Pain Somatoform Disorder 

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

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

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

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]

 

Presentation

History

Obtain a history of physical symptoms from parent and child. When one pain symptom is reported, inquire about other symptoms as well.

Obtain a psychosocial history, including separate interviews with the parent and child to facilitate disclosure. Psychosocial factors implicated in pain disorder include the following[21, 22, 23, 24] :

  • Family history of anxiety, depression, and psychiatric problems

  • Family history of somatization and preoccupation with illness

  • Nontraditional family structure

  • Chronic physical illness in a parent

  • Economic stress in the family

  • History of negative life events

  • Disorganized chaotic family functioning

  • Academic difficulties experienced by the patient

  • Involvement in bullying, especially as a victim[25, 26]

  • Previous history of somatization, behavior problems, or psychiatric illness

Positive evidence of the role of psychological factors includes the following[27] :

  • Onset of pains after stressful event

  • Exacerbation linked with stressful events

  • Relief of symptoms following removal of stressor

  • Pain out of proportion to objective medical findings

  • Disability or handicap out of proportion to reported pain

  • Secondary gain

Physical

A thorough physical examination is imperative for purposes of diagnosing the symptoms and, when indicated, reassuring the family. Examining the patient with and without the parents present is advisable.

Causes

Numerous theories regarding the causes of pain disorder have been proposed; they should not be considered mutually exclusive. Theories include the following:

  • Biologic factors: Adoption studies have found somatization disorders to be 5-10 times more common in first-degree relatives of probands with somatization than in the general population.

  • Stress: Stress may induce gut motility dysfunction and mucosal dysfunction through corticotropin-releasing hormone, acetylcholine release, or both

  • Psychodynamic theory: An unconscious conflict, wish, or need is converted into a somatic symptom, thus protecting the individual from conscious awareness of it.

  • Trauma and abuse: An association between physical abuse, psychological abuse, or both and somatization has been well documented.

  • Learning theory: The child learns from role models for illness behavior within the family. The child learns about secondary gains from the modeled sick role.

  • Emotions and communication: Limited vocabulary and concrete thinking may cause a child to express distress in terms of physical symptoms.

  • Environmental and social influences: In families and cultures in which psychological problems are stigmatized, the individual may communicate distress through a somatic symptom.

  • Family systems theory: The child's sick role is encouraged because it serves to perpetuate specific family dynamic patterns. According to the model developed by Minuchin, families of somatizing children use 4 distinct transactional patterns: (1) Enmeshment, (2) overprotection, (3) rigidity, (4) lack of conflict resolution.

 

DDx

Diagnostic Considerations

See the list below:

  • Malingering or factitious disorder

  • Pain disorder associated with a general medical condition: A general medical condition has a major role in the onset, severity, exacerbation, or maintenance of the pain. If psychological factors are present, they are not judged to have a major role.

  • Pain secondary to undiagnosed medical condition

  • Associated disorders (ie, anxiety, depression, attention deficit hyperactivity disorder, conduct disorder)

Differential Diagnoses

 

Workup

Laboratory Studies

The primary physician orders laboratory studies based on clinical suggestion of a specific medical condition.

Imaging Studies

The primary physician orders imaging studies based on clinical suggestion of a specific medical condition.

Otti et al studied patients with somatoform pain disorder using resting functional MRI. Although the study demonstrated the resting functional network connectivity among pain-related interactions, it was unable to conclusively characterize the reasons for the pain[28]

Other Tests

The diagnosis of pain disorder rests not only on the physician’s inability to fully explain the pain on an organic basis, but also on the presence of psychological factors. The following are prerequisite conditions for successful referral by a medical practitioner to a mental health professional:

  • Timely, thorough medical evaluation

  • Interview and observation of family for psychosocial problems

  • Early mention of possibility that symptoms are stress-related

  • Discussion of negative medical workup results

  • Rationale provided for mental health referral

  • Assurance of ongoing medical follow-up care and collaboration with mental health specialist

Mental health evaluation may involve the following:

  • Quantifying the pain: Faces Pain Scale–Revised (FPS-R) and Color Analog Scale (CAS) are self-report pain scales

  • Observation scales are used with preschool-aged children

  • Direct scaling techniques that ask that young children pick out from a graded series the drawings of faces that match the way they feel

  • Pain questionnaires for older children and adolescents

  • Screening instruments, such as the Child Behavior Checklist, to identify children with somatic symptoms and possible somatoform disorders

  • Trauma Symptom Checklist for Children

  • ISPCAN Child Abuse Screening Tool Children's Version (ICAST-C)

  • Child Trauma Questionnaire-Short Form A self report questionnaire which may be used with adolescents[29]

  • Comprehensive structured interviews, such as the Diagnostic Interview for Children and Adolescents (DICA), that contain questions on somatization[29]

  • The Personality Inventory for Children (PIC), which has been used in the diagnosis of somatoform disorders in children

Projective tests that may help clarify underlying psychological issues and add to the evidence for a somatoform diagnosis include the Thematic Apperception test (TAT), the Children's Apperception Test (CAT), the Rorschach test, and sentence completion. Psychoeducational evaluation is recommended for patients with academic difficulties and prolonged school absence.

 

Treatment

Medical Care

Medical care for physical illness must be appropriate for the diagnosed medical problems and requires judicious use of analgesics.

Effective mental health treatment for children is family-centered. Goals for therapy include the following[30, 31, 32, 33, 34, 35] :

  • Gaining understanding of pain as a product of the interaction of physical and psychological factors

  • Improved family functioning

  • Increased assertiveness in victims of bullying

  • Learning strategies that produce some control over symptoms or reaction to pain, although symptoms may not be eradicated totally

  • Dealing successfully with anxiety generated by pain

  • Decreasing disability caused by pain

  • Limiting medical testing that is not helpful or necessary

Types of treatment include the following:

  • Counseling

  • Relaxation training (eg, progressive muscle relaxation, induced self-hypnosis)[31]

  • Behavioral methods (eg, behavioral-cognitive therapy)

  • Biofeedback

  • Family therapy (eg, focus on communication and appropriate responses)

Comorbid conditions (eg, anxiety, depression) should be treated.

Consultations

Subspecialist consultations based on suspicion of specific medical disorders include the following:

  • Neurologist (chronic headache pain)

  • Gastroenterologist (chronic abdominal pain)

  • Mental health specialist

Activity

Encourage early gradual return to normal activity.

 

Medication

Medication Summary

Medical care for physical illness must be appropriate for diagnosed medical problems and requires judicious use of analgesics.[11]

 

Follow-up

Further Outpatient Care

See the list below:

  • Medical care for physical illness must be appropriate for diagnosed medical problems and requires judicious use of analgesics.

  • Close communication should be maintained between the primary care physician and the mental health professional. A team approach helps assure that all aspects of the child's health are being addressed.

Further Inpatient Care

See the list below:

  • Medical care for physical illness must be appropriate for diagnosed medical problems, and inpatient care should be limited to concerns about acute or chronic serious medical illness.

Prognosis

See the list below:

  • Outcome measure (physical symptoms): In the spectrum of physical symptoms, recurrent abdominal pain has been studied.

    • Seventy percent of patients continue to experience abdominal pain into adulthood; the symptom does not impair activity as in childhood but is more significant than in control subjects.[36]

    • Additional symptoms, such as headaches, develop in 30% of patients.

    • Multiple symptoms in childhood predict poorer adult outcome.

  • Outcome measure (functional and psychiatric status): In adulthood, individuals with a childhood history of recurrent abdominal pain are more likely than control subjects to have an anxiety disorder, hypochondriacal beliefs, or poor social functioning, and they are more likely to be treated with psychoactive medication.[37]

  • With psychological intervention, improved short-term and long-term outcomes have been reported.

Patient Education

See the list below:

  • Encourage the patient's acceptance of an alternative diagnosis of the pain other than severe illness.

  • Help the patient understand the role of psychological factors.

  • Help the patient discover strategies for coping with the symptoms.

  • Seek ways to reduce stressors that maintain the symptoms.