Somatic symptom disorder is characterized by excessive or maladaptive responses to physical symptoms that are not feigned or deliberately produced. The symptoms can be new or chronic, widespread or specific, and fluctuate. The impaired reaction to symptoms lasts for at least 6 months, are distressing, often impair functioning, and can be associated with prolonged hospitalizations.
Somatic symptom disorder refers to the excessive thoughts, feelings, and/or behaviors related to somatic symptoms that may or may not be explained by another medical condition. Data on the prevalence of somatic disorder are limited. Some retrospective studies estimate the prevalence in the young adult and adult populations to range from between 4 and 9% (1). However, its prevalence in children is less certain.
Related disorders include the following:
Illness anxiety disorder: Children are extremely afraid that they have or will acquire a serious disorder. They can be so preoccupied with the idea that they are or might become ill that their anxiety can impair daily functioning or cause 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.
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 medical 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 or medical child abuse (previously referred to as Munchausen syndrome by proxy): Caregivers (typically a parent) intentionally falsify or produce physical symptoms in a child, without any obvious external rewards. For example, they may add blood or other substances to urine specimens to simulate a urine infection. This leads health care professionals to order unnecessary tests and provide unnecessary treatments.
Factitious disorder imposed on self: The child may pretend to have physical symptoms or do something to themselves to produce physical symptoms, without any obvious external rewards.
Malingering: Malingering, not classified under related disorders, is differentiated by causing, feigning, or exaggerating physical symptom(s) for personal gain.
Psychological factors affecting other medical conditions: Children with medical symptoms and another medical condition may experience psychological or behavioral factors that adversely affect the medical condition by influencing its course, treatment, or underlying pathophysiology.
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 do actually experience the symptoms they describe.
General reference
1. Klastrup LK, Rosendal M, Rask MT, Christensen KS, Rask CU. Functional somatic symptoms in youths in general practice: A cross-sectional study on prevalence, clinical management and perceived burden. J Psychosom Res. 2022;156:110765. doi:10.1016/j.jpsychores.2022.110765
Diagnosis of Somatic Symptom Disorder
Psychiatric assessment
Diagnostic and Statistical Manual of Mental Disorders, Fifth edition, Text Revision (DSM-5-TR) criteria
Sometimes tests to exclude other disorders
Diagnosis of somatic symptom disorder is based on criteria from the DSM-5-TR (1). Generally, for 1 of these disorders to be diagnosed, the presence of 1 or more somatic 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. The somatic symptoms or health concerns must also result in at least one of the following thoughts, feelings or behaviors:
Disproportionate and persistent thoughts about the seriousness of one’s symptoms
A persistently high level of anxiety about health or symptoms
Excessive time and energy devoted to these symptoms or health concerns
Some individuals may have somatic symptoms that predominantly involve only pain; this should be recognized and screened for.
At first presentation, physicians should take an extensive history (sometimes conferring with family members) and do a thorough examination. Often, additional testing to determine whether a underlying medical disorder is the cause may be needed. Because children with somatic symptom disorder may also develop general medical 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 general medical disorder exists (even when there is none) and unnecessary diagnostic tests may themselves traumatize children.
If no general medical disorder can be identified, doctors may use standardized mental health tests to help determine whether symptoms are due to a somatic symptom or a related disorder. Doctors usually also talk to the children and family members to try to identify underlying psychological problems or troubled family relationships.
Diagnosis reference
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR), Washington: American Psychiatric Association, 2022.
Treatment of Somatic Symptom and Related Disorders
Cognitive behavioral therapy (CBT) that focuses on helping the child understand the link between stress and physical symptoms, develop positive coping mechanisms (eg, breathing exercises, relaxation, mindfulness), challenge unhealthy physical beliefs about their health and symptoms, and encourages normal activities and school attendance
Physical therapy and rehabilitation to improve physical fitness, endurance, and ability to participate in activities
Parent support/coaching to help parents learn to support their child's new coping strategies and reinforce positive behaviors
Sometimes medications to relieve symptoms of anxiety and depression
Children and adolescents with somatic symptom and related disorders benefit from a multidisciplinary treatment approach that incorporates CBT with or without their family members, parental support/coaching, physical therapy, medications to manage comorbid anxiety and depression, and coordinated care by their primary care provider (1).
The main goal of treatment is to improve the child's ability to function daily (not necessarily to eliminate all the physical symptoms) and to encourage the child to engage in normal activities, even if symptoms remain present.
The prognosis of somatic symptom and related disorders in children and adolescents is generally favorable, with most experiencing complete or partial functional recovery, especially when there is full parental acceptance and engagement with the diagnosis and treatment process. Hospitalized patients with family that fully accepted the diagnosis of a somatic disorder are reported to have a greater likelihood of accepting counseling, having lower rates of readmission, and achieving recovery compared to those whose families rejected or only partially accepted the diagnosis (2).
Treatment references
1. Soe KC, Lopez WL. Clinical progress note: Management of somatic symptom and related disorders in pediatric inpatients. J Hosp Med. 2022;17(12):996-999. doi:10.1002/jhm.12947
2. Gao X, McSwiney P, Court A, Wiggins A, Sawyer SM. Somatic Symptom Disorders in Adolescent Inpatients. J Adolesc Health. 2018;63(6):779-784. doi:10.1016/j.jadohealth.2018.06.026
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 1 severe symptom, typically pain.
Do appropriate examinations and tests initially to exclude a general medical disorder as the cause of symptoms and, if symptoms change significantly or objective signs develop, to check for a new general medical disorder.
Treatment may involve CBT, usually combined with a rehabilitation program and parent support/coaching that aims to help children get back into a normal routine (even if symptoms persist).
