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Somatoform Disorders and Trauma in Medically-Admitted Children, Adolescents, and Young Adults: Prevalence Rates and Psychosocial Characteristics Katharine Thomson PhD, Edin Randall PhD, Patricia Ibeziako MD, I. Simona Bujoreanu PhD

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S0033-3182(14)00080-2 http://dx.doi.org/10.1016/j.psym.2014.05.006 PSYM463

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Psychosomatics

Cite this article as: Katharine Thomson PhD, Edin Randall PhD, Patricia Ibeziako MD, I. Simona Bujoreanu PhD, Somatoform Disorders and Trauma in MedicallyAdmitted Children, Adolescents, and Young Adults: Prevalence Rates and Psychosocial Characteristics, Psychosomatics, http://dx.doi.org/10.1016/j. psym.2014.05.006 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting galley proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Somatoform Disorders and Trauma in Medically-Admitted Children, Adolescents, and Young Adults: Prevalence Rates and Psychosocial Characteristics Katharine Thomson, PhD1 Edin Randall, PhD1 Patricia Ibeziako, MD1 I. Simona Bujoreanu, PhD1 Affiliation: 1 Boston Children’s Hospital / Harvard Medical School, Boston, MA Send correspondence and reprint requests to: Katharine Thomson, PhD Department of Psychiatry Boston Children’s Hospital 300 Longwood Ave Boston, MA, 02115 [email protected] 617-355-4409

Abstract Objective: The purpose of this study is to describe past traumatic experiences in medicallyadmitted pediatric and young adult patients diagnosed with somatoform disorders, and to explore demographic, diagnostic, and psychosocial differences between those with and without trauma histories. Methods: Retrospective chart reviews were performed for patients (aged 3-29) seen by the Psychiatry Consultation Service (2010-2011) at a pediatric medical hospital and diagnosed with a somatoform disorder. Clinical data collected included: demographics, medical history, current physical symptoms, psychiatric diagnoses and history, trauma history, coping styles, family

psychiatric and medical history, peer and family factors, psychiatric disposition after discharge, and service utilization. Results: Mean age for the 180 identified patients was 15.14 years. The majority of patients were female (75.0%) and White (71.7%). Somatoform diagnoses were primarily pain (51.4%) and conversion disorders (28.9%). Rates of trauma were similar to national norms (29.7%). Trauma history did not correlate with age, sex, race, income, length of hospitalization, or type of somatoform disorders. Patients with trauma histories, however, had significantly higher rates of psychiatric comorbidities (76.0% vs. 50.8%), past psychiatric treatment (81.1% vs. 59.1%), parent mental illness (69.8% vs. 38.6%), and family conflict (52.8% vs. 37.0%), and were more likely to require inpatient psychiatric hospitalization upon discharge (18.9% vs. 6.3%). Conclusion: Prevalence of trauma in a sample of medically-admitted pediatric and young adult patients with somatoform diagnoses was similar to national norms. However, patients with a history of trauma had unique psychiatric and psychosocial profiles compared to those without a history of trauma. Key words: Somatoform disorders, somatic symptom disorders, children, young adults, trauma, psychiatry consultation service

Introduction Somatic symptoms are commonly reported among children, adolescents, and young adults, with up to 50% of pediatric primary care visits reported to include medically unexplained symptoms.1 Somatic symptoms occur when a patient’s subjective report of physical symptoms is not supported by clear medical pathology and are associated with discomfort, functional 2

limitations, and increased health care costs.2 Somatic symptoms are present in virtually every psychiatric diagnosis, and the majority of research to date has focused on somatic symptoms (versus somatoform disorders) among adults particularly in outpatient settings. Few known studies examine somatoform disorders among pediatric and/or young adult samples in inpatient medical settings. This study adds to the literature by: (1) focusing on children, adolescents, and young adults seen in an inpatient medical setting and diagnosed with somatoform disorders and (2) investigating the links between trauma and psychopathology in this population. Given the paucity of research on somatoform disorders in pediatric/young adult samples, the following review will draw from studies examining somatic symptoms as well as somatoform disorders among adult populations. Recent literature outlines several factors which predispose and precipitate somatic symptoms in pediatric patients, including physical illness, developmental transitions, school pressures, high-achieving families, dysfunctional family patterns, internalizing coping mechanisms, “good child” temperament, psychiatric co-morbidities, and a history of trauma.2–4 Despite suggestions that multiple factors are associated with the development and maintenance of somatoform disorders, clinical and empirical accounts often prioritize the connection between trauma and somatic symptoms.5–7 Several theories have been proposed to explain the connection between somatic symptoms and trauma. For example, arousal in the context of trauma is thought to perpetuate a hypersensitivity and hyperarousal in response to bodily sensations6, and dissociation, especially when related to contact trauma, is proposed as a moderator in the association between trauma and somatic symptoms.8,9 Furthermore, childhood trauma is hypothesized to precipitate an 3

insecure attachment style and lead to healthcare seeking behaviors (i.e. secondary gain).10 Finally, neurobiological models propose that trauma alters the body’s stress response (e.g., hypothalamus-pituitary-adrenal axis, cortisol levels, cardiac vagal tone), thus impacting one’s ability to cope with subsequent stressors,11,12 which may also explain why multiple stressors are linked with higher severity of somatic symptoms.6,13 Many studies examining relationships between trauma and somatic symptoms demonstrate high rates of past sexual abuse (32-45%), physical abuse (26-34%), and medical trauma (8%) in adult samples.14–17 Some factors may moderate the strength of the relationship between trauma and somatic symptoms: a meta-analysis found that males and patients with PTSD yielded the strongest associations between trauma and somatic symptoms7 (the latter of which may bolster the theory that dissociation moderates the relationship between trauma and somatic symptoms8,9). Other studies indicate that adults with past sexual abuse have more somatic symptoms, greater functional impairment, and higher rates of psychopathology when compared to adults with somatoform disorders and no past sexual abuse.5,14,16 Emotional abuse has also been linked to adult somatization disorder.4 The few existing studies on pediatric somatoform disorders are generally descriptive and focus on less acute samples from outpatient settings.6 One study found that among a group of psychiatrically hospitalized adolescents, somatic symptoms were higher among those with trauma histories than among those without trauma histories.18 No studies to our knowledge target somatoform disorders and trauma in children or young adults in acute inpatient medical settings. Although estimating prevalence rates of childhood trauma is challenging, over 675,000 unique and substantiated cases of child abuse were reported in the US in 2011,19 with victims 4

equally distributed across girls and boys. Regarding race and ethnicity, a longitudinal study found that the prevalence of trauma varied across groups of White, Black, and Latino participants; however, there were no interaction effects found between trauma and ethnicity related to psychiatric outcomes.20 Within the general population of US children and adolescents, lifetime prevalence of trauma ranges from 8 to 24% for sexual trauma, 9 to 29% for physical assault, and 13 to 39% for interpersonal violence,21–23 with 1/4 of children and adolescents experiencing at least one traumatic event before the age of 16.24 In light of the current study’s aim to identify characteristics seen among traumatized youth with somatoform disorders, a review of the factors associated with childhood trauma is warranted. A comprehensive report from the World Health Organization identified several variables associated with trauma in youth including age; pre-existing emotional, behavioral, learning, or medical problems; intergenerational patterns of abuse; caregiver psychiatric illness and substance use; high parental stress and poor family coping; and limited community resources.25 Results from the Adverse Childhood Experiences studies indicated that childhood trauma is associated with increased risk of long-term physical health consequences as well as mental illness sequelae (e.g., depression, anxiety, and psychosis).23 We hypothesized that many of the traumatized youth with somatoform disorders in our sample would present with some of the aforementioned risk factors. In sum, the current study aims to describe the prevalence of past traumatic experiences in medically-admitted pediatric and young adult patients diagnosed with somatoform disorders, and to compare demographic, diagnostic, and psychosocial characteristics between those with trauma histories to those without. The current study proposes that the majority of patients in the sample 5

will not have a trauma history. However, patients with somatoform disorders and a history of trauma are hypothesized to present with a unique constellation of factors that will distinguish them from non-traumatized patients with somatoform disorders and reflect a profile often seen among general samples of traumatized youth. Method Particpants and Procedure Data were obtained from a retrospective review of electronic medical records of 180 medically admitted patients to a tertiary pediatric hospital between January 1, 2010 and December 31, 2011. This study was approved by the hospital’s institutional review board. Patients were identified by the admitting medical service as requiring a psychiatric consultation due to somatic concerns and were subsequently diagnosed with a somatoform disorder by the Psychiatry Consultation Service (PCS). The diagnosis of somatoform disorder can challenging and requires careful collaboration between psychiatry and medicine.26 The diagnosis of somatoform disorder can challenging and requires careful collaboration between psychiatry and medicine. Psychiatry works closely with the medical team on all cases involving suspected somatic symptoms and diagnoses of somatoform disorders are made based on a combination of medical and psychiatric data, as well as collateral from outside providers upon receiving parental consent. Only cases for which a diagnosis of somatoform was clear were included (i.e. suspected somatoform diagnoses or “rule outs” were excluded from the analyses). Diagnoses were made using the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text Revision (DSM-IV TR).27 These diagnoses, which were labeled as “Somatoform Disorders”, have been reviewed and recategorized under “Somatic Symptom and Related Disorders” in the new DSM-5.28 In the 6

DSM-5, the names and/or criteria of some diagnoses changed slightly, while others diagnoses were merged together.29 Informed by the literature on factors thought to be associated with somatoform disorders, psychiatric and medical clinical notes were reviewed by post restrospectively, with the majority of the clinical information gathered from the psychiatric evaluations conducted by PCS clinicians (i.e. interviews with patients and family at the time of the inpatient consultation). De-identified information collected for this study included: (1) demographics (age, sex, race, ethnicity, family income) and service utilization (admitting service, length of stay, readmissions with PCS involvement during study period, psychiatric disposition), (2) patient psychiatric characteristics (diagnoses, treatment, co-morbidities, functional impairment), (3) trauma history, (4) temperament and coping style, (5) family characteristics (family conflict, parent psychiatric history, family stressors), and (6) peer and social characteristics (sexual activity, dating, peer violence, extracurricular involvement). Each PCS case is supervised by an attending psychologist or psychiatrist and each patient undergoes a similar and comprehensive evaluation, regardless of the specific consultation questions. PCS procedures require clinicians to screen for several risk factors for all patients (whether or not somatoform symptoms are suspected), including trauma history; developmental, social, and academic histories; patient and family psychiatric history; and family stressors. Variables were coded dichotomously, with “yes” representing cases in which the factor was endorsed by patient/caregivers and “no” indicating that the factor was denied or not mentioned. More subjective variables, such as temperament and coping style, were based on clinicians’ assessments and observations along with verbal reports from patients and caregivers in response 7

to questions about personality, attitude, decision making style, affective expression, and strategies used to cope with stress. Interrater reliability was assessed and remained consistently substantial across several time points (K > 0.8).30 Using SPSS (Version 19, 2010), descriptive analyses, chi-square tests, and t-tests were performed on the two subsamples (i.e., patients who reported vs. denied a history of trauma). For repeat admissions during the 2-year period, only information from the final admission was included to avoid replication of data in the descriptive analysis; however, re-admission rates were considered while analyzing service utilization. Results Sample characteristics Participants included 180 children, adolescents, and young adults (M =15.14 years, SD = 3.40, Range = 3 – 29 years), representing 14.8% of the total number of unique patients seen by the PCS during the 2-year period (n = 1214). The PCS was consulted 216 times on these 180 patients, which represents less than 0.01% of the overall number of hospital admissions to units served by the PCS during the 2 year period (29, 744). The majority of patients were female (75.0%), White (71.7%), and between the ages of 11-17 (71.7%; see Figure 1). Table 1 details the demographic and hospitalization characteristics of the sample. The median household income for the patients’ communities, as determined by US census track data from 2010 and 2011,31 was $74,615, and ranged from $15,994 to $204,435. The most common admitting services were General Pediatrics (36.7% of patients), Neurology (26.1%), and Gastroenterology (12.8%). The majority of patients in the current sample were diagnosed with pain disorder (51.7%), followed

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by conversion disorder (28.9%). Comorbid non-somatoform psychiatric disorders were also common (see Table 2). Twenty-nine percent of the patients in the entire sample reported a history of trauma. More specifically, 17.2% of the full sample reported interpersonal trauma (e.g., exposure to domestic violence, attachment disruptions such as traumatic loss or multiple temporary home placements), 10.0% sexual abuse, 9.4% “other” traumas (e.g., witnessing/being in a traumatic accident, community violence), 6.7% physical abuse, and 1.7% medical trauma (see Table 3). Of the patients who reported a history of trauma, 49.1% reported exposure to more than one type of trauma (i.e. within or across trauma categories). No significant differences were found between the trauma (T) and non-trauma (NT) groups regarding age, sex, race, income, types of somatoform diagnoses, length of hospitalization, or admitting service. However, 27.6% of the NT-group had either no insurance or state insurance as compared to 49.1% of the T-group [x2(1,180)=7.71, p=.005)]. The mean length of hospitalization was 4.9 days (range 1 to 30 days) and 14.8% of patients were admitted more than once within the 2-year period; no differences were detected between T- and NT-groups. Patients in the T-group were referred to psychiatric inpatient or residential level of care by the PCS significantly more often than those in the NT-group [18.9% vs. 6.3%, x2(1,180)=6.56, p=.01)]; however, patients in the NT-group were referred for outpatient individual therapy more often [85.0% vs. 64.2%, x2(1,180)=9.80, p=.002)]. Individual factors There was a significant difference in rates of comorbid non-somatoform psychiatric diagnoses between the two groups (see Table 2). Three-quarters of patients in the T-group were 9

diagnosed with at least one additional non-somatoform psychiatric disorder versus 50.4% in the NT-group [x2(1,180)=9.64, p=.002)]. After the differences in rates of PTSD were accounted for (34% of trauma-exposed patients met criteria for PTSD), there were still significant differences in rates of other psychiatric disorders between the T- and NT-groups. Depressive disorders were significantly more prevalent within the T-group [37.7% vs. 21.3%, x2(1,180)=5.26, p=.022)] as was Attention Deficit Hyperactivity Disorder (ADHD) [13.2% vs. 3.9%, x2(1,180)=5.17, p=.023)]. Patients in the T-group reported higher rates of prior psychiatric treatment [81.1% vs. 59.1%, x2(1,180)=8.072, p=.004)], past psychiatric diagnoses [75.5% vs. 45.7%, x2(1,180)=13.39, p=.000)], and current psychiatric medications [47.2% vs. 25.2%, x2(1,180)=8.34, p=.004; see Table 4] than those in the NT-group. There were no significant differences in rates of past psychiatric medications (17.8% overall). The overall sample reported high rates of anxious/sensitive temperament (77.2% overall), internalizing and avoidant coping style (75.6% and 39.4%, respectively), and “good child”/compliant temperament (68.3%). However, patients in the NT-group were significantly more likely to report high expectations of themselves as compared to those in the T-group [55.9% vs. 32.1%, x2(1,180)=8.50, p=.004; see Table 4]. Family factors The rate of mental illness in a biological parent of patients in the T-group was higher than in the NT group [69.8% vs. 38.6%, x2(1,180)=14.62, p=.000)] as was family conflict [52.8% vs. 37.0%, x2(1,180)=3.85, p=.005)]. Furthermore, the youth in the T-group were less likely to endorse high expectations from their families [20.8% vs. 36.2%, x2(1,180)=4.13, p=.042); see Table 4]. Interestingly, no significant differences between the two groups were found regarding 10

rates of parent divorce or separation (47.2% overall), recent family move (33.3%), financial stress (30%), other relative with a physical illness (29.4%), parent with a physical illness (28.3%), loss of a significant adult (16.7%), new stepparent (13.9%), or loss of a sibling (12.8%). However, the two groups differed on the total number of these above-named family factors, with the T-group reporting significantly higher rates of these family characteristics overall [90.6% vs. 72.4%, x2(1,180)=7.11, p=.008]. Social factors The patients in the T-group had significantly higher rates of history of romantic dating [41.5% vs. 18.9%, x2(1,180)=10.05, p=.002)], sexual activity [22.6% vs. 5.5%, x2(1,180)=11.62, p=.001)], and peer violence [13.2% vs. 4.7%, x2(1,180)=4.016, p=.045)] than those in the NTgroup (see Table 4); however, they were less likely than patients in the NT-group to participate in extracurricular activities [22.6% vs. 44.8%, x2(1,180)=11.62, p=.001)] or competitions [13.2% vs. 36.2%, x2(1,180)=9.53, p=.002)]. No significant differences were found regarding making friends or being bullied (22.2% and 20.6% respectively overall). Discussion No known studies have examined the prevalence of trauma and other psychosocial descriptors in a sample of medically-hospitalized children and young adults with somatoform disorders. Our study highlights that trauma is not a prerequisite for the presence of a somatoform disorder. In fact, other variables appear to be more prevalent among medically hospitalized young patients with somatoform disorders. Nonetheless, findings suggest that assessing for trauma is necessary; patients with somatoform disorders and trauma histories demonstrate a

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unique cluster of characteristics, and thus warrant tailored assessment and treatment considerations. The majority of patients with somatoform disorders in the sample did not endorse a history of trauma (over 70%). In fact, rates of trauma were comparable to those in national nonpsychiatric samples, yet lower than rates found among adults with somatoform disorders. It is possible that trauma was under-reported in this sample. Alternatively, lifetime childhood trauma may be a risk factor for somatic symptoms later in adulthood, 5,14–17 but not during childhood or young adulthood. It may also be that community-based outpatient samples (i.e. the majority of previous research)7 present with different risk factors when compared to groups of medicallyhospitalized inpatients. The current study was able to make meaningful comparisons between the T-and NTgroups as these two groups were similar with regards to sex, age, race, and family income. Patients in the T-group reported higher rates of psychiatric comorbidities, even beyond the expected differences in rates of PTSD. This finding underscores that trauma responses may include depression, anxiety, somatization, PTSD, or a combination of symptoms.12 This result may also represent limitations associated with the DSM-IV diagnostic criteria for PTSD among pediatric patients. The DSM-528 has broadened the diagnostic criteria for PTSD to include a more comprehensive definition of traumatic experiences as well as specific responses for children, which may lead to different rates of PTSD in future similar studies. The patients in the T-group were also much more likely to be taking psychiatric medications, to have received psychiatric treatments, and to need a higher level of psychiatric care upon discharge than those in the NT-group. Utilization of psychiatric services in the T12

group may be due to higher rates of psychiatric comorbidities. The high rate of biological parents with a history of mental illness within the T-group (over two thirds) may suggest a genetic vulnerability for psychiatric comorbidities. Mental illness in biological parents may also explain the high levels of family conflict seen among the T-group and could also serve as a risk factor for trauma exposure.25 Patients in the T-group also reported higher rates of dating, sexual activity, and peer violence. The vulnerability of these patients is reflected in the bi-directionality of these behaviors; peer variables may increase a young person’s exposure to peer-inflicted traumas (e.g., witnessing a violent crime) and may also be a consequence of post-traumatic reactions (e.g., dysregulation).32–34 Those patients with trauma histories may be even more vulnerable if part of an overwhelmed family system with limited resources to provide support.35 Patients with trauma histories reported much lower rates of extracurricular activities, such as clubs, sports, and competitive teams, and were less likely to endorse high self-expectations and high family demands, which might also reflect a lack of protective factors and community resources available for some traumatized youth.36 While there were many factors unique to the T-group, there were also many characteristics that remained salient across groups, supporting the “typical” psychosocial profile of youth with somatoform disorders described in prior studies: female sex, “good” child, anxious or sensitive temperament, and internalizing and avoidant coping styles.2,3 These aspects appear to be part of the psychosocial profile of youth with somatoform disorders in the current sample, upon which additional and unique characteristics describe those with trauma and somatoform diagnoses. 13

Potential family-related stressors – such as divorce, moves, financial stress, physical illness, and loss – did not appear to be salient factors on their own for either the T- or NTgroups. Family conflict was particularly high among the T-group, though none of the other family factors had high rates in either group. (N.B. The high rate of children in the full sample with divorced/separated parents paralleled national norms).37 That said, the T-group appeared particularly vulnerable, with over 90% of the T-group endorsing at least one of these familyrelated factors. It may be that the specific nature of these family factors is less salient than the context in which they occur (e.g., total number of stressors, family coping/functioning). Trauma during childhood is associated with a variety of family factors, such as family pathology, high rigidity and poor adaptability, low cohesion, boundary and role confusions, and poor coping skills;38 it may be that these additional family factors play a more important role in the development of somatoform illness than childhood trauma per se. This formulation also supports the cumulative model of stress discussed in research of somatoform disorders in adults.6,13 Furthermore, based on previous literature ,39 it is possible that the higher rate of state insurance in the trauma group indicates increased involvement with protective agencies and foster care systems among traumatized youth and represents yet another psychosocial stressor for medically hospitalized youth with trauma and somatoform disorders. This article explored the long-held assumption that somatoform disorders are explained by a history of trauma. Research suggests that many patients who experience trauma do not go on to meet criteria for somatoform disorders (or any psychopathology for that matter), even among high risk groups.12,40,41 Although a history of childhood trauma may be evident among some adults with somatic presentations,14–17 even within our medically hospitalized sample, 14

many patients with somatoform disorders did not report a history of trauma. In fact, many other factors are more strongly linked to somatoform diagnoses (e.g., family mental illness, psychiatric comorbidity). By concentrating efforts on searching for traumatic experiences only, clinicians may miss other potential salient risk factors. Although assessing for trauma remains vital, providers should consider several other salient psychosocial factors, as medically hospitalized patients with somatoform disorders are diagnostically and psychosocially complex.3 Providers should be aware that patients presenting with somatoform disorders who also endorse a history of trauma may be particularly vulnerable and require additional supports. Limitations and Future Directions This study has several limitations. As with all retrospective chart review studies, data were not collected prospectively or in a standardized fashion with validated measures. Generalizability of findings is limited given that the study lacked a comparison sample and included only those youth referred to a tertiary, urban medical hospital. An additional limitation is the small sample; while this allowed for a more comprehensive and thorough investigation of the participants, power may have been compromised. The wide age range of the sample may also limit generalizability of findings; however, some pediatric hospitals are trending to include more young adult patients and delay transition to adult care. As such, the inclusion of young adults with somatoform disorders was an intentional effort to provide information about patients seen in some pediatric hospitals today. Finally, the study dichotomized the trauma variable, therefore precluding consideration of a “dose-response” relationship between trauma and somatic symptoms.5

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Given the cross-sectional nature of the current study, future research should utilize longitudinal data to detect differential trajectories towards somatoform disorders for children and young adults. Additionally, an investigation of protective factors associated with positive outcomes will also be essential to inform strength-based treatment models. Of note, the use of “Somatic Symptom and Related Disorders” in the DSM-5 may yield different results in future similar studies. Some of the new diagnoses have combined two or more previous categories from the DSM-IV-TR such that the distribution across disorders will likely be different.29 Research is needed to determine whether there will be any changes to overall rates of somatic symptom disorders. Conclusion The current study indicated that trauma is not the most common factor associated with somatoform disorders among youth. The vast majority of our sample of medically-admitted children, adolescents, and young adults with somatoform diagnoses did not endorse a history of trauma and prevalence rates of trauma were comparable to those found in non-psychiatric US samples.21,22,24 However, a unique cluster of psychosocial and psychiatric characteristics was detected among patients with past trauma and a somatoform diagnosis (e.g., psychiatric comorbidities, past psychiatric treatment, family mental illness, family conflict, peer violence). Furthermore, such patients appeared to require more psychiatric support in their recovery (e.g. psychiatric medications and psychiatric inpatient treatment). Findings support the need for a multidisciplinary treatment approach to address both the medical and psychological needs of these youth.42

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Disclosure Statement The authors report no proprietary or commercial interest in any product mentioned or concept discussed in this article.

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Table 1. Demographic and Hospital Variables of Patients Medically Admitted With Somatoform Diagnoses, Comparing Those With a History of Trauma to Those Without (N = 180) Trauma Group n=53 Age (in years); mean (SD)

Non-Trauma Group n=127

15.46 (3.68)

15.01 (3.28)

Sex; n (%) Female Male

38 (71.7%) 15 (28.3%)

97 (76.4%) 30 (23.6%)

Race/Ethnicity; n (%) White (not Hispanic or Latino) Black White/Hispanic or Latino Asian Other

35 (66.0%) 9 (17.0%) 5 (9.4%) 0 (0.0%) 3 (5.7%)

93 (73.2%) 12 (9.4%) 13 (10.2%) 1 (0.8%) 8 (6.3%)

Length of stay (number of days); mean (SD)

4.77 (4.75)

4.94 (4.95)

74,000 20,700 163,000

74,625 15,994 204,435

9 (17.0%)

16 (12.6%)

Admitting service General Pediatrics Neurology Gastroenterology Pain Orthopedics Adolescent Medicine Surgery Other service

26 (49.1%)* 12 (22.6%) 5 (9.4%) 3 (5.7%) 2 (3.8%) 2 (3.8%) 0 (0.0%) 3 (5.7%)

40 (31.5%)* 35 (27.6%) 18 (14.2%) 13 (10.2%) 6 (4.7%) 5 (3.9%) 3 (2.4%) 7 (5.5%)

Psychiatric Disposition Outpatient individual therapy Inpatient psychiatric care Outpatient psychiatric medication management Outpatient family therapy In-home therapy Intensive Outpatient Program

34 (64.2%)* 10 (18.9%)* 12 (22.6%) 4 (7.5%) 2 (3.8%) 0 (0%)

108 (85.0%)* 8 (6.3%)* 21 (16.5%) 6 (4.7%) 4 (3.1%) 1 (0.8%)

Median annual household income + (in USD); median Minimum Maximum Re-admissions between 2010-2011, n (%)

Note. + Values compiled via census tracks based on recorder patient address, for the year patient was evaluated by PCS. * p < .05.

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Table 2. Psychiatric Diagnoses Given to Patients Medically Admitted With Somatoform Diagnoses, Comparing Those With a History of Trauma to Those Without (N = 180)

Somatoform Diagnoses Pain Disorders Conversion Disorder Somatoform Disorder NOS Undifferentiated Somatoform Disorder Somatization Disorder Other Psychiatric Diagnoses Given PTSD Anxiety Disorders (not including PTSD) Depressive Disorders Mood Disorders ADHD Adjustment Disorder Eating Disorders Learning and Developmental Disorders (including PDD) Other diagnoses (ODD, CD, substance use) No other diagnosis

Trauma Group n=53 53 (100.0%)

Non-Trauma Group n=127 127 (100.0%)

27 (50.9) 16 (30.2%) 7 (13.2%) 3 (5.7%) 2 (3.8%)

66 (52.0%) 36 (28.3%) 20 (15.7%) 8 (6.3%) 2 (1.6%)

40 (75.5%)*

64 (50.4%)*

18 (34.0%)* 18 (34.0%) 20 (37.7%)* 2 (3.8%) 7 (13.2%)* 1 (1.9%) 4 (7.5%) 6 (11.3%) 5 (9.4%) 13 (24.5%)*

0 (0.0%)* 30 (23.6%) 27 (21.3%)* 4 93.1%) 5 (3.9%)* 4 (3.1%) 5 (3.9%) 17 (13.4) 6 (4.7%) 63 (49.6%)*

Note. * p < .05. PTSD: Post-traumatic Stress Disorder; ADHD: Attention Deficit Hyperactivity Disorder; PDD: Pervasive Developmental Disorder; ODD: Oppositional Defiant Disorder; CD: Conduct Disorder

Table 3. Types of Traumas Reported by Patients Medically Admitted With Somatoform Diagnoses (N = 180) Denied past trauma Reported trauma + Interpersonal trauma Sexual abuse Physical abuse Other traumas Medical trauma Multiple traumas +

127 (70.6%) 53 (29.4%) 31 (17.2%) 18 (10.0%) 12 (6.7%) 17 (9.4%) 3 (1.7%) 26 (14.4%)

Non-mutually exclusive categories

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Table 4. Characteristics of Patients Medically Admitted With Somatoform Diagnoses, Comparing Those With a History of Trauma to Those Without (N = 180) Trauma Group n=53

Non-Trauma Group n=127

Individual Factors Non-somatoform psychiatric comorbid diagnosis Prior psychiatric treatment Current psychiatric medications Past psychiatric medications High self demands Internalizing coping style Anxious/sensitive temperament “Good child”/ compliant temperament Avoidant coping style

40 (75.5%)* 43(81.1%)* 25 (47.2%)* 13 (24.5%) 17 (32.1%)* 43 (81.1%) 42 (79.2%) 35 (66.0%) 24 (45.3%)

64 (50.4%)* 75 (59.1%)* 32 (25.2%)* 19 (15.0%) 71 (55.9%)* 93 (73.2%) 98 (77.2%) 88 (69.3%) 47 (37.0%)

Family Factors Biological parent with mental illness Conflict with family High expectations from family Parent divorce or separation Family financial stress Recent family move Parent with physical illness Relative with physical illness Loss of a significant adult New stepparent Loss of a sibling

37 (69.8%)* 28 (52.8%)* 11 (20.8%)* 26 (49.1%) 20 (37.7%) 17 (32.1%) 16 (30.2%) 15 (28.3%) 11 (20.8%) 6 (11.3%) 5 (9.4%)

49 (38.6%)* 47 (37.0%)* 46 (36.2%)* 59 (36.2%) 34 (26.8%) 43 (33.9%) 38 (29.9%) 38 (29.9%) 9 (15.0%) 19 (15.0%) 18 (14.2%)

Peer/Social Factors Dates Sexually active Peer violence Participated in teams/clubs Participates in competitive activities/sports Difficulty making friends Is bullied by peers

22 (41.5%)* 12 (22.6%)* 7 (13.2%)* 12 (22.6%)* 7 (13.2%)* 10 (18.9%) 12 (22.6%)

24 (18.9%)* 7 (5.5%)* 6 (4.7%)* 62 (48.8%)* 46 (36.2%)* 30 (23.6%) 25 (19.7%)

* p < .05.

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Figure 1. Age distribution of sample (N = 180), comparing those with a history of trauma (n = 53) to those without (n = 127). There were no significant differences between T- and NT-groups regarding age distribution.

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Somatoform disorders and trauma in medically-admitted children, adolescents, and young adults: prevalence rates and psychosocial characteristics.

The purpose of this study is to describe past traumatic experiences in medically-admitted pediatric and young adult patients diagnosed with somatoform...
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