Rule Out Physical Causes
Before attributing any symptom to stress or psychological issues, it’s critical to make sure there isn’t a physiological basis for concern, according to pediatric otolaryngologist Ellen M. Friedman, MD, professor of otolaryngology–head and neck surgery and director of the Center for Professionalism at Baylor College of Medicine in Houston. “There are certain coughs and throat clearing that do have a characteristic quality consistent with a psychological problem,” said Dr. Friedman, “but even then, I take steps to be sure that there isn’t another coexisting medical issue.”
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June 2021During the pandemic, Dr. Friedman has seen an increase in stress-related symptoms in children as young as three, including facial tics and throat clearing, and has found that the number of these patients with stress-related symptoms is higher than in all previous years.
When Dr. Friedman is satisfied that there’s no ongoing physiological concern, she tells the family that the good news is she has been able to rule out many of the really serious medical problems that can cause the cough or tic. She then wonders if stress could be responsible for the new-onset behavior in their child. Most of the parents seem relieved and acknowledge that they themselves thought the symptoms might be behavioral or stress related.
“The families then go on to relate the stress associated with the pandemic—for example, not seeing beloved grandparents for an extended period of time, missing planned vacations, or financial worries. I find that reassuring them that I’ve seen other children of a variety of ages with similar presentations is effective,” Dr. Friedman said.
She also offers to arrange a visit with a psychologist or a social worker. While some families decline, saying they’re adequately reassured that the problems are stress related and will take steps to lessen the stress in their home environment, others are grateful for the referral.
Dr. Mann believes his first role is to be a good detective and investigate symptoms with an open mind. When patients have conditions that are exacerbated by stress or anxiety, he shares his concerns that their symptoms may be affected by their mental state. He finds that often the patient agrees and is happy to have a provider recognize this. He also finds it can help with their buy-in on treatments or further testing that he recommends.
“The difficulty is when patients present with somatic complaints that have no objective findings. When patients suffer from a medically unexplained symptom, invasive testing or procedures often aren’t beneficial if they return normal results,” he said. “Instead of reassuring a patient, they can actually increase the patient’s health anxiety and worsen their symptoms.” He added that if a reasonable workup doesn’t produce objective evidence of disease, then the best way to help the patient is to limit further testing. “I usually offer reassurance only and then communicate directly with the referring physician about my concerns,” he said.