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Somatic Symptom and Related Disorders


Pediatric psychosomatic medicine deals with the relation between physical and psychological factors in the causation or maintenance of disease states. The process whereby distress is experienced and expressed in physical symptoms is referred to as somatization or psychosomatic illness . Even though present in virtually every psychiatric disorder, physical symptoms are most prominent in the various somatic symptom and related disorders.

In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), illnesses previously referred to as “somatoform disorders” are classified as somatic symptom and related disorders (SSRDs). In children and adolescents, the SSRDs include somatic symptom disorder ( Table 35.1 ), conversion disorder ( Table 35.2 ), factitious disorders ( Table 35.3 ), illness anxiety disorder ( Table 35.4 ), and other specified/unspecified somatic symptom disorders ( Table 35.5 ), as well as psychological factors affecting other medical conditions ( Table 35.6 ).

Table 35.1
Adapted from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association, p 311.
DSM-5 Diagnostic Criteria for Somatic Symptom Disorder

  • A

    One or more somatic symptoms that are distressing or result in significant disruption of daily life.

  • B

    Excessive thoughts, feelings, or behaviors related to the somatic symptoms or associated health concerns, as manifested by at least one of the following:

    • 1

      Disproportionate and persistent thoughts about the seriousness of one's symptoms.

    • 2

      Persistent high level of anxiety about health and symptoms.

    • 3

      Excessive time and energy devoted to these symptoms or health concerns.

  • C

    Although any one somatic symptom may not be continuously present, the state of being symptomatic is persistent (typically >6 mo).

  • Specify if:

    • With predominant pain (previously known as “pain disorder” in DSM IV-TR): for individuals whose somatic symptoms predominantly involve pain.

    • Persistent: A persistent course is characterized by severe symptoms, marked impairment, and long duration (>6 mo).

Table 35.2
Adapted from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association, p 318.
DSM-5 Diagnostic Criteria for Conversion Disorder or Functional Neurologic Symptom Disorder

  • A

    One or more symptoms of altered voluntary motor or sensory function.

  • B

    Clinical findings provide evidence of incompatibility between the symptom and recognized neurologic or medical conditions.

  • C

    The symptom is not better explained by another medical or mental disorder.

  • D

    The symptom causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation.

    • Specify symptom type: weakness or paralysis, abnormal movements, swallowing symptoms, speech symptom, attacks/seizures, anesthesia/sensory loss, special sensory symptom (e.g., visual, olfactory, hearing), or mixed symptoms.

Table 35.3
Adapted from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association, p 324.
DSM-5 Diagnostic Criteria for Factitious Disorders

Factitious Disorder Imposed on Self

  • A

    Falsification of physical or psychological signs or symptoms, or induction of injury or disease, associated with identified deception.

  • B

    The individual presents himself or herself to others as ill, impaired, or injured.

  • C

    The deceptive behavior is evident even in the absence of obvious external rewards.

  • D

    The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.

    • Specify if: single episode or recurrent episodes.

Factitious Disorder Imposed on Another (Previously “Factitious Disorder by Proxy”)

  • A

    Falsification of physical or psychological signs or symptoms, or induction of injury or disease, in another, associated with identified deception.

  • B

    The individual presents another individual (victim) to others as ill, impaired, or injured.

  • C

    The deceptive behavior is evident even in the absence of obvious external rewards.

  • D

    The behavior is not better explained by another mental disorder, such as delusional disorder or another psychotic disorder.

    • Note : The perpetrator, not the victim, receives this diagnosis.

    • Specify if: single episode or recurrent episodes.

Table 35.4
Adapted from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association, p 315.
DSM-5 Diagnostic Criteria for Illness Anxiety Disorder

  • A

    Preoccupation with having or acquiring a serious illness.

  • B

    Somatic symptoms are not present, or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (e.g., strong family history is present), the preoccupation is clearly excessive or disproportionate.

  • C

    There is a high level of anxiety about health, and the individual is easily alarmed about personal health status.

  • D

    The individual performs excessive health-related behaviors (e.g., repeatedly checks his or her body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctor appointments and hospitals).

  • E

    Illness preoccupation has been present for at least 6 mo, but the specific illness that is feared may change over that time.

  • F

    The illness-related preoccupation is not better explained by another mental disorder.

    • Specify whether: care-seeking type or care-avoidant type.

Table 35.5
Adapted from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association, p 327.
DSM-5 Diagnostic Criteria for Other Specified/Unspecified Somatic Symptom and Related Disorders

Other Specified

  • This category applies to presentations in which symptoms characteristic of a somatic symptom and related disorder that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning predominate but do not meet full criteria for any of the disorders in the somatic symptom and related disorders diagnostic class.

  • Examples of presentations that can be specified using the “other specified” designation include the following:

    • 1

      Brief somatic symptom disorder: duration of symptoms is <6 mo.

    • 2

      Brief illness anxiety disorder: duration of symptoms is <6 mo.

    • 3

      Illness anxiety disorder without excessive health-related behaviors: Criterion D for illness anxiety disorder is not met (see Table 35.4 ).

    • 4

      Pseudocyesis : a false belief of being pregnant that is associated with objective signs and reported symptoms of pregnancy.

Unspecified

  • This category applies to presentations in which symptoms characteristic of a somatic symptom and related disorder that cause clinically significant distress or impairment in functioning predominate but do not meet criteria for any of the other disorders in the somatic symptom and related disorders diagnostic class.

Table 35.6
Adapted from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association, p 322.
DSM-5 Diagnostic Criteria for Psychological Factors Affecting Other Medical Conditions

  • A

    A medical symptom or condition (other than a mental disorder) is present.

  • B

    Psychological or behavioral factors adversely affect the medical condition in one of the following ways:

    • 1

      The factors have influenced the course of the medical condition, as shown by a close temporal association between the psychological factors and the development or exacerbation of, or delayed recovery from, the medical condition.

    • 2

      The factors interfere with the treatment of the medical condition (e.g., poor adherence).

    • 3

      The factors constitute additional well-established health risks for the individual.

    • 4

      The factors influence the underlying pathophysiology, precipitating or exacerbating symptoms or necessitating medical attention.

  • C

    The psychological and behavioral factors in Criterion B are not better explained by another mental disorder (e.g., panic disorder, major depressive disorder, posttraumatic stress disorder).

  • Specify if: mild, moderate, severe, or extreme.

With the exception of illness anxiety disorder, in which there is a high level of anxiety about health in the absence of significant somatic symptoms, and psychological factors affecting other medical conditions, in which psychological and/or behavioral factors adversely affect a medical condition, SSRDs are classified on the basis of physical symptoms associated with significant distress and impairment, with or without the presence of a diagnosed medical condition. The symptoms form a continuum that can range from pain to disabling neurologic symptoms and generally interfere with school/home life and peer relationships.

Most patients with SSRDs are seen by primary care practitioners or by pediatric subspecialists, who may make specialty-specific diagnoses such as visceral hyperalgesia, chronic fatigue syndrome, psychogenic syncope, or noncardiac chest pain. Even within psychiatry, SSRDs are variously referred to as functional or psychosomatic disorders or as medically unexplained symptoms . The nosologic heterogeneity across the pediatric subspecialties contributes to the varying diagnostic labels. There is a significant overlap in the symptoms and presentation of patients with somatic symptoms who have received different diagnoses from different specialties. Moreover, SSRDs share similarities in etiology, pathophysiology, neurobiology, psychological mechanisms, patient characteristics, and management and treatment response, which is indicative of a single spectrum of somatic disorders.

It is helpful for healthcare providers to avoid the dichotomy of approaching illness using a medical model in which diseases are considered physically or psychologically based. In contrast, a biobehavioral continuum of disease better characterizes illness as occurring across a spectrum ranging from a predominantly biologic to a predominantly psychosocial etiology.

Epidemiology

Between 10% and 30% of children worldwide experience physical symptoms that are seemingly unexplained by a physical illness. Estimated prevalence varies greatly between studies based on the type of symptoms and the study methodology. The frequency and heterogeneity of complaints increase with age, with symptoms occurring more frequently in girls than boys.

Many children with persistent complaints of abdominal pain meet criteria for somatic symptom disorder with predominant pain in DSM-5. Headaches and back, limb, and chest pain are also frequently occurring pain symptoms in adolescents. Prevalence rates of conversion disorder in adolescents are 0.3–10%. Nonepileptic seizures, loss of consciousness, and motor symptoms are common conversion symptoms across cultures.

Risk Factors

Individual

Temperament/Coping Styles

Somatic symptoms have been found to be more common in children who are conscientious, sensitive, insecure, internalizers, and anxious, and in those who strive for high academic achievement. Somatization may also occur in children who are unable to verbalize emotional distress. Somatic symptoms are often seen as a form of psychological defense against intrapsychic distress that allows the child to avoid confronting anxieties or conflicts, a process referred to as “primary gain.” The symptoms may also lead to what is described as “secondary gain” if the symptom results in the child being allowed to avoid unwanted responsibilities or consequences.

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