Persistent somatic symptoms and complaints are present in many children and adolescents and cause both suffering and functional impairment (Dell & Campo, 2011
; Marwah et al., 2016
). In many cases, no clear physical cause for the complaints can be established. For example, many children experience chronic head or abdominal pain, even in the absence of any identifiable and diagnosable physical illness. In other cases, the somatic complaints are more easily understood to be the symptoms of a recognized illness or condition.
The dualism between that which is “physical” and that which is “mental” that held sway for much of Western history, and influenced beliefs about health and functioning, exerted great influence on attitudes toward poorly understood somatic symptoms. Indeed, patients who present with such symptoms have in the past been viewed as “neurotic,” “hysterical,” and in some cases as lacking in morality. In 1895, Freud and Breuer published Studies in Hysteria, a seminal book that described unexplained neurologic symptoms as resulting from psychological forces, and in particular from sexual incidents in the patient’s history. The book presented five case studies, the most famous of which is that of Anna O (Bertha Pappenheim), who suffered from partial paralysis; impaired vision, hearing, and speech; and hallucinations. Freud and Breuer suggested that these symptoms were rooted in unresolved feelings relating to her father’s illness and death. This case, along with the others described in the book, is credited with laying the foundation for the development of Freud’s psychoanalytic theories and treatment approach.
Dualism has given way in more modern times to a unitary view of health as a biopsychosocial construct and to the recognition that physical and mental health are not discrete categories. Nonetheless, dualism continues to exert influence on both attitudes and medical services. Although somatic symptoms that are clearly tied to underlying pathophysiology of disease are generally accepted as “valid” and “real,” symptoms that are not linked to a disease are often met with considerable doubt and skepticism. Such symptoms (often termed functional somatic symptoms) are still frequently questioned for both their validity (do they actually exist?) and their implications (why does the child have them?). This kind of skepticism can amplify the child’s suffering and leave parents feeling bewildered, confused, and angry with the child, the doctor, or both. Statements such as “It’s all in her head” remain not uncommon and are often perceived, or even intended, as disparaging.
These negative attitudes on the part of physicians confronted with unexplained somatic symptoms can reflect the sense of helplessness that can stem from a problem that appears outside of their domain of expertise, but which they are expected to be able to address. Although many mental health problems remain largely “unexplained,” as no clear pathophysiology has been determined for the most common mental health problems, these disorders have achieved a greater validity in the lay and professional thinking through the establishment of clear diagnostic categories. The development of clearer nosologic categories for somatic symptoms may be useful in reducing stigma and confusion around somatic symptoms as well.
In its most recent iteration, the Diagnostic and Statistical Manual of Mental Disorders
) (American Psychiatric Association, 2013
) has taken further steps toward establishing a unitary approach to somatic symptoms. One important shift is deemphasizing the “unexplained” nature of somatic symptoms. Instead, DSM-5
focuses on the presence of somatic symptoms (whether explained or not) and on the distress and impairment caused by the symptoms. As such, somatic symptom disorder, the primary somatic diagnostic category under DSM-5
, can include both symptoms that are “unexplained” and those that are more clearly linked to a known physical cause. This shift not only changes significantly the actual diagnostic criteria but also implicitly acknowledges that symptoms that are unexplained at one point in time may be understood differently at another. Grouping the somatic symptoms together, with no requirement that they be unexplained, recognizes that lack of a known physical cause is not in and of itself evidence of a root mental cause. Furthermore, the shift away from a focus on unexplained symptoms allows for a focus on other features that are clearly present. Thus, instead of basing the diagnosis on what is not present (a clear medical explanation for the symptoms), DSM-5
focuses more on patterns of maladaptive cognitive, emotional, and behavioral functioning that clearly are.
Another diagnosis that highlights the inextricable link between physical and mental health is that of psychological factors affecting medical conditions. This refers to situations in which a nonmental condition is present, and psychological or behavioral factors are adversely impacting the medical condition or hampering or delaying its treatment.
Alongside these diagnoses, DSM-5 also recognizes several other diagnoses characterized by somatic complaints or a focus on physical well-being. Illness anxiety, newly introduced in DSM-5, refers to excessive preoccupation with being or becoming seriously ill. Conversion disorder (functional neurological symptom disorder) is diagnosed in patients who present with abnormal motor or sensory function that is not compatible with known neurologic conditions. As such, conversion disorder retains the focus on the seemingly unexplained nature of the symptoms. And factitious disorder refers to the deliberate falsification of symptoms in oneself or in others.
DIAGNOSIS, DEFINITION, AND CLINICAL FEATURES
The currently recognized somatic diagnoses and their key diagnostic features are summarized in Table 18.1
and include Somatic Symptom Disorder, Illness Anxiety Disorder, Conversion Disorder (Functional Neurological Symptom Disorder), Psychological Factors Affecting Other Medical Conditions, and Factitious Disorder, as well as Other Specified Somatic Symptom and Related Disorder and Unspecified Somatic Symptom and Related Disorder.
Somatic Symptom Disorder
The key diagnostic criteria for establishing a diagnosis of somatic symptom disorder are that somatic symptoms are persistently present, cause distress or impairment, and excessive thoughts, feelings, or behaviors are devoted to them or to related health concerns. The specific somatic symptoms may vary and change over time, but some symptoms will be present for a period of typically at least 6 months. The diagnosis is further classified according to the current severity and number of the somatic symptoms, and according to whether or not the
symptoms predominantly involve pain. When symptoms are severe and persistent (more than 6 months), the diagnosis is also classified as “persistent.”
TABLE 18.1 Main Diagnostic Categories for Somatic Disorders in DSM-5 and Key Criteria
Key Diagnostic Criteria
Somatic symptom disorder
Persistent somatic symptoms
Symptoms cause distress and/or functional impairment
Excessive thoughts, feelings, or behaviors related to the symptoms or to health
Excessive preoccupation with having or developing an illness
Anxiety about health
Performing excessive health-related behaviors or avoiding medical procedures
Somatic symptoms are not present or are mild and not the source of impairment
Psychological factors affecting other medical conditions
A physical medical condition is adversely affected by psychological or behavioral factors (e.g., the condition is exacerbated or recovery impeded)
The psychological factors are exerting a clear negative impact on the medical condition
Deliberate falsification of physical or psychological symptoms
Can include exaggeration of real symptoms and/or fabrication of symptoms or medical signs
In some cases, the deliberate induction of illness or injury
Can be imposed on the self—individual falsifies their own symptoms
Can be imposed on another—individual falsifies symptoms of another person (e.g., a parent falsifies symptoms of a child)
Importantly, the somatic symptoms in somatic symptom disorder may, or may not, be associated with another medical condition. For example, a child who underwent a medical procedure and experiences persistent somatic symptoms following the procedure may meet criteria for the diagnosis, despite the link to the medical procedure, if all other criteria are met.
Children with somatic symptom disorder are typically chronically worried about their health. They may interpret their somatic symptoms as signs of a serious medical condition and fear grave illness or death. In severe cases, the concerns around the somatic symptoms may take on a central focus of the child’s identify and life. The child may view themselves as “sick,” require many medical examinations, and avoid activities because of fear of becoming more ill or of exacerbating their symptoms. This concern can appear to be immune to any reassurance that is provided by adults and experts in the child’s life. For example, a visit to the doctor, with a reassuring message that the child is not seriously ill, may provide only very temporary relief, which is soon replaced by renewed anxiety and worry. Furthermore, the preoccupation with health and somatic symptoms may make the child more likely to notice any small physical experience and perceive it as another indication of the seriousness of their overall condition. It is common for somatic symptoms to accumulate, for example, for a child with chronic complaints of abdominal discomfort, to also develop headaches, leading to further impairment.
Although any somatic symptom can be present in somatic symptom disorder, headache, abdominal distress or pain, fatigue, and chest pain are among the most common complaints. The somatic symptoms, and the anxiety they cause, can lead to serious impairment in a child’s ability to function normally. School attendance is a major challenge, and absenteeism is common.
Illness Anxiety Disorder
The central features and diagnostic criteria of illness anxiety disorder are preoccupation with having or developing an illness, high levels of anxiety about health, and the performance of excessive health-related behaviors or the avoidance of health-related procedures and situations. Somatic symptoms are either not present in illness anxiety disorder or are present but are mild. And the impairment in illness anxiety disorder is not caused by the presence of the somatic symptoms, although such symptoms can contribute to the anxiety about becoming sick. When illness anxiety is diagnosed in a person who also suffers from a diagnosable medical condition, the anxiety is excessive in relation to the severity of the medical condition. For example, a child with a benign and nondangerous heart murmur may be excessively preoccupied with the risk of heart failure, in a manner that is not proportionate to the realistic risk.
Children with illness anxiety disorder may exhibit high interest in news or information relating to health and disease. Hearing about another person, such as a grandparent, becoming ill can trigger severe anxiety in the child, leading them to seek out additional information and potentially perpetuating a cycle of elevated anxiety. For some children with illness anxiety, the preoccupation with health and disease will be extensive enough to interfere with most other interests and activities. Dinner table conversations may repeatedly center around health-related topics, for example, causing frustration and exasperation to other family members. The child may also engage in frequent self-checks, examining parts of their body for signs of illness. For example, the child may frequently take their temperature, search for signs of hair loss, or attempt to inspect their own throat in the mirror. The child may also pressure their parents to take them to frequent medical check-ups, and parents who are attempting to reassure the child may accommodate by arranging such visits. Reassurance from the medical professional, however, is unlikely to relieve the anxiety for more than a brief period of time.
Conversion disorder (functional neurological symptom disorder) is diagnosed when a patient presents with sensory or motor symptoms that are not compatible with established neurologic or medical conditions. Symptoms can include muscle weakness or paralysis, tremors, abnormal posture or gait, and reduced skin sensation. Some symptoms of conversion disorder appear similar to seizures, as when a patient appears to shake or twitch and lose consciousness, but neurologic examination will not be consistent with seizure. Speech and vision can also be abnormal or altered. For example, a child may report seeing double or may show difficulty articulating words.
An important note is that the absence of neurologic findings to support a diagnosis compatible with the symptoms is not in and of itself sufficient to establish a diagnosis of conversion disorder. That is to say, a child who presents with symptoms that are strange and remarkable or a child whose symptoms are not clearly aligned with any established neurologic condition should not be diagnosed with conversion disorder based solely on the fact that no known condition matches their symptoms. Rather, the diagnosis should only be established when there is clear evidence of actual incompatibility between the symptoms and neurologic conditions. One example of such incompatibility
is the presence of tremors that cease when the child is distracted by some other action. The tremor entrainment test is a procedure in which a patient who presents with a tremor on one side of the body, for example, in the
right hand, is asked to follow the doctor’s rhythmic motions with their left hand. When the tremor in the right hand changes as a result (e.g., the child begins to make the same motion with the right hand as well), this would be incompatible with “true” neurologic tremor behavior. This guideline on diagnosing conversion disorder only when there is clear evidence of incompatibility with neurologic conditions is important, because not adhering to it could lead to misdiagnosis of conversion disorder in children who may later be found to be suffering from an as-yet undiagnosed condition.
The diagnosis also does not rest upon ascertaining that the child is not deliberately producing (or misreporting) their symptoms. This is a difficult judgment to make and is not required. Likewise, although secondary gains (i.e., external rewards derived by the child from the symptoms) may be present, they are not part of the diagnostic considerations. In some cases of conversion disorder, patients exhibit a seeming lack of interest or concern about the symptoms (sometimes referred to as la belle indifférence).
Psychological Factors Affecting Other Medical Conditions
This diagnosis is appropriate when a patient has a medical condition or symptom (not a mental health disorder) and psychological or behavioral factors are adversely affecting that condition. The psychological factors could be exacerbating the condition, hampering recovery, or interfering with treatment of the condition. The diagnosis is specified as mild when the psychological factors are increasing medical risk, moderate when they are aggravating the underlying medical condition, severe when they result in hospital visits or stays, and extreme when they pose a life-threatening risk.
Examples of psychological and behavioral factors that could contribute to this diagnosis are distress that exacerbates the physical condition, engaging in maladaptive health-related behaviors, lack of adherence to treatment protocols, and denial of symptoms. A child with asthma or migraines, for example, may experience more symptoms due to anxiety. Another example is a youth with diabetes who manipulates their insulin intake with the aim of losing weight, leading to poorer treatment of the diabetes and potentially dangerous blood sugar fluctuations.
This diagnosis should only be conferred when the psychological or behavioral factors are exerting a clear and negative effect on the medical condition. Psychological problems that emerge in response to the medical condition but are not adversely impacting its course or treatment do not meet this criterion. Thus, for example, a child who is diagnosed with a serious illness and develops depression, without evidence that the depression is impacting the illness, may meet criteria for an adjustment disorder, but would not be diagnosed with psychological factors affecting other medical conditions. Likewise, when a medical condition directly causes psychological symptoms (as when a hormonal imbalance leads to a deterioration in mood), a diagnosis of mental disorder due to another medical condition may be appropriate, rather than psychological factors affecting other medical conditions.
Factitious disorder refers to the deliberate falsification of physical or psychological symptoms, or to the deliberate induction of illness or injury. The factitious behavior must be present even in the absence of obvious external rewards that may be gained by performing it.
Factitious disorder is divided into two subtypes: factitious disorder imposed on self, in which the person falsifies their own symptoms or causes themselves illness or injury, and factitious disorder imposed on another, in which the person falsifies the symptoms of another person or deliberately causes them illness or injury (this is the syndrome formerly referred to as Munchausen by proxy). In both cases, the diagnosis should specify whether a single episode of factitious behavior is known or whether multiple episodes have occurred.
Falsifying symptoms could include exaggeration of actual symptoms, simulation of physical signs, and lying about the presence of symptoms. When the factitious behavior occurs in the context of an actual physical illness, it causes the patient to be perceived as more sick or impaired and has the potential to lead to unnecessary medical interventions.
For children, the most common scenario for a diagnosis of factitious disorder imposed on another is when parents or caregivers are falsifying the child’s symptoms or causing them deliberate harm and seeking medical attention. In all cases, the diagnosis is conferred on the person enacting the factitious behavior, not on the child victim of the behavior. Such behavior may also be criminal on the part of the caregiver. The diagnosis, however, does not address the forensic aspect or the motivations of the perpetrator, beyond establishing that the behavior is not clearly motivated by external rewards. Thus, a parent who lies about a child’s symptoms to protect themselves from legal liability (an external reward) would not meet criteria for this diagnosis unless the falsification was clearly beyond what is necessary for the legal protection. This condition is also discussed in detail in Chapter 24
on child abuse and neglect.
EPIDEMIOLOGY AND DEMOGRAPHICS
Somatic symptoms are very common in children and adolescents (Perquin et al., 2000
), but the prevalence of somatic symptoms disorder is less clear. Most research focuses on the presence of particular symptoms and group of symptoms, rather than on the diagnosis, and many studies have focused on adults rather than children.
In both clinical and community samples, some somatic symptoms are reported by as many as half of all youth, and many report the presence of multiple somatic symptoms (Domenech-Llaberia et al., 2004
; Saps, 2017
). Indeed, the presence of one somatic symptom consistently predicts the presence of at least one, and often multiple, additional complaints (Alfven, 1993
). Furthermore, the presence of somatic symptoms at one point in time predicts future somatic symptoms, which could be a recurrence of the same symptom, a different symptom, or both. Particularly common in youth are complaints of pain symptoms, including headache, stomach ache, and musculoskeletal pain, with headache being the most common of all (Perquin et al., 2000
; Shanahan et al., 2015
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