Definitions and classification
Somatization is defined as the presence of a physical symptom inconsistent with a clear physical illness (3, 4). Somatization is a common and, most of the times, benign event in childhood and adolescence (5). However, when symptoms have a considerable negative impact on patients’ feelings and behaviours, somatization becomes a disorder. Pain is the most commonly reported symptom by patients with somatization or SSD (6, 7).
The Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5) defines the somatic symptom disorder (SSD) as a condition in which the patient’s subjective reporting of physical symptoms is associated with distress, disruption of daily functioning and disproportionate thoughts, feelings and behaviors related to such symptoms (8). Table 1 shows the diagnostic criteria for somatic symptom and related disorders, according to the DSM-5. In children and adolescents with a marked limitation in daily activities lasting for at least one month, an SSD diagnosis can be made.
Table 1
Diagnostic and Statistical Manual of Mental Disorders 5th Edition diagnostic criteria for somatic symptom and related disorders.
Somatic Symptom Disorders and Related Disorders Somatic Symptom Disorder: - One or more somatic symptoms - Excessive thoughts, feelings, or behaviors related to the somatic symptoms or other associated symptoms such as excessing thoughts regarding the seriousness of symptoms, anxiety about the symptoms, or excess time and energy devoted toward the symptoms. - The patient is persistently symptomatic and the somatic symptoms may change over time (typical duration of six months) - Specifiers: with predominant pain, persistent, mild, moderate, severe Illness Anxiety Disorder: - Preoccupation with having or acquiring illness - Somatic symptoms are either mild or not illness: - If a medical condition is present or there is a high risk of a medical condition, the preoccupation is excessive and disproportionate to the risk of illness - High level of anxiety about health - Performs excessive health-related behaviors or maladaptive avoidance - Preoccupation with illness lasting at least six months, although the specific illness that is feared may change over that time - Specifiers: care-seeking type, care-avoidant type Functional Neurologic Symptom Disorder (Conversion Disorder): - At least one symptom of altered voluntary motor or sensory function - Clinical findings are incompatible with patient clinical presentation - Specifiers: - with weakness/paralysis - with abnormal movement - with swallowing symptoms - with speech symptom - with attacks/seizures - with anesthesia/sensory loss - with special sensory symptom - with mix symptom - acute episode (< 6 months), persistent (> 6 months) - with psychological stressor, without psychological stressor Psychological Factors affecting General Medical Condition: - Presence of medical condition - Psychological or behavioral factors adversely affect the medical condition by potentially (1) interfering with treatment, (2) increasing health risk, (3) influencing underlying pathophysiology, and/or (4) close temporal association between these factors and exacerbation of illness - Specifiers: mild, moderate, severe, extreme Factitious Disorder: - Falsification of physical or psychological signs or symptoms associated with identified deception - Presents self to others as ill - Deceptive behavior can be present without identified external gains - Specifiers: single episode, recurrent episode, imposed on self or imposed on other Shared features: - Not better explained by another mental disorder or physical health condition - Symptoms cause significant impairment and/or distress |
Reasons for a clinical practice
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Psychosomatic pain is a common occurrence in childhood and adolescence. Epidemiological studies show that 15–20% of children and adolescents refer to primary care due to somatization (9). One study conducted at a tertiary level pediatric emergency department showed that 8.6% of children who complained of pain met the diagnostic criteria for SSD (10).
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Children and adolescents with psychosomatic pain and SSD show a worse quality of life, spend more days at home, miss more days of school, use the health care system more frequently when compared to healthy peers and to patients affected by organic diseases (6).
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Children and adolescents with psychosomatic pain and SSD, complain physical symptoms, thus they refer more frequently to primary care, emergency services and medical wards, than mental health services (6). EDs may be the only place where these families seek medical assistance. Therefore, pediatricians and emergency physicians should be trained to identify, address, and manage these patients.
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An appropriate approach to these patients could reduce the inappropriate use of emergency services and related costs (11).
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To our knowledge, there are no clinical guidelines focused on the approach and management of patients with psychosomatic pain and SSD at the ED.
Recognition and diagnosis
The diagnosis of somatization and SSD should be a positive diagnosis and not an exclusion one. ED physicians should be fully aware that this diagnosis should also be made in an ED setting. Validated and internationally recognized diagnostic criteria are available and should be used (Table 1).
Despite the absence of pathognomonic markers of these conditions, some specific features of patients with somatization and SSD are available and should be considered clues to the diagnosis (6, 12–15):
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Adolescence age
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Female sex
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Presence of an already diagnosed chronic disease
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Presence of mild intellectual disability
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Previous psychiatric diagnosis, mainly anxiety disorder or depression
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History of high family or social expectations on the subject
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History of high conflictual level inside the family
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Familiarity with psychiatric disorders
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History of chronic school absenteeism or bullying and victimization
The emergency physician should recognize the specific features of psychosomatic pain:
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Psychosomatic pain may be present in any part of the body, but is more commonly reported as headache or abdominal pain.
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It could be present simultaneously in multiple parts of the body or change localization with time.
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Usually, it starts as a recurrent pain and then it presents every day, and this continuous presence leads to a progressive limitation of the subject’s normal daily activities.
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Common analgesic drugs are ineffective, including opioids and adjuvants such as gabapentin and neuroleptics.
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It lasts for months, sometimes years, without a useful therapy.
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Frequently, it is associated with marked fatigue.
Patients with SSD present long-lasting physical symptoms, causing distress and considerable limitation of their everyday activities. The key to diagnosis is that these patients show a disproportionate functional impairment caused by their symptoms. They are unable to frequent school, pursue hobbies, practice sports. Usually, they have an impaired social life with peers and spend most of the time at home. They may develop a real disability made of incongruous medicalization or inappropriate use of medical aids such as wheelchair or crutches.
Functional impairment in these patients can negatively impact on the entire family, with parents spending much time dealing with their children’s symptoms.
Commonly, patients with somatization and SSD have a medical history remarkable for many already performed diagnostic tests and specialistic evaluations, sometimes in different facilities and cities. They may present a notable medical dossier at the visit, collecting the medical report of all their evaluations and tests. These features, as well as, a history of chronic school absenteeism should be considered as highly suggestive of SSD.
Therefore the emergency physician should actively ask about school attendance (14–15). A history of bullying or victimization should be taken in two account, because it is frequently present in patients with SSD.
A substantial percentage of patients with SSD have psychiatric comorbidity, primarily anxiety disorder or depression. Therefore, features suggestive of these conditions should be investigated (16).
The presence of an already diagnosed chronic disease should not be considered as an exclusion factor for the diagnosis (8). On the contrary, according to the most recent diagnostic criteria, SSD diagnosis does not take into account the presence or absence of any organic disease. Moreover, the presence of a documented chronic illness should be thought of as a risk factor for SSD development (17).
Usually, the physical examination of these patients is unremarkable.
Recommended management in the ED
When unrecognized and untreated, SSD could be extraordinarily disabling and might lead to a progressive loss of life and social opportunities for intellectual growth. It may result in a poor adulthood outcome, leading to a permanent functional disability (20, 21). Therefore, the ED setting can represent a unique window of opportunity to identify and support these patients.
At first, the ED physician should learn to actively ask patients and families the appropriate questions to highlight the amnestic features suggestive of somatization and SSD, especially in recognizing the disproportion between reported symptoms, physical examination, and significant functional limitation in daily activities caused by symptoms, accompanied by chronic school absenteeism and social withdrawal.
In case of highly suggestive history and clinical features, diagnostic tests to exclude organic diseases should be limited as much as possible, giving value to the already made diagnostic work-up results. These patients are commonly exposed to an incongruous medicalization and doctor shopping supported by families and even by physicians themselves (22). Remarkably, the emergency physician should have the strength to oppose to an inappropriate request for further investigations and suggest additional diagnostic tests only when substantially required.
Emergency physicians should learn to communicate the diagnosis positively, according to the DSM-5 criteria. Patients and families can be reassured by their word, feeling relieved on the anxiety of suffering from un unknown disease. Reassurance may be enough in mild cases.
On the other hand, doctors should also consider that patient and families may not easily accept such a diagnosis. Therefore, they should dedicate time for explanations, and in some cases have a private conversation with the parents. When available, an evaluation with a child psychiatrist or psychologist could be helpful.
If an acceptance of the diagnosis seems unlikely, a referral to a dedicated service or a hospital admission should be suggested.
In any case, the diagnostic suspect should be mentioned in the ED medical record to facilitate the future physician’s approach and leave an overt trace of the physician’s conclusions. A diagnosis supported by a written explanation of its essential elements should be written on the discharge report.
SSD diagnosis requires a child psychiatrist confirm, but it could be hypothesized and expressed in an ED setting in front of a highly suggestive clinical picture. SSD patients require a multidisciplinary treatment that goes beyond the ED setting. Nevertheless, the emergency physician should know which are the cornerstones of treatment.
Psychological support is fundamental for these patients and families, and the emergency physician should suggest a psychological evaluation or refer them to a dedicated service (23, 24). Psychotherapy aims to divert attention from symptoms, regain functioning and social life, look for possible trigger factors, and learn the coping strategies necessary to deal with this condition.
In general, as more time passes from the onset of symptoms to the diagnosis of SSD, the more severe the case and the higher the impairment level experienced by the patient. In these cases, a hospital admission will be required to activate multidisciplinary support with pediatricians, child psychiatrists, psychologists, nurses and physiotherapists to clarify the diagnosis and to start a funtional “rehabilitation” (23–27).
In the case of discharge, the ED physician should share the clinical opinion and diagnosis with the patient’s general practitioner. General practitioners will play a pivotal role with explanations, follow-up of patients and their families, and could guide the need for further specialistic evaluations. General practioners could also involve all the professional figures that work with children, such as psychologists, school teachers, sports trainers, occupational therapists and child’s life specialists, to coordinate these patients’ care.
Pharmacological treatment is not indicated for these patients, except for psychiatric comorbidities. Psychosomatic pain usually does not respond to common analgesics and neither to major opioids or adjuvants. Therefore, their use is not recommended (27–28).
Furthermore, digital therapeutics and distraction technologies can be prescribed to help alleviate the symptoms that the patient may be experiencing.
Possible pitfalls
Remember to actively ask for school attendance, sport activities and social life with peers.
The presence of an organic disease is not relevant for the diagnosis, and a negative diagnosis: “nothing is wrong in this child” is inappropriate and should be avoided.
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Prescribe analgesics. Pharmacological therapies and, in particular, analgesics are not useful for these patients and should be avoided.
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Not adequately communicating the diagnosis to patients and families, and not reporting it in the ED medical record, preferring a descriptive or vague description of symptoms. A presumptive diagnosis of SSD can be made in the ED setting, according to the criteria of the DSM-5.
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Lacking of awareness that a patient with SSD has a severe condition, a high risk of poor outcomes when not appropriately recognized and managed.
Proper diagnosis in the ED setting could lay the foundation for the healing process. Conversely, a missed diagnosis could prompt families to search for a not understood or unknown disease, contributing to the persistence and amplification of symptoms and inappropriate medicalization.