Psychosomatic medicine is a field of various theories. The modern heritage of psychosomatic medicine in children and adults developed as a result of attempt to correlate psychoanalysis with psychosis.
The emphasis is on the relationship of external events in the of internal process in the milieu.
Psychosomatisation stem from the work of Freud and Brewer (1893) with their investigation of conversion processes through hypnosis and ultimately dream analysis.
The term “psychosomatic” as used in this assignment includes a range of meanings that cannot be bracketed by a single definition. It covers from psychosomatic diseases, which distinguishes between conversion symptoms, functional disturbances (organic neurosis) and disease in the narrower terms of the word to general somato-psychological interactions involved in the development of disease.
Children react to stress in different ways e.g. loss of appetite, emotional throbbing of the heart, obesity, sleep disorders, failure to thrive, delayed milestones, etc. The symptoms usually subside after the triggering stimulus has subsided.
Before citing the various disorders, it is essential to outline the main groups of psychosomatic disorders commonly encountered in children namely:
1. Conversion Symptoms
These are secondary somatic responses working over a neurotic conflict. They may represent an attempt to solve the conflict e.g. vomiting, hysterical paralysis and etc.
2. Functional Syndromes
There is functional disturbance in the different organ with no evidence of tissue damage.They may involve nervous systems, locomotory systems or any system in the body.
Underlying these disorders is a primary physical reaction to a conflict situation or stress. Such reaction is accompanied by morphologically demonstrable tissue lesion and objective organic findings e.g.
- Bronchial Asthma
- Anorexia Nervosa etc
The following conditions may have a psychological basis in some instances
1. Bronchial Asthma
This is a disturbance in respiration and it may occur at any age. Children under 10 years are mostly affected.
One aspect of bronchial asthma is “conditioning”. A child who is asthmatic to flowers may have an attack by seeing an artificial flower.
A personality profile of a disturbed relation between parents at early life is evident in asthmatics. The goal of treatment modality is to resolve the conflict that is in the child. If too much is expected from the child, to cope, the child may go into an abrupt breakdown and psychotic decompensation which was presumably a sequel of radical intervention.
The modalities of therapy includes:
- Giving information on the etiology and pathophysiology of the disease.
- Training on safe and suitable codes of behavior.
- Teaching relaxation and breathing techniques.
Group therapy: Patients should exchange ideas and personal experiences and gain a feeling of security.
The above methods have been shown to improve the attack rate and social wellbeing and in turn reduce the need for medication significantly.
2. Coughing and Singultus
The primary purpose of cough is to clear the respiratory tract of the foreign bodies and attendant irritants. Oppressive emotions can promote bronchial secretions and gastric secretions. Coughs that have some physiological influence are usually without expectoration and reflect inner tension. The cough then serves as a relief. It can also embody an attempt to get rid of inner desires that are felt as alien and dangerous.
Sometimes the cause for cough is an inner feeling of anger or furry that the patient cannot express in words. The protest is usually directed against a specific person within a conscious reach.
Singultus is an inspiratory disorder usually seen in children exposed to unpredictable oscillation between extreme generosity and punitive severity on the part of the parent who do not really have love to give them. The attack occurs as a result of deterioration in the situation or as a result of insecurity.
ASPECT OF EATING BEHAVIORS IN CHILDREN
In children satisfaction of hunger produces a feeling of security and well being. Children in distress usually exhibit poor eating habits, like poor feeding. This results in growth failure or retardation in infancy. In adolescent the psychic disturbance may manifest itself in Anorexia nervosa or Belumia nervosa.
Even a small baby may exhibit poor mother child relationship by refusing to feed even on breast. This result in feeding which only fills the stomach with no or little satisfaction in the child needs.(psychological needs) or satisfaction.
The example to give is “colic”. The feeling of insecurity produce a feeling of anxiety in the mother. This in turn produce tension in the infant, together with crying, the mother thinks the child is hungry, gives the child food that further increases tension which is present, which again makes colic worse.
Owing to close connection between food and mood, mealtime is regarded as suitable time for correcting children and giving them lectures. Arrogance of a child at mealtime ruins appetite and impedes the process of revitalization that should accompany every meal.
On the other hand a child may exhibit excessive food intake that may result in obesity. The psychic impairment results in predominance of the parasympathetic innovation, which reduces the metabolic process. For such children eating is not prompted by hunger, but external stimuli and various forms of discomfort and unconsciousness trigger their appetite.
The perpetual desire to eat, or sudden bulimia are not expression of an increased needs for food. It is rather that when confronted with conflict and problems, the child reverts to feeding as an attempt to overcome their feeling of discomfort and displeasure. Food then becomes a consolation for satisfying other unfulfilled emotional needs.
Slimming is never effective unless is possible to change the patient’s institual-affective behavior in such a way that he no longer feels that he has to overeat to overcome his internal conflict.
The child compliance in therapy is enhanced by active participation of children in the treatment. Treatment plan should be drawn together with the child taking into account his personal situation.
Besides being obese from overeating, children may exhibit of Anorexia nervosa from poor feeding despite the presence of balanced diet. This usually occurs in the adolescence as a subconscious feeling to obtains self-esteem and independence. Female children are mostly affected than boys. The concern about self image and body shape plays an important role in this age group. The earliest presentation Anorexia nervorsa is amenorhoea. Some girls present with delayed menarche due to anorexia that stem from puberty.
In all these disorders, before a psychological component can be blamed on organic cause must be excluded.
GASTRIC AND DUODENAL ULCERS
Glatzel described peptic ulceration and the development of gastric and duodenal ulcers arising in certain stressful situation in persons predisposed to react to such experience with somatic disorders of gastrointestinal tract by virtue of their personality structure and life history.
Anxiety and strong emotions causes pylorospasm and slows gastric emptying. Chronic anxiety and conflict that produces hostile reaction increases gastric secretion which if in excess causes mucosal changes and erosion. The mucosal that has undergone acid erosion is vulnerable to minor trauma. A pin-point of trauma if subjected hydrochloric acid secretion may lead to ulcer formation. Reduction in stress tends to make an ulcer early managed and responsive to treatment.
Constipation in a young child should always be taken as a protest reaction, usually as a protest against excessive toilet training. Parents expect a child to pass a stool everyday. If this does not happen, the child is put on a potty for a long time in vain. As soon as the child is off the pot, she does it in her pants.
Diet and training and sound toilet training may have surprisingly good results. Symptom oriented psychotherapeutic discussion are indicated, which in the long run give good results.
This is one of the most frequent functional disturbances of the bowel. It is associated with hypermotility of long intestines and involves diarrhea alternating with constipation.
The underlying causes of bouts are usually situation anxiety or overstrain. The personality appears to be marked by a fear of authority and a sense of helpless dependence. Impression of being subjected to excessive demands, together with a feeling of weakness overcompensated by an exaggerated desire to recognition and achievement.
Medication alone is clearly inadequate for treatment. The underlying conflict can be successfully worked through in the cause of individual or group therapy provided the patient is motivated to accept it.
PSYCHOSOMATIC AND PSYCHOSOCIAL DISORDERS OF THE ENDOCRINE SYSTEM
Some of the endocrine disorders with psychosomatic components are:
- Diabetes Mellitus.
- Other forms of Allergies.
A characteristic feature of hyperthyroidism is that it develops suddenly as a result of either strong emotion or critical situation when the predisposing factor exists. Deaths, accidents and experience of loss may not only trigger the disorder but also cause and stabilizes hyperthyroidism to take turn for the worse.
The personality profile of such patients is those children who are expected to become independent before they are ready. This may be because of early death of parents, early participation in family conflicts, or in upbringing of younger siblings, with significant frequency the patients are found to be the eldest of several children.
Alexandra (1951) considered patients with hyperthyroidism to be people who had gone through a lifelong struggle to hold out against their fears.
From psychotherapeutic viewpoint, working through a triggering situation at the focus of conflict is of great value. An addiction to medical treatment, a supportive psychotherapy can have positive influence and reduces the number of relapses.
Cannon demonstrated that emotions and stress can lead to elevated blood sugar levels and glycosuria by increasing sympathoadrenal stimulation.
Patients with mature onset Type II Diabetes Mellitis do not show any particular anxiety but certain measure of masked depression is unmistakable. Their ego syntonic personality tends to manifest in depressive reaction when under strain.
The Juvenile – onset diabetes, however, may exhibit personality trait that border on schizoid features.
The psychosomatic concept expounded on several papers on the development of diabetes were summarized by Rudolf as follows:
- Eating satisfies conflicts and normal needs. Excessive appetite and obesity may then develop and lead to constant hyperglycemia.
- As a result of identification of food with love, withdrawal of affection produces an emotional experience of hunger, hence giving rise independently of intake of food, to hunger, metabolism that tends to compare to that of diabetic patient.
- Lifelong unconscious fear result in a constant flight – flight reaction accompanied by hyperglycemia. Despite this, there is no truly diabetic personality. However, particularly in juvenile diabetes, psychic factors do have considerable effect on the course of the disease and the success of the treatment.
According to Benedek, the risk of Ketoacidosis may be increased by attempt to force the patient to diet which may generate anxiety, conflict and feeling of guilt.
Somatic equilibrium can be achieved and can be alleviated by stabilization of patient mind and body.
It is essential that psychosomatic outputs in addition to medical treatment. Certain psychotherapeutic skills need to be employed e.g. it remains up to the physician handling the case to give the parents and the child support, to encourage him the master life and develop new creative potential despite the cramped perspective suggested by the disease.
The psychosomatic approach is directed towards the psychosocial etiology of allergic response.
De Boor (1965) cited an example of asthma patient whose allergen was discovered in a carpet. Although the carpet was removed, attack received after the patient was discharged from the hospital and only ceased when the carpet’s meaning was disclosed in the course of psychotherapy.
Another connection of the example of the connection between allergic reaction is that a person’s emotion is hay fever. A fairly large quantity of allergens would not produce reaction if there were no other stress or emotions intervening as precipitating factor. In other words, psychic factors can lower the sensitivity threshold to allergen.
Even in the absence of any psychopathological condition, the skin is one of the most important organs of emotional expression. This is made visible when certain types of feelings and excitement produce blushing, pallor, sweating, itching and gooseflesh.
The skin has long been known to be the site of inner conflict and an illustrated by such expression as “thick skinned” or “Jump out of ones skin”.
The skin and the CNS are derived from the ectoderm. It is then not suprising that nervous action can be reflected on the skin. “It can thus be said that skin is an everted nervous system.”
Strong emotion can precipitate or aggravate and itching. This is often observed in people who react with irritability, anxiety and agitation under emotional tension. Feeling of guilt, fear and anger can all evoke itching and scratching.
From psychosomatic aspect this disorder is regarded as an expression of disturbance in the mother /child relationship. It usually develops in children of mothers who avoid skin contact with their children. It usually resolves spontaneously after the first year of life when the child’s emotional development matures.
This refers to self-inflicted damage to in the absence of any direct conscious suicidal instinct. This is found mostly in young girls. Psychological studies showed that these children have severe intrapsychic tension, depressed mood, inhibited aggression, strong affect block and low frustration threshold. It is seen frequently in adolescent.
Psychotherapy and behavioral modification techniques play an important role in the treatment.
Most children and even adults have headache after upsetting and annoying experience.
According to Keilhots. The tension headache goes through 3 stages. The first one is the asthenic stage where the patient is unstable and extremely sensitive. The second stage, the psychosomatic symptoms appear and first and foremost with headache. It is not until the third stage that the depressive symptoms appear. Headache can occur in individuals with psychopathic personality in a symptom of parathymic conditions in stress situation.
Again headache may present as psychosomatic symptoms in endogenous psychosis.
According to Condaru (165) and Senodern (1966) women suffering from Dysmenorhoea are those having inner conflicts. They are usually neurotic, inadaptable, frigid and afraid of sexual contact. They may have masculine personality that makes them feel degraded by menstrual process.
Others have remained in the infantile in their emotional behavior, they seek maternal protection and recast from duties they are expected to perform as wives.
In adolescent who engages in premarital sex, the subconscious fear of pregnancy and STD may result in vaginismus and frigidity to anorgamia. Treatment should always be directed towards resolving the underlying conflict.
In conclusion various ailments that have organic basis may also have the psychic component manifesting as somatic symptoms. As shown in research that practical medicine has from its very inception, always been psychosomatic in essence.
Plato expressed that it is impossible separate the body from the mind and the “whole” has to be studied, for part can never be well unless whole is well.