The term somatoform disorder is used to describe mental illnesses that occur with physical complaints and dysfunction that cannot be explained by organic reasons and are thought to be due to psychosocial or emotional factors. The views that psychosocial and emotional factors play a role in the development of physical symptoms have been accepted for a long time. Patients with somatization complain of physical symptoms, or the symptoms are exaggerated to an extent that would not be expected from physical pathology. These patients, who attribute their somatic symptoms to a physical disorder, seek medical help. These patients present difficulties in diagnostic approach and treatment for physicians. Physical symptoms that cannot be explained organically have been seen frequently in children for a long time and have been a problem in pediatric clinics.
In somatoform disorders, the symptoms are not revealed consciously. As in anxiety disorders, anxiety is also the source of physical dysfunction or physical complaints in psychodynamic terms. Therefore, these can actually be considered anxiety disorders. However, the clinical presentation is dominated by physical symptoms, not anxiety.
In DSM-IV, somatoform disorders are divided into five specific and two residual diagnostic categories. Specific somatoform disorders include (1) somatization disorder, (2) conversion disorder, (3) hypochondriasis, (4) body dysmorphic disorder, (5) pain disorder. Residual diagnostic categories include (1) undifferentiated somatoform disorder, (2) somatoform disorder not otherwise specified. Somatoform disorders in ICD-10 include (1) somatization disorder, (2) undifferentiated somatoform disorder, ( It was classified as 3) hypochondriac disorder, (4) somatoform autonomic dysfunction, (5) persistent somatoform pain disorder, (6) other somatoform disorders, (7) unspecified somatoform disorder. In ICD-10, unlike DSM-IV, conversion disorder is considered among dissociative disorders.
Conversion disorder and somatoform disorders in children and adolescents. Since somatization disorder is more common, in this article we will focus on conversion disorder and somatization disorder. Precautions will be given.
Hypochondriasis: Its definition is that the patient is excessively preoccupied with fears that he has a serious illness, even though the patient is medically explained that he does not have a significant illness. The patient interprets normal body sensations, such as heartbeats, peristalsis or mild coughing, as if they were a disease, and becomes frightened accordingly. Barsky pointed out the existence of a tendency between intense bodily sensations and the development of hypochondriasis. Although it can occur at any age, it begins primarily in young adulthood. It is often associated with anxiety, depression, and compulsive or narcissistic personality traits. It is distinctly similar to somatization disorder, and its etiology and course may be common.
Body dysmorphic disorder: It is a state of preoccupation with intense thoughts about an imaginary defect in appearance in a normal-looking person. Most teenagers are extremely concerned with their appearance during adolescence. They constantly question the appearance of their bodies. This situation is especially evident when the person enters puberty significantly earlier or later than their peers. Therefore, in such cases, it is necessary to be especially careful in the differential diagnosis between normal adolescence and body dysmorphic disorder. It is difficult to make a differential diagnosis of this disorder during adolescence. According to reports, this disorder is associated with schizoid, narcissistic and obsessional personality traits. In clinical judgment, a distinction should be made especially between prolonged normal adolescence, somatic preoccupations, hypochondriasis and body dysmorphic disorder.
Phillips et al. reported that body dysmorphic disorder is closer to affective and obsessive-compulsive disorders than to other somatoform disorders. They reported that the disease of 30 adults from their patient group started around the age of 15 on average and showed a chronic course with remissions and exacerbations.
Brawman-Mintzer et al. (1995) investigated the frequency of body dysmorphic disorder in a group of patients with anxiety disorder and major depression, and this disorder was found to be most common in patients with social phobia and obsessive-compulsive disorder. As a result the finding These suggest that body dysmorphic disorder may have common etiological elements with social phobia and obsessive-compulsive disorder. (1)
Pain disorder: In the clinical picture, there is a complaint of pain without any physical findings. According to DSM-IV, there are two types. In one, psychological factors are prominent, in the other, both psychological factors and the general medical condition are related. Pain due to a medical condition is not a psychiatric disorder. In the past, children presenting with unexplained pain, such as recurrent headaches, chest and physical aches, were diagnosed with conversion disorder. Today, literature information on differentiating pain disorder from conversion disorder in children is very limited. In fact, unexplained pain is often associated with other conversion symptoms in children.
Undifferentiated somatoform disorder: This diagnosis is made when the patient has organically unexplained physical symptoms and does not fully meet the criteria for somatization disorder. Its treatment is the same as the treatment of somatization disorder.
Somatoform disorder not otherwise specified: This is the diagnosis made if the patient has symptoms for less than 6 months and does not meet the criteria for a specific somatoform disorder or adjustment disorder with physical symptoms.
EPIDEMIOLOGY:
There are few studies on the incidence of childhood conversion disorder, and the results are controversial. The fact that conversion symptoms are generally addressed in primary healthcare settings and psychiatric evaluation cannot be performed creates difficulty in determining the true incidence. While the incidence reported in foreign publications for outpatients in child mental health departments varies between 1.3-5%, this rate is reported as 4-22% for inpatients. In a study conducted in the USA in children with conversion disorder, pseudoseizure, paresis and syncope were listed as the most common symptoms, while in a study conducted in our country, 74% pseudoseizure, 10% globus hystericus, 6.9%. limb paralysis, 6.9% inability to speak, 3.4% blindness.
Conversion. While the disorder is more common in adolescents than in children, the probability of it being seen under the age of 5 is very low. While it is seen equally in boys and girls during the prepubertal period, the rate of occurrence in girls during adolescence is twice as high as in boys. The incidence of conversion disorder is higher in families with low socio-economic levels or in families living in rural areas. While conversion disorder is less common in western countries, it is more common in countries such as Turkey or India. The role played by socio-cultural factors is important here.
Unexplained pain complaints are especially common in children and adolescents. Headache ranks first among pain complaints. In community screenings, the rate of children and young people reporting that they have headaches every day or frequently is between 10-30%. Other common pain complaints are abdominal pain (10-25%), extremity pain (5-10%) and chest pain (7-15%). Apart from pain complaints, dizziness, nausea and fatigue are the most common symptoms. Abdominal pain is reported more frequently in children and headaches in young people. Somatization is usually polysymptomatic and the number of symptoms increases with age.
Conversion Disorder:
In conversion disorder, there is usually a loss of function in the movement and sensory organs that is not based on an organic basis. or there is proliferation. Conversion disorder is a disease in which various emotional problems and conflicts are transferred to voluntary organs and transformed into physical symptoms. This disorder, in which symptoms of both sensorimotor and autonomic system dysfunction can be seen, can mimic any physical disease. Conversion disorder occurs in the form of attacks and has one or more symptoms.
Impairment in motor functions, paralysis, lack of strength, weakness, ptosis, posture disorders or astasia-abasia (standing or walking). difficulty). Children who have difficulty standing or walking appear unable to maintain their balance and have jerking movements. But they rarely fall and They usually do not harm themselves. According to some authors, when an extremity is affected, it is usually the non-dominant extremity that does not hinder the patient's life much, and this is usually the left extremity.
Conversion symptoms that occur in the form of impairment in sensory functions are most commonly double or unilateral blindness or deafness. , visual field limitation, glove-style anesthesia and paresthesias.
Pain may be accompanied by a conversion symptom. Patients who come to clinics with unexplained pain are usually diagnosed with conversion disorder. However, if pain is the only symptom, it should be categorized as somatoform pain disorder.
Among the conversion symptoms, fainting, convulsions or convulsions are the most common. Various terms have been used to describe the same clinical condition. These include hysterical seizures, conversion seizures, psychogenic seizures, pseudo-seizures, and pseudo-epileptic seizures.
However, since the majority of patients do not have hysterical personality traits, the term hysterical seizure is no longer used. Psychogenic seizures can mimic any type of epileptic seizure. These patients generally fall while being protected by other people. Self-harming falls, tongue biting, foaming at the mouth, and urinary incontinence usually do not occur. The seizure can last a long time, it does not occur during sleep, the patient can talk during the seizure, respond to painful stimuli, and the seizure usually ends with crying. Psychological stressors that initiate a seizure are often passed on by the family. Although detailed history, physical examination, neurological examination and tests are performed, the differential diagnosis between epileptic seizures and psychogenic seizures can be difficult. A large proportion of patients have an artistic tendency to imitate real epileptic seizures. Among complex partial seizures, frontal seizures most often resemble psychogenic seizures.
Sometimes, the presence of both true epileptic seizures and psychogenic seizures in the same patient makes the diagnosis difficult. After EEG monitoring began, it has been shown that 10-30% of patients previously diagnosed with psychogenic seizures have accompanying real epileptic seizures. Similarly, diagnostic
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