What Is Paediatric Somatic Symptom Disorder?

  • Helen McLachlanMSc Molecular Biology & Pathology of Viruses, Imperial College London

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Paediatric somatic symptom disorder (SSD) is diagnosed in children who have excessive worries over physical symptoms like headaches or abdominal pain. Children may experience excessive thoughts and feelings about these symptoms. This psychological distress is expressed as physical symptoms. 

With paediatric somatic symptom disorder, doctors don’t find a clear physical illness or cause of the symptoms, though the symptoms are real. Children feel distressed over them and this may interfere with their daily life. Often it results in frequent doctor’s visits, increased use of medications and absences from school.1 These bodily symptoms can be temporary in some cases, but for others they may persist. 

Feeling psychological distress as physical distress is known as somatisation. In paediatric settings, somatisation is thought to account for an estimated 25–50% of visits.2 The most common symptoms are headaches and abdominal pain, followed by back pain, pain in the limbs and fatigue. 

Causes and risk factors 

Many factors can contribute to the development of paediatric somatic symptom disorder, including childhood trauma, medical illness or injury, and learning difficulties.1

Coping behaviours 

How we cope with stress impacts our emotional regulation and adjustment to adverse circumstances. Studies have found that children with SSD are described as insecure, internalising and perfectionistic.2 Children that cope with stress by internalising their feelings can struggle with expressing emotion and may convey their emotional distress through physical symptoms. 

Gender

Younger children and females tend to be at a higher risk of developing somatisation.3 Before puberty, somatisation affects both genders equally, but girls show increased rates after puberty. 

Cognitive and learning disabilities 

Children who have cognitive disabilities may not have the social capacity or the emotional language to process ongoing stress and are at higher risk of developing SSD.4 

Childhood illness

A history of physical illness can also be a risk factor for SSD. In these cases, children may experience symptoms of the illness more intensely than is usual, take longer to recover, experience symptoms after the illness has been treated or experience other symptoms unrelated to the illness. The condition can trigger symptoms of SSD even after it’s been treated. 

Genetics 

Families of children with SSD have shown to have higher rates of physical disease. Children living with a mother with chronic illness may be at a greater risk of developing SSD and this may be a result of a genetic predisposition. 

Anxiety and depression rates are also higher in the family of children with SSD. Studies have found that children with SSD have higher rates of anxiety and depressive disorders.1 Feelings like sadness and worry can influence how we feel physical symptoms and contribute to the development of SSD. 

Biological factors 

Children with SSD may be more vulnerable to pain hypersensitivity. Research has found impairments in the brain structures involved in registering pain and perception in children with SSD.1 Children who are hypersensitive to sensory stimuli are also more likely to show signs of somatisation. 

Childhood trauma and stress

Negative life events can predict SSD in older children. Events that can trigger somatisation include the beginning of the school year and falling grades. Bullying is a risk factor for the development of SSD. Childhood trauma like physical abuse, sexual abuse, emotional abuse or neglect is also an important factor. 

Symptoms 

Symptoms of paediatric somatic symptom disorder can be general, gastrointestinal, and neurological.5 They may include:

  • Headaches 
  • Abdominal pain 
  • Back pain
  • Pain in the joints 
  • Chest pain
  • Nausea
  • Vomiting 
  • Bloating 
  • Diarrhoea
  • Difficulty swallowing
  • Feeling a lump in the throat
  • Reduced vision or blindness  
  • Reduced hearing or deafness
  • Seizures
  • Loss of voice (aphonia)
  • Numbness of skin

Diagnosis 

Paediatric somatic symptom disorder can be difficult to diagnose. If children have physical symptoms that cause them to miss out on school and other activities, it’s important to see a doctor. Doctors may carry out a physical exam and ask questions about a child’s symptoms. A diagnosis of SSD does not mean that the child may not have a physical illness. It’s possible to have SSD and a physical illness at the same time. Often SSD diagnosis can require a team of healthcare professionals, like a paediatrician or a psychiatrist, to evaluate the case. If SSD is suspected, doctors may request a mental health specialist to consult on the case to understand the cause of the child’s distress and how best to help them. 

Treatment 

Paediatric somatic symptom disorder is treated with psychotherapy.1 Cognitive behavioural therapy (CBT) is a type of therapy that can help children and family members identify thought patterns that reinforce the symptoms. Through CBT techniques like biofeedback and relaxation training, children will learn strategies that allow them to have more control over their emotions and symptoms and learn to deal with stressful situations more effectively.

CBT might also be combined with physical rehabilitation. This can treat actual physical effects of SSD, if the symptoms have resulted in reduced mobility in patients. Sometimes, medications like selective serotonin reuptake inhibitors (SSRIs) might be recommended by doctors to treat anxiety or mood disorders like depression, as these conditions can make the physical symptoms worse.  

Related disorders 

In paediatric somatic symptom disorders, children show symptoms which can be similar to other disorders. These include:

  • Conversion disorder
  • Illness anxiety disorder  
  • Factitious disorder imposed on another (or Munchausen syndrome by proxy) 
  • Factitious disorder imposed on self (or Munchausen syndrome)

Conversion disorder 

Conversion disorder, also known as functional neurological disorder, is a mental health condition that results in physical symptoms.6 Just like children with paediatric somatic symptom disorder, patients with conversion disorder spend a lot of time thinking about their symptoms and feel very anxious about them. In conversion disorder, one of the symptoms is brain-related. Symptoms of conversion disorder include non-epileptic seizures, pain, muscle tension, spasms or tremors, and disruptions of the senses, like tunnel vision, hearing loss or numbness. Conversion disorder is diagnosed when these symptoms interfere with daily life like work and relationships. It can affect children and adults. 

Illness anxiety disorder  

Illness anxiety disorder is also known as hypochondriasis or health anxiety. This is where individuals worry excessively that they may be seriously ill.7 People with this condition might worry despite having no physical symptoms, or they may believe that minor symptoms are signs of an illness. Individuals may constantly check their body for signs of illness, frequently make medical appointments,avoid care out of fear of being diagnosed with an illness, and avoid people and activities out of fear of health risks. This distress can disrupt daily life and some people can become severely depressed. It is treated with CBT and medications that help relieve anxiety and depression. 

Factitious disorder imposed on another (FDIA)

FDIA occurs when a person acts like someone they are caring for has an illness even though they are not actually sick. People with FDIA lie about an illness in someone else.8 This person is usually someone dependent on them, like a child or an elderly or disabled adult. This mental illness is dangerous as it can lead to unnecessary medical testing or procedures on someone that isn’t sick. Often, people with FDIA demonstrate medical knowledge, accept invasive procedures for diagnosis without concern and seek out attention and approval from medical staff. The dependent of someone with FDIA can have normal results in response to tests by doctors, have medical conditions that don’t seem to respond to treatment and have a history of hospitalisations.  When children are involved, FDIA is considered child abuse. It is more common in mothers, though it can also be seen in fathers.

Factitious disorder imposed on self (FDIS)

Previously known as Munchausen syndrome, this disorder is when a person deceives others by pretending to be ill or deliberately causing symptoms of an illness in themselves.9 People with FDIS may travel from hospital to hospital seeking treatment for different illnesses. They do not do this for financial gain or to get out of work; rather, they have a need to be seen as sick and want people to care for them. People with FDIS might injure themselves, have extensive medical knowledge and show a willingness to undergo medical tests and procedures. 

Outlook

Many children benefit from treatment and for some, symptoms will disappear. During times of change or stress, symptoms can reappear or intensify, but being aware of this can help prevent this or aid a smoother recovery if symptoms reoccur. 

Summary

Paediatric somatic symptom disorder is a condition that results in physical symptoms without an obvious medical cause. Children with this disorder think and worry over their symptoms excessively, to the point that it disrupts their daily life, leading to absences in school and disengagement in activities they usually enjoy. Throughout childhood it affects males and females equally, but after puberty it is more common in females. Many factors can contribute to its development including individual coping behaviours, childhood trauma, genetics and cognitive disabilities. Treatment for the disorder often requires a multidisciplinary approach to support children in managing their anxiety and symptoms and returning to a normal routine.

References

  1. Malas N, Ortiz-Aguayo R, Giles L, Ibeziako P. Pediatric somatic symptom disorders. Curr Psychiatry Rep [Internet]. 2017 Feb 11 [cited 2023 Nov 15];19(2):11. Available from: https://doi.org/10.1007/s11920-017-0760-3
  2. Andresen JM, Woolfolk RL, Allen LA, Fragoso MA, Youngerman NL, Patrick-Miller TJ, et al. Physical symptoms and psychosocial correlates of somatization in pediatric primary care. Clin Pediatr (Phila) [Internet]. 2011 Oct [cited 2023 Nov 15];50(10):904–9. Available from: http://journals.sagepub.com/doi/10.1177/0009922811406717
  3. Bujoreanu S, Randall E, Thomson K, Ibeziako P. Characteristics of medically hospitalized pediatric patients with somatoform diagnoses. Hosp Pediatr. 2014 Sep;4(5):283–90. Available from: https://pubmed.ncbi.nlm.nih.gov/25318110/
  4. Kingma EM, Janssens KAM, Venema M, Ormel J, de Jonge P, Rosmalen JGM. Adolescents with low intelligence are at risk of functional somatic symptoms: the trails study. Journal of Adolescent Health [Internet]. 2011 Dec 1 [cited 2023 Nov 15];49(6):621–6. Available from: https://www.sciencedirect.com/science/article/pii/S1054139X11001558
  5. Administration SA and MHS. Table 3. 31, dsm-iv to dsm-5 somatic symptom disorder comparison [Internet]. 2016 [cited 2023 Nov 15]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t31/
  6. Peeling JL, Muzio MR. Conversion disorder. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 Nov 15]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK551567/
  7. French JH, Hameed S. Illness anxiety disorder. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 Nov 15]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK554399/
  8. Faedda N, Baglioni V, Natalucci G, Ardizzone I, Camuffo M, Cerutti R, et al. Don’t judge a book by its cover: factitious disorder imposed on children-report on 2 cases. Front Pediatr [Internet]. 2018 Apr 18 [cited 2023 Nov 15];6:110. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5915702/
  9. Carnahan KT, Jha A. Factitious disorder. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 Nov 15]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK557547/

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This content is purely informational and isn’t medical guidance. It shouldn’t replace professional medical counsel. Always consult your physician regarding treatment risks and benefits. See our editorial standards for more details.

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