Sara Williams, Ph.D and Nicole Zahka, Ph.D are the authors of Treating Somatic Symptoms in Children and Adolescents, a recently published manual for clinicians seeking to better understand physical symptoms that are not necessarily linked to a known medical problem. They collaborated on all answers to all questions in this interview.
Providing education on your approach utilizes CBT to treat children with somatic symptoms. Why CBT?
Cognitive behavioral therapy is an evidence-based treatment for children with somatic symptoms. In cognitive theory, automatic negative thoughts protect a person by alerting them to danger. However, in the case of somatic symptoms, which are real but not acutely dangerous, automatic negative thoughts may lead people down an unnecessarily anxious, symptom amplifying and avoidant path.
This is where CBT comes in as an effective treatment. It teaches people to become aware of inaccurate or automatic negative thinking patterns and change them so that they will have more balanced feelings—both physical and emotional—and improved function. This is an active, skills-based approach that provides children with the tools to respond to stressors in a more adaptive way.
You write in the book that the biopsychosocial model is a more detailed and better developed take on the “mind-body connection.” How else would you explain the biopsychosocial approach to understanding somatic symptoms and treatment to those who had no previous knowledge, ex. the families of children, or children/adolescents themselves?
The term “biopsychosocial” is really all about how the mind, the body and the world we live in all work together to influence our every day experiences. This concept is especially important to understand when it comes to somatic symptoms because all three of those factors work together to influence how the body feels—and not any one of these alone!
A common misconception is that somatic symptoms are solely due to anxiety, and in fact, many children with somatic symptoms have been told the experience is “all in their heads.” The biopsychosocial model helps to explain why this is not true, because somatic symptoms are the result of how the body processes stressors in combination with emotional and social experiences. It takes working with all three factors to understand what influences somatic symptoms in the first place, and most importantly how children can learn to cope with them.
You write about the anxiety and avoidance cycle that often occurs when somatic symptoms are present. What is this cycle and what role does it play in exacerbating symptoms or inhibiting treatment?
The anxiety avoidance cycle describes a response pattern that is beneficial in that it leads to temporary relief of anxiety, however, it reinforces avoidance of the feared situation in the long term which is often maladaptive.
Relating this to somatic symptoms, the same pattern occurs: Symptoms occur and are perceived as dangerous (or uncomfortable); as a result the child experiences distress so avoids the situation which produces a feeling of relief. While this may be successful in the short-term, this often leads to long-term problems.
For a child with somatic symptoms, the challenge is (a) they cannot avoid the symptoms, because they are occurring in their own body, (b) they typically cannot avoid all situations where symptoms occur, and (c) the longer they avoid the situation, the more stressful it becomes.
For instance, if a child develops the belief that it’s best to avoid school to prevent symptoms and the more school gets avoided, the more stressful it is to go back and the more likely the symptoms are to occur. Because of this pattern, one of the key factors to successful treatment of somatic symptoms is giving children the ability to break this cycle by giving them the knowledge that their symptoms are not dangerous, and the tools to cope with somatic symptoms in different situations, so that they are able to reduce distress and increase their function.
Depending on how long children have had symptoms before beginning treatment, it can sometimes occur that symptoms get worse before they get better as children are re-engaging in their lives after having avoided activities due to symptoms. It is especially important to stay the course in treatment to help children see that symptoms then reduce in intensity and frequency over time.
What is the Gate Control Theory, and what significance does this have in working with children with somatic symptoms? You actually write that you can learn techniques to “close the gate” which would lessen one’s experience of pain. That is amazing. Can you give an example of a technique that would help?
The Gate Control Theory applies to how we understand the way that pain is experienced in the nervous system. More than 50 years ago, two pain researchers, Melzak and Wall, were puzzled by the idea that two people could go through exactly the same type of painful experience yet exhibit two completely different pain responses.
This led them to study the neurological underpinnings of pain and discover that there is a chemical reaction between the spinal cord and the brain that functions something like a gate that can open or close, which changes the intensity of the pain signal. There are many factors that can change the position of the gate and therefore influence the amount of pain a person feels–one example is distraction from pain closes the gate, and attention to pain opens the gate.
Many people can understand this connection easily by thinking of a time they were in a theater watching a really great movie. When the movie is over, all of a sudden they feel that pain signal in their bladder is telling them–maybe urgently–that it’s time to use the restroom. But think about it. Did their body all of a sudden fill up their bladder right as the credits rolled? Of course not! Chances are, they have had to use the restroom for a while, but the gate was closed on that signal due to their engagement in the movie and it wasn’t until that distraction stopped that the gate could open enough for them to attend to their bladder’s signal.
Your unified approach to treatment helps clinicians and families “put down the magnifying glass” and determine a collaborative plan of action to restore function in the child or young person. It may be more obvious to some, but what would you say are the benefits to approaching treatment in this way of paying more attention to the solution than the problem?
The key to coping with somatic symptoms is to focus more on function and normal activity than on disability and impairment related to symptoms. Spending time searching for why the symptoms are happening means that kids are still experiencing distressing symptoms, in addition to some normal worry related to missing school, frequent doctor’s visits or stressed parents; all of which are out of the child’s control and are not improving the child’s function.
Instead, it’s important for the mental health provider to devote energy to what is within child’s and family’s control, which is learning the coping tools and using these tools to improve function. The benefit to this approach is helping children take their focus off of suffering with their symptoms, and get back to living their lives.
For more about the work of Dr. Sara Williams and Dr. Nicole Zahka, check out their new book.