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J. Indian Assoc. Child Adolesc. Ment. Health 2017; 13(2):135-148
Original Article
Children with unexplained physical symptoms referred to psychiatry: A descriptive
study
Bheemsain Tekkalaki, Sameeran S. Chate, Veerappa Y. Patil, Nanasaheb M. Patil ,
Jitendra Mugali
Address for correspondence: Bheemsain Tekkalaki, MD, Assistant Professor,
Department of Psychiatry, K.L.E University’s J.N Medical College, Belagavi, and
Karnataka, India. [email protected]
Abstract:
Background: Unexplained physical symptoms are reported to be common in pediatric
population, and are associated with excessive medical resource use, poor quality of life
and long term psychiatric complications. Researches focusing on such children are
sparse. Aims: This study was done with the aim to assess the sociodemographic and
clinical characteristics of children who were referred to psychiatry department for
assessment of unexplained physical symptoms. Methods: A retrospective chart analysis
of all children and adolescents below 19 years of age, referred to psychiatry for
evaluation of unexplained physical symptoms, from January 2010 to December 2015 was
done. Data collected and statistical analysis done. Results: Sixty children and adolescents
were included in the study. Mean age of the sample was 12.44(±3.21) years, with slight
male predominance (58.33%).Most common complaints were headache (26.66%),
followed by loss of consciousness (18.33%) and other body aches (15%). Mean number
of symptoms per subject was 1.5. Most common psychiatric diagnoses were somatoform
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and dissociative disorders (48.33%), followed by depressive disorder (11.67%).
Pharmacotherapy was started in significantly more number of girls compared to boys
(84% v/s48.57%). Conclusion: Majority of subjects referred for evaluation of
unexplained somatic symptoms were adolescent males. Abnormal body movements, head
ache, and other body aches were the commonest presenting complaints. Somatoform and
dissociative disorders, depressive disorders were the commonest psychiatric diagnoses.
Key words: Unexplained physical symptoms, Pediatric somatoform disorder, Pediatric
liaison psychiatry, General hospital psychiatry.
Introduction
Unexplained physical symptoms also known as functional somatic symptoms are
common in pediatric population [1].Children with functional somatic symptoms often are
first seen by general practitioner or a pediatrician. They are referred to mental health
professionals late in the course of illness, often leading to excessive, unnecessary
investigations and overuse of medical services [2]. According to one estimation, about
20% of pediatric visits to primary care are because of unexplained somatic symptoms and
about 47% of the patients referred to pediatric specialist have functional somatic
symptoms [3].
According to the literature available, children with functional somatic symptoms often
utilize more medical resources, report more school absenteeism, poor functioning and
quality of life [4]. Psychiatric comorbidies are very common in these children [5]. Data
also suggests that children with functional somatic symptoms continue to have
psychiatric morbidities even in adolescence [6].
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Data on unexplained physical symptoms in children is sparse and also there are very few
studies from India. We took up this study with the aim to assess the sociodemographic
and clinical characteristics of children and adolescents who were referred to psychiatry
department for assessment of unexplained physical symptoms.
Materials and methods
Study was carried out in a tertiary care super-specialty teaching hospital of a south Indian
city. We conducted a retrospective review. Case files of all children and adolescents
(mentioned simply as “children” hereafter unless specified) referred to Psychiatry OPD
for assessment of unexplained physical symptoms, for a period of five years from 1st
January 2010 to 31st December 2015 were analyzed. Socio-demographic and clinical
details were collected using a semi structured proforma. Data was tabulated and
appropriate statistical tests were applied using Epi Info-7 software.
Results
A total of 232 children and adolescents were referred during this period. Out of them,
sixty children were referred for the evaluation of unexplained physical symptoms, which
formed the sample of our study.
Mean age of the sample was 12.44(±3.21) years, with male sex being slightly
predominant (58.33%). About half of the subjects (53.33%) were referred from the
department of neurosciences, comprising of neuro-medicine, neurosurgery and pediatric
neurology. Next most common source of referrals were department of pediatrics
(28.33%). (Table no.1).
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Majority (83%) of these subjects had not received any medical/surgical diagnosis. Four
(6.67%), children had comorbid seizure disorder and other 6 (10%) had various other
comorbidities. On an average, each subject had 1.5 unexplained medical symptoms. Most
common complaints were headache (26.66%), followed by loss of consciousness
(18.33%) and other body aches (15%) (Table no.1).
Most common psychiatric diagnoses were somatoform and dissociative disorders
(48.33%), followed by depressive disorder (11.67%), tic disorder (11.67%) and anxiety
disorders (8.33%). Almost equal number of subjects received pharmacotherapy (51.67%)
and non-pharmacotherapy (49.33%) (Table no.1).
We further made comparisons between boys and girls (Table no.2) and between children
and adolescents (Table no.3). The only statistically significant difference observed was
that, significantly large number of girls (84%) were started on pharmacotherapy
compared to boys (48.57%).
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Discussion
In this study, out of 232 children referred to psychiatry, 60 were for evaluation of
unexplained physical symptoms, which is about 25.82% of all referred children. Similar
figures (20.5%) were reported by Mullick (2002) in his clinical study [7], suggesting high
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prevalence of functional somatic symptoms in clinical population.
Mean age of our sample was 12.44 (±3.41) years. A Similar findings were reported by
available studies from Indian subcontinent and elsewhere [7-9]. Adolescents being more
communicative than children may be a reason for this age distribution. Slight male
predominance (58.33%) was observed in our study, a finding similar to the data from
Indian subcontinent [7, 10], but different from western data (only 29% were males in a
study by Coffelt et al) [9], including the large epidemiological Copenhagen study [11],
Socio-cultural differences in help seeking may be the reason for this discrepancy.
About half (58.33%) of these children were referred from the Neuroscience departments
(Neurology, Neurosurgery and Pediatric Neurology). This may be
because, many
psychiatric problems such as pseudo seizures, dissociative motor disorders, and sensory
disorders resemble neurological disorders. Literature states that about 15% of the patients
seen by neurologist have no physical base for their symptoms and in another 15%, the
symptoms are out of proportion to the cause [12, 13]. The next major other source of
referral was the department of pediatrics (28.33%), which is understandable considering
the pediatric sample of this study. These findings also reflect the pathway of care for such
symptoms. Given the obvious physical nature of these symptoms, stigma associated with
psychiatric consultations and lack awareness about psychiatric illness in general may be
the reasons why these children usually visit a pediatrician first. This further indicates the
need for sensitization of non-psychiatric physicians about the prompt identification and
timely referral of such children.
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Mean number of symptoms in our study (1.5) was much smaller compared to the other
prospective studies on unexplained physical symptoms in children. Mullick has reported
a mean of 14.21 symptoms [7], and Konijenberg et al have reported a mean of 8.4
symptoms in boys and 10.7 symptoms in girls [14]. The striking differences in the
findings are due to the retrospective nature of our study and the clinicians might have not
made extensive efforts to explore all somatic symptoms. Another reason may be that, no
structured tool were used to assess functional somatic symptoms (Konijenberg et al. [14]
have used Children Somatic Inventory). These findings imply that a number of somatic
symptoms may go undetected if an extensive work up is not done looking for all possible
somatic symptoms.
About 11.67% and 8.33% of these children were diagnosed with depressive and anxiety
disorders respectively. Depressive and anxiety symptoms are known to commonly cooccur functional somatic symptoms (FSS) and in fact FSS are a common reason for
depressed adolescent to seek treatment [5]. In a study, 86% of depressed youth reported
at least one FSS [15]. Some researchers have reported that the likelihood of comorbid
anxiety and depression increases with the number of FSS and also pediatric anxiety and
depressive symptoms are associated with heightened likelihood of multiple FSS in later
life. They have also questioned the existing nosology that classifies anxiety and
depressive syndromes as different from somatic syndromes and, have argued that there is
a strong reciprocal association between them. These findings imply that, the clinicians
should actively look for unrecognized anxiety and depression in children with FSS in
general medical setting [5].
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Almost equal number of subjects received pharmacological (51.67%) and nonpharmacological (49.33%) therapy. Benzodiazepines (28.33%) and Selective serotonin
reuptake inhibitors (21.7%) were the commonest groups of drugs used. Although there
are no strong evidences suggesting use of psychotropic medications in functional pain
symptoms, clinicians often use antidepressants based on the experience from adult
patients [16]. High proportion of dissociative symptoms in this sample may be the reason
for benzodiazepine prescription and presence of depressive and anxiety symptoms may
be the reason for frequent prescription of SSRIs. Relatively high reliance on
pharmacotherapy may also be because of the fact that, the Indian patients (parents in this
case) expect therapist to follow a medical model and less receptive for nonpharmacological intervention [17].
We further divided the sample and made comparisons like boys v/s girls (table no.3) and
children v/s adolescents (table no.4). These comparisons did not reveal any statistically
significant differences in terms of demographic variables and clinical presentation, and
diagnoses, except that more number of girls received pharmacotherapy than the boys.
This may be because symptoms in girls may be more severe than boys. Existing literature
also suggests that girls present with more number of symptoms than boys [18].
The study findings should be interpreted with the following limitations in the mind, that
this is a retrospective study with no standard screening or diagnostic tool used to assess
the functional somatic symptoms. Relatively small sample size also is a limitation of this
study. Nevertheless, this is one of the earliest efforts to study the children referred to
psychiatry for unexplained physical symptoms in Indian context.
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Conclusions
Evaluation of unexplained physical symptoms was the reason for psychiatric referral in
about a quarter of children referred to psychiatry. Adolescent males formed the majority
of the sample. Neurosciences departments and department of pediatrics were the
commonest sources of referral. Abnormal body movements, head ache, and other body
aches were the commonest presenting complaints. Majority of these children had not
received any medical/surgical diagnoses. Somatoform and dissociative disorders,
depressive disorders and anxiety disorders were the commonest psychiatric diagnoses.
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Bheemsain Tekkalaki, MD. Assistant Professor; Sameeran, S. Chate MD. Associate
Professor; Nanasaheb M. Patil MD, Professor; Sandeep Patil MD. Assistant Professor.
Department of Psychiatry, K.LE University’s J.N Medical College, Belagavi, Karnataka,
India. Veerappa Y. Patil, MD. Post-Doctoral Fellow in Addiction Medicine, Department
of Addiction Medicine, NIMHANS, Bengaluru. Jitendra Mugali MD. Assistant
Professor, Department of Psychiatry, Gadag Institute of Medical Sciences, Gadag,
Karnataka, India.