Overview

The somatoform disorders are a group of psychological disorders in which a patient experiences physical
symptoms that are inconsistent with or cannot be fully explained by any underlying general medical or
neurologic condition. Medically unexplained physical symptoms account for as many as 50% of new
medical outpatient visits.[1] Physical symptoms or painful complaints of unknown etiology are fairly common
in pediatric populations.[2] Many healthy young children express emotional distress in terms of physical pain,
such as stomachaches or headaches, but these complaints are usually transient and do not effect the
child's overall functioning. The somatoform disorders represent the severe end of a continuum of somatic
symptoms.
Somatization in children consists of the persistent experience and complaints of somatic distress that
cannot be fully explained by a medical diagnosis. They can be represented by a wide spectrum of severity,
ranging from mild self-limited symptoms, such as stomachache and headache, to chronic disabling
symptoms, such as seizures and paralysis. These psychological disorders are often difficult to approach
and complex to understand. It is important to note that these symptoms are not intentionally produced or
under voluntary control.
In somatoform disorders, somatic symptoms become the focus of children and their families. They
generally interfere with school, home life, and peer relationships. These youngsters are more likely to be
considered sickly or health impaired by parents and caretakers, to be absent from school, and to perform
poorly in academics. Somatization is often associated temporarily with psychosocial stress and can persist
even after the acute stressor has resolved, resulting in the belief by the child and his or her family that the
correct medical diagnosis has not yet been found. Thus, patients and families may continue to seek
repeated medical treatment after being informed that no acute physical illness has been found and that the
symptoms cannot be fully explained by a general medical condition. When somatization occurs in the
context of a physical illness, it is identified by symptoms that go beyond the expected pathophysiology of
the physical illness.
Recurrent complaints often present as diagnostic and treatment dilemmas to the primary care practitioner
(PCP) who is trying to make sense of these symptoms. The PCP may feel poorly prepared and/or may
have little time to assess or treat the somatic concerns. While the more disabling somatic complaints are
more likely to be referred to a mental health professional, these youngsters presenting with these disabling
physical symptoms bridge both medical and psychological domains and present a puzzling quandary for
professionals from either field if working with them alone. [3] The nature of these symptoms requires an
integrated medical and psychiatric treatment approach to successfully decrease the impairment caused by
these disorders.[4]

Morbidity
The morbidity associated with unexplained pediatric somatic complaints can be significant. Patients with
these disorders typically present to general medical settings rather than to mental health settings. [1] Patients
with such symptoms can place significant burden on the healthcare delivery system, with heavy utilization
of resources through repeated hospitalizations, consultations from different specialists, and ineffective
investigations and treatments.[5] Somatoform disorders are associated with poor school performance and
attendance and overall impaired functioning. [6] Appropriate and timely diagnosis combined with collaborative
psychiatric and medical interventions may decrease significant long-term morbidity and suffering.

Clinical
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)[7] classifies somatoform
disorders in the following diagnoses: somatization disorder, undifferentiated somatoform disorder,
somatoform disorder not otherwise specified (NOS), conversion disorder, pain disorder, body dysmorphic
disorder, andhypochondriasis. These disorders all involve clinically significant distress or impairment in
daily functioning.
The diagnostic criteria for these somatoform disorders are established for adults, but not many published
case studies and research have focused on pediatric populations.
It must be noted that DSM-IV is currently under revision with a proposal to rename the classification to
somatic symptom disorders and complex somatic symptom disorders. [8] As DSM-V is yet to be finalized, this
article reviews the DSM-IV criteria for each somatoform disorder and outlines available and pertinent
pediatric literature. Clinical vignettes are included to illustrate each disorder, and the reader is referred to
comprehensive Medscape Reference articles for further reading. The conclusion of the article includes
suggested methods to approach assessment and treatment.

Somatization Disorder
Somatization disorder
The essential feature of a somatization disorder is a pattern of many physical complaints in persons
younger than 30 years that occurs over several years and results in unnecessary medical treatment and/or
causes significant impairment in functioning. This diagnosis was historically referred to as hysteria or
Briquet syndrome.[9] The somatic symptoms are neither intentionally produced nor feigned and appear to be
unconscious to the patient. All the following historical criteria are required for a diagnosis [7] :

Four different pain sites (eg, head, abdomen, back, joints, extremities, chest, rectum) or painful
functions (eg, menstruation, sexual intercourse, urination)

Two gastrointestinal symptoms other than pain (eg, nausea, bloating, vomiting, or intolerance of
several different foods)

One sexual or reproductive symptom other than pain (eg, erectile or ejaculatory dysfunction,
irregular menses, excessive menstrual bleeding)

One pseudoneurological symptom (eg, impaired balance, paralysis, aphonia, urinary retention)
After appropriate investigation, a known general medical condition or direct effects of a substance cannot
explain the multiple symptoms. When a related medical condition is present, the physical complaints are in
excess of what would be expected. The criteria for somatization disorder were designed for adults, and
attempts have been made to apply criteria to pediatric populations since adolescents can present to
primary care facilities with many of these symptoms. Nevertheless, this diagnosis is rarely made in the
adolescent population, mainly because of the time requirement of several years that is needed to meet the
symptom criteria.
Somatization disorder case example
Susan was a 15-year-old girl with a 2-year history of body aches, fatigue, fevers (reported but not
documented), headaches, diarrhea, nausea, joint pain, dysuria, and irregular menses. Her mother stated
that she had chronic fatigue syndrome(CFS). During multiple medical clinic visits, Susan repeatedly had
normal findings on physical and extensive laboratory examinations. The patient repeatedly denied
stressors, psychological trauma, and/or victimization despite assessments by an adolescent medical
specialist and a psychiatrist.
While being evaluated by neurology department personnel for her headaches, Susan became completely
mute. Following a negative medical workup, she was admitted to a psychiatry inpatient unit, where she
began talking upon arrival. During this admission, she disclosed that her stepbrother had been sexually
abusing her and her mother's boyfriend had physically abused her for several years. Gambling and
domestic violence in the home were also identified. Susan was placed in foster care, resulting in some
decrease in her somatic complaints. Susan subsequently recanted her previous allegations of physical and
sexual abuse to child protective services. Despite family court involvement, she was allowed to return
home and was lost to follow-up.
Susan met criteria with 2 years of complaints of recurrent aches and pains, pain with urination, nausea, and
constipation. CFS was in the differential diagnosis. It was felt that her somatic complaints were a reflection
of her distress from secretly living with incest, physical abuse, and domestic violence. It was necessary to
build rapport and remove her from her family before she could begin to share her family secrets.
Undifferentiated somatoform disorder and somatoform disorder not otherwise specified
Children and adolescents are more likely to meet DSM-IV criteria for an undifferentiated somatoform
disorder or somatoform disorder NOS than for a somatization disorder.[9] The criteria for undifferentiated
disorder require only one or more unexplained physical complaints, functional impairment, and duration of
6 months. Symptoms of less than 6 months duration are coded in DSM-IV for a NOS disorder.[7] Again, the
difference may be in the developmental course of somatoform disorders and possible differences in illness
severity and expression of sexual symptoms in childhood. No evidence exists to predict which patients will
go on to develop the full symptom criteria for somatization disorder, although one might expect that
comorbid psychopathology (ie, depressive and/or personality disorders), chronic family distress, or refusal
of the patient and family to accept and work on psychological factors might be important predictors.
Undifferentiated somatoform disorder case example
Ben was a 13-year-old "worrier" with a history of 2 years of successful psychopharmacologic management
for anxiety. At the start of school, his parents separated after an increase in parental conflict. In this context,
Ben developed recurring headaches and stomachaches of unknown etiology that resulted in almost daily

visits to the school nurse. He increasingly became more anxious about school, his somatic symptoms
intensified, and his school performance declined. The complaints continued until he began to miss school.
He responded well to supportive psychotherapy and cognitive-behavioral techniques to decrease anxiety
that began 8 months after his somatic symptom development. Ben was able to recognize the association
between his worry about his parents' separation and worsening stomachaches and headaches. This led to
a significant reduction in somatic complaints and a subsequent improvement in his functioning.
Ben did not meet full symptom criteria for a somatization disorder, but he did meetDSM-IV criteria for an
undifferentiated somatoform disorder. If the symptom duration had been less than 6 months, a diagnosis of
somatoform disorder NOS would be considered.

Conversion disorder
This DSM-IV disorder involves unexplained symptoms or deficits affecting voluntary motor or sensory
function that suggest a neurological or other general medical condition. [7] Psychological factors are judged
to be temporally associated with the symptoms or deficits because conflicts or other stressors precede their
initiation or exacerbation. Symptom models and comorbid individual/family psychopathology are also
helpful in making the diagnosis.[4]
The symptom or deficit is not intentionally produced or feigned. Four different types of symptoms or deficits
are described: (1) motor, (2) sensory, (3) seizures, and (4) mixed presentations.
This disorder is 3 times more common in adolescents than children and rarely occurs in children younger
than 5 years.[10] Females predominate among adolescents with conversion disorders. Recent family stress,
unresolved grief reactions, and family psychopathology occur at a higher frequency in conversion
symptoms.[11] Adjustment difficulties to changes in the family situation (eg, birth of a sibling or parental
divorce) are commonly associated with the development of conversion disorders. [12]
Anxious families preoccupied with disease, chaotic families, and overbearing and conflict-prone parenting
styles have all been associated with conversion disorder.[13]The onset of symptoms can be precipitated by
stressful family events, including divorce and death of a loved one. [14] Some evidence suggests that when
the diagnosis of conversion disorder is made early and with certainty, the parental acceptance and
recovery is easier and less expensive.[15] A strong positive correlation exists between duration of conversion
symptoms and the necessary treatment time to resolve them.[16]
The major diagnostic concern is to exclude occult neurological or other general medical conditions or
substance (including medication)induced etiologies. Neuroimaging such as head MRI or CT scanning is
helpful for the evaluation of symptoms of sensory and motor loss. Video-EEG monitoring is the criterion
standard for diagnosing nonepileptic seizures and helps parents comprehend the emotional, nonelectrical
nature of these events as the seizures occur in the absence of electrical activity.[17]
The diagnosis of conversion disorder is, however, not one of exclusion. The presence of biopsychosocial
risk factors described above should be elicited as positive symptoms. If the consultant is unable to elicit any
of the diagnostic criteria except for the motor or sensory symptoms, then the possibility of an underlying
general medical condition should be reconsidered. The physician must also be alert to the dual existence of
a physical condition and a conversion disorder (eg, epileptic and nonepileptic seizures) in the same patient.
[4]

Conversion disorder case example

Julia was a 15-year-old pregnant Hispanic girl who presented in the emergency department with her right
elbow held in a flexion position and her left toe pointed downward in plantar extension. When asked about
her symptoms, she stated with little affect that, "I'll get used to it." Her presentation could not be explained
by any known medical condition and was subsequently diagnosed as a conversion disorder. She
subsequently reported that her boyfriend, who was the father of the baby, had recently started seeing
another girl. Julia noted that she was so angry with her ex-boyfriend that she wanted to hit and kick him,
yet, with her current symptoms, she could not do so.

Pain disorder
A pain disorder is diagnosed instead of a conversion disorder if the predominant physical symptom and
focus of clinical attention is pain. The DSM-IV divides pain disorders into those associated with
psychological factors, those with both psychological and medical factors, and those in which the medical
condition is the major factor in the pain symptom.[7]

Recurrent abdominal pain (RAP) is the most common recurrent pain complaint of childhood. RAP has been
defined by intermittent pain with full recovery between episodes lasting more than 3 months.
[8]
Epidemiological studies suggest that RAP effects 8-25% of school-age children aged 9-12 years, is more
prevalent among girls, and accounts for 2-4% of pediatric office visits. [18] An estimated 10% of these patients
have documented physical illness, with one third of these being urinary abnormalities. Approximately 90%
of pediatric patients with normal physical examination findings, along with normal complete blood cell
counts, urine analyses findings, and erythrocyte sedimentation rates, do not have a general medical illness
to account for their abdominal pain.
There is a strong relation between RAP and anxiety in children. The lifetime prevalence of anxiety disorders
in children with RAP is substantially higher than would be expected in the general population. Studies show
that parents dealing with RAP rated their children significantly higher than healthy children on measures of
anxiety, affective problems, and somatic symptoms.[18]
Reflex sympathetic dystrophy (RSD) has been referred to as a complex regional pain syndrome in which
pain spreads beyond the area of injury along a dermatomal pattern to a regional one. [19] While more
common in adults, in childhood it can be quite problematic and disabling. RSD is characterized by pain,
autonomic dysfunction, edema, movement problems, and atrophy, depending on severity. It typically
presents with chronic painful swelling in a previously injured extremity, along with decreased skin
temperature, cyanosis, delayed capillary refill, and limitation in functioning. [5]
In one study of 70 patients younger than 18 years, RSD was almost 6 times more common in girls than in
boys, and the lower extremity was most often involved.[20]Anxiety and depression are frequent
accompanying problems following the development of RSD. In a recent study of RSD children in an
inpatient rehabilitation setting, 38% of patients exhibited at-risk/elevated mood symptoms (anxiety or
depression) based on self-report or parent report.[19]
Pain disorder case example
Sheila was a 9-year-old girl evaluated for possible rheumatoid arthritis. She woke up with pain in one knee,
which caused her to limp through her day at school. Findings from her medical workup were negative, and
the pain shifted to her other leg. Social history revealed that her maternal grandfather, who had a limp
caused by an old hip injury, had died 3 weeks before the onset of symptoms. Sheila was close to him and
felt guilty for not playing checkers with him during their last visit. The pain waxed and waned but persisted
for 10 days. The pain gradually decreased and resolved with supportive medical evaluation and family
attention.

Body dysmorphic disorder

Body dysmorphic disorder (BDD) is defined as the preoccupation with an imagined defect in appearance or
excessive concern over a slight physical anomaly.[7] The distressing preoccupation may involve any part of
the body; however, it most often involves imagined or slight flaws of the face or head such as acne, scars,
thinning hair, facial asymmetry, or excessive facial hair.[4] There has been little written about this disorder in
the child and adolescent literature because most patients are secretive about their symptoms and are
reluctant to seek psychiatric treatment. The onset often occurs during adolescence, with the male-to-female
ratio being almost equal, unlike many other somatoform disorders.[4] Many of these patients have had
consultations with surgeons and dermatologists and often seek cosmetic surgery but are poor candidates
because they are unlikely to be satisfied with the results.[21]
A high proportion of individuals with BDD report a history of childhood maltreatment, including physical,
sexual, and emotional abuse and physical neglect.[22] Comorbid psychiatric disorders include but are not
limited to depression,obsessive-compulsive disorder (OCD), social phobia, delusional disorder, anorexia
nervosa, gender identity disorder, and narcissistic personality disorder. BDD is also associated with high
rates of suicidal ideation and attempts, with 24-28% having attempted suicide. [10, 23]
BDD case example
Sylvia was an attractive college student who complained of her face being slightly asymmetrical. She felt
this was the first thing noticed about her; yet, it was an almost imperceptible feature. She went to a
craniofacial surgeon to try to have this corrected. In his opinion, she was not disfigured, so he sent her to a
mental health specialist for evaluation.

Hypochondriasis
This DSM-IV disorder is defined as a preoccupation with fears of having or the idea that one has a serious
disease based on misinterpretation of bodily symptoms. [7]This preoccupation persists despite appropriate

medical evaluation and reassurance. Hypochondriasis is distinguished by a set of beliefs and attitudes
about illness. There is poor supporting literature for hypochondriasis as a childhood disorder, and it is more
commonly seen in late adolescence and adulthood.[24]
Patients with hypochondriasis have been found to have high correlations with depression, anxiety, and
somatic symptoms, and patients often have higher rates of personality disorders and amplified perceptual
style. Comorbid OCD is common, with an 8% lifetime prevalence of OCD in those with hypochondriasis
(compared to 2% in the general population).[10] In hypochondriasis, the strong disease conviction acts as the
over-evaluated ideal that is characteristic of OCD.[25] Individuals with this disorder are frequent users of
medical services but often report dissatisfaction with the care they receive.
Hypochondriasis case example
Jennifer was a mildly anxious and depressed 17-year-old girl who feared the possibility of having cancer.
She became convinced she had cancer when her breast development was asymmetrical. She felt her hair
was falling out, and, in her mind, this further confirmed her diagnosis. She was seen by her pediatrician,
who reassured her that her symptoms were normal and provided her with information about her normal
physical examination findings. Antidepressants improved her symptoms of depression and anxiety, and
somatic complaints decreased with a combination of reassurance and psychopharmacologic intervention.

Factitious Disorders and Malingering

The somatoform disorders should not be confused with disorders in which patients are intentionally
simulating or creating their problems. These are factitious disorders and malingering. In these latter
disorders, false information regarding physical symptoms is given intentionally, whereas, in somatoform
disorders, intentional deception does not occur.

Factitious disorders
In factitious disorders, the simulated somatic complaints are done consciously but for unconscious reasons
(ie, to assume a sick role to obtain the caring that comes with medical treatment). In contrast, malingering
symptoms are produced in the context of readily apparent external incentives for the behavior (ie,
economic gain, avoidance of legal responsibility, or avoidance of other difficult situations). No specific
targeted material or external gain exists in factitious disorder. Malingerers, on the other hand, have a very
specific goal in mind as an outcome of the feigned symptoms.
In a review of 41 adults with factitious illness, most patients improved when confronted with their behavior,
although less than one third acknowledged the factitious nature of their symptoms. Most of the patients in
this study were immature, passive, and hypochondriacal. Factitious disorder has been associated with
borderline personality traits and substance abuse disorders.
Factitious disorder case example
A 17-year-old girl named Sarah complained to her doctor of chronic intermittent diarrhea. Her family
confirmed her symptoms. A test for phenolphthalein (an ingredient that used to be common in laxatives)
was positive, suggesting that Sarah was inducing her symptoms. During the course of therapy, Sarah
subsequently acknowledged that she enjoyed the attention she received while in the sick role.
Factitious disorder by proxy
Factitious disorder by proxy (FDP) is synonymous with Munchhausen syndrome by proxy and is not a
somatoform disorder. It is a form of child abuse in which a parent (usually the mother) fabricates or
produces illness in a child and/or creates physical signs that persistently result in unnecessary medical
treatment.[26] While FDP is not recognized as a separate diagnostic category, the DSM-IV Text Revisiondoes
outline the following research criteria: (1) FDP is the intentional production or feigning of physical or
psychological signs or symptoms in another person who is under the individuals care, (2) the motivation for
the perpetrators behavior is to assume the sick role by proxy, and (3) external incentives for the behavior
(eg, economic gain) are absent.[7]
The American Professional Society on the Abuse of Children has recommended that the child who is the
victim of this abuse is diagnosed with pediatric condition falsification (PCF) and that the psychiatric
diagnosis of FDP be reserved for the caretaker who causes the abuse. [27]
The following differential diagnoses are considered when one is dealing with this syndrome in which
medical illness is falsified:

Neglect and failure to thrive

Direct physical abuse injury
Delusional parenting
Anxious parents and vulnerable child
Chronically ill child
Help-seeking parents
Factitious disorder by proxy
Some healthcare professionals are not aware of this possible diagnosis [28] ; for others, it does not readily
come to mind when treating relevant patients. It is a diagnosis most commonly identified in young children,
but often after several months or years of unexplained and unseen illnesses and unnecessary procedures
and tests.
FDP case example
A 9-month-old infant named Samuel was admitted almost monthly to the children's hospital with complaints
of bloody diarrhea. This was never witnessed until the mother brought a diaper to the clinic and it contained
a bloody red streak with a small amount of guaiac-negative stool in the middle of it. Examination of the
blood revealed that it was mother's type, and it was thought to be menstrual blood. The mother left the
hospital against medical advice, stating that she needed a better medical opinion. It was discovered that
the child was admitted to another hospital, and a report was made to Child Protective Services.

Malingering
In malingering, the patient has intentional and obvious goals, such as financial compensation or avoidance
of duty or school, evasion of criminal prosecution, or obtaining of drugs. Such goals may resemble
secondary gain in conversion symptoms, but with the distinguishing feature being the conscious intent in
the production of the symptoms. Compared with malingering, factitious illness by proxy has unconscious
and unclear goals.

Is It Medical or Psychiatric?
Comorbid psychiatric conditions
Anxiety disorders (eg, separation anxiety, posttraumatic stress disorders) can present with somatic
complaints (eg, headaches, stomachaches, nausea, vomiting). [3] Thus, it is critical to consider comorbid
psychiatric illnesses (eg, anxiety, depression) in any pediatric patient presenting with medically unexplained
symptoms.
Depression is a common comorbid condition with somatoform disorders. [10]Somatic complaints appear to be
twice as common in children and adolescents who meet DSM-IV criteria for depression than in control
subjects,[29] with the somatic symptoms arising as long as 4 years after the onset of the depression. [30]
Psychological factors affecting medical conditions
The DSM-IV contains a nonmental disorder classification termed psychological factors affecting medical
conditions. The essential feature is the presence of one or more specific psychological or behavioral factors
that adversely affect a general medical condition. The following psychological factors that can impact a
diagnosable general medical condition are noted as criteria: mental disorder, personality traits, coping style,
maladaptive health behaviors, and/or stress-related physiological responses. This classification differs from
the somatoform disorders, in which no medical conditions exist to completely account for the symptoms
produced.

Neurological and medical conditions

The presence of neurological or general medical conditions is the major diagnostic concern. Somatoform
disorders can imitate many neurologic conditions. Migraine syndromes, temporal lobe epilepsy, and CNS
tumors have presented difficult diagnostic dilemmas. [4] The dual existence of a medical condition and a
somatoform disorder (eg, seizures and pseudoseizures) can occur in up to 50% of patients and is another
consideration that must be addressed during treatment. [31]The list of systemic medical disorders that could
present with unexplained physical symptoms is large and may include multiple sclerosis, myasthenia
gravis, periodic paralysis, endocrine disorders, chronic systemic infections, acute intermittent
porphyria, polymyositis, fibromyalgia, and other myopathies.[4]
Chronic fatigue syndrome has been considered to be a possible somatoform disorder.[1] In adolescents,
chronic fatigue syndrome often has an extensive disease course that may lead to considerable school

absence and long-term consequences for educational and social development. [32] The criteria to diagnose
chronic fatigue syndrome involve the occurrence of severe mental and physical exhaustion that cannot be
attributed to exertion or diagnosed disease.[33] A viral etiology has been theorized. Presently, chronic fatigue
syndrome is viewed as a legitimate physical illness, overlapping with many psychiatric and medical
diagnoses.[34]
Neurologic condition case study
Cynthia was a 3-year-old girl who had a strong family history of schizophrenia and was admitted to a
children's hospital because she was complaining of seeing bugs and feeling as if bugs were crawling on
her. The symptoms resolved, and it was thought that this might have been a somatic attention-seeking
symptom reflective of the distress associated with being in a new home. The symptoms recurred, but they
were associated with a distant stare to the right. An EEG revealed complex partial seizures, and she was
treated with antiseizure medications with no recurrence of somatic or visual symptoms.
Systemic medical disorder case study
Mary was a tall, thin African American girl in the seventh grade. She had multiple somatic complaints and
was seen in a pediatric walk-in clinic. She gave intense and almost fearful eye contact, stating, "I'm hot,"
and then she hesitated stating, "I'm weak," and almost collapsed to the floor. She had just started at a new
school; she gave a history of having few friends and wishing it was still summer vacation. Her history also
included an upper respiratory tract infection 2 weeks before this visit.
The chief resident told the medical student he thought she was a "crock" because she was unattractive and
school had just started, but he thought that she probably should be admitted and observed. By the evening,
Mary clearly had muscle weakness. Her CBC count showed an elevated white blood cell count. She
developed increasing respiratory distress overnight, requiring intubation. Her medical course was
consistent with Guillain-Barr syndrome.

Factors Contributing to the Development of Somatoform Disorders

Developmental considerations
Somatoform disorders follow a developmental sequence as youngsters experience affective distress in the
form of somatic sensations. In early childhood, these symptoms are recurrent abdominal pain and,
somewhat later, headaches. As age increases, neurologic symptoms, insomnia, and fatigue tend to
emerge.[6] Difficulty expressing emotional distress verbally is widely thought to underlie the presentation of
physical symptoms that cannot be explained in medical terms. [35] The increased reporting of somatic
symptoms in younger children may be due to an inability to verbalize emotional distress. Many prepubertal
children may experience psychological distress as somatization symptoms. Prior to puberty, the male-tofemale ratio of somatic symptoms is nearly equal. However, adolescent girls tend to report nearly twice as
many functional somatic symptoms than adolescent boys. [36]

Personality characteristics
Stuart and Noyes[37] have hypothesized that somatizing behavior is best understood as a unique form of
interpersonal behavior driven by an anxious and maladaptive attachment style. They believe that
somatizing behavior is fostered by real or perceived rejecting responses from significant others. Patients
who somatize attempt to elicit care by using persistent complaints of pain or physical illness. Unfortunately,
the self-defeating nature of this behavior ultimately leads to rejection by others and further fuels the
patient's somatic complaints.
Poor coping styles and reinforcement-seeking behavior may also place an individual at risk for developing
a somatoform disorder. Youth with more complaints of pain and physical symptoms not only report being
angry more often,[38, 39] but also use less-effective strategies to cope with their anger.[40] Higher levels of anger
mood, rumination, and support-seeking coping styles have shown to predict somatic complaints. [41]
Disengagement, avoidance, and internalizing coping strategies are endorsed more often in children with
frequent somatic symptoms.[18] Krishnakumar and colleagues believe that having more negative affect,
being more sensitive to change in the environment, and not persisting in the completion of tasks elevates
the risk of developing a conversion disorder in childhood. [42] In addition to using ineffective coping strategies,
children with recurrent somatic symptoms tend to focus more intently on bodily sensations and have
heightened emotional responses to stress.[18]

Genetic contributions to the development of somatoform disorders

Some evidence indicates that physical symptoms have an inheritable component. Somatization disorder
occurs in as many as 10-20% of first-degree relatives and has a higher concordance rate in monozygotic
twin studies.[4] In families with somatizing children, functional abdominal pain, anxiety, depression, and other
somatic symptoms are common[43] ; mothers of these youth tend to have a history of irritable bowel
syndrome, chronic fatigue, and somatoform disorder.[44]

Family environment
Antecedents of somatization may include cohabitation with a family member with physical illness (referred
to as a symptom model), cultural beliefs, parental over protection, high-achieving families with familial
pressure on the child, a history of family secrets, and family stressors such as parental divorce or child
maltreatment.[3] Patients with medically unexplained symptoms appear to come from families with a high
rate of physical illness during the individual's childhood.[45]
Some evidence suggests that medically unexplained symptoms are related to prior experience of illness in
the family and previous unexplained symptoms in the individual. This may reflect a learned process
whereby illness experiences lead to symptom monitoring. It has been hypothesized that adverse childhood
experiences (eg, loss of parents) may contribute to more tender points in fibromyalgia. [46]

Trauma
Adolescents with histories of physical and sexual abuse score higher on measures of somatization than
adolescents without histories of abuse . Severity of abuse and number of traumatic events experienced
correlate with the number of somatoform symptoms reported.[47, 48] Emotional abuse may be the primary
maltreatment that leads to somatization. High levels of rejection or hostility in fathers (not mothers) have
been found to be more strongly associated with somatization than abuse. [49]
Many families react to trauma by denying its impact and avoiding future discussion and follow-up care. This
unconscious avoidance sets the stage for the conflict to be expressed as physical symptoms. Associations
between childhood trauma and somatic symptoms must be made with care. Although clinicians need to
inquire about abuse experiences in patients with multiple medical and psychiatric symptoms, it is important
to remember that symptoms often occur with other risk factors described above, without any history of
trauma.

School environment
School stressors have been demonstrated as one of the most common environmental factors for the
development and maintenance of somatic disorders. [12] Difficulties with academic and social competence at
school are associated with increases in somatic symptoms in youngsters, especially for those who come
from high-achieving families.[3]

Screening
A thorough psychiatric interview is key to diagnosing these disorders. [50] Some rating scales for children
have been developed to aid in the assessment of physical symptom clusters and somatization. The
Childrens Somatization Inventory (CSI)[51] is a 35-item self-report scale with child and parent versions. This
screen provides information about pediatric somatic symptoms over the 2 weeks prior to assessment [52] and
may be used in children as young as 7 years. The Functional Disability Inventory (FDI) can be used along
with the CSI to assess severity of symptoms. The FDI correlates with both school absences and somatic
symptom reports.[52] Illness Attitude Scales and Soma Assessment Interview (SAI) are parental interview
questionnaires.[53]

Treatment
An integrated medical and psychiatric approach is strongly recommended. [9, 43] The goals are to improve
overall functioning, to identify concurrent psychiatric disorders, to rule out concurrent physical disorders,
and to minimize doctor shopping and unnecessary invasive tests. It is important for the family to directly
hear from their pediatric practitioner that the symptoms are not solely due to a physical condition, thereby
facilitating acceptance of the role of psychiatric factors in their childs symptomatology.[43] Given that somatic
complaints generally present initially in the medical setting,[1] the process of referral from a pediatric
practitioner to a mental health clinician must be handled carefully. This can be accomplished by presenting
mental health consultation as part of a comprehensive evaluation, thereby minimizing stigma and distrust,
while emphasizing coping and support.[54]
Pediatric practitioners must recognize that most families with children who have somatoform disorder
initially believe in the presence of a currently undiagnosed physical disorder as the underlying problem.

Also helpful is for them to be aware of their own reactions to these patients, as they may find themselves
feeling frustrated by the time consumed for their care and/or perceiving these youngsters as not really
being sick.[24] In this context, patients feel offended if the practitioner infers that their physical symptoms are
"just in their head." This approach can lead to resistance on the part of patients and their families in
considering a psychological etiology for their symptoms.
[9]

Important to recognize is that patients with somatoform disorders truly do suffer from their symptoms and
are not just putting them on. It is most helpful for the practitioner to convey an attitude that demonstrates
empathic understanding of the patients distress. Characteristics of approaches reported to have good
outcome include an attitude of belief in the childs symptoms, moving the family towards a psychological
understanding, and instituting a multidisciplinary rehabilitative approach. [35]
Cognitive-behavioral techniques and family therapeutic interventions are recommended treatments to
address underlying stressors, to provide active coping strategies, to improve overall functioning, and to
reduce levels of relapse.[3, 43]Contingent reinforcement of coping behavior is helpful to reduce secondary
gain associated with the sick role and to increase compliance with the prescribed regimen. Antidepressants
should be considered when comorbid mood or anxiety disorders are present. Frequently, multiple causal
attributions coexist and contribute to a presentation associated with co-occurring depression and illness
behavior.[55]
Some children have such severe disabling functional impairment that these symptoms lead to excessive
expenditure of healthcare dollars and services. For patients in the severe group with profound functional
impairment, more intensive psychiatric treatment is indicated. [1] A decrease in medical service use and an
appropriate increase in exposure to psychiatric interventions can be achieved with an admission to an
inpatient medical-psychiatric unit or some physical rehabilitative settings. [56]
When the child is being treated in an outpatient setting, a collaborative follow-up plan with a focus on
rehabilitation generally works best. Many patients feel abandoned by their primary care practitioner if
planned follow-up care is only with a mental health clinician. Regularly scheduled visits to the practitioner
may help alleviate anxiety and potentially reduce the frequency of unnecessary emergency department
visits, diagnostic workups, and inpatient hospitalizations.[43] Many patients miss school because of their
symptoms. It is therefore also important to establish regular contact with key school personnel to provide
guidance and education on how to address the childs physical symptoms and complaints in school. Even if
it may not be possible to "cure" the somatization symptoms, improving overall functioning is an achievable
goal.
Sound empirical research on treatment of somatization disorders is relatively lacking, and the existing
literature exhibits a number of methodological problems, including small sample size, lack of standardized
measurement, and heterogeneous samples. Further research is needed regarding treatment for children
with a somatoform disorder and their families.

Recommendations
Recommendations for assessment and treatment of pediatric somatoform disorders in primary
care settings
The following recommendations are adapted from Calabrese (1998), [57] Campo and Negrini (2000),[58] Campo
and Fritz (2001),[51] Taylor and Garralda (2003),[59]DeMaso and Beasley (2005),[9] Shaw and DeMaso (2006),
[4]
Shaw et al (2010),[10]and Ibeziako et al (2011)[43] :

In all somatoform disorders, the biological, psychiatric, and social dimensions need to be
evaluated both separately and in relation to each other. Given the common diagnostic uncertainty in
these disorders with frequent dual medical/psychiatric diagnoses, a combined treatment program is
strongly recommended. An integrated and simultaneous medical and psychiatric approach sidesteps the
organic versus psychiatric dilemma faced in these patients. It is essential that the medical and
psychologic investigations are undertaken side-by-side as much as possible so that the patient and the
patient's family accept the psychological basis rather than the destructive belief that the psychological
basis was a result of a lack of medical evidence rather than an accepted diagnostic possibility.
Somatoform disorders are characterized by physical symptoms or complaints with no
demonstrable organic basis or by more severe symptoms than would be expected by an organic
condition alone. Remember that these symptoms are not consciously produced. These symptoms
generally represent a coping strategy to deal with emotional discomfort generally outside of their
awareness, resulting in a decrease in the child's overall functioning. It is important to acknowledge the
patient's suffering and physical concerns. Assessment of stressors and the temporal relationship to
symptoms can be helpful in identifying possible unconscious conflicts perpetuating symptoms.

Given that the presenting symptoms are physical, the diagnosis and treatment begins with the
pediatric primary care practitioner and/or pediatric subspecialist. Even if a psychiatric basis is readily
apparent, the outcome is best accomplished with ongoing primary care involvement. In many cases,
reassurance and suggestion from the primary care practitioner that the symptom will improve is helpful.
However, in more complicated cases, mental health consultation is indicated.
The primary care practitioner should explain to the child and the family that a comprehensive
evaluation of the symptoms includes exploring physical and psychological factors simultaneously. This, in
turn, helps to set the stage that psychological factors are legitimate areas of concern, which facilitates
disclosure and decreases the stigma attached to a psychogenic etiology.
As with any complex case, a complete psychiatric examination is needed, with particular note of
any recent stressors. A complete medical, neurological, and mental status examination is essential.
Conservative diagnostic workups are appropriate. Unnecessary tests should be avoided, with continuing
awareness of possible unrecognized physical disease.
Mental health consultation early in the assessment process is helpful in reducing the resistance of
patients and their families to psychological help. The manner in which mental health consultation is
introduced to the family is key to whether they follow up with recommendations. It is helpful to normalize
the referral, just as would be done with any other condition that needs further assessment (ie, "I need
help in determining what coping strategies will help your child, and I need help in determining if any
stresses are contributing to or exacerbating symptoms."). It is useful to point out that this consult is
helpful for the practitioner to design a rehabilitation program to help the child be functional as quickly as
possible.
Patients themselves may be resistant. They often have difficulties tolerating sad, angry, or
depressed feelings. They may have troubling worries (eg, worrying about having a terminal illness). It can
be helpful to observe the child because the symptoms may change in different environments, with
different people, or under different circumstances. The families of children with somatoform disorders are
often more comfortable with the belief that the child has a medical diagnosis that has not yet been found.
The families may not be open to psychological explanations, especially when concerns about family
privacy or secrets exist.
After the assessment is complete, the pediatric practitioner and the mental health clinician should
meet together with the family in an informing conference to review the diagnosis and treatment plan. In
this meeting, the patient and family are presented with the significant medical and psychological aspects
in a supportive and nonjudgmental manner.
The pediatric practitioner should build a foundation for an integrated medical and psychiatric
intervention program. The explanation of the diagnosis and the way the news is delivered plays a crucial
role in how satisfied the family is, how well they follow up with recommendations, and, ultimately, in the
recovery of the child. An explanatory model of symptoms associated with stress can be helpful. Avoid
telling families that "we found nothing wrong" or "it is all in your head." Instead, point out how much was
learned by diagnostic tests (eg, "your EEG findings showed no irregular brain activity, the tests have
ruled out any terrible problems or cancers in the stomach"). It may be effective to use the analogy of a
tension headache caused by worry and point out that it is not uncommon for other body parts to hold onto
stress in unexpected ways.
It is useful to follow a rehabilitation model in which the target is to get the patient back to
developmentally normal routines as soon as possible. This often helps eliminate secondary gain (ie,
special attention or avoid a stress circumstance) that might be perpetuating the symptoms. The program
would encourage the reward of healthy behavior, while using negative reinforcement for sick behavior. It
can be suggested that the symptoms may be difficult to eliminate, yet you expect them to decrease and
disappear given the combined medical and psychiatric treatment program. It is helpful to emphasize
stress reduction as a means of enhancing coping abilities, as well as encouraging the child to self-monitor
and the parents to reinforce self-treatment techniques (eg, relaxation, self-hypnosis, biofeedback).
Physical therapy is a commonly used modality in mobilizing patients.
The mental health clinician may likely use a variety of modalities, including individual therapy,
cognitive-behavioral therapy, family therapy, and/or parent guidance. For example, the treatment of
conversion disorder might involve providing support and reassurance combined with indirect and direct
suggestions (ie, physical therapy, behavioral techniques). Direct confrontation is rarely helpful.
Hypochondriasis presents with significant cognitive distortions and fears of disease. The meaning that
patients associate with their symptoms is an important source of perpetuating the disorder. Cognitive
symptoms and automatic thoughts that may reinforce somatization can be addressed by a therapist
skilled in cognitive-behavioral techniques. Methods that assist in symptom eradication using techniques
such as hypnotherapy, relaxation therapy, or biofeedback have been proven very helpful in the treatment
regimen.
It is helpful to have regular follow-up appointments with the patient and family. This allows for
further opportunities to reassure the patient and family. Regular thorough examinations are important to

identify any changes in physical findings that might call the somatoform diagnosis into question. Once the
diagnosis is made to everyone's satisfaction, further diagnostic testing should be discouraged. The
frequency of medical appointments is best determined by the continuance of the physical symptoms
combined with collaboration with the mental health clinician.
Antidepressants or anxiolytics can be useful for specific target symptoms (eg, depression, anxiety)
or comorbid psychiatric disorders. The use of placebo is not a useful technique for long-term help in these
patients. At a minimum, they do not enhance the internal symptom control that is important to their
recovery. Consultation with a child and adolescent psychiatrist is recommended when psychotropic
medication is being considered.

Guidelines for Parents

Dealing with pain
The following guidelines for dealing with pain (eg, headaches, stomachaches) are adapted from tips by
Rebecca Blakeman, PhD, and the team at Children's Mercy Hospital in Kansas City. They were created for
parents to help their children learn to participate in home and school activities despite any pain the children
may be experiencing (eg, headaches, stomachaches). It is important to recognize that the pain
experienced by a child with somatization is real and not just in their heads, while maintaining the goal of
increasing the child's ability to cope with the pain and participate in school and social relationships. It is
important to provide parents with the following points of advice:

Limit or remove attention for pain behavior. Parents should limit their discussion and attention to
their child's reports of pain. When your child tells you about pain, you should briefly respond by
acknowledging your child's pain but keep the discussion to a minimum. For example, you could tell your
child that you are sorry the pain has returned and encourage him or her to use relaxation or the coping
skills he or she has been taught. If you continue to talk about your child's pain, your child will be unable to
shift his or her attention from the pain to other activities, such as homework or play.
Be sure that your child goes to school each day. If your child complains of a stomachache or
headache in the morning before school, limit your discussion about it. Continue your morning routine,
making it clear to your child that he or she will be going to school. If your child reports pain at school,
please arrange for the teacher, principal, or school nurse to have your child rest quietly for a brief period
and then return to the classroom. Interrupted activities (eg, school tests) should be resumed when your
child returns to the class or, if necessary, be rescheduled at the earliest possible convenience. There will
be times when your child is sick and needs to stay home. Signs and symptoms of illness (eg, fever, runny
nose, sore throat, diarrhea) are different from those of chronic stomachaches. Any new symptoms should
be reported to your child's doctor.
Help your child identify stress at home and school. Be sure that you know when your child is
experiencing stress about certain home or school activities. Only you and your child will know what might
be bothering him or her, but some examples include visits from relatives, tests in school, book reports or
special projects due, and teasing from friends. When your child is under stress, be sure that you have
discussed with the therapist ways to help your child cope with stress. Coping skills may help your child
learn ways to handle stressful situations that might be related to episodes of pain.
Provide attention and special activities on days when your child does not have pain. Make a list of
special privileges (eg, making a favorite snack, going to the mall with mom or dad, staying up 30 min later
at night) that your child can earn for days when he or she completes daily activities without allowing pain
reports to interfere. Be sure to let your child know how pleased you are when he or she has days that
pain reports are not used to avoid activities and responsibilities. Remember that your child may have to
learn to cope with the pain while continuing his or her daily activities. You can help your child learn to
cope with pain by giving him or her your attention and positive comments for completing responsibilities
and participating in daily activities.
Limit activities and interactions on sick days. Your child may stay home some days because of
stomachaches, headaches, or nausea. On those days, your child should follow medical advice. Provide
school materials, such as homework papers, books, and special projects to work on. This means no
puzzles, television, comic books, video games, and other playthings. During the day, if your child notices
that he or she is feeling better, take your child to school. Be sure to talk with the teacher or principal to
make sure it is all right if your child comes during the middle of the day. Additionally, identify a peer buddy
who can be responsible for getting homework assignments.
Be sure not to talk about any excessive discomfort or illness you may have. Some children have
learned that when mom or dad is sick, they are able to stay home and avoid daily activities. During the
next several weeks, try not to discuss your headaches, stomachaches, backaches, and other illnesses in
the presence of your child. Try not to take sick days, except for emergencies, during the first few weeks of
this program.

Have your child practice relaxation techniques. If a therapist has taught your child relaxation
techniques, including self-hypnosis, be sure he or she practices these relaxation skills. Whether you are
using relaxation tapes or a checklist of relaxing postures or if your child is doing this approach without
home assistance, encourage your child to practice at least once a day. With regular practice, your child
will learn this skill. Suggest that your child discuss results of the specific relaxation techniques with the
therapist.

Educate personnel working with your child. Provide teachers and other educators information
about your child's problem. It may be helpful to set up a strategy at the beginning of the school year so
that if some school time is missed, a procedure goes into effect immediately to allow as little to be missed
academically as possible.
In addition, the reader is encouraged to refer to the AACAP Practice Parameter for the Psychiatric
Assessment and Management of Physically Ill Children and Adolescents.
For patient education resources, see the Muscle Disorders Center, as well asFibromyalgia, Chronic Fatigue
Syndrome, and Chronic Pain