Residency · Residency · Child Adolescent Psychiatry

Somatic Symptom and Related Disorders in Children

Introduction

Somatic symptom and related disorders in children involve distressing physical symptoms accompanied by excessive thoughts, feelings, or behaviors related to those symptoms. The DSM-5 shifted the diagnostic emphasis from the absence of medical explanation to the presence of maladaptive responses to somatic symptoms. These disorders are common in pediatric settings and frequently result in extensive medical workups, school avoidance, and significant functional impairment.

Epidemiology

Functional somatic symptoms are reported in 10-30% of children and adolescents. Conversion disorder, also known as functional neurological symptom disorder, has an estimated prevalence of 2-5 per 100,000 children. There is a higher prevalence in females at a ratio of 2:1, particularly after puberty. Peak onset occurs in adolescence, though functional abdominal pain is common in younger children. These disorders are associated with higher healthcare utilization and costs.

DSM-5 Diagnostic Categories

Somatic Symptom Disorder

Somatic symptom disorder requires one or more somatic symptoms causing distress or functional impairment along with excessive thoughts, feelings, or behaviors related to those symptoms. These may manifest as disproportionate anxiety about health, excessive time and energy devoted to symptoms, or a high level of health-related anxiety. Importantly, the symptoms may or may not have a medical explanation.

Conversion Disorder (Functional Neurological Symptom Disorder)

Conversion disorder involves symptoms affecting voluntary motor or sensory function that are incompatible with recognized neurological conditions. Common presentations include non-epileptic seizures, gait disturbance, weakness, sensory loss, and movement disorders. Positive clinical signs, such as the Hoover sign and tremor entrainment, support the diagnosis.

DSM-5 Somatic Symptom and Related Disorders Summary

Illness Anxiety Disorder

Illness anxiety disorder involves preoccupation with having or acquiring a serious illness with mild or absent somatic symptoms. It is less common in children than in adults.

Factitious Disorder (Imposed on Self or Another)

Factitious disorder involves falsification of symptoms or induction of injury or disease. Factitious disorder imposed on another, formerly known as Munchausen syndrome by proxy, is a form of child abuse in which a caregiver fabricates or induces illness in a child.

Etiology and Risk Factors

Biological Factors

Central sensitization, which involves amplification of pain and sensory signals in the central nervous system, plays an important role. Alterations in the hypothalamic-pituitary-adrenal axis contribute to symptom generation. Genetic predisposition to somatization exists, and prior medical illness or injury may serve as a precipitant.

Psychological Factors

Alexithymia, the difficulty in identifying and expressing emotions, is a common feature. Anxiety and depressive disorders are comorbid in 50-75% of cases. History of trauma or adverse childhood experiences, perfectionism, high achievement orientation, and learning difficulties with school-related stress all increase vulnerability.

Social and Family Factors

Parental modeling of illness behavior, family stress, conflict, or secondary gain dynamics, excessive parental attention to somatic complaints, and cultural factors shaping the expression of distress all contribute to symptom development and maintenance.

Common Presentations in Children

The most common presentations include functional abdominal pain, which is most frequent in school-age children; headache, with tension-type and migraine overlapping with functional headache; functional neurological symptoms including seizure-like episodes, limb weakness, and gait abnormalities; chronic fatigue, which overlaps with chronic fatigue syndrome; and functional limb pain, which is often migratory and inconsistent with anatomical patterns.

Assessment

Clinical Approach

A thorough but targeted medical evaluation should be conducted, avoiding excessive testing that reinforces illness behavior. Positive diagnostic criteria should be used rather than relying solely on exclusion of medical disease. Assessment for comorbid anxiety, depression, and trauma is essential. Functional impairment across school attendance, peer relationships, and activities should be evaluated. Family stressors and dynamics around the symptoms should be screened.

Key Principles

Clinicians should never tell the child or family that symptoms are "all in your head," as the symptoms are real and distressing. Reframing the explanation in terms such as "your brain and body are miscommunicating" or "your nervous system alarm is too sensitive" helps families understand the condition without feeling dismissed. The dualistic separation of "medical" versus "psychiatric" illness should be avoided.

Treatment

Psychoeducation

Explaining the biopsychosocial model of symptom generation, normalizing the mind-body connection, and setting expectations for gradual functional improvement rather than symptom elimination form the foundation of treatment.

Cognitive-Behavioral Therapy

CBT is the most evidence-based psychotherapy for pediatric somatic symptom and related disorders. It targets catastrophic cognitions, avoidance behaviors, and excessive symptom monitoring. Components include graded exposure to avoided activities such as school and physical activity, along with relaxation training and biofeedback.

Physical Rehabilitation

Graded exercise and physical therapy address motor symptoms and deconditioning. Occupational therapy supports functional impairment in daily living skills. Physiotherapy-led rehabilitation programs are effective for functional neurological disorder.

Pharmacotherapy

Comorbid anxiety and depression should be treated with SSRIs. Low-dose amitriptyline has an evidence base for functional abdominal pain. Opioids and benzodiazepines should be avoided. Medication should support, not replace, psychotherapeutic and rehabilitative interventions.

Family Intervention

Reducing reinforcement of sick-role behaviors, promoting normal activity and school attendance, and addressing family conflict and parental anxiety about the child's health are key components of family-level intervention.

Clinical Pearls

Functional somatic symptoms are diagnoses to be made, not diagnoses of exclusion; positive clinical signs and criteria should be used. Excessive medical testing can iatrogenically reinforce illness behavior and should be limited to clinically indicated investigations. Comorbid anxiety and depression are the rule, not the exception, and should always be screened for and treated. Multidisciplinary care involving psychiatry, pediatrics, psychology, and rehabilitation produces the best outcomes.

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Arlington, VA: APA; 2013.
2. Garralda ME. "Unexplained Physical Complaints." Pediatric Clinics of North America. 2011;58(4):803-813.
3. Kozlowska K, et al. "Functional Neurological Disorder in Children and Adolescents." Handbook of Clinical Neurology. 2016;139:309-326.
4. Campo JV. "Annual Research Review: Functional Somatic Symptoms and Associated Anxiety and Depression." JCPP. 2012;53(5):575-592.

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