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.
PATHOPHYSIOLOGY: CONVERSION DISORDER
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 ...