Pediatric emergency medicine trisk 1052

Assuming a patient’s symptoms are due to a somatic symptom disorder without first performing an appropriate medical assessment is ill-advised.. Conversely, it is relatively rare for a pe

Children with psychiatric illnesses can be medically ill Assuming a patient’s symptoms are due to a somatic symptom disorder without first performing an appropriate medical assessment is ill-advised Conversely, it is relatively rare for a pediatric patient who is given the diagnosis of somatic symptom disorder to be subsequently

diagnosed with an underlying medical condition

ED physicians are typically best served by maintaining their usual

“pretest probability threshold” for ordering tests, consultations, and medical interventions based on the clinical presentation at hand Expanding the scope of evaluation and/or treatment to reassure parents or to accede to their demands is often both ineffective at calming parents and countertherapeutic for the patient

It is important to remember that the symptoms encountered with somatic symptom disorders are not consciously produced Patients are truly experiencing the symptoms and functional impairment that they are reporting ED clinicians should be clear that they believe that the patient is truly suffering from the symptoms/impairment that they are reporting, that they are not “making it up,” and that it is not

“all in their head.” Patients cannot get well if they still need to

convince people that they are sick

Patients with somatic symptom disorders are typically in

significant distress; they are often trapped in seemingly unsolvable dilemmas and are very much in need of appropriate and supportive care

Placebo trials without the family’s consent should typically be

avoided Even when “successful,” they tend to make families feel betrayed

How physicians discuss psychosomatic symptoms with patients and families can have a major impact on the clinical outcome

Family beliefs about psychological versus medical illness typically play a significant role in the development and perpetuation of

psychosomatic symptoms and must be addressed as part of

effective treatments

ED physicians should frame the negative findings and lack of

need for further medical intervention as “good news.” For example, the fact that a patient’s MRI shows that they do not have a brain

tumor is good news, even if the patient and family seem

disappointed or frustrated by the negative result Being able to stop

or avoid initiation of medications that have real and potentially

significant side effects is also “good news.”

A patient’s presentation is very rarely ever 100% due to medical factors or 100% due to psychological factors Psychological factors commonly impact the onset, severity, perpetuation, and/or recovery from medical illness and psychological stressors often have

physiologic consequences ED physicians may want to take as

much of an “agnostic” view of the cause of the symptoms as

possible (and acknowledging that a nonemergent medical illness may have helped triggered the patient’s course) and focus instead

on the ways to promote recovery and return to functioning The

framing of treatment interventions using the model of physical

rehabilitation can be particularly effective

Clinical Considerations

Conversion disorder is defined by one or more symptoms of altered voluntary motor or sensory function that are incompatible with recognized neurologic or medical conditions and that cause significant distress and/or impairment in functioning The term “psychosomatic” symptoms or

“functional” medical disorders can be used to refer to symptoms in other systems that meet similar criteria Psychological factors can also frequently contribute to the development, perpetuation, or exacerbation of the suffering from underlying medical illnesses In fact, it should be considered the exception, rather than the rule, when there are NO psychological factors impacting a patient’s illness

Initial Assessment

There is no single finding or test result that can definitively rule in or out conversion disorder or other psychosomatic symptoms Clinical recognition must be based on a thorough review of the history including prior testing results, close observation and examination of the patient, and any further testing as indicated Conversion disorder and other psychosomatic symptoms should also not be considered a diagnosis of exclusion ED physicians

should look for risk factors, signs, and symptoms that positively support the diagnosis

Patients and their families may not often acknowledge significant stressors In some cases, the patient might not be fully aware of the presence

or impact of a potential stressor That being said, a thorough history including a detailed psychosocial assessment can often help the ED physician identify likely contributing factors Patients and their families should be interviewed individually and together Information gathered from the interview that would support a diagnosis of conversion disorder is listed

in Table 126.28

TABLE 126.28

HISTORICAL FEATURES OF A PSYCHOSOMATIC DIAGNOSIS

Temporal relationship between onset of symptoms and psychosocial

stressor

Families who accept physical illness but not psychological symptoms as a cause for disability, have a strong belief that there is a single

undiagnosed explanation for the symptoms, and/or lack faith in the

medical system

Reinforcement of the medical symptoms and functional impairment via increased sympathy and attention from family/friends, increased

attention from medical providers, and/or avoidance of stressful

situations such as school attendance

Traumatic life events or significant family or psychosocial stressors

Physical illness/disability in the family (which can provide an “illness

model” to the patient)

Personality/coping styles that include a difficulty or avoidance of

verbalizing feelings; introspectiveness; poor self-concept; pessimism;

“Good kids” who are people pleasers and reluctant to burden others with their stress

Comorbid psychiatric illnesses such as depression and anxiety

History of prior unexplained or functional medical symptoms

As noted above, ED physicians should adhere to their normal clinical decision-making processes when working up a patient’s symptoms Symptoms that could legitimately have an emergent underlying medical etiology should be assessed accordingly Conversely, ED physicians should avoid performing unnecessary tests, especially for nonemergent diagnoses Unnecessary testing rarely reassures families; it overmedicalizes patients, strengthens the reinforcement of the symptoms/impairment, places patients

at risk for the sequelae of false-positive or incidental findings, confers iatrogenic risk and discomfort without clear benefit, and distracts attention away from interventions that are more likely to be successful The same concept holds true for prescribing medications or other treatment

interventions ( Table 126.29 ).

Efforts should focus on relaying the “good news” of the negative findings and the lack of need for further intervention at this time Education about the nature of psychosomatic symptoms should be given in a supportive and nonjudgmental way Treatment recommendations should focus on referrals for psychological support, providing anticipatory guidance and advice to parents around supporting return to function (including the use of physical therapy when indicated)

In some circumstances, inpatient medical admission may be necessary, including in cases where video EEG monitoring is indicated or patients are unable to orally hydrate themselves or ambulate It can be helpful at these times for the ED physician to try to “set up” the admission as one that may very well not lead to the identification of an underlying medical illness or alleviate all of the symptoms but rather to facilitate further workup, specialists consultation to put an appropriate aftercare plan into place Psychiatric etiologies should be listed in a nonjudgmental fashion as part of the differential and involvement of the mental health team for diagnostic purposes and support of recovery should be presented, whenever possible, from the start