Abstract
Somatic symptom disorder is a complex condition linking distress in the mind to physical distress in the body. However, in addition to the disorder itself, experienced clinicians know that children and youth frequently experience somatizing symptoms. With an increasing prevalence of anxiety in the pediatric population, symptoms attributable to process of “somatizing” are common, and early identification and rapport building to address the root causes of a child’s distress are critical for a good outcome. In the acute care setting, clinicians are often reluctant to make the diagnosis of somatization. Part of the challenge is encouraging clinicians to see that somatization is not a “diagnosis of exclusion.” We want to encourage clinicians to routinely consider risk factors for somatization in their histories, actively discuss the mind–body connection with patients and families, and include somatization in a carefully considered differential diagnosis. The more we can break down the siloing of physical from mental health, the better we will serve our patients.
Keywords
Somatization is a ubiquitous experience of physical symptoms resulting from stress or emotions. Most people can remember a time they were nervous and felt nauseous or were embarrassed and felt their face flush. The mind–body connection is very real and cannot be discounted in modern times when we often overlook the impact of our emotions and stress on our health and well-being. Children commonly experience stress and anxiety in a physical way, and symptoms of physical distress can cause significant worry for both the child and their caregivers. When these concerns are not addressed, symptoms can become persistent and pervasive in the child’s life and family. Somatic symptoms are associated with iatrogenic injuries (through over-investigation or treatment), functional impairment (Campo et al., 1999), and unnecessarily high health care costs through high service utilization (Belmaker et al., 1985).
When somatization interferes with daily life, it requires treatment. Experienced clinicians know that children and youth frequently experience somatization. With an increasing prevalence of anxiety in the pediatric population, symptoms attributable to process of “somatizing” are common, and early identification and rapport building to address the root causes of a child’s distress are critical for a good outcome. The majority of children with somatizing symptoms can be treated by their family doctor or pediatrician with a collaborative, family-based approach that creates understanding and builds capacity.
When you consider that children with somatizing disorders account for 10%–15% of medical visits in primary care and are the second leading cause of psychiatry consultation in children’s hospitals, we should accept that all clinicians must be experts in making the diagnosis and explaining the disorder to their patients (Ibeziako et al., 2019). We must routinely consider risk factors for somatization in our histories, actively discuss the mind–body connection with patients and families, and include somatization in a carefully considered differential diagnosis. We must have language to educate children and families in a supportive way around this diagnosis. The literature tells us that both physicians and families experience frustration with this diagnosis as many clinicians feel they lack the skills and training to make the diagnosis and discuss it, and families are therefore left feeling uncared for and frustrated (Malas et al., 2017).
In the acute care setting, clinicians are often reluctant to make the diagnosis of somatization. It can be incorrectly viewed as a “diagnosis of exclusion,” making clinicians reluctant to consider it in their initial differential diagnosis. The diagnosis can be seen as lacking the same rigor as “appendicitis” or “pneumonia,” and when not presented with the same confidence as other more “medical” diagnoses, we can inadvertently set the tone with a family that this diagnosis is somehow inferior to a “medical” one. When clinicians lack the language and confidence to make a diagnosis of somatization, we can become part of the process that medicalizes the child. This changes the quality of our relationship with the child and family and makes them feel like “we don’t know” or “gave up” when we finally present somatization as an explanation for their physical suffering.
Even in the emergency department, the biopsychosocial approach is critical to accurately diagnosing our patients and connecting them with the right care to restore their health. Part of the challenge is encouraging clinicians to see this not as a “diagnosis of exclusion” but as a diagnosis no different than any other diagnoses they would consider. Not addressing our patients in entirety leads to over-investigation, a sense of despair in patients that no one can “find the answer,” and an underestimation of the role mental health and psychosocial issues play in the health of the children and youth. When we educate children and families with language that is empowering and connect them to appropriate resources and follow-up, we can often impact their symptoms and change the direction of their experience.
When the symptoms progress, a formal psychiatric diagnosis should be made, and a multidisciplinary, integrated team becomes essential in the management. The primary diagnoses that capture somatization are somatic symptom disorder and conversion disorder (functional neurological symptom disorder). Other diagnoses are psychological factors affecting other medical conditions (when a psychological or behavioral factor affects another medical condition), other somatic symptom and related disorders (SSRDs; for, for example, pseudocyesis—the false belief of being pregnant associated with physical symptoms), and the unspecified SSRD (American Psychiatric Association, 2013). However, it should be noted that other psychiatric diagnoses account for somatization as part of the presentation. For example, muscle tension is part of diagnostic criteria for generalized anxiety disorder. It is important to remember that somatization can occur alongside another medical diagnosis and the two do not need to be mutually exclusive.
There is some debate as to whether to label somatization directly as there is the fear that this may cause the patient and families to disengage with care. At times when the diagnosis is not clear or there is concern that the family is not completely receptive to the diagnosis, using the phrase “there is a component of somatization” allows treatment for somatization to occur concurrently with medical work-up. Our fear in not labeling the symptom directly as somatization is that it can lead to misunderstanding regarding treatment course and also perpetuate stigma toward mental illness. We do recognize that the general pediatric setting can be different from the child psychiatry setting, in that inherent to consenting to psychiatric evaluation, there is generally already some awareness of the possibility of a mental health component. In the pediatric setting, frequently more simple presentations resolve with reassurance, and the need for more formal diagnosis and longer discussion is not required unless the child is repeatedly presenting.
Somatic symptom disorder is a complex condition linking distress in the mind to physical distress in the body. By definition, the disorder occurs when medical tests are normal or do not explain the person’s symptoms, and history and physical examination do not indicate the presence of a known medical condition that could cause them. In addition, the patient must be excessively worried about their symptoms and the worry must be out of proportion to the severity of physical complaints and persist for over 6 months (American Psychiatric Association, 2013).
One of the barriers to identifying SSRDs in the acute care setting is lack of understanding and training in approaching patients with somatic symptoms. In addition, the limited literature to support the treatment of SSRDs in youth can also contribute to physicians’ feelings of an inability to present an appropriate treatment path. Physicians are not adequately compensated for the amount of time these patients take, and thus with financial and other clinical pressures, the system does not support the patients receiving the care that they require. Another challenge is that although this diagnosis can be made solely by a pediatrician, in more complex presentations, the collaboration between a psychiatrist and a pediatrician can allow for more diagnostic certainty, and this can be a barrier in certain non-tertiary settings where child psychiatry may not be easily accessible.
Risk factors
Factors that can increase suspicion for somatization include a history of somatizing symptoms (frequent stomach aches before school is a common example), correlation with recent stressful event, cultural factors, and excessive concern given the severity of the presentation. Familial factors include somatization of parents, organic disease of a close relation, psychopathology of close family members, dysfunctional family climate, and traumatic experiences in childhood and insecure attachment (Schulte & Petermann, 2011). It has been shown that the personality trait of neuroticism, harm avoidance, and general worry will increase risk of somatization (American Psychiatric Association, 2013). Frequently, children with somatizing symptoms have a history of expressing emotional distress in a physical manner, and inquiring about prior reactions to stressful life events may illuminate an inappropriate response. Inquiring specifically about family conflict (including parental marital concerns) is recommended (Salmon et al., 2003). It is also important to evaluate the primary versus secondary gain for a symptom and exclude malingering or factitious disorder in the evaluation.
Two assessment tools that may aid in the diagnosis are the Children’s Somatization Inventory and the Functional Disability Inventory (both are validated for use in children) (Campo & Fritz, 2001; Walker & Greene, 1991).
Strategies
When a diagnosis is made, using clear and consistent language in discussing somatization is key to family and patient acceptance and understanding. In general, we encourage a discussion normalizing the experience of somatization through use of examples (facial flushing or butterflies in stomach when nervous) and explaining the mind–body connection. Once the patient and family have acknowledged their understanding of the existence of this phenomenon, the explanation for the patient’s symptoms is usually better received. Avoiding language implying symptoms are “not real” or “all in their head” or that the patient has conscious control “faking it” is also critical as these are frequent terms patients with SSRDs hear from medical providers and allied health providers. When possible, including all providers involved can allow for the diagnosis to be better received. Following up the meeting with provision of written or visual material can also reinforce and legitimize the diagnosis (as many families would not have heard of somatization prior to the meeting).
Another point is many patient and families will deny the presence of any type of emotional stress for “they are always happy” and “they never seem upset.” However, at times when assessing a new diagnosis of somatization, it can become clear that there is an identifiable stressor. Do note that the patient may not always self-identify this stressor as the physical symptom may be a manifestation of an unrecognized emotion. In situations where a stressor is identified, it is worth exploring with the family a way to have that stressor more manageable and balanced. An example is in the case of an overscheduled student athlete; potentially a recommendation might be to reduce the academic load or remove a training session. In general, not completely removing the stressor is recommended as this can reinforce the unconscious avoidance behavior. Following the example above, we would not recommend removing the patient entirely from school.
A large portion of the treatment of somatization for children involves the family and understanding how family dynamics may influence the symptom. Emotional expression could be discouraged in some families, or in some cultures emotional distress is communicated through expression of physical symptoms (Craig et al., 2002). In cases where parental involvement may be reinforcing the symptom, ensuring the family is aware of these factors and providing age-appropriate responses are crucial. An example is when a somatic symptom has dramatically increased the attention and time spent with a caregiver—it is worth exploring whether this is unconsciously reinforcing.
When a diagnosis of somatization is made, it is very important that the primary medical physician remains involved in the case. This allows the family and mental health providers to liaise as physical symptoms arise and also provides support to the patient. This also helps prevent the family from seeking care from multiple or duplicate providers.
Treatment
In the general medical setting, patients are traditionally managed with reassurance, education, and frequent follow-up and accommodation to identified stressors. Consideration can be given to connecting the child or youth with a community-based counselor depending on their presentation, but especially if there is a comorbid diagnosis of anxiety or depression. Many excellent online resources exist, including websites and apps that focus on anxiety and mindfulness activities. It can also be helpful to ensure the child’s overall mental wellness is optimized by addressing their sleep habits, nutrition, and exercise and screen time. It can be helpful to provide materials about somatization to educate the family and further legitimize the diagnosis.
A more comprehensive plan should address symptom management, emotional expression/awareness, family dynamics, and daily activities. In general, cognitive behavioral therapy is the recommended therapeutic approach (Kroenke, 2007). The professional handbook developed by a group from Canada (Newlove et al., 2019) very comprehensively addresses the individual elements above and is an excellent resource for clinicians and families. When symptoms are more complex or long-lasting, involving a multidisciplinary and integrated team of mental health, rehabilitation services, allied health providers, complementary medicine providers, and medical specialists can provide a robust treatment plan that treats both mental health and medical conditions (Ibeziako et al., 2019).
A recent clinical pathway for the diagnosis and treatment of somatic symptoms and related disorders in hospital was recently published in Hospital Pediatrics that provides guidance that can be applied both in and out of hospital (Ibeziako et al., 2019). Key themes that emerged are the importance of early identification of somatization during a simultaneous process of physical and mental health evaluations. Patients are more accepting of the diagnosis when the involvement of mental health professionals is normalized. A delay in the involvement of mental health professionals can create a feeling of having been “handed off” when clinicians cannot find a “medical” explanation for symptoms, further stigmatizing the patient and their symptoms. When an interdisciplinary team is available to meet and review the diagnosis, it can help to ensure that the patient and family’s expectations align with their health care team. Communication is critical to keeping everyone on the same page and the message clear so that the child and family can avoid the confusions and frustration that come from receiving mixed messages often through inconsistent use of language (Ibeziako et al., 2019).
Conclusion
Mental and physical health are not exclusive from one another. In Western medicine, the separation of the mind and the body has led to parallel systems for physical illness and mental illness and perpetuated the view that physical illness is “real” and that mental illness is somewhat less legitimate or not real (Fabrega, 1990). This separation of the mind and body has stigmatized mental health and is a false dichotomy—as health care providers we must work to reintegrate our practices to address patients holistically and recognize the mind–body connection in all practice settings. The more we break down silos in our views of health and view our patients from a holistic perspective, the more effective we can be in restoring health and function.
Footnotes
Practical resources
For families
For clinicians
Video—body talk: stories of somatization
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.