OVERVIEW: What every practitioner needs to know





What other disease/condition shares some of these symptoms?






What are the DSM diagnostic criteria for somatoform disorders?
Psychological Factors Affecting a General Medical Condition
  • A general medical condition is present.


Conversion Disorder



  • The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance or as a culturally sanctioned behavior or experience.

  • The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of Somatization Disorder and is not better accounted for by another mental disorder.

  • Can be further classified as presenting with motor symptom or deficit, with sensory symptoms or deficit, with seizures or convulsions, or with mixed presentation.

Pain Disorder
  • Pain in one or more anatomical sites is the predominant focus of the clinical presentation and is of sufficient severity to warrant clinical attention.

  • The pain causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

  • Psychological factors are judged to have an important role in the onset, severity, exacerbation, or maintenance of the pain.

  • The symptoms or deficit is not intentionally produced or feigned (as in Factitious Disorder or Malingering).

  • The pain is not better accounted for by a Mood, Anxiety or Psychotic Disorder and does not meet criteria for Dyspareunia.

  • For Pain Disorder Associated With Psychological Factors: psychological factors are judged to have the major role in the onset, severity, exacerbation, or maintenance of the pain. (If a general medical condition is present, it does not have a major role in the onset, severity, exacerbation, or maintenance of the pain.) This type of Pain Disorder is not diagnosed if criteria are also met for Somatization Disorder.

  • For Pain Disorder Associated With Both Psychological Factors and a General Medical Condition: both psychological factors and a general medical condition are judged to have important roles in the onset, severity, exacerbation, or maintenance of the pain.

Somatization Disorder (NB This diagnosis is of limited utility for pediatricians, given the difficult-to-meet symptom requirements)




Undifferentiated Somatoform Disorder




  • The duration of the disturbance is at least 6 months.

  • The disturbance is not better accounted for by another mental disorder.

Somatoform Disorder Not Other Specified (NOS)
  • This diagnosis can be used when patients do not meet full criteria for the other somatoform disorders. For example, when symptoms consistent with undifferentiated somatoform disorder have been present for less than six months.


  • The preoccupation persists despite appropriate medical evaluation and reassurance.



  • The duration of the disturbance is at least 6 months.

Body Dysmorphic Disorder



What caused this disease to develop at this time?






What elements of the medical history or physical examination would support a diagnosis of a psychosomatic illness?

There are no fail-safe pathognomonic signs or symptoms of psychosomatic illness. However, there are certain elements of a patient’s history and physical exam that can suggest or support the diagnosis. They include the following:

  • Onset of symptoms is correlated to a significant psychosocial stressor.

  • A prior pattern of somatization or a family history of somatization disorder.

  • Waxing and waning of symptoms that is temporally associated with specific stressors, suggestion, or care-giver attention.

  • Symptoms or impairments that are not consistent with medical knowledge. Examples would include non-dermatomal distribution of sensory deficits, a positive Hoover test in the setting of leg weakness, engagement in protective behaviors while seemingly unconscious (example: when a patient’s hand is held up over their head and allowed to drop, the hand would avoid hitting their head and fall to the side), and a clear sensorium immediately following an event otherwise suggestive of a grand mal seizure.


  • There are no specific laboratory tests that can confirm the diagnosis of a psychosomatic illness. Laboratory tests should be ordered to rule out plausible medical etiologies in the differential diagnosis.

Would imaging studies be helpful? If so, which ones?

  • As with laboratory studies, there are no specific imaging studies that can confirm the diagnosis of a psychosomatic illness.

Are there additional forms of testing that can be helpful?
  • For patients presenting with symptoms suggestive of non-epileptiform seizures, video EEG monitoring can be particularly useful for establishing the diagnosis.

  • For patients with intermittent cardiac symptoms, Holter monitoring can also be helpful in ruling out arrhythmias.

Confirming the diagnosis

  • Currently, there are no widely-accepted clinical decision algorithms for suspecting/confirming the diagnosis of psychosomatic illness. When available, clinicians should make use of algorithms for assessing the patient’s chief complaint.








How should you convey the diagnosis?








If you are able to confirm that the patient has psychosomatic illness, what treatment should be initiated?

  • One of the most important elements of effective treatment for psychosomatic illness is ongoing involvement of the medical provider. Pediatricians should make it clear that they remain concerned about the patient and that they are going to continue providing and coordinating their patient’s care. Pediatricians should schedule frequent follow-up appointments to monitor the child’s progress and to assess any new symptoms. Frequent follow-up appointments may also help decrease the frequency of urgent calls and emergency room visits.

  • Once a diagnosis of a psychosomatic illness has been made, pediatricians should discontinue unnecessary treatments, being careful to taper medications with significant discontinuation symptoms. Further medical evaluation should be halted, with the caveat that any new concerning symptoms will be appropriately evaluated. Pediatricians should also work to consolidate care, serving as gatekeepers for specialist, emergency, and inpatient care.

  • Pediatricians should organize their treatment recommendations around a rehabilitation model. Instead of focusing on finding a cure for the symptoms, pediatricians should encourage children and their families to focus their efforts on returning to the child’s previous state of functioning and maximizing recovery in spiteof their ongoing symptoms. Children with neuromuscular symptoms or significant deconditioning should be referred for physical and/or occupational therapy.

  • Children with psychosomatic illness can benefit from being taught techniques such as deep-breathing, progressive muscle relaxation, meditation, and biofeedback. When co-morbid psychiatric illness–such as anxiety or depression– has been identified, or in cases with significant impairment in functioning, pediatricians should refer patients for mental health treatment consisting of individual therapy (including cognitive-behavioral therapy), family therapy, and, where indicated, medications such as antidepressants and benzodiazepines. Group therapy may also provide some benefit.

  • Families (and in the case of hospitalized patients, healthcare providers) should institute behavioral interventions aimed at rewarding recovery and limiting benefits of being sick. Punishing impairment or lack of engagement in recovery tends to be a far less effective approach. An example of positive reinforcement would be planning a fun parent-child outing to celebrate a first full week back at school. An example of removing reinforcement of illness behaviors would be for parents to limit attention paid to physical symptoms and to not excuse children from normal activities, such as completing chores.

    Tying recovery to anticipated events can also be useful. For example, a parent could tell their child that they will know they are well enough to attend their friend’s birthday party when they are well enough to go to school, complete their homework, and clean their room. When children are in the hospital, hospital staff should institute similar behavioral plans. Parental visitation, computer access, and trips to the game room can all be linked to participation in treatment and return to functioning. Again, the emphasis should be on rewarding steps towards recovery instead of punishing ongoing impairment or disengagement in treatment.

  • Pediatricians should also take an active role in promoting the return to a full level of functioning–especially when it comes to school participation. This includes encouraging immediate return to school and excusing absences only when the physician feels the child’s symptoms require urgent medical evaluation or when objective data suggest that the child has a contagious illness.

    Pediatricians should take a proactive role in educating school personnel about the nature of the child’s psychosomatic illness and the importance of helping the child remain in school despite their symptoms. Direct communication with school personnel–especially school nurses–can be quite useful. In cases where severe impairment is present, children may require a more gradual transition back to school, with scheduled visits to the nurse’s office to check in and provide time to use relaxation, pain management, or anxiety management techniques.

  • In severe cases, referral to specialized inpatient or partial psychiatric hospital units may be indicated.

  • If families refuse to accept the diagnosis of a psychosomatic illness, they will likely continue to seek more testing and treatment and continue to support their child’s ongoing impairment in functioning.

    If the family refuses to accept the diagnosis and/or mental health intervention, psychiatric consultants can still provide guidance to the medical team as to how to structure behavioral plans, respond to the patient’s and family’s behaviors or demands, and support clinicians in their efforts to provide safe and appropriate care.

    In severe cases, pediatricians should consider consulting their local hospital’s child abuse pediatrician team, if available, and/or contacting child protective services to express their concern for medical child abuse.

What are the adverse effects associated with each treatment option?

What are the adverse effects associated with medication options for treatment of psychosomatic disorders?
  • There are no specific medciations to treat psychosomatic illness.

  • All patients with a suspected psychosomatic illness should be screened for anxiety and depression. If present, clinicians should initiate appropriate treatment, including referring the patient to counseling and considering initiation of medications.

What are the possible outcomes of somatoform disorders?

Untreated psychosomatic illness, including the formal somatoform disorders, can lead to significant impairment. School absenteeism, poor academic performance, anxiety and depression, and social isolation are all common sequelae. Patients may suffer direct and indirect complications from unnecessary medical evaluations and treatment.

Examples of direct damage include pain associated with invasive procedures, radiation from imaging studies, and side effects from medications used to treat symptoms such as pain or mistakenly-diagnosed medical conditions (e.g., side effects from anti-seizure medications in patients with non-epileptiform seizures).

Indirect damage from exhaustive medical evaluations or unnecessary treatments include reinforcement of the patient’s and family’s belief that there is an underlying medical cause to the patient’s symptom; misused time, money, and energy spent on medical evaluations and treatment; and a delay in initiation of proven rehabilitative and psychological treatments.

With proper treatment, patients can return to full levels of functioning with no long-term sequelae.

What complications might you expect from the disease of treatment of the disease?

Rehabilitative and psychotherapeutic treatments for somatoform disorders or even the psychological factors that affect patients with general medical conditions can be time-intensive and difficult to obtain, although some patients respond quite rapidly. For those patients with significant impairment who require intensive psychiatric treatment on specialized day-treatment and inpatient units, significant engagement of both the patient and the family is required.


  • There are several psychometric instruments that can be used to support a diagnosis of psychosomatic illness. These include the Minnesota Multiphasic Personality Inventory-Adolescent (MMPI-A), the Children’s Somatization Inventory, and the Functional Disability Inventory.

  • Hypnosis and drug-assisted interviews have been used to help diagnose and treat conversion disorders, but the data to support their use are limited and the results are mixed.

  • Methacholine challenges have been used to rule out reactive airway disease as a source of respiratory symptoms. However, methacholine challenges are not frequently used in children.

How can psychosomatic illness/somatoform disorders be prevented?

There is almost no research on the prevention of somatoform disorders. Interventions that reduce the prevalence of major risk factors for somatization–such as treatment of depression and anxiety or prevention of childhood sexual abuse– could help prevent the development of somatization disorder. One study using cognitive behavioral therapy (CBT)-based psychoeducation in healthy adults in the primary care setting did not demonstrate a decrease in the development of somatoform disorders, although it did lead to a decline in overall psychiatric morbidity.

What is the evidence?

“American Academy of Pediatrics. The classification of child and adolescent mental diagnoses in primary care. Diagnostic and statistical manual for primary care (DSM-PC), child and adolescent version”. 1996. (A manual for pediatric practitioners that is based on the DSM-IV.)

“American Psychiatric Association. Diagnostic and statistical manual of mental disorders, fourth edition, text revision”. 2000. (Official description of the diagnostic criteria and a review of the epidemiology of somatoform disorders.)

Roesler, TA, Jenny, C. “Medical child abuse: beyond Munchausen syndrome by proxy”. 2008. (Comprehensive textbook on the topic of medical child abuse.)

Shaw, RJ, Spratt, EG, Bernard, RS, DeMaso, DR, Shaw, RS, DeMaso, DR. “Somatoform disorders”. 2010. pp. 121-40. (A comprehensive review of the epidemiology, pathogenesis, diagnosis, and treatment of pediatric somatoform disorders.)

Silber, TJ. “Somatization disorders: diagnosis, treatment, and prognosis”. Pediatr Rev. vol. 32. 2011. pp. 56-63. (Review article.)

“American Psychiatric Association. DSM-5: The future of psychiatric diagnosis”. (Online publication of proposal from the somatoform disorders working group for changes to diagnostic criteria and classification of disorders for the DSM-V.)

Ongoing controversies regarding etiology, diagnosis, treatment

There is disagreement over how somatoform disorders should be named and classified. Criticisms of the current classification system include that the distinctions between the diagnoses are often unclear, that etiological factors and treatment interventions are similar across the diagnoses, and that the requirement that symptoms be medically unexplained is both unreliable and promotes the unhelpful and outdated notion of mind-body dualism.

As a result, the group responsible for the somatoform disorder section of the DSM-V is proposing several significant changes. Under their current proposal, Somatization Disorder, Undifferentiated Somatoform Disorder, Hypochondriasis, Pain Disorder Associated with Psychological Factors, and Pain Disorder Associated with Psychological Factors and a General Medical Condition would all be subsumed under the newly-termed Simple Somatic Symptom Disorder and Complex Somatic Symptom Disorder. The presence of medically-unexplained symptoms would no longer be a diagnostic requirement. Instead, focus would be placed on the presence of somatic complaints that are either distressing or significantly disrupt functioning and that are associated with either the child’s and/or a parent’s disproportionate and persistent concerns about the medical seriousness of one’s symptoms, a high level of health-related anxiety, or excessive time and/or energy devoted to health concerns

The group also proposes reclassifying Body Dysmorphic Disorder as an anxiety disorder, renaming Conversion Disorder as Functional Neurological Symptoms, and introducing new diagnoses of Illness Anxiety Disorder and Acute Somatic Symptom Disorder. The diagnosis of psychological factors affecting a general medical condition would be maintained.

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