Pediatrics

Psychosomatic illness

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OVERVIEW: What every practitioner needs to know

Pediatricians are frequently confronted with physical symptoms that are either without clear medical etiology or where an emotional component appears to play a significant role in the child's illness. In fact, at least 25% of outpatient visits to pediatricians are for symptoms without an identifiable underlying illness. Chief complaints typically cluster into the following categories: gastrointestinal, cardiovascular, neurological, and pain.

Many physical complaints with a psychological underpinning resolve spontaneously, cause no significant impairment, and tend to require little more than a pediatrician's reassurance. (For example, a child's bellyache on the morning of a big test at school.) However, for some patients, psychologically-driven physical complaints can lead to major impairment in functioning, the use of extensive medical resources, and large amounts of the pediatrician's time. These can also be the source of significant distress and frustration for patients, families, and providers alike.

The term psychosomatic illness can be used to define any illness that is caused, exacerbated, or perpetuated--either fully or partially-- by psychological factors. Alternatively, psychosomatic illnesses, which are termed somatoform disorders in the Diagnostics and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR), can be defined as the presence of one or more physical symptoms without an adequate medical explanation that cause significant distress or impairment in functioning. Medical specialists tend to use the term 'functional disorders' to describe similar phenomena.

Psychosomatic illnesses should be distinguished from malingering and factitious disorders. Malingering occurs when patients intentionally feign or cause medical symptoms for external gain (such as economic benefit or avoiding consequences of their behavior). Factitious disorder and factitious disorder by proxy occur when patients or their parents, respectively, intentionally feign or cause illness in order to assume the sick role. Factitious disorder by proxy, often referred to as Munchausen Syndrome by Proxy, may be more accurately conceived of as medical child abuse.

What other disease/condition shares some of these symptoms?

Many patients with psychosomatic illness will present with common chief complaints, such as headache, weakness, or abdominal pain. Conditions that vary from common to exceedingly rare and from benign to life-threatening can be confused with psychosomatic illness. While an exhaustive list of differential diagnoses would be too lengthy to be of clinical utility, clinicians should consider several easy-to-miss diagnoses.

  • For GI complaints, these include abdominal migraines, celiac disease, eating disorders, food allergies, H. pylori infections, irritable bowel syndrome (IBS), lactose intolerance, and porphyria.

  • In the setting of neuromuscular complaints, clinicians should consider acute disseminated encephalomyelitis (ADEM), atypical migraines, frontal or temporal lobe seizures, Guillain-Barré syndrome, Lyme disease, multiple sclerosis, myasthenia gravis, myositis, and Todd's paralysis.

  • Cardiac arrhythmias, hyperparathyroidism, hyperthyroidism, and systemic lupus erythematosus (SLE) are also easily-missed medical diagnoses.

  • Psychiatric illnesses that can present with somatic chief complaints include panic disorder, generalized anxiety, and obsessive-compulsive disorder (OCD). Malingering and factitious disorders should also be considered.

What are the DSM diagnostic criteria for somatoform disorders?

Psychological Factors Affecting a General Medical Condition

  • A general medical condition is present.

  • Psychological factors adversely affect the general medical condition in one of the following ways: (1) the factors have influenced the course of the general medical condition as shown by a close temporal association between the psychological factors and the development or exacerbation of, or delayed recovery from, the general medical condition; (2) the factors interfere with the treatment of the general medical condition; (3) the factors constitute additional health risks for the individual; (4) stress-related physiological responses precipitate or exacerbate symptoms of the general medical condition.

Conversion Disorder

  • One or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition.

  • Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors.

  • The symptom or deficit is not intentionally produced or feigned (as in Factitious Disorder or Malingering).

  • The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance or as a culturally sanctioned behavior or experience.

  • The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of Somatization Disorder and is not better accounted for by another mental disorder.

  • Can be further classified as presenting with motor symptom or deficit, with sensory symptoms or deficit, with seizures or convulsions, or with mixed presentation.

Pain Disorder

  • Pain in one or more anatomical sites is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention.

  • The pain causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  • Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain.

  • The symptoms or deficit is not intentionally produced or feigned (as in Factitious Disorder or Malingering).

  • The pain is not better accounted for by a Mood, Anxiety or Psychotic Disorder and does not meet criteria for Dyspareunia.

  • For Pain Disorder Associated With Psychological Factors: psychological factors are judged to have the major role in the onset, severity, exacerbation, or maintenance of the pain. (If a general medical condition is present, it does not have a major role in the onset, severity, exacerbation, or maintenance of the pain.) This type of Pain Disorder is not diagnosed if criteria are also met for Somatization Disorder.

  • For Pain Disorder Associated With Both Psychological Factors and a General Medical Condition: both psychological factors and a general medical condition are judged to have important roles in the onset, severity, exacerbation, or maintenance of the pain.

Somatization Disorder (NB This diagnosis is of limited utility for pediatricians, given the difficult-to-meet symptom requirements)

  • A history of many physical complaints beginning before age 30 years that occur over a period of several years and result in treatment being sought or significant impairment in social, occupational, or other important areas of functioning.

  • Each of the following criteria must have been met, with individual symptoms occurring at any time during the course of the disturbance: (1) four pain symptoms: a history of pain related to at least four different sites or functions (e.g., head, abdomen, back, joints, extremities, chest, rectum, during menstruation, during sexual intercourse, or during urination); (2) two gastrointestinal symptoms: a history of at least two gastrointestinal symptoms other than pain (e.g., nausea, bloating, vomiting other than during pregnancy, diarrhea, or intolerance of several different foods); (3) one sexual symptom: a history of at least one sexual or reproductive symptom other than pain (e.g., sexual indifference, erectile or ejaculatory dysfunction, irregular menses, excessive menstrual bleeding, vomiting throughout pregnancy); (4) one pseudoneurological symptom: a history of at least one symptom or deficit suggesting a neurological condition not limited to pain (conversion symptoms such as impaired coordination or balance, paralysis or localized weakness, difficulty swallowing or lump in throat, aphonia, urinary retention, hallucinations, loss of touch or pain sensation, double vision, blindness, deafness, seizures; dissociative symptoms such as amnesia; or loss of consciousness other than fainting).

  • Either (1) or (2): (1) after appropriate investigation, each of the symptoms in Criterion B cannot be fully explained by a known general medical condition or the direct effects of a substance (e.g., a drug of abuse, a medication); (2) when there is a related general medical condition, the physical complaints or resulting social or occupational impairment are in excess of what would be expected from the history, physical examination, or laboratory findings.

  • The symptoms are not intentionally produced or feigned (as in Factitious Disorder or Malingering).

Undifferentiated Somatoform Disorder

  • One or more physical complaints (e.g., fatigue, loss of appetite, gastrointestinal or urinary complaints).

  • Either (1) or (2): (1) after appropriate investigation, the symptoms cannot be fully explained by a known general medical condition or the direct effects of a substance (e.g., a drug of abuse, a medication); (2) when there is a related general medical condition, the physical complaints or resulting social or occupational impairment is in excess of what would be expected from the history, physical examination, or laboratory findings.

  • The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  • The duration of the disturbance is at least 6 months.

  • The disturbance is not better accounted for by another mental disorder.

Somatoform Disorder Not Other Specified (NOS)

  • This diagnosis can be used when patients do not meet full criteria for the other somatoform disorders. For example, when symptoms consistent with undifferentiated somatoform disorder have been present for less than six months.

Hypochondriasis

  • Preoccupation with fears of having, or the idea that one has, a serious disease based on the person's misinterpretation of bodily symptoms.

  • The preoccupation persists despite appropriate medical evaluation and reassurance.

  • The belief in is not of delusional intensity (as in Delusional Disorder, Somatic Type) and is not restricted to a circumscribed concern about appearance (as in Body Dysmorphic Disorder).

  • The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  • The duration of the disturbance is at least 6 months.

Body Dysmorphic Disorder

  • Preoccupation with an imagined defect in appearance. If a slight physical anomaly is present, the person's concern is markedly excessive.

  • The preoccupation causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  • The preoccupation is not better accounted for by another mental disorder (e.g., dissatisfaction with body shape and size in Anorexia Nervosa).

What caused this disease to develop at this time?

  • Genetics -While somatization disorders do tend to run in families, there are little data to support specific genetic abnormalities as a direct cause.

  • Biological- Abnormalities such as decreased cerebral glucose metabolism, impaired cortical somatosensory activation, elevated plasma bradykinin, decreased serum tryptophan, increased inflammatory cytokines, abnormal functional connectivity between limbic and motor regions, and enlarged caudate nuclei volumes have been linked to somatization disorders. However, whether these findings represent cause, effect, or mere association has yet to be fully determined.

  • Exposures- Stressful life events--such as trauma, neglect, and abuse-- place patients at risk for developing patterns of somatization. Family conflict, relationship difficulties, parental absence, and significant illness in family members have all been implicated as predisposing, precipitating, and perpetuating factors. The physiological mechanisms through which these exposures may lead to the development of somatization are not entirely clear. However, alterations to the body's hypothalamic-pituitary-adrenal (HPA) axis have been implicated.

  • Individual Factors-There are a range of personal characteristics that can place a child at risk for somatization. Some studies have found associations between somatization and anxious temperament, high conscientiousness, insecurity, ineffective coping mechanisms, increased anger, and alexithymia (difficulty expressing feelings with words). Alexithymia has been correlated with somatosensory amplification, which is a heightened sensitivity to unpleasant physical sensations--such as colonic distention. Patients with somatosensory amplification are more likely to present with physical complaints in the absence of an underlying medical disorder.

  • Familial Factors- Families of children who present with somatoform disorders may have higher levels of conflict, overprotectiveness, rigidity, and impaired cohesion. It has been argued that, in these families, the child's physical symptoms may function to divert attention away from distressing conflict (such as marital discord). Alternatively, children in these families may be reluctant to add to or participate in family conflict . Physical illness may be the only 'safe' way to communicate distress or to avoid being pulled into the conflict. Even in seemingly-cohesive, low-conflict families, parents, (as well as health care providers) can unwittingly reinforce somatizing behaviors by enabling the child to remain in the sick role and reap rewards (such as increased sympathy) and/or avoid anxiety-provoking tasks (such as attending school). Some parents lack the comfort, ability, or willingness to respond to their child's emotionaldistress but find it easy to respond to their child's physicaldistress. Their child, in turn, ends up learning that the most effective way to receive parental care is through being sick. Thus, the child is more likely to both experience and communicate distress through physical symptoms. In addition, given that somatoform disorders tend to run in families, the use of illness as a kind of 'get-out-of-functioning' or 'get-out-of-conflict' card can be a highly-modeled pattern of behavior that is passed from one generation to the next.

What elements of the medical history or physical examination would support a diagnosis of a psychosomatic illness?

There are no fail-safe pathognomonic signs or symptoms of psychosomatic illness. However, there are certain elements of a patient's history and physical exam that can suggest or support the diagnosis. They include the following:

  • Onset of symptoms is correlated to a significant psychosocial stressor.

  • A prior pattern of somatization or a family history of somatization disorder.

  • Waxing and waning of symptoms that is temporally associated with specific stressors, suggestion, or care-giver attention.

  • Symptoms or impairments that are not consistent with medical knowledge. Examples would include non-dermatomal distribution of sensory deficits, a positive Hoover test in the setting of leg weakness, engagement in protective behaviors while seemingly unconscious (example: when a patient's hand is held up over their head and allowed to drop, the hand would avoid hitting their head and fall to the side), and a clear sensorium immediately following an event otherwise suggestive of a grand mal seizure.

What laboratory studies should you request to help confirm the diagnosis? How should you interpret the results?

  • There are no specific laboratory tests that can confirm the diagnosis of a psychosomatic illness. Laboratory tests should be ordered to rule out plausible medical etiologies in the differential diagnosis.

Would imaging studies be helpful? If so, which ones?

  • As with laboratory studies, there are no specific imaging studies that can confirm the diagnosis of a psychosomatic illness.

Are there additional forms of testing that can be helpful?

  • For patients presenting with symptoms suggestive of non-epileptiform seizures, video EEG monitoring can be particularly useful for establishing the diagnosis.

  • For patients with intermittent cardiac symptoms, Holter monitoring can also be helpful in ruling out arrhythmias.

Confirming the diagnosis

  • Currently, there are no widely-accepted clinical decision algorithms for suspecting/confirming the diagnosis of psychosomatic illness. When available, clinicians should make use of algorithms for assessing the patient's chief complaint.

What concerns should you keep in mind while trying to establish or rule out the diagnosis of a psychosomatic illness?

  • Pediatricians should be cautious about jumping to a diagnosis of a psychosomatic illness in patients with psychiatric histories without ruling out medical causes first. Patients with strong personal or family psychiatric histories become medically ill, too. In fact, they are more likely than their non-psychiatrically ill peers to suffer from significant medical illness.

  • Somatoform disorders are not merely diagnoses of exclusion. It is not enough to rule out known medical causes. Clinicians should look for positive signs that support the diagnosis of a psychological underpinning to the symptoms or the level of impairment.

  • Conversely, the presence of an identifiable medical disorder does not rule out the possibility that there are psychological components to the patient's presentation or a concomitant somatoform disorder (e.g., seizures and non-epileptiform seizures/conversion disorder.) In addition, the presence of a biological explanation for a patient's symptoms at one point in their illness--such as initial presentation--does not necessarily mean that it remainsthe cause.

  • Whenever possible, psychiatric consultation should be sought while the medical investigation is ongoing. Families tend to be more open to accepting psychiatric involvement when it is introduced early on as a means of identifying and addressing any psychosocial stressors that might be contributing to the patient's impairment and helping patients and families cope with illness. It can be particularly useful to describe the psychiatric consultants as experts at helping children cope with "what is hard about being sick" and noting that they "help patients with all different types of medical illness." When pediatricians wait until the medical work-up is completed to involve psychiatry, families tend to be more defensive and less open to mental health assessment and intervention.

  • Care should be taken to balance the potential benefits of medical testing (e.g., identifying underlying medical illness) with the potential risks. The risks of continued testing include iatrogenic damage (radiation, adverse reactions to sedation, etc.), incurring unnecessary costs, reinforcing patient/family beliefs that the symptoms are due to a serious underlying medical issue, and focusing time and effort away from interventions such as physical therapy and counseling that could truly benefit the patient. If you are ordering an additional test, despite an already thorough work-up, in the hopes that if/when it comes back negative your patient and their family will finally accept a diagnosis of a psychosomatic illness, you are likely to be disappointed with the results.

  • The use of placebo exposures or treatments as a diagnostic tool may be enticing, but this is ethically fraught and often clinically unproductive. When placebos are used without the family's and patient's involvement, they tend to cause anger and alienation and do not help a family accept a diagnosis of a psychosomatic illness. Placebo tests can be helpful in certain situations, such as if the patient and family agree to food exposures where they are blinded to whether a food contains an ingredient suspected of causing physical symptoms.

  • It is important to acknowledge that dealing with patients with psychosomatic illness can be frustrating for pediatricians. Some clinicians may feel like they are 'wasting their time' with patients who 'aren't even sick.' Others may resent being put in the position of being pushed by patients or their families to 'over-test' or 'over-treat'. Some may be wary of facing patient/family ire or lawsuits by presenting the diagnosis of a psychosomatic illness. In these circumstances, it may be useful to remember that children present with these symptoms in the setting of sometimes-extreme emotional distress. They may be the victims of abuse or emotionally overwhelmed by stressors over which they have no control. While there may be no identifiable underlying medical pathology, these children are still suffering, and as the child's pediatrician, you may be the best (or only) adult in their life who is in the position to provide them with the help they need and ease their distress.

How should you convey the diagnosis?

When pediatricians suspect that psychological factors are playing a significant role in a patient's identified medical illness, they should discuss their concerns openly with the family and the patient. They should engage in education with the family about how these psychological factors might be playing a role and how they can be addressed (see below). If the family is resistant, it can be useful for pediatricians to state that they would never want to treat only part of an illness or prescribe only a partialdose of medication. Therefore, in this case, in order to treat the entire illness and make sure the patient receives 100% of the treatment they need, that means addressing psychological or behavioral issues that might be making the illness worse or getting in the way of recovery.

When a diagnosis of a somatoform disorder has been made, pediatricians are advised to convene an 'informing conference' with the family, the psychiatrist, and, when indicated, subspecialty consultants. The patient's primary physician should run the meeting and should begin by summarizing the patient's presentation and illness course. The primary physician should also summarize the results of the medical testing. The fact that the evaluation has not turned up an underlying medical etiology for the patient's symptoms should be presented as good news.

The pediatrician should subsequently explain that there are lots of ways in which the mind and the body affect one another in profound ways. It can be useful to offer everyday examples such as getting butterflies in your stomach or stress headaches and more extreme examples such as how people can faint when they are overwhelmed or abruptly scared.

Pediatricians should also provide examples of more subtle interactions--especially ones that patients are not conscious of, such as how being stressed can weaken our immune systems or alter our body's hormone levels. Providing examples of unconscious processes by which emotions affect physiology is of particular importance, since many patients will state that they aren't feelingoverwhelmed or aren't awareof any stressors. "That may be true," one might respond, "but sometimes our bodies know things before our brains do."

It is imperative for pediatricians to stress at this point that they believe the patient is truly experiencing their symptoms, that it isn't "all in their head," and that they aren't "faking it." The patient's symptoms are real, their impairment is real, and so is the family's concern.

If patients or families are incredulous that emotional issues can cause real physical impairment, it can be useful to describe the findings such as the results of an fMRI study that demonstrated impaired activation of the contralateral somatosensory cortex in conversion disorder patients presenting with unilateral leg numbness. This study can be used as an example of the emotion center of the brain being "so overwhelmed that it cuts off the signals from the body to the brain" and how the patients "really weren't feeling their legs."

When conveying the diagnosis of a somatoform disorder, pediatricians should be sure to stress that treatments are available and full recovery is possible. If families continue to press for further diagnostic work-up or ongoing medical treatment, and if they continue to ask about the possibility that it couldbe something else medical, it is important to acknowledge there is almost always someother test that could be run (or repeated) but that one always has to balance the pros and cons of additional testing and that, at this moment, not only do you believe that further medical evaluation/treatment isn't indicated, you think it would be counterproductive and possibly dangerous.

If you are able to confirm that the patient has psychosomatic illness, what treatment should be initiated?

  • One of the most important elements of effective treatment for psychosomatic illness is ongoing involvement of the medical provider. Pediatricians should make it clear that they remain concerned about the patient and that they are going to continue providing and coordinating their patient's care. Pediatricians should schedule frequent follow-up appointments to monitor the child's progress and to assess any new symptoms. Frequent follow-up appointments may also help decrease the frequency of urgent calls and emergency room visits.

  • Once a diagnosis of a psychosomatic illness has been made, pediatricians should discontinue unnecessary treatments, being careful to taper medications with significant discontinuation symptoms. Further medical evaluation should be halted, with the caveat that any new concerning symptoms will be appropriately evaluated. Pediatricians should also work to consolidate care, serving as gatekeepers for specialist, emergency, and inpatient care.

  • Pediatricians should organize their treatment recommendations around a rehabilitation model. Instead of focusing on finding a cure for the symptoms, pediatricians should encourage children and their families to focus their efforts on returning to the child's previous state of functioning and maximizing recovery in spiteof their ongoing symptoms. Children with neuromuscular symptoms or significant deconditioning should be referred for physical and/or occupational therapy.

  • Children with psychosomatic illness can benefit from being taught techniques such as deep-breathing, progressive muscle relaxation, meditation, and biofeedback. When co-morbid psychiatric illness--such as anxiety or depression-- has been identified, or in cases with significant impairment in functioning, pediatricians should refer patients for mental health treatment consisting of individual therapy (including cognitive-behavioral therapy), family therapy, and, where indicated, medications such as antidepressants and benzodiazepines. Group therapy may also provide some benefit.

  • Families (and in the case of hospitalized patients, healthcare providers) should institute behavioral interventions aimed at rewarding recovery and limiting benefits of being sick. Punishing impairment or lack of engagement in recovery tends to be a far less effective approach. An example of positive reinforcement would be planning a fun parent-child outing to celebrate a first full week back at school. An example of removing reinforcement of illness behaviors would be for parents to limit attention paid to physical symptoms and to not excuse children from normal activities, such as completing chores.

    Tying recovery to anticipated events can also be useful. For example, a parent could tell their child that they will know they are well enough to attend their friend's birthday party when they are well enough to go to school, complete their homework, and clean their room. When children are in the hospital, hospital staff should institute similar behavioral plans. Parental visitation, computer access, and trips to the game room can all be linked to participation in treatment and return to functioning. Again, the emphasis should be on rewarding steps towards recovery instead of punishing ongoing impairment or disengagement in treatment.

  • Pediatricians should also take an active role in promoting the return to a full level of functioning--especially when it comes to school participation. This includes encouraging immediate return to school and excusing absences only when the physician feels the child's symptoms require urgent medical evaluation or when objective data suggest that the child has a contagious illness.

    Pediatricians should take a proactive role in educating school personnel about the nature of the child's psychosomatic illness and the importance of helping the child remain in school despite their symptoms. Direct communication with school personnel--especially school nurses--can be quite useful. In cases where severe impairment is present, children may require a more gradual transition back to school, with scheduled visits to the nurse's office to check in and provide time to use relaxation, pain management, or anxiety management techniques.

  • In severe cases, referral to specialized inpatient or partial psychiatric hospital units may be indicated.

  • If families refuse to accept the diagnosis of a psychosomatic illness, they will likely continue to seek more testing and treatment and continue to support their child's ongoing impairment in functioning.

    If the family refuses to accept the diagnosis and/or mental health intervention, psychiatric consultants can still provide guidance to the medical team as to how to structure behavioral plans, respond to the patient's and family's behaviors or demands, and support clinicians in their efforts to provide safe and appropriate care.

    In severe cases, pediatricians should consider consulting their local hospital's child abuse pediatrician team, if available, and/or contacting child protective services to express their concern for medical child abuse.

What are the adverse effects associated with each treatment option?

What are the adverse effects associated with medication options for treatment of psychosomatic disorders?

  • There are no specific medciations to treat psychosomatic illness.

  • All patients with a suspected psychosomatic illness should be screened for anxiety and depression. If present, clinicians should initiate appropriate treatment, including referring the patient to counseling and considering initiation of medications.

What are the possible outcomes of somatoform disorders?

Untreated psychosomatic illness, including the formal somatoform disorders, can lead to significant impairment. School absenteeism, poor academic performance, anxiety and depression, and social isolation are all common sequelae. Patients may suffer direct and indirect complications from unnecessary medical evaluations and treatment.

Examples of direct damage include pain associated with invasive procedures, radiation from imaging studies, and side effects from medications used to treat symptoms such as pain or mistakenly-diagnosed medical conditions (e.g., side effects from anti-seizure medications in patients with non-epileptiform seizures).

Indirect damage from exhaustive medical evaluations or unnecessary treatments include reinforcement of the patient's and family's belief that there is an underlying medical cause to the patient's symptom; misused time, money, and energy spent on medical evaluations and treatment; and a delay in initiation of proven rehabilitative and psychological treatments.

With proper treatment, patients can return to full levels of functioning with no long-term sequelae.

What complications might you expect from the disease of treatment of the disease?

Rehabilitative and psychotherapeutic treatments for somatoform disorders or even the psychological factors that affect patients with general medical conditions can be time-intensive and difficult to obtain, although some patients respond quite rapidly. For those patients with significant impairment who require intensive psychiatric treatment on specialized day-treatment and inpatient units, significant engagement of both the patient and the family is required.

Are additional laboratory studies available; even some that are not widely available?

  • There are several psychometric instruments that can be used to support a diagnosis of psychosomatic illness. These include the Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A), the Children's Somatization Inventory, and the Functional Disability Inventory.

  • Hypnosis and drug-assisted interviews have been used to help diagnose and treat conversion disorders, but the data to support their use are limited and the results are mixed.

  • Methacholine challenges have been used to rule out reactive airway disease as a source of respiratory symptoms. However, methacholine challenges are not frequently used in children.

How can psychosomatic illness/somatoform disorders be prevented?

There is almost no research on the prevention of somatoform disorders. Interventions that reduce the prevalence of major risk factors for somatization--such as treatment of depression and anxiety or prevention of childhood sexual abuse-- could help prevent the development of somatization disorder. One study using cognitive behavioral therapy (CBT)-based psychoeducation in healthy adults in the primary care setting did not demonstrate a decrease in the development of somatoform disorders, although it did lead to a decline in overall psychiatric morbidity.

What is the evidence?

"American Academy of Pediatrics. The classification of child and adolescent mental diagnoses in primary care. Diagnostic and statistical manual for primary care (DSM-PC), child and adolescent version". American Academy of Pediatrics. 1996.

(A manual for pediatric practitioners that is based on the DSM-IV.)

"American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fourth edition, text revision". American Psychiatric Publishing. 2000.

(Official description of the diagnostic criteria and a review of the epidemiology of somatoform disorders.)

Roesler, TA, Jenny, C. "Medical child abuse: beyond Munchausen syndrome by proxy". American Academy of Pediatrics. 2008.

(Comprehensive textbook on the topic of medical child abuse.)

Shaw, RJ, Spratt, EG, Bernard, RS, DeMaso, DR, Shaw, RS, DeMaso, DR. "Textbook of pediatric psychosomatic medicine". American Psychiatric Publishing. 2010. pp. 121-40.

(A comprehensive review of the epidemiology, pathogenesis, diagnosis, and treatment of pediatric somatoform disorders.)

Silber, TJ. "Somatization disorders: diagnosis, treatment, and prognosis". Pediatr Rev. vol. 32. 2011. pp. 56-63.

(Review article.)

"American Psychiatric Association. DSM-5: The future of psychiatric diagnosis". http://www.dsm5.org..

(Online publication of proposal from the somatoform disorders working group for changes to diagnostic criteria and classification of disorders for the DSM-V.)

Ongoing controversies regarding etiology, diagnosis, treatment

There is disagreement over how somatoform disorders should be named and classified. Criticisms of the current classification system include that the distinctions between the diagnoses are often unclear, that etiological factors and treatment interventions are similar across the diagnoses, and that the requirement that symptoms be medically unexplained is both unreliable and promotes the unhelpful and outdated notion of mind-body dualism.

As a result, the group responsible for the somatoform disorder section of the DSM-V is proposing several significant changes. Under their current proposal, Somatization Disorder, Undifferentiated Somatoform Disorder, Hypochondriasis, Pain Disorder Associated with Psychological Factors, and Pain Disorder Associated with Psychological Factors and a General Medical Condition would all be subsumed under the newly-termed Simple Somatic Symptom Disorder and Complex Somatic Symptom Disorder. The presence of medically-unexplained symptoms would no longer be a diagnostic requirement. Instead, focus would be placed on the presence of somatic complaints that are either distressing or significantly disrupt functioning and that are associated with either the child's and/or a parent's disproportionate and persistent concerns about the medical seriousness of one's symptoms, a high level of health-related anxiety, or excessive time and/or energy devoted to health concerns

The group also proposes reclassifying Body Dysmorphic Disorder as an anxiety disorder, renaming Conversion Disorder as Functional Neurological Symptoms, and introducing new diagnoses of Illness Anxiety Disorder and Acute Somatic Symptom Disorder. The diagnosis of psychological factors affecting a general medical condition would be maintained.

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