Somatic symptom disorder and related disorders are characterized by persistent physical symptoms that are associated with excessive or maladaptive thoughts, feelings, and behaviors in response to these symptoms and associated health concerns. These disorders are distressing and often impair functioning.
(See also Overview of Somatization.)
Somatic symptom and related disorders include the following:
Conversion disorder: Typically, symptoms involve apparent deficits in voluntary motor or sensory function but sometimes include shaking movements and impaired consciousness (suggesting seizures) and abnormal limb posturing (suggesting another neurologic or general physical disorder). Children may present with impaired coordination or balance, weakness, paralysis of an arm or a leg, loss of sensation in a body part, seizures, unresponsiveness, blindness, double vision, deafness, aphonia, difficulty swallowing, sensation of a lump in the throat, or urinary retention.
Factitious disorder imposed on another (previously referred to as Munchausen syndrome by proxy): Caregivers (typically a parent) intentionally falsify or produce physical symptoms in a child. For example, they may add blood or other substances to urine specimens to simulate a urine infection.
Factitious disorder imposed on self: The child may pretend to have physical symptoms or do something to themselves to produce physical symptoms.
Illness anxiety disorder: Children are extremely afraid that they have or will acquire a serious disorder. They are so preoccupied with the idea that they are or might become ill that their anxiety impairs daily functioning or causes significant distress. Children may or may not have physical symptoms, but if they do, their concern is more about the possible implications of the symptoms than the symptoms themselves.
Somatic symptom disorder: Children may develop multiple somatic symptoms or only one severe symptom, typically pain. Symptoms may be specific (eg, pain in the abdomen) or vague (eg, fatigue). Any part of the body may be the focus of concern. The symptoms themselves or excessive worry about them is distressing or disrupts daily life.
Somatic symptom and related disorders are equally common among young boys and young girls but are more common among adolescent girls than adolescent boys.
Symptoms and treatment of somatic symptom and related disorders are very similar to those of anxiety disorders. The symptoms are not consciously fabricated, and children are actually experiencing the symptoms they describe.
Diagnosis
Psychiatric assessment
Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) criteria
Sometimes tests to rule out other disorders
Diagnosis of somatic symptom or a related disorder is based on criteria from the DSM-5-TR. Generally, for one of these disorders to be diagnosed, symptoms must cause significant distress and/or interfere with daily functioning, and children must be excessively concerned about their health and/or symptoms in thoughts and actions.
At first presentation, physicians take an extensive history (sometimes conferring with family members) and do a thorough examination and often testing to determine whether a physical disorder is the cause. Because children with somatic symptom disorder may also develop physical disorders, appropriate examinations and tests should be done whenever symptoms change significantly or when objective signs develop. However, extensive laboratory tests are generally avoided because they may further convince children that a physical problem exists and unnecessary diagnostic tests may themselves traumatize children.
If no physical problem can be identified, doctors may use standardized mental health tests to help determine whether symptoms are due to somatic symptom or a related disorder. Doctors also talk to the children and family members to try to identify underlying psychologic problems or troubled family relationships.
Treatment
Psychotherapy
Sometimes medications to relieve symptoms
Children, even when there is a satisfactory relationship with a primary physician, are commonly referred to a psychotherapist. Children may balk at the idea of visiting a psychotherapist because they think their symptoms are purely physical. However, individual and family psychotherapy, often using cognitive-behavioral techniques, can help children and family members recognize patterns of thought and behavior that perpetuate the symptoms. Therapists may use hypnosis, biofeedback, and relaxation therapy.
Psychotherapy is usually combined with a rehabilitation program that aims to help children get back into a normal routine. It can include physical therapy, which has the following benefits:
It may treat actual physical effects, such as reduced mobility or loss of muscle, caused by somatic symptom or a related disorder.
It makes children feel as if something concrete is being done to treat them.
It enables children to participate actively in their treatment.
Medications to treat concurrent psychiatric disorders (eg, depression, anxiety) may help; however, the primary intervention is psychotherapy.
Children also benefit from having a supportive relationship with a primary care physician, who coordinates all of their health care, offers symptomatic relief, sees them regularly, and protects them from unnecessary tests and procedures.
Key Points
Children are preoccupied with and excessively worried about their health, physical symptoms, or the possibility of having or acquiring a serious illness.
Children may have multiple symptoms (eg, impaired coordination or balance, weakness, paralysis or loss of sensation, seizures, blindness, double vision, deafness) or one severe symptom, typically pain.
Do appropriate examinations and tests initially to rule out a physical disorder as the cause of symptoms and, if symptoms change significantly or objective signs develop, to check for a new physical disorder.
Treatment may involve psychotherapy, usually combined with a rehabilitation program that aims to help children get back into a normal routine.
