Somatoform disorders in the
pediatric population

D. RICHARD MARTINI, MD

aSpring 1997

SOMATOFORM DISORDERS  are described by the American Psychiatric Association as follows: "One or more physical complaints (e.g., fatigue, loss of appetite, gastrointestinal or urinary complaints) where either appropriate evaluation uncovers no organic pathology or pathophysiologic mechanism (e.g., physical disorder or the effect of injury...) to account for the physical complaints," or "when there is related organic pathology, the physical complaints or resulting social or occupational impairment is grossly in excess of what would be expected from the physical findings."¹ The etiology of somatoform disorders is not clear; the problem seems to be multidetermined. There is usually evidence of a time relationship between a significant stressor and the development of the somatic complaint. In addition, the cases that come to the attention of professionals are usually more complicated, because parents typically try to handle these problems in the home environment. A frequent response is to play down the symptoms or attempt to provide some palliative care.

Accompanying signs of distress are usually the hallmarks of organic disease. Children and adolescents with physical illness have a progressive course, with deteriorating school performance, visual loss, fatigue, posture abnormalities, and a variety of symptoms that suggest a medical disorder. Psychogenic disorders, on the other hand, usually have a rapid onset, with a family history of similar presentations, a clear discrepancy between the physical findings and the patient's complaint, and some conscious or unconscious motivation for the maintenance of these symptoms (see Table 1). Patients have an inappropriate level of disability and distress and increased utilization of health care services.

Epidemiology

Garber et al. in 1991 noted that 52% of patients in a general clinic have evidence of a somatoform disorder.² In a study of a pediatric population, the rates of these diagnoses vary according to presentation; 25% of children with headaches have somatoform disorders as do 23% with low energy, 21% with sore muscles, and 17% with abdominal discomfort. Recurrent abdominal pain was more prevalent in patients younger than age 12³ and may affect from 10% to 15% of all school children.⁴ These percentages may be inflated because the problem is frequently polysymptomatic. Garber (1991) stated that 50% of children report one somatic complaint, 15% four or more, and 1% have as many as 12 symptoms.³ This trend is more common in adolescents. Studies have shown rates of multiple complaints to be approximately 11% in adolescent boys and 15% in adolescent girls. There is no difference in the rates of somatoform disorder between sexes until adolescence, when the prevalence in females increases. Conversion disorder, for example, is at least three to five times more common in adolescent girls than in boys of the same age. Patients usually have been suffering for some time (more than two months) or had multi-system involvement. Although few studies have determined the prevalence of the disorder in young children, when it appears in children younger than six years of age, abuse should be suspected.

The majority of pediatric conversion disorder patients seen by the psychiatric service has neurologic problems. These include pseudoseizures and syncope, motor dysfunction, sensory disturbances, headaches, dizziness, sleep difficulties, eating disorders, vomiting, hiccups, psychogenic cough and tremors (see Table 2). The prevalence of these problems increases with age into adolescence.

Somatoform disorders appear to cluster in families. Twin studies have not yet demonstrated a genetic etiology for this trend, although personality characteristics that predispose to somatoform disorder may be inherited. Parents of children who somaticize have high rates of chronic physical illness and disability. Family members may also model somatizing behavior for their children. The assessment of these families is particularly challenging because they do not present with an obvious psychiatric history and do not consider themselves particularly vulnerable to these problems. The character of the home environment is a determining factor, but the literature addressing this question is sparse. In general, patients from lower socioeconomic class and with less education are at greater risk. Cultural factors may play an important role, particularly among non-Western societies, but conclusions are speculative in the pediatric population.

Medical Evaluation

The diagnosis of a somatoform disorder begins with a thorough and appropriate medical evaluation. This allows the patient, family and physician to more comfortably address psychological factors in the presentation. Yet the extent of such an assessment is often subjective and varies from one physician to another. In addition, the workup may be limited by practical and financial constraints. Physical disease and somatoform disorder can certainly coexist, and the presence of a diagnosed medical problem does not cancel the need to address psychiatric issues. When patients present with somatic complaints, referrals to mental health professionals usually follow repeated unsuccessful efforts by the physician to address the physical complaints or follow the discovery of additional psychiatric disorders such as school refusal and conduct disorder that require treatment. Parents may consider the physical symptoms to have only an organic basis and believe that psychiatric intervention will somehow invalidate the child's complaints. The clinician must balance the need to assess the presence of physical findings with the fear of reinforcing psychiatric symptoms in the patient. Occasionally pursuing the clinical investigation will escalate somatoform symptoms in the patient. The assessment may uncover minor anomalies unrelated to the presenting complaints that are nevertheless explored because of a desire to thoroughly pursue a diagnosis. This is dangerous when it exposes the child to the risks of invasive procedures. The assessment of these young patients may be helped or hindered by the existence of a multi-generational family history of somatoform disorder. Family members may recognize familiar patterns of behavior in their child and assist the physician in diagnosis or may repeat long-standing beliefs that the symptoms are indicative of a medical disorder.

Characteristic features of the physical exam can effectively demonstrate somatoform symptoms in the patient. For example, video EEG can discriminate pseudoseizures from a genuine seizure disorder, the hysterically blind patient will usually look at a mirror drawn across his face, and sensory mapping usually reveals a pattern that does not conform to any known dermatome when a somatoform disorder is suspected.

Psychological Basis for the Disorder

Patients may be in a situation that presents few options other than communicating distress through illness. Symptoms are usually supported by allies in the family or among physicians. The psychosocial problems in the young patient include parental separation and divorce; violence, abuse or neglect; poor peer relationships; and deteriorating school performance characterized by declining grades, increased anxiety around attendance, or specific learning disabilities. Children of low social competence tend to rely on somatic symptoms in the presence of stressful life events. Success in the classroom does not protect the child from the emotional consequences of social problems.

Theories about somatization in adults have emphasized the development of symptoms as a result of repressed anger developed through life experiences. Studies in this population, however, have not yet supported this view. The literature has noted that adult patients who practice self-disclosure have improved immune function and more positive reports on health indices when compared to a group that does not. There is little speculation on the contribution to psychologically mediated symptoms.

Secondary gain seems to be an important factor in symptom development. Patients that are prone to neurotic disorders are more likely to develop somatic complaints when financial gain or litigation is imminent. The relationship between these findings and somatoform disorder is not clear, and the literature on the effect of litigation has been inconsistent. There is no definitive proof that legal action and monetary gain aggravate symptoms or prolong the duration of somatoform symptoms in children. The design of such studies is problematic and contributes to the lack of conclusive data. Another more common source of secondary gain may be found in the family dynamics. Children with illness and disability become the focus for family attention and shift emphasis away from marital, financial or interpersonal issues. Families may have histories of recurrent medical problems that play into the child's current presentation.

Comorbidity

The majority of children with somatic complaints do not have a psychiatric disorder. However, the incidence of psychiatric disorder in this group is higher than in a normal population. An association between somatoform symptoms in children and adolescents and additional psychiatric disorders has been described in several studies with patients of varying ages. The presence of psychiatric disorder is more likely with certain physical symptoms. Children with stomachaches, for example, are more likely to suffer from psychological problems than those experiencing headaches. Concomitant psychiatric disorder seems to be a more important factor in the development of somatization disorder than any of the psychodynamic formulations described earlier.

Children and adolescents with depression are more likely to have somatic complaints, suggesting an association between somatoform and mood disorders. The frequent overlap in symptoms between depression and medical illness (e.g., changes in appetite or weight, fatigue) presents a problem for the clinician who is trying to decide between organic and psychiatric disorders. Recent studies, however, suggest that somatic symptoms may not be an important source of confusion and may not radically influence diagnosis. Heiligenstein and Jacobsen (1988) found that eliminating the somatic items from the Children's Depression Rating Scale (CDRS-R) did not significantly change the correlation of the CDRS-R score with clinical judgment of depression in children and adolescents with cancer.⁵ The clinician may, therefore place more emphasis on psychological symptoms when diagnosing depression in medically ill or somatoform disorder patients.

Anxiety disorders have a strong association with somatic complaints, particularly separation anxiety disorder, panic disorder and school refusal. Panic may develop in conjunction with somatoform disorder in children.⁶ The symptoms of panic disorder include physiologic complaints that can present in patients with a medical disorder as an exacerbation of their illness. In the adult literature, the most common complaints of patients suffering from panic include cardiac symptoms, such as chest pains, tachycardia and irregular heart beat; gastrointestinal complaints, such as epigastric distress; and neurologic problems, such as headaches, dizziness, vertigo, syncope or periostosis. The overlap between somatoform disorder and panic was clearly demonstrated in a National Institutes of Mental Health study, which found that patients with somatization disorder, a type of somatoform disorder, were 90 times more likely to experience panic than patients without somatization. One explanation for the relationship between panic and somatoform disorder is the increased sensitivity to physical complaints among anxious patients. They become more aware of their bodies and their threshold for symptomatic illnesses is lower.⁷

Classification of Somatoform Disorders

A number of diagnoses fall within the broad category of somatoform disorders. Some are based on the symptom presentation; others are based on the circumstances leading to the disorder. The following is a brief summary of diagnoses that may be classified as somatoform.

Pain Disorder

Pain disorder is a preoccupation with pain alone in the absence of appropriate physical findings. The problem may be related to psychological factors, psychological factors and a general medical condition, or a general medical condition alone. The disorder should be present in one or more anatomical sites, there should be evidence of a functional deficit, and the psychological factors should not be intentionally produced.

Conversion Disorder

Conversion disorder begins with a disturbance in physical functioning that suggests a pediatric disorder but that cannot be explained after sufficient medical assessment. In addition, psychological factors are thought to be etiologically involved, although the symptoms are not voluntarily produced. Evidence for the role of psychological issues is in the temporal relationship between an environmental stressor and the development of symptoms. In addition, the disorder frequently allows the child or adolescent to avoid a potentially stressful situation. If the presentation is limited to pain, the diagnosis would more appropriately be pain disorder.

These children may have a wide variety of symptoms including pseudoseizures, gait disturbances, sensory problems and respiratory difficulties. The disorder is rarely found in children under ten years of age, is usually found in a relatively narrow age range, and the patients are predominately female. Conversion symptoms do not always appear in children with a history of frequent medical complaints. In fact, it may be the absence of such a history that leads parents to suspect a medical disorder. Patients with conversion disorder have a high incidence of additional psychiatric diagnoses, including depression, psychosis and personality disorder. Conversion disorders are often present in subjects with a tendency toward internalizing behaviors, particularly anxiety symptoms. On self-rating scales, these patients consider themselves to be more anxious than individuals with an anxiety-disorder diagnosis.

Hypochondriasis

Hypochondriasis is a recurrent and unremitting fear that one has a serious illness, a fear that cannot be alleviated by medical reassurance. These patients tend to be hypervigilant and misinterpret normal bodily sensations as signs of physical disorder. Hypochondriasis is a complicated phenomenon that draws patients toward somatization disorder. The patient is more likely to experience the symptoms he or she is most worried about. Their preoccupations are likely to be accurate sensations, although subtle and not necessarily pathologic. These changes are, however, perceived as a threat. The problems may be considered diffuse, as in malignancy, or specific, as in heart disease. Hypochondriacs are more likely to develop new symptoms when suffering from anxiety or depression. The result is an escalation of the anxiety symptoms in the face of new complaints. This disorder has rarely been diagnosed in children and infrequently in adolescents.

Somatization

These patients have recurrent medical disorders involving multiple systems over an extended period of time. The diagnosis is rarely made in young patients and is most often associated with hysterical personality disorder. Children who have recurrent conversion-disorder diagnoses are likely candidates for somatization disorder. Somatization diagnosis requires four pain symptoms, two GI complaints, one sexual symptom and one pseudoneurologic symptom, according to DSM-IV criteria.¹ Typically in cases of somatoform disorder, the patient is either not experiencing any illness or is excessively dysfunctional when suffering from a medical problem.

Factitious Disorder

Factitious disorder presents with physical symptoms feigned or intentionally produced with a goal of maintaining the sick role. These patients fabricate medical histories or deliberately produce physical symptoms in order to meet an unconscious need. There seems to be an overrepresentation of females, nurses, paramedical personnel and patients with borderline personalities in the adult sample. It is not known, although it is suspected, that similar trends exist in the parents of pediatric patients. Munchausen's disorder is classified as a factitious disorder; Munchausen's by proxy, a diagnosis that is most often made in the pediatric setting, is included in this category. In as many as 20% of the cases of Munchausen's by proxy, mothers may be diagnosed as having Munchausen's syndrome. Children under the age of five are considered at higher risk because they are dependent upon their parents and lack the developmental sophistication to protect themselves. These patients may present with psychological signs, physical signs or both.

Malingering

Malingering is the intentional production or feigning of physical symptoms with motivation being some incentive such as financial compensation, avoiding uncomfortable situations, or obtaining drugs. The problem with malingering is that the symptoms are often based on a documented medical problem that the patient has experienced. The problems are exaggerated and the disability greater than expected. Occasionally patients convince themselves that they are, in fact, seriously ill. Final diagnosis is based on the observation of the patient in several settings: home, school and social situations, with the mental health professional alert for inconsistencies in presentation. This method is particularly successful when the patient does not suspect that he or she is being observed. No effective psychiatric treatment methods have been found for malingering, and the consequences of the actions are usually the strongest deterrents.

Psychological factors affecting medical conditions

Psychological factors affecting medical condition includes situations where some significant emotional stimuli are temporally related to the initiation or exacerbation of a physical condition or a physical problem. The disorder should interfere with treatment and pose additional health risks. Stress-related factors, for example, exacerbate physical symptoms. The patients who suffer from tension headaches, episodes of poor diabetic control and respiratory distress secondary to asthma or heart disease would meet these criteria.

Treatment

Research on the treatment of somatoform disorders is sparse; the bulk of the literature is based on anecdotal accounts. General practitioners may choose to treat these children, but the youngsters are clearly referred for more follow-up appointments and secondary services than other patients.⁸ These children are also more likely to be medicated. Physicians may provide additional support to these children, but the most significant aspects of that treatment are not clear. Individual style in dealing with the child and the parent seems to be paramount. For example, mothers have reported that empathic expressions of support are appreciated and considered helpful. Education also has a role in the approach to parents. Caregivers can learn some simple interventions and receive behavioral management training that improves their effectiveness. In addition, the physician can point out to parents and to the patient the association between pain and stress. The implication is that treatment will involve interventions both for the physical and psychological problems. Parental concern may be an indicator of the motivation to maintain the symptoms. Parents may be unaware of the support they give to greater levels of disability.

Patients with somatoform disorders may respond to medical interventions that rule out a serious medical illness or that identify a relationship between a psychosocial stressor and symptom onset. In fact, many hospitalized children will show a complete resolution of their symptoms prior to discharge. Others will show at least partial improvement. Physicians may also encourage a gradual improvement in levels of functioning by referring patients to occupational or physical therapy or by working together with schools and families. The medical practitioner can provide reassurance, ease stressors and initiate psychological interventions that may be enough to relieve an acute episode.

Garralda (1994) recommended that the primary pediatrician become comfortable with the following skills:⁹
1. An awareness of important psychosocial factors in the child's presentation and the interview skills needed to gather relevant information.
2. An ability to make simple recommendations on the management of behavioral problems like tantrums, oppositional behaviors and separation anxiety.
3. Counseling skills to intervene and eventually advise families on solutions to ineffective discipline techniques and concerns about the school environment.
4. Familiarity with family dynamics in order to identify marital problems and overprotection of the child.
5. An ability to make an appropriate referral to psychiatric services. The referral should follow some diagnostic uncertainty about psychological factors in the case, evidence of a psychiatric disturbance, or evidence of significant family problems that are contributing to the symptoms.

The psychiatric assessment and treatment of somatoform disorders are intended to prevent additional medical intervention, develop a hypothesis for the appearance of somatoform symptoms, provide a means of physical recovery for the patient usually in conjunction with the physician, and begin a psychosocial intervention that will target appropriate concerns. Treatment should not be so directive and demanding that it becomes punitive for both the patient and family. This may result in a contest of wills between the therapist and patient that ultimately is destructive and may lead to a worsening of symptoms. At the time of psychiatric referral, families often see physicians in a negative light for failing to diagnose and treat the medical problem in their child. Occasionally, these families have long histories of difficult experiences with physicians and the medical profession, sometimes going back for generations. Treatment may suggest relationships between these preconceived notions of medicine and the development of the child's somatic complaints. The clinician should be sensitive to these issues and not present the formulation as either purely organic or functional. In this process, the family is always free to pursue additional medical assessments as needed. The important caveat in this process is adequate communication between the designated primary medical care provider and the mental health professional. According to Leslie (1988) 85% of a pediatric sample with conversion disorder responded to either a combined pediatric-psychiatric or a purely psychiatric treatment plan.¹⁰

Treatment options that focus on the symptoms of somatoform disorder include individual psychotherapy, particularly as applied to self-management skills and relaxation training. Behavioral interventions, including positive and negative reinforcement, have been successful, as have biofeedback and hypnosis. Cognitive therapies have been effective in breaking the automatic cycle that maintains the symptoms—one that includes repeated self-observation, false belief and continued fear. When patients are disease-phobic because they are afraid of contracting a fatal disease, exposure therapy has been successful. Exposure therapy gradually introduces patients into environments they consider dangerous because of contagion and teaches them relaxation techniques to relieve feelings of extreme anxiety.

The presence of a major depressive disorder or anxiety disorder warrants treatment, and the addition of a plan to directly address these problems is likely to improve the patient's physical condition as well. For example, the resolution of sleep-continuity disorders or appetite disturbances is likely to improve the child's health. Children with somatoform disorders have been described as frequently having rigid, controlled and obsessive personality styles. Changing these styles is a challenge, particularly because the patient is unlikely to cooperate without the support and assistance of the family. Occasionally these traits are shared by one or both of the parents, indicating a need by the therapist to be supportive and nonjudgmental in his or her approach. The reduction of physical complaints as a treatment goal may be very anxiety-provoking for the child and will require much support from the parents to achieve. The addition of conjoint family therapy is recommended in a number of cases. Psychopharmacology is an effective adjunct when treating concomitant psychiatric disorders that contribute to the child's presentation.

Organic disorders that could explain the presenting complaint may be found over time in patients diagnosed with somatoform disorders. The literature is not clear on the frequency of such a finding and notes percentages ranging from 10% to 40% of cases.⁷ This is further evidence that the focus of treatment should not be on whether the patient is experiencing purely organic or functional disorders, but on whether the level of disability is appropriate to the physical presentation.

Prognosis

The literature is equivocal on the long-standing effects of somatoform disorder on the development or psychiatric health of adults as well as children. Most studies have focused on the presenting complaint, including symptom picture, rather than on level of functioning. The prognosis for patients who have suffered from a somatoform disorder may be quite poor when overall functional and emotional histories are examined.

REFERENCES

1. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Washington DC: American Psychiatric Association, 1994.

2. Garber J, Walker LS, Seman J: Somatization symptoms in a community sample of children and adolescents: Further validation of the Children's Somatization Inventory. J Consult Clin Psychol 1991; 3:588–595.

3. Oster J: Recurrent abdominal pain, headache and limb pains in children and adolescents. Pediatrics 1972; 50:429–436.

4. Sanders MR, Shepherd RW, Cleghorn G, Woolford H: The treatment of recurrent abdominal pain in children: A controlled comparison of cognitive-behavioral intervention and standard pediatric care. J Consult Clin Psychol 1994; 62(2):306–314.

5. Heiligenstein E, Jacobsen PB: Differentiating depression in medically ill children and adolescents. J American Acad Child & Adolesc Psychiatry 1988; 27(6)716–719.

6. Beidel D, Christ MAG, Long PJ: Somatic complaints in anxious children. J Abnormal Child Psychol 1991; 19:659–670.

7. Katon W: Panic disorder: epidemiology, diagnosis, and treatment in primary care. J Clin Psychiatry 1986; 47 Suppl:21–30.

8. Garralda ME, Bailey D: Psychosomatic aspects of children's consultations in primary care. Eur Arch Psychiatry & Neurol Sci 1987; 236:319–322.

9. Garralda ME: The management of functional somatic symptoms in children. In: Mayou R, Bass C, Sharpe M (Eds): Treatment of Functional Somatic Symptoms. Oxford: Oxford University Press, 1995, 353–370.

10. Leslie SA: Diagnosis and treatment of hysterical conversion reactions. Arch Dis Child 1988; 63:506–511.

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