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1. www.4MedStudents.com Somatoform Disorders1.Conversion Disorder = Hysterical DisorderqPhysical symptoms which represent CONVERSION of anxiety / emotional conflict INTO physical symptom unconsciously.qChildren < adults.qHas symbolic significance:1º gain: When symptoms serve to keep internal conflict/ need out of awareness. e.g. hand is paralyzed after father had beaten him.2º gain: A way of avoiding unwanted/ unpleasant/ anxious provoking situations. e.g. inability to speak in the viva !qCommon symptoms:Blindness + paralysis + aphonia + anesthesia of part of body.Child show no concern about symptoms despite disability (la belle indifférence).

2. 2.Epidemic hysteria: qCFx: dizziness + faintness + headaches etc. qStart in one child  other children. qPrevention of spread: Isolate affected children & strong suggestions to rest of them. 3.Dissociative disorders: q  Uncommon in childhood. qCharacteristics: Subject is unaware of underlying problem, and is NOT malingering. Changes in identity & motor behavior. qDx: by excluding physical disease / other psychological disorders which explain symptoms. a)Psychogenic amnesia: = memory loss (for particular events/ people) during some period of time. b)Psychogenic fugue = assuming new identity & wandering away. c)Multiple personality disorder ≥ 2 personalities at different times. d)Depersonalization disorder = feelings of altered perception of self.

3. Mx:qAssessment: Hx, P/E  may reveal inconsistencies between S/S  rule out physical disease. MSE  psychiatric disorders (esp. emotional diso, depression).qShould be treated as early as possible  delay may allow symptoms to become enriched & fixed.qOn out-patient basis, but if family maintains the problem  admission.q↓ Any stressful events.qIndividual psychotherapy encouraging child to talk about problems.qFamily sessions: to explain Absence of physical diseases. In some children, emotional distress  physical symptoms!qBehavioral therapy: +ve reinforcement: to encourage desirable behaviors, while ignoring the symptoms.qFace saving solution: e.g. Physiotherapy for the paralyzed limbs without losing face. Placebo medication.qHypnosis: effective in highly suggestive children.

4. 4.Hypochondriasis:qRare in childhood, but common in adolescence.qThey exhibit exaggerated physical symptoms. Abdominal pain (commonest), headache, nausea .etc.qA/w anxiety or depressive symptoms.qMx: help child deal with stress that produces symptoms & develop alternate coping strategies. Parents should focus on adaptive behavior rather than symptom behavior.5.Abnormal illness behavior:qChild is enjoying benefits of sick role.q♀= ♂ in childhood. In adolescence > ♀.

5. Depressive Disorders qDepressive symptoms (sad mood, misery, tearfulness) occur in 20-25% of children & adolescents, but are part of emotional or conduct disorders. q Suicidal thoughts & attempts are common in 1/3 of adolescents (DSH is rare). q Clinical syndrome of depression: 15-20% of children & adolescents attending psychiatry clinic. CFx: Persistent low mood (dysphoria). Anhedonia. depressive cognition (hopelessness, worthlessness, self-deprecation, guilt). qDiagnostic criteria: 1.Persistent low mood (dysphoria)  misery, sadness, tearfulness. 2.A/w: irritability, hypochondriasis, impaired concentration, social refusal, anxiety, OCD, running away from home, separation anxiety (school refusal, abd. pain, decline in school work, acting out behavior). Vegetative symptoms (sleep / appetite disturbance) > in adolescents. 3.Symptoms lasted for > 4 weeks. 4.Impairment of functioning.

6. qEtiology: multifactorial. Risks factors are:1.Genetic predisposition.2.Temperament: anxious & sensitive children who are slow to warm up and adapt to new experiences  predisposed to emotional diso.3.Traumatic experiences in early childhood: e.g. maternal deprivation, separation from attachment figure.4.Chronic life adversity: adverse family circumstances, neglected/ abused children.5.Individual factors: poor self-esteem due to perceived lack of competence in school.6.Life events: Bereavement  N. emotional response (depressive symptoms).7.Social learning: development of self-esteem might be impaired by experiences of being in pain/ unpleasant situations over which they have no control.8.Depression may 2º to other disorders: Viral febrile illnesses e.g. infectious mononucleosis. Psychiatric diso: conduct diso, adjustment diso, separation anxiety, OCD etc.

7. Mx:qDepends on severity & extent to which symptoms impair functioning.qIf suicidal intent  admit the child !qIdentified stressed should be alleviated.qMild-moderate reactive cases of depression may be treated by out-patient counseling, environmental manipulation, individual psychotherapy, family therapy. Cognitive therapy = to enhance child’s self-esteem & confidence.qModerate-severe cases  anti-depressants e.g. imipramine amitriptytline, SSRI.Outcome:Most children respond to intervention & grow up to be normal adults. However, if he/she develop psychiatric illness later, it’s more likely to be depression.

8. Suicide & parasuicide(Deliberate self-harm = DSH) qDefinitions: qCompleted suicide are not known to before the age of 10. qThreats of suicide & attempts are not uncommon in children. oIncidence of DSH is highest in the age group 15-19. oSuicide > ♂, Parasuicides > ♀ and the common method is OD. qAssessment of suicidal intent: 1.Planned attempt. 2.Measures to avoid discovery. 3.Final act (leaving a note, calling a friend). 4.Making sure that nobody is near the scene. 5.Use of violent / dangerous method.

9. qRisk factors:1.Child factors: academic difficulties, school refusal, relationship problems, anti-social behavior, substance abuse, physical / psychiatric illness, sexual difficulties (sexual abuse, homosexuality, pregnancy).2.Family factors: loss of parents, mental illness (depression, suicidal behavior), substance abuse, extremes of parental control etc.3.Environmental factors: access to means of suicide, suicidality in close friend, precipitating factors e.g. hearing bad news (school failure, death of someone close), arguments with someone close. > common on special occasions e.g. Christmas, death anniversary.

10. Mx:qAll suicide attempts should be taken SERIOUSLY as a communication of desperation & limited problem solving skills.qChildren who committed suicide:½ would have talked about, threatened / attempted suicide.¼ would have consulted their GP in previous week.¼ had anti-social behavior.qAll children should be admitted following OD.qAssessment of social & psychological factors should be carried out with neutral & non-judgmental attitude.qInformation should be obtained from: family, school, relevant resources.What might appear trivial to others may have deep personal significance for the patient.

11. Con’t Mx:q20% of cases show NO psychiatric illnesses. Main aim of Rx is to enable patient to resolve difficulties led to incident, and for any future crisis without self harm.q60% of cases show evidence of psychiatric illness.q20% of cases, there’s moderate-severe psychiatric disturbance. Depression & conduct diso. are the commonest conditions a/w DSH. Substance abuse is imp. risk factor suicide.Outcome:For most of children & adolescents  outcome is GOOD. Minority continue to have social & psychiatric problems. 10-15% repeat during the course of one year, and 4-5% eventually kill themselves .