Psychiatric Annals

CME Article 

Pediatric Somatic Symptom Disorder: An Overview

Neha Sharma, DO; Mary Daley, MD; Teresa Vente, DO, MPH

Abstract

Prevalence estimates of somatic symptom disorder (SSD) in the pediatric population are highly variable, due in part to the evolution of terminology and diagnostic criteria used to define the illness. The likelihood of encountering patients with somatic symptoms is quite high regardless of specialty, as it is well-established that SSD is associated with significant health care use across all settings. The diagnostic uncertainty inherent to SSD can lead to frustration and distrust of the health care system, creating substantial challenges in maintaining a strong therapeutic alliance. Mental health consultation concomitant with medical testing can expedite the diagnostic process, foster a therapeutic alliance, and help build trust with the team of providers, while providing support for children and their families. The recommended treatment is a multidisciplinary approach with an emphasis on symptomatic relief and return of function, while avoiding any excessive medical testing or treatment. [Psychiatr Ann. 2017;47(10):507–511.]

Abstract

Prevalence estimates of somatic symptom disorder (SSD) in the pediatric population are highly variable, due in part to the evolution of terminology and diagnostic criteria used to define the illness. The likelihood of encountering patients with somatic symptoms is quite high regardless of specialty, as it is well-established that SSD is associated with significant health care use across all settings. The diagnostic uncertainty inherent to SSD can lead to frustration and distrust of the health care system, creating substantial challenges in maintaining a strong therapeutic alliance. Mental health consultation concomitant with medical testing can expedite the diagnostic process, foster a therapeutic alliance, and help build trust with the team of providers, while providing support for children and their families. The recommended treatment is a multidisciplinary approach with an emphasis on symptomatic relief and return of function, while avoiding any excessive medical testing or treatment. [Psychiatr Ann. 2017;47(10):507–511.]

The definition of somatoform disorders in the psychiatric community has been debated for more than 40 years.1 Prior to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5),2 diagnostic criteria had extensive overlap that likely affected the ability to measure the incidence and prevalence of somatoform disorders, especially among children and adolescents.3DSM-5 includes somatic symptom disorder (SSD) and functional neurological symptom disorder (previously known as conversion disorder) with an emphasis on somatization as disruptive and recurrent physical distress with no identifiable physical basis. The current diagnostic criteria are outlined in Table 1.2

Diagnostic Criteria for Somatic Symptom and Functional Neurological Symptom Disorders

Table 1:

Diagnostic Criteria for Somatic Symptom and Functional Neurological Symptom Disorders

Prevalence

Quantifying the prevalence of somatization has been difficult due to limited epidemiologic studies. Prevalence estimates for pediatric populations range from 0.59% to 13% for any somatoform disorder or syndrome and as high as 57% for specific disorders based on prior criteria.4–6 Overall, somatic symptoms are reported more commonly in the female gender and in adolescents compared to children, and the number of symptoms reported increases with age.4,5,7–11 Rates of somatic symptoms reported per ethnicity and socioeconomic status are debated, with some studies reporting higher rates in white urban children, whereas others report higher rates in ethnic minority groups.5,8 The most common somatic symptoms leading to inpatient referrals in children are pain including musculoskeletal pain and headache, neurological symptoms such as psychogenic nonepileptic seizures (PNES) or movement disturbance, and gastrointestinal symptoms such as abdominal pain or nausea.9,11,12

Health Care Use

Despite difficulty determining true prevalence rates of SSD, practitioners agree that the presentation of somatic symptoms in children and adolescents is common in both inpatient and outpatient settings, and involves frequent health care use.10,13 This includes multiple physician visits, specialist consultations, diagnostic tests and procedures, and high rates of emergency department use.13,14 An examination of childhood conversion disorder cases reported health service use was high, with each patient seeing an average of two specialists.15 More than one-half of the cases reported having had diagnostic testing that included blood work.15 Less than one-half reported having had imaging including magnetic resonance imaging or computed tomography scan, whereas 30% had an electroencephalogram and 70% were admitted to the hospital.15

Etiology and Neurophysiology

The etiology of SSD is unclear, and increased health care use with involvement of multiple providers can lead to diagnostic uncertainty. In children and adolescents presenting with somatic symptoms, priority should be given to ruling out medical etiologies including iatrogenic illness or injury.1,4 However, it is important to remember that the absence of a medical explanation should not necessarily imply the presence of a psychiatric illness. In children with somatic symptoms, comorbid medical conditions may be present and are often chronic (asthma or Crohn's disease) or functional in nature (migraines or cyclic vomiting).9 Similar to medical comorbidities, children and adolescents with somatic symptoms also have increased risk of psychiatric comorbidities, with prevalence rates as high as 17%.9 The most common comorbid psychiatric diagnoses include anxiety, depression, and panic disorder.6,14,16

A broad differential diagnosis should be considered at initial presentation in children and adolescents with somatic symptoms.17,18 Multiple psychosocial factors have been shown to have a role in precipitating the onset of somatic symptoms; the most common being school or academic stressors, peer conflict, and life stressors at home.6,9,11,16,19 Higher reports of somatic symptoms occur when family members or close nonrelative adults have a physical illness.20 Somatic symptoms are also highly correlated with experience of lifetime adverse events during childhood or adolescence.14,16

More recently, the scientific community has explored the role that neurobiological changes may have on the presentation and etiology of somatic symptoms, and several studies have emerged over the course of the last decade that identify complex patterns in which the limbic system and higher order processes involving the prefrontal cortex can influence basic motor function.21–24 This can result in the manifestation of neurological symptoms without an identifiable neurological etiology. For example, one study showed that functional motor symptoms were associated with decreased activity in the supplementary motor area (SMA) and decreased functional connectivity between the SMA and dorsolateral prefrontal cortex compared with healthy controls.21 This is consistent with other studies, which have also noted the absence of identifiable differences in motor inhibitory areas between patients with functional paralysis and healthy controls, lending support to the involuntary nature of conversion disorder, or functional neurologic symptom disorder.22,23

In addition to these deficits in the SMA, multiple studies have found increased activity in the limbic system and basal ganglia in patients with functional neurological symptoms, including PNES.23,24 The pathways by which changes in the limbic system and basal ganglia might suppress the function of motor or sensory functions has not been delineated, but the evidence suggests such pathways might explain how alterations in emotion can manifest as various forms of conversion disorder. These findings not only shed light on the neurophysiological changes underlying conversion disorder, but also validate the involuntary nature of the symptoms.

Diagnostic Uncertainty and the Role of Psychiatry

The uncertainty and desire for diagnosis in children with somatic symptoms can be a cause of distress. A qualitative study by Moulin et al.13 found that adolescents and their parents expressed distress and anger with providers that had failed to diagnose their condition or understand their problems, and had prescribed unsuccessful treatments. Parental and patient desire for an explanation can often put an emphasis on prioritizing or ruling out medical conditions.15 This process can leave practitioners and families focused on negative medical findings and fear of a missed diagnosis. Feelings of invalidation can affect the therapeutic alliance and obstruct diagnosis and treatment.18 Primary medical teams can have difficulty introducing the possibility of psychiatric etiology with patients and families. Communicating the diagnosis as a bio-behavioral disease continuum, or spectrum of biological to psychosocial etiologies, may be helpful in building a diagnostic approach for families of children with somatic symptoms.

The recommended approach to diagnosing and treating somatic symptoms in children should be multidisciplinary. Psychiatry and other mental health care providers can play a key role in helping families to feel supported and in conveying the biopsychosocial explanation for the patient's symptoms. Although there is a focus on ruling out a medical etiology for somatic symptoms, medical providers need not wait for medical diagnoses to be ruled out before introducing mental health consultation.17,18 Having psychiatric or mental health consultation concomitant with the medical testing will emphasize support and rehabilitation, while at the same time reducing stigma and distrust of the health care system.18 Previous articles have identified seven key steps to forming a relationship with children and adolescents and their families (Table 2), which emphasize acknowledging family concerns and patient suffering and building a foundation for intervention.20,25 The goal is to shift the family's focus from searching for the cause of the symptoms to increasing the patient's functioning.18 There is evidence to suggest poor outcomes including persistence of somatoform disorders and higher rates of substance use without referral and involvement of mental health providers.25

Key Steps for Building a Provider-Patient Relationship in Somatic Symptom Disorder

Table 2:

Key Steps for Building a Provider-Patient Relationship in Somatic Symptom Disorder

The goal of early involvement of mental health practitioners is to expedite the diagnostic process, to foster a therapeutic alliance, and to build trust with the team of providers while supporting children and their families. Even with early involvement in the care team, some children and families have negative opinions regarding the efficacy and necessity of mental health treatment. Parents may express reluctance to involve psychiatry due to perceived social stigma or difficulty accepting that their child's symptoms are caused by a psychological condition. Children and adolescents have reported feeling that the recommendation to involve mental health professionals was because their report of symptoms was not believed.15 Providers have reported difficulty discussing somatic symptoms with families or referring to psychiatry because they felt the labels and diagnoses in the International Statistical Classification of Diseases and Related Health Problems, 10th revision26 were pejorative.14 This emphasizes the need for mental health providers to have early involvement as members of the patient and family treatment team who are available as psychoeducation providers.

Treatment

The treatment approach to SSD is commonly multidimensional and consists of various combinations of behavioral interventions, physical therapy, and pharmacotherapy. When making the diagnosis of SSD, it is vital to convey the diagnosis clearly to the patient and family. Careful attention to the timing and choice of language when discussing the diagnosis is essential to building and maintaining the therapeutic alliance.

Psychotherapy and Other Nonpharmacological Interventions

The initial approach to treatment should focus on addressing symptoms that are interfering with the patient's ability to function while avoiding any excessive medical testing or treatment. Nonpharmacological interventions for SSD include cognitive-behavioral therapy (CBT), physical therapy, relaxation exercises, hypnosis, guided imagery, yoga, mindfulness, or acupuncture. Of these, CBT has been most extensively studied. An example of applying CBT principles outside of a formerly structured treatment setting would be teaching self-monitoring techniques to patients with a de-emphasis on physical symptoms, thereby encouraging effective coping mechanisms and reinforcing healthy behaviors.

Treatment for SSD will likely only be successful if the patient and family are supportive of the recommended treatments. The uncertainty of SSD often results in maladaptive family relations. Therefore, family-based interventions are likely also effective, and possibly more effective, than individualized treatments.

Biofeedback, an approach to modify behavior through technology that monitors physiological changes and provides instantaneous feedback to the patient, has also been used for various somatic symptoms. The goal of biofeedback is to enhance self-awareness and thus provide the opportunity for the patient to gain control over his or her symptoms. Sowder et al.27 showed significant improvement of symptoms in patients with functional abdominal pain using biofeedback, with an emphasis on the role of autonomic dysregulation.

Pharmacotherapy

The use of pharmacotherapy for the treatment of SSD should be reserved for cases in which nonpharmacologic interventions have been ineffective or in which comorbid psychiatric diagnoses that warrant pharmacologic intervention are present. As identified earlier, anxiety is a common comorbid psychiatric diagnosis in children with SSD, and for this reason the most common pharmacological intervention is the use of selective serotonin reuptake inhibitors (SSRIs). In a small open-label study, Campo et al.28 showed significant improvement in recurrent abdominal pain and other somatic complaints in pediatric patients with comorbid depression or anxiety treated with citalopram. The other class of antidepressants that are used occasionally for functional abdominal pain or headaches are the tricyclic antidepressants. However, given the risks of cardiac events and toxicity, their use is generally discouraged in this population.28 Benzodiazepines can be used to address moderate to severe anxiety associated with somatic symptoms, but should be used only on a short-term basis for stabilization. Although evidence is lacking, commonly used agents for longer-term treatment of somatic symptoms with comorbid anxiety include SSRIs, alpha-agonists, beta blockers, or hydroxyzine. Regardless of the specific agent selected, psychotherapy and other nonpharmacological interventions should remain an important part of the treatment plan.

Discussion

Although the definition of SSD and the terminology used to describe it have evolved in recent decades, the core features remain the same. The diagnosis captures somatic symptoms with no identifiable physical basis that cause distress or impair a patient's ability to function. With the recognition that the absence of an identifiable organic or physical cause does not necessarily equate to the presence of a purely psychiatric illness, the medical community has seen significant changes not only in terminology, but in the approach to treatment. The overarching goal is to provide compassionate care and to prevent patients and families from experiencing feelings of invalidation, distrust, or hopelessness. The recommended treatment approach is one in which physicians partner with the patient and family to target symptomatic relief and return of function.

A multidisciplinary approach is the gold standard of treatment. Engaging psychiatric or mental health consultation concomitant with the medical testing is preferable, as this can emphasize support and rehabilitation, while at the same time reducing stigma and distrust of the health care system.16 In an ideal setting, the psychiatrist would be involved as a member of the multidisciplinary team early in the diagnostic process, as children with chronic or recurrent illness often have mental health needs, regardless of whether a physical basis of their symptoms is identified. Mental health consultation should assist other medical providers with developing an appropriate treatment plan for patients and families. The most important aspect of effective treatment is that the patient and family feel supported and validated, and that physical and emotional health are optimized through an individualized approach.

A biopsychosocial framework is the key to integrating the complex nature of SSD and helping families to accept the limitations of the medical testing. As we learn more about the physiologic basis of SSD and the various biologic and environmental factors that lead to their development, the diagnostic process and approach to treatment will undoubtedly continue to evolve in coming years.

References

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Diagnostic Criteria for Somatic Symptom and Functional Neurological Symptom Disorders

Somatic Symptom Disorder (Somatoform and Related Disorders) Functional Neurological Symptom Disorder (Conversion Disorder)
One or more somatic symptoms that are distressing/disrupt daily life Excessive thoughts, feelings, or behaviors related to symptoms or associated health concerns <list-item>

Disproportionate and persistent thoughts

</list-item><list-item>

Persistently high level of anxiety

</list-item><list-item>

Excessive time and energy devoted to symptoms/concerns

</list-item>
Persistent (>6 months) of being symptomatic
One or more symptoms of altered voluntary/motor/sensory function Incompatibility between symptoms and recognized medical condition Symptom not better explained by other disorder Symptom causes distress or impairment in function or warrants medical evaluation

Key Steps for Building a Provider-Patient Relationship in Somatic Symptom Disorder

<list-item>

Acknowledge family concerns and patient suffering

</list-item><list-item>

Explore prior assessment and treatment experience

</list-item><list-item>

Investigate patient and family fears provoked by the symptom

</list-item><list-item>

Keep an open mind

</list-item><list-item>

Avoid unnecessary tests

</list-item><list-item>

Avoid diagnosis of exclusion

</list-item><list-item>

Build a foundation for intervention

</list-item>
Authors

Neha Sharma, DO, is the Program Director, Child & Adolescent Psychiatry, and an Assistant Professor. Mary Daley, MD, is an Instructor. Teresa Vente, DO, MPH, is an Instructor. All authors are affiliated with the Department of Pediatrics, Psychiatry & Child and Adolescent Psychiatry, Tufts Medical Center, Tufts School of Medicine.

Address correspondence to Neha Sharma, DO, Program Director, Child & Adolescent Psychiatry, Tufts Medical Center, Tufts School of Medicine, 800 Washington Street, Boston, MA 02111; email: nsharma@tuftsmedicalcenter.org.

Disclosure: The authors have no relevant financial relationships to disclose.

10.3928/00485713-20170831-01

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