DSM-IV classifies somatoform disorders as somatization disorder, undifferentiated somatoform disorder, somatoform disorder not otherwise specified, conversion disorder, pain disorder, body dysmorphic disorder (BDD), and hypochondriasis.The diagnostic criteria for somatoform disorders are establishedfor adults and need additional study in pediatric populations.
Somatization disorder involves multiple unexplained physical complaints, including pain, gastrointestinal, sexual, and pseudoneurologic symptoms not caused by known mechanisms. The criteria used to diagnose this disorder are listed in Table 16-2. Given the requirement for at least one sexual or reproductive symptom, the diagnosis is unusual in children and the onset is common during adolescence. Prevalence estimates range from 0.2% to 2% in females and less than 0.2% in males. Early onset of somatization disorder is associated with poor prognosis.
Undifferentiated somatoform disorder (Table 16-3)includes one or more unexplained physical complaints accompanied by functional impairment that last for at least 6 months. Children and adolescents are more likely to meet DSM-IV criteria for an undifferentiated somatoform disorder than for a somatization disorder, and no evidence exists to predict which patients will go on to develop the full symptom criteria for somatization disorder.
Conversion disorder involves symptoms affecting voluntary motor or sensory function and is suggestive of a neurologic illness in the absence of a disease process (Table 16-4).Adjustment difficulties, recent family stress, unresolved grief reactions, and family psychopathology occur at a high frequency in conversion symptoms. A physical condition and a conversion disorder (e.g., epileptic and nonepileptic seizures) may coexist in the same patient. There are four subtypes of conversion disorder based on whether the symptoms presented are primarily motor, sensory, nonepileptic (seizures), or mixed.
Presenting symptoms follow the psychological stressor by hours to weeks and may cause more distress for others than for the patient. This seeming lack of concern regarding potentially serious symptoms is referred to as la belle indifference.
Presenting complaint is a physical symptom. Physical symptom is caused by a known physiologic mechanism. Physical symptom is stress induced. Patient may recognize association between symptom and stress. Symptom frequently responds to medication, biofeedback, and stress reduction.
Presenting complaint is physical (loss of function, pain, or both).
Physical symptom is not caused by a known physiologic mechanism. Physical symptom is related to unconscious idea, fantasy, or conflict.
Patient does not recognize association between symptom and the unconscious. Symptom responds slowly to resolution of unconscious factors.
Requires more than 13 physical symptoms in girls, more than 11 in boys (see Table 16-2) Physical symptoms are not caused by a known physiologic or pathologic mechanism.
Physical symptoms are related to need to maintain the sick role.
Patient convinced that symptoms are unrelated to psychological factors. Symptoms tend to persist or change character despite treatment.
Presenting complaint is a physical sign or symptom. Patient interprets physical symptom to indicate disease. Conviction regarding illness may be related to depression or anxiety. Symptom does not respond to reassurance. Medication directed at underlying psychological problems often helps.
Presenting complaint is a physical symptom. Physical symptom is under voluntary control. Physical symptom is used to gain reward (e.g., money, avoidance of military service). Patient consciously recognizes symptom as factitious. Symptom may not lessen when reward is attained (need to retain reward).
Presenting complaint is symptom complex mimicking known syndrome.
Symptom complex is under voluntary control.
Symptom complex is used to attain medical treatment (including surgery).
Patient consciously recognizes symptom complex as factitious but is often psychologically disturbed so that unconscious factors also are operating.
Symptom complex often results in multiple diagnoses and multiple operations.