Fatigue and somatic symptoms

Headaches

Headaches, along with stomach ache and backache, are the commonest chronic symptoms in adolescence apart from fatigue. The differential diagnosis can be fairly extensive. Most cases will be forms of muscular tension headaches. Migraine affects only about 2% of adolescents.

Other common causes of headache include extracranial problems (ear, sinus, or tooth infections, or temporomandibular joint disease) and excess caffeine consumption (from coffee or fizzy drinks). It is worth while excluding poor visual acuity as a cause of tension headaches. Uncommon causes of headachesare similar to those in adults, although it is important to note that benign intracranial hypertension is relatively more common in adolescence.

Abdominal pain

Recurrent abdominal pain may present a particular diagnostic dilemma in early adolescents. This is particularly so in girls, in whom gynaecological causes of pain could be present. In older adolescents, the range of symptoms is more similar to that in adults. Upper abdominal pain may suggest non-ulcer dyspepsia, and Helicobater pylori infection should be excluded. Changes in bowel habit (such as diarrhoea or increased frequency of stools with pain that is relieved by defecation) may suggest irritable bowel syndrome, which can be seen from mid-adolescence onwards.

Frequency of serious morning fatigue in 11-17 year olds in Europe. Adapted from Health behaviour in school-aged children, 1997-1998 (see first graph)

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Chronic fatigue syndrome

Fatigue in young people is serious when it persists for more than three months and impairs school attendance, academic results, and peer relationships. The definition of chronic fatigue syndrome (CFS) in adults has been much debated. The syndrome, often known by patients as myalgic encephalomyelitis or postviral fatigue syndrome, was first commonly described in the 1980s and is now claimed by some researchers to be the commonest medical cause of long term absence from school. Recent epidemiological evidence suggests that chronic fatigue syndrome, as defined on the basis of the criteria of the Centers for Disease Control and Prevention (CDC), occurs in about 0.2-0.6% of adolescents aged 11-15 years.

Continuing controversy over the existence of CFS, together with uncertainty and contradictory research findings about aetiology and treatment, has made the management of CFS extremely difficult for health professionals and patients alike. In Britain, this situation recently led to a report by the chief medical officer that acknowledged the reality of the illness in children and young people and emphasised that good quality, evidence based care should be provided.

The aetiology of CFS is unknown, with many hypotheses proposed. No convincing evidence exists to support persisting viral infection. Patients do show an excess of depression, other psychological symptoms, and low self esteem, although data on the psychological and endocrine states of patients show that CFS is not merely a masked form of depression, somatoform disorder, or refusal to attend school. Given the high prevalence of acute postviral fatigue syndromes in adolescence, it is unclear why acute fatigue syndromes become chronic in some young people. One study among adults has suggested that major events and depression around the time of Epstein-Barr virus infection may be linked to the persistence of fatigue.

CFS is likely to be a collection of different conditions and that several biopsychosocial “causal pathways” can lead to chronic fatigue. It is therefore best understood as a chronic low functioning state in which biological causal factors have resolved yet the illness remains because of physical deconditioning, sleep disturbance, and psychosocial factors. In adolescence, CFS usually occurs soon after the transition from primary to secondary school (onset peaks at 12-14 years). This is a time when young people are exposed, through mixing in larger schools, to new infections (such as Epstein-Barr virus) and to considerable stresses from the greater demands of secondary school. Rest and withdrawal from school and normal activities can lead to frustration, alternating overactivity and underactivity, disturbed sleep, social isolation, and depression, all of which may help to maintain the chronic fatigue.

Patients must be assessed with a combined biopsychosocial approach (once treatable conditions have been excluded). The differential diagnosis includes endocrine abnormalities, connective tissue disorders, neurological disorders, and psychological disorders (including depression, eating disorders, and refusal syndromes). Psychosocial assessment should include consideration of individual and family function; relationships with friends; school performance; and history of bullying, refusal to attend school, and psychiatric disorders. The most common comorbid psychological problems include depression and sleep disturbance.

CFS in young people should be diagnosed promptly and authoritatively and not be a delayed diagnosis of exclusion. Published case series suggest that most young people are substantially better or cured within two to three years.

Management of fatigue and somatic symptoms

After treatable causes of persistent somatic symptoms have been excluded, management based on a rehabilitative model is helpful for most young people. However, it is essential not to label symptoms as psychological, as this will often alienate the family. Some families readily understand the nature of psychosomatic causation, but many young people and their families are resistant to a psychological explanation for the symptoms and feel that such explanations mean they are not being believed.

It is generally more helpful to avoid such simplistic mind-body splits and avoid searching for psychological problems or “causes” within the family. But acknowledge such problems where they are apparent.

It is most useful to take a two pronged pragmatic approach, based on improving function while controlling symptoms. With a pragmatic approach, families generally accept the importance of psychological factors if it is recognised that these factors may equally be consequences as much as causes of illness. Rehabilitation involving physical, psychological, and social elements can be useful in chronic pain or chronic fatigue syndromes.

Chronic fatigue syndrome

Randomised clinical trials in adults have shown that cognitive behaviour therapy and graded exercise programmes are helpful in most patients. Uncontrolled studies in young people suggest that outpatient multidisciplinary rehabilitation and cognitive behaviour therapy within the family are helpful. An individual programme should be developed for each patient, based on theidentification of maintenance factors that prevent recovery: biological factors (such as sleep disturbance and physical deconditioning); psychological factors (such as personality, coping style, and comorbid depression); and social factors (such as family losses or stress, or parental conflict over management of their child's condition).

Chronic pain

Management of recurrent or persistent pain can be extremely difficult. When symptoms are severe, persistent, and unexplained, it may help to consider the problem as a regional chronic pain syndrome. This focuses the management on chronic pain as a symptom rather than on finding a cause related to the specific site of the pain. Lack of exacerbating and relieving factors and lack of response to analgesia are common characteristics of chronic pain syndromes. The most effective treatment for such syndromes in young people is multidisciplinary rehabilitation alongside symptom control. Although this can be done in primary care, the involvement of a chronic pain service with experience of adolescents can be extremely useful.

Deborah Christie is consultant clinical psychologist at the Middlesex Adolescent Unit, University College London Hospitals NHS Foundation Trust, London.

The ABC of adolescence is edited by Russell Viner, consultant in adolescent medicine at University College London Hospitals NHS Foundation Trust and Great Ormond Street Hospital NHS Trust (rviner{at}ich.ucl.ac.uk). The series will be published as a book in summer 2005.