Article psychosocial pediatrics

Somatization Disorders in
Children and Adolescents
Tomas Jose Silber, MD,*
Objectives After completing this article, readers should be able to:
Maryland Pao, MD†
1. Describe the various manifestations of somatization disorders in children and
adolescents.
2. Delineate the association of psychosomatic disorders with stress, parental anxiety, or
pressure for a child to perform.
3. Distinguish between primary and secondary gain.
4. Explain why school attendance should be assessed with every recurrent complaint.
5. Explain why pediatricians should establish a partnership with patients and their parents
when addressing their symptoms.
6. Develop a cost-effective investigation of suspected somatoform disorders and an
approach to insurance companies regarding reimbursement of services.

Introduction
The diagnosis and treatment of children and adolescents who have somatization disorders
constitute a challenge for pediatricians: On one hand, they raise the specter of “missing
something”; on the other, any “false step” in explaining the condition risks alienating both
the patient and the family. Many clinicians rise to the challenge, but many more are baffled
by the onslaught of symptoms, become annoyed by the time consumed in caring for
patients who are “not really sick,” or feel frustrated by the never-ending recurrent
complaints.
To make matters worse, these disorders have been scantly researched; neither meta-
analysis nor evidence-based medicine has contributed significantly to the field. Paradoxi-
cally, although somatoform disorders in children have been defined as psychiatric disor-
ders, psychiatrists seldom see these patients except for the most extreme, unusual, and
bizarre cases. Most children and adolescents who have functional symptoms are seen by
primary care physicians. This review, therefore, focuses on understanding and assessing
somatization as well as developing strategies for the day-to-day management of these
conditions.

Definition and Classification

Somatization has been defined as the occurrence of one or more physical complaints for
which appropriate medical evaluation reveals no explanatory physical pathology or patho-
physiologic mechanism. Somatization also can coincide with a physical illness. Somatiza-
tion is deemed to exist in conjunction with a physical illness whenever the physical
complaints resulting in impairment are grossly in excess of what would be expected from
the known illness or findings. Thus, the central feature of somatoform disorders is that they
present with symptoms suggestive of an underlying medical condition, yet such a condi-
tion either is not found or does not fully account for the level of functional impairment.
The diagnostic criteria for somatoform disorders originally were established for adults
and are applied to children because no child-specific alternative system has been developed.
This is unfortunate because the current classification lacks a pediatric research base.
Nevertheless, some progress has been made with a recent classification of child and

*Professor, Department of Pediatrics, The George Washington University School of Medicine and Health Sciences; Director,
Adolescent Medicine Fellowship Program, Children’s National Medical Center, Washington, DC.
†
Office of the Clinical Director, National Institute of Mental Health, National Institutes of Health; Clinical Assistant Professor
of Psychiatry, The George Washington University School of Medicine and Health Sciences, Washington, DC.

Pediatrics in Review Vol.24 No.8 August 2003 255

psychosocial pediatrics somatization disorders
Current Classification of
Table 1.
Somatization Disorders in
Children and Adolescents
● Somatic complaint variation (v 65.49)
● Somatic complaint problem (v 40.3)
● Somatization disorder (300.82)
● Somatoform disorder (undifferentiated) (300.82)
● Somatoform disorder, not otherwise specified
(300.82)
● Pain disorder (307.8)
● Conversion disorders (300.6)
From Wolraich ML, Felice ME, Drotar D. The classification of child
and adolescent mental diagnosis in primary care. In: Diagnostic and
Statistical Manual for Primary Care (DSM-PC) Child and Adolescent
Versions. Elk Grove Village, Ill: American Academy of Pediatrics; 1996
adolescent mental diagnosis in primary care, which takes
into account developmentally appropriate consider-
ations. This review focuses on somatic complaint varia-
tion, somatic complaint problem, undifferentiated so-
matoform disorder, pain disorder, and conversion
disorders (Table 1). Factitious disorder (300.16), which
sometimes is included in the classification, does not fit
very well because the signs and symptoms presented to
the physician have been staged deliberately, rather than
experienced, by the patient.
Epidemiology
Somatoform disorders seem to follow a developmental
sequence. Children appear to experience affective distress
in the form of somatic sensations. Initially, these are
monosymptomatic, with recurrent abdominal pain and
headaches predominating in early childhood. Limb pain,
neurologic symptoms, insomnia, and fatigue tend to
emerge with increasing age. The prevalence of somatic
symptoms is high in the pediatric population: Recurrent
abdominal pain accounts for 5% of pediatric office visits,
and headaches have been reported to affect 20% to 55%
of all children. During adolescence,10% of teenagers
report frequent headaches, chest pain, nausea, and fa-
tigue. A general teenage population survey (ages 12 to
16 y) found that distressing somatic symptoms were
present in 11% of girls and 4% of boys. This gender
disparity seems to persist into adulthood. There is a
higher rate of somatization among lower socioeconomic
groups.
256 Pediatrics in Review Vol.24 No.8 August 2003
Pathogenesis: Genetic and Family Factors
Information on the genetics of somatoform disorders is
limited. However, recent genetic studies have shown that
somatoform disorders are concordant in twins. They also
cluster in families in which there is attention deficit
disorder and alcoholism above what would be expected
by chance.
More commonly, clinicians consider somatization to
be a learned behavior. It probably begins with the expe-
rience that children’s somatic complaints are more ac-
ceptable in many households than is the expression of
strong feelings. When children cannot get attention for
emotional distress, they may gain attention for the phys-
ical symptoms that often accompany the disturbed emo-
tional state. This reinforcing “psychosomatic pathway”
can manifest through a spectrum of somatization disor-
ders, ranging from the mild “somatic complaint varia-
tion” (transient complaints that do not interfere with
normal functioning) to the severe “somatoform disor-
der” (associated with significant social and academic
problems).
The importance of psychosocial factors in the family
of origin is highlighted by the finding that if a family
member had a chronic physical illness, there were more
somatic symptoms among the children. Even more strik-
ing is the finding that somatizing children often live with
family members who complain of similar physical symp-
toms. Theoretic contributions stemming from systemic
family therapy also indicate the importance of the family.
The symptoms are proposed to be displayed by the child
as a way of protecting distressed parents who, when
galvanized into caring for their suffering child, are dis-
tracted from their own personal concerns. Stress has been
implicated as a triggering factor that often is bound to
parental anxiety. The most common form of stress con-
sists of pressure on the child to perform. Finally, adoles-
cents who have histories of physical or sexual abuse often
present with somatic complaints, develop a somatization
disorder, and score higher on measures of somatizations
than do controls.
Clinical Aspects
Children and adolescents readily report pain and somatic
complaints in their sick visits. These complaints often
result from a disease such as tonsillitis, gastroenteritis, or
urinary tract infection. However, they can voice similar
complaints in the absence of physical disease, and these
reports must be approached as possible somatization.
The diagnosis of a somatization disorder involves a con-
tinuum that ranges from everyday aches and pains to
disabling “functional symptoms.” Symptoms are sponta-

neous and not feigned (which distinguishes them from
malingering and factitious disorder) and are not better
explained by another mental illness (such as depression
or anxiety disorder).
Somatic Complaint Variation
This variation involves discomfort and complaints that
do not interfere with everyday functioning. It is a univer-
sal experience. In infancy, the complaints probably man-
ifest as transient gastrointestinal distress. In childhood,
classic recurrent abdominal pain, headaches, and “grow-
ing pains” make their appearance. Adolescents may ex-
perience menstrual discomfort and other transient aches
and pains, but these characteristically do not impair their
ability to function. Females report more somatic com-
plaints after puberty.
Somatic Complaint Problem
This consists of one or more physical complaints that do
cause sufficient distress and impairment (physical, social,
or school) to be considered a problem. In infancy, this
would occur when gastrointestinal symptoms seriously
interfere with feeding and sleep. In childhood, it entails
avoiding or refusing to undertake expected activities (eg,
increased school absences). As adolescence approaches,
in addition to the somatic complaints, more emotional
distress, social withdrawal, and academic difficulties be-
gin to appear. More severe complaints may result in
refusal to attend school, aggressive behavior, and recur-
rent pain syndromes.
Undifferentiated Somatoform Disorder
This condition emerges during adolescence, causing sig-
nificant impairment. Multiple severe symptoms of at least
6 months’ duration are required to make the diagnosis.
They include, but are not limited to, pain syndromes,
gastrointestinal or urogenital complaints, fatigue, loss of
appetite, and pseudoneurologic symptoms. To qualify
for this diagnosis, the symptoms should not be explained
better by another mental disorder, such as a mood or
anxiety disorder, and should not be feigned or intention-
ally produced. A more severe form, the classic somatiza-
tion disorder, usually is an adult condition.
Somatoform Disorder, Not Otherwise Specified
This classification encompasses adolescents who have
somatoform symptoms that do not meet the criteria for
any specific somatoform disorder, such as pseudocyesis,
in which the false belief of being pregnant often is
accompanied by endocrine changes. Another common
psychosocial pediatrics somatization disorders
example is unexplained physical complaints (eg, fatigue,
weakness) of fewer than 6 months’ duration.
Pain Disorder
There are three types of pain disorder: pain associated
with psychological factors, pain associated with both a
psychological and general medical condition, and pain
associated with a general medical condition. The onset of
pain may be related to psychological stressors or avoid-
ance of something threatening. Pain disorders frequently
begin as a mild pain syndrome. Pain can worsen due to
the inadvertent secondary gain achieved by avoiding
stress or academic pressures. These symptoms may be
associated with frequent visits to the pediatrician and
parental pressure for unnecessary testing and interven-
tions.
Conversion Disorders
In conversion disorders, one or more symptoms or defi-
cits affects a sensory or voluntary motor function (eg,
blindness, paresis), suggesting a medical or neurologic
condition, yet the findings are not consistent with any
known neuroanatomic/pathophysiologic explanation.
The symptoms tend to have a “symbolic meaning,”
dealing with an unsolved and unconscious conflict (often
relating to themes of aggression or sexuality). The symp-
toms appear to be an attempt to resolve the conflict
(primary gain), although they often result in increased
attention for the patient (secondary gain). This form of
somatization disorder frequently, but not always, is ac-
companied by “la belle indifference,” an attitude of
disinterest by the patient despite the serious symptoms
experienced. Although the symptoms are usually self-
limited, resolving within 3 months, they may be associ-
ated with chronic sequelae, such as contractures. There is
frequently a model for the symptoms, with the patient
sometimes serving as his or her own model, as is the case
with pseudoseizures in patients who have epilepsy. How-
ever, over time, up to one third of patients in whom
conversion disorder is diagnosed develop a neurologic
disorder.
The fourth edition of the Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV) from the Amer-
ican Psychiatric Association includes additional disorders
in the list of somatization disorders: hypochondriasis
(preoccupation with the idea of having a serious disease)
and body dysmorphic disorder (overpreoccupation with
an imagined or exaggerated defect in physical appear-
ance). They are uncommon and seen primarily during
adolescence and young adulthood.
It is beyond the scope of this review to address specif-
Pediatrics in Review Vol.24 No.8 August 2003 257
psychosocial pediatrics somatization disorders
Differential Diagnosis in
Table 2.
Pediatric Somatization
● Unrecognized physical disease
● Unrecognized psychiatric disorder (eg, depression,
anxiety)
● Factitious disorder/by proxy
● Psychological factors affecting medical condition
ically the large variety of common symptoms that may
have a psychogenic origin or component, such as consti-
pation and encopresis, enuresis, vomiting, headaches,
syncope, and fainting. All have been reviewed in detail in
Pediatrics in Review (see Suggested Reading).
Psychiatric Disorders and Somatic Complaints
Psychiatric disorders such as depression and anxiety dis-
order often present initially with physical complaints
such as poor concentration; fatigue; weight loss; and an
increase in headaches, stomachaches, and chest pains.
They must be considered as primary or possibly comor-
bid conditions in the evaluation of somatoform disor-
ders. This is important to look for because epidemiologic
studies show that 14% to 20% of American children have
one or more moderate-to-severe psychiatric disorders,
with the overall prevalence rising.
Evaluation
Establishing the diagnosis of a somatoform illness
evolves over time along three simultaneous tracks:
1) Ruling out an organic disease as the cause of the
symptoms, 2) Identifying psychosocial dysfunction, and
3) Containing and alleviating stressors. A concomitant
biopsychosocial assessment by itself is therapeutic and
often is followed by improvement and sometimes even
resolution of symptoms. It also is important to highlight
that the differential diagnosis is not based solely on a
process of exclusion, but incorporates instead a set of
positive findings (Table 2).
It can be unclear whether a particular complaint even-
tually will be functional or reflect an underlying disease.
Therefore, it is important to consider explicitly psycho-
somatic etiology in the initial patient evaluation. This will
make any future “disclosure” easier.
Findings that are highly suggestive of a somatization
disorder include a history of multiple somatic com-
plaints, multiple physician visits and specialty consulta-
tions, a family member who has chronic and recurrent
258 Pediatrics in Review Vol.24 No.8 August 2003
symptoms, and dysfunction in the primary areas of life
(family, peers, and school). Additional inquiry should
include: Does the parent have any concern about the
child’s behavior or emotional well-being? Is there a fam-
ily history of psychiatric disorder or “bad nerves”? A de-
tailed school history that reviews each year and the
numbers of days missed is essential.
In the process of evaluating somatic complaints, the
clinician should avoid the temptation to perform unnec-
essary, repetitive, or extensive testing in an attempt to
demonstrate to the family that the presenting complaint
is of psychosomatic origin.
A cost-effective method of determining the extent of
laboratory and radiographic evaluation is to base it on the
presence of “red flags”; that is, the detection of com-
plaints and findings that suggest an organic pathology,
such as syncope on exercise, asymmetric location of pain,
anemia, or weight loss. When the history and physical
examination findings are suggestive of somatization, a
basic laboratory screening consisting of a complete blood
count, an erythrocyte sedimentation rate or assessment
of C-reactive protein, a urine dipstick evaluation, and
sometimes a blood chemistry and occult blood stool test
is sufficient. More extensive assessments are reserved for
the “red flags.”
Eventually, the clinician needs to “bite the bullet,” so
it is important to present initially to the family a differ-
ential diagnosis that includes the possibility that the
symptoms may be related to stress, temperamental sen-
sitivity, anxiety, or whatever term may be tolerated by the
family to accept a behavioral intervention or even a
request for psychological assessment. The best method
of persuasion is to precede any disclosure with a clear
demonstration that one has taken the complaint very
seriously. This is best accomplished with a careful history
and a detailed physical examination of much longer
duration than the patient has been used to. The aim is to
convey a sense of specialness to the child and family,
which may serve as a buffer to the narcissistic injury
stemming from having to recognize that “something is
wrong” in the child’s life. Finally, it is necessary to
reassess the course of illness and remain alert to the
presence of the most common psychiatric disorders,
which frequently present initially to the pediatrician.
Therefore, pediatricians treating children who have re-
current somatic complaints need to become familiar with
screening for anxiety disorder, depression, attention-
deficit/hyperactivity disorder, substance use disorder,
and conduct disorder.

Principles of Treatment
Table 3.
of Pediatric Somatization
● Form an alliance with the patient and family
● Be direct; avoid deception in explanations and
treatments
● Offer reassurance when appropriate
● Use cognitive and behavioral interventions
● Use a rehabilitative approach
● Use positive and negative reinforcement
● Teach self-monitoring techniques (eg, hypnosis,
relaxation, biofeedback)
● Consider family and group therapies
● Improve communications between clinicians and
school
● Consolidate care when possible
● Aggressively treat comorbid psychiatric conditions
● Consider psychopharmacologic interventions
● Monitor outcome
Adapted from Campo and Fritz, 2001.
Management/Disclosure
Correct identification of somatization disorders may not
be sufficient to provide help to patients and families, who
often are reluctant to accept the explanation. Therefore,
successful communication about the condition and the
needed treatment is a crucial but sometimes elusive goal
(Table 3). In preparation for disclosure of concerns
about a possible somatization disorder, it is very impor-
tant to ask the child and family about their fear or
“fantasy of disease.” This may elicit surprising answers,
such as fear that the child may have cancer or heart
disease. Conversely, the reply may convey an already
harbored suspicion or understanding of the problem,
such as “It may be stress or nerves.” In any case, patients
will be willing to listen to the pediatrician only if he or she
first listens to them. A clear, supportive, matter-of-fact
explanation also should assure families that the pediatri-
cian will be available to help with the onslaught of
feelings that many families experience at the time of
diagnosis.
It is important for pediatricians to recognize their own
response to the family resistance and reluctance to lay
aside the “search for disease” and not inadvertently trans-
mit their own frustration about the difficult and time-
consuming task they are facing.
A primary reason that patients are angry and reject the
diagnosis of somatization disorder is that they feel disre-
spected and not believed: “You think it is all in my head,
but I know I hurt and that there is something wrong.” In
part, this relates to the unfortunate term “psychosomat-
psychosocial pediatrics somatization disorders
ic,” which conveys the mistaken notion of a body-mind
duality, and for some still has the connotation of crazi-
ness (“psycho”). Therefore, it is important to explain
that a “functional versus organic” paradigm is old-
fashioned and does not reflect current thinking, which
suggests a more complex interplay of multiple factors
underlying the patient’s symptoms.
Essentially, the pediatrician must convey understand-
ing that the patient’s pain is real. That is, the doctor has
learned that pain is due to a neural nociceptive compo-
nent and an affective component, both processed by the
central nervous system and influenced by personal expe-
rience, genetics, and the environment.
To help patients and parents become more open to
the concept of somatization, they can be reminded of
how themes in language acknowledge the connection
between emotions and bodily processes. For example, we
talk about having a “gut reaction,” having “butterflies in
my stomach,” feeling “all choked up,” and that some-
thing “makes me vomit.” In addition, we also note that
embarrassment can manifest as blushing, fear as cold
sweat, and anger as stiffening muscles and clenching
teeth, thus facilitating explanations such as “blushing of
the gut” and “spastic colon.” Another strategy is to help
them view somatization as a sensitivity, a phenomenon of
“amplification” of otherwise normal body sensations.
Treatment
At the center of any successful program is the untiring
effort to motivate patients and parents toward a partner-
ship in dealing with the symptoms and complaints. It
could be argued that the risk of antagonizing patients
with a diagnosis of somatization and the subsequent
running away and “doctor shopping” calls for simply
helping patients by medicating them with analgesics,
tranquilizers, anxiolytics, and other agents from the
pharmacopeia, including placebos. Although this may be
tempting and certainly is easier, such an approach should
be avoided when possible because it may reinforce the
search for the “magic pill” and a never-ending pursuit of
a technological solution. At a deeper level, the reason for
informing patients and families of the nature of the
disorder involves the principle of respect for persons; it is
an ethical duty, with few exceptions, to share with pa-
tients our understanding of their situation. The primary
exception to this rule, which allows for justified paternal-
ism and “face-saving” suggestive therapies, is patients
who have conversion disorders and cannot make use of
the information. This may be due to the nature of the
disorder, which often does not allow them to realize that
Pediatrics in Review Vol.24 No.8 August 2003 259
psychosocial pediatrics somatization disorders
they are experiencing stress or that their response to the
stressor is dysfunctional.
The diagnosis of somatization never should lead a
patient or parent to the perception that this diagnosis will
be raised as a barrier to preempt future complaints.
Instead, it should become clear that the diagnosis is made
in the spirit of offering an interpretation that may call
for newer and more effective treatments such as stress
management and individual or family counseling. So-
matoform disorders do respond to treatment and reha-
bilitation. Cognitive and behavioral interventions; use
of positive and negative reinforcements; and self-
monitoring techniques such as hypnosis, relaxation, and
biofeedback have been proven successful. Family coun-
seling and good communication between the clinician
and the school often can “turn things around.”
An important consideration when treating patients
who have somatization disorders is that although the
presence of a concomitant psychiatric disease is much
lower in children than in the adult population, children
can be afflicted by comorbidities such as mood disorders,
anxiety disorders, and substance abuse, which should be
sought to assure successful treatment. Patients who have
a comorbid condition do not respond to treatment un-
less the psychiatric condition is addressed. Conversely, a
patient not responding to intensive treatment should be
evaluated for the possibility of comorbidity.
Judicious use of psychopharmacologic treatment in
somatoform disorders may be appropriate when comor-
bid depression or anxiety is suspected or the severity of
symptoms has led to significant and prolonged impair-
ment (⬎3 mo). If the pediatrician can convince the
patient and family to seek additional treatments such as
therapy and evaluation for the use of medication, it is
important that the consulting psychiatrist be asked to
provide feedback directly to the pediatrician. Families
often otherwise report that the psychiatrist said there was
“nothing wrong, it was all medical.” The consultant
should be expected to tell the referring pediatrician what
services will be provided and what the pediatrician is
expected to monitor. For pediatricians who are sophisti-
cated in the use of psychotropic medications, a psychiat-
ric referral might not be necessary.
Often families worry that the diagnosis of somatiza-
tion will be followed by abandonment by the physician.
This concern can be dispelled by arranging frequent
follow-up visits, which have the potential to “preempt”
the frequent emergence of new symptoms, prevent emer-
gency department visits, and ease the overall manage-
ment of symptoms. It is helpful to emphasize that all
forthcoming symptoms will be examined with the atten-
260 Pediatrics in Review Vol.24 No.8 August 2003
tion they deserve because somatizing under stress is very
common and does not “provide immunity” against ap-
pendicitis, lupus, diabetes, and other conditions. Most
families, even when disagreeing with their physicians, can
accept (albeit grudgingly) treatment recommendations if
they are assured of an attentive, open-minded, and reg-
ularly scheduled follow-up.
Administrative Issues
The structure of medical services conspires against opti-
mal care for patients afflicted by somatization disorders,
in part because procedural interventions historically have
been valued above spending time with patients and in
part because many organizations “carve out” these types
of disorders for treatment through the mental health
coverage. Frequently, such “carve outs” mean that pa-
tients have to pay their pediatrician out of pocket or from
their mental health benefits. At other times, services
simply go unpaid.
Depending on contractual arrangements, pediatri-
cians currently have three less-than-satisfying options:
1) accept the rate of reimbursement for their services and
bill the rest to the family, 2) refer the family to a consul-
tant and coordinate care, or 3) negotiate directly with the
payer about the case (armed with the DSM-IV).
Prognosis
With appropriate intervention, the prognosis for most
somatization disorders in children and adolescents is very
good. However, many untreated children risk continu-
ous somatization as adults. On occasion, somatization is
the proverbial “tip of the iceberg” that calls attention to
a psychiatric disorder that requires mental health consul-
tation and treatment. The most severe form, the undif-
ferentiated somatoform disorder, probably is related
closely to personality disorders, is of long duration, and
has a persistent course, continuing into adulthood.
From a professional development perspective, advo-
cacy work must continue to emphasize that changes in
medical economics and the recognition of the financial
impact of somatization on utilization call for increased
funding for research and training in this area.
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psychosocial pediatrics somatization disorders

PIR Quiz
Quiz also available at www.pedsinreview.org.

1. You are evaluating a 10-year-old girl for abdominal pain. She complains of generalized vague abdominal
pain that has occurred almost daily for 6 weeks. There is no associated vomiting, diarrhea, or weight loss.
She has missed a total of 2 weeks of school because of her pain, but overall she is a good student. Findings
on her physical examination are normal. Of the following, the most likely diagnosis is:
A. Conversion disorder.
B. Factitious disorder.
C. Somatic complaint problem.
D. Somatic complaint variation.
E. Undifferentiated somatoform disorder.

2. A 12-year-old girl comes to your office with the complaint of an inability to walk for 2 days. Her father
carries her into the examination room. Except for refusal to walk, findings on the neurologic examination
are completely normal. Further history reveals that she is a good student and that her parents are insistent
that she make all A’s in school so she can get a scholarship to college. When you ask the girl how she feels
about her inability to walk, she appears indifferent. Of the following, the most likely diagnosis is:
A. Conversion disorder.
B. Depression.
C. Factitious disorder.
D. Pain disorder.
E. Somatoform disorder, not otherwise specified.

3. Which of the following statements about somatoform disorders in children is true?

A. Adolescents who have somatization disorders feign pain for secondary gain.
B. An extensive laboratory evaluation is required before making the diagnosis.
C. It is rare for coexistent psychiatric disorders to be present.
D. Parents often complain of symptoms similar to the child’s complaint.
E. The rate of somatoform disorders is higher in boys than in girls.

4. Which of the following statements regarding the evaluation and treatment of somatoform disorders is
true?
A. Biofeedback and hypnosis are often effective treatments.
B. Medication rarely is indicated because it perpetuates the patient’s feelings that there is a true medical
problem.
C. Screening for coexistent psychiatric disorders is recommended only if there is a family history of
psychiatric illness.
D. Telling a family initially that the problem may be due to stress usually angers the family and jeopardizes
the doctor-patient relationship.
E. The most effective method of treating the patient’s complaint is to ignore it and explain that there is
no medical explanation for the problem.

262 Pediatrics in Review Vol.24 No.8 August 2003


Appendix: Sections of the Relevant Criteria
of the Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV)
The purpose of this appendix is to provide details on the
diagnostic categories for the DSM-IV disorders perti-
nent to children. The disorders are listed in alphabetical
order.
Diagnostic Criteria for Conversion Disorder
300.11
A. One or more symptoms or deficits affecting vol-
untary motor or sensory function that suggest a neuro-
logic or other general medical condition.
B. 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.
C. The symptom or deficit is not intentionally pro-
duced or feigned (as in factitious disorder or malinger-
ing).
D. 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.
E. The symptom or deficit causes clinically significant
distress or impairment in social, occupational, or other
important areas of functioning or warrants medical eval-
uation.
F. 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 ac-
counted for by another mental disorder.
Specify type of symptom or deficit:
With Motor Symptom or Deficit
With Sensory Symptom or Deficit
With Seizures or Convulsions
With Mixed Presentation
Diagnostic Criteria for Pain Disorder 307.80
A. Pain in one or more anatomical sites is the pre-
dominant focus of the clinical presentation and is of
sufficient severity to warrant clinical attention.
B. The pain causes clinically significant distress or
impairment in social, occupational, or other important
areas of functioning.
C. Psychological factors are judged to have an impor-
tant role in the onset, severity, exacerbation, or mainte-
nance of the pain.
D. The symptom or deficit is not intentionally pro-
duced or feigned (as factitious disorder or malingering).
E. The pain is not better accounted for by a mood,
psychosocial pediatrics somatization disorders
anxiety, or psychotic disorder, and does not meet criteria
for dyspareunia.
Specify if:
Acute: duration of less than 6 months
Chronic: duration of 6 months or longer
307.89 Pain Disorder Associated With Both
Psychological Factors and a General Medical
Condition
Both psychological factors and a general medical condi-
tion are judged to have important roles in the onset,
severity, exacerbation, or maintenance of the pain. The
associated general medical condition or anatomical site
of the pain is coded.
Specify if:
Acute: duration of less than 6 months
Chronic: duration of 6 months or longer
Note: The following is not considered to be a mental
disorder and is included here to facilitate differential
diagnosis.
Pain Disorder Associated With a General
Medical Condition
A general medical condition has a major role in the onset,
severity, exacerbation, or maintenance of the pain. (If
psychological factors are present, they are not judged to
have a major role in the onset, severity, exacerbation, or
maintenance of the pain.) The diagnostic code for the
pain is selected based on the associated general medical
condition if one has been established or on the anatom-
ical location of the pain if the underlying general medical
condition is not yet clearly established – for example, low
back (724.2), sciatic (724.3), pelvic (625.9), headache
(784.0), facial (784.0), chest (786.50), joint (719.4),
bone (733.90), abdominal (789.0), breast (611.71),
renal (788.0), eye (379.91), throat (784.1), tooth
(525.9), and urinary (788.0).
Diagnostic Criteria for Somatization Disorder
300.82
A. 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.
B. 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 (eg, head, abdomen,
Pediatrics in Review Vol.24 No.8 August 2003 263
psychosocial pediatrics somatization disorders
back, joints, extremities, chest, rectum, during menstru-
ation, during sexual intercourse, or during urination)
(2) Two gastrointestinal symptoms: a history of at least
two gastrointestinal symptoms other than pain (eg, nau-
sea, 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 (eg, sexual
indifference, erectile or ejaculatory dysfunction, irregular
menses, excessive menstrual bleeding, vomiting
throughout pregnancy)
(4) One pseudoneurological symptoms: a history of at
least one symptom or deficit suggesting a neurologic
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, deaf-
ness, seizures; dissociative symptoms such as amnesia; or
loss of consciousness other than fainting)
C. Either (1) or (2):
(1) After appropriate investigation, each of the symp-
toms in criterion B cannot be fully explained by a known
general medical condition or the direct effects of a sub-
stance (eg, a drug of abuse, a medication).
(2) When there is a related general medical condition,
the physical complaints or resulting social or occupa-
tional impairment are in excess of what would be ex-
pected from the history, physical examination, or labora-
tory findings.
D. The symptoms are not intentionally produced or
feigned (as in factitious disorder or malingering).
Diagnostic Criteria for Somatoform Disorder,
Not Otherwise Specified 300.82
This category includes disorders with somatoform symp-
toms that do not meet the criteria for any specific so-
matoform disorder. Examples include:
(1) Pseudocyesis: a false belief of being pregnant that
is associated with objective signs of pregnancy, which
264 Pediatrics in Review Vol.24 No.8 August 2003
may include abdominal enlargement (although the um-
bilicus does not become everted), reduced menstrual
flow, amenorrhea, subjective sensation of fetal move-
ment, nausea, breast engorgement and secretions, and
labor pains at the expected date of delivery. Endocrine
changes may be present, but the syndrome cannot be
explained by a general medical condition that causes
endocrine changes (eg, a hormone-secreting tumor).
(2) A disorder involving nonpsychotic hypochondri-
acal symptoms of less than 6 months’ duration.
(3) A disorder involving unexplained physical com-
plaints (eg, fatigue or body weakness) of less than 6
months’ duration that are not due to another mental
disorder.
Diagnostic Criteria for Undifferentiated
Somatoform Disorder 300.82
A. One or more physical complaints (eg, fatigue, loss
of appetite, gastrointestinal or urinary complaints)
B. 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 (eg, a drug
of abuse, a medication).
(2) When there is a related general medical condition,
the physical complaints or resulting social or occupa-
tional impairment is in excess of what would be expected
from the history, physical examination, or laboratory
findings.
C. The symptoms cause clinically significant distress
or impairment in social, occupational, or other important
areas of functioning.
D. The duration of the disturbance is at least 6
months.
E. The disturbance is not better accounted for by
another mental disorder (eg, another somatoform disor-
der, sexual dysfunction, mood disorder, anxiety disorder,
sleep disorder, or psychotic disorder).
F. The symptom is not intentionally produced or
feigned (as in factitious disorder or malingering).