Stress and negative emotions can cause a child to feel physical symptoms such as headaches and abdominal pain. PHOTO: ISTOCKPHOTO

SINGAPORE – Arielle Nur Shafiqa Shafarizal was 15 when she started getting headaches during her year-end examinations in school. Sometimes, they would last for 30 minutes, and other times, as long as two to three hours.

Once, she had such an “immense throbbing headache” that she had to skip an exam.

“Sometimes, I felt the headaches were due to the feeling of being overwhelmed and stressed due to exams,” says the 17-year-old, who is now doing a diploma in biomedical science at Republic Polytechnic.

As a result, Arielle’s quality of life was affected in secondary school.

“I would not be able to sleep at night due to the headaches. This led to me sleeping in class, making me miss out on lessons, and getting scolded frequently,” she adds.

At times, she had to skip school because of the headaches. She also sat out of activities during physical education lessons and her cross-country co-curricular activity.

Over time, Arielle also started having stomachaches, feeling nauseous and experiencing tingling sensations in her fingertips that would sometimes travel up to her elbows.

Her symptoms prompted her to go to a polyclinic in September 2020, but the medicines prescribed did not help.

In March 2021, she was referred to KK Women’s and Children’s Hospital (KKH), where, after ruling out medical conditions, she was asked if she would like to undergo the Resilience in Children and Adolescents with Psychosomatic symptoms programme, known as Recap.

It is a five-session outpatient programme administered by clinical counsellors and psychiatrists that includes educating both parent and child about what psychosomatic symptoms are, and identifying the factors that may trigger them.

The programme, established in November 2020, is offered to children and teenagers with moderate symptoms over six to 12 months. It also focuses on increasing the child’s emotional self-awareness, improving the way he or she copes with stress and teaching relaxation strategies.

Psychosomatic symptoms

Experts tell The Straits Times that stress and negative emotions can cause a person to feel physical symptoms such as headaches, abdominal pain, heart palpitations, chest pain and shortness of breath. These are referred to as psychosomatic symptoms.

Ms Candace Chan, clinical counsellor at KKH’s department of psychological medicine, says such physical health symptoms may or may not be associated with a medical or psychological condition, but can be extremely distressing or cause anxiety.

“Often, children who have such psychosomatic symptoms can have difficulty recognising, understanding or talking about their stress and negative emotions,” she adds.

Arielle Nur Shafiqa Shafarizal practising mindfulness with Ms Candace Chan, clinical counsellor at KKH’s Department of Psychological Medicine. ST PHOTO: GIN TAY

For example, a child who is nervous about going to school could experience intense stomach pains the night before a school day. This could happen several times, and the child may or may not realise that the physical pain is connected to the school-related stress he or she is experiencing.

The child may then become very sensitive about the pain and increasingly worried about why he or she is experiencing it and whether there is an underlying illness or disease, adds Ms Chan.

After the establishment of the Recap programme, from November 2020 to September 2022, the hospital received about 220 referrals a year to assess children and teens aged seven to 17 with psychosomatic symptoms.

This is an increase from 17 referrals a year from 2018 to 2019.

Dr Vicknesan Marimuttu, head and senior consultant at KKH’s child and adolescent mental wellness service, says a possible reason for the increased referrals is due to the training that KKH paediatricians have in identifying psychosomatic symptoms.

“This has led to greater awareness and early identification, and referral for further assessment as well as education,” he adds.

Stress factors

The Covid-19 pandemic may have also led to the increase in referrals.

“Navigating the pandemic has been difficult for many young people and their families. Emotional distress and feeling stressed can manifest as psychosomatic symptoms,” he notes.

In particular, there has been a two fold increase in referrals in September in the past two years, possibly related to the end-of-year examination period, says Ms Chan.

“With the weight of year-end exams and promotional exercise, it is common that students may face academic stress on top of other stressors they may already be having,” she says.

Dr Leong Choon Kit, a family physician at Mission Medical Clinic in Serangoon, often sees patients aged seven to their early 20s with psychosomatic symptoms during primary school to university exams.

“During the non-exam period, I see around one patient a week with psychosomatic symptoms. But during the exam period, there can be as many as one to two a day. Generally, during the exam period, the numbers can shoot up 10 times,” he says.

His patients complain of symptoms such as headaches, giddy spells, gastric pain, loss of appetite, abdominal pain, nausea and vomiting. “Some may also binge-eat and become obese, while others may lose so much weight till they look sick,” says Dr Leong.

Some also exhibit anxiety symptoms. “They are often quick to panic and jumpy. They have cold sweat, a blank mind and some say they feel like exploding,” he says.

A small group of cases are related to bullying in school, and a much smaller group are affected by adjustment, such as moving to a new class or new school and getting used to new teachers at the beginning of the school year or term, he adds.

While anxiety and stress are multifactorial, Dr Leong says: “Parents and society are the greatest cause and source of stress for those patients I have seen.”

He notes that many parents have unrealistic expectations, such as wanting their children to go to schools which do not fit their profile, or hoping they will become doctors or lawyers.

“These expectations can bring about stress that can cause physical health symptoms to come about,” he adds.

Annabelle Psychology, a private psychology practice, sees about seven patients aged seven to 18 with psychosomatic symptoms weekly.

“Apart from exams, other triggers include family conflict, relationship issues, trauma including abuse, neglect or violence, and emotional distress,” notes Dr Annabelle Chow, its principal clinical psychologist.

Besides symptoms such as stomachaches, migraines or muscle joint pain, patients may have skin issues like hives and eczema, trouble falling asleep or sleeping through the night, or a general sense of fatigue or feeling ill.

Underlying medical condition?

Many parents think such symptoms are a result of an underlying medical condition.

Dr Dale Lim of Tenteram Clinic in Whampoa says: “They often get anxious that despite repeated visits to the doctors, the child continues to complain of these symptoms. An explanation that these symptoms are common and normal responses to psychological stress often provides some reassurance to the parents.”

He sees one or two children a month between the ages of 10 and 12 with psychosomatic symptoms.

To determine whether the patient is experiencing psychosomatic symptoms, doctors must first rule out any physical medical conditions and causes.

Usually, a few consultations may be needed to obtain a thorough medical and psychosocial history, coupled with a physical examination and simple laboratory investigations to exclude common medical causes, says Dr Lim.

Parents also play an important role in identifying the cause of symptoms.

“By providing information about the child’s performance in school and behaviour at home, they can help doctors determine if the symptoms are psychosomatic and caused by psychological stress,” he says.

Management and treatment

Dr Leong says management is targeted at the various possible causes and would involve counsellors, psychologists and psychiatrists to manage the child’s condition.

Medical doctors would also need to treat the patients for their symptoms, such as headache and abdominal pain, with medication, he notes.

“Some may need to continue with their medicines even after the exams. We would continue to monitor their condition and work closely with the psychiatrist,” says Dr Leong.

At a psychology clinic, common treatments include cognitive behavioural therapy (CBT) and mindfulness-based therapies, says Dr Chow.

In CBT, psychologists work with the child to identify unhelpful thought patterns that manifest as psychosomatic symptoms. “The psychologist seeks to modify such dysfunctional thinking that results in a corresponding change in behaviour,” she adds.

As for mindfulness, the psychologist guides the child to return to being aware in the present moment and teaches him or her simple things to do so even when alone, says Dr Chow.

Arielle, who underwent KKH’s five-session Recap programme with her mother, says the painkillers she was initially prescribed at the polyclinic did not work.

But things have improved with regard to the frequency and intensity of her headaches since she saw a counsellor.

“I was encouraged to write in a diary whenever I had a headache. I would note down the date and time of the headaches, what I was doing and how I felt at the moment I had the headache. The counsellor then went through all the entries with me to find out the possible triggers,” says Arielle.

She also learnt mindfulness exercises and breathing techniques that calmed her down when she felt stressed or overwhelmed.

“All of these relaxation strategies have helped me. I used to be very frustrated about the headaches, but now I see them as a sign to take a break and come back to the task later,” she says.

Source: The Straits Times © SPH Media Limited. Reproduced with permission.

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