The assessment and management of children and adolescents who present with medically unexplained symptoms or symptoms in excess of what would be expected for a particular medical illness can be difficult task. According to the Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5), illnesses previously referred to as somatoform disorders are defined as somatic symptom and related disorders.¹ These disorders are classified on the basis of distressing somatic symptoms and excessive thoughts, feelings, or behaviors in relation to these symptoms. Somatic symptom and related disorders form a continuum that can range from pain to disabling neurological symptoms. The physical symptoms are not explained better by another mental illness, are spontaneous in nature, and are not contrived by the child or adolescent.² In addition, a medical condition if present does not fully account for the level of impairment the child is displaying.²

In early childhood, the most common somatic symptoms are recurrent abdominal pain and headaches, while older children tend to experience neurological symptoms, insomnia, and fatigue.² The symptoms can be severe, recurrent, and impairing. Impairment often involves withdrawal and avoidance of everyday responsibilities and stresses.³ As a result, the child and family may have contact with multiple medical providers with the expectation of medical treatment.³

The diagnosis and management of somatic symptom and related disorder often present significant challenges to primary care clinicians and pediatric subspecialists.⁴ The pediatrician trying to formulate an understanding of these symptoms without multidisciplinary support may feel poorly prepared and have little time to assess or treat the somatic concerns.⁵ Somatic symptom and related disorders comprise a small but important number of costly medical visits that increase exposure to unnecessary medical tests and procedures⁶ because of the fear that an organic etiology will be missed.³ This patient population is more likely to present to pediatricians than to psychiatrists, and they disproportionately consume health resources by overutilizing the emergency department, inpatient, and consultation services, and may seek multiple health providers in pursuit of a medical etiology.^3,7,8 To understand the multiple factors that can contribute to the development of somatic symptoms, it is critical to keep in mind the biological, psychological, developmental, and sociocultural factors in the child’s life.

BIOLOGICAL FACTORS

According to the DSM-5, conversion disorder, also known as functional neurological symptom disorder, is one of the somatic symptom and related disorders and is characterized by clinically significant distress leading to impairment in functioning due to a deficit affecting voluntary motor and sensory functioning. The symptoms cannot be better accounted for by another medical condition or mental illness.² Hyper­activity of the anterior cingulate cortex has been found in patients with conversion disorder, along with either increased or decreased activity of the dorsolateral prefrontal cortex.⁹ Patients with non-epileptic seizures have increased activity of neurobiological stress systems with lower heart rate variability at baseline and during recovery from an induced stress condition.^10,11 Decreased heart rate variability is associated with increased arousal and poor emotion regulation.¹² Patients with conversion disorders also have increased diurnal cortisol levels that were not explained by depression, medication, smoking, current seizures, or group differences in sympathetic nervous system activity when compared to controls.¹³

PSYCHOLOGICAL AND SOCIAL FACTORS

Psychological factors that can contribute to the etiology of conversion disorder include attachment, environmental stress, family discord, trauma as well as culture. In several studies, insecure-avoidant attachment behavior was associated¹⁴ with a predisposition for increased complaints of physical symptoms, whereas secure attachment correlated with health-maintaining behaviors.¹⁵ There is often a model for the patient’s symptoms such as a parent or family member. In a study of conversion disorder, a significant proportion of patients had family members who reported having medical conditions with similar presentations.¹⁴ There are times that the patient may be their own symptom model; a common example of this is children with epilepsy who also have pseudoseizures.² Recent family stress, unresolved grief reactions, and family psychopathology occur at a higher frequency in cases of conversion symptoms.¹⁶

External environmental factors such as school stress or change in family situation and internal factors such as coping deficits or poor behavioral self-control are common in children presenting with conversion disorder.¹⁴ Common school stressors in this patient population include bullying, fear of exams, extracurricular activities, as well as beginning the new school year.^14,17 Family dysfunction and less support within the family system are common in children with conversion disorders. A transition within the family system such as death of a family member, birth of a sibling, parental divorce, physical punishment by parents, and an increase in the number of arguments between parents have all been linked to conversion symptoms.^14,17 Conversion symptoms sometimes do not immediately follow a specific stressor, but instead can occur months or years later. One study showed that children with non-epileptic seizures had significantly higher life events and stress scores the preceding year compared to the seizure group and control group.¹⁷

Conversion disorder presents differently in various cultures. The use of nonverbal body language as a way of communication or expression of self in response to interpersonal conflicts may represent a culturally determined and socially learned behavior.⁴

Emerging literature indicates the risk of conversion disorder may be higher in adolescents who have anxiety related to sexual behaviors, sexual orientation, or gender identity.¹⁸ The adolescent may struggle with communicating their internal turmoil due to fear of parental rejection, peer isolation, stigmatization, and victimization.

CLINICAL PRESENTATION

It is estimated that 17% to 30% of patients referred to comprehensive epilepsy centers have non-epileptic seizures.⁷ Studies indicate that episodic loss of consciousness, typically syncope or non-epileptic seizures, and motor functioning, typically abnormal gait or the inability to walk, are the most frequently reported symptoms of conversion disorder in childhood.⁴ Conversion disorder may be accompanied by “la belle indifference,” which is an attitude of disinterest by the patient despite the serious symptoms experienced.² Early diagnosis can prevent symptom fixation and the performance of expensive and sometimes painful invasive procedures.

DIFFERENTIAL DIAGNOSIS

When evaluating a child with conversion symptoms it is important to keep in mind other medical causes that may lead to the same presentation. Thus it is important to consider temporal lobe epilepsy, tumors of the central nervous system, multiple sclerosis, and myopathies. The pediatrician should keep in mind that the presence of a conversion disorder does not exclude the possibility of a physical condition in the same patient.¹⁹

Apart from conversion disorder, other psychiatric disorders may cause similar presentations such depression, anxiety, factitious disorder, and malingering. Factitious disorder involves the intentional production of physical or psychological symptoms or signs to assume the sick role. External incentives for the behavior such as economic gain or avoiding legal responsibility are absent.¹ Malingering occurs when patients intentionally produce false or exaggerated physical or psychological symptoms and are motivated by external incentives such as avoiding work, financial compensation, or obtaining drugs.¹ The disorders of falsification are generally described in adults, although some cases in older children and adolescents have been reported.²⁰ It is not uncommon for depression in children to present as somatic symptoms. Acute stress disorder and symptoms of post-traumatic stress disorder can present with symptoms similar to that of conversion disorder.¹⁹ Conversion symptoms can occur within other somatic symptom disorders with a combination of pain and gastrointestinal, sexual, and pseudoneurologic symptoms.

DIAGNOSTIC EVALUTION

Early diagnosis is important because it avoids unnecessary hospitalization and investigations that result in an economic burden for the family, clinicians, and health system.⁴ Video-EEG monitoring remains the gold standard in diagnosing non-epileptic seizures. EEG monitoring also helps parents to understand the emotional non-electrical nature of these episodes, as the episodes occur in the absence of electrical activity on the EEG.²¹ The use of provocative testing to confirm a diagnosis of non-epileptic seizures is very controversial. The most common method is injecting a placebo, typically saline, that has been described to the patient as an anticonvulsant agent. Proponents of these techniques believe the gains include decreased healthcare cost, shorter time to diagnosis, and the avoidance of adverse effects of use of antiepileptic drugs. Arguments against provocative testing cite ethical concerns of using deception and the damage it may cause the physician-patient relationship.¹¹

Other neuroimaging studies and lumbar puncture with CSF analysis may be indicated in certain types of conversion disorders, although avoiding invasive procedures when possible is preferred. For all types of conversion disorders, a psychiatric evaluation should be conducted in addition to the medical work-up, to assess for biopsychosocial contributing and risk factors that would inform the diagnosis and treatment plan.

BIOLOGICAL FACTORS

According to the DSM-5, pain disorders have been reclassified as somatic symptom disorders with predominant pain, and should be suspected when there are excessive thoughts, feelings, or behaviors in relation to pain symptoms, an intense preoccupation with the pain, and resultant disruption of daily life.² The reactivity and recovery of the nervous system during time of stress can influence the experience of pain.²² Children with recurrent abdominal pain (RAP) exhibit a lower threshold to internal and external pain cues of painful stimuli.¹⁹ In addition, when there is a strong expectation of pain, the anterior insular cortex is activated in proportion to this expectation. Thus the preactivation will predict the subjective intensity of subsequent pain stimulus.²³ In studies of long-term pain, including migraine and tension type headache, there appears to be progressive loss of gray matter density in brain structures involved in registering pain such as the somatosensory cortex, anterior cingulate cortex, and insula. Also, there is loss of gray matter density in structures such as the dorsolateral and medial orbital prefrontal cortex and periaqueductal gray region of the brainstem involved in inhibiting the pain signal.²³

PSYCHOLOGICAL FACTORS

Psychological factors related to pain include temperament, attention biases toward system-related stimuli, and coping strategies that are developed and used by the child.²² Subjective representations of pain can occur as a result of emotional states, thoughts, beliefs, intentions, suggestions, injuries to social or attachment relationships, memories of past injuries, and the emotional state of others.²⁴ Negative emotions such as sadness, fear, or anger can significantly influence how the brain processes pain and can increase the degree of pain felt by the child.²⁴

A recent meta-analysis shows that internalizing symptoms, as measured by parents and self report, is approximately six times more likely to occur in children with recurrent abdominal pain than matched healthy controls.²⁵ Attachment-based theoretical perspectives of pain have portrayed insecurely attached individuals as having a greater risk of developing chronic pain, being less able to internally manage the distress associated with pain and access and maintain external supports and form a consistent therapeutic alliance. This same patient population perceives more negative intent, evokes more negative responses, and may sabotage therapeutic efforts from health professionals. Thus insecure attachment is a risk factor to the adjustment to pain, and patients with this attachment type have poor outcomes from a range of treatment interventions.²⁶