Pain Somatoform Disorder

Updated: Oct 04, 2013
  • Author: Dolores Protagoras-Lianos, MD; Chief Editor: Caroly Pataki, MD  more...
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Overview

Background

According to the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV), somatoform disorders are characterized by "the occurrence of one or more physical complaints for which appropriate medical evaluation reveals no explanatory physical pathology or pathophysiologic mechanism, or, when pathology is present, the physical complaints or resulting impairment are grossly in excess of what would be expected from the physical findings." [1] The Diagnostic and Statistical Manual for PrimaryCare (DSM-PC) Child and Adolescent Versions, issued by the American Academy of Pediatrics, is based on the DSM-IV and continues to be a guide for the practicing pediatrician Pain disorder is a somatoform disorder in which the predominant focus of the clinical presentation is pain in one or more anatomical sites.

  • The pain cannot be fully attributed to a known medical disorder.
  • The pain causes clinically significant distress, impairment, or both in social, academic, occupational, or other areas of functioning.
  • Psychological factors are judged to play an important role in the onset, severity, exacerbation, or maintenance of the pain. [2]
  • The pain is not intentionally produced or better accounted for by a mood disorder, anxiety disorder, or psychotic disorder.

The 3 types of pain disorder are as follows [2] :

  • Pain associated with psychological factors
  • Pain associated with psychological and a general medical condition
  • Pain disorder associated with a general medical condition
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Pathophysiology

Pain has a neurophysiologic sensory component, which signals that tissue insult is occurring, and a perceptual psychological component, which affects the subjective experience of pain.

Psychological stress may result in tangible physical effects. [3, 4]

  • Stress affects immune responses through the hypothalamus-pituitary-adrenal axis and the sympathetic nervous system. Neuropeptides and neurotransmitters are released, triggering various GI responses, such as gut dysmotility. In recurrent abdominal pain, nonspecific inflammatory changes can be found on biopsy specimens at all levels of the GI tract, suggesting that immunomodulation plays a role in the pathogenesis of the symptom.
  • Emotional distress can cause muscular pains and headaches through increased muscular tension.
  • Psychologically induced changes in behavior, such as compulsive activity or prolonged bed rest, lead to secondary physiologic changes and attendant symptoms.

The following factors may modify the experience and expression of pain [5, 6, 7] :

  • A heightened awareness of bodily sensations (ie, somatosensory amplification) characterizes a personality style.
  • Attentional bias towards imminent physical stimuli [8]
  • Pain is interpreted as a signal of severe tissue damage
  • Although pain threshold is similar in males and females, with increasing age, girls report pain and more readily seek relief.
  • Pain catastrophizing by the child or parent increases pain intensity, disability, and school absenteeism. [9, 10]
  • Affective states, such as anxiety and depression, may increase a subjective sense of suffering. [11]
  • Cultural and ethnic groups differ in the acceptability of expressing discomfort and in the value placed on pain tolerance.
  • Developmental stage plays a role because children experience pain no less intensely than adults, but children younger than 8 years express more overt distress.
  • Family influences affect the degree of disability caused by pain (ie, dysfunction due to pain is more pronounced in some families as a result of modeling and positive reinforcement of the sick role
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Epidemiology

Frequency

United States

Recurrent abdominal pain accounts for 5% of pediatric office visits. Headaches have been reported to affect 20-55% of all children, with 10% of teenagers reporting frequent headaches, chest pain, nausea, and fatigue. [12, 13]

International

Internationally, researchers note a continuing rise in the incidence of psychosomatic symptoms in children and adolescents in their respective countries. [14, 15, 16]

A 2012 study on 4066 children aged 4-11 years across 8 European countries found the prevalence of all psychosomatic symptoms to be 45.7%. [17]

Mortality/Morbidity

Psychological stress may result in numerous physical effects, including the following:

  • Stress affects immune responses through the hypothalamus-pituitary-adrenal axis and the sympathetic nervous system. Neuropeptides and neurotransmitters are released, triggering various GI responses, such as gut dysmotility. In recurrent abdominal pain, nonspecific inflammatory changes can be found on biopsy specimens at all levels of the GI tract, suggesting that immunomodulation plays a role in the pathogenesis of the symptom.
  • Emotional distress can cause muscular pains and headaches through increased muscular tension.
  • Psychologically induced changes in behavior, such as compulsive activity or prolonged bed rest, lead to secondary physiologic changes and attendant symptoms.

Race

Frequency varies among ethnic groups. For example, psychosomatic symptoms are more frequent among school-aged children in Japan than in Sweden. [18]

Sex

Medically unexplained somatic symptoms are more frequent in girls than in boys, and the difference is more marked in adolescence. Differences in pain threshold have not been noted, but girls more readily report pain and seek relief.

Age

Children experience pain no less intensely than adults; however, children younger than 8 years express more overt distress. Medically unexplained pains occur more frequently with increasing age. Younger prepubertal children with pain disorder are usually monosymptomatic; recurrent abdominal pain is the most frequent symptom, followed by headaches. With increasing age, more children report symptoms from various locations. Adolescents with pain disorder are often polysymptomatic, with increasing frequency of headaches, limb pain, and chest pain in the same individual. [19, 20]

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