Hypochondriasis is the preoccupation with the fear ofhaving a serious disease based on misinterpretation of bodilysymptoms and functions. This fear should be present for6 months. The presenting complaint is a physical sign orsymptom, which is normal but is interpreted by the patientto indicate disease despite reassurance of a physician (e.g., atension headache perceived as a brain tumor). This diagnosisis more commonly seen in late adolescence and adulthood. An underlying depression or anxiety disorder may be relatedto the symptoms. Prevalence of obsessive-compulsive disorder (OCD) is four times greater than in the general population. When the belief or preoccupation is limited to animagined defect in appearance, the diagnosis is body dysmorphic disorder (BDD), not hypochondriasis.
Body dysmorphic disorder is a preoccupation with animagined or slight defect in physical appearance that causesclinically significant distress or impairment in functioning. It is usually seen in adolescents (the male-to-femaleratio being almost equal) and is distinguished from common developmental preoccupations with appearance bythe presence of clinically significant distress and/or impairment in functioning. Any bodily area can be a focus, butexcessive concerns about the skin (scars and acne) and body shape are common. Because BDD can be associatedwith shame and the need for secrecy, the diagnosis may bemissed unless clinicians ask directly about symptoms. Parents of children with BDD report excessive mirror checking, grooming, attempts to camouflage a particular bodyarea, and reassurance-seeking. Patients may cause self-injury as a consequence of attempts to fix the perceived flaw.
Many of these patients have had consultations with surgeons and dermatologists and often seek interventions butare unlikely to be satisfied with the results.
BDD is considered to be related to OCD. The prevalence of BDD has been reported to be 0.7% in children, 2% in adolescents, and up to 5% in patients seeking cosmetic surgery. Many individuals with BDD report a history of childhood maltreatment; comorbid psychiatric disorders, including depression, OCD, social phobia, and anorexia nervosa; gender identity disorder; delusional disorder; and narcissistic personality disorder. BDD is also associated with high rates of suicidal ideation and attempts, with 28% of sufferers having attempted suicide.
Fatigue is a common physical complaint, affecting up to50% of adolescents. CFS specifically refers to a conditioncharacterized by at least 6 months of severe, disabling fatigueassociated with self-reported limitations in concentration and short-term memory, sleep disturbance, and musculoskeletal aches and pains, where alternative medical andpsychiatric explanations have been excluded. CFS is oftenassociated with depression and can be incapacitating. CFS israre in childhood and uncommon in adolescence, with prevalence below 1%. Onset typically follows an acute post-viralillness in approximately two thirds of pediatric cases. Treatment is nonspecific, unless a psychological or general medical cause is uncovered.
Screening tools for somatoform disorders include the Children’s Somatization Inventory (child and parent versions) and the Illness Attitude Scales and Soma Assessment Interview (parental interview questionnaires). The Functional Disability Inventory assesses the severity of symptoms.
Treatment for somatoform disorders should use an integrated medical and psychiatric approach. The goals are to identify concurrent psychiatric disorders, rule out concurrent physical disorders, improve overall functioning, and minimize unnecessary invasive tests and doctor shopping. This works when mental health consultation is presented as part of a comprehensive evaluation, thereby minimizing stigma and distrust.