Basic and Behavioural Sciences

Psychosomatic Disorders in Pediatrics

Susan R. Brill, Dilip R. Patel and Emily MacDonald

Overlook Hospital Children's Medical Centre, Summit, New Jersey and Michigan State University,
Kalamazoo Centre for Medical Studies, Kalamazoo, Michigan, USA.

Abstract. Psychosomatic symptoms are by definition clinical symptoms with no underlying organic pathology.
Common symptoms seen in pediatric age group include abdominal pain, headaches, chest pain, fatigue, limb pain,
back pain, worry about health and difficulty breathing. These, more frequently seen symptoms should be
differentiated from somatoform or neurotic disorders seen mainly in adults. The prevalence of psychosomatic
complaints in children and adolescents has been reported to be between 10 and 25%. These symptoms are
theorized to be a response to stress. Potential sources of stress in children and adolescents include schoolwork,
family problems, peer pressure, chronic disease or disability in parents, family moves, psychiatric disorder in
parents and poor coping abilities. Characteristics that favour psychosomatic basis for symptoms include vagueness
of symptoms, varying intensity, inconsistent nature and pattern of symptoms, presence of multiple symptoms at
the same time, chronic course with apparent good health, delay in seeking medical care, and lack of concern on
the part of the patient. A thorough medical and psychosocial history and physical examination are the most valuable
aspects of diagnostic evaluation. Organic etiology for the symptoms must be ruled out. Appropriate mental health
consultation should be considered for further evaluation and treatment. [Indian J Pediatr 2001; 68 (7) : 597-603]

Key words : Psychosomatic; Somatization; Factitious disorder; Neurotic disorders; Somatoform disorders

The influence of mind and emotions over physical
functions has been well recognized in medicine. Most
pediatricians witness this p h e n o m e n o n on a daily
basis; for example, the young toddler whose cut feels
better immediately after applying an adhesive
bandage. With more persistent symptomatology, such
as chronic abdominal pain or persistent headaches, the
practitioner often recognizes the 'flavour' of a
psychosomatic presentation, and needs to differentiate
such symptoms from those of underlying organic
pathology. This article reviews definitions,
epidemiology, .theories of etiology, and general
principles of diagnosis and management of children
and adolescents who present with psychosomatic
complaints.
DEFINITIONS
Psychosomatic symptoms are by definition clinical
symptoms with no underlying organic p a t h o l o g y . 1'2'3'4
According to the Diagnostic and Statistical Manual for
Primary Care (DSM-PC)4somatization is defined "as the
Reprint requests : Dr. Dilip R. Patel, MD, MSU/KCMS/
Pediatrics 1000, Oakland Drive, Kalamazoo, Michigan State
49008, United States of America.
E-mail : patel@kcms.msu.edu
occurrence of one or more physical complaints for
which appropriate medical evaluation reveals no
explanatory physical pathology or pathophysiologic
mechanism or, when physical pathology is present, the
physical complaints resulting in impairment are
grossly in excess of what would be expected from the
known physical findings." Somatic symptoms are also
seen in children with chronic or terminal disease (such
as asthma or malignancy) as well as in primary
psychiatric disorders (such as major depressive
disorder or anxiety disorder). Common psychosomatic
symptoms seen in children and adolescents are listed
in Table 1. TM The more frequently reported
psychosomatic symptoms should be differentiated
from less frequently seen somatoform disorders as
described in the Diagnostic and Statistical Manual of
Mental Disorders-W (DSM-IV-Text Revision)? Similar
disorders are classified as neurotic disorders in the
International Classification of Diseases (ICD-9
Revised). 2
S o m a t o f o r m disorders are specific psychiatric
d i s o r d e r s c h a r a c t e r i z e d p r i m a r i l y b y somatic
complaints that are chronic and cause significant
distress and functional impairment for the patient,
such as in occupation or in the school for the child or
the adolescent, s There is no organic basis for their
symptoms, the patients maintain insight into their

Indian Journal of Pediatrics, Volume 68--July, 2001 597

 Susan R. Brig et al
TABLE1. Common Psychosomatic Symptoms
Recurrent abdominal pain, nausea
Headaches
Fatigue, weakness
Musculoskeletal pain, limb pain
Chest pain
Hyperventilation, difficulty breathing
Dizziness, fainting
Back pain
Worry about health
Worry about physical appearance
Pseudoneurological symptoms (such as loss of balance,
blindness, pseudoseizures)
conditions, and their behaviour generally remains
socially acceptable. 2 Somatoform or neurotic disorders
are outlined in Table 2. 2~ Patients with psychosomatic
s y m p t o m s or s o m a t o f o r m d i s o r d e r s are not
malingering. Factitious disorders are characterized by
patients, knowingly and intentionally, presenting with
p h y s i c a l or p s y c h o l o g i c a l c o m p l a i n t s w i t h no
underlying primary medical problem, s These patients
assume the "sick role." Patients who are malingering
also present with physical or psychological symptoms
that have no organic basis and are intentionally
produced; however in these patients secondary gain is
apparent. 2~
TABL~2. Somatoform/Neurotic Disorders
American Psychiatric Association Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV-TR)Classification of
Somatoform Disorders
Somatization disorder : Multiple symptoms present for years,
including gastrointestinal, sexual, & pseudoneurological.
Undifferentiated somatoform disorder : Less severe symptoms
than somatization disorder, present for at least 6 months.
Coversion disorder : Symptoms affecting voluntary motor or
sensory functions that mimic neurological condition.
Pain disorder : Pain is the predominant feature.
Hypochondriasis: Preoccupation with the fear of having a
serious disease. Patient misinterprets multiple physical
symptoms.
Body dysmorphic disorder : Preoccupation with perceived
deficits in physical appearance.
Somatoform disorder not otherwise specified : Any somatoform
disorder that does not fully meet
criteria for above disorders.
598
EPIDEMIOLOGY
The prevalence and nature of psychosomatic
s y m p t o m s and somatoform (or neurotic disorders)
may vary by age, gender, culture and developmental
stage of the child and adolescent. 614The prevalence
rate for psychosomatic complaints in children and
adolescents has been reported to be between 10 and
25%. 1,12-1sThere is a higher prevalence in girls during
adolescence. Symptoms peak around age 7 years in
boys and ages 6 and 16 in girls.lSThe most commonly
reported symptoms are stomach aches (peak at age 9
years), headaches (peak at age 12 years),
musculoskeletal pain, and chest pain. ~,ls While many
psychosomatic complaints are seen frequently in the
pediatric age group; somatoform or neurotics
disorders as described in adults are relatively
uncommon in this age group. 4~'~s Although, during
adolescence somatization is not rare and early
symptoms of some of these disorders may be noted,
such as anxiety and depressive states, conversion
reaction or hysteria, hypochondriasis and obsessive
compulsive behaviours. In addition, concerns about
bodily functions and appearance are especially
common during early to mid-adolescent develop-
mental stages. ~6 The prevalence of somatoform
disorders in adults has been generally reported to be
ranging from 0.2 to 2% in females and less than 0.2% in
Classification of Neurotic Disorders according to the
International Classification of Diseases (ICD-9-R)
Anxiety states : A n x i e t y symptoms not attributable to real
danger.
Compensation neurosis : Neurotic reaction in which secondary
gain is predominant.
Depersonalization : Disturbed perceptions of external
stimuli; the patient is aware of the subjective nature of the
symptoms.
Depression : Depressive state that is disproportionate to the
distressing event that precipitated the symptoms.
Hypochondriasis : Same as DSM-W-TR
Hysteria : Similar to Conversion disorder in DSM-W-TR
Neurasthnia : Predominant symptoms of fatigue, irritability,
insomnia, anhedonia.
Obsessive-compulsive states : Uncontrollable feelings of
subjective compulsions and obsessional thoughts.
Occupational neurosis : Dysfunction of a group of muscles
related to one's occupation.
Phobic disorders : Unrealistic intense fear and anxiety
predominate.
Somatization disordOr : Similar to DSM-IV-TR
Indian Journal of Pediatrics, Volume 68--July, 2001
 Basic and Behavioursl Sciences Psychosomatic Disorders
males, s The exact prevalence of these disorders in
adolescents is not known.
THEORIES OF ETIOLOGY
The cause of the somatization response is often obscure
when first evaluating the patient. These disorders have
been explained on the basis of response to stress27-19
"Stress" can arise from the patient's environment, such
as a death in the family or from internal, emotional
turmoil, such as the experience of depression or anxiety
(Table 3). 3'12,16-2~The s y m p t o m s m a y be a normal
response to excessive stress or a heightened response to
normal amounts of stress. Genetic and cultural
concerns often overlay the response to the particular
stress. With persistent stress, there is dysregulation of
the traditional "fight or flight" response, resulting in
anxiety disorders, posttraumatic stress disorders, or
psychosomatic symptomatology. 1,3,13,~6The stress is
often understood consciously (a teenager can describe
the particulars in his life that are "stressing him out"),
TABL~ 3. Potential Sources of Stress
School changes
Conflicts with teachers
School workload
Family moves, new residence
Normal changes of puberty
Poor coping abilities
Peer pressure
Chronic disease and disability in parent/s
Psychiatric disorder in parent
Conflicts and arguments between parents
Rigid parenting style
Physical or sexual abuse
Sociocultural expectations
Family financial problems
Death, illness, injury in family
Frequent change in job of parents
Family involved in litigation
Excessive alcohol intake by parents
Serious accidents in family
but also is processed atsubconscious level; it is in this
way that the tension becomes a real physical symptom.
Singh et aI described the relationship b e t w e e n
stressful family life events and non-specific complaints
in 477 school children ages 11 to 17 years. 12The study
noted a significant increase in somatic complaints in
direct proportion to the number of stressful events in
the family. Boyce described several studies that found
reliable associations between stress and overall health
outcome. The n u m b e r of s t r e p t o c o c c a l illnesses,
injuries, d u r a t i o n of respiratory illnesses, overall
illnesses, and hospitalizations showed correlation with
stress/life event scores. 17 Biologic connections have
also been investigated. In a study of first year dental
Indian Journal of Pediatrics, Volume 68--July, 2001
students, salivary i m m u n o g l o b u l i n A levels were
measured throughout the school year. The researchers
found that the levels of immunoglobulin A correlated
negatively with stress levels during examinations. 2~In
clinical practice, academic stress is ubiquitous in junior
and high school students and often seen in m a n y
children in elementary school. 15~2
Robinson et al i n v e s t i g a t e d 115 a d o l e s c e n t s
presenting to an adolescent medicine clinic. TM They
c o m p l e t e d a q u e s t i o n n a i r e d e s i g n e d to m e a s u r e
'negative life events', such as a recent move, change in
school or illness in a family member. Self-esteem and
family adaptability were also measures. These results
were compared with the diagnoses generated by the
visit, which sorted out into well care, acute illness, or
functional somatic symptoms. The study found that
those teenagers with functional somatic complaints
reported significantly more negative life events and
had a lower self-evaluation than those teens presenting
for routine health maintenance. Interestingly, there
were more negative life events in those teens found to
have an acute organic illness as well.
Another study found that among female high school
s t u d e n t s , illness or injury to a family m e m b e r ,
increased arguments with parents and breaking up
with boyfriends or girlfriends were associated with
high somatic symptoms27 Males experienced more
symptoms if there was absence of a parent from the
home or if there was trouble with siblings. A recent
s t u d y e v a l u a t e d the relationship b e t w e e n school-
related stress and psychosomatic symptoms in a large
group of Norwegian adolescents. 22 Increased school
distress was associated with several psychosomatic
symptoms, while social support via teachers or other
students reduced the risk of symptoms.
AN APPROACH TO DIAGNOSIS
It is important to differentiate between psychosomatic
symptoms, somatoform disorders and factitious
disorders. The latter are psychiatric conditions and are
relatively u n c o m m o n in pediatric practice. In some
children and adolescents persistent somatization may
later evolve into somatoform disorders. In treating
patients with somatic complaints, t h e r e is often a
concern that a patient may be malingering. As noted
earlier, Factitious disorders are characterized b y
symptoms that are intentionally produced to maintain
a 'sick role. '5 The malingering patient may be reporting
symptoms to avoid school or incarceration, or to obtain
drugs.
The Medical and Psychosocial History
The initial goal of the clinician is to determine if an
organic disease is present. As the history is obtained,
599
 Susan R. Brill et al
the time course, location and pattern of symptoms, as
well as the degree of disability, should be noted. An
increase in the intensity of the symptoms, consistency
in location and worsening pattern w o u l d be
worrisome; on the other hand overall measures of
good health (such as weight gain and pubertal
progression) are reassuring. The clinician should
obtain a complete medical as well as psychosocial
history. This may not be possible in one visit but may
be accomplished in two to three sessions as time
allows, because the relationship between the physical
symptoms and the psychosocial dysfunction may not
be apparent at first visit2 8
Rickert has described the SAFE interview as one
approach to assess psychosocial factors2 5This acronym
reflects queries regarding Severity, Affect, Family and
Environment. The severity of the symptoms may be
acute, intermittent or chronic. If a patient, especially an
adolescent, describes the pain in great detail, and
embellishes the history with imagery, it may suggest
that the pain is part of a coping response to significant
stress. Conversely, m a n y patients report several
i n c a p a c i t a t i n g s y m p t o m s casually, and a p p e a r
u n c o n c e r n e d a b o u t their illness; these affective
presentations often favour a diagnosis of functional or
somatic s y m p t o m s . The parental affect is equally
important in determining the nature of the symptoms.
Family stressors play an important role in the
development and maintenance of somatic symptoms.
Major psychosocial stresses, such as parental alcohol or
substance abuse, may not be revealed initially. Gentle
probing in a confidential environment can often reveal
'family secrets.' There may be secondary gain within
the family by the child maintaining a sick role. For
example, focusing on a sick child may deter the family
from sources of conflict. Thus, although the child is not
malingering, the family dynamics may help maintain
the symptoms.
The environment in which a child lives plays a
crucial role in shaping his or her social interactions. As
c h i l d r e n enter school, the a c a d e m i c and social
TASL~4. Characteristics that Favour a Psychosomatic Basis
for Symptoms
Vagueness of symptoms
Inconsistent nature and pattern of symptoms
Varying intensity
Symptoms cannot be reproduced consistently
Presence of multiple symptoms at the same time
Chronic, intermittent course with apparently good health
Delay in seeking medical care
Exacerbation related to increase stress
Apparent lack of concern on the part of the patient
Lack of impairment in social and school functioning
Lack of response to treatment
600
performances can become sources of stress. School
p e r f o r m a n c e and p e e r r e l a t i o n s h i p s s h o u l d be
assessed. M a n y p a t i e n t s with p s y c h o s o m a t i c
symptoms give a history of frequent absences, but peer
r e l a t i o n s h i p d i s t u r b a n c e is m o r e w o r r i s o m e .
C o m p e t i t i v e c o m m u n i t y e v e n t s (such as s p o r t s
participation) can a d d additional stress for some
children and adolescents. Relief from competition may
often be a s e c o n d a r y gain from c o n t i n u e d
psychosomatic symptoms.
Physical and Mental Status Examination
A thorough general physical and mental status
examinations are essential, and normal findings are
most reassuring for the patient and parents.
Role of Laboratory Investigations
In general, once the history and physical examinations
are completed, a working diagnosis should be
presented to the patient and family. Effective
communication with the patient and his or her parents
is important throughout the assessment and treatment
of patients with psychosomatic symptoms. Even if the
clinician is fairly sure there is no organic pathology, the
s y m p t o m s need to be taken seriously as an illness,
albeit a functional one. It is crucial neither to state nor
imply "it's all in your head". Appropriate screening
tests to rule out organic etiology should be discussed.
The laboratory work-up is directed towards the
presenting symptoms; some basic tests recommended
include a complete blood count, erythrocyte
sedimentation rate, C-reactive protein, serum
electrolytes and liver function tests. 16~3These tests, if
normal, w o u l d help exclude significant infectious,
hematologic or rheumatologic diseases. A tuberculin
test (Purified Protein Derivative), screening test for
human immunodeficiency virus infection, and Epstein-
Barr virus titers are often performed but should be
ordered judiciously, when there are risk factors or the
clinical presentation indicate. More invasive
procedures or radiology studies should generally be
avoided as a "fishing expedition".
CASE REPORT
Case 1: Respiratory distress :
A 14-year-old male presented to the Emergency room
(Casualty department) with a three-hour history of
difficulty breathing. The s y m p t o m s began as
substernal chest pain and progressed to difficulty
breathing, relieved when the patient took deep breaths.
There was no past history of cardiac or respiratory
Indian Joumal of Pediatrics, Volume 68--July, 2001
 Basic and Behavioural Sciences Psychosomatic Disorders
conditions. The patient had a large high fat meal the
evening before presentation. In the emergency room
pulse oximetry was 100% in room air; physical
examination, chest X-ray, and electrocardiogram were
all normal. A diagnosis of possible esophageal reflux
was entertained. Additional history revealed that the
evening prior to the symptoms, the patient was
preparing for his upcoming interview for a competitive
local high school. The patient was discharged to
follow-up with his pediatrician for psychosocial
support.
Hyperventilation, often concurrent with anxiety
states, is a c o m m o n p s y c h o s o m a t i c s y m p t o m in
adolescents. 24 Associated s y m p t o m s m a y include
dizziness, fainting, palpitations, or even tetany. In one
study, thirteen out of t w e n t y three patients w i t h
hyperventilation referred for psychiatric evaluation
were diagnosed with anxiety disorder and three met
criteria for depression25
Case 2: A b d o m i n a l pain
An l 1-year-old girl presented to an adolescent
medicine practice for abdominal pain of three-year
duration, to 'rule out' gynecologic pathology. She was
also evaluated in the past by a pediatric
gastroenterologist. The pain was described as
occurring daily, in the periumbilical region but
occasionally in other areas. The discomfort was
accompanied by increased flatulence. The patient also
experienced weakness, muscle aches and joint pain,
but in no discernible pattern. Chest pain was also a
frequent complaint. Prior work-up included complete
blood count, complete metabolic panel, stool culture,
stool examination for ova and parasites, and
Helicobacter pylori titers; all results were negative.
Breath hydrogen test was negative, except for a
borderline result suggesting lactose intolerance.
Psychosocial history revealed three older siblings with
severe behavioural problems including social phobia
and anxiety disorder. The patient had just begun
middle school and was having difficulty with getting
along with her peers. Physical examination was
normal. Height and weight were at the 50th percentile
for age. The patient had Tanner 3 breast and pubic hair
development.
Management consisted of reassurance of normal
growth parameters; screening laboratory tests were
rechecked and were normal. A lactose free diet was
prescribed, and counselling was offered concerning the
socialization difficulties. Over the next several weeks,
patient showed a gradual resolution of symptoms, had
b e g u n to m e n s t r u a t e , g r o w n two inches, a n d
socialization in school had improved.
Indian Journal of Pediatrics, Volume 68--July, 2001
Biopsychosocial factors often c o n t r i b u t e to
a b d o m i n a l pain. Several studies h a v e s h o w n an
increase in c o n c u r r e n t p s y c h o l o g i c a l d i s o r d e r s ,
especially anxiety a n d / o r depression. 15,2sParental
anxiety and family health problems are also common.
Interestingly, studies comparing children with organic
and non-organic abdominal pain, have also found that
both groups show relatively more emotional distress,
family illness, and p s y c h o p a t h o l o g y than control
groups. 15,25
Case 3 : Headaches
A 17-year-old male presented to adolescent clinic with
a two-year history of headaches. They occurred mostly
in the late afternoon, but occasionally in the morning;
with equal frequency on weekdays and weekends. He
had missed school several times this year, and believed
the headaches were worse now. There was concurrent
nausea but no vomiting, and no photophobia. Patient
had moved to the United States a year ago. He was
active in several sports, and was an above average
student. He denied smoking, alcohol and drug use.
Physical examination, including visual acuity and
full neurological examination, were normal. A working
diagnosis of tension headaches was made, and he was
asked to keep a record of his headaches to be reviewed
at a follow-up visit. The patient was reassured of
benign nature of the headaches, and counselling was
started. On follow-up one month later, the headaches
continued, and were noted two to three times per week
and were often precipitated by hunger or stress. They
were pounding, and relieved with sleep. A diagnosis of
migraine headache was more evident now and was
treated accordingly with improvement.
Headaches in adolescents are c o m m o n and are
g e n e r a l l y p r e s u m e d to be stress related, tension
headaches. 26The etiological diagnosis is largely based
on a thorough history. Headaches are often coupled
with other somatic symptoms, and, like abdominal
pain, can comprise a 'pain s y n d r o m e ' . The exact
prevalence of headaches in the adolescents is not
known. The majority of teens and young adults do not
seek medical care for headaches as they are often
a m e l i o r a t e d w i t h c o m m o n analgesics a n d are
perceived as benign. Thus the adolescent presenting
with a complaint of recurrent headaches may represent
a m o r e select p o p u l a t i o n in n e e d of a careful
evaluation.
T R E A T M E N T PRINCIPLES
The m a n a g e m e n t of children and adolescents with
psychosomatic complaints requires a skilful
601
 S u s a n R. Brill e t al
TASTE5. Suggestions for Managing Pediatric Somatization
Acknowledge that the patient's pain and the family's concern are real
Do not attempt to challenge the reality of the symptoms
Be alert to possibility of undiagnosed organic cause.
Identify social or interpersonal reinforcers for the symptoms
Begin psychological assessment early to identify symptoms of mental health disorders
Discuss the diagnosis in a simple and direct manner with patient and parents
Minimize the reinforcement of the sick role
Set up regular follow-up visits.
Avoid making physician contact contingent on sick role behaviour.
Emphasize the importance of continuing daily activities such as school attendance
Take a rehabilitative approach and avoid the promise of a cure
Identify and reward healthy, adaptive behaviours
Encourage cognitive coping skills, self-monitoring, relaxation training
Try to consolidate medical treatment with the patient's primary physician
assessment. Treatment needs to be individualized
depending on the severity and nature of symptoms.
Mild symptoms, such as those associated with an
adjustment to a new school or final examinations, often
improve spontaneously. The clinician needs to offer
encouragement and support as well as reassurance of
general good health. The more severe and persistent
symptomatology, with school absences or refusal,
requires further evaluation into environmental and
family dysfunction. This may require several visits to
ascertain a full medical and psychosocial history.
Reassurance following normal screening laboratory
tests should help alleviate the patient and family from
worry about serious organic disorder as a cause for the
symptoms.
Cases that are acute a n d m o n o s y m p t o m a t i c in
nature can be approached with the goal of complete
improvement, but pervasive or multisymptomatic
complaints are best approached in terms of managing
s y m p t o m s . P e r s i s t e n t s y m p t o m s tl~at s u g g e s t
depression, anxiety, or panic disorder, require a mental
health consultation, but the clinician can offer several
t h e r a p e u t i c a p p r o a c h e s in tandem. Together, the
p e d i a t r i c i a n a n d m e n t a l health p r o f e s s i o n a l c a n
formulate a plan that attempts to deemphasize and
reduce family dysfunction. Some practical suggestions
for management are outlined in Table 5. 27Behavioural
techniques, (for example, the contingent reinforcement
of coping behaviour) are effective in reducing the
secondary gains that may be associated with the sick
role, as well as increasing c o m p l i a n c e w i t h the
prescribed treatment regimen. 27
In addition, e m p o w e r i n g the adolescent to take
control of the symptoms is a key concept in treatment.
Several techniques can be employed, separately or in
combination. These include stress management, time
602
management, self-hypnosis, and relaxation training.
Stress and time management counselling may involve
the use of journals, with s u b s e q u e n t r e v i e w a n d
identification of potential changes. A coaching model
may be used for both parents and patients to enhance
healthy techniques for stress relief.
CONCLUSION
Treating psychosomatic s y m p t o m s requires a
paradigm shift in the approach to patient care. The
traditional biomedical model' presumes organic
pathology and psychological disturbance to be
separate entities. The biopsychosocial model, on the
other hand recognizes that the course of an organic
illness is often modified b y the patient's emotional
environment. In psychosomatic illness, such
correlations are important to recognize in order to
understand the pathogenesis as well as to approp-
riately manage the illness.
REFERENCES
1. Reeve A, Strasburger VC: Is it "real" or is it
"psychosomatic"? Basic principles of psychosomatic
medicine in children and adolescents, 352-366. In
Greydanus DE, Wolraich ML, eds. Behavioural
Pediatrics. New York, Springer-Veflag, 1992.
2. International Classification of Diseases (9th Revision):
Clinical Modification, 6th edition, Los Angeles,
California Practice Management Information
Corporation, USA, 2001.
3. Brown RT: Adolescents with psychosomatic problems.,
Comprehensive Therapy. 1996; 22 : 810.
4. American Academy of Pediatrics: The Classification of
Child and Adolescent Mental Diagnoses in Primary
Care : Diagnostic and Statistical Manual for Primary
Care (DSM-PC) Child and Adolescent Version.
Indian Joumal of Pediatrics, Volume 68--July, 2001
 Basic and Behavioural Sciences Psychosomatic Disorders
American Academy of Pediatrics, Illinois Elk Grove
Village, USA, 1996.
5. American Psychiatric Association: Diagnostic and
Statistical Manual of Mental Disorders, 4th edn, Text
Revision, W a s h i n g t o n DC, A m e r i c a n Psychiatric
Association, 2001.
6. H a c k e t t R, H a c k e t t L, Bhakta P, G o w e r s S: The
prevalence and associations of psychiatric disorder in
children in Kerala, South India. J Child Psychol
Psychiatry. 1999; 40 : 801.
7. Patel V, Pereira J, Mann AH: Somatic and psychological
models of common mental disorder in primary care in
India. Psychosomatic Medicine. 1998; 28 : 135.
8. Alexander PJ, Joseph S, Das A: Limited utility of ICD-
10 and DSM-IV classification of dissociative and
conversion disorders in India. Acta Psychiatr Scand.
1997; 95 : 177.
9. C h a t u r v e d i SK, Bhandari S, Beena MB, Rao S:
Screening for a b n o r m a l illness b e h a v i o u r .
Psychopathology. 1996; 29 : 325.
10. Weiss MG, R a g u r a m R, C h a n n a b a s a v a n n a SM:
Cultural d i m e n s i o n of psychiatric diagnosis: a
comparison of DSM-III and illness explanatory models
in south India. British J Psychiatry. 1995; 166 : 353.
11. Srinath S, Bharat S, Girimaji S, Seshadri S:
Characteristics of a child inpatient population with
hysteria in India. J Am Acad Child Adolesc Psychiatry.
1993; 32 : 822.
12. Singh H, Soni PK, Gill PJS, Kaur L: Stressful family life
events and nonspecific somatic complaints in school
children. Indian Pediatrics. 1991; 28 : 1483.
13. Greene JW, Walker LS: Psychosomatic problems and
stress in adolescence. Pediatric Clinics of North America.
1997; 44 : 1557.
14. Webster ML: Psychological problems manifested by
somatic symptoms. Adolescent Medicine. 1998; 9 : 403.
15. Rickert VI, Jay MS: Psychosomatic disorders: the
Indian Joumal of Pediatrics, Volume 68---July, 2001
approach. Pediatrics in Review 1994; 15 : 448.
16. Hofmann, AD: Psychosomatic, anxiety and conversion
Disorders. In H o f m a n n AD, G r e y d a n u s DE, eds.
Adolescent Medicine. Appleton and Lange, Stamford,
Connecticut, USA, 1997, pp. 820-834.
17. Boyce WT: Stress and child health: an overview. Pediatr
Ann 1985; 14 : 539.
18. Strasburger VC, Reeve A: The adolescent with chronic
pains: basic principles of psychosomatic medicine.
Adolescent Medicine. 1991; 2 : 677.
19. Robinson P, Greene J et al: Functional somatic
complaints in adolescents: Relationship to negative life
events, self-concept, and family characteristics. Journal
of Pediatrics 1988; 113 : 588.
20. Poikolainen K, Kanerva R et al: Life events and other
risk factors for somatic s y m p t o m s in adolescence.
Pediatrics 1995; 96 : 59.
21. Jemmott JB, Borysenko JZ et al: Academic stress, power
motivation and decrease in secretion rate of salivary
secretory immunoglobulin A. Lancet 1983; 1 : 1400.
22. Natvig GK, Albrektsen Get ah School-related stress and
psychosomatic symptoms among school adolescents. J
Sch Health 1999; 69 : 362.
23. Rosenfeld W, Walco G: One test too many: toward an
integrated a p p r o a c h to p s y c h o s o m a t i c disorders.
Adolescent Medicine. 1997; 8 : 483.
24. H o m n i c k D, Pratt H: Respiratory diseases with a
psychosomatic component in adolescents. Adolescent
Medicine. 2000; 11 : 547.
25. Webster ML: Psychological problems manifested by
somatic symptoms. Adolescent Medicine. 1998; 9 : 403.
26. Liner M, Stewart W: An e p i d e m i o l o g i c s t u d y of
headache among adolescents and young adults. JAMA
1989; 261 : 2211.
27. Fritz GK, Fritsch S, Hagino O: Somatoform disorders in
children and adolescents: a review of the past 10 years.
J Am Acad Child Adolesc Psychiatry 1997; 36 : 1329.
603