Bullying Victimization in Medically Hospitalized Patients With Somatic Symptom and Related Disorders: Prevalence and Associated Factors

Clinical and psychopathological profiles of children with somatic symptom disorders in a pediatric emergency unit: an observational study before and during the SARS-CoV-2 pandemic

Somatic symptom disorders (SSDs) are a group of clinical conditions characterized by heterogeneous physical symptoms, not directly supported by a demonstrable organic process. Despite representing a growing problem in the pediatric age, the literature lacks studies assessing the psychopathological and clinical features of subjects with SSD, particularly during the SARS-CoV-2 pandemic. This is a retrospective, observational study, involving two historical cohorts of children admitted to a tertiary referral Italian hospital over the 2 years preceding and following the start of the SARS-CoV-2 pandemic. Demographic, clinical, socio-economical, and psychological variables were investigated. Standardized tests for the developmental age were administered to assess psychopathological variables. Overall rates and trends of accesses for SSD, as compared to the total accesses for any cause at the Pediatric Emergency Room during the same periods, were reported as well. Fifty-one (pre-pandemic, 29; pandemic, 22) children with SSD were enrolled (age, 11.4 ± 2.4 years, F = 66.7%). Subjects in the pandemic historical cohort reported more frequently fever (p < 0.001), headache (p = 0.032), and asthenia (p < 0.001), as well as more chronic conditions in personal and family history, and fewer previous hospital accesses, as compared to the pre-pandemic cohort. Depressed mood and anxious traits were documented in both samples. None of them had an ongoing or a previously reported SARS-CoV-2 infection. During the pandemic, a clinical psychologist was more frequently consulted before the hospital discharge to mental health services, to support the diagnosis.  Conclusion: This study showed the significant burden of SSD in children, highlighting the need to implement pediatricians' education to optimize the management of these patients. Children with SSD who accessed during the SARS-CoV-2 pandemic presented specific clinical features. Future studies, conducted on longitudinal and controlled samples, are indicated to further investigate children with these conditions. What is Known:    • Somatic symptoms disorders (SSDs) are frequent in the pediatric age, especially in early adolescence.    • Evidence remains scarce on the impact of the SARS-CoV-2 pandemic on SSDs in children. What is New:    • Children with SSD who accessed during the SARS-CoV-2 pandemic presented specific clinical features.    • The implementation of pediatricians' education and a multidisciplinary approach are needed to optimize the management of SSDs.

The Development of Somatic Symptom Disorder in Children: Psychological Characteristics and Psychiatric Comorbidity

BACKGROUND

Somatic symptom disorder (SSD) is one of the most common pediatric psychiatric disorders in adolescents, and several biological, psychological, and social factors have been considered to contribute to its development.

OBJECTIVE

The aim of the present study was to elucidate the link between psychological functioning (depression and anxiety), psychological characteristics (perfectionism and alexithymia), negative life events, and parental accommodation in children diagnosed with SSD.

METHODS

Fifty patients (age range 7-18 years) were diagnosed with SSD in an outpatient clinic and completed multiple self-report questionnaires on SSD symptoms, negative life events, and psychological factors. Linear regression models were used to indicate predictors of SSD symptoms. Cluster analysis was performed to identify gastrointestinal and abdominal complaints and their associations.

RESULTS

Association with SSD symptoms was strongest for state anxiety (standardized β = 0.85, 95% confidence interval [CI] = 0.44, 1.27, P = 0.0006), depression (β = 0.72, 95% CI = 0.38, 1.06, P = 0.0006), trait anxiety (β = 0.60, 95% CI = 0.22, 0.98, P = 0.0005), and family accommodation (β = 0. 49, 95% CI = 0.23, 0.75, P = 0.001). These factors were associated with gastrointestinal but not with neurological complaints. Family accommodation was associated with somatic complaints among children younger than 12 years (r = 0.57, P = 0.007), while state anxiety (r = 0.69, P = 0.007) and depression (r = 0.65, P = 0.007) were significantly associated among older children.

CONCLUSIONS

Several psychological factors may result in a somatic response. The phenotypic expression of these factors may vary among different ages. Somatic complaints were related to parental accommodation among young children, while it was strongly associated with anxiety and depression among adolescents.

Somatic symptom and related disorders in a tertiary paediatric hospital: prevalence, reach and complexity

Specialist paediatric services manage a variety of presentations of functional somatic symptoms. We aimed to describe the presentation and management of children and adolescents with somatic symptom and related disorders (SSRDs) requiring admission to a tertiary children's hospital with the objective of informing the development of a local clinical pathway. Patients admitted to any hospital department from May 2016 to November 2017 were identified through an electronic medical record (EMR)-linked diagnosis of SSRD. Each record was reviewed for demographic details and admission histories. The frequency of interspecialty consultations and multidisciplinary team (MDT) family meetings were recorded. One hundred twenty-three patients with SSRD were admitted on 203 occasions to 17 different departments. The median (range) age was 14.3 (7.3-18.3) years. Interspecialty consultations occurred in 84.6% of patients, and MDT family meetings occurred in 18.9% patients. SSRD was diagnosed as an inpatient in 79.9% patients, yet only 40.7% of patients, including those with multiple admissions, had SSRD recorded as a discharge diagnosis.Conclusion: Despite high rates of consultation with hospital teams, the frequency of MDT family meetings was low, and less than half the patients had SSRD documented at discharge. This affirms the value of developing a local clinical pathway. What is Known • Functional somatic symptoms are commonly seen in children and adolescents. • Few studies have explored the reach of functional somatic symptoms across a tertiary paediatric hospital; the majority of inpatient studies have focused on a limited set of disorders or cases referred to psychiatry departments. What is New • Symptoms that spanned multiple body systems were the most common presentation of SSRDs in admitted children and adolescents. • Somatic symptom disorders are less likely to be recorded as a discharge diagnosis compared with functional neurological symptom disorder.

How to recognize and manage psychosomatic pain in the pediatric emergency department

Aim

Children and adolescents affected by somatization and somatic symptom disorder commonly refer to emergency services. Due to the absence of specific guidelines for the emergency setting and to a possible lack of knowledge, these patients are at risk of being unrecognized and mismanaged. This study aims at proposing a clinical practice to approach and manage these patients and their families in the emergency setting.

Methods

This manuscript derived from the work of a research group of italian pediatric emergency physicians and anesthesiologists, with an expertise in pain management, members of the PIPER group. The research group reviewed the literature about psychosomatic pain and somatic symptom disorder and developed a clinical practice specific for the pediatric emergency setting.

Results

The manuscript provides information about the main clinical features shared by patients with psychosomatic pain and about current diagnostic criteria and appropriate management in the emergency setting. Furthermore, it highlights the possible pitfalls in which the emergency physician may run into dealing with these patients.

Conclusion

This clinical practice should be seen as a starting point toward a better understanding of patients with psychosomatic pain and a standardization of care in the pediatric emergency setting.

Case Report: Somatic Symptoms Veiling Gender Dysphoria in an Adolescent

Background: Somatic symptom disorder is common in children and adolescents; usually, it is an expression of a mental health problem or other conditions that lead to psychosocial impairment and suffering. Among these, in pubertal age, gender dysphoria should be considered. Case Presentation: We present the case of a 15-year-old girl admitted to the hospital because of a 2-month history of scattered arthralgia and myalgia, headache, and fatigue, with repeated visits to the emergency room. The physical exam was unremarkable, except for step walking and pain. Repeated diagnostic tests were normal, and consecutive psychological interviews disclosed intense suffering due to a gender incongruence. Referral to the hospital gender service was offered and refused by the parents. Conclusions: In pubertal age, gender dysphoria may be expressed through somatoform symptoms. Diagnosis is challenging to accept for the parents even in the presence of adequate multi-disciplinary hospital services.

Prevalence, Patterns, and Correlates of Pain in Medically Hospitalized Pediatric Patients With Somatic Symptom and Related Disorders

BACKGROUND

Somatic symptom and related disorders (SSRDs) and pain are highly comorbid in the pediatric population. Little is known about the prevalence of pain and factors that may predispose and perpetuate pain in hospitalized youth with SSRD.

OBJECTIVE

To describe the prevalence of pain and widespread pain symptoms in hospitalized youth with SSRD and describe differences between patients who endorsed limited (1-4 sites) versus widespread (5-8 sites) pain.

METHODS

Retrospective chart reviews were conducted of pediatric patients with SSRD seen over a 32-month period at a tertiary pediatric hospital and assessed by the psychiatry consultation service. During admission, patients completed the Childhood Somatization Inventory, which assessed pain and other physical symptoms. Descriptive statistics, one-way analysis of variances, Pearson's χ², stepwise linear regressions, and internal consistency analyses were used.

RESULTS

Of the 219 patients (aged 8-18 y), 97% reported pain symptoms, and of those reporting pain (n = 213), 48% reported widespread pain. Patients with widespread pain had greater rates of comorbid depression (P = 0.012), neglect (P = 0.016), family psychiatric history (P = 0.013), diagnostic tests/procedures (P = 0.012), and prescribed opioid use (P = 0.016), when other medical and demographic factors were considered. When compared dichotomously to youth with limited pain, there was no difference in prevalence of medical conditions; however, patients with widespread pain had higher rates of trauma and stressor-related disorders (P = 0.017), sexual abuse (P = 0.031), emotional abuse (P = 0.041), and prior child protective service involvement (P = 0.011).

CONCLUSIONS

Pain symptoms and widespread pain are common in medically hospitalized youth with SSRD, with unique psychiatric and psychosocial factors associated with widespread pain.

School bullying: an increasingly recognized etiology for psychogenic non-epileptic seizures: report of two cases

Psychogenic non-epileptic seizures (PNES) are seizure-like episodes that are not associated with changes on electroencephalogram. They are the result of a wide range of possible psychological stressors including being a victim of bullying. Currently, reports regarding PNES in bullied patients are lacking. In this case report, we describe two cases; the first is a 10-year-old boy who presented to the emergency room once for visual loss and another for inability to walk. The other is a 12-year-old boy who has experienced recurrent episodes of loss of consciousness. Based on the negative investigations for any other possible diagnosis, and upon the nature of the episodes, a diagnosis of PNES was made after a history of bullying victimization was revealed. This suggests that PNES can result from psychological distress caused by school bullying victimization in children and highlights the importance of screening for bullying in patients with PNES.

Facing somatic symptom disorder in the emergency department

Somatic symptom disorder is a condition in which a patient's subjective report of physical symptoms is associated with distress; disruption of day-to-day functioning; or disproportionate thoughts, feelings and behaviours regarding the symptoms, whether or not they are associated with an identified medical condition. While somatic symptom disorder affects a considerable proportion of children and adolescents presenting to the emergency department (ED), it has not been well investigated in the ED literature, nor is there much formal training in, or guidelines for, how to care for affected patients in the ED. The aim of this paper is to highlight the historical clues commonly reported by these patients in order to try to help the emergency physicians recognise patients affected by a somatic symptom disorder. Adolescent age, the presence of daily subjective symptoms presenting daily for weeks or months, a long medical history record, an extensive diagnostic workup and, most of all, disproportionate functional impairment related to the symptoms are all features strongly suggestive of this disorder. Emergency physicians should become used to taking advantage of these clues to formulate a positive diagnosis of somatic symptom disorder according to the most recent diagnostic criteria. Emergency physicians have the unique opportunity to contribute to the correct diagnosis and treatment of these patients and to have a positive impact on their prognosis.

Perception and Impact of Life Events in Medically Hospitalized Patients With Somatic Symptom and Related Disorders

OBJECTIVES

We describe the prevalence and perceived impact of life events reported by medically hospitalized patients with somatic symptom and related disorders (SSRD) and highlight patient characteristics and outcomes associated with highly impactful life events.

METHODS

Retrospective chart reviews were conducted of patients with SSRD at a tertiary pediatric hospital who were seen by the psychiatry consultation service and completed various instruments while medically admitted, including a de novo life events checklist. Descriptive statistics, correlations, χ² tests, and internal consistency analyses were used.

RESULTS

Charts of 70.2% of patients with SSRD who completed the life events checklist (N = 172; age range 8-25 years) were reviewed. Of those studied, 94% reported at least 1 life event in the last year, with academic events most prevalent, 81% reported life events across multiple domains, and 56% perceived the life event(s) as having a great impact on their lives. Patients who perceived more great impact life events were older, from households with lower median incomes, had higher self-reported somatization, greater functional disability, more comorbid psychiatric diagnoses, required more psychotropic medications, and had longer medical admissions.

CONCLUSIONS

Findings reveal that although the majority of medically hospitalized patients with SSRD reported at least 1 relevant life event, it was the patients' perception of the impact of the life event(s) that correlated with high levels of disability and health care use. An assessment of the perception of life events in patients with SSRD may help hospitalists and interdisciplinary providers identify high-risk patients for whom early psychiatry referrals can be made.

Association between bullying and pediatric psychiatric hospitalizations

Objectives:

Bullying is a serious public health issue. We sought to demonstrate an association between bullying victimization and hospital admissions for acute psychiatric problems. We described the demographics and types of bullying in a sample of hospitalized patients in Staten Island, NY, and compared bullying victimization scores with psychiatric versus medical admissions.

Methods:

Patients in grades 3–12 were recruited from the Staten Island University Hospital Inpatient Pediatrics unit and emergency department. Patients completed the validated Olweus Bully/Victim Questionnaire (OBQ) was analyzed to formulate a report of bullying in our sample as well as a sub-score measurement of bullying victimization. Pediatric residents simultaneously documented whether the subject was a medical versus an in-patient psychiatry admission. Statistical analysis was performed to look for an association between the victimization sub-score and a psychiatric indication for admission.

Results:

A total of 185 surveys were analyzed. Peak bullying occurred in 7th and 8th grades. Demographics and types of bullying in our sample were described. A strong association between bullying victimization and hospitalization for in-patient psychiatry was demonstrated. Association between bullying victimization and suicidal ideation, psychiatry, and social work consults was also shown. Concern for an association between hospitalization for psychogenic illness and bullying victimization was also raised.

Conclusions:

There is a significant association between bullying victimization and psychiatric hospital admissions. This raises the specter of the serious consequences of bullying as it is the first study to prospectively link hospital admissions to bullying. Studies using a valid measure of psychogenic illness to look for an association with bullying victimization are needed.

Pediatric Somatic Symptom Disorders

Somatic symptom disorder (SSD) is a common disorder encountered in pediatric medicine. It involves the presentation of physical symptoms that are either disproportionate or inconsistent with history, physical examination, laboratory, and other investigative findings. SSDs result in significant impairment with considerable increase in healthcare utilization, school absenteeism, and the potential for unnecessary diagnostic evaluation and treatment intervention. Patients and families often feel dismissed and may worry that a serious condition has been missed. Primary care providers are frequently frustrated due to a lack of a successful approach to patients and families impacted by SSD. The result is often a cycle of disability, frustration and missed opportunities for collaboration towards enhanced patient functionality. This review summarizes the current evidence-based understanding, as well as insights from clinician experience, on the evaluation and management of pediatric SSD.