Somatoform Disorders

John V. Campo

Gregory K. Fritz

The biomedical model central to many of the triumphs of Western medicine maintains that the subjective suffering of our patients, most commonly described as illness, can best be understood as consequent to demonstrable biophysical or biochemical processes characterized as disease. It is nevertheless well known that many patients presenting with physical symptoms and associated disability in general medical settings do not suffer from explanatory disease in the traditional sense. Such patients are ubiquitous and are seen across all branches of medicine, in both primary and specialty care, and in both traditional medical and mental health settings. Conceptual problems associated with presumably “unexplained” symptoms are peculiar to the Western medical tradition (1), where a psychological model of illness causation developed alongside the biomedical model, with its own analogous terminology (psychopathology) and a separate system for reimbursement and care delivery (mental health). While it is increasingly well accepted that physical and mental health are inextricably linked and that health is a unitary construct, a practical dualism continues to influence our conceptualizations, attitudes, behaviors, and the structure of modern health care. The goal of this chapter is to introduce the clinical problems posed by youth presenting for the evaluation and management of somatic symptoms in the absence of discernible tissue damage or pathology, to place these problems into cultural and epidemiological context, to describe modern attempts at classification, and then to outline a practical approach to management that avoids mistakes rooted in dualistic thinking and professional bias.

There are cultural expectations associated with illness. Being “sick” implies that the affected individual suffers, is not responsible for the illness, and will seek competent medical help (2). Furthermore, cultural sanctions associated with the sick role such as exemptions from usual duties and obligations (school attendance), are dependent on whether a physician has evaluated, diagnosed, and thus legitimized the patient’s illness. While illness associated with disease is readily accepted as “legitimate,” otherwise subjectively real symptoms and sufferings in the absence of “proper” objectified disease may be stigmatized as somehow “illegitimate,” and considered due to individual weakness or sociomoral failure. It takes little imagination to appreciate how individuals with medically unexplained or “functional” somatic symptoms are viewed similarly to those with other common mental disorders. Indeed, the term “neurosis” was initially applied to patients with “nervous symptoms” that did not appear to be associated with explanatory pathology in the brain or nervous system. The term somatization has been used descriptively to refer to the experience of physical symptoms where standard medical evaluation reveals no disease or biophysical process sufficient to explain the symptoms or their impact; such symptoms have commonly been referred to as functional 3,4. A variety of related descriptive terms for presumably medically unexplained symptoms include “psychogenic,” “nonorganic,” and “hysterical,” each typically falling out of favor with ongoing use, generally after acquiring a pejorative connotation and becoming viewed as problematically dualistic.

This chapter builds on several prior reviews of the limited available research literature addressing pediatric somatoform illness and specific functional somatic symptoms and syndromes 5,6,7,8. Given the demands of space and the reality that this chapter at best will provide an overview of the problem, considerable license will be taken in bundling findings about youth with a variety of different sorts of unexplained physical symptoms (e.g., chronic pain, fatigue, conversion symptoms). The reader should nevertheless appreciate the very real insufficiencies of the knowledge base and understand that existing approaches to one sort of somatoform problem may or may not prove to be applicable to others over time.

Nosology

Not surprisingly, efforts to classify the problems suffered by patients with medically unexplained or functional somatic symptoms diverge depending on whether they were initiated in general medicine, where the approach has been to develop criteria for functional somatic syndromes based on the organ system of interest, or in the mental health sector, where such problems have been incorporated into the existing classification system for mental disorders.

Somatoform disorders are defined by the presence of physical symptoms that suggest a physical disorder but are not fully explained by the presence of a general medical condition, the direct effects of a substance, or another mental disorder (9); the symptoms must cause distress or functional impairment and should not appear to be voluntarily or intentionally produced. Seven specific somatoform disorders are described in the DSM-IV: somatization disorder; undifferentiated somatoform disorder; conversion disorder; pain disorder; hypochondriasis; body dysmorphic disorder (BDD); and somatoform disorder, not otherwise specified (9). Somatoform disorders were introduced into modern psychiatric classification as a speculative diagnostic category in order to account for physically ill patients who do not suffer from an explanatory general medical condition or disease.

In order to diagnose a somatoform disorder, the clinician must make a judgment about whether a particular physical symptom is caused by a physical disease or general medical disorder, and whether that disease is sufficient to account for the patient’s functional impairment and distress. This clearly can be quite subjective, raising questions about the diagnostic reliability of somatoform disorders as a category. In the case of a child who has been diagnosed with a functional somatic illness such as irritable bowel syndrome, clinicians might struggle to determine whether it is reasonable to consider that such a diagnosis “explains” the patient’s symptoms. Different diagnosticians may conceptualize particular symptom constellations such as irritable bowel syndrome, chronic
fatigue, or fibromyalgia differently, with some considering such syndromes representative of a bona fide, explanatory general medical condition and others considering the associated physical symptoms medically unexplained. Similarly, if a physical disease is present, the clinician might attempt to judge if the patient’s impairment is greater than what might be “expected” based on objective pathology. Furthermore, the examiner must also infer the patient’s sense of control over the production of the symptom.

Pediatric somatoform disorders are distinguished from factitious disorders and malingering, both disorders where physical symptoms are voluntarily fabricated, feigned, or intentionally produced (9). Another distinction is made from psychological factors affecting medical condition, in which psychological factors have an adverse effect on a general medical condition that would be coded on Axis III (9). Physical symptoms are also included in some of the criteria used to diagnose specific anxiety and depressive disorders, and the diagnostic manual notes that the clinician must determine whether the somatic symptoms are “better explained” by a “comorbid” emotional disorder. Diagnosis may thus be influenced by clinician training and experience, as well as by the site of initial presentation (10), findings suggesting that the diagnosis of somatoform disorder in children and adolescents is likely to be relatively unreliable in its current form. Unfortunately, studies addressing the reliability or validity of the diagnosis of somatoform disorder per se in children and adolescents have not been performed.

The somatoform disorder category remains the subject of intensive debate, with several authorities in favor of abolishing the category altogether, coding functional somatic symptoms and syndromes (e.g., fibromyalgia, irritable bowel syndrome) on axis III, and redistributing some of the disorders currently grouped within the somatoform disorders to other diagnostic categories (11). They argue persuasively that: 1) The category is inherently dualistic and culturally limited; 2) the diagnoses are unreliable, in part because of poorly defined symptom thresholds and ambiguities in the exclusionary criteria; 3) the included subgroupings are not coherent; and 4) the diagnoses have not been well accepted by patients or adopted by our colleagues in general medicine (11). Such revisions could help avoid false dichotomies in determining whether a particular symptom is “physical” or “mental,” and are more consistent with current approaches in general medicine.

Currently accepted specific somatoform disorders are described below.

Somatization Disorder

The diagnosis of somatization disorder is rooted historically in early diagnostic conceptualizations of “Briquet’s syndrome” or “hysteria” and refers to a recurrent disorder beginning before the age of 30 years that is characterized by multiple and diverse somatic complaints associated with medical help seeking and/or significant functional impairment. The French physician Briquet described patients with multiple medically unexplained physical symptoms and suggested that most of these patients developed symptoms and associated disability before the age of 20 years; early onset was associated with an especially poor prognosis (12). Diagnostic criteria for somatization disorder are quite specific yet may appear to be somewhat arbitrary, with the diagnosis requiring a history of pain in at least four different body sites, at least two gastrointestinal symptoms, one sexual or reproductive symptom, and one pseudoneurologic symptom other than pain (9). The criteria are based on the work of psychiatric researchers in the Midwest, and earlier editions of the DSM employed elaborate symptom counts from an extensive list of physical symptoms (13). Current DSM-IV criteria are an empirically based simplification aimed at addressing the core features of the disorder. Given the requirement for at least one sexual or reproductive symptom, the diagnosis is unusual in children, but not unheard of 14,15.

Undifferentiated Somatoform Disorder

Children and adolescents with multiple somatic complaints across numerous different body locations who do not meet criteria necessary to justify a diagnosis of somatization disorder are likely to meet diagnostic criteria for undifferentiated somatoform disorder, a somatoform disorder characterized by the presence of one or more physical complaints (e.g., individual symptoms of fatigue, urinary, or gastrointestinal distress) lasting at least 6 months (9). Neurasthenia is a diagnosis with a long tradition in Western medicine that is sometimes made in Europe, but not included in the DSM-IV. Neurasthenia is characterized by persistent and troubling complaints of fatigue after mental effort or minimal physical effort, as well as at least two symptoms from a list that includes muscular aches and pains, dizziness, headache, sleep disturbance, inability to relax, irritability, and dyspepsia (16). Children with so-called neurasthenic symptoms of sufficient duration would be diagnosed with undifferentiated somatoform disorder.

Conversion Disorder

Conversion disorder is the somatoform diagnosis made when the clinician is confronted by one or more deficits or symptoms affecting voluntary motor or sensory function that suggest a neurologic or other general medical condition, and psychological factors are judged to be associated with the symptoms or deficits (9). The presence of psychological factors is inferred from an association of the symptom with a significant psychosocial stressor such as family conflict, bereavement, or trauma. Presenting symptoms classically resemble neurologic dysfunction (paralysis, paresis, anesthesia, paresthesia), follow the psychological stressor by hours to weeks, and may cause more distress for parents or physicians than for the patient (la belle indifferénce). Symptoms frequently reported in children and adolescents include nonepileptic seizures, paralysis or paresis, sensory symptoms such as paresthesias, and gait disturbances 17,18,19,20. Symptoms are usually self limited but may be associated with chronic sequelae such as contractures or iatrogenic injury (8). There are four subtypes of conversion disorder in the DSM-IV, based on whether the symptoms presented are primarily motor, sensory, nonepileptic seizures, or mixed.

Pain Disorder

Pain disorder is diagnosed when there is pain in one or more anatomic sites of sufficient severity to warrant clinical attention and to cause significant distress or functional impairment (9). The three subtypes are: pain disorder associated with psychological factors, in which psychological factors are judged to play the predominant role in the causation or persistence of the pain; pain disorder associated with both psychological factors and a general medical condition, in which psychological factors and a general medical condition are judged to interact significantly in the development or maintenance of pain; and pain disorder associated with a general medical condition, in which psychological factors appear to play no more than a minimal role. The third subtype is not considered a mental
disorder and is coded on Axis III. The pain disorder diagnoses are considered acute if less than 6 months in duration and chronic when lasting 6 months or more.

Hypochondriasis

Hypochondriasis is diagnosed when an individual fears or believes that they suffer from a serious physical disease, and these fears or beliefs persist for at least 6 months despite the reassurance of a physician (9). Such illness fears or disease convictions may be rooted in misinterpretation or exaggeration of the threat associated with one or multiple physical sensations, a process sometimes referred to as somatosensory amplification (21). In hypochondriasis, the patient’s disease conviction is not of delusional intensity, as in a delusional disorder, somatic type. Hypochondriasis is also not diagnosed when the belief or preoccupation is limited to an imagined defect in appearance, as in body dysmorphic disorder (see following). Hypochondriasis may overlap with obsessive-compulsive disorder, and there is good reason to consider grouping hypochondriasis among the anxiety disorders as a health anxiety disorder or phobia (11).

Body Dysmorphic Disorder

Body dysmorphic disorder (BDD) is defined in the DSM-IV as a preoccupation with an imagined or slight defect in physical appearance causing clinically significant distress or impairment in functioning (9). The psychiatric literature on BDD in children and adolescents is limited and consists primarily of case reports (22), though approximately 10% of a recent large case series were age 18 or younger (23). BDD is distinguished from common developmental preoccupations with appearance by the presence of clinically significant distress and/or impairment in functioning. Excessive concerns about the skin are probably the most common manifestation of BDD in adolescents, with preoccupations focusing on scars or facial acne, but any body area can be a focus of concern. Patients may sometimes cause self-injury as a consequence of attempts to “fix” the perceived flaw (e.g., compulsively picking at the skin), and some patients may even deliberately self-mutilate or attempt to perform surgical procedures on themselves. Insight is often poor, and patients are more likely to present in general medical settings, where they may seek costly and potentially dangerous dermatologic and surgical treatments. Because BDD can be associated with considerable shame and the need for secrecy, the diagnosis may be missed unless clinicians ask directly about symptoms. Parents of children with BDD report excessive mirror checking, grooming, attempts to “camouflage” a particular body area, and reassurance seeking by the child. BDD may prove to be quite time consuming as a result of efforts to examine the perceived defect and/or conceal it. BDD may be related to obsessive-compulsive disorder (24), and it has been suggested that BDD would be better classified in the same category as that disorder (11) given a rather low likelihood of other comorbid somatoform disorders (23).

Somatoform Disorder, Not Otherwise Specified

Somatoform disorder, not otherwise specified is diagnosed when symptoms consistent with a somatoform disorder are present, but criteria for a specific disorder are not met (9). Examples include unexplained physical symptoms such as fatigue or hypochondriacal concerns of less than 6 months’ duration.

Epidemiology

Prevalence

Medically unexplained physical symptoms and complaints (functional somatic symptoms) are exceptionally common in children and adolescents, yet most available studies are not comprehensive, relying on self- or parent-report checklists, focusing on some physical symptoms but not others, and failing to include independent medical assessments to determine if the reported symptoms are truly “medically unexplained” 5,8,25. Furthermore, with rare exception (26), most available studies have not assessed the prevalence of specific somatoform disorders, and standardized research interviews for pediatric somatoform disorders have yet to be widely used. With these caveats aside, all manner of functional somatic symptoms have been reported by youth in clinical and community based studies. Approximately half of preschool and school aged children will report at least one somatic complaint in the previous 2 weeks 27,28,29, and approximately 15% endorse at least four symptoms 27,29.

Although individuals presenting for medical evaluation typically focus on a single symptom, the presence of one type of somatic complaint predicts another (30). Empirical support for a “somatic complaints syndrome” is provided by principal components analysis of parent ratings for over 8,000 youth referred for mental health services (31). The Ontario Child Health Study (32) found recurrent distressing somatic symptoms in 11% of girls and 4% of boys ages 12 to 16 years, and other studies have reported multiple and frequent somatic complaints in 10 to 15% of adolescents (33). Groups of somatic symptoms tend to cluster, with examples including pain/weakness, gastrointestinal symptoms, conversion/pseudoneurological symptoms, and cardiovascular symptoms 29,34,35.

Chronic complaints of pain are particularly common in children and adolescents. A 3 month prevalence of 25% has been reported, with over half of affected children taking medication and over 40% seeking medical help for the pain over a 3 month period (36). Pain can be defined as an unpleasant sensory and emotional experience that is associated with tissue damage or perceived as representative of such damage (37). Pain and nociception are not identical. Pain is essentially subjective, and must be assessed by self-report. While typically considered a sign of tissue damage, pain can arise spontaneously in the absence of nociceptor activity; conversely, pain can be minimal or absent in the presence of great nociceptor activation. The experience of subjective pain and peripheral nociception can be modified by central nervous system mechanisms, and prior tissue damage can also sensitize peripheral nociceptors, with resultant hyperalgesia at the site or in surrounding, presumably undamaged areas.

Headache appears to be the most common type of pain reported by school aged children and adolescents, with 10 to 30% endorsing “frequent” headaches or headaches on an at least weekly basis 28,38,39,40,41. Headache is cited as the reason for 1 to 2% of pediatric ambulatory visits (42). The classification system currently in use for headaches is descriptive in nature, since most headaches are considered “primary” and not attributable to an underlying physical disease (43). The primary headaches of greatest relevance are migraine and tension type headache (TTH). Migraine may be diagnosed when: a child or adolescent presents with a history of at least 5 headache attacks where the headache lasts 1 to 72 hours (4 to 72 hours in adults); the headache has at least two of the following characteristics— unilateral location, pulsating quality, moderate to severe pain intensity, and/or is aggravated by routine physical activity; and the headache
is accompanied by nausea and/or vomiting or photophobia and phonophobia. Migraine may be accompanied by aura, defined as focal neurological features that may precede or accompany the headache such as visual scintillating scotoma, sensory symptoms such as numbness, tingling, or paresthesias, and motor symptoms such as motor weakness or dysphasia. TTH may be episodic or chronic, with the main features being bilateral location, nonpulsatile quality, mild to moderate intensity, and lack of aggravation by routine physical activity (43).

Functional abdominal pain (FAP) is also quite common, with a prevalence of 7 to 25% in school aged youth 44,45,46, and is responsible for 2 to 4% of pediatric visits (42). It is the most common somatic symptom reported by preschool children (27). Gastrointestinal (GI) symptoms such as nausea, vomiting, and bowel related complaints are also common, often in association with abdominal pain. Gastrointestinal symptoms are commonly associated with headache, particularly with migraine 44,47. Cyclical vomiting syndrome refers to recurrent and stereotyped episodes of intense, unexplained vomiting that appears to be related to migraine (48). Interestingly, dizziness is another common symptom reported by up to 15% of children in surveys 29,39 that may also be related to migraine. Most cases of pediatric abdominal pain are considered functional, particularly in the absence of clues to serious physical disease such as weight loss, bleeding, fever, other systemic symptoms, or laboratory abnormalities (49). Gastroenterologists apply symptom based diagnostic criteria that have been developed for pediatric functional gastrointestinal disorders (FGID), with the best known FGID associated with pain being irritable bowel syndrome (IBS) (i.e., FAP with at least two of the following: relief with defecation; change in bowel frequency; change in bowel character) (50).

Chest pain is reported by approximately 10% of school aged children and adolescents 5,29, and is a frequent presentation in pediatric emergency rooms and in pediatric cardiology 51,52. Other common pains include musculoskeletal pains such as limb pain and back pain (5). Approximately one-third of Finnish youth reported musculoskeletal pain at least once per week in a community study, with 7.5% endorsing widespread musculoskeletal pains in a number of sites and approximately 1% meeting criteria for fibromyalgia (a functional somatic syndrome characterized by at least 3 months of multiple musculoskeletal aches and pains and pain to palpation on physical examination in at least 11 of 18 “tender point” sites) (53). Other varieties of musculoskeletal complaints may present in pediatric settings. Although more commonly seen among adults, complex regional pain syndrome type I, formerly known as reflex sympathetic dystrophy, may also occur in children and adolescents (54). The condition typically presents following a history of immobilization or trauma to the limb (injury, venipuncture, intramuscular injection), though there is no correlation between the severity of the injury and the ensuing syndrome. Clinical features include: pain disproportionate to any inciting event such as allodynia (pain from innocuous tactile stimulation) and/or hyperalgesia (an exaggerated response to painful stimulation), as well as swelling, changes in skin blood flow, or changes in skin temperature at some stage of the illness, and limitation of functioning. The pathophysiology of complex regional pain syndrome type I is still undetermined, and though psychological mediators have been proposed, scientific support is limited (55).

Fatigue is among the most common physical symptoms reported by youth, with up to one-half of adolescents complaining of at least weekly fatigue and 15% reporting daily fatigue 33,39,56. Chronic fatigue syndrome (CFS) more specifically refers to a condition characterized by severe, disabling fatigue of at least 6 months’ duration that is associated with self-reported limitations in concentration and short-term memory, sleep disturbance, and musculoskeletal aches and pains, and where alternative medical and psychiatric explanations (e.g., hypothyroidism, malignancy, hepatitis, narcolepsy, obstructive sleep apnea, medication side effects, major mood disorder, schizophrenia, or eating disorder) have been excluded (56). Available studies are limited, but CFS appears to be rare in childhood and uncommon in adolescence, with prevalence likely below 1%. Onset typically follows an acute febrile illness in approximately two-thirds of cases (57).

A variety of respiratory symptoms may appear to be medically unexplained or somatoform in nature, including complaints of cough and shortness of breath or dyspnea (58). Vocal cord dysfunction (VCD) is an often-unrecognized condition in which presumed vocal cord spasm leads to symptoms that can mimic acute asthma. Affected youth may present with a history of “asthma” unresponsive to aggressive medical management. VCD may be differentiated from asthma by the absence of nocturnal symptoms, localization of wheezing to the upper chest and throat, normal blood gases despite extreme symptoms, and significant adduction of the vocal cords when visualized on laryngoscopy 59,60. The prevalence of VCD in children’s hospitals is unknown, and clinicians are often unaware of its existence (61).

Conversion symptoms (those suggestive of a neurologic illness in the absence of neurological disease) have generated considerable interest in the psychiatric literature, but are unusual in community samples of Western youth 5,41,62,63. Presentations with conversion symptoms become increasingly common in tertiary referral centers and pediatric neurology services, where nonepileptic seizures, unresponsiveness, faints, falls, and abnormalities of gait or sensation are the most commonly reported symptoms 17,18,19,64,65,66,67. Nonepileptic seizures, sometimes described as “pseudoseizures,” resemble epileptic seizures but are not associated with the electroencephalographic abnormalities or clinical course characteristic of true epilepsy, though affected individuals may also suffer from concomitant epilepsy. Relatively little definitive is known about course, though the outcome is favorable in the majority of cases (68), with most resolving within 3 months of diagnosis 18,69. Though past clinical teaching has emphasized that symptoms considered to be representative of conversion disorder are commonly found to be caused by unrecognized physical disease (70), a systematic review found that the rate of misdiagnosis of conversion symptoms averaged 4% across the studies conducted since 1970 (71).

A prospective epidemiologic study of somatoform disorders and symptoms in a sample of 3021 German youth aged 14 to 24 year olds found the lifetime prevalence of any specific somatoform disorder to be 3% at baseline, and clinically meaningful somatoform illness that did not meet diagnostic criteria for a specific somatoform disorder was reported by an additional 10% of the sample (26). Pain disorder was the most common specific diagnosis, with most affected youth falling into the nonspecific, “undifferentiated,” or “subsyndromal” category. Somatization disorder and hypochondriasis both appear to be quite rare in children and adolescents, as no cases of either were identified, and the lifetime prevalence of conversion disorder was only 0.3%. Somatoform illness was relatively stable and persistent over time, as about half of subjects with a specific somatoform disorder or nonspecific somatic complaints reported persistent symptoms over the next four years. There was nevertheless considerable fluidity in the overall symptom profile of individual subjects. Onset of somatoform illness was predicted by female gender, lower socioeconomic status, a history of sexual trauma or physically threatening events, and premorbid anxiety, depressive, or substance abuse disorder, whereas symptom persistence was predicted by female gender, history of a serious accident,
and the presence of an affective, substance abuse, or eating disorder (26).

The community prevalence of BDD has been reported to be 0.7% (72). A somewhat higher prevalence has been reported in youth, with one study finding BDD prevalence to be 2% in a community sample of adolescents (73).

Demographics and Sociocultural Factors

Age appears to be an important variable in the presentation of functional somatic symptoms and syndromes. In general, somatic symptom reporting appears to increase with increasing age into adolescence 40,74. Unfortunately, there are few methodologically sound longitudinal studies (5). Though headache appears to be the most common type of pain reported across childhood and adolescence, FAP appears to be the most common complaint in early childhood, with headache peaking at approximately age 12 27,40. Polysymptomatic presentations become more common in adolescence 32,75,76. Conversion disorder is especially rare in very young children, and clinicians are advised to be skeptical of the diagnosis in children younger than age 6 years 17,18,67,77 Body dysmorphic disorder is similarly more common during adolescence than early childhood (73).

In general, recurrent complaints of pain occur equally in boys and girls until late childhood and puberty, after which female symptom reporting predominates 29,40,76. Chronic fatigue is also more common in females (57), and conversion symptoms appear to be more common among girls than boys across all age groups 19,64,66. Girls may be more likely to use health services for functional symptoms than are boys (36), and appear to be more consistent in reporting somatic symptoms over time (78). Female gender has been associated with both the onset and persistence of somatoform symptoms and disorders in adolescents (26).

Low socioeconomic status and low levels of parental education have been associated with somatic symptom reporting in childhood and adolescence in some studies 26,66,79,80, as well as with symptom stability (26), but not in others 76,81. The impact of race/ethnicity and the role of social and cultural factors have been inadequately studied. Cultural influences may nevertheless be influential. Conversion symptoms have been reported to be common presentations of psychiatric disorder in non-Western clinical settings, including Turkey and India 69,82, and cultural differences in pain expression and behavior have been suggested, but existing studies may confound ethnicity, socioeconomic status, and acculturation (83).

Family, Genetic, and Temperamental Factors

There is growing evidence that youth with a variety of different medically unexplained physical symptoms are more likely to have parents and family members who perceive their own health more negatively and report more somatic symptoms and complaints than those of unaffected peers 14,40,67,75,76,84,85,86,87,88. Somatization disorder, though relatively uncommon, appears to cluster in the family members of affected patients (89), and children of parents with somatization disorder are more likely to report medically unexplained physical symptoms than children of controls (90). Chronic fatigue also appears to cluster in families of affected children (56).

Exposure to illness in a parent has been associated with the experience of functional somatic symptoms in adulthood, and the offspring of adults with functional somatic symptoms are more likely to suffer from health anxieties and higher levels of health service use for functional somatic symptoms than those of controls (91). Parents may encourage illness related behaviors and particular coping styles in youth with functional somatic symptoms, and thus behaviorally influence the experience of somatic symptoms by the child and the associated level of disability 92,93,94,95. A number of observers suggest that there is often a family “model” for the child’s symptoms 17,18,65,67. Parents of youth with functional somatic symptoms have been described as overprotective 17,77,86 and prone to view their children as particularly vulnerable (96), which may increase the degree to which the child’s symptom are viewed as threatening.

Family systems theorists have sometimes understood pediatric somatoform illness as serving a specific function within the family system, with the child’s symptoms potentially allowing the family to avoid conflict, most notably parental marital conflict, and thus preserving family homeostasis 97,98. Families of youth with medically unexplained physical symptoms are more likely than those of peers to be described as low in perceived support (99), and affected children are more likely to come from nonintact families (100) and those characterized by parental marital conflict 65,88,101. Some observers have also called attention to how a particular child’s somatic symptoms may serve a communicative function in the family on the order of body language or a plea for help 102,103.

Functional pain syndromes, anxiety, and depression have been associated with temperamental traits such as behavioral inhibition, harm avoidance, neuroticism, and negative affect 104,105,106,107,108,109. These traits share associations with pessimistic worry, fear of uncertainty, and a tendency to respond to environmental challenge at lower thresholds 110,111. FAP may be the best studied variety of pediatric chronic pain, and is more likely to be reported by the family members of affected youth than by those of controls 40,75,78,88,100. The same is true for nongastrointestinal symptoms such as headache, including migraine 100,112, raising questions as to whether these are pain prone families (45). Mothers of youth with chronic pain in clinical 75,84,100 and community settings 88,112, also report higher levels of anxiety and/or depressive symptoms than mothers of unaffected children, but do not differ from mothers of psychiatrically referred children 84,113,114. In a multivariate regression model, maternal history of anxiety and depression was significantly associated with childhood FAP, while maternal somatic symptoms dropped out of the model once psychiatric symptoms were entered (100). Physiologic responses of youth with FAP to a social stressor also appear more akin to those of anxiety disordered youth than of healthy controls (115).

Only gold members can continue reading. Log In or Register to continue