Somatoform Disorders of Dialysis Patients or Mental Pain: Which Support?

Chronic kidney disease is the cause of the difficult times for the hemodialysis teenager; these moments can be evaluated with somatoform disorders which complicate the management of the patient. The objective of this study is to formulate a clinical form of these somatoform disorders or subjective pains through the clinical observation of two cases, a boy and a girl who manifested these disorders for 6 months, the adequate psychological care has allowed reducing these psychic pains.


Introduction
Kidney failure is not synonymous with personality disorders or mental disorders, but the sick child goes through sometimes difficult moments sometimes making it too plaintive with a projection of "a pain in the head" in a context of somatoform disorders. This somatoform disorder covers different diagnostic entities, which pose constant difficulties for the practitioners concerned in evaluation and management. The aim of this study is to formulate a clinical form of this somatoform disorder or subjective pain through two clinical vignettes. Definition of somatoform disorder: In the International Classification of Diseases (ICD), somatoform disorder is a mental disorder in the category of neurotic disorders, stress-related disorders and somatoform disorders. It is therefore paralleled with other mental disorders. According to Bernard Granger [1] "the name Somatoform disorders appeared in 1980 in the DSM-III, the objective was to bring together in a single chapter a set of diagnoses characterized by a symptomatology focused on the body. This new chapter included the hypochondriac disorder (corresponding to the neurotic hypochondria of DSM-II) and three pathologies that previously belonged to hysterical neurosis: the conversion disorder, somatization disorder and psychogenic pain ". According to the World Health Organization somatoform disorders are "characterized by physical symptoms associated with requests for medical investigation, persistent symptoms despite negative balance sheets repeated. Patient opposes any psychological hypothesis that may explain his disorders." and Quemada [2] state that these disorders correspond to the psycho-functional disorders of CFTMEA R. 2000. ICD-10 further specifies that "these patients try to attract the attention of others, especially when they fail to convince their doctor of the essentially physical nature of their illness and the need for further investigation. and further examinations ". The diagnosis of somatoform disorder according to Duverger [3] can only be made after ruling out any possibility of organic disease and / or mental disorder (mainly anxiety disorders and depression).
In adolescents, some studies have focused on somatoform disorders or mental pains in children, (Misès & Quemada [2], Hayez [4]). Conversely, in adults according to Kirmeyer, Robbins & Paris [5], somatoform disorders are planetary and historical, and several series have been published. In a study of 2548 patients, with a follow-up of 42 months, Lieb, Zimmermann & Friis [6] found an incidence of 25.7% of disorders. somatoforms with 48% somatoform disorders reported as stable. Thomassen et al. [7] review a series from 1984 to 1991 of 13,000 consultations in liaison psychiatry, concluding that 544 patients with somatoform of which 39.5% were diagnosed as a conversion disorder .Recent research has focused on disrupting the complex relationships between the various body functions in patients with somatoform disorders and this is reflected, for example, in a reduction in physical activity and responsiveness Juniper Online Journal of Case Studies of the hormonal system or by neuroendocrine changes in the brain, generated by pain [8,9].

Materials and Methods
Clinical observations in two adolescents with somatoform disorders persisting for more than 6 months, during dialysis sessions at the ORAN hospital-university center. An organic pain was eliminated by a series of complementary exploration. A liaison psychologist was asked for interviews with our two patients.

Résult 1st Observation
A. Fayçal, aged 16, is in charge of child hemodialysis in the pediatric intensive care unit for 08 years for a familial nephropathy. He weighs 31kg, is 1.50m tall, he is in 2nd year of average education with satisfactory academic performance despite many absenteeism during his dialysis sessions. He arrived in F during its meetings this year to be very angry, impulsive, sometimes aggressive not supporting some nurses to puncture the arteriovenous fistula, has from time to time a set of complaint and multiple physical symptoms, variable , recurrent, fluctuating such as: headache, chest pain with feeling of tightness, or abdominal pain. He sometimes says to have pain everywhere without being able to describe this pain while the monitoring of its vital parameters is correct. Medical treatment as placebo perdialyse makes disappear in Fayçal these alleged painful symptoms during the sessions and were repeated every time the child was feeling stressed. The subjective complaint of these symptoms prompted us to carry out repeated complementary examinations, which were practically negative. A thorough anamnesis with his mother who accompanies him at each session recently found a divorce from parents and an abandonment of the father who has shirked any responsibility for his sick child. The intervention of a psychologist during several sessions on the day of dialysis resolved the problem of somatic pain in our teenager.

2nd Observation
B. Hayat, 14 years old, dialyzed for 4 years for vascular nephropathy recently complained of abdominal pain during each dialysis session. The abdominal palpation did not find any objective pain, the abdomen remaining flexible with each palpation. This teenager described a subjective pain equivalent to 8/10 on a visual analogue scale. The abdominal ultrasound done on the spot at the first complaint by the teenager found no organic abnormality. In addition, she presented during a few dialysis sessions a form of autonomic dysautonomia type, hot flashes or chills, tremors, hyperventilation, hiccups.
Monitoring of vital parameters such as heart rate and mean arterial pressure were correct. All blood tests such as serum sodium, serum calcium and parathyroid blood levels returned to normal. A placebo type infusion of 10cc saline serum at 0.9% removed this subjective pain during 4 consecutive dialysis sessions. For one week, the patient did not show any painful complaints. Then there was a resurgence of psychic pain and this fact was repeated in each dialysis; in this way, the somatic pain became, according to the patient, muscular and articular pains, whereas the biological explorations did not show any anomaly explaining these disorders. These plaintive pains started as soon as the teenager reached adulthood and she guessed that she was in a "transition zone" and that she would have to leave the pediatric unit to join an adult service. This prompted us to seek the intervention of a psychologist during each dialysis session and, after four months of psychotherapy, our teenager stopped suffering from this somatoform disorder.

Discussion
Marchand, Saravane & Gaumond [10] state that the field of somatoform disorders represents a considerable demand for the current health care system, but also probably the most varied expression of mental suffering, in which pain is a recurring complaint" In our study, both cases complained of pain that are medically unexplained symptoms, this is confirmed by (Cathébras, Weber, Rousset, 2006) Functional symptoms, health anxiety or somatic expression of psychiatric disorders is also present in subjects with one or more organic diseases, which is the case of our adolescent patients with chronic renal failure, Marquis et al. [11] state that somatoform disorders are common among the adolescent population, Fiertag et al. [12] argue that functional (somatic) symptoms are very common in children and adolescents, who often have difficulty expressing their feelings and emotions through language. Therefore, psychological distress can be expressed by functional symptoms. (Cathébras, Weber, Rousset, 2006) explain elsewhere that the somatic symptoms are most often painful such as pain of the spine, limbs, abdomen, chest of headache next to fatigue and vertigo. These symptoms are associated in 75% of patients with mood disorders. These mood disorders are represented in the patient A. Fayçal by the anger, the impulse aggression and the refusal of the taking charge by some nurses whereas it presented abdominal pains, cephalgia's, and thoracic pains with feelings of oppression. The second patient suffered from abdominal pain. We concluded that these persistent somatoform pain syndromes in both adolescents are of psychological origin after medical and biological examinations were normal, Dierick et al. [13] assure that psychological factors play an important role in the onset of intensity, aggravation or persistence of pain, in the same context Gervaise, Wanquet-Thibaullt & Saez [14] state that the pain associated with a somatoform disorder does not correspond to any organic pain but is based on confirmed psychopathology, Rouby, Dauchy & Landrieux [15] have reaffirmed the role of psychological or psychopathological factors in the frequency of pain syndrome. Regarding risk factors for somatoform disorder in children and adolescents according to Tordjman & Ouss-Ryngaert [16] include the presence of a minor physiological Juniper Online Journal of Case Studies dysfunction and the contribution of familial factors as somatic parental history and / or psychiatric, reinforcing behaviors of the entourage by excessive preoccupation. Our second patient began to manifest somatoform disorders in a clinical form of neurovegetative dysfunction as soon as she thought about the transition to adult service.
We cannot begin periods of adaptation in an adult dialysis unit for our teenager and who is our weakness in the adequate care for our dialysis patients of age of transfer in an adult unit. As mentioned by some authors, we must be reassured about the future of this patient to avoid the feeling of abandonment; it is the pediatric team that is responsible for organizing the conditions conducive to the success of this initiative, Wallaert & Turck [17]. After sessions with the psychologist, we concluded that this teenager was using two defense mechanisms, denial and regression. She refused to grow up and wanted to stay in the childhood stage, she thought she could never grow into adulthood since she was not doing any activities except going to the hospital for dialysis sessions and then to go home to rest, while her little sister was transformed into an elegant young woman, well made up while pursuing her studies. This situation triggered in this teenager medically unexplained symptoms that Schulz [18] considers "that from the results of 06 studies on symptoms not explained medically, it appears that 50% to 75% of patients with these symptoms improve, Pascuttini, et al. [19] find that "somatoform disorders have long been considered difficult to access treatment, the latest meta-analyzes confirm the good results of psychotherapeutic approaches of the cognitive-behavioral type, Lemogne [20] suggest that Several studies have shown the effectiveness of cognitive and behavioral therapies, based on cognitive restructuring and the extinction of avoidance behaviors, as well as mindfulness-based therapies. The intervention of the psychologist during each dialysis session for more than 6 months with our two young dialysis patients was very necessary.
To treat somatoform disorders in our young patients the psychologist used cognitive and behavioral psychotherapy which according to Olié, Gallarda, Duaux [21] must be endowed with psychotherapeutic means including technique of stress management, cognitive techniques for correction of erroneous beliefs on the nature of the disorders, not forgetting supportive psychotherapy [22]. In the case of Fayçal, the psychologist suggested a therapeutic relationship of trust between the adolescent and the health care team, which was to improve his communication by empathic support for the patient and his mother. The nurses expressed their support through their attentions and encouragement from patient in his school career. Regarding the mother she understood that she had to rest to reduce the stress of her child, she told her daughter to accompany Fayçal to his dialysis sessions. In the case of Hayat, the health care team began to sensitize her to maturity (e.g., appreciate her hair color and hairstyle), the nurses shared jokes with her, then cooking recipes, then the psychologist convinced the patient to continue her education. Hence the intervention of a nurse that registered her at the National Office of Education and Distance Learning, the teenager attended the office to take support classes. The results were satisfactory, the somatic pain disappeared for both patients, and their transfer to the service of adults was smooth [23,24].

Conclusion
The two clinical vignettes illustrate the somatoform disorders or "psychic pain" in our two teenagers, the first case of which corresponds to a persistent painful somatoform disorder and the second to the form of somatoform neuro-vegetative dysfunction. These two disorders are characterized by a deep pain, felt authentically physically by our two teenagers, and speaking on a somatic plane whereas this origin, which is in most cases, normally refuted by the patient. Management will begin with a diagnosis of elimination of physical disorders and a good knowledge of the mechanisms of this "psychic pain" in order to better adapt an appropriate therapy based on cognitivebehavioral approach and individual psychotherapy.