FROM THE ACADEMY OF CONSULTATION-LIAISON PSYCHIATRY
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.1 Additionally, a small subset of patients have multiple somatic complaints and tend to access crisis and emergency services and hospital services at higher rates. They also have high recidivism rates.2
Despite the recognition of the impact of SSRDs on pediatric health care, clinicians and patients/families continue to be frustrated 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.2,3 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 road map for evaluation and management, care can be inconsistent and misuse of health care resources may occur, which, in turn, can lead to poor outcomes.
As SSRDs most often present in nonpsychiatric settings, a patient’s first contact with a mental health care provider may be through psychiatric consultation in the emergency department or in a hospital setting. Therefore, psychiatric consultation should be considered as early as possible to foster the perception that consultation-liaison (CL) psychiatrists are an integral part of the multispecialty team.
CASE VIGNETTE
“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.
Work-up included a complete blood count, comprehensive metabolic profile, thyroid studies, C-reactive protein test, erythrocyte sedimentation rate, abdominal x-ray, abdominal ultrasound, upper and lower endoscopy, and stool culture, all of which were unremarkable. Eliminating 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 work-up.
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 prescribed mirtazapine 7.5 mg at bedtime for anxiety and sleep difficulties. Her symptoms improved by discharge, and she was minimally symptomatic upon follow-up with her primary care provider
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.4,5 As such, there is a 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.3
Epidemiology
Most SSRDs are seen in nonpsychiatric settings, with approximately 6% of hospitalized children relaying symptoms consistent with an SSRD.2 The most common complaints include neurologic symptoms, pain, gastrointestinal distress, and fatigue.6 SSRDs can present at any age, but they are more common and less problematic in prepubertal youth, with increasing impairment and pathology in adolescents.7,8 Prevalence rates are equal across sexes prior to puberty; after puberty, higher prevalence is seen in female sex.9,10 Although psychological trauma, particularly sexual trauma, is a well-associated risk factor for SSRDs in adults, it is not necessarily associated with SSRDs in youth.9 However, if present, trauma in youth with SSRDs often results in a more complicated treatment course, more severe symptoms, and increased risk for need of higher levels of psychiatric care.11
Evaluation, Collaboration
The evaluation and management of youth experiencing an SSRD are predicated on early recognition of risk factors (Table 1). The foundation of an SSRD evaluation is built on concurrent mental health and physical health evaluation, unified evidence-based language that is consistent across disciplines, and direct communication with the family regarding the multifactorial nature of SSRD presentation. Care of youth with SSRDs requires close interprofessional team support. This includes collaboration among the primary care physician (PCP), emergency physician, hospitalist physician, nursing, social work, child life, rehabilitative staff, subspecialty pediatricians, and CL psychiatrist/psychologist. Roles should be delineated early in the management course.
CL psychology/psychiatry should be consulted at the earliest suspicion of an SSRD to normalize psychiatric involvement in comprehensive care. Beyond assessment, CL psychology/psychiatry can aid with framing conversations with the patient and family, providing evidence-based interventions, and addressing psychiatric comorbidities. Although SSRDs do not necessarily accompany other discrete psychiatric conditions, anxiety disorders and mood disorders may be present in up to 50% of youth with SSRDs. These comorbidities should be incorporated in the case formulation for proper management of these conditions.6,9 Ultimately, this process is dynamic and highly interactive and should adapt to the needs of the patient and family.
Discussion of symptom development and diagnostic conceptualization should be paired with management strategies, highlighting the multifactorial contributors to symptom development. Pairing the multiple biopsychosocial factors allows for a coherent, systematic approach to rehabilitative care, psychotherapeutic management, and judicious use of targeted psychopharmacology. Joint communication by all involved physicians and other clinicians using consistent DSM-5 language and clear discussions of a conceptual framework for symptom development, highlighting mind-body interactions, are crucial.
Once the evaluation is complete and the diagnosis of SSRD is confirmed, it is helpful to have an interprofessional care meeting with the patient family to share the diagnosis. Explaining a conceptualization of how symptoms formed, progressed, and continue to present—along with the related biopsychosocial factors influencing presentation—is the most critical part of this conversation. This is accomplished via joint physical health and mental health providers using consistent DSM language with the relationship of physical, environmental, psychological, social, and cognitive factors to symptom development. For the patient and family to invest in the diagnoses and partner in the ongoing management of SSRD, they must understand this conceptualization.
Importantly, clinicians should gauge the patient’s and family’s readiness to accept the information. As such, communication must be geared to the individual’s understanding, values, and readiness. It is often valuable to pair discussions with the use of motivational interviewing to enhance engagement and understand the patient’s or family member’s experience. Discussions may start with a more biological conceptualization, emphasizing concepts such as somatosensory amplification and visceral hypersensitivity; analogies may be used to highlight mind-body interactions. Some families may be able to appreciate and incorporate psychological constructs earlier in the discussion of this conceptual framework. It is important to validate emotions while shifting discussions to functionality. Patients may want to focus on their impairment; it is, therefore, important to pivot conversation to highlight strengths, abilities, and incremental improvements.
Treatment Management
Management of an SSRD in youth is an iterative process that begins with setting clear goals and expectations. Misalignment of expectations is often a point of conflict. Patients and families may expect complete resolution of symptoms following initial encounters. Here, psychoeducation is key to the initial framing of the concept of somatization, discussing mind-body interactions, and describing joint medical and psychiatric management. Cognitive behavioral therapy (CBT) has a strong evidence base in addressing psychological factors underpinning pediatric SSRD.12 CBT aids in greater awareness of how cognition, emotions, and other psychological processes impact physical sensations, and it empowers the patient with strategies to dampen somatic complaints. It focuses on improving functioning in small, achievable steps while shifting the focus away from impairment.
CBT psychotherapy can occur in tandem with delivery of rehabilitative services. As many as 50% of youth with an SSRD will have a comorbid depressive or anxiety disorder, making treatment of psychiatric comorbidities an important component of SSRD management.5 Close involvement with the PCP is necessary, including proactive, regularly scheduled brief visits. These visits should be used to coordinate services, address questions, monitor progress, provide reassurance, and promote functioning. PCPs should conduct judicious evaluations of new concerns, collaborating with psychiatry, psychology, and subspecialty pediatrics as needed. In this way, the propensity to seek care in crisis and pursue care in a disjointed fashion can be extinguished over time.
Care should be provided in the setting that best matches the patient’s needs and severity of illness. For youth with severe worsening of function without a clear diagnostic understanding, medical admission may be warranted for further evaluation and management. Youth with significant psychiatric comorbidity may benefit from inpatient or partial psychiatric hospitalization. Those patients with significant rehabilitative needs will benefit from intensive outpatient or inpatient rehabilitation. Most youth, however, can be successfully managed in the outpatient setting with regular PCP evaluations, ongoing psychotherapy, and psychiatric care, as well as additional rehabilitative and pediatric subspecialty follow-up.1 This approach, which aligns with national consensus, provides the best framework for youth to regain functioning, improve symptomatically, and succeed in the care of SSRD.2,13
Role of the CL Psychiatrist
Care of youth with SSRDs highlights the important liaison role of CL psychiatry. CL psychiatrists aid in the dissemination of information and develop a shared understanding with the patient and family; they also support appropriate language use and incorporate psychological, social, psychiatric, familial, and cognitive factors in the overall assessment with the larger care team. This should include clearly defining care team roles, as well as setting expectations with patients and their families (Table 2).
The CL psychiatrist should describe mind-body interactions using analogies that simplify understanding for the patient and family. For example, a computer analogy helps explain SSRDs, in which physical disease is more akin to a hardware problem and psychosocial and environmental factors are more akin to a software issue. Similarly, it can be helpful to describe SSRDs as the body’s alarm system being overactive or hypersensitive to somatosensory interactions, which can lead to identification of factors that can heighten or dampen normative reactions to bodily sensations. The goal is to aid patients and families in understanding the interplay of physiologic, psychological, social, and emotional factors that influence somatic symptoms.
Given the diverse and wide-ranging issues and the number of team members involved in effective SSRD care, the CL psychiatrist should also be at the forefront in aiding standardization of multidisciplinary, evidence-based interventions. This should be informed by existing consensus guidelines, such as those published by the AACAP in 2020, and local resources, systems of care, and practice experiences.
CL psychiatrists may be asked about the use of psychopharmacology in managing SSRDs. There is no evidence to demonstrate that psychopharmacology can directly ameliorate the symptoms of SSRDs, and this should be expressed clearly to patients and families as well as to the larger care team.14 At times, youth and families may become frustrated that psychopharmacology has not resulted in resolution of symptoms. Therefore, it is important to reiterate, early on, that management of SSRDs is predicated on a multidisciplinary approach that targets the factors fostering symptom-development and persistence. Here the focus is shifted to improvement in functioning and incremental rehabilitation of cognitive, emotional, and physical health factors.
Psychopharmacology can be helpful in addressing psychiatric comorbidities and may provide more immediate relief for other psychiatric factors resulting in acute distress. When provided, psychopharmacological options should have clear targets for management with clear expectations within the greater context of treatment. It is important to explore familial expectations and continue to set realistic expectations, emphasizing the importance of ongoing engagement with other care teams, including psychology and rehabilitative services.
Concluding Thoughts
CL psychiatry can also have an important role in informing longitudinal management of SSRDs, which may be accomplished through collaborative clinical models. Such models often have psychiatry and psychology providing integrated care in a primary care or subspecialty pediatric practice. Inpatient psychiatric care may be needed for young patients with severe psychiatric comorbidities, safety concerns related to suicidal ideation or behavior, or severe psychological trauma. Ultimately, disposition planning must account for the level of training, experience, resources, and standardization of practice that exists within different settings in a given health system.
Dr Yaqub is a child and adolescent psychiatry fellow at the University of Michigan. Dr Biermann is clinical assistant professor in the Department of Psychiatry at the University of Michigan. Dr Andersen is a clinical instructor and associate medical director of the Nyman Family Unit in the Department of Psychiatry at the University of Michigan. Dr Malas is associate professor in the Departments of Psychiatry and Pediatrics at the University of Michigan.
References
1. Malas N, Donohue L, Cook RJ, et al. Pediatric somatic symptom and related disorders: primary care provider perspectives. Clin Pediatr (Phila). 2018;57(4):377-388.
2. Kullgren KA, Shefler A, Malas N, et al. Taking the pain out of somatization: development and implementation of a hospital-based clinical practice guideline to address pediatric somatic symptom and related disorders. Hosp Pediatr. 2020;10(2):105-113.
3. Ibeziako P, Brahmbhatt K, Chapman A, et al S. Developing a clinical pathway for somatic symptom and related disorders in pediatric hospital settings. Hosp Pediatr. 2019;9(3):147-155.
4. Shaw RJ, Pao M, Holland JE, DeMaso DR. Practice patterns revisited in pediatric psychosomatic medicine. Psychosomatics. 2016;57(6):576-585.
5. Bujoreanu S, White MT, Gerber B, Ibeziako P. Effect of timing of psychiatry consultation on length of pediatric hospitalization and hospital charges. Hosp Pediatr. 2015;5(5):269-275.
6. Ibeziako P, Bujoreanu S. Approach to psychosomatic illness in adolescents. Curr Opin Pediatr. 2011;23(4):384-389.
7. Rask CU. Functional somatic symptoms in 5-7 year old children: assessment, prevalence and co-occurrence. Dan Med J. 201;59(11):B4537.
8. Jones GT, Silman AJ, Power C, Macfarlane GJ. Are common symptoms in childhood associated with chronic widespread body pain in adulthood? results from the 1958 British Birth Cohort Study. Arthritis Rheum. 2007;56(5):1669-1675.
9. Malas N, Ortiz-Aguayo R, Giles L, Ibeziako P. Pediatric somatic symptom disorders. Curr Psychiatry Rep. 2017;19(2):11.
10. Plioplys S, Doss J, Siddarth P, et al. Risk factors for comorbid psychopathology in youth with psychogenic nonepileptic seizures. Seizure. 2016;38:32-37.
11. Thomson K, Randall E, Ibeziako P, Bujoreanu IS. Somatoform disorders and trauma in medically-admitted children, adolescents, and young adults: prevalence rates and psychosocial characteristics. Psychosomatics. 2014;55(6):630-639.
12. Liu J, Gill NS, Teodorczuk A, et al. The efficacy of cognitive behavioral therapy in somatoform disorders and medically unexplained physical symptoms: a meta-analysis of randomized controlled trials. J Affect Disord. 2019;245:98-112.
13. Ibeziako P, Randall E, Vassilopoulos A, et al. Prevalence, patterns, and correlates of pain in medically hospitalized pediatric patients with somatic symptom and related disorders. Psychosomatics. 2020:S0033-3182(20)30146-8.
14. Kleinstäuber M, Witthöft M, Steffanowski A, et al. Pharmacological interventions for somatoform disorders in adults. Cochrane Database Syst Rev. 2014;(11):CD010628.❒
