This article was written by Drs. Tareq Yaqub, Bernard Biermann, Laura Andersen, and Nasuh Malas. It originally was published on the Psychiatric Times website.
Somatic symptom and related disorders (SSRDs) are a set of psychiatric conditions characterized by physical symptoms that are inconsistent with physical disease and influenced by psychological factors. They are common in pediatric medicine, with prevalence rates ranging from 13% to 50% depending on the setting. Across all ages, SSRDs account for nearly 20% of health care spending annually. There is also a small subset of patients who have multiple somatic complaints and tend to access crisis and emergency services, hospital services at higher rates. They also have high recidivism rates.
Despite the impact of SSRDs on pediatric health care, there is a high level of clinician and patient/familial frustration associated with the evaluation and management of these conditions.1 Without early incorporation of a broader biopsychosocial conceptualization, there can be an undue focus on disability, impairment, and somatic complaints. This leads to low-yield diagnostic testing and increased polypharmacy interventions that do not address the rehabilitative needs of the patient and family. In the absence of an explanatory model for symptoms, patients and families may feel they are being dismissed, creating a dynamic of mistrust between patients/families and the medical system. Ultimately, without a clear roadmap for evaluation and management, care can be inconsistent and there may be misuse of health care resources, ultimately leading to poor outcomes.
As SSRDs most often present in non-psychiatric settings, a patient’s first contact with a mental health care provider may be through psychiatric consultation in the emergency department or a hospital setting. Therefore, psychiatric consultation should be considered as early as possible in order to foster the perception that consultation-liaison psychiatrists are an integral part of the multispecialty team.
SSRDs account for approximately 15% to 20% of psychiatric consults in the pediatric hospital setting and have been reported as the second most common reason for consultation after suicide assessments. As such, there is growing effort to standardize the evaluation and management of pediatric SSRDs. Most recently, the American Academy of Child and Adolescent Psychiatry (AACAP) published a Clinical Consensus Pathway for SSRD Evaluation and Management.
“Julie,” a previously physically healthy 12-year-old female, presented with 6 months of abdominal pain, weight loss, and emesis that began shortly after her parents divorced. As a result, she missed several weeks of schooling.
Workup included a complete blood count, comprehensive metabolic profile, thyroid studies, C-reactive protein, erythrocyte sedimentation rate, abdominal X-ray, abdominal ultrasound, upper and lower endoscopy, and stool culture, all of which were unremarkable. Elimination of gluten from her diet was not helpful. The patient had no previous physical health concerns, including no previous gastrointestinal pathology. There was no history of substance use, sexual activity, psychological trauma, or abuse.
Julie was admitted for her fourth medical admission within 4 months. Child and adolescent psychiatry was consulted for evaluation of anxiety. Julie and her parents were skeptical about any psychological factors influencing her presentation and were hesitant to agree to psychiatric consultation. The parents were advocating for the use of opioids for her pain and an expanded workup.
The patient received concurrent evaluation by the pediatric hospitalist service, gastroenterology, psychology, and psychiatry. No further diagnostic testing was pursued. The team found Julie had comorbid learning difficulties, nonspecific anxiety, maladaptive coping, and increased familial expressed emotion contributing to her presentation in the context of the recent divorce. A multidisciplinary meeting was held with Julie and her parents to discuss the diagnosis of somatic symptom disorder (DSM-5 300.82). The family was presented with a conceptual framework for symptom development by the multidisciplinary care team, in addition to biopsychosocial contributors to her presentation and a future management plan.
Julie was referred for outpatient cognitive behavioral therapy and mirtazapine 7.5 mg at bedtime as initiated for anxiety and sleep difficulties. Her symptoms improved by discharge, and she was minimally symptomatic upon follow up with her primary care provider.