

Question 3

Define “functional” recurrent abdominal pain.

Answer 3

Severe, impairing, occurs at least once a week for 3 months. No organic cause.

Question 4

How common is functional abdominal pain?

Answer 4

: present in about 10% of children in the general population

Question 5

Which features would suggest that the abdominal pain is from an organis cause rather than functional?

Answer 5

Functional is usually on or around the umbilicus, they should not wake up at night, and have no other symptoms or findings. Improvement occurs on weekends and on school holidays.

Question 6

What investigations would you do for functional abdominal pain? What are the risks of investigating?

Answer 6

Should be in keeping with the history and limit investigations if history strongly suggests somatisation.

Overinvestigation can be counterproductive as it can cause reinforcement of the pain and harm may result from more invasive investigations e.g. laparoscopies.

Question 7

What are the differentials for functional abdominal pain?

Answer 7

Should screen for anxiety and depression

Question 8

What are the psychological and biological symptoms of anxiety?

Answer 8

Question 9

How common is anxiety in functional RAP?

Answer 9

75% of children have co-morbid anxiety

Question 10

What are the two types of anxiety disorders?

Answer 10

Generalised - anxiety, panic disorder

Restricted - to specific environments or objects e.g. separation from parents, social phobia, specific phobias

Question 11

What are the symptoms of depression?

Answer 11

Question 12

Which frameworks is used when investigating a diagnosis of FRAP?

Answer 12

Biopsychosicial framework - biological, psychological and social/environmental domains. If there are risk factors in all three domains there can be risk of maladjustment.

Question 13

Give examples of how biological and psychological factors can contribute to FRAP.

Answer 13

Question 14

Give examples of how social factors can contribute to FRAP.

Answer 14

Question 15

When diagnosing FRAP you can also use a systemic or systematic approach.

1. Thinking systemically – thinking about factors occurring within the child and in its immediate and wider environment
2. Thinking systematically – in a rational structural way; e.g. thinking about different factors one at a time

Answer 15

Question 16

CASE**: 12yr old, second child, 6 month history of on and off abdominal pain. Attendance reduced from 98% to 50%.

Answer 16

SOCRATES – periumbilical, non-radiating pain which is worst on Mondays and least on Saturdays.

DEVELOPMENTAL – periods, pain not related to menstrual cycle

RED FLAGS – no blood in stools, no changes in bowel habit, no weight loss, no change in appetite

SOCIAL HISTORY – be curious and ask “Do you have a best friend at school?” etc.

1. Home
2. Education – grades and friends at school
3. Activities
4. Drugs/Drinking
5. Sex
6. Self-harm, depression & suicide
7. Safety (including social media/online) – do you feel safe at home

Broader social – boyfriend, friends outside of school

Family – parents and at home

Individual – any hobbies which can be a protective factor, risk factors can be the personality type (anxious, sensitive, conscientious), if hypersensitivity to pain (e.g. if immunisations)

EXAMINATION:

Basic observations, listen to heart and chest and do an abdominal examination.

Some basic bloods: FBC, U&Es and CRP

Question 17

How do you explain or educate about FRAP?

Answer 17

Talk about:

1. Frequency of RAP in the general population (10%)
2. Prognosis for resolution is good (~50% improve after a medical consultation)
3. In 15% of consulting children RAP will be persistent
4. Acknowledge symptoms and that the pain is real, be empathetic.

Question 18

How you do manage the pain in FRAP?

Answer 18

1. Relaxation
2. Distraction techniques
3. Negionated graded return to school if appropriate

Question 19

How can you address contributory factors in FRAP?

Answer 19

1. Decrease attention by parents to the symptoms (–> reinforcement)- NB: this does not mean paying less attention to the child, just to the pain.
2. Set up non-pain based shared activities
3. Seek to reduce stresses in school/peer interactions

Question 20

Summarise the management of FRAP.

Answer 20

1. Explain and educate
2. Pain management
3. Address contributory factors
4. Treat comorbid anxiety/depressive disorder
5. Consider CBT family treatment if persistent problems