CHAPTER 16 Somatoform Disorders

The somatoform disorders involve a complaint of physical symptoms (pain or loss of function) that suggest a medical condition but are not fully explained by either a medical condition, a pharmacologic effect, or another psychiatric condition (Table 16-1). The symptoms are usually recurrent and involve multiple clinically significant complaints (Table 16-2). In evaluating somatic complaints, the evidence for medical disorders and for psychological symptoms should be sought simultaneously. The physical complaints are commonly signals of distress, not indication of a serious psychiatric illness.

Affected children are more likely to come from families with a history of marital conflict. Other members of the child’s family may also have unexplained symptoms. Lifetime prevalence of somatoform disorders is 3% and subclinical somatoform illness as high as 10%. Somatoform illness is relatively stable and persistent, but with time, the overall symptom profile changes. Polysymptomatic presentations, including somatization disorders, hypochondriasis, conversion disorder, and body dysmorphic disorder, are more common with increasing age. Somatoform illness is more common in females, and children with lower socioeconomic status, history of sexual trauma or physical threats, parental neglect, substance abuse, depression, and premorbid anxiety.

Youths with somatoform disorders have high rates of anxiety and depressive symptoms. Cough and dyspnea are highly associated with anxiety, depression, attention-deficit/hyperactivity disorder (ADHD), and substance abuse. Vocal cord dysfunction is suspected in 10% of dyspneic people who are being evaluated for unresponsive asthma. In vocal cord dysfunction, vocal cord spasm mimics acute asthma. Vocal cord dysfunction is differentiated from asthma by lack of improvement despite aggressive asthma management, the absence of nocturnal symptoms, normal blood gases despite severe symptoms, and significant adduction of the vocal cords on laryngoscopy.

Treatment approaches for somatoform problems are complex. The patient must believe that the physician, in finding no evidence of disease, will not judge the symptoms to be feigned or imagined. Reassurance that a life-threatening or serious physical disease is not present helps decrease anxiety. Avoiding unnecessary medical procedures after the diagnosis is made decreases morbidity.

Antidepressant medications (fluoxetine, citalopram, clomipramine) may be of benefit in the treatment of unexplained headaches, fibromyalgia, body dysmorphic disorder, somatoform pain, irritable bowel syndrome, and functional gastrointestinal disorders. Tricyclic antidepressants should be avoided in youth with functional abdominal pain (FAP) because they have no proven efficacy in either pain management or mood disorders. In chronic fatigue syndrome (CFS) with comorbid depression and anxiety, a more activating antidepressant, bupropion, is useful. Stimulants may also be helpful in CFS. Cognitive-behavioral methods, which reward health-promoting behaviors and discourage disability and illness behaviors, help in the treatment of recurrent pain, CFS, fibromyalgia, and FAP. Interpersonal and expressive psychotherapies in the presence of psychological trauma are particularly useful. Self-management strategies, such as self-monitoring, relaxation, hypnosis, and biofeedback, provide some degree of symptomatic relief and encourage more active coping strategies. Family therapy and family-based interventions are very useful in some cases. Home schooling should be avoided, and school attendance and performance should be emphasized as important indicators of appropriate functioning.

Somatization disorder involves multiple unexplained physical complaints, including pain, gastrointestinal, sexual, and pseudoneurologic symptoms. These physical symptoms are not caused by known mechanisms and may be related to the patient’s need to maintain a sick role. The patient is frequently convinced that the symptoms are unrelated to psychological factors. The criteria used to diagnose this disorder are listed in Table 16-2. Given the requirement for at least one sexual or reproductive symptom, the diagnosis is somewhat unusual in children.

The onset of the condition is common during adolescence. Prevalence estimates range from 0.2% to 2% in females and less than 0.2% in males. The symptoms tend to persist or vary in intensity and character despite ongoing treatment. There is an increased risk of the disorder in first-degree relatives, especially female relatives (10% to 20%). Patients with somatization disorder and their family members experience higher rates of major depression, anxiety, personality disorders (antisocial, histrionic, borderline), and substance abuse and dependence. Medical conditions with multiple systemic symptoms need to be ruled out. Factitious disorder or malingering may coexist with somatization disorder. Extensive workup is often performed, so once a diagnosis is made, the major goal is to limit morbidity from unnecessary medical procedures and tests. Early onset of somatization disorder is associated with poor prognosis.

Undifferentiated somatoform disorder includes one or more unexplained physical complaints that last for at least 6 months. The number of physical complaints is less than that required for a diagnosis of somatization disorder (Table 16-3). These symptoms are not explained by medical conditions or drugs. Patients may recognize an association between their symptoms and stress.

Conversion disorder symptoms, suggestive of a neurologic illness in the absence of disease, include nonepileptic seizures, unresponsiveness, faints, falls, and abnormalities of gait or sensation (Table 16-4).

Falling out syndrome (falling down with altered consciousness) is common in several cultures throughout the world. Stocking glove (nonanatomic) anesthesia is another common finding. Symptoms are often inconstant; patients may move a paralyzed extremity when they think that no one is watching. Presenting symptoms follow the psychological stressor by hours to weeks and may cause more distress for others than for the patient (la belle indifference). Symptoms are usually self-limited but may be associated with chronic sequelae, such as contractures or iatrogenic injury. There are four subtypes of conversion disorder based on whether the symptoms presented are primarily motor, sensory, nonepileptic (seizures), or mixed.

Nonepileptic seizures, sometimes described as pseudoseizures, resemble epileptic seizures but are not associated with the electroencephalographic abnormalities or a clinical course characteristic of true epilepsy. Affected individuals may also suffer from concomitant epilepsy. Most cases resolve within 3 months of diagnosis.

The cause of conversion symptoms may be related to an unconscious idea, fantasy, or conflict. The patient does not recognize an association between the symptoms and the conflict. The rate of misdiagnosis of conversion symptoms averages 4%. Myasthenia gravis, multiple sclerosis, dystonias, and dyskinesias (abnormal movements) are conditions commonly mistaken for conversion disorder.

Conversion disorders are uncommon in children and adolescents, with a lifetime prevalence of 0.3%. They are practically nonexistent in children older than 6 years of age. The prevalence increases in psychiatric (1% to 3%) and surgical (1% to 14%) patients. Conversion symptoms are more commonly seen in first-degree relatives of affected people, in patients with family history of unexplainable medical problems, in people living in rural areas, and in people of low socioeconomic status.

Treatment is best accomplished by reassuring patients that the symptoms usually go away. Multiple medical treatments and diagnostic interventions can solidify the symptoms, delay recovery, and increase morbidity. The course of the condition is often benign, although 20% to 25% of patients experience a recurrence. Good prognostic characteristics include symptoms of paralysis, aphonia, blindness; acute onset, above-average intelligence, presence of an identifiable stressor, and early diagnosis and psychiatric treatment. Poor prognostic characteristics include tremor and pseudoseizures.

Pain disorder is characterized by pain as the predominant complaint. Psychological factors are important in the onset, severity, and maintenance of this disorder (Table 16-5). The diagnosis is considered acute if the condition lasts less than 6 months and chronic when it lasts 6 months or more. Chronic, recurrent pain disorders in childhood most commonly involve abdominal pain, headache, limb pain, or chest pain. It is unusual for children to exhibit more than one pain syndrome at the same time, although chronic, recurrent pain in a different location in the past is not uncommon. Most chronic, recurrent pain disorders have no clear organic or emotional origin; organic etiology is found in only about 10% of children.

Pain disorder is the most common pain-related diagnosis. FAP appears to be the most common pain complaint in preschoolers (responsible for up to 4% of pediatric visits in this age group) followed by headache (responsible for up to 2% of pediatric ambulatory visits), which peaks at approximately 12 years of age. FAP may present with nausea, vomiting, and bowel-related complaints. Most cases of pediatric abdominal pain are considered functional in the absence of weight loss, intestinal bleeding, fever, other systemic symptoms, or laboratory abnormalities. Seventy-five percent of children with FAP have an anxiety disorder. Common types of headaches are migraine and tension-type headache. Migraine may be associated with dizziness, gastrointestinal symptoms, and cyclical vomiting syndrome, characterized by recurrent and stereotypical episodes of intense, unexplained vomiting. Patients with functional chest pain, a condition that is seen in 10% of school-aged children and adolescents, may present to the emergency department. Other common pain disorders are musculoskeletal pains (limb pain and back pain), fibromyalgia, and complex regional pain syndrome type I (previously known as reflex sympathetic dystrophy).

Diagnostic studies should be undertaken in response to specific findings that suggest an organic etiology. Evidence of psychological stress usually is found by the time the child exhibits a chronic problem. The nurturing responses of the family may provide secondary gain that prolongs the pain. Complaints or frustration with failure to find a specific cause may lead to accusations of malingering and to increased stress on the child, exacerbating the problem.

Reassurance is the primary treatment of pain disorder. Symptom diaries, including the events that precede and follow the pain episode, aid in initial assessment and ongoing management of the problem. Minimizing secondary psychological consequences of recurrent pain syndromes is important.

Hypochondriasis is the preoccupation with the fear of having a serious disease based on misinterpretation of bodily symptoms and functions. This fear should be present for 6 months. The presenting complaint is a physical sign or symptom, which is normal but is interpreted by the patient to indicate disease despite reassurance of a physician (e.g., a tension headache perceived as a brain tumor). Symptoms typically do not respond to reassurance. An underlying depression or anxiety disorder may be related to the symptoms. Hypochondriasis may overlap with obsessive-compulsive disorder and can be considered a health anxiety disorder or phobia. When the belief or preoccupation is limited to an imagined defect in appearance, the diagnosis is body dysmorphic disorder, not hypochondriasis.

Psychotropic medications directed at underlying psychiatric problems can be helpful. Limiting medical procedures can help decrease morbidity.

Body dysmorphic disorder (BDD) is a preoccupation with an imagined or slight defect in physical appearance that causes clinically significant distress or impairment in functioning. It is usually seen in adolescents and is distinguished from common developmental preoccupations with appearance by the presence of clinically significant distress and/or impairment in functioning. Any body area can be a focus, but excessive concerns about the skin (scars and acne) and body shape are common. Patients may cause self-injury as a consequence of attempts to fix the perceived flaw. Insight is often poor, and patients often seek costly and potentially dangerous treatments. Because BDD can be associated with shame and the need for secrecy, the diagnosis may be missed unless clinicians ask directly about symptoms. Parents of children with BDD report excessive mirror checking, grooming, attempts to camouflage a particular body area, and reassurance-seeking. BDD is considered to be related to obsessive-compulsive disorder. The prevalence of BDD has been reported to be 0.7% in children, 2% in adolescents, and up to 5% in patients seeking cosmetic surgery.

Psychological factors affecting physical condition is a diagnosis in which physical illness is exacerbated by psychological or behavioral factors, often in patients with chronic medical conditions. These factors can worsen the underlying illness or affect its treatment (e.g., a child with type 1 diabetes mellitus whose stressors and maladaptive behaviors interfere with the ability to effectively monitor blood glucose levels).

Fatigue is a common physical complaint, affecting up to 50% of adolescents. CFS specifically refers to a condition characterized by severe, disabling fatigue of at least 6 months’ duration that is associated with self-reported limitations in concentration and short-term memory, sleep disturbance, and musculoskeletal aches and pains, where alternative medical and psychiatric explanations (e.g., hypothyroidism, malignancy, hepatitis, narcolepsy, obstructive sleep apnea, medication side effects, major mood disorder, schizophrenia, or eating disorder) have been excluded. CFS is rare in childhood and uncommon in adolescence, with prevalence below 1%. Onset typically follows an acute febrile illness (postviral) in approximately two thirds of cases. It is often associated with depression and can be incapacitating. Treatment is nonspecific, unless a psychological or general medical cause is uncovered.

Malingering is a condition in which a physical symptom that is under voluntary control is used to gain reward (money or avoidance of school, jail, or military service). The motivation is usually not readily apparent, but the patient consciously recognizes the symptom as factitious. Malingering is difficult to prove unless the patient is directly observed or confesses. Symptoms may not lessen when the reward is attained.

Factitious disorder is a condition in which physical or psychological symptoms are produced intentionally to assume the sick role. This diagnosis is made either by direct observation or by eliminating other possible causes. The presenting complaint, often a symptom complex that mimics a known syndrome, can include subjective complaints (abdominal pain), falsified objective signs (blood in urine), or self-inflicted injury. It can also be an exaggeration of symptoms of existing conditions (e.g., pseudoseizures in patients with epilepsy). This condition often leads to unnecessary medical tests, procedures, and treatments, including surgeries. The patient, usually female, may not know the motivation for feigning symptoms. Approximately 1% of patients who receive psychiatric consultation have factitious disorder. The most common comorbid condition is substance abuse.

The evaluation of factitious disorder must include a thorough medical evaluation or a psychiatric evaluation if the symptoms are psychiatric. Approximate answers reported during a mental status examination are most commonly found in factitious disorders. This term is applied when patients give close answers (e.g., 20 − 3 = 18).

Munchausen syndrome by proxy (MBP) is a form of factitious disorder by proxy, where a parent mimics symptoms in his or her child. The motivation is believed to be a psychological need to assume a sick role through the child. MBP is a type of child abuse. Boys are more commonly abused in this way, and neonates and preschoolers are the most common victims. The overwhelming majority of MBP perpetrators are women, usually the child’s mothers. Of these mothers, more than 72% have a history of factitious disorder or a somatoform disorder. Up to 80% of involved parents have some health care background.

Both factitious disorder by proxy and pediatric condition falsification are needed for diagnosis. Pediatric condition falsification occurs through simulation (i.e., false reporting of symptoms or contaminating laboratory samples) and/or production of symptoms. The estimated incidence of MBP is 2 to 2.8 per 100,000 in children younger than 1 year of age and 0.4 per 100,000 in children younger than 16 years of age. The mean age of children with MBP is 1 to 2 years.

Differentiating MBP from other cases of factitious illness is crucial, because children with MBP are in much greater danger. Mortality may be as high as 33% when suffocation or poisoning is involved. Siblings of these children are also at risk; 61% have symptoms similar to the victims, and 25% die. Virtually all children suffer serious psychological sequelae from this form of abuse, and 8% of victims of MBP suffer long-term morbidity. It is likely that as many as 5% of patients in allergy clinics and 1% of those in asthma clinics have MBP.

Common presenting symptoms include vomiting, diarrhea, respiratory arrest, asthma, seizures, incoordination, fever, bleeding, failure to thrive, rash, hypoglycemia, and loss of consciousness. Simulation of psychiatric disorders is rare.

Nearly 75% of the morbidity to the child occurs in hospitals from invasive procedures. Once confronted with negative test results or discharge planning, the perpetrators may become intensely enraged and acutely suicidal. They may initiate legal action. The treatment team should take appropriate precautions. Treatment involves protecting the child from further abuse and reporting to child protective services.