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.  Physical symptoms or painful complaints of unknown etiology are fairly common in pediatric populations.  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.  The nature of these symptoms requires an integrated medical and psychiatric treatment approach to successfully decrease the impairment caused by these disorders. 
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.  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.  Somatoform disorders are associated with poor school performance and attendance and overall impaired functioning.  Appropriate and timely diagnosis combined with collaborative psychiatric and medical interventions may decrease significant long-term morbidity and suffering.
The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV)  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, and hypochondriasis. 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.  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.
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.  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  :
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.  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.  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 meet DSM-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.
This DSM-IV disorder involves unexplained symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition.  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. 
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.  Females predominate among adolescents with conversion disorders. Recent family stress, unresolved grief reactions, and family psychopathology occur at a higher frequency in conversion symptoms.  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. 
Anxious families preoccupied with disease, chaotic families, and overbearing and conflict-prone parenting styles have all been associated with conversion disorder.  The onset of symptoms can be precipitated by stressful family events, including divorce and death of a loved one.  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.  A strong positive correlation exists between duration of conversion symptoms and the necessary treatment time to resolve them. 
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. 
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. 
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.
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. 
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.  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.  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. 
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.  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. 
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.  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. 
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 (BDD) is defined as the preoccupation with an imagined defect in appearance or excessive concern over a slight physical anomaly.  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.  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.  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. 
A high proportion of individuals with BDD report a history of childhood maltreatment, including physical, sexual, and emotional abuse and physical neglect.  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.
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.  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. 
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).  In hypochondriasis, the strong disease conviction acts as the over-evaluated ideal that is characteristic of OCD.  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.
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.
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.  While FDP is not recognized as a separate diagnostic category, the DSM-IV Text Revision does 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 individual’s care, (2) the motivation for the perpetrator’s behavior is to assume the sick role by proxy, and (3) external incentives for the behavior (eg, economic gain) are absent. 
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. 
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
Anxious parents and vulnerable child
Chronically ill child
Factitious disorder by proxy
Some healthcare professionals are not aware of this possible diagnosis  ; 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.
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.
Anxiety disorders (eg, separation anxiety, posttraumatic stress disorders) can present with somatic complaints (eg, headaches, stomachaches, nausea, vomiting).  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.  Somatic complaints appear to be twice as common in children and adolescents who meet DSM-IV criteria for depression than in control subjects,  with the somatic symptoms arising as long as 4 years after the onset of the depression. 
Psychological factors affecting medical conditions
The DSM-IV contains a non–mental 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.
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.  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.  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. 
Chronic fatigue syndrome has been considered to be a possible somatoform disorder.  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.  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.  A viral etiology has been theorized. Presently, chronic fatigue syndrome is viewed as a legitimate physical illness, overlapping with many psychiatric and medical diagnoses. 
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-Barré syndrome.
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.  Difficulty expressing emotional distress verbally is widely thought to underlie the presentation of physical symptoms that cannot be explained in medical terms.  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-to-female ratio of somatic symptoms is nearly equal. However, adolescent girls tend to report nearly twice as many functional somatic symptoms than adolescent boys. 
Stuart and Noyes  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.  Higher levels of anger mood, rumination, and support-seeking coping styles have shown to predict somatic complaints. 
Disengagement, avoidance, and internalizing coping strategies are endorsed more often in children with frequent somatic symptoms.  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.  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. 
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.  In families with somatizing children, functional abdominal pain, anxiety, depression, and other somatic symptoms are common  ; mothers of these youth tend to have a history of irritable bowel syndrome, chronic fatigue, and somatoform disorder. 
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.  Patients with medically unexplained symptoms appear to come from families with a high rate of physical illness during the individual’s childhood. 
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. 
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. 
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 stressors have been demonstrated as one of the most common environmental factors for the development and maintenance of somatic disorders.  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. 
A thorough psychiatric interview is key to diagnosing these disorders.  Some rating scales for children have been developed to aid in the assessment of physical symptom clusters and somatization. The Children’s Somatization Inventory (CSI)  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  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.  Illness Attitude Scales and Soma Assessment Interview (SAI) are parental interview questionnaires. 
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 child’s symptomatology.  Given that somatic complaints generally present initially in the medical setting,  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. 
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.”  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.
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 patient’s distress. Characteristics of approaches reported to have good outcome include an attitude of belief in the child’s symptoms, moving the family towards a psychological understanding, and instituting a multidisciplinary rehabilitative approach. 
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. 
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.  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. 
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.  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 child’s 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.
The following recommendations are adapted from Calabrese (1998),  Campo and Negrini (2000),  Campo and Fritz (2001),  Taylor and Garralda (2003),  DeMaso and Beasley (2005),  Shaw and DeMaso (2006),  Shaw et al (2010),  and Ibeziako et al (2011)  :
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.
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.
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Eve G Spratt, MD, MSc Professor of Pediatrics and Psychiatry, Division of Developmental Pediatrics, Medical University of South Carolina; Director, Pediatric Consultation Liaison Psychiatry, Medical University of South Carolina Children’s Hospital at Charleston
Eve G Spratt, MD, MSc is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry
Disclosure: Nothing to disclose.
Patricia I Ibeziako, MBBS Assistant Professor of Psychiatry, Harvard Medical School; Director, Psychiatry Consultation Service, Children’s Hospital Boston
Patricia I Ibeziako, MBBS is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, International Association for Child and Adolescent Psychiatry and Allied Professions
Disclosure: Nothing to disclose.
David R DeMaso, MD Gardner Monks Professor of Child Psychiatry and Professor of Pediatrics, Harvard Medical School; Psychiatrist-in-Chief and Chairman of Psychiatry, Boston Children’s Hospital
David R DeMaso, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, American Psychiatric Association
Disclosure: Received royalty from Am Psychiatric Press Inc for book.
Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference
Disclosure: Nothing to disclose.
Caroly Pataki, MD Health Sciences Clinical Professor of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, David Geffen School of Medicine
Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, Physicians for Social Responsibility
Disclosure: Nothing to disclose.
Chet Johnson, MD Professor of Pediatrics, Associate Director and Developmental-Behavioral Pediatrician, KU Center for Child Health and Development, Shiefelbusch Institute for Life Span Studies; Assistant Dean, Faculty Affairs and Development, University of Kansas School of Medicine
Chet Johnson, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.
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