Somatic symptom and related disorders (SSRDs) make up a new category in the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 which replaces the somatoform disorders from DSM-IV with the intent to eliminate diagnostic overlap across disorders. While DSM-IV emphasized medically unexplained symptoms, the current version allows for unexplained symptoms and those that may accompany diagnosed medical disorders. SSRDs involve physical symptoms (pain or loss of function), may occur in the context of a physical illness, and are identified by symptoms that go beyond the expected pathophysiology, affecting the child’s school, home life, and peer relationships. SSRDs are often associated with psychosocial stress that persists beyond the acute stressor, leading to the belief by the child and family that the correct medical diagnosis has not yet been found.

The prevalence of SSRDs in children is not clearly known and represents only a minority of outpatient visits in the pediatric population. Adolescent girls tend to report nearly twice as many functional somatic symptoms as adolescent boys, whereas prior to puberty the ratio is equal. Affected children are more likely to have difficulty expressing emotional distress, come from families with a history of marital conflict, child maltreatment (including emotional, sexual, physical abuse), or history of physical illness. In early childhood, symptoms often include recurrent abdominal pain (RAP). Later, headaches, neurological symptoms, insomnia, and fatigue are more common.

Explainable medical conditions and an SSRD (e.g., seizures and pseudoseizures) can coexist in up to 50% of patients and present difficult diagnostic dilemmas. The list of systemic medical disorders that could present with unexplained physical symptoms includes chronic fatigue syndrome (CFS), multiple sclerosis, myasthenia gravis, endocrine disorders, chronic systemic infections, vocal cord dysfunction, periodic paralysis, acute intermittent porphyria, fibromyalgia, polymyositis, and other myopathies.

Depression is a common comorbid condition and frequently precedes the somatic symptoms. Anxiety and panic also commonly present with somatic complaints. Disorders included in the SSRD group include somatic symptom disorder (SSD), illness anxiety disorder, conversion disorder, factitious disorder, and psychological factors affecting other medical conditions. The diagnostic criteria for SSRDs are established for adults and need additional study in pediatric populations.

SSD typically involves one or more somatic symptoms that are distressing or result in significant disruption in daily life. The criteria used to diagnose this disorder are listed in Table 16.1 . Individuals with SSD include the majority of those previously diagnosed with somatization disorder and hypochondriasis. Key symptoms of the disorder are excessive thoughts, feelings, or behaviors regarding the somatic complaint (e.g., excessive fatigue or pain). Prevalence estimates for SSD in children are unclear; however, between 5% and 7% of adults may be identified with SSD, with a greater proportion being female.

Illness Anxiety Disorder ( Table 16.2 ) involves children who have a preoccupation with having or acquiring a serious illness. Typically, somatic symptoms are not present, and there is a high level of anxiety about health status. The child may be alarmed by illness in others, and they seldom respond to reassurance regarding their health. An elevated rate of medical utilization is common, and individuals may repeatedly seek reassurance from family, friends, and medical staff regarding their health. Approximately 25% of those previously diagnosed with hypochondriasis fall into this disorder and can be distinguished from those with SSD by their high anxiety and absence of somatic symptoms. Prevalence estimates in children are unknown due to the new DSM classification system; however, there appears to be similar prevalence rates in boys and girls.

TABLE 16.2

Criteria for Diagnosis of Illness Anxiety Disorder

A. Preoccupation with the idea that one has or will get a serious illness. B. Somatic symptoms are not present or, if present, are only mild in intensity. If another medical condition is present or there is a high risk for developing a medical condition (e.g., strong family history is present), the preoccupation is clearly excessive or disproportionate. C. There is a high level of anxiety about health, and the individual is easily alarmed about personal health status. D. The individual performs excessive health-related behaviors (e.g., repeatedly checks his or her body for signs of illness) or exhibits maladaptive avoidance (e.g., avoids doctor appointments and hospitals). E. Illness preoccupation has been present for at least 6 months, but the specific illness that is feared may change over that period of time. F. The illness-related preoccupation is not better explained by another mental disorder, such as somatic symptom disorder, panic disorder, generalized anxiety disorder, body dysmorphic disorder, obsessive-compulsive disorder, or delusional disorder, somatic type.

Specify whether: Care-seeking type: Medical care, including physician visits or undergoing tests and procedures, is frequently used. Care-avoidant type: Medical care is rarely used.

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