Somatoform Symptoms In Adolescents Who Visit The Emergency Department: Alexithymia And Defensive Strategies

Abstract

Somatoform symptoms represent one of the main reasons of access to emergency department (ED) in adolescence. Research in this field has limitedly focused on difficulties to recognize and cope with their own emotions, considering the access rate to an ED. The present study aims to verify whether adolescents who accessed an ED for somatoform symptoms show high alexithymia traits and use specific defense strategies. Adolescents (range: 15-24 years) who visited an ED for somatoform symptoms (N=37) or who accessed to an ED for somatoform symptoms in the past (N=37) were involved in this study and completed the TAS-20 to assess alexithymia and the REM-71 to assess use of defense mechanisms. A control group of adolescents from general population were paired. Adolescents who visited an ED for somatoform symptoms shown more alexithymic traits and a higher use of maladaptive defense strategies respect to control group. Higher rates of access to ED are associated with more use of repression, but only for adolescents who accessed to an ED in the past. Finally, alexithymic characteristics are associated with use of specific defense strategies. Our findings confirm that ED is one of the most used services of young people suffering from somatoform symptoms. In this perspective, ED visits are to be considered as adolescents’ unconscious attempt to seek psychological help. These findings evidence the importance of prevention programs based on increasing of awareness and acceptance of unconscious needs and on the promoting of use of adaptive defense mechanisms.

Keywords: Somatoformadolescentemergent departmentalexithymiadefences

Introduction

Somatoform symptoms represent common features of psychological and psychosomatic disorders which induce a broad spectrum of pain and physical discomfort, including recurrent tension headache, abdominal inflation, gastrointestinal symptoms and other somatic symptoms that are inconsistent or cannot be medically explained (Murray et al., 2015; Dehoust et al., 2017; Heidari et al., 2017).

According to DSM-5 (American Psychiatric Association, 2003), somatoform symptoms generally occur in adolescence (Klineberg et al., 2014) and tend to persist through adulthood without treatment (Winter et al., 2014; Jeon, 2015).

In adolescence, it has been evidenced a rate of prevalence of approximately 11% to 22% (Hildernik et al., 2013; van Geelen, Rydelius, & Hagquist, 2015) with an increment during development. The most common adolescents’ somatoform symptoms are continuous headache, dizziness, fatigue, musculoskeletal pain, stomachache and abdominal pain (Thomson et al., 2014). However, manifestation of somatoform problems tend to be usually polysymptomatic (Emich-Widera et al., 2012). Especially after puberty, there is a distinct difference in gender in which females adolescent girls reporter higher psychosomatic problems respect to adolescent boys, with a ration of 5:1 (Bujoreanu et al., 2014; Ruchkin & Schwab-Stone, 2014). Moreover, it has been evidenced that 18.3% of adolescents who suffering from someone of these signs of somatic pain generally experience pain more than once per week (Larsson & Sund, 2007; Jeon, 2015). Individual tend to attributes these symptoms to a physical illness and this conduce to seeking medical advices (Fiertag & Eminson, 2014). Developmental clinicians and researchers have suggested that in adolescence can be difficult express own feeling and emotions through language. In this time, faster biological, cognitive and social changes that occur may increase negative affect and emotional reactivity. Because of this, adolescents may often manifested their emotional hardship through physical (somatic) symptoms (Mohapatra et al., 2014). In particular, according to psychodynamic framework, psychological distress of somatoform adolescent patients has been interpreted as a consequence of an unconscious repression of intolerable affects in order to avert interpersonal conflicts, which would lead severe negative emotions (Beutel et al., 2008). Moreover, also increased concern to body sensations that characterized adolescents who recurrent experience somatic symptoms, play a key role to distract person from interpersonal conflicts (de Greck et al., 2013; Casini, 2015; Probst et al., 2017).

Several studies focused on factors that may increased the risk of experiencing somatoform symptoms, have shown that somatic pain and functional pain medically unexplained are caused by dynamic and reciprocal interactions between biological, psychological and interpersonal factors, including pressure from schools and families, and poor quality of family functioning (Basch et al., 2015). Moreover, it has been reported that adolescents suffering from somatoform symptoms have a higher risk to develop social and emotional maladjustment (Mohapatra et al., 2014), especially anxiety and depressive symptoms (Bellini et al., 2013), missing schools and academic stress (Cozzi et al., 2017), withdraw and avoid social relationship with peers (Cottrell, 2016).

Problem Statement

Please replace this text with context of your paper. Recently, several authors have point out that somatoform symptoms in adolescents population are one of the main reasons of access to primary care services for seeking professional help and performing a number of specialist examinations (Casini, 2015; Tøt-Strate et al., 2016). Indeed, it has been reported that approximately 25-50% of emergency department (ED) visits by adolescents are for non urgent and non organic problems (Alderman, 2012; Cozzi et al., 2017). Research among adults population have shown that somatoform symptoms are significant associated with both difficulty in expressing and verbalizing emotional states and experiences (Panayiotou et al., 2015; Saariaho et al., 2016) and use of immature defense mechanisms (Hyphantis et al., 2013a, 2013b). Moreover research have widely underlined the presence of significant associations between alexithymia and immature defense strategies (Alilu et al., 2014). In contrast, only few studies have examined the above associations in adolescent samples, suggesting that somatoform symptoms are correlated to adolescents’ difficulties to recognize and cope with their own emotions (Tozzi et al., 2013). In particular, adolescents whit recurrent psychosomatic diseases reported a high level of alexithymic traits (Burba et al., 2006; Casini, 2015; Cerutti et al., 2016a, 2017) and massive use of maladaptive defense strategies (Xiao & Fu, 2006; Mulloy, 2013) compared with healthy controls

Research Questions

To the authors’ knowledge, however, there is a dearth of studies focused on possible associations between alexithymia and use of specific defense mechanisms in adolescents with somatoform symptoms, considering the access rate to an ED

Purpose of the Study

Based on these theoretical and empirical premises, the principal aim of this paper was to evaluate whether adolescents whit somatoform symptoms who visited an ED reported higher levels of alexithymia and maladaptive defense mechanisms. In particular, the present study aims to verify:

• whether adolescents suffering from somatoforms symptoms show difficulties to recognize and describe their own emotions and use specific defense mechanisms

• whether a higher rates of access to ED are associated with more alexithymic characteristics and a massive use of defense mechanisms

Research Methods

Findings

Conclusion

This study aimed to verify whether adolescent’s who visited an ED for somatoform symptoms shown difficulty to recognize, describe and cope with emotions of self and others effectively, considering the rate of access. Our results have confirmed that ED is one of the most used services of young people suffering from somatoform symptoms, with higher healthcare costs involved due to heavy utilization of resources (Weiss, D'Angelo & Rucker, 2014). Psychodynamic clinicians (Witthöft & Hiller, 2010; Casini, 2015) have interpreted ED visits as adolescents’ unconscious request to receive psychological help. In particular, our data evidenced the presence of massive use of defense strategies in adolescents with somatoform symptoms, especially in adolescents who visited an ED in the past (Group B). We hypothesized that adolescents of Group A reported a lower use of defense mechanisms due to the particular environment where they were (ED), which has been suggested to be associated with a lowering of defenses (King, Churchill, & Cross, 2007). Regarding our second aim, our findings confirmed that adolescents with somatoform difficulties have higher levels of alexithymic traits and are coherent with recent studies that have shown the presence of strong association between alexhitymic features and somatoform symptoms (Casini, 2015; Cerutti et al., 2016b). Moreover, higher rates of access to ED of adolescents who accessed to an ED in the past are significant associated with use of specific defense strategies (i.e., repression). Finally, in accordance with previous studies (Helmes et al., 2008), our results have confirmed that alexithymic characteristics were associated with use of specific defense strategies. These findings could evidence the importance of prevention programs focused on increasing of awareness and acceptance of unconscious needs and on promoting use of adaptive defense mechanisms (de Greck et al., 2013). This study has some limits: the sample homogeneity in terms of cultural, geographical, and socio-economic status limits generalizations of the results; we did not evaluate adolescents’ emotional-behavioral functioning and/or the presence of psychopathological symptoms as suggested by previous studies (Rajindrajith et al., 2013); we did not examine family functioning and quality of relationships of adolescents with their peers that literature have underlined to be widely linked to somatoform symptoms in adolescence (Basch et al., 2015). To the authors’ knowledge, moreover, no other study have focused on possible associations between adolescents’ somatoform symptoms with both alexhitymic traits and defensive strategies, considering adolescents’ rates of access to an ED

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