اختلالات شبه جسمی و تروما در کودکان، نوجوانان، و نوجوانان از لحاظ پزشکی بستری شده: شیوع و خصوصیات روانی اجتماعی

The purpose of this study is to describe past traumatic experiences in medically-admitted pediatric and young adult patients diagnosed with somatoform disorders and to explore the demographic, diagnostic, and psychosocial differences between those with and without trauma histories. Methods Retrospective medical record reviews were performed for patients (aged 3–29 years) 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 The mean age of the 180 identified patients was 15.1 years. Most patients were girls (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. However, patients with trauma histories 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 on 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.

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 limitations, and increased health care costs.2 Somatic symptoms are present in virtually every psychiatric diagnosis, and most research to date has focused on somatic symptoms (vs. somatoform disorders) among adults particularly in outpatient settings. Few known studies examine somatoform disorders among pediatric 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 draws from studies examining somatic symptoms as well as somatoform disorders among adult populations. Recent literature outlines several factors that 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 comorbidities, and a history of trauma.2, 3 and 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, 6 and 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 sensations,6 and dissociation, especially when related to contact trauma, is proposed as a moderator in the association between trauma and somatic symptoms.8 and 9 Furthermore, childhood trauma is hypothesized to precipitate an insecure attachment style and lead to health care–seeking behaviors (i.e., secondary gain).10 Finally, neurobiologic models propose that trauma alters the body׳s stress response (e.g., hypothalamus-pituitary-adrenal axis, cortisol levels, and cardiac vagal tone), thus affecting one׳s ability to cope with subsequent stressors,11 and 12 which may also explain why multiple stressors are linked with a higher severity of somatic symptoms.6 and 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, 15, 16 and 17 Some factors may moderate the strength of the relationship between trauma and somatic symptoms: a meta-analysis found that men and patients with posttraumatic stress disorder (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 and 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 and 16 Emotional abuse has also been linked with adult somatization disorder.4 The few existing studies on pediatric somatoform disorders are generally descriptive and focus on less complex 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 the prevalence rates of childhood trauma is challenging, more than 675,000 unique and substantiated cases of child abuse were reported in the United States in 2011,19 with victims 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, the lifetime prevalence of trauma ranges from 8%–24% for sexual trauma, 9%–29% for physical assault, and 13%–39% for interpersonal violence,21, 22 and 23 with one-fourth of the children and adolescents experiencing at least one traumatic event before the age of 16 years.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 with those without. The current study proposes that most patients in the sample 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 would distinguish them from nontraumatized patients with somatoform disorders and reflect a profile often seen among general samples of traumatized youth.