Rhode Island Medical Home Portal - Somatic Symptom Disorder & Functional Neurologic Disorders

Overview

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.”

ICD-10 Coding

F45.1, Undifferentiated somatoform disorder
F45.9, Somatoform disorder, unspecified
F44.x, Dissociative and conversion

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
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.

Behavioral Health Screening
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.

Suicidal Ideation
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.

Pain
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

Routine: The human body craves routine. For children with SSDs, focus on healthy routines is critical to regaining control of symptoms and functioning. Symptoms can easily interfere with appetite, sleep cycles, daytime energy, and motivation. Identifying specific lifestyle deficits provides targets for treatment and monitoring that can significantly reduce symptom burden. Consistency is more important than exact numbers of sleep hours, water volume, etc. Ideally, working towards a daily routine that is healthy and sustainable will go a long way towards functional improvement.

Nutrition: Focus on taking in nutrition throughout the day, avoiding getting too hungry or too full, which can result in symptom exacerbation.

Hydration: Dehydration is a primary reason for symptom worsening. For many kids and adolescents, the simple act of consistently drinking water can be challenging and may require some problem-solving.

Exercise: As with any behavior, integrating daily exercise into a scheduled automatic activity can be difficult and will require a paced approach with lots of reinforcement.Sleep: Routine sleep and wake times, consolidated sleep, and avoiding daytime napping are all helpful to help the body reset and keep the focus on health and functioning.

Relaxation exercises are an integral part of lifestyle treatments for chronic pain and functional difficulties. Physically, pain relief, muscle relaxation, sleep, heart rate, and blood pressure are all improved with regular meditative focus. Emotionally, focus on neutral or positive stimuli help with feeling calmer, more relaxed, and comfortable. Cognitively, perceived control of symptoms, reframing of helplessness, and function all benefit from regular relaxation training.

Medical Monitoring and Support

The child/adolescent should have frequent visits with their primary health provider to monitor symptoms, provide reassurance, and reduce medical anxiety. Positive and reassuring health messaging is a powerful intervention for primary care providers who act as gatekeepers to care escalation and promoters of healing and coping with the patient’s physical symptoms.

Physical Rehabilitation

When functioning is significantly impaired, referral to physical medicine and rehabilitation or individual services, such as PT or OT, may be appropriate. Deconditioning often occurs as a result of activity avoidance. When children avoid activities, they become more sedentary, resulting in greater weakness and symptom exacerbation with activity. Although they may have normal strength on testing, discomfort with movement is often high. Physical therapy and rehabilitation can support reconditioning in a paced and constructive manner.

Cognitive Behavioral Therapy

Behavioral treatment, especially cognitive behavioral therapy, is the mainstay of management. For children with SSDs, identifying and redirecting thoughts that fuel overfocus and associated distress is a first step in retraining the nervous system to control uncomfortable symptoms. Other CBT techniques, like relaxation, mindfulness, and pairing exposures with coping tools, are useful methods for extinguishing symptoms and improving recovery. [Lunkenheimer: 2020]

Medications

A physician may suggest medications to reduce discomfort associated with symptoms or address comorbid anxiety or depression, which can worsen symptoms or interfere with treatment or motivation. Medications used are not specifically for SSD but for associated conditions or symptoms.

Subspecialist Collaborations

Behavioral Therapies (see RI providers [31])
A mainstay of the management of SSD and all patients should be referred.
Pediatric Neurology (see RI providers [17])
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 RI providers [6])
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 Rhode Island (RI)

Service Categories	RI	NW		NM	NV	OH
Behavioral Therapies	31	1	8	20	1	35
Developmental - Behavioral Pediatrics	12	1	2	2	2	9
Occupational Therapy	19	1	17	27	2	39
Pediatric Neurology	17		5	5		5
Pediatric Physical Medicine & Rehabilitation	6	3	3	3	3	15

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.

Studies

Somatic Symptom and Related Disorders (ClinicalTrials.gov)

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

Initial publication: August 2021

Current Authors and Reviewers:

Author:	Lynne M. Kerr, MD, PhD
Reviewer:	Deirdre Caplin, Ph.D., MS

Page Bibliography

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

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