Somatic Symptom Disorder & Functional Neurologic Disorders
Somatic symptom disorder (SSD) and functional neurologic disorder (FND), aka conversion disorder), although similar, have different antecedents and refer to different clinical presentations.
SSD applies to those patients who experience thoughts or feelings related to physical symptoms, such as pain or weakness, that are excessive enough to create disproportionate focus or distress and interfere with functioning. Symptoms are typically multiple and may involve single or multiple body systems (including cardiopulmonary, gastrointestinal, genitourinary, musculoskeletal, and neurologic complaints) as well as pain and fatigue. SSD can and does occur in the context of other medical/pain disorders. SSD is a common diagnosis, affecting 10-15% of the child and adolescent population presenting to primary care physicians. Females are about ten times more likely to carry an SSD diagnosis than males, and incidence peaks between adolescence to about age 30. [Ibeziako: 2019]
FND occurs when there is a problem with decreased function of the central nervous system, typically presenting with psychogenic seizures, difficulty walking or swallowing, and/or motor-sensory deficits, but there is no underlying structural disease such as multiple sclerosis or epilepsy. The distinctive feature of FND is that symptoms/signs do not follow known neurologic patterns. Examples include loss of sensation on the whole right hand (in a glove distribution), whereas numbness would occur in a peripheral or regional nerve distribution. Individuals with functional neurologic disorders continue to have symptoms even when testing does not show any neurologic problems. The symptoms in FND are biological and not simply a physical manifestation of a mental health concern. However, the etiology is a complex interplay between the mind and the body. SSDs may develop as a byproduct of physical or psychological triggers. It is important to recognize that patients do not have control over these symptoms and are not malingering, which is defined in DSM-5 as the “intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives.”
Clinical Assessment
Consider somatic symptom disorder when a child or adolescent has more severe symptoms than expected for an existing medical condition or are unrelated to any medical cause that can be identified. Pain is the most common reported symptom. Other common presentations include fatigue or low energy, abdominal distress (pain, nausea, vomiting), breathing difficulties, rapid heart rate, dizziness, fainting, and disordered movements. It is important to remember that the defining feature of SSD is the way the patient interprets and reacts to the symptoms. The specific physical symptoms may vary over time.
Diagnostic testing is of questionable utility and can be expensive; however, it is not unusual for children and adolescents with SSDs to undergo extensive testing or evaluation from a variety of medical subspecialties before the diagnosis is reached. In a meta-analysis performed in adults, evaluation did not decrease somatic symptoms. [Rolfe: 2013] Repeated or expansive testing may lead to side effects of the tests themselves, a risk of false-positive results, symptom exacerbation, and is associated with decreased patient and family satisfaction with care.
Genetic factors, which may be revealed by family history, and medical illness or injury are risk factors for developing SSDs. Comorbid anxiety and depression are present in up to 60% of patients with SSD. Significant distress and anxiety surrounding physical symptoms are also markers but can present as overfocus or obsessive thinking about symptoms.
Functional disability is common as excessive symptom focus disrupts normal function, especially attending school, and participation in other activities may also be disrupted.
Screening
Functional Disability Screening Children and adolescents with SSD often struggle to participate in daily activities. Functional disability is common, resulting in physical deconditioning, reduced ability to challenge self, poor sleep regulation, nutrition and hydration, and school participation and attendance. Functional disability should be screened for at diagnosis and periodically during management. School attendance should be tracked at each visit. [Kashikar-Zuck: 2011]
- The Functional Disability Inventory (FDI) is useful for identifying difficulties in daily activity functioning. Subscription is required for access to the screen.
Stress, anxiety, depression, parental anxiety, and other mental health problems can and do interfere with symptom frequency and intensity as well as impede treatment efficacy. If SSD is suspected, patients should be screened for mental health using scales found at: [Richardson: 2010] [Mossman: 2017]
- Patient Health Questionnaire (PHQ) Screeners are free screening tools in many languages with scoring instructions to be used by clinicians to help detect mental health disorders. Select from right menu: PHQ, PHQ-9, GAD-7, PHQ-15, PHQ-SADS, Brief PHQ, PHQ-4, PHQ-8.
Inquire about if depression is found using the PHQ Screeners above and/or: [Jellinek: 1999]
- The Pediatric Symptom Checklist is a brief screening questionnaire used by pediatricians and other health professionals to improve the recognition and treatment of psychosocial problems in children. Free PDF download.
The Pain Catastrophizing Scale may also be helpful to identify maladaptive thinking around symptoms and parent/child symptom distress. [Wilson: 2014]
- The Pain Catastrophizing Scale (PCS) has 13 questions for parents and children from the Measurement Instrument Database for the Social Sciences (MIDSS).
Treatment
Lifestyle Changes
Medical Monitoring and Support
Physical Rehabilitation
Cognitive Behavioral Therapy
Subspecialist Collaborations
-
Behavioral Therapies
(see NV providers
[19])
A mainstay of the management of SSD and all patients should be referred. -
Pediatric Neurology
(see NV providers
[5])
May be helpful in diagnosis of a SSD, although management will more likely be done by physical medicine and rehabilitation and/or primary care. -
Pediatric Physical Medicine & Rehabilitation
(see NV providers
[3])
May be helpful for patients with functional disability e.g., deconditioning, trouble walking, etc.) and for management.
Resources
Information & Support
Related Issues
- Anxiety Disorders (FAQ)
- Depression
- Sleep Issues
- Postural Orthostatic Tachycardia Syndrome (POTS)
- Fibromyalgia, amplified musculoskeletal pain syndrome (AMPS), complex regional pain syndrome (CRPS)
For Professionals
Best Practices for Treating Youth with Somatic Symptom (Psychiatric Times)
Clinicians, families, and patients all report frustration with SSRD treatment in hospitals. It’s time to improve it.
January 5, 2021
Tareq Yaqub, MD, Bernard Biermann, MD, PhD, Laura Andersen, MD, MPH, Nasuh Malas, MD, MPH
Ask the Expert: What is Somatization? (BC Children's Hospital)
Why somatic symptom disorder is so poorly understood and what integrated mental and physical care looks like.
For Parents and Patients
Help With Somatic Symptom Disorder (APA)
Definition, symptoms, treatment, and related disorders.; American Psychiatric Association.
Somatic Symptom Disorder (Mayo Clinic)
Symptoms, causes, diagnosis, medical treatment and lifestyle changes.
Children's Health and Illness Recovery Program (CHIRP): Teen and Family Workbook (Programs That Work)
Treatment activities designed to combat the additional stress faced by youth coping with long-term health problems. Tasks
target improvement in physical functioning, school functioning, and personal functioning and support the creation of new tools
for managing the impact of illness, such as stress management, coping and relaxation techniques, and communication skills.
Overcoming Functional Neurological Symptoms: A Five Areas Approach (Paperback Book)
A 320-page book that discusses the 5 areas model of Cognitive Behavior Therapy (CBT) to help people experiencing a range of
medically unexplained symptoms, including chronic headaches, fatigue, dizziness, loss of sensation, weakness and numbness;
by C. Williams, MD et. al. (2011).
Services for Patients & Families in Nevada (NV)
Service Categories | # of providers* in: | NV | NW | Other states (3) (show) | | NM | RI | UT |
---|---|---|---|---|---|---|---|---|
Behavioral Therapies | 19 | 1 | 17 | 31 | 36 | |||
Developmental - Behavioral Pediatrics | 3 | 1 | 2 | 12 | 9 | |||
Occupational Therapy | 23 | 1 | 17 | 20 | 36 | |||
Pediatric Neurology | 5 | 5 | 17 | 8 | ||||
Pediatric Physical Medicine & Rehabilitation | 3 | 3 | 3 | 6 | 11 |
For services not listed above, browse our Services categories or search our database.
* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.
Helpful Articles
D'Souza RS, Hooten WM.
Somatic Syndrome Disorders.
StatPearls [Internet]..
2021.
PubMed abstract
Henningsen P.
Management of somatic symptom disorder.
Dialogues Clin Neurosci.
2018;20(1):23-31.
PubMed abstract / Full Text
Lunkenheimer F, Domhardt M, Geirhos A, Kilian R, Mueller-Stierlin AS, Holl RW, Meissner T, Minden K, Moshagen M, Ranz R, Sachser
C, Staab D, Warschburger P, Baumeister H.
Effectiveness and cost-effectiveness of guided Internet- and mobile-based CBT for adolescents and young adults with chronic
somatic conditions and comorbid depression and anxiety symptoms (youthCOACHCD): study protocol for a multicentre randomized
controlled trial.
Trials.
2020;21(1):253.
PubMed abstract / Full Text
Rosmalen JGM, van Gils A, Acevedo Mesa MA, Schoevers RA, Monden R, Hanssen DJC.
Development of Grip self-help: An online patient-tailored self-help intervention for functional somatic symptoms in primary
care.
Internet Interv.
2020;19:100297.
PubMed abstract / Full Text
Authors & Reviewers
Author: | Lynne M. Kerr, MD, PhD |
Reviewer: | Deirdre Caplin, Ph.D., MS |
Page Bibliography
D'Souza RS, Hooten WM.
Somatic Syndrome Disorders.
StatPearls [Internet]..
2021.
PubMed abstract
Henningsen P.
Management of somatic symptom disorder.
Dialogues Clin Neurosci.
2018;20(1):23-31.
PubMed abstract / Full Text
Ibeziako P, Brahmbhatt K, Chapman A, De Souza C, Giles L, Gooden S, Latif F, Malas N, Namerow L, Russell R, Steinbuchel P,
Pao M, Plioplys S.
Developing a Clinical Pathway for Somatic Symptom and Related Disorders in Pediatric Hospital Settings.
Hosp Pediatr.
2019;9(3):147-155.
PubMed abstract
Jellinek MS, Murphy JM, Little M, Pagano ME, Comer DM, Kelleher KJ.
Use of the Pediatric Symptom Checklist to screen for psychosocial problems in pediatric primary care: a national feasibility
study.
Arch Pediatr Adolesc Med.
1999;153(3):254-60.
PubMed abstract / Full Text
Kashikar-Zuck S, Flowers SR, Claar RL, Guite JW, Logan DE, Lynch-Jordan AM, Palermo TM, Wilson AC.
Clinical utility and validity of the Functional Disability Inventory among a multicenter sample of youth with chronic pain.
Pain.
2011;152(7):1600-1607.
PubMed abstract / Full Text
Lunkenheimer F, Domhardt M, Geirhos A, Kilian R, Mueller-Stierlin AS, Holl RW, Meissner T, Minden K, Moshagen M, Ranz R, Sachser
C, Staab D, Warschburger P, Baumeister H.
Effectiveness and cost-effectiveness of guided Internet- and mobile-based CBT for adolescents and young adults with chronic
somatic conditions and comorbid depression and anxiety symptoms (youthCOACHCD): study protocol for a multicentre randomized
controlled trial.
Trials.
2020;21(1):253.
PubMed abstract / Full Text
Mossman SA, Luft MJ, Schroeder HK, Varney ST, Fleck DE, Barzman DH, Gilman R, DelBello MP, Strawn JR.
The Generalized Anxiety Disorder 7-item scale in adolescents with generalized anxiety disorder: Signal detection and validation.
Ann Clin Psychiatry.
2017;29(4):227-234A.
PubMed abstract / Full Text
This study evaluates a brief, self-report scale—the Generalized Anxiety Disorder 7-item Scale (GAD-7)—in adolescents with
generalized anxiety disorder.
Richardson LP, McCauley E, Grossman DC, McCarty CA, Richards J, Russo JE, Rockhill C, Katon W.
Evaluation of the Patient Health Questionnaire-9 Item for detecting major depression among adolescents.
Pediatrics.
2010;126(6):1117-23.
PubMed abstract / Full Text
Rolfe A, Burton C.
Reassurance after diagnostic testing with a low pretest probability of serious disease: systematic review and meta-analysis.
JAMA Intern Med.
2013;173(6):407-16.
PubMed abstract
Rosmalen JGM, van Gils A, Acevedo Mesa MA, Schoevers RA, Monden R, Hanssen DJC.
Development of Grip self-help: An online patient-tailored self-help intervention for functional somatic symptoms in primary
care.
Internet Interv.
2020;19:100297.
PubMed abstract / Full Text
Wilson AC, Moss A, Palermo TM, Fales JL.
Parent pain and catastrophizing are associated with pain, somatic symptoms, and pain-related disability among early adolescents.
J Pediatr Psychol.
2014;39(4):418-26.
PubMed abstract / Full Text