Adolescent Somatic Symptoms: Masks for Individual and Family Psychopathology Stuart
Fine
R
PAINS IN THE ABDOMEN, head and limbs, dizziness, ECURRENT fatigue and skin problems are common in adolescents and in many cases social stresses or intrafamilial pathology can be found to be a precipitating or a perpetuating factor. The prevalence of these functional complaints is hard to assess, as different clinics have different definitions of the presenting complaints and the final diagnosis. However, in one ambulatory care clinic for adolescents, 29% presented with functional complaints. In some of these, gross psychosocial reasons for disease were apparent.’ In a Danish study of 2000 children aged 6- 19 yr, 14.4% suffered from recurrent abdominal pains and 20.6% from recurrent headaches over an 8 yr period. The abdominal pain reached a peak incidence at the age of 9 yr and the headaches at the age of 12 yr. The theories to elucidate the psychosocial factors causing somatic pain include the idea that imitation of parent’s complaints occurs. Also, there is frequently spasm of voluntary or involuntary muscle which may well cause pain. Anxiety can cause increased head muscle spasm, and intestinal spasms have been shown in children with recurrent abdominal pain. External stresses, internal stresses, and conflicts can all cause emotions such as anxiety or anger which can then manifest as somatic symptoms. The choice of the site of symptom may depend upon whether previous pathology has occurred in that area. Children tend to describe the somatic feelings of certain emotions as occurring in certain parts of the body.” Figure I may help to clarify these ideas. The adolescent may suffer because he has not managed to master some of the tasks with which his peers are struggling. Some of these tasks include establishing a new relationship with parents and authority figures, maintaining old and cstablishing new peer relationships, establishing a sexual identity, making some decisions about what he or she is going to do after leaving school and changing values especially in regard to what is meant by achievement and adjustment in society. If the adolescent has sufficient anxiety about several or one of these tasks somatic symptoms may occur. Some adolescents seem to be particularly aware of somatic sensations and they are concerned about changes in their body shape. They may be more than usually aware of the beating of their hearts, the noise of blood going through the arteries when their head is on the pillow, the presence of vitreous opacities in the eyes, the ease with which blushing occurs and the presence of any physical blemish like a pimple or a scar. Some individuals who complain of recurrent pains either in the
From
rhe Deportment
Stuart
Fine, M.B..
Reprrnr
reyue.rts
ofPs_vchiotry,
F.R.C.P.(C. should
Universily
of British Columbia.
1, F. F. Psych: Assistant
he addressed
to Prof‘rssor
Projessor.
Sruarr
Vancouver
University
Canada
o/British
Ftne, 717 We.\1 IOrh .4 venue.
Columhia. Vanuurl~rr.
B. C., Canada.
c 1977
hl. Grune
Comprehensive
& Stratton.
Inc.
Psychiatry, Vol 18. No. 2 (March/April),
1977
135
136
STUART
External
FINE
Life Stresses
loss of significant
people
Poor peer relationships Poor school performance Family conflict
Emotions
\
Anger Sadness Anxiety ElInternal
Stresses
Fear
Somatic Symptoms Headaches Dizziness Abdominal
Pain
/
Sexual feelings New body image New values in conflict with family Fig. 1.
Mechanisms
by which somatic symptoms
may occur from psychosocial stresses.
abdomen, head, or limbs may have a constitutionally low pain threshold. This low pain threshold is likely to be present in other members of the family, although the site of the pain may vary. EXTERNAL
STRESSES
There are various stresses to which adolescents may be subjected. An attempt has been made to give these stresses numerical values, called life change units.0 These life change units were established by assessing 3500 children for the amount of social stress they had had in the preceding year. (The birth or adoption of a sibling was used as a standard and an arbitrary value of 50 life change units was assigned.) The life change units of some representative stresses are: beginning senior school 45 units, beginning to date 55 units, suspension from school 54 units, and becoming involved with drugs and alcohol 70 units. The vulnerability of an individual to stress may increase so that the effects of several stresses may be cumulative. There is tremendous variation in response to stress from individual to individual and in the same individual from time to time. External stresses and internal impulses may produce conflicts which result in certain emotions. These emotions may elicit autonomic nervous system effects and ultimately certain somatic symptoms. Three representative case histories follow: CASE
STUDIES
Case I QB is a 14 yr old from a town in the interior of British Columbia. He refused to go to school for the last 5 wk of the school year. He complained of dizziness and headaches and no organic cause for these symptoms could be found. He was in a special class at school although subsequently he was found to have an average intelligence on psychometric testing. He was admitted to hospital and an ophthalmologist found that he was unduly preoccupied with vitreous opacities. He noted that he was the most depressed boy that he had ever seen.
SOMATIC SYMPTOMS
On psychiatric
interview
137
he did present
as a very quiet inhibited
adolescent
who was reluctant
to
walk to the interview room because he felt dizzy. He said that he had been told that a viral illness had caused his dizziness, however he was concerned that he might have affected himself because he “smoked pot on one occasion.” He showed little interest in the future and most questions were answered with the response “I don’t care.” A family interview revealed an aggressive hard drinking father, who was a logger, and a very timid mother who also drank a fair amount of alcohol. There were two younger siblings, twins, who had no behavior problems. There was some conflict between the parents as to how to handle Q’s refusal to go to school. Mother did not want to “push Q too hard” and she told us that Q’s best friend had been expelled from school. Q was given amitryptylene 10 mg t.i.d. and was encouraged to get up and get dressed every morning. A program was started in occupational therapy. He was discharged to participate in the day program but mother again was reluctant to “push him” to come. Although Q still complained of dizziness he did not allow this to contine him to bed. His mother could accept that his somatic symptoms were related to his entering a special class, to losing his best friend from school, and some of the marital turmoil that she was experiencing with her husband. Q‘s symptoms abated a little and his day to day functioning increased a 101.
Case 2 FE is a I7 yr old male of Greek origin, He presented with headaches and dizziness and fear of the dark. His older brother and mother had moved with him to the city 3 months prior to referral. His father had remained in a rural area where he worked. F said that he was concerned that he had damaged himself by smoking pot. He ruminated a great deal about this concern. Also he felt that he could not relate well to girls and he felt ignorant about how to talk to them. He had become more reticent at home and his parents were concerned that he was suicidal. His father came to the city and his parents argued a great deal, especially about how to handle F. F presented as a tense boy who had been sleeping poorly. He had difficulty getting off to sleep. He had lost weight and had a poor appetite and did have feelings that life was not worth living. Ten individual interviews took place and he was given amitryptylene IO mg. t.i.d. He was also encouraged to come to adolescent group discussions. F’s somatic symptoms improved considerably and he had no more feelings of wanting to commit suicide. He asked for frequent reassurance that he had not done himself harm by smoking
pot.
Case 3 1-Q is a I6 year old male, who presented with severe “skin problems” and refusing to go to school. He wanted to get A grades at school and felt that his B average was not good enough. He was also concerned that he was unattractive to girls. L’s parents had separated 3 yr prior to the referral. L decided to stay with his father. His mother decided to join a commune. She thought that her son needed megavitamins and took him to a specialist to obtain these. His father had taken him to several dermatologists for his alleged “acne.” None of the dermatologists was impressed with the acne. L had a previous history of dizziness in grade 5. This was extensively investigated and no organic cause was found. In that year he missed a great deal of school. In the interview he presented as a rather tense but verbal 16 year old. He ruminated a great deal about what he was missing in life and felt that life was not worth living. He was very critical of his own achievement and envious of others. He admitted that parental and peer approval were extremely important to him. Amitryptylene was prescribed but he did not take it. He attended adolescent group discussions and was very challenging to the group leaders. He returned to school but continually arranged situations so that he needed to be treated differently or specially. Several interviews with L and father revealed that father was reluctant to “push” L as father had been “pushed” as an adolescent and subsequently suffered from a depressive illness which required electroconvulsive therapy. Mother was also very solicitous towards L. Over the summer vacation L became more and more withdrawn and refused to go out. He would lie on his bed for long periods and would ask his father to
138
STUART
FINE
tell his friends that he was out if they called him. L would have bursts of activity and he ran for class president and was an assistant editor on the school journal. His somatic symptoms abated but his obsessive ruminations persisted after 8 mo of individual and group therapy. He does realize that when he is angry or embarrassed he has a flare up of his “acne” and he accepts that expressing his feelings verbally sometimes aborts an acne attack.
DISCUSSION
Several patients were extensively investigated by specialists. The psychosocial stresses often became apparent only after many interviews, and in 2 cases it was months before all members of the family could be persuaded to come in. In the case of QB he was very similar to his mother who was reticent and inhibited. FE’s father had somatic symptoms which caused him to miss work and LQ’s father had several somatic symptoms for which he had sought medical advice from several specialists. In all three there was a family pattern of expressing emotions through somatic symptoms. It was striking how frequently the adolescents had had a recent introduction to drugs or alcohol and they feared that the drugs or alcohol would cause irreparable harm. Also disagreement between the parents as to how to handle their child was almost invariable. Psychopathology in adolescents is controversial. Adolescence is a time of flux both in the physical and emotional spheres. The adolescent turmoil that was thought to be short lived is probably not so; and those adolescents showing many symptoms both somatic and behavioral do not grow out of these symptoms. Depression in adolescents can mean the symptom of sadness. It can mean a constellation of somatic and behavioral symptoms or it can mean a diagnostic entity which includes a specific response to treatment and a possible genetic predisposition. There is some question as to whether the diagnostic entity of severe psychotic depression, as it occurs in adults, occurs in adolescents, especially young adolescents. Some adolescents have a depressive life style that may have persisted from early childhood. This was the case with QB who had never been an outgoing lad. Some adolescents have somatic symptoms which may mask a depressive mood. We say this because the somatic symptoms respond to antidepressants and uncovering of self directed anger. Anxiety can also be well masked and a casual facade may be presented to the interviewer, yet in an anxiety provoking situation, such as school, the anxiety becomes quite apparent. Another observer, the teacher or the school nurse, may be able to see this manifest anxiety. Family psychopathology may also be carefully masked.’ In some families anger is only expressed verbally in the form of somatic symptoms. For example, mother gets her migraine each time her daughter comes in late from a date. Dad’s abdominal pains are exacerbated by his son’s poor attendance at school. Also certain expectations may be placed upon adolescents.* If the parents expect promiscuity in their adolescent daughter and she reminds them of a relative who was promiscuous, the parents vigilance may provoke promiscuity. This process is seen in adolescents who run away or become involved in hard drugs. Oversolicitousness may result in eliciting somatic symptoms: “This discussion is not giving you a headache is it?”
SOMATIC
139
SYMPTOMS
The adolescent
may set one parent
against
the other
and if there is already
some marital turmoil the situation is aggravated. In the assessment a school report of academic achievement, peer relationships, and previous psychological testing can be invaluable and there are several professionals in the community who are keen to help and are often not used sufficiently. The school nurse is a good example of this. Treatment may include somatic agents such as antidepressants, individual, family, or group therapy. Sometimes a procedure to investigate the condition can give the adolescent a face-saving device to give up his or her symptoms; usually, however. special investigations seem to make the somatic symptoms harder to give up. Counselling these adolescents can be rewarding. One must be prepared for many cancelled appointments. Anthony” suggests that one should schedule several appointments in quick succession perhaps twice weekly and then allow a break and resume the relationship once again. Adolescents can also be very difficult to persuade to go to group therapy; they are always afraid that this indelibly labels them as sick and at the group there will be other “kooks” to reinforce this label. However, once they have come to one or two group meetings their attendance is usually very conscientious. In the group other adolescents are good at confronting those who complain of many somatic symptoms. In family therapy the words used to express emotions may need to be changed from somatic complaints to more explicit terms of how each family member feels. Family members will be encouraged to use the words angry, happy, sad, disappointed. PROGNOSIS
Although Apley’O has stated “little bellyachers become big bellyachers” or they develop other somatic symptoms, another follow-up study” of 64 patients over an average of 2!2 yr showed that 65970 of them were considerably improved, 25% were somewhat improved and 10% were not improved or were worse. Of the 64, 11 had had some sort of treatment, either psychotherapy, environmental changes, or a tranquilizer. SUMMARY
AND CONCLUSIONS
Recurrent somatic symptoms in adolescents are frequent. The psychosocial stresses on the family and individual should be assessed by an individual interview and a family interview. Intervention by individual, family, and group therapy can be effective in mobilizing the adolescent; and in those cases where depression is suspected, antidepressants seem to alleviate some of the symptoms. Some of the precipitating events may seem trivial to us as adults but to adolescents their move to a high school, their first experience with drugs or alcohol and the arrival of a new step-parent may be sufficient to trigger somatic complaints. A comprehensive assessment may make it clear that psychosocial factors are playing a big part in the adolescents’ symptoms. REFERENCES I. Hofmann AD, Gaman M: The adolescent outpatient, medical, social and emotional needs. Postgraduate Med 50:245-249, 1971
2. Oster headache adolescents.
J: Recurrent abdominal and limb pains in children Pediatrics 50:429-436. 1972
pain. and
140
3. Simonds JF: Physical symptoms without organic basis in children: modeling relationships. MO Med 691746749, 1973 4. Dimson SB: Transit time related to clinical findings in children with recurrent abdominal pain. Pediatr 47:666-674, 1971 5. Lewis WC, Wolman RN, King M: The development of the language of emotions. Amer J Psychiatry 127:1491-1497, 1971 6. Heisel J’S, Ream S, Raitz R, et al: The significance of life events as contributing factors in the diseases of children III. A study of pediatric patients. J Pediatr 83:119-123, 1973 7. Koch CR, Minuchin S, Donovan WM: A
STUART
FINE
case of somatic expression of family and environmental stress, Clin Pediatr (Phila) 13:815-818, 1974 8. Raybin JB: The curse a study in family communications. Am J Psychiatry 127:617-625, 1970 Psychotherapy of 9. Anthony EL: adolescence, in American Handbook of Psychiatry, Arieti S (ed), New York, Basic Books, 1974, pp 234249 IO. Apley J: The Child with Abdominal Pains, Oxford, England, Blackwell, 1959 1 I. Friedman R: Some characteristics of children with psychogenic pain. Observations on prognosis and management. Clin Pediatr (Phila), 11:331-333, 1972
Fine
R
PAINS IN THE ABDOMEN, head and limbs, dizziness, ECURRENT fatigue and skin problems are common in adolescents and in many cases social stresses or intrafamilial pathology can be found to be a precipitating or a perpetuating factor. The prevalence of these functional complaints is hard to assess, as different clinics have different definitions of the presenting complaints and the final diagnosis. However, in one ambulatory care clinic for adolescents, 29% presented with functional complaints. In some of these, gross psychosocial reasons for disease were apparent.’ In a Danish study of 2000 children aged 6- 19 yr, 14.4% suffered from recurrent abdominal pains and 20.6% from recurrent headaches over an 8 yr period. The abdominal pain reached a peak incidence at the age of 9 yr and the headaches at the age of 12 yr. The theories to elucidate the psychosocial factors causing somatic pain include the idea that imitation of parent’s complaints occurs. Also, there is frequently spasm of voluntary or involuntary muscle which may well cause pain. Anxiety can cause increased head muscle spasm, and intestinal spasms have been shown in children with recurrent abdominal pain. External stresses, internal stresses, and conflicts can all cause emotions such as anxiety or anger which can then manifest as somatic symptoms. The choice of the site of symptom may depend upon whether previous pathology has occurred in that area. Children tend to describe the somatic feelings of certain emotions as occurring in certain parts of the body.” Figure I may help to clarify these ideas. The adolescent may suffer because he has not managed to master some of the tasks with which his peers are struggling. Some of these tasks include establishing a new relationship with parents and authority figures, maintaining old and cstablishing new peer relationships, establishing a sexual identity, making some decisions about what he or she is going to do after leaving school and changing values especially in regard to what is meant by achievement and adjustment in society. If the adolescent has sufficient anxiety about several or one of these tasks somatic symptoms may occur. Some adolescents seem to be particularly aware of somatic sensations and they are concerned about changes in their body shape. They may be more than usually aware of the beating of their hearts, the noise of blood going through the arteries when their head is on the pillow, the presence of vitreous opacities in the eyes, the ease with which blushing occurs and the presence of any physical blemish like a pimple or a scar. Some individuals who complain of recurrent pains either in the
From
rhe Deportment
Stuart
Fine, M.B..
Reprrnr
reyue.rts
ofPs_vchiotry,
F.R.C.P.(C. should
Universily
of British Columbia.
1, F. F. Psych: Assistant
he addressed
to Prof‘rssor
Projessor.
Sruarr
Vancouver
University
Canada
o/British
Ftne, 717 We.\1 IOrh .4 venue.
Columhia. Vanuurl~rr.
B. C., Canada.
c 1977
hl. Grune
Comprehensive
& Stratton.
Inc.
Psychiatry, Vol 18. No. 2 (March/April),
1977
135
136
STUART
External
FINE
Life Stresses
loss of significant
people
Poor peer relationships Poor school performance Family conflict
Emotions
\
Anger Sadness Anxiety ElInternal
Stresses
Fear
Somatic Symptoms Headaches Dizziness Abdominal
Pain
/
Sexual feelings New body image New values in conflict with family Fig. 1.
Mechanisms
by which somatic symptoms
may occur from psychosocial stresses.
abdomen, head, or limbs may have a constitutionally low pain threshold. This low pain threshold is likely to be present in other members of the family, although the site of the pain may vary. EXTERNAL
STRESSES
There are various stresses to which adolescents may be subjected. An attempt has been made to give these stresses numerical values, called life change units.0 These life change units were established by assessing 3500 children for the amount of social stress they had had in the preceding year. (The birth or adoption of a sibling was used as a standard and an arbitrary value of 50 life change units was assigned.) The life change units of some representative stresses are: beginning senior school 45 units, beginning to date 55 units, suspension from school 54 units, and becoming involved with drugs and alcohol 70 units. The vulnerability of an individual to stress may increase so that the effects of several stresses may be cumulative. There is tremendous variation in response to stress from individual to individual and in the same individual from time to time. External stresses and internal impulses may produce conflicts which result in certain emotions. These emotions may elicit autonomic nervous system effects and ultimately certain somatic symptoms. Three representative case histories follow: CASE
STUDIES
Case I QB is a 14 yr old from a town in the interior of British Columbia. He refused to go to school for the last 5 wk of the school year. He complained of dizziness and headaches and no organic cause for these symptoms could be found. He was in a special class at school although subsequently he was found to have an average intelligence on psychometric testing. He was admitted to hospital and an ophthalmologist found that he was unduly preoccupied with vitreous opacities. He noted that he was the most depressed boy that he had ever seen.
SOMATIC SYMPTOMS
On psychiatric
interview
137
he did present
as a very quiet inhibited
adolescent
who was reluctant
to
walk to the interview room because he felt dizzy. He said that he had been told that a viral illness had caused his dizziness, however he was concerned that he might have affected himself because he “smoked pot on one occasion.” He showed little interest in the future and most questions were answered with the response “I don’t care.” A family interview revealed an aggressive hard drinking father, who was a logger, and a very timid mother who also drank a fair amount of alcohol. There were two younger siblings, twins, who had no behavior problems. There was some conflict between the parents as to how to handle Q’s refusal to go to school. Mother did not want to “push Q too hard” and she told us that Q’s best friend had been expelled from school. Q was given amitryptylene 10 mg t.i.d. and was encouraged to get up and get dressed every morning. A program was started in occupational therapy. He was discharged to participate in the day program but mother again was reluctant to “push him” to come. Although Q still complained of dizziness he did not allow this to contine him to bed. His mother could accept that his somatic symptoms were related to his entering a special class, to losing his best friend from school, and some of the marital turmoil that she was experiencing with her husband. Q‘s symptoms abated a little and his day to day functioning increased a 101.
Case 2 FE is a I7 yr old male of Greek origin, He presented with headaches and dizziness and fear of the dark. His older brother and mother had moved with him to the city 3 months prior to referral. His father had remained in a rural area where he worked. F said that he was concerned that he had damaged himself by smoking pot. He ruminated a great deal about this concern. Also he felt that he could not relate well to girls and he felt ignorant about how to talk to them. He had become more reticent at home and his parents were concerned that he was suicidal. His father came to the city and his parents argued a great deal, especially about how to handle F. F presented as a tense boy who had been sleeping poorly. He had difficulty getting off to sleep. He had lost weight and had a poor appetite and did have feelings that life was not worth living. Ten individual interviews took place and he was given amitryptylene IO mg. t.i.d. He was also encouraged to come to adolescent group discussions. F’s somatic symptoms improved considerably and he had no more feelings of wanting to commit suicide. He asked for frequent reassurance that he had not done himself harm by smoking
pot.
Case 3 1-Q is a I6 year old male, who presented with severe “skin problems” and refusing to go to school. He wanted to get A grades at school and felt that his B average was not good enough. He was also concerned that he was unattractive to girls. L’s parents had separated 3 yr prior to the referral. L decided to stay with his father. His mother decided to join a commune. She thought that her son needed megavitamins and took him to a specialist to obtain these. His father had taken him to several dermatologists for his alleged “acne.” None of the dermatologists was impressed with the acne. L had a previous history of dizziness in grade 5. This was extensively investigated and no organic cause was found. In that year he missed a great deal of school. In the interview he presented as a rather tense but verbal 16 year old. He ruminated a great deal about what he was missing in life and felt that life was not worth living. He was very critical of his own achievement and envious of others. He admitted that parental and peer approval were extremely important to him. Amitryptylene was prescribed but he did not take it. He attended adolescent group discussions and was very challenging to the group leaders. He returned to school but continually arranged situations so that he needed to be treated differently or specially. Several interviews with L and father revealed that father was reluctant to “push” L as father had been “pushed” as an adolescent and subsequently suffered from a depressive illness which required electroconvulsive therapy. Mother was also very solicitous towards L. Over the summer vacation L became more and more withdrawn and refused to go out. He would lie on his bed for long periods and would ask his father to
138
STUART
FINE
tell his friends that he was out if they called him. L would have bursts of activity and he ran for class president and was an assistant editor on the school journal. His somatic symptoms abated but his obsessive ruminations persisted after 8 mo of individual and group therapy. He does realize that when he is angry or embarrassed he has a flare up of his “acne” and he accepts that expressing his feelings verbally sometimes aborts an acne attack.
DISCUSSION
Several patients were extensively investigated by specialists. The psychosocial stresses often became apparent only after many interviews, and in 2 cases it was months before all members of the family could be persuaded to come in. In the case of QB he was very similar to his mother who was reticent and inhibited. FE’s father had somatic symptoms which caused him to miss work and LQ’s father had several somatic symptoms for which he had sought medical advice from several specialists. In all three there was a family pattern of expressing emotions through somatic symptoms. It was striking how frequently the adolescents had had a recent introduction to drugs or alcohol and they feared that the drugs or alcohol would cause irreparable harm. Also disagreement between the parents as to how to handle their child was almost invariable. Psychopathology in adolescents is controversial. Adolescence is a time of flux both in the physical and emotional spheres. The adolescent turmoil that was thought to be short lived is probably not so; and those adolescents showing many symptoms both somatic and behavioral do not grow out of these symptoms. Depression in adolescents can mean the symptom of sadness. It can mean a constellation of somatic and behavioral symptoms or it can mean a diagnostic entity which includes a specific response to treatment and a possible genetic predisposition. There is some question as to whether the diagnostic entity of severe psychotic depression, as it occurs in adults, occurs in adolescents, especially young adolescents. Some adolescents have a depressive life style that may have persisted from early childhood. This was the case with QB who had never been an outgoing lad. Some adolescents have somatic symptoms which may mask a depressive mood. We say this because the somatic symptoms respond to antidepressants and uncovering of self directed anger. Anxiety can also be well masked and a casual facade may be presented to the interviewer, yet in an anxiety provoking situation, such as school, the anxiety becomes quite apparent. Another observer, the teacher or the school nurse, may be able to see this manifest anxiety. Family psychopathology may also be carefully masked.’ In some families anger is only expressed verbally in the form of somatic symptoms. For example, mother gets her migraine each time her daughter comes in late from a date. Dad’s abdominal pains are exacerbated by his son’s poor attendance at school. Also certain expectations may be placed upon adolescents.* If the parents expect promiscuity in their adolescent daughter and she reminds them of a relative who was promiscuous, the parents vigilance may provoke promiscuity. This process is seen in adolescents who run away or become involved in hard drugs. Oversolicitousness may result in eliciting somatic symptoms: “This discussion is not giving you a headache is it?”
SOMATIC
139
SYMPTOMS
The adolescent
may set one parent
against
the other
and if there is already
some marital turmoil the situation is aggravated. In the assessment a school report of academic achievement, peer relationships, and previous psychological testing can be invaluable and there are several professionals in the community who are keen to help and are often not used sufficiently. The school nurse is a good example of this. Treatment may include somatic agents such as antidepressants, individual, family, or group therapy. Sometimes a procedure to investigate the condition can give the adolescent a face-saving device to give up his or her symptoms; usually, however. special investigations seem to make the somatic symptoms harder to give up. Counselling these adolescents can be rewarding. One must be prepared for many cancelled appointments. Anthony” suggests that one should schedule several appointments in quick succession perhaps twice weekly and then allow a break and resume the relationship once again. Adolescents can also be very difficult to persuade to go to group therapy; they are always afraid that this indelibly labels them as sick and at the group there will be other “kooks” to reinforce this label. However, once they have come to one or two group meetings their attendance is usually very conscientious. In the group other adolescents are good at confronting those who complain of many somatic symptoms. In family therapy the words used to express emotions may need to be changed from somatic complaints to more explicit terms of how each family member feels. Family members will be encouraged to use the words angry, happy, sad, disappointed. PROGNOSIS
Although Apley’O has stated “little bellyachers become big bellyachers” or they develop other somatic symptoms, another follow-up study” of 64 patients over an average of 2!2 yr showed that 65970 of them were considerably improved, 25% were somewhat improved and 10% were not improved or were worse. Of the 64, 11 had had some sort of treatment, either psychotherapy, environmental changes, or a tranquilizer. SUMMARY
AND CONCLUSIONS
Recurrent somatic symptoms in adolescents are frequent. The psychosocial stresses on the family and individual should be assessed by an individual interview and a family interview. Intervention by individual, family, and group therapy can be effective in mobilizing the adolescent; and in those cases where depression is suspected, antidepressants seem to alleviate some of the symptoms. Some of the precipitating events may seem trivial to us as adults but to adolescents their move to a high school, their first experience with drugs or alcohol and the arrival of a new step-parent may be sufficient to trigger somatic complaints. A comprehensive assessment may make it clear that psychosocial factors are playing a big part in the adolescents’ symptoms. REFERENCES I. Hofmann AD, Gaman M: The adolescent outpatient, medical, social and emotional needs. Postgraduate Med 50:245-249, 1971
2. Oster headache adolescents.
J: Recurrent abdominal and limb pains in children Pediatrics 50:429-436. 1972
pain. and
140
3. Simonds JF: Physical symptoms without organic basis in children: modeling relationships. MO Med 691746749, 1973 4. Dimson SB: Transit time related to clinical findings in children with recurrent abdominal pain. Pediatr 47:666-674, 1971 5. Lewis WC, Wolman RN, King M: The development of the language of emotions. Amer J Psychiatry 127:1491-1497, 1971 6. Heisel J’S, Ream S, Raitz R, et al: The significance of life events as contributing factors in the diseases of children III. A study of pediatric patients. J Pediatr 83:119-123, 1973 7. Koch CR, Minuchin S, Donovan WM: A
STUART
FINE
case of somatic expression of family and environmental stress, Clin Pediatr (Phila) 13:815-818, 1974 8. Raybin JB: The curse a study in family communications. Am J Psychiatry 127:617-625, 1970 Psychotherapy of 9. Anthony EL: adolescence, in American Handbook of Psychiatry, Arieti S (ed), New York, Basic Books, 1974, pp 234249 IO. Apley J: The Child with Abdominal Pains, Oxford, England, Blackwell, 1959 1 I. Friedman R: Some characteristics of children with psychogenic pain. Observations on prognosis and management. Clin Pediatr (Phila), 11:331-333, 1972
